I sat there watching the IV go into my arm. Normally, IVs don’t bother me; I know that taking my blood, or G-d forbid, needing to give me blood, is good for me, but I have this particular squeamishness about having foreign substances put into my body. Heaven only knows where it came from, but I can remember having it all my life. At least, I’m totally risk free of becoming some kind of drug addict. Good things come where you least expect it.
Anyway, the problem with this particular IV was that it was neither taking nor giving me blood. Rather, it was a standard dye for a stress test cardiogram, one, I might add, that I never had before. Of more significance on this particular sunny morning is that I hadn’t bothered to read the pre-test instructions and I was not mentally prepared for the procedure.
They finished injecting the dye and had me sit in the waiting room for 45 minutes “for the dye to get into your system.” Just what I needed. I could imagine that dye—an alien substance, radioactive no less, threading its way through my veins. My head got light. I knew immediately what was happening. The last time I fainted, my little girl, then about seven, was being tested for allergies with a “scratch test” where they put a small amount of allergens with needles into the skin, a row of scratches up and down her little arms. She was fine but I had fainted.
I took the garbage basket at hand and put my head down between my knees. It didn’t help. All the while I kept telling myself, “Deb, breathe, take nice, deep breaths,” just like I say to my clients when we do relaxation exercises for anxieties and phobias. But it didn’t help one bit. How embarrassing! I, the practitioner of overcoming just about anything, was stuck caving into my heebie-jeebies.
“I hear you had a little problem in the waiting room,” the tech said later with kindness. “It wasn’t the dye, was it?” I asked. “Oh, no, there are no side effects of this dye at all. In fact, for my thesis, I studied over a thousand people and no one got a reaction,” he replied pleasantly.
Thanks a lot, I thought. Well, next time I need such a test, I’d better have a serious conversation with myself about how that dye is really very good for me—or something. The good thing about being a therapist is that I’ll know when the internal conversation will work and when it won’t.
The Solicitous Spouse Increases Back Pain
The other good thing about being a therapist is that I can appreciate—up close and personal—the amazing power of the mind. Any mind. Even my own mind. The power of suggestion is so strong that in 2002, at the annual conference of the Society for Neuroscience, one study showed that the pain suffered by people with severe, chronic backaches would increase three-fold when their “solicitous husbands and wives—those who clucked most lovingly over the spouse’ discomfort” were present in the room where electric shocks were applied to their aching backs. “The more the husbands or wives dwelt on their partners’ pain, the worse it felt, the neural monitors showed” stated the lead investigator (as reported in the Miami Herald, November 5, 2002). The report explained that “Through the feedback loops of a marriage or long partnership, the patient’s pain has shaped the helping behavior of the solicitous spouse, who in turn has become a stimulus to provoke the pain.”
Imagine that! A well-meaning partner increases the pain just by being there because in the past he or she was solicitous. By directing attention to the pain, activity increased in the brain’s anterior cingulate cortex. It doesn’t take a solicitous spouse to create the same effect.
Fake Knee Surgery Works!
The Miami Herald reported on July 11, 2002 the results of a study carried out by the Houston Veterans Affairs Medical Center researchers. Patients with severe pain in the knee caused by osteoarthritis were either given the real surgery or a placebo. In the placebo condition, “patients were given a sedative and only received small skin incisions.” Guess what? Amazingly enough, “All patients reported reduced pain and better knee function, but there was no difference in outcome between those who had real surgery and those who got the placebo procedure.”
The writer defines a placebo effect as “the improvement that people get from a treatment because they expect it to work.” Of particular interest is that in the above study, all patients were told ahead of time that they might receive the fake surgery. Those who weren’t interested opted out beforehand.
How and why can such things happen? Researchers postulate five ways that the placebo effect might work.
How The Placebo Effect Works
1. Spontaneous Remission
Gavin Andrews, a psychiatrist reporting in the 2001 issue of The British Journal of Psychiatry, in his article, “Placebo Response in Depression: Bane of Research, Boon to Therapy,” is astonished at the “unusually large” placebo response found regularly in antidepressant research. In teasing apart the many reasons for a powerful placebo response, he states, “Spontaneous remission accounts for a considerable amount of the improvement observed.” That is, people left alone with their depression will often get better by themselves anyway.
He cites two studies in which nothing was done but determine how long people’s depression lasted. These studies had an average between them of 50% spontaneous remission within 8 weeks. (In one, 75% recovered in 22 weeks and in the other, 75% recovered in 16 weeks. We are using their 8 week figure with the lower remission rate because, frequently, that is the length of time for research protocols.)
Read this interesting article online at http://bjp.rcpsych.org/cgi/content/full/178/3/192.
2. Attention
There are always those people who are not about to get better by themselves. In hundreds of outcome research studies for depression, the single most critical factor affecting results was the therapeutic alliance. This term refers to the relationship between the client, patient, or research subject and the therapist, doctor, or scientist. This is a critical component of “talk therapy” in that the relationship between the client and therapist plays a significant role in the therapeutic outcome.
