Placebo, Ritual & Imagination

Placebo, Ritual & Imagination

‘I don’t love science – I want to know what heals people’ – Ted Kaptchuk, Professor of Global Health and Social Medicine at Harvard and Director of the Harvard-wide programme in Placebo Studies and the Therapeutic Encounter

The purely rational forms the fundamental basis of our society in the West. But there is an often forgotten or ignored border, where this observable logic meets the ever more mystifying realms of philosophy and spirituality on a daily basis. In stripping away a lot of the ancient ritual and ceremony in life through progress, it has become easy to forget that everything is so much more than just the sum of its parts.

Most of us have heard of the KISS principle – ‘Keep It Simple Stupid’, a modern adaptation of Occam’s Razor (where the simplest solution is usually the correct one). This reduction and simplification of complex issues allows us to move on from paralysis by analysis, often by boxing the things into neatly packaged underlying assumptions. Difficulties arise when there are viable challenges to our existing paradigm or core beliefs, as we can often be reluctant to work back from first principles.

A new scientific truth is not usually presented in a way to convince its opponents. Rather, they die off, and a new generation is familiarised with the ‘truth’ from the start. – Max Planck, originator of Quantum Theory

Between two opposing and extreme sides, it’s usually somewhere in the middle of all the discourse that solutions are to be found. A good example of this is the grey area between our alternative and conventional approaches to health. It’s one thing to be clinically cured and another to be holistically healed, both Eastern and Western approaches would benefit in finding more ways to operate in synergy, instead of being driven apart and made to seem entirely at odds.

Whilst the expansive views of philosophy and spirituality observe the bigger picture and emergent properties of things, science works from a more reductionist approach. There are many authors that write about marrying these often conflicted sides, one of my favourites being Oxbridge PhD scientist and researcher Rupert Sheldrake, in his books ‘science and spiritual practices’ and ‘the science delusion’.

When science observes a phenomenon, it assumes that it is its true nature; the perceptual is the actual. However, in the modern fields of relativistic and quantum physics, observation affects the process being observed, with a different outcome than if the process were unobserved.

In certain philosophies, that which is being studied is a reflection of the observer and the two are intrinsically linked. “As above, so below”: the universe is a symbolic reflection of what is happening inside of ourselves. The quest for knowledge becomes a spiritual journey to return to a state of unity.

If that all sounds a little too woo-woo for an opening, stay with me while we explore an interesting mind-body phenomenon which perfectly demonstrates the bond between the internal and environmental, as well as the lost art of ritual and ceremony within modern medicine – the scientifically-backed concept known as the Placebo effect. Abundant evidence shows that if you give people a simple sugar pill, despite the contents of the ‘fake’ tablet having no direct pharmacological effect, many participants will get better. This is especially true for patients with chronic, stress-related conditions and works even better if the ‘medicine’ is administered by someone in whom they have a lot of confidence and trust.

It gets even crazier than that. After a quarter of a century of hard work, today’s leading lights of placebo science have recently demonstrated that if you tell someone their normal milkshake is a diet beverage, their gut may respond as if the drink were low fat. Take athletes to the top of the Alps, put them on exercise machines and hook them up to an oxygen tank and they will mostly perform better than when they are breathing room air – even if room air is all that’s in the oxygen tank. The practice has gone as far as to give people sham operations, where the participant is knocked out and a few harmless incisions are made – completely clearing up their symptoms.

This every day miracle is just that. It’s effects are everywhere, all the time – from the placebo controlled comparisons of a gold standard clinical trial, to the flashy packaging and colours on a pack of Nurofen that serve to hoick up the efficacy (and the price) next to a basic own-brand. And yet in recent discussion, such a phenomenon has always been referred to as ‘just’ the placebo effect.

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At its inception, there was an element of deception involved that gave the Placebo effect a slightly nasty after-taste. A gold standard trial has always been ‘double-blind’, meaning that neither the participant nor the administrator would know whether the medicine was ‘real’ or ‘sham’. However it’s come to light that even the element of deception need not be a feature. Studies have shown that you can give a patient with a chronic condition a sugar pill, identify it as such, tell them that sugar pills are known to be effective when used as placebos, and some will get better. The effectiveness of this, has been shown to be further improved by taking the time to deliver the message with warmth, connection and close attention. In other words, an authentically human and caring touch.

In spite of the copious amount of evidence, the Placebo effect has a serious image problem. In the words of psychiatrist Gary Greenberg:

it has a reputation as ‘fake medicine’, doled out by the unscrupulous to the credulous. It also has, so far, resisted a full understanding, its mechanisms shrouded in mystery.

