Monday, May 3, 2010

Placebos Empower the Mind

As happens on occasion, I am late to a party. I do not feel too bad about it, because I am often happy enough to have gotten there at all.

Today, the party concerns some new research on the placebo effect, as reported by Steve Silberman in Wired, last August. Link here.

Silverman reports that in recent clinical trials new drugs have not been doing very well when compared to placebos. It's not because the medications are getting worse, but because the placebos are getting better.

There you have it: science has succeeded in building better placebos.

And scientists have been taking notice. If a dummy capsule "can kick start the body's recovery mechanism," scientists believe now that by studying the placebo effect they can gain "a better understanding of the healing process and how to guide it more effectively."

Some have suggested that we owe this effect to the expert marketers who work for the pharmaceutical manufacturers. I would take it one more step, and say that it testifies to our abiding faith in science, our believe that scientific knowledge can solve all problems.

And it also demonstrates that science has taken over some traditional functions of religion, like healing despair and comforting anguish. I assume that we all know that prayer and religious ritual serve an emotionally therapeutic function. It is not an accident that some modern forms of psychotherapy make use of meditation and refer openly to spirituality.

With placebos, as with religion, what matters is belief and faith. You must believe in the power of the substance you are being offered and you need to have sufficient faith to see yourself as being cured of your pains. If you maintain doubts about a placebo, or about God's powers, they are going to be less effective.

Apparently, when the mind has true faith in an outcome, it eliminates its anxiety about the effects of the illness and prepares itself in advance for cure. Thus, it participates in the curative process, even without the presence of a biochemically active agent. As Silberman puts it: "the promise of treatment activates areas of the brain involved in weighing the significance of events and the seriousness of threats."

Silberman reports that placebos function by activating opioids in the brain. By their nature these opioids: "relieve pain," "modulate heart rate and respiration." Moreover: "Mechanisms like these can elevate mood, sharpen cognitive ability, alleviate digestive disorders, relieve insomnia, and limit the secretion of stress-related hormones like insulin and cortisol."

Of course, placebos have caused the most trouble in clinical trials for new anti-depressants. Now that everyone knows that SSRIs cure depression, the cure rates for people taking anti-depressants and for those taking placebos are too close for drug company comfort.

But research into the placebo effect has, by extension, shed some light on what causes some people to benefit from psychotherapy. We can certainly ask how many patients report being cured by psychotherapy because the treatment ritual exerts a placebo effect.

Placebos work best when the patient talks over his problems with his physician, when the physician explains the mechanism of the illness, and where the physician expresses optimism about the outcome. The human connection, accompanied by the credibility of science, propels the placebo effect.

Some therapists will consider that this is exactly what they do with their patients. Others, especially those influenced by psychoanalysis, insist that their work has nothing to do with establishing human connections or with expressing optimism about the possibilities for cure.

If we know the similarities between some forms of therapy and religious practice, we should also emphasize the differences. Religion involves congregating in a social group. And religion, beyond its teaching about metaphysical entities, also contains strict ethical guidelines that promote social skills.

When we are talking about physical illness, the placebo effect supplements and supports medical treatment. Placebos do not cure cancer or heart disease. They facilitate the treatment. The psychological support of a caring and optimistic physician will surely help, as will participation in a therapeutic ritual.

And yet, if medicine had never worked, if it had not performed miracles, then people would probably not believe so wholeheartedly in the power of placebos. And, as Silberman notes clearly, something that enhances cure is not in itself a substitute for a therapeutic agent. Religion performs vital psychotherapeutic functions for believers. It does not cure cancer or heart disease or Alzheimer's.

Remember, in the mid-fourteenth century religion proved itself powerless to stop the horror of the bubonic plague. Having begun in Florence in 1348 the plague decimated Europe at a level that was never seen, before or since. It also shook people's faith in religion and religious institutions, to say nothing of their faith in God.

The plague, I would suggest, was one of the most important turning points in Western civilization. It ended the Middle Ages, helped give rise to the Renaissance, and revived interest in scientific research.

When people expect that therapy will treat what ails them, it may very do so. For someone suffering from alienation and isolation, a conversation with a kindly therapist might well provide treatment. And also, like a placebo, it works in some cases because people have seen their friends and neighbors improve while in therapy.

Something that facilitates the curative process does not in itself provide a cure. That can only take place if the patient changes the way he conducts his life. Ethical behavior and character building are, to my mind, the real cure of mental anguish and despair.

Even 12 step programs, which were structured like a religious revival, do not work if the addict cannot change his behavior. Surely, this process is facilitated by the support of a sponsor or a therapist or a coach, but let's not believe that therapy can cure psychosocial problems without there being another active element within the equation.

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