Wednesday, October 14, 2015

Placebo Cures in Psychotherapy

You may know it-- then again, you may not-- but I have a special interest in placebo cures. Not the kind  produced by sugar pills, but the kind that are elicited by different kinds of psychotherapy.

Surely, placebos do work, on occasion and under the right condition. If placebos work anywhere, they should be easily discernible in various attempts to therapy the human psyche. After all, where better to find testimony to the power of belief. Those who take placebos believe so strongly that the substance is a therapeutic agent that they feel that they are geting better, even if they are ingesting a sugar pill.

When I was writing my book The Last Psychoanalyst I wanted to address the fact that some people, a diminishing number, insist that Freudian treatment did them a world of good. The numbers were not high enough and the benefit not sustained enough to continue to make psychoanalysis a viable profession, but the sugar pills of Freudian interpretation did appear to help some of the people some of the time. I concluded that psychoanalysis worked for some people because they, and the surrounding culture, believed that it worked.

It is worth noting that, from Freud on down, psychoanalytic treatment forces people to believe, fully and unreservedly, in the truth of their analysts’ interpretations and, by extension, in Freud’s theories. When Freud bemoaned the ineffectiveness of the treatment, he attributed it to his patients’ failure to believe completely in the truth that he had discovered.

In my book I did not consider in detail the problems that arise when the placebo effect wears off, but I would again cite the great work on this topic by Helen Block Lewis in her book: Shame and Guilt in Neurosis. The least we can say, recalling the cases that Lewis recounts, is that when the placebo effect diminishes former psychoanalytic patients find themselves in big trouble.

Be all of that as it may, medical science has recently discovered an astonishing cultural phenomenon. By and large Americans are more susceptible to placebo cures than are people in Europe and Asia. We might be falling behind the world in most measures of achievement, but we are leading the world in gullibility. Americans are the world’s biggest dupes.

Specifically, scientists studied what happened when people who were in pain took painkillers or sugar pills. They discovered that, when it comes to pain reduction, sugar pills were more effective with Americans than they were with people in other parts of the world. In the good old USA placebos were almost as effective as other forms of painkillers.

Melissa Dahl reports the findings in New York Magazine:

It’s a mystery of modern medicine: Americans — and only Americans — are becoming more likely to report feeling very real physical effects after taking totally fake painkillers, say scientists from McGill University. According to their findings, published this week in the journal Pain, the placebo effect has gotten stronger since the early 1990s, but only in drug trials conducted within the U.S. — not ones conducted in Europe or Asia.

The McGill University researchers analyzed 84 clinical drug trials of pain medications tested between 1990 and 2013. Over that 23-year period, they focused on the patients’ self-reports of their level of pain after taking either the actual drug or the placebo, and found some striking figures. According to the patient responses, in 1996, medications were rated as being 27 percent more effective painkillers, on average, as compared to placebos. By 2013, however, that difference had shrunk to just 9 percent.

How do the researchers explain the cultural disparity?

Dahl continues:

The researchers have zeroed in on two potential explanations. First, the U.S. is one of only two countries worldwide in which drug companies are allowed to advertise directly to consumers. (The other is New Zealand.) So it’s possible that hearing the lofty promises pledged by pharmaceutical firms in these ads may have increased consumer expectation of the potential efficacy of any old drug handed to them by a person in a lab coat.

Of course, it’s not merely the Mad Men of Madison Ave. who are responsible for this. We are all exposed to television dramas, sitcoms and docudramas where physicians are presented as heroic warriors who can cure just about anything.

Just as criminal juries are influenced by a CSI effect, so too are medical patients influenced by fictional physicians who almost never lose a patient.

From Marcus Welby to Dr. Ben Casey to Dr. Kildare to Gregory House to all the physicians on Grey’s Anatomy… Americans are exposed to a constant drumbeat about how great physicians are. Surely, this cultural ambiance influences the expectations that patients bring with them when they are given a pill by someone in a white coat.

When it comes to the psycho healing professions, I would remark a point I made in my book. If psychoanalysis was producing placebo cures, it needed to be functioning in a cultural environment that presented it as a therapeutic, even medical enterprise.

Analysts and their enablers accomplished this with movies like Spellbound and Suddenly, Last Summer, with newspaper and magazine columns that showed therapists to possess a superior understanding of the human psyche, with television therapists like Dr. Phil and with all of the forensic psychiatrists and psychologists who explain away all manner of human horrors. And, let’s not forget the academic studies that show how well psychoanalysis works when applied to literary characters.

As for the study Dahl reports on, she emphasizes that in America the drug trials are made to appear more professional, more medical, more legitimate. Patients do not just receive a pill from someone in a white coat, they are treated like real patients. In other words, the accoutrements of a real medical treatment disabuse them of any suspicion that they might not be receiving a real medicine:

And as these trials have grown, they’ve added more non-pharmaceutical aspects, such as hiring nurses to consult with the trial participants, Jeffrey Mogil, who led the study, told Nature. All of these factors may infuse the entire experience with an official, legitimized kind of feeling, which may also be contributing to the rise in placebo effectiveness.