A serious problem if this is ever to become a mainstream armament that can be credibly deployed. Furthermore, what would Big Pharma and its love of life-long prescriptions peddle out for the chronically-ailed now?

Current theories as to how Placebo works are mostly based along the lines of a Pavlov’s Dog effect. Ivan Pavlov is notable for conducting an experiment in which he trained dogs to associate the ringing of a bell, with the delivery of food. Eventually, their bodies became conditioned to react to the expectancy of food just by ringing the bell. No food was delivered but they would involuntarily salivate and physically prepare themselves for a meal at the trigger sound. These theories suggest that the mind acts upon the body to bring about a physical response. The difficulty in bringing such psychological theories into the mainstream has currently been the lack of molecular measurability. There are no molecules for conditioning or expectancy, that we know of, in the realms of complex conscious and unconscious processes.

Ted Kaptchuck is one of the individuals that might be about to change this. He is the head of the Harvard Medical School Programme for Placebo Studies and the Therapeutic Encounter. Using Functional Magnetic Imaging (FMRI), Ted and his team may be beginning to scratch the surface when it comes to the kinds of biochemical reactions that may be occurring. In other words, some of the molecules are emerging, molecules that may reveal fundamental flaws in the way we have come to understand the body’s healing processes.

COMT is one of these molecules. It’s an enzyme known to affect people’s responses to pain and pain killers. Levels of this enzyme are already known to be correlated with Parkinson’s, Depression and Schizophrenia: all conditions that respond well to Placebo. It is not possible to assay levels of COMT directly in a living brain, but there is a snippet of the genome (rs4680) that is responsible for the production of the enzyme, which allows us to measure COMT levels indirectly. This rs4680 gene varies from one person to another, one variant predicts low COMT levels (which is correlated with higher levels of dopamine) and the other, high levels of COMT (comparatively lower levels of dopamine). It was found that those with the high-COMT variant (lower dopamine group) generally had the weakest placebo responses, whereas those with a low-COMT variant, generally responded most strongly. The latter group were also most sensitive to the impact of the relationship with the healer.

This isn’t to say that those with a high-COMT variant are not receptive to placebo effect at all. In a 2013 study conducted by Hall looking at Women’s Cardiovascular Health, the high-COMT variant category showed the lowest rates of disease in women taking placebo, compared to women taking either daily vitamin E, aspirin or vitamin E with aspirin. This shows that placebo and drug are not separate, psychological and physical processes, rather they are part of a highly complex interaction between mind, genetics, environment and the types of drugs being used.

As an interesting aside, I was listening to a podcast featuring Dr Rhonda Patrick (phD in Biochemical science and expert on nutritional health) the other day and she recommends that healthy individuals take 6 fish oil capsules a day (as she does), to effectively increase dopamine in the prefrontal cortex – especially beneficial to memory and mood.

The genetic correlation to the placebo response has sparked some scientists to embark on a mission to discover what they term, the ‘placebome’. A biochemical ensemble that could one day take its place among the genome and the microbiome. COMT produces catecholamines (neuro-chemicals including dopamine and epinephrine), which are associated with reward, illness, health and stress – most especially the chronic stress conditions that respond well to placebo.

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It has become standard practice to measure the efficacy of a drug by isolating the imagination. In order to gain FDA recognition, a new drug has to outperform placebo in at least 2 trials. The paradox therefore, is that the placebo effect is treated as an important part of every treatment, but is not given the same respect as a stand alone option or even extensively used in synergy with medication to improve current practices. Despite affecting such a large majority of the population and offering comparatively few side effects physically, mentally and financially, it has come to be viewed as a mere outlier and been included by the regulatory industry, only as a means of ruling it out.

The pharmaceutical industry is finding that it is becoming increasingly difficult to surmount the placebo effect, which seems to get stronger as time goes on. The result is that 90% of pain medications now fail at this stage of the trial. It could be that if medications are allowed to be marketed direct to consumers, as they are, they can become conditioned to expect greater effects; Or in studies performed by contract organisations where it is the nurses’ only job to perform placebo trials, perhaps there is a stronger triggering-interaction. Either way, these are all factors that should be investigated in themselves and integrated into a more holistic approach to remedy and recovery.

‘Science is designed to get rid of the husks and find the kernels.’

What’s most interesting, is that in studies conducted by Kaptchuk, the positive results of placebo were strongest in patients that received the most warmth and care. The encounter itself, provoked a biological response and the more intense and focused, the more healing it evoked. This demonstrates the effectiveness of connection and environmental ritual, when combined with alchemy in mental and physical health.

