-'
.
L.
.The Placebo Response
Howard Brody
The placebo is nol so muen a pill as a process.
~inning with the patients confidcncc in Ihe
doctor .... The process works no: bccausc of
any magie in the teblcts bul becausc the
human body is its own best apothecary and
bccausc Ih~ mas: suecc>.rrul prc-:::;-¡~Iion; are
thosc Ihal are fillcd by thc bod. i:.<.:If.
NO~AN c.:OV$IN$
1n his play Tbe D~CT0:··.'- Dilw17I1t7
(wri rten in 1911), George Bernard Shaw described one of
rus characters, Dr. Sir Ralph Bloomfield Bonington
("B.B.") as follows.
... cheering, reassuring. healing bv che mere incornparibilirv of
disease or anxiery wirh his we lcorne presence. Even broken
bones, ir is said, have been known ro unire at che sound of his
\'olce .. , ,
~Iedical srudents who have had me opporruniry ro
"coat-tail" with well-esrablished and respecred physicians
as they see parienrs may have observed sorneone with at
leasr sorne of those qualiries. (Few physicians are so
blessed as ro possess al! of thern ro mar degree.)
Cnforrunarel~-, in Shaw's play, Dr. B,B, is a disappoinr-
mene Ir rums OUemar he has no understanding whatso-
ever of me scienrific mechanisms underlying disease and
rrearmenr, and ar me end of rhe plav a patient dies as a
direer result of his igncrance.
Exarnples like Dr. B,E. ha ve had a signiricanr irnpact
on how modem physicians think about me "science" and
me "arr" of medicine. They have ofren fallen into me trap
of rhinking of mesé rwo parts of pracrice as if me}' were
fundarnentallv opposed. The sciencific practirioner pre-
surnably knO\I'S how ro cure successfully and hence has
no need for "art." On me other hand, me ig-noramus or
me quack uses me "arr" beca use mar is aU he or she has
at rus or her disposal. According ro chis view, physicians,
if anything, oughr ro avoid having tOO good a "bedside
---~... -~---------------
~,
rnanner,' lest other physicians think that thev are corre-
spondingly lacking in scienci6c knowledge. BU( is growl-
ing: or being surlv ro patients me besr way to "in peer
approval.
The critica! medical srudent, thinking further about
Dr. B,B" will realize that mere is no logical reason \\'h~'
he neccssarily had ;:0 be an idior in scienrific rnarters. Sup-
pose, on me other hand, he had a fuI! knowledge of sci-
en o fi c facts and princi ples.and. in addition. possessed all
me personal quali ries mar Shaw descri bes. '\'\"ouldn 't we
then hove, in rnanv \\'a:-s. me ideal pbysician, one able ro
use scieritific medicine in wharever way would beriefir che
parient. However. where scienrific medicine has gaps or
uncertainries (which occur much more fr equenrlv than
rnanv., in our socierv r ealize and more often than rnanv.
phvsicians or me cical scientists ";sh ro adrnit), me phy-
sician can supplernenr me pO\\'ers of science with the
po\\'ers of his or her personal healing influence over me
paoenr.
Consider this in another \\'ay, A patienr with depres-
sion can be helpe d through medication and also rhrouzh
supporrive psvchozherapv. _-\.physician who offered me
parie nr a pill bur nor counselling (or vice versa) would
effecrively be holding Out and failing te benefit me pa tiene
1:0 me fulJ exrenr possible. By me sarne logic, if patients
can be h'ealed in pan through "scienrific" medicine and
in pan via me personal influence of a supportive, caring
physician. doe sn: the end gOJI of medical practice-s-ben-
