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File 3 - Article 11 Previous Index Next
Author: Keith Pearce
Title: Placebo and Self-healing

I wrote this article some time ago. It subsequently appeared in the journal Holistic Health. It is a synopsis of the book Understanding the Placebo Effect in Complementary Medicine, Theory, Practice and Research Edited by David Peters. Churchill Livingstone 2001. I thought it might be of interest to the participants of the N.C. File. It seems to me, to throw some light on the 'intangibles' or the 'non specific factors in healing', which are common across the board in both the conventional and the unorthodox approaches to healthcare. It might contribute one more tool to the understanding of the enigmas of health and disease.

David Peters has assembled and edited a useful collection of twelve chapters on the placebo effect as seen from the perspective of complementary medicine.

At least that is what the title leads us to believe.

In fact the contents are much more exciting and revolutionary than that. The initial chapter by Helman shows that placebo in common with other beliefs and concepts is a cultural construction. The final chapter by Fenwick shows how a different cultural construction (other than positivist scientific medicine) could lead to a reformulation/rehabilitation or even a replacement of the placebo concept.

The ten chapters in between show from a variety of perspectives and experiences how the importance of the so-called placebo effect has grown and become shaped into something seen as fake, to be guarded against and side-lined. They also show how a re-viewing of the concept can give it a whole new life as it is basically showing us that the human body is largely self-healing given the right circumstances.

This conclusion will come as no surprise to many outside the field of conventional allopathic and conventional complementary medicine. The German Interwar Nature Cure movement carried to the USA by Henry Lindlahr and Britain by James C. Thomson amongst others (still represented in Britain by the ISRN) is founded on this fact. The work of Georg Groddeck, also in interwar Germany, linked this fact with psychotherapeutic practice in parallel with (and largely approved by) Freud. He (Groddeck) is seen by many as the father of psychosomatic medicine.

Unfortunately psychosomatic medicine as developed in the USA in the pre- and post- Second World War period gradually discarded Groddeck's founding insights in favour of a more 'rational' scientific approach, which attempted to demonstrate a causal link between certain physical symptoms and definite psychological precursors. This approach ultimately proved unconvincing. So 'psychosomatic' went the way that placebo has gone since, derided and despised, used as a term of derogation by most, led by the scientific medical profession.

Peters usefully introduces each chapter with a short commentary on where he sees it fitting into an emerging picture of placebo, which differs from the medical-scientifically degraded view, which virtually equates it with 'fake'. He doesn't quite go as far as to fully endorse the views of some of his contributors that patient self-healing powers could largely explain the importance of placebo in many controlled medical trials and the difficulties researchers have had trying to eliminate or allow for the placebo effect (seeming often to regard it as a methodological nuisance). Neither does he fully endorse the final two chapters by Heron and Fenwick. However his choice to include these two contributions opens the way to a new paradigm which could not only rehabilitate the placebo concept but ultimately lead to its replacement with a model of health and health research which might finally free contemporary health-care from the distortions imposed by the constraints of the 'modern' (as opposed to post-modern) scientific framework which currently dominate.

In the meantime, several of the contributors do a first-class job in beginning to bridge the gap between the usual attempts to minimise or exclude placebo effects from medical research and the recognition that these effects are of value in themselves. For example Withers gives two case studies of the interaction between psychoanalytical understanding and acupuncture and homoeopathic treatments. He utilises psychotherapeutic categories such as transference and projection to explain the placebo effects in his acupuncture treatment of a man with rheumatoid arthritis and a woman with back pain whom he treated homoeopathically.

Hawkins uses the term 'non-specific effects' as a synonym for placebo and in his chapter he focuses on how to optimise them and most importantly how to put them into practice as well as reading and thinking about them. As an orthopaedic physician, acupuncturist, hypnotherapist and yoga teacher as well as running therapy groups he is, as the editor comments, used to moving 'fluently between the physical and the psychological....'

Latey has contributed a very thoughtful and thought-provoking chapter on placebo responses in bodywork on the basis of his long experience as an osteopath. He describes some of the effects that arise in longer term work when interpersonal relationships develop and there is the possibility of transition from what he calls persuasion to rapport. At this point and beyond he suggests that placebo, non-specific factors and rapport can be more effective in patient healing/self-healing than any techniques or persuasion on the part of the therapist. He gives lots of detailed clues as to the components of rapport both physical and interpersonal (i.e. verbal) exchanges. He goes on to speak of feelings and intimacy in this process and introduces the notions of 'structural coupling' and intertransference which refer to a kind of resonance or entrainment which takes place between two organisms working together 'in tune' towards a common goal. The intimacy that can develop need be neither sexual nor infantile and can only happen he says if the relationship is participative. He suggests that there are only two ways in which manual therapists achieve success with patients - persuasion is one, the other is the placebo response.

