SUGGESTION AND THE PLACEBO EFFECT —
WHY DO ALTERNATIVE THERAPIES WORK?

"To array a man's will against his sickness is the supreme art of medicine."
Henry Ward Beecher, preacher and writer (1813-1887)

(Investigator 144, 2012 May)



There are two principal reasons as to why people recover from illness, these are (a) the natural self-healing capacity of the human body and (b) the fact that many illnesses serve an emotional need, and, for various reasons, once the period of "ill-health" has served its purpose, the individuals recover.

As Gardner (1957) indicated these two processes enable many quacks to undeservedly claim a great deal of credit for the recovery of their patients. There is another influence on recovery from illness which can explain why it is that alternative therapies have little or no valid basis and their quack remedies which generally lack any curative properties, sometimes appear to be effective in producing a cure.

What is often not appreciated is that in most of these instances it is not necessarily the alternative treatments that produce the cure, but rather the individual's belief, their expectation that the treatment will be effective, which triggers a powerful and complex natural healing process known as the Placebo Effect! So, what is this process, and, in particular, how does it operate?

The actual psychological and physiological functions involved in producing illness and in the subsequent recovery are exceedingly complex and while still not fully understood, it is known that psychological aspects play a major role in both areas. This is evident from the existence of psychosomatic disorders, (from psycho = the mind + soma = the body), which are forms of physical illnesses that are produced principally by various mental or emotional factors.

One of the most common psychosomatic disorders is asthma. As Graham, Rutter, Yule and Pless (1967) indicated, especially in children, this is frequently precipitated by incidents of emotional stress which produces a general physical response that includes tightening of the muscles. When the muscles of the diaphragm constrict it impedes the movement of the lungs, making breathing difficult.

The production of negative psychosomatic effects, ones that produce detrimental responses, are known as "Nocebos"; e.g. Schweiger and Parducci (1981) produced headaches in subjects who believed an imaginary electrical current was being passed through their heads. In the same manner that psychosomatic processes can create an imagined illness, the "placebo" effect operates in the opposite manner, psychosomatically alleviating and even curing illness.

The term placebo, from the Latin meaning "I shall please" went through several different phases of meaning until, in 1811 a medical dictionary defined it as, "…an epithet given to any medicine adapted more to please than benefit the patient." (Moerman, 2002, p. 11) In modern usage the term generally refers to a sham medicine that when given to a patient is accompanied with a definite, or inferred, suggestion that it can assist in the healing process.

Particularly significant is that this placebo response can be triggered by a variety of techniques, even by outright trickery, since the important aspect is to use the placebo as an activating agent, something designed to trigger the placebo response.

It appears that, for the placebo to be effective, it is necessary to create a belief and an expectation that the placebo will assist in the recovery and cure. As Weese, Wood and Korol (1998) indicated, the effectiveness of the placebo effect relies to a considerable extent upon the patients' faith in the therapist and the efficacy of the treatment or medication.

It appears that the combination of these two factors, in some, as yet not fully understood manner, activates a complex psychophysiological process that as Fuente-Fernandez, Lidstone, and Stoessl (2006) noted, also includes a general feeling of well-being that contributes to the overall healing process.

The concept that out beliefs can influence our physical health is not new; medicine-men, witch-doctors, shamans, priests and physicians have been using variations of this technique for thousands of years. While, especially in the past, they may have been ignorant as to the causes of disease, they were clever enough to know that their intervention would not only give the patient hope, but when, in the course of time the patient recovered, they would receive the credit for the cure.

The activating or placebo agents they used varied considerably. For the medicine-man and the witch-doctor, it was their brightly coloured feather headdress or terrifying mask and their assortment of arcane accoutrements, for the ancient priests it was their knowledge and access to the healing deities, for the physicians it was their knowledge of the healing arts.

Whatever the facade these various practitioners adopted, the ordinary people viewed them as an expert elite, people of power who possessed an arcane knowledge of the healing arts and even today these attributes continue to be important attributes for both the physician and the alternative therapist.