eticing- the P2Q.:r::-rt,.¡¡úrc' thar we offer the parienr both
rather than orie o~ rhe other-
Lers C31J Dr. B.B,·s scienrifically asrure rwin brother
or sister a healing so rr of person. Today's medical sru-
dent, who wants ro become a healing son: of person ..has
arnajor advantaze over srudents in Shaw's dav, The sru-
dent of me earl~- rwenrierh cenrur:-- had a g~od deal oí
experienrial and anecdotal evidence ro draw on but vir-
ruallv no scienrific evidence. Toda,", althouzh mere re-
mai~s much ro learn abour me role'of emoo;nal suPPOrt
and cornpassion in healing. we nevertheless have begun
ro accumulare a solid body of scieni:ific research.
343
 ", : .. ~..
'
PLACEBOS AND PLACEBO UFECTS
A placebo rnay be defined as any fonn of medical crear-
mene mar is presurned to havc no irnpact on the body's
physiology through any physical or pharmacologic:al
means. Therefore, if a patienr's healrh status changes for
berrer or worse afrer being adminisrered a placebo, our
medical rheories require mar mis result be e:.... plained bv
whatever irnpact mis rrearment rnighr exert on me pa-
tient's ernotions or thought processes or on the parienr's
social serrina.
Ler's expand mis a bit. 1 ,\;11 be defining placebo ef-
fect as a general explanation for whv charizes occur in me
patient's health status. Box 23-1 shows three \"ery general
sorts of explanatioris mar are commcnlv given for ob-
served changes. ,"e would hope that me chznges ar~ for
me berrer , but each rype of explanarion can account for
both nega rive and positive changes. To say mar a placebo
effecr has occurred is to say mar we observed a change in
me patienr's health, and we C071710t account for ir on me
basis of either me specific rreatrnenr thar me physician
pr escribed or whar would norrnallv occur in me course of
that disease process even if the parient had not visited a
physician at al!. .' Ve merefore assum e thar mere was
sornething about me svmbolic (i.e., psychological, emo-
cional, or cognirive) aspecrs of the phvsician-parienr en-
ccunter mar caused me observed chanzes.
\\ny would medical scientists want ro srudy placebos?
1would like ro say mar it was because rhey wanred ro find
Out h ow physicians could become healing sorts of persons
by figuring out more precisely ho\\" emocional suppon.,
care, and cornpassion can change 2. persons illness for the
berrer. If that had been me case, we rnighr rcdav know a
good deal more about mis subject, be cause me practica]
goals and applicaricns of me research wculd have been
forernost in me minds of those who designed me e.>..-per-
irnents.
The medica] scientists who srudied placebos over me
pasr half cenrury had sornething quite differenr in mind.
Thev were strorizlv influenced bv min d-bodv du.alism
'\'hi~h holds cl)dt~~e. mind and 'me Qody ar~ rwo ven:
I BOX i.3·1. Thrcc cxplanalions lar why a palien: irnprovcs sfter
;rcin!; the phy;ician
I J. The pacen! improves beca use of th-e specific
¡ ph2nmcological or phy-siological pOten.::' of roe n=trnen!
prescribed.
1 2. The pacent i~pro,'cs bccause of the n.run.l hisron; (i(me
~
. disorder ~nd me bod)"s inherent recupeI"2rin pow~rs .
.. The p~cent improves beca use of me symbolie, cogniri"e, or
emocional dimensions in the healing encounrer (roe placebo
response).
~OTI:: COrTesP9nding ryp~ of el.llhnloons en be pro.-ided '\.t·hen
p:uic:m hils {(I impro,'(" or \4'orsens.
