Hi I’m Ted Kaptchuk. I’m a Professor of Medicine at Harvard Medical School. And I’m Director, of the Program in Placebo Studies and the Therapeutic Encounter, which is hosted at the Beth Israel Deaconess Medical Center. What is placebo? And what is the placebo effect. A placebo is very easy to describe, it’s either a sugar pill or a cellulose pill. It’s a sham simulation of therapy. A placebo effect is sometimes called the effect of an inert substance, the effect of a sugar pill. That’s an oxymoron, it doesn’t make sense, the effect of something that has no effect. Actually what a placebo effect is, is a way of describing, quantifying, and understanding everything that surrounds those pills. The interaction between the patient and the provider, the symbols, the rituals, the pills that we take, the amount of support we get. The placebo effect is about everything that’s not in the tool box, but is in the environment when we go and see a provider. What is the therapeutic encounter? When a person goes to a doctor, a nurse, an allied health professional, or complementary therapist, everyone thinks it’s the drug, or the moving of the hands, or the exercises we do, but in fact one of the major contributors to the outcome of what happens, what the major contributor to why a person feels better is the empathy, attention, emotional support, thoughtfulness, acts of decency, laying on hands that goes on between a patient and doctor or any other kind of therapist.
It’s feeling trust, feeling a bond that potentiates good medicines and makes them better. It’s a critical part of all health care. What should I know about the placebo effect when it comes to my health care decision-making? I think the bottom line is that the fact that cellulose or sugar pills can change how you feel suggests that there are lots of other things that can change how you feel. That we’re not locked in to complaints of pain, fatigue, headache, nausea. We’re actually, those symptoms change, sugar pills can change them, and looking for ways in your ordinary life that actually help you reduce those complaints, and avoid exacerbating those complaints is an important message. A second message is the placebo effect is not only about cellulose and sugar, it’s about the therapeutic encounter. Do you feel supported by your health care provider, do you feel understood, do you trust your health care provider, do you feel that he or she is on your side and they got your back.
Unless you feel that, that’s an important quality that you need to have in your health care. If you don’t feel that from your provider maybe think about changing it, because we know that the clinical interaction between patient and provider changes how you feel in important complaints. Are some people more likely to respond to a placebo than others? One question is “Do some people get more from the clinical environment, the therapeutic encounter, than other people?” Probably, but right now we’re not sure.
But a bottom line is if a patient doesn’t feel comfortable with their provider, their clinician, consider changing it. Because we know that that interaction will make the clinical outcome of whatever your complaint is, whatever your problem is, that will resolve quicker and more completely in a therapeutic relationship that is based on trust, comfort, and support. Placebos generally are not used by health care providers to treat a patient, but why are they important in research? The question of “When do we use placebos?” In general, any health care provider is not allowed to deceive a patient. You can’t give a person a sugar pill or cellulose pill and say “This is a real drug.” That’s absolutely unethical, there’s no transparency there, it involves deception.
That said there are two situations that, one situation that’s indispensable to use placebos, another that’s interesting. The one that’s indispensable is that when we do research trying to study the effect of a drug we compare it to a placebo. Meaning sometimes because people’s illnesses get better by time. Tincture of time is real. And we want to find out if the drug really works or is it really time and spontaneous remission? So we do what is called double blind experiments, where neither the provider, or the researcher, or the patient knows that they’re getting a drug or placebo and the patient has to be told about the procedure and has to sign an informed consent. That’s a way of protecting the patient. There’s another situation where people are just beginning to think about, can you give placebos and tell people they might work? It’s still, it’s very early in infancy that kind of research. But right now, in general, that would be ethical, if you’re honest. But right now, in general, we say that placebos, especially in the context of deception, is not an ethical thing to do.
But in research for drug development, placebos are really indispensable. Can placebos have an effect on certain illnesses? It’s very important to remember, placebos can relieve many complaints: pain, fatigue, depression, anxiety, stomach unease. But it’s very unlikely, there’s no evidence that placebos can shrink a tumor, can lower cholesterol, or deal with serious medical conditions. Placebos are about changing how we perceive ourselves, our complaints, changing our relationship to complaints. It’s a way of, it deals with a very common disorders that accompany serious illnesses, like fatigue, pain, that kind of stuff.
What is the nocebo effect? Placebo is about positive benefits we get from rituals and symbols and the interaction between patient and clinician. There’s also negative effects like apple pie, too much is not so good, or good things can do bad things and there’s also something called the “nocebo effect” which is negative consequences of taking sugar pills or cellulose, or even when you take a drug and sometimes you get side effects that actually are due to the anticipation of the side effects. Very similar in a sense that placebo is probably related to the anticipation of positive benefit. If someone reads you a long list of various complaints some of those complaints will happen more frequently and that’s called a nocebo effect. Nothing is only good..