The mind can hold tremendous power over our bodies. People walking over burning coal with no sign of pain, seemingly average people achieving feats of superhuman strength, or even just the everyday Joe overcoming tremendous adversity - we’ve all heard the stories. This influence of the mind is often undermined and even brushed aside as wishful thinking. But how far can the power of the mind really go? How much can you really do simply with belief? Could you, for example, get rid of a headache just by ‘thinking it off’? Could you get fitter just by believing you exercised? How about reducing the symptoms of a debilitating disease without a cure? These things might sound too good to be true, but hear me out. There’s actually a whole field of scientific, empirical research out there dedicated to this phenomenon.
I’m talking about the Placebo effect.
It’s generally understood as an effect where your mind tricks you into believing that a not-so-real treatment has real therapeutic results. People seem to experience a benefit after taking a look-alike pill or drug that has no active ingredients in it. Sometimes the placebo effect can be induced by words alone. All this should have no medical effect on the patient, and yet it does. There are different kinds of placebos too- pills, drinks, injections. Interestingly, some of these placebos are more effective than others– but I’ll get to that later.
In most cases, people receiving placebos believe they are getting real medical treatment. For example, in a clinical trial for COVID-19 prevention, a medical team chose a vitamin C supplement tablet as the placebo. It was chosen as such because there is a widely held view that vitamin C supplements help prevent the common cold, and diseases like COVID-19 - even though there is almost no evidence to prove that that’s the case. In this instance, the general perception was enough to essentially “hide” the pills as placebos, whilst the rest of the medicines were actual treatments. Remarkably, however, in certain scenarios, placebos tend to work even when the patients receiving them know that it’s only a sugar pill.
Regardless, for the majority of the history of the placebo effect, deception has played a key role. In fact, the name “Placebo” originates from the term “Placibo Singers” - people who, according to french custom, would show up at funerals. They almost never had anything to do with the deceased, and would only show up for a share of the funeral food and drinks. Funeral crashers, if you will. And they wouldn’t just show up. They would express great sadness and despair at the loss of the deceased, you know to complete the act. This fake ‘act to please’ is what the term ‘placebo’ stood for for a long time, before finally being introduced in medical vernacular. And after introduction, while this term still retains a lot of the deception implied in giving someone a sugar-pill in lieu of actual medication, the placebo effect is now common in the gold-standard of rigorous medicinal practices.
So, how did this ‘act of deception’ make its way to medical practice? Well, as with all good inventions, it started off with doubt. In the 1770s, John Haygarth, a british physician, was curious about the efficacy of “perkins rods.” These were pointy metal rods that were supposed to “draw out” rheumatic fever and gout. You can already see where this was going. Other than being absolute crap, this “treatment” was also expensive. Funny enough, Haygarth’s doubt seemed to have been borne out of a suspicion for the price rather than the ridiculousness of the procedure - which, to be fair, wasn’t all that ridiculous back in those days anyway. But it was still enough for him to contest that similar results could be achieved using much cheaper rods. To prove his point, he used wooden rods instead of metal ones, and reported that 4 out of the 5 patients saw improvements. And thus the placebo effect was formally observed for the first time. From there, scientists wondered what could’ve caused such a medicine-like effect in fake look-alikes, which shed light on the mechanisms of the body that the placebo effect relies upon.
Here, the most prominent theory seems to be the idea that there is and always has been a correlation in the minds of patients about medical care and its results. Known for his research into the placebo effect, Irving Kirsch attributes the placebo effect to “self-fulfilling effects of response expectancies.” Essentially, we expect medical care to do its job. You might wonder how true it is today, considering there is so much skepticism in certain health-care practices. ‘A patient cured is a customer lost” - you’ve probably heard the quote. Yet, for some reason, the expectation remains that if you are prescribed something by someone who is supposed to know what they’re talking about, it’s probably going to work.
You and I are all conditioned to believe that people take a pill when they want to get better. This association has seemingly more to do with the act of pill-taking, or any medical intervention, than the contents of it. Besides, there is a case to be made that a caring physician can go a long way to relieve us of pain, maybe not medical pain, but psychological pain. All these contribute towards our perception of a medical intervention. We don’t necessarily see a pill as just a stand-alone chemical compound that we are supposed to swallow, but rather along with all of the information about who gets it, how well it works, who prescribes it, and so on. Besides, the effect tends to vary depending on the nature of the intervention. For example, an injection is perceived to be more invasive than a pill and, therefore, tends to induce a stronger placebo effect.
And thus arises a new concern. If the simple act of taking a pill can benefit the user by relieving their pain, what reason is their to develop a medically active drug like a pain-killer in the first place? Besides, a lot of these pain killers, like other medications, tend to carry a plethora of possible side-effects, and the potential for dependency and drug abuse.
Well, that’s where the randomized double-blind placebo trial comes in. During the course of such a trial, a patient can be administered with either a medically active drug - the drug that’s being tested, or a placebo - usually a sugar-pill, and then both of these groups are compared to a group that does nothing, no pills, no drugs, no placebos. Neither patient, nor researcher knows who gets what. It is completely randomized and blinded. This is done to control 2 things.
- The possibility of unfair care from the medical professionals, based on the knowledge of knowing who is getting the actual medication.