---- .... _-- -'-------_ ...
•••••
- _ ..
~.-:.. •••
_-_._,..
-""> •••••••• " • .., ••••••
•.......•'-"'._ ...._ ..-
;,..;.._~
-_.
-: :
."-;'
different sorts of substances related ro each other in orilv . r
me most renuous fashion, if at a11.Furt:hermore, bodi~
are physical objecrs and accordingly obey me laws of
physics and chernisrry, whereas me mind, wharever thar
is, could DOt possibly be understood by those lawsvT'har
rneant thar if medicine was supposed te be a science, ir
could do whar ir was supposed ro do only by srudying
bodies and rrying ro ignore me mind as complerely as
possible. If you are a psychiarrist, for exarnple, you can do
mis bv. decidinz - mar a11mental illness is acruallv. a disease
of the brain and that vou leam how to crear brain disease
by srudying me brain's anaromy and biochemistry: what
a mentally ill person thinks, feels, or experiences is so
much noise and can sirnplv be disregarded,
Ther e rurned Out ro be ¡J problem, however , with me
goal of zertinz me rnind ro zo awav so that scicnrists could
happil~'- srudv me body. ,\ number of body treatme nts
appeared at first glance LO be srrikingly effecúve in curing
disease, onlv ro pe shown by larer research ro be quite
ineffecrive. (Box n-::! pr ovides a srrik.ing exarnple.) The
I30'X 2.3.~. /V,amm·ary artery li~ation: An cxample 01 a placebo
response in rcsearch
Tbe rrearmenr of =gma p~CIOriSprovides an interesring
illustration of me placebo r~spoD.5e. Benson and ]\"1eC:illie
(1979) have develcped an inrriguing historical review of me
arra:' of medica] and surgical rr eatmenrs tha t, ahhough now
disavos .:ed, were previously though; effective in crearing angina
p~CIOriS. ÜDe of rhese rreatrnents, mammary an:er)' ligarion,
W2$ popular in me 1950s and was based on me theory thar ir
would improve collareral circulation and increase coronary
blood fio w, \\oeo me procedure v-as new, published repores
showed that 65~ tO 75% of patients reporred considerable
postoperarive irnprovemenr (Beecher, 196 J). Because sorne
surgeoru had considerable doubt 2S tO the phvsiological basis
for this treannent, =0 independenr rearas of invesrigarors
carried Out. series of placebo surge.t}' rrials. Sharn surge.r;.' is
something obviously unacceprable by today's ethical standards,
bu! me resulrs of mese trials rernain useful in characterizinz
roe placebo response, In both srudies :ill parients received che
skin incision. but me inrernal mamrnarv arteries were liQ:aed
only in a ran·domJy selected group. On~ tea m reponed iliat :ill
me nonligared patients and 76% of me ligated patients
experienced deo-eased need for nitroglycerin and increased
exercise tolerance. "These changes lasted as long as 8 rnonrhs in
nonligared psrierirs. The other investigarors rcported greater
than 40% subiecrrve irnprovement and 38% re ducrion of
nirroglycerin use in equal nurnbers of ligared 2nd nonligated
pacentS. !Dese w"estü,acions succeeded in demonsrrating: m.t
mam.mary arttt}' ligaci;n offercd no more mm sl.:in incision
alone. ,\1051: ilJwninating ro me meruca.l "'orld toda}" i.s me
recognicion crut bom procedures could generate a suscained
and compclling pi. cebo effea.
R~r(7'm("
Beecher, ~ Su.-ger;.· ~s placebo: A guancit:lcve srudy of bi~5,
7.1:\1A 176:1101-1107.
me- Beruon H, lI·!~lie DP: Angina peCIoris and me placebo
effecr.]\' Engl J :\1<11 300:1-1~4-1429. 1979.
 ,,'/ ."