Thousands of years ago the priest-practitioners of the Egyptian and Greek sleep temples appear to have been aware of the importance of the mental attitudes in the treatment of the sick. They would bring the patients into a peaceful temple environment where they were encouraged to rest, meditate and to concentrate on their recovery.

To encourage rest, relaxation and sleep, they were given herbal soporifics, often without their knowledge, and the priests were not beyond using subterfuge to influence the level of patients' belief that they would be healed.

As the patients lay in a drug induced stupor, young novices would crawl into a space in the roof above the patient's room and, speaking through a small opening, would claim they were the god Asclepius come to heal them. In their soporific condition the patients were especially amenable to these suggestions. Far from being primitive healing, such ancient healing techniques are now recognized as containing powerful psychological and hypnotic processes capable of influencing psychosomatic healing.

Four attributes of these ancient practices, (1) the use of a quiet environment, (2) the use of a "mental device" repeating a word or phrase, (3) being passive and focusing on the healing, and (4) being comfortable, have been identified by Benson (1975) as four psychophysiologic elements that are part of the general relaxation response.

There has been a growing tendency since the 20th century to examine the psychosomatic, "mind — body" relationship, and to consider psychological influences on both the placebo and nocebo effects. It became apparent that the stress response was a major contributor to physiological disease.

McLester (1927) found that of 1,600 patients with digestive problems 32.6% showed no evidence of any actual physical disorder, suggesting it was psychosomatic. Jacobson (1929) observed that in many patients whose disorders appeared to be stress related that when the stress was removed, or even reduced, by the use of simple relaxation exercises many of their physiological disorders disappeared, without recourse to medication.

Selye (1950, 1964, and 1977) and others noted that the immune system tended to operate at a decreased level of efficiently when individuals were under stress; they experienced clusters of stress-related disorders such as high blood pressure, cardiovascular diseases, ulcers, headaches, aches, pains and nausea. Selye's explanation for these phenomena was that, during periods of stress, corticoids were released into the bloodstream interfering with the efficiency of the immune system leaving the individual more vulnerable to infection, and even such complaints as cancer. Thus any actions that could reduce the stress, whether physical or mental, or even a placebo, could contribute to increasing the efficacy of the immune system.

Hall et al (1992a; 1992b) were the first to demonstrate that deliberate psychological intervention could actually produce a measurable effect on the human immune system. Using cyberphysiologic techniques, they had patients imagine their white blood cells were becoming increasingly sticky, and, despite the simplicity of this process, it was found to increase the potency of their auto-immune system.

Olness (1989, 1999) found that when children suffering from migraine headaches used Cyberphysiology, self-hypnosis or relaxation, there was an 81% reduction in tryptase levels. When reduced, this substance, which is associated with mast cell activity, and an important factor in producing inflammatory disorders, including asthma and migraines, (Theoharides, Donelan, Kandere-Grzybowska, and Konstantinidou, 2005), resulted in a corresponding reduction in their migraines. Conversely, amongst those children unable to learn any of these techniques there were no reduction in tryptase, and no subsequent reduction in migraine headaches.

Olness et al (1999) concluded that the use of such self-regulation techniques was much more effective in preventing and controlling childhood migraine than was conventional medication and it did so without the negative side effects of drugs. Such research is of assistance in explaining why such techniques as visualization, hypnosis and biofeedback techniques can help to produce the placebo effect, which can assist the healing process.

It appears that if a patient accepts as factual a verbal suggestion that a particular form of medicine or treatment will be effective, a belief is formed in the right frontal cortex. This area has direct connections to the limbic system, an area that integrates emotions, and which can stimulate neural activity in the hypothalamus, a small organ that links the nervous system, via the pituitary gland, to the endocrine system. This system is responsible for triggering the stress response, and it seems that when an individual believes that healing will occur, there is a reduction in the level of corticoids, and a subsequent improvement in the operation of the auto-immune system.