- Controlling the results to be based solely on the act of the medical intervention taken, for example, giving them a pill, rather than the contents of the medicine itself. Only if a medicine is able to perform against a placebo in such a trial in a statistically significant manner is it even able to be considered for approval.
Well, that certainly makes sense. You’re testing a medicine against possible issues to be as certain as possible about its effectiveness, right? But, these sort of tests are usually run when there is an ailment to cure in the first place. So, that means, a part of the testing demographic is being withheld from a medicine that could potentially help them. As you can see, there is an ethical concern here. To go back to the example of the COVID-19 trial. Imagine being promised by a group of researchers that they are working with promising medication that could reduce your chances of contracting the virus. But, lo and behold, a part of those subjects were given no such medication while being lied to, legal aspects aside. Obviously, you and I know that it’s being done for the greater good, and researchers generally take layers of precautions to prevent any serious damage. And as more evidence emerges, the know-nothing anxiety about the virus is now turning into just general caution. But still, how would you have felt if you were one of the people who were given the placebo?
All of this makes the waters a bit murky for placebo research. Besides, we know for a fact that even with illnesses where the placebo effect offers some comfort, the underlying problem that caused the discomfort, more often than not, goes untreated. Take asthma for example. It’s one of the chronic illnesses that has seen consistent improvement from the use of placebos. Some patients were put on trial with an inhaler with a drug called “albuterol”- designed to open airways. Others were put on an inhaler with a placebo, and others were given no intervention at all. At this point, you should not be surprised to find that the patients who were on the placebos self-reported a much higher level of comfort than those who were on put on nothing. The placebo comfort scores followed closely those of the actual drug. But upon closer inspection, it turns out that objective measures of lung function had only noticeably improved for patients who took the medically active drug, which makes sense. This tells us that the placebo does not alter our bodily mechanisms as much as it alters our subjective experiences - which is not to downplay their importance, of course. A lot of the time, illnesses like asthma are exacerbated notsomuch by the closing of the airways, but rather a heightened state of anxiety from a feeling of suffocation - which might explain why patients with no improvements in lung function still “self-report” them saying that they did.
Placebos have led to other remarkable findings too. To answer the questions at the start - yes, a study regarding a drug called “Maxalt” has shown that simply the labelling of the drug patients are taking allowed them to experience migraine attacks of reduced intensity. They were tricked into imagining that they took migraine medication when they actually did not, and it still worked. And, yes, hotel cleaning staff that thought that they had exercised through their regular work had all noticed significant changes to their body weight, waist to hip ratio, and even their blood pressure. And, yes, patients with Parkinson's disease who were randomly switched to placebos still kept experiencing healing. This is all great news, as it opens up avenues of potential treatments and ways in which patients’ quality of life can be improved. In fact, the placebo effect is seemingly getting bigger, which makes these findings all the more important.
There are reasons to doubt the placebo effect, however. For instance, just as researchers might be inclined to nudge participants one way or another to affirm their own beliefs about the efficiency of a drug, participants, too have their own set of biases. The Hawthorne effect talks about a scenario where participants alter their responses once they realize they’re being observed. The novelty of the experience of being part of a trial, the increased attention - all these things might affect what a participant is saying. Since so much of the effectiveness of placebos have been derived from how patients are “feeling” - in other words their subjective experiences - this is a crucial, and potentially experiment changing variable. There’s also the idea of “regression to the mean'' - meaning the natural tendency of most patients to get better with time. They might incorrectly attribute this natural improvement to the medicine they are taking - placebo or not. Additionally, if the “magic” of the placebo effect depends on our ability to make associations between medical care and relief, then, I’m afraid, it could also turn into sorcery. Known as the nocebo effect, this phenomenon describes a situation where the expectation of a negative outcome induces negative therapeutic results - the exact opposite of the placebo effect.
For example, the same placebo has been found to raise blood pressure, heart rate, and induce sleepiness depending on whether it was given to the participants as a stimulant or a depressant. The changes were significant, mind you, in both cases. It’s just that they were exactly opposite. And that’s both fascinating and alarming. That’s because it goes to show the power of such an association and how that could be used to improve so many lives, but on the other hand, it also makes you wonder how many people are miserable because they are thinking the wrong things. Take fad diets for example. Once you have established that food A is incredibly harmful for you because someone on the internet said so, you start developing a very strong negative association. You start off by just avoiding that one food. But then you start reading labels, and you find out this has a little bit of this and a little bit of that, and you slowly start taking things off of the plate. The result, almost always, is an unsustainable diet - not to mention possibly unhealthy. You end up miserable and in a constant battle against your will - a far-cry from the healthy life-style you started the diet for in the first place. And the funny, or sad thing is, that that said food may not even have been bad for you in the first place.
It’s remarkable how the history of the placebo effect has panned out. From hungry thieves who would do anything for a morsel, to treatments that were considered largely a failure against the rigors of the medical system, from the association with care that spans generations to ethical qualms that still cast doubt, the placebo effect has come a long way. And if you have ever taken a clinically approved piece of medicine, chances are it has probably helped you in one way or another. But the placebo effect has always been more than that. It’s about medicine sure. But it's also about us humans and how we respond to our stresses, and how important it is to just feel right. If so much is possible just by the power of imagination, then perhaps you’re just a few good thoughts away from happiness?
In case you’ve forgotten, at the end of the day, it’s all in your head.
- MA, MM