In a 2000 meta-analysis of 79 research pieces on this topic by Martin, Garske, and Davis in the Journal of Consulting and Clinical Psychology, the authors conclude:
“If a proper alliance is established between a patient and therapist, the patient will experience the relationship as therapeutic, regardless of other psychological interventions.” What does this mean? Simply that the power of the relationship between professional and client in and of itself is therapeutic regardless of other methods used to treat that person. The link for this article is http://psycnet.apa.org/journals/ccp/68/3/438/
In the domain of pharmaceutical research, in 2006, Krupnick, Sotsky, Elkin, Simmens, Moyer, Watkins, and Pilkonis, writing, “The Role of the Therapeutic Alliance in Psychotherapy and Pharmacotherapy Outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program” in The American Psychiatric Association Journal, Focus, report, “Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy.” The link to this research is http://www.ncbi.nlm.nih.gov/pubmed/8698947
The implication here is that part of the outcome in any clinical trial is the interest, questioning, and careful listening of the researcher to the client/subject. So the very act of being paid attention will contribute to the placebo affect.
3. Expectations
Bruce E. Levine, clinical psychologist, and author of, Commonsense Rebellion: Taking Back Your Life from Drugs, Shrinks, Corporations, and a World Gone Crazy, writes:
“Research shows that one of the most important variables predicting the effectiveness of antidepressants is faith in the treatment. In a 2004 Journal of Clinical Psychiatry study on an experimental antidepressant, depressed patients who expected the antidepressant to be ‘very effective’ had approximately three times higher rate of positive responses than those patients expecting it to be only ‘somewhat effective.’” See his thorough analysis of the STAR*D research and pharmaceutical relationships with government at http://www.dissidentvoice.org/July06/Levine01.htm.
In his 2006 article, “Are Patient Expectations Still Relevant for Psychotherapy Process and Outcome?” in The Clinical Psychology Review, Roger P. Greenberg concludes, “Discussion of results affirms the continuing relevance of patient expectations [and] suggests that they may be even more vital to the psychotherapy process than is often acknowledged.” You can find the abstract here: http://www.sciencedirect.com/science/article/pii/S0272735805000255
4. Family Role
In his 1995 article, “Role of the Family in Recovery and Major Depression,” published in the American Journal of Psychiatry, Keitner, Ryan, Miller, Kohn, Bishop and Epstein’s opening line is: “Major depression is significantly influenced by the family environment of the depressed patient.” Their article concludes that the healthy functioning of that family environment will have a large, long-term effect on the recovery process of the patient. It follows that if the family is supportive and voluntarily decreases stress within its confines, the same positive advantage of the therapeutic alliance should apply to family relationships.
5. Side Effects
Roger P. Greenberg (cited above) and Seymour Fisher are psychologist/researchers at the State University of New York in Syracuse in the Departments of Psychiatry and Behavioral Sciences. In 1989, Greenberg and Fisher edited a book, The Limits of Biological Treatments for Psychological Distress: Comparisons with Psychotherapy and Placebo, and co-authored an article in it, “Examining antidepressant effectiveness: Findings, ambiguities, and some vexing puzzles.” In 1992, Greenberg and other colleagues published, “A meta-analysis of antidepressant outcome under blinder conditions” published in the Journal of Consulting and Clinical Psychology. In 1997, Greenberg and Fisher published their landmark book, From Placebo to Panacea: Putting Psychiatric Drugs to the Test, and included an article of their own, “Mood-mending medicines: Probing drug, psychotherapy and placebo solutions.” This link, http://www.ncbi.nlm.nih.gov/pubmed?cmd=PureSearch&term=Greenberg%20RP[Author], will take you to a PubMed page listing over 80 research articles on this topic by these authors.
What these pieces of research show is the role of side effects in creating the placebo effect. When people in a presumably “blind” study notice a side effect (such as dizziness, nausea, sexual performance problems, and so on), they immediately believe they are taking the antidepressant and not the sugar pill. As Duncan, Miller, and Sparks explain, in reviewing the Greenberg, et al. work, as soon as people feel the side effects, “they and their clinicians often correctly guess who got the real drug; their hopes and expectations then rise and they are more likely to notice positive life changes and ascribe them to the drug. This mechanism holds true even when depressed subjects are treated with drugs that are not antidepressants but have strong side effects: those subjects tend to show as much improvements as research subjects who are given antidepressants.”
Recently, a Navajo man was able to withdraw from the Marines because he discovered that he has “gifts” as a medicine man which conflict with killing. He considers himself a healer, and the title he now bears since his spiritual experience—“hand trembler”—is “deeply revered by the tribe.” I expect he does actually heal people. Such is the power of the mind.