..,' , J

problern was that mese body treatrnents were at the same BOX 23-3_ (/eneralIyacceptcd findings about the placebo effect
rime mind trearmentS, and me irnprovernenr seemedro .. _~.. ' . '. .
resulr from me mental effect alone. The parients expected . ;.:, i_. o~ ~~ge, ~~u~ ~~e- t:hird of~~Ch subjects g¡~:~--f-:'~"
to ger berter beca use they had taken a pill or had under- - -;.. _-' placebo ,,-il] demonstrate irnprovernent, although thisrare
:.-'i.: "-mes considenbly smoag srudies. .
gone surgery, and me physicians who treared them ex- _". 2_ Almou"o-h placebos Can be powerful agents in ~¡j~g ~ .
pected thern ro get berrer. Sorne of thern, or even rnany . or anriery, placebo responses are noc restricted to mese'
of rhern, gor berrer, bur me scieritists found out only s}'rnp~rns; indeed, alrnost any potenrially reversible
rnuch larer that ir was me rnind rrearment and not me syrnpcO<n has been shown at one time or another ro respcnd
body trearrnent that acrually "worked." ro placebo,
B ecause m e scientists were inrerested onlv in bodies,
.
3. Placebos can effecr borh "organic" and "psychogenic"
syrnproms; response to placebo does not necessarily pro\"e
they had to eliminare this confusing and bothersome in- that me sympcom was psychogenic in narure.
terference from their experirnents. T'hev did this by de- 4. Placebos alter pbysiologically rneasureable variables such as
veloping me method of me double-blind controlled blood g-Iucose be] and not merely me individual's
clinical trial, If neither physicians nor parienrs knew who subjecrive state,
was gernng
. m"e real"1 treatmenr and who was gerting a 5. PI. cebo responses can be srriking in inrensiry and durarion
~ - and in general can mirnic me pharmacodynarnics of "a ctive"
dummy mar ourwardly resembled me treatrnent (i.e., a drug responses.
placebo), the p5:i}G?0logical factors should be me sarne in 6. Placebos can also produce mm}' of me side effecrs seen wirh
both groups of subjecrs (me experimental group and me rypical medicnions.
control group). lf me result of me treatment was me sarne '''-''f' Efforrs ro idenrify a "placebo personaliry rype" have
in me two groups, me scientists could conclude that me generaIl: nor beea fruirful. Response ro placebo seems-ro be
more of 3 situationalrésponse rather than m endwing
psychological factors alone accounred for any irnprove- personaliry rraic; relarively fe'" people consisrenrly respond
ment mar was observed and thar trearment would hence- ro placebos, or consisrently fail ro respond, in a variery of
forth be discredired as a legitimare medical therapy. If, on cirCUITh-..:U1CCS.
me other hand, mere was a measura ble difference in Out-' 8, In sorae snrdies, subjects haveresponded posirively to
placebo medicati~n even after being' informed of its
come berween me rwo -groups, ir musr result from the pharmacologically inert narure.
physiologic or pharrnacologic effecr oí me treatrnent
cornpared wirh me dummy. ?-haL, in rurn, meant thar me
treatrnenr had scientific rnerir.
This rnethod of clinical research has produced a great
deal of medical knowledge and has allowed us to select dine is generallv accepred as eftective ulcer therapv, abour
useful trea tmerits while elirninaring a number of harmful half of me- srudies showed rhar cimetidine was berrer than
ories. We all are much berter off roda,' because of me placebo, and half showed rhar it was nor. i\10errnan
widespread use of conrrolled clinical trials, bur an unfor- showed tha; me differences in outcornes arnong me srud-
tunare consequence of mis rnethod is mar few, if any, ies had nothing ro do wirh me performance of cime cdirie:
scienrists looked directly ,H me psvchological aspectS of in each srudv. berween 70% and 75% of me ulcers wer e
healing as sornething worthy of use and encouragement healed wirhin 1 rnonth in me experimental drug group oí
in its 0\\11 righr, Th2C means, in t1.L."1L thar a good deal of subjecrs. The different ourcornes of me srudies were re-
what we know today abour che placebo effecr (surnrna- sulred solelv frorn differences in che group of subjects re-
rized in Box 23-3) is what we have learned through me ceiving placebos. which varied over a wide range. In orie
back door, as ir were, in spite of ourselves, If sornerhing srudy, only 10% of me placebo subjects' ulcers had
interesting or imporrant happened in me placebo group healed, in anorher srudv it \\"2S 80%. Ironicallv, in those
of subjects, mar mighr be reponed, bur the artention of srudies mar showed mar cimeridine was "no berrer than
me scientists was focused insread on whar was happening placebo," ir was not beca use me cirneridine was worse
in me "active" rrearrnenr group. If rhe s-ame thing hap- than usual bur because me placebo was berter than usual ~
pened in me experimental group and the placebo group In our terrns. whar .\loerman found our was mar ca-
(because both were subjected ro me same psychological rain g-roups oí rese~'rch physicians rnay have be en btcllil/g
srirnuli), it might never be obsen'ed or reponed ae all, SOI""t<of peno/;.< ro a grearer degree than sorne of their col-
because me scientistS were interesred only in me diffcr- leagues. Sad ro sa~-':mis large body of research tel!s us
mees bet\\'een mose t\\·o groups. nexr ro noming abour ho7.:: mey managed tO do mis: me
The problems wim learning about' placebo effeccs srudies, aher aIl, \,'ére inreresred únly in me cimetidine
mrough me back door is wel! illustrared in sorne research and nor in me placebo.
conducttd by anmropologisr Daniel.\loemnn, Moerrnan This reséarch ShOW5the imponance of discinguishjng-
re\iewed 36 studjes mar compared an anriulcer drug, cj- bemeen a placebo and the placebD effect, A placebo. or
metidine, \Aim placebo in treating pepric ulcers (wim an dummy medicaoon or inten'enr:ion, ma;.' be used in a \'ery
endoscope being used ro \isualize and measure me size of small propornon of al! medic:J! encoumers (primarily in
me ulcers befare and afrer trearment), AJmough cimeo- research). bur \\"t h8\'e suggested mat me placebo effecc

