In a technology-based culture, you learn from infancy that truth is what can be counted and measured. That makes it easy to divide any conversation into what you learned (important!) and how you learned it (immaterial). What your medical tests reveal is vital; how your doctor tells you, her “bedside manner,” is a sideshow; a different, lesser kind of information. Obvious as it seems, this division may be a myth. Case in point: This paper, published last month in PLoS One, reports that sugar pills worked quite effectively on Irritable Bowel Syndrome patients who knew there was no active medication in their placebo “drug.” Meanwhile, the control group for the study received no pills of any kind. They just got the same attention and “warm-patient provider relationship” as did the placebo-takers, write Ted J. Kaptchuk and his co-authors. Yet those people also improved.
The explanation, I bet, lies in the how aspect of daily life—the kind of information we tend to devalue as “noise” and “subjective impressions.” In a conversation, it consists of the facts we exchange that aren’t about quantities and logic; facts about the conversation itself, and our place in it. For instance, the paper quotes one of the study patients, who wrote: “I liked the one-on-one attention with the MD, able to ask questions about IBS with a person trained in the illness; this MD is very kind.” These perceptions aren’t physical facts about pharmaceuticals or symptoms; they’re social-psychological facts created by (among other things) moods, memories, class status, and the way the patient and caretaker see each other.
The anthropologist Dan Moerman noted the importance of these kinds of facts in Steve Silberman’s fascinating post about placebos in general and the PLoS paper in particular. Moerman doesn’t think the no-pills cohort should be called a “no-treatment” group. He told Silberman: “They, and everyone else, received exemplary treatment here: they were listened to, examined, encouraged, supported. They were able to talk with, and be taken seriously by, people who understood their issues, things they probably had serious difficulty discussing with their own families.” One of the study’s authors, Irving Kirsch, told Silberman much the same thing. “We assume,” he said, “that the therapeutic relationship is an important component of the placebo effect.”
While all 80 patients in the study benefitted from kindly care, though, the placebo-takers did better. (In fact, their improvement measures were in line with those of people given standard drug therapies for IBS.) So what did placebos add to the benefits of positive relationships with caregivers?
Well, the placebo cohort wasn’t just instructed to take their pills and good luck. Instead, they were told they would be getting “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.” Moreover, these patients were told to follow a regimen of pill-taking twice a day, because it was important to train themselves to believe in the pills. Another of the researchers’ assumptions, Kirsch said to Silberman, is that “you have to offer the patients a convincing rationale to use placebos.”
So the placebos worked for the patients because they had faith that placebos would work. But that faith was instilled by the “very kind” MD’s and nurses who explained it to the patients. If their relations hadn’t been so positive—if the physicians had made patients feel stupid, rushed, confused, unworthy—how could they have felt the necessary trust and confidence? The study indicates that placebos work better than “mere” humane care, but it suggests, to me at least, that humane care is still the root of their success. While all patients experienced a direct benefit from the study doctors’ good bedside manner, the placebo-takers also received an indirect benefit: Because they trusted the doctors, they were receptive to those doctors’ message that the placebos would help them.
Faith and trust are both fragile fruits, as Silberman points out. If placebos depend on people’s confidence that they’ll work, he asks, then would their effectiveness go up and down with every new Internet rumor? Would they work better if the patients were in a good mood? Or when it was sunny out?
That maddening variability is one of the things that makes the rationalist hierarchy of information so attractive. If only health could be reduced to white blood cells, milligrams of medicine, body temperatures and other physical quantities that don’t change whenever a new person walks into the room! A technocratic society privileges that information, but it seems that the human mind does not.
Still, there’s a lot of testing and diagnosing in our society, and all of it is premised on that rationalist hierarchy of information—the notion that this math test, blood assay, job interview or questionnaire will find some objective truth about the test-taker. A truth unaffected by “noise” like what she had for breakfast, what she was thinking about before beginning, her feelings about her place in society, or the weather outside.
I’ve seen many studies recently that cast doubt on that dogma (see, for example, here and here and here and here). They all suggest that the “noise” of emotional and social facts can’t be ignored in favor of the “objective facts” about aptitude, illness, job suitability, personality etc. that our instruments supposedly measure. Because, like it or not, all those instruments are affected by both the “hard” facts and the social ones.
If that’s so, then we can’t fix the trouble with those procedures just by saying, “yes, yes, it matters how we talk about the facts.” Instead, we’ll need new models, in which social and emotional facts are given their due. In such a model, your recovery from an illness would be seen as the consequence of your prescription and how you were made to feel while waiting for the doctor and how you’re made to feel at work. A theory that accounts for all that won’t just be a caboose to the old rational-mind theories. It will revolutionize daily life.
Kaptchuk, T., Friedlander, E., Kelley, J., Sanchez, M., Kokkotou, E., Singer, J., Kowalczykowski, M., Miller, F., Kirsch, I., & Lembo, A. (2010). Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome PLoS ONE, 5 (12) DOI: 10.1371/journal.pone.0015591