Reilly's chapter is the only one that reproduces the lecture actually given at the conference in 1997 which gave rise to this book. His theme is that doctors have forgotten/lost/been trained out of the ability to have a human encounter. This is evident in hospital doctors' bedside manner, the GP's 7-minute appointment and the medical students learned disrespect for the human person beginning with cutting up a corpse. The emphasis on learned communication skills rather than acknowledgement and use of innate abilities is just one example (the nurse being disapproved of for spending time sitting with a patient rather than keeping paperwork up-to-date). Also the emphasis on publication of research findings as an example of where priorities lie. He wishes to be heard loud and clear that healing begins (and may end) with the quality of the encounter between patient and professional. At present he sees that medicine is not nearly subtle enough, human relationships are 'ripped to shreds', the simple core of the person-to-person encounter is being lost in a welter of rush and jargon. He goes on to address the 'magical' qualities which are associated with placebo effects and the similarities between placebo and hypnosis. In the latter context he re-emphasises the damaging distinction which pervades all modern medicine between 'organic' (real/physical) and 'functional' (no tissue changes) illness. This is merely the reflection of the mind/body split which has dominated western scientific thinking since Descartes in the 17th century. Finally, and arguably, most importantly, Reilly speaks of the way he is with patients and how that has changed over the years. Now he doesn't use hypnosis as such having replaced all formal procedures with a simple human encounter which sounds very much like a session with Georg Groddeck in 1920s Baden Baden or a modern day session with a good non-directive humanistic counsellor or psychotherapist.

Clow describes some of the details of psychoneuroimmunology (PNI) or the 'new psychosomatics'. As the editor points out there is more to this than the old dismissive, 'it's all in the mind'. The possibility is raised that mainstream medicine could embrace a scientific approach to triggering self-healing, that the term placebo response may in fact cover quite specific effects. In Clow's terminology the possibility is demonstrated of behavioural conditioning of the immune system. What she seems to be doing is breaking down the polarisation between intentional desired therapist controlled outcomes and uncontrolled placebo responses and saying that reality is not so black and white.

There are three other chapters in part one of the volume - Clow's is the fourth. The first by Helman has already been referred to above. The other two review and consolidate the current theoretical position of placebo. Ernst first overviews the present understandings of placebo effects looking at various facets, myths and determining factors. He goes on to look at how science understands (or doesn't) the effects. As Peters points out in his introduction to the chapter as science teases out the details of what is involved in the 'black box' labelled 'placebo' the notion will almost certainly be abandoned in its present form. Kienle and Kiene extend this theme by critically reanalysing the concept and magnitude of the placebo effect and questioning its existence in the narrow sense in which it is often used (to mean imitation therapy). This paper introduces the term 'patient self-healing'.

There are three other papers, two in the practice section (one by Richardson, the other by Wright and Sayre-Adams) and one in the penultimate section on research. The latter by Craen and others looks at the methodological aspects of including placebo/non-specific factors in randomised clinical trials.

One significant detail that should be mentioned is the companion notion of nocebo (belief can kill) which Helman mentions in his opening chapter - the voodoo or hex death.

In the context of the book as a whole the definitions of placebo (and nocebo) do not attract a great deal of attention. However there is scope for a brief discussion of it here. Nocebo could perhaps be more usefully defined as negative non-specific effects. Placebo has variously been defined as 'given more to please than to benefit the patient' and fake medicine. However much more attention could and perhaps should be given to the 'placebo effect' over the 'placebo' as a thing. Whether it is a medicine or other treatment or whether it is the intangible aspects of the therapeutic relationship/encounter, surely the effect experienced by the patient is the most important thing. And here we come to the crux of the matter because it is arguably not an effect on the patient more an effect in the patient, the release / support / encouragement / empowerment / catalysing of the patient's self-healing powers which is the most important placebo effect.

Peters and the publishers have undersold the significance of this volume which has truly revolutionary potential. The conference from which it grew was held in 1997 in conjunction with the Scientific and Medical Network which deserves a much higher profile (as does BHMA) in my opinion. An earlier conference held at Harvard in 1994, the proceedings of which were published in 1997, and two other important books on placebo are mentioned by Peters in his Preface. However the real importance of placebo hinted at by Peters and others in this book is that it represents the human being's almost limitless and uncrushable (even by modern high-tech and pharmacological medicine - cut, burn and poison) ability to heal itself.