The ritual itself is part of what makes the procedure effective, as if the combined experiences of the healer and the patient, reinforced by the special-but-familiar surroundings, evoke a healing response that operates independently of the treatments specifics. Rituals trigger specific neurobiological pathways that specifically modulate bodily sensations, symptoms and emotions. It seems that if the mind can be persuaded, the body can sometimes act accordingly.

According to Kaptchuk, it would be a mistake to reduce the placebo response to its molecules. While Hall’s research serves to demonstrate its credibility, he states that ‘once you start measuring the placebo effect in a quantitative way, you’re transforming it to be something other than what it is’, sparking his fears that it would become ‘yet another thing on the conveyor belt of routinised care’. His wish is to ‘help re-configure biomedicine by rejecting the idea that healing is only the application of mechanical tools’, when ‘caring in the context of hope qualitatively changes clinical outcomes’. This calls into question a lot of the morals and ethics around the duty to deliver an uncertain prognosis as a clinical practitioner. As well as questions around whether a practitioner’s bed side manner should be tailored to a patients genes.

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In his own words, Kaptchuk says that he worries that progress has the capacity to ‘destroy the stuff that has to do with wisdom, preciousness, imagination, the things that are actually critical to who we are as human beings’… but that he ‘has to believe that there is an infinite reserve of wisdom and imagination, that will resist being reduced to simple materialistic explanations.’

In a feature article for the NY Times, Gary Greenberg closes by stating that ‘there’s nothing like being sick to make a person toss that kind of intelligence aside in favour of the certainties offered by modern medicine.’ And that ‘armed with our confidence in them, we’re pleased to give ourselves over to their ministrations’. This is exactly what makes the issue so morally pressing. In a sense, the feeling of loss of full function, or betrayal by a component of one’s own mind or body and the emotional confusion and distress that often accompanies that, leads people to place their broken trust in third parties who they believe to have their best interests at heart. But in the long term, during recovery, it often also has the chance to awaken a profound sense of philosophical enquiry, purpose, desire to better listen to and trust oneself and magnify a sense of wonder and gratitude for the present.

People have given their health to their doctor, their money to their banker, their soul to the preacher, their children to the education system and in doing so, have lost control over their own lives.

Such changes in perspective and approach can briefly be glimpsed in some of the differences between conventional Psychoanalysis and Logotherapy, of which here are 10 respectively, extracted from the book ‘Ikigai: the Japanese Secret to a Long and Healthy Life’:

  1. The person reclines on a couch like a patient  →  The person sits facing the therapist, who guides him or her without passing judgement
  2. Is retrospective: it looks to the past  →  Looks toward the future
  3. Is introspective, analysis neuroses  →  Does not delve into the person’s neuroses
  4. The drive is toward pleasure  →  The drive is toward purpose and meaning
  5. Centres on Psychology  →  Includes a spiritual dimension
  6. Works on Psychogenic neuroses  →  Also works on noogenic, or existential, neuroses
  7. Analysis the unconscious origin of conflicts (instinctual dimension)  →  Deals with conflicts when and where they arise (spiritual dimension)
  8. Limits itself to the persons instinct  →  Also deals with spiritual realities
  9. Is fundamentally incompatible with faith  →  Is compatible with faith
  10. Seeks to reconcile conflicts and satisfy impulses and instincts  →  Seeks to help the person find meaning in his life and satisfy his moral principles.

I think that in recent times, language such as ‘spirituality’ and ‘faith’ have come to mean often distasteful, either new age-y or archaic ideologies to a modern, secular society. It does well to remember that such broad concepts are not about blindly subscribing to a trend, movement or stereotype, even if such movements often do come into vogue in waves and build prominent identities and communities. It’s about finding a way to re-introduce that element of mystery, imagination, wonder, ritual and ceremony back into life. It’s about finding what suits you as a unique individual in your approach to a healthily, holistic lifestyle – finding that grey area that resonates, because very little in life is often just black and white.

Do not shun any healing possibility simply out of an ignorant following of current popular opinion. Nor is it wise to follow any ‘magic cure’ out of faith, wishful thinking or new age glamour. Educate yourself. Learn how your body works – Josephine Mccarthy

making life a ceremony

This article was inspired by the work of Gary Greenberg, author of ‘The Book of Woe: The DSM and the unmasking of psychiatry’ and his feature for the NY Times. As well as work by the Society for Interdisciplinary Placebo Studies.

 

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