The Placebo Response 345

.- -.--_._------------------------'--'~~=~'---'-'-~~-
 ._-_._,_ ...-,_ .. _--.- ..._~ .---.c:....-._
.... "._._ ....•.... ,~,,;:
ÓsÓ;:--::-;,. • ..:.; .••• ::.;~:._~~.~~ ••

;.~.'.

,....
·"~:V;:.

~~.;,':;'ji
;;;
~iV~~
"

'-_'._ ~-~:

An arnulct wom by a Mi~;i;;ippi sharccrcppcr lo war d off erthritis Courtcsy of thc

Collccuons of thc Librar)' oí CO;¡~;CS;;,\'\!a,hin~lon, D,C.

Bclie! systcrns are poweriul dctcrrninsnts 01 bchevior. ano' peticnts can cxpcricncc
considcrsblc relicl from sytnpiorns from thcir cxpcctetion thet rclie! is lortb cornin;:,

occurs in virrually all me dical encounre rs. inciuding rh()c.~' p:111tnr is :::::::>ro,<ehed, ro be sur", rhar the right atrnos-
wher e no placebo is anvwhere ro he se en. :\;: long as me phere is eres red :15 p:"¡ of rhe encounrer. along with what-
patient's rhoughr proces~e, or ernorional srare is chanseJ ':\'::1 other ,:r:ienri:ic inrerve nrions are used.
2.S a~,of_encounrering me physician, a placebo effecr
h2s:QC~Ílrred, Ir is alrnosr a marter of historical accidenr HO\"":/ TO STVDY HEALlNCl
c§ll
thaf;:;;,:e' this ornnipresenr aspecr of parienr care a p/fI-
febo ~e€{ :a~:all; ir just happens thar ir was 'b;' srudvi nr; 1i srandard double-blind conrrolled uials rell us lirtle
placebos tha r medicine ti,~r bec.une uwar e of che: power ;¡!)lltllthis important Jspecr o! h:::1Jin~, what sort of re-
, ofws p:l'ieriOme¡¡On: tSimihrl;', the label rEdiscn cffe ct " scnrch _\I'Ot:!C [1': bt:-;:c:r: \\11<::1 \\'c: nsk ahout placebo ei-
in p1i~'sics tell sus norh in c :lhout Wh:H th e eff<.:n i, 01' h o vv [ccts. we ;:~e r eally :lsk.ing rwo sorrs of qucsrions. which
often .iroccurs: its JUSI a hisrorical note about who firsc rcquire nI (, diff<.:renr research ,;1pprosches. First, we want
rejrorred it.) A h,ealing sorr of phvsician is nor eme wh o ro knovv «har has ro happen ro creare thar particular son
hands Out placebos; ir i, one who is careful in ho\\' each oi relatiori-hip. or a rmosph e r e. berwecn physician and pa-

346 Behavioralvledicinc

tiént so thar healing is more likely ro take place; in other
words, whar kind of encounter berween physician and pa-
tient has me rnaximum beneficial .rYllJbo/ie impact on the
patient? The second question is: Once this symbolic irn-
pact has occurred, whar further sreps must cake place
within me patient's body to rranslare that symbolic stirn-
ulus inro physioiogical change ar rhe org<ln or cellular
leve]?
To take me second question firsr, research performed
in me pasr 20 years has helped ro illurninare me various
biochemical pathways mar could account for sorne pla-
cebo effeces (Box 23-4). A. great deal srill needs ro be ex-
plairied, and 3S yer we rernain largely unable ro sa~' mar
_\Ir. J enes gor berrer as a resulr of me symbolic aspeces of
his encounrer with his physician pn?cisc~r because his en-
BOX 2.3-