We can apply this principle to the way placebo cures are used in psychoanalysis. As we recall, Freud stated clearly that nothing about medical school prepared one to study psychoanalysis. And yet, for a very long time major American psychoanalytic institutions proudly refused to train anyone who was not a physician. Only within the last couple of decades have they admitted psychologists, to say nothing of social workers to their ranks.

So, the question arises: why did these institutions insist on restricting the profession to physicians? If it’s not a medical practice and isn’t really science, why do its practitioners need to have MDs?

The analysts responded that only a physician could distinguish between a mental illness and a physical condition. This makes very little sense.

First, anyone suffering from anything resembling a physiological ailment will normally consult with a physician who specializes in medicine, not one who works on the human mind. When you have a gastrointestinal illness or a sprained ankle or a cardiac arrhythmia, it does not cross your mind to ask your psychiatrist for treatment. If a patient has anything like a medical condition, a non-physician will be more likely to refer him to a physician and less likely to believe that he knows what is going on.

This leaves one other plausible reason for restricting psychoanalysis to physicians: the ability to produce a placebo effect. If your psychoanalyst is a physician, if he displays his medical degrees on the wall, as a sign of his legitimacy, if he tells you that his interpretations are scientific fact, you will be more likely to believe that you are receiving a medical treatment and thus more likely to believe that it is going to help you to get well.


Ares Olympus said...

This is a very confusing topic to me. Its not clear to me what "Placebo cure" means in regards to therapy.

And if the primary use for the placebo effect is acute pain relief, then its doing exactly what we expect from a drug. As well, we understand that pain is a symptom, all pain relief is doing is masking the symptom so we don't expect it to do anything else.

So in regards to pain "Placebo cure" would not be accurate. It's a "placebo mask" perhaps?

But a placebo also might have other uses, like if you imagine a process called "healing", and that the body heals itself, but there may be conditions such as anxiety that slow or prevent healing, than a placebo that reduces anxiety might allow the body to heal itself.

So if we're talking about "placebo to mask psychological pain", it is reasonable to expect it is a short term effect, while having that psychological pain reduced might allow other healing to occur that otherwise would not, and that healing might come actively, like being able to bring poor thinking to light, or passively, perhaps unconscious conflicts will resolve themselves and we might not even notice the change, or need to know what changed.

So it problematic to say "its just a placebo effect" as if that means "its not real" while the placebo effect can interact with something that is real.

I can see the reason practitioners want to separate the placebo effect from a cause-and-effect. Like a chemist might find a 732 step process to generate a chemical compound, and 697 of those steps are irrelevant, so only trial and error can help clarify which steps are necessary and which are unnecessary.

But that level of scientific method is probably not be appropriate to psychology, and a good reason why some psychologists say psychology is not a science, because it can't be done in a simple cause-and-effect manner, and might even depend on "placebo" effects, that help change a state of consciousness to one that healing can occur. And it might even be that a technique that one psychologist develops works for him, but can't be directly taught to someone else. So that's a messy problem certainly.

In that regard I think of a quote from Deepak Chopra, although in part he's arguing against Richard Dawkin and his book "The God delusion", and Dawkins is also very distrustful of anything that can't be proven by cause-and-effect.

"Rational science is based on the subject-object split. I'm the observer, and that's the observed, and it does extremely well based on this split. I'm hoping that a deeper truth can be found when we develop a science of consciousness that goes beyond the subject-object split. Nature doesn't decide that this is the subject, and that is the object. Nature says both the subject and the object are my activity. So my prayer is that science will evolve to include consciousness in its evolition." Deepak Chopra, 2010, The Future of God debate

Anonymous said...

Thomas Szasz accurately identifies three sources of pain.

First, pain can result from actual disease or disability. The adult patient can seek a remedy for this cause of pain by complaining to a doctor. The doctor's role is to apply indexical knowledge of the causes of pain or disability and the known remedies.

Second, pain can result from adverse social conditions. A person may be enduring forms of neglect as a child or enduring forms of abuse as an adult. Although women and children get more sympathy via empathy men also endure neglect and abuse particular if we learned to do so as children, or we perpetrate neglect and abuse via identification with males who expressed those patterns in our earliest experience. So adverse social conditions tend to drag the past into the present via karma: the repeating patterns of thought, speech, and social interaction. One may complain to doctors, psychiatrists, police, court systems, social workers, or to psychologists. The remedies for adverse social conditions are more like political economic interactions based on moral and ethical ideas of those who want to help others improve their living conditions in society.

Third, pain can be generated by persistent personal memories. Emotional memories are the "stuff" of human interaction so they cannot be isolated from the practice of medicine, psychiatry, justice, social work, or psychology. The best model for understanding persistent pain and its remedy is the Four Noble Truths. The person must seek and find a remedy within the self otherwise the source of pain (a memory) persists even though one manages to generate pleasure as a temporary distraction. If one can see through the many distractions in life then a great spiritual pleasure is generated such as one might attribute to legendary holy men and women in every age.

Psychotherapy is primarily concerned with resolving pain associated with social norms and values. However some persons are content with social norms and values and others are caused suffering by efforts to conform to social norms. Spiritual liberation from personal pain is the only way out for those of us who have contempt for the superficial appearances of polite society. Pleasure is not gained by efforts to conform to social norms. A placebo in metaphysics would be a distraction against pain or some sort of hypnotic trance that temporarily alleviates a painful idea or memory.