Fuente-Fernandez, Lidstone, and Stoessl (2006) also noted that this general response also influences the release of endogenous dopamine, a hormonal neurotransmitter, which contributes to the general placebo effect by interacting with the "pleasure centre" of the brain, in particular the nucleus accumbens and the ventral tegmental area, creating a sense of well-being and increasing positive feelings of motivation.

Furthermore, as Arias-Carrion and Poppel (2007) indicated there is evidence to suggest that when a subject anticipates a positive result from their particular form of treatment, (reward-anticipation), the production of dopamine is also increased, producing additional positive feelings.

When examining the placebo effect with alternative therapies it appears that the principal initiating factors are:-
a)    A powerful belief that the therapist has special healing abilities or knowledge;
b)    A belief in the effectiveness of the alternative form of treatment; or,
c)    A belief in the effectiveness of some orally administered "healing agent".

It seems these factors combine to produce the psychophysiological process described above, and that it is this reaction that is in part responsible for the placebo response.

Rossi (1993) suggested that there is a definite psychobiological basis to these forms of healing, and that suggestion plays an important role in the process. Kroger (1977) observed that suggestion is, "...the uncritical acceptance of an idea...the process by which sensory impressions are conveyed in a meaningful manner to evoke altered psychophysiologic responses." (p. 7).

Those who believe in the efficacy of alternative health processes have a pre-existing belief and a powerful expectation in the effectiveness of both the therapist and the treatment and suggestion plays a role by reinforcing this already existing belief system.

Whatever the form of treatment, whether it is Homeopathy or Bach Flowers, where the product is nothing more than water, or a "bioenergetic" healing technique, such as Rei-ki and Therapeutic Touch, all of these rely heavily upon the power of suggestion.

Numerous examples of the role of suggestion in the treatment of the sick can be found in the many gimmicks, gadgets and snake-oil concoctions that were once so common amongst quack practitioners. One famous example was the Perkins metallic tractors, claimed to remove excessive amounts of animal magnetism from the body.

However, after British doctor, John Haygarth proved that a set of tractors made from wood and painted to look like the metal ones were just as effective it was soon realized that the tractors were doing nothing more than activating the imagination of suggestive patients.

Phineas Quimby, one of the most famous and most successful 19th century mesmeric healers discovered how powerful the role of suggestion in healing was. He had an assistant, Lucius Burkmar, whom he would mesmerize believing this would give Lucius clairvoyant and mediumship powers. In his trance Lucius would "diagnose" the illnesses of those who had come for treatment, and would recommend some common medicine as a cure.

Quimby would write down the medicine and the patients would take his note to the local apothecary who would prepare the medicine. However, on one occasion Lucius recommended a medicine for a woman that Quimby knew was far too expensive for her to afford, so he wrote down the name of a much cheaper drug. Later, the woman returned to thank him telling him how well the recommended drug had been in producing a complete recovery. Quimby was puzzled by this, but as he thought about it, he slowly began to realize the truth. What was curing these patients had nothing whatsoever to do with the mesmeric trances, the clairvoyance, the pills or the potions "... but simply in the invalid's faith that these pills and potions could cure." (Zweig, 1932, p. 122)

It was at that point that Quimby realized that was a very real and very powerful principle underlying mesmerism. He realized it was the power of suggestion, and nothing else that had cured so many of his patients. Everything else, the trances, the claimed clairvoyant abilities of Lucius to diagnose the illnesses and all the other elaborate aspects of his treatments was simply a facade that gave the process an air of authority and mysticism. It was at this point that Quimby dropped Lucius and began using a more direct approach, what he called the "mind cure" — what he began to refer to as, "direct suggestion".

On this basis it perhaps becomes easier to appreciate why alternative therapies can be so effective in treating many mild forms of illness. The patient's belief, reinforced by a litany of suggestions from the therapist and with an established belief in the efficacy of the treatment virtually preconditions them to trigger the placebo response. It is perhaps rather significant that, when dealing with more severe illness, especially terminal diseases, where the belief is rarely strong enough to activate a sufficiently powerful placebo effect, alternative therapies perform poorly.


REFERENCES:

Arias-Carrion, O. And Poppel, E. (2007) Dopamine, learning, and reward-seeking behavior. Acta Neurobiologiae Experimentalis, 67(4), 481-488
Benson, H. (1975) The Relaxation Response. New York: William Morrow.
Fuente-Fernandez, R. de la and Stoessl, A. J. (2002) The placebo effect in Parkinson's disease. Trends in Neurosciences, 25:6, 302-306
Fuente-Fernandez, R. de la, Lidstone, S. and Stoessl, A. J. (2006) Placebo effect and dopamine release. Neural Transmission Supplement, 70, 415-418
Gardner, M. (1957) Fads and Fallacies in the Name of Science. New York: Dover Publications, Inc.
Graham, P. J., Rutter, M. L., Yule, W, and Pless, I. B. (1967) Childhood asthma: a psychosomatic disorder? Some epidemiological considerations. British Journal of Preventative and Social Medicine, 21 :2, 78-85
Hall H. R., Minnes L., Tosi M., Olness K. (1992a) Voluntary modulation of neutrophil adhesiveness using a cyberphysiologic strategy. International Journal of Neuroscience; 63: 287-297
Hall H. R., Mumma G. H., Longo S, Dixon R. (1992b) Voluntary immunomodulation: A preliminary study. International Journal of Neuroscience; 63: 275-285
Jacobson, E. (1929) Progressive Relaxation. Chicago: University of Chicago Press
Kroger, W. S. (1977) Clinical and Experimental Hypnosis in Medicine, Dentistry, and Psychology.  Philadelphia: J. B. Lippincott Company
Mc Lester, J. S., (1927) Psychic and Emotional Factors in their Relation to Disorders of the Digestive Tract. Journal of the American Medical Association, LXXXIX, 1019
Melechi, A. (2005) Dance macabre. Fortean Times, 203: 30-34
Moerman, D. E. (2002) Meaning, Medicine and the 'Placebo Effect'. Cambridge: Cambridge University Press
Olness K, (1989) Hypnotherapy: a cyberphysiologic strategy in pain management. Pediatric Clinician North America, 36: 4, 873-874
Olness, K., Hall, H., Jacek J., Rozniecki, J. J, Schmidt, W. and Theoharides, T. C. (1999) Mast Cell Activation in Children With Migraine Before and After Training in Self-regulation. Headache: The Journal of Head and Face Pain. 39:2, 101-107
Rossi, E. L. (1993) The Psychobiology of Mind/Body Healing: New Concepts of Therapeutic Hypnosis. New York, NY: W.W. Norton
Schweiger, A. and Parducci, A. (1981) Nocebo: the psychologic induction of pain. Pavlovian Journal of Biological Science, 16(3), 140-143
Selye, H. (1950) Stress. Montreal: Acta Inc
Selye, H. (1964) A new system: Dr. Hans Selye's theory of stress and adaptation. In R. Friedrich (editor), Frontiers of Medicine. New York, NY: Collier Books, Inc
Selye, H. (1977) Stress Without Distress. London: Hodder and Stoughton Theoharides T. C., Donelan, J., Kandere-Grzybowska, K. and Konstantinidou, A. (2005). The role of mast cells in migraine pathophysiology. Brain Research Reviews, 49 (1) 65-76
Weese, K., Wood, J. and Korol, C. (1998) Psychoneuroimmunology: The Placebo Effect. Paper submitted in partial fulfillment of the OAC Biology curriculum at Ursuline College, Chatham
 www.wincom.net/kweese/body.htm
Zweig, S. (1932) Mental Healers Mesmer, Eddy, Freud. New York: Garden City Publishing Co. Inc.



From: Eddie, L. 2008 A Skeptical Look At Alternative Therapies and Beliefs


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