Placebo pillIn the world of medical research, placebo is almost always talked about in the negative, as the baseline against which all other treatments are tested. Randomized placebo-controlled clinical trials are often considered the gold standard of study design. According to Oxford Dictionaries Online, placebo is defined as “a medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.” When surveyed, 1 in 5 Canadian MDs admit to prescribing placebo, or using medications significantly below the active dose. (1) In an American survey of internists and rheumatologists, over 50% of those surveyed had recommended a placebo treatment to a patient in the year prior. (2)

It is commonly accepted that placebo works approximately 20-30% of the time for most conditions. Why then do we continue to define it as having no physiological effect? Perhaps we should stipulate that we are only now starting to understand the reasons why and how placebo is so effective. Instead of discounting its effects as only placebo, we might employ its healing power in the treatment of many illnesses. Placebo can help us to gain a greater understanding of ourselves, and teach us how to harness this power for healing.

Only recently has research into placebo been conducted in its own right, outside of drug trials. This field of research has revealed the role of our innate self-healing mechanism in relieving pain and inflammation, reducing GERD (gastro-oeosophageal reflux disease) symptoms, alleviating depression, as well as shifting neurotransmitter, hormone and immune regulator production. (3,4) Clearly, placebo works. But how?

ObecalpThe mechanism of the placebo response is more elusive. Some researchers attribute it to the subjective meaning attached to the placebo treatment, whether that is an inert pill, a sham acupuncture treatment, or even a fake surgery. Others argue that the relationship with the practitioner is the key to eliciting the placebo effect.(5) Likewise, many have suggested that the term placebo is inadequate to describe this process and have proposed amended terminology such as therapeutic meaning response or interpersonal healing.(6,7)

The use of placebo in clinical practice however raises certain challenges, in particular ethical issues. Obviously, it is grossly unethical to tell a patient they are taking a drug (or a supplement or an herb for that matter) when they are in fact taking placebo. But what if the patient were told they are taking a placebo?

Recently, a different kind of placebo study was conducted that compared open-label placebo to no treatment in people diagnosed with irritable bowel syndrome (IBS). Participants in the placebo group were informed they were taking inert sugar pills. They were also told placebo has been shown to promote significant mind-body self-healing processes. Based on a subjective symptom scale, the placebo group showed clinically significant improvement compared to those who received no treatment. In other words, placebo works better than no treatment, even when people know they’ve been given placebo.(8)

In spite of clinical research showing the benefits of using placebo in specific clinical contexts, doctors (naturopathic or otherwise) aren’t regularly recommending informed placebo as a form of treatment. By and large, placebo research has not impacted the everyday clinical practice of physicians. And yet, the potential should not be underestimated. Various strategies to maximize the effects resulting from the patient’s subjective meaning of an intervention and the positive aspects of therapeutic relationship provides benefit well beyond the commonly accepted science of health and medicine. Practising mindfulness, bearing witness to a patient’s story, employing ritual, and imbuing objects and/or therapies with positive meaning are all examples of how to use the placebo response to create a space for healing.

In the naturopathic context, placebo can be understood as the work of the vis medicatrix naturae, where the physician is the facilitator between the patient’s current state of health and their broader self-healing capacity. Research into placebo demonstrates the incredible healing power of the bodyself as a whole, the importance of the doctor-patient relationship, and the role of belief and meaning in the context of health. It invites us to revive the art of medicine as it was practised in centuries past, but with a postmodern attention to hierarchy and power, informed consent, and patient empowerment in the service of self-healing.

References
(1) Raz A et al. Placebos in clinical practice: Comparing attitudes, beliefs, and patterns of use between academic psychiatrists and non-psychiatrists. Can J Psychiatry. 2011;56(4):198-208.
(2) Tilburt J et al. Prescribing “placebo treatments”: results of a national survey of US internists and rheumatologists. BMJ. 2008;337:a1938.
(3) Cremonini F et al. Meta-analysis: the effects of placebo treatment on gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2010 Jul;32(1):29-42.
(4) Miller FG, Colloca L, Kaptchuk TJ. The placebo effect: illness and interpersonal healing. Perspect Biol Med. 2009 Autumn;52(4):518.
(5) Kaptchuk TJ et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008 May 3;336(7651):999-1003.
(6) Walach H, Jonas WB. Placebo research: the evidence base for harnessing self-healing capacities. J Altern Complement Med. 2004;10 Suppl 1:S103-12.
(7) Leder D, Krucoff MW. Toward a more materialistic medicine: The value of authentic materialism within current and future medical practice. J Altern Complement Med. 2011;17(9):859-865.
(8) Kaptchuk TJ et al. Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS ONE PLoS One. 2010 Dec 22;5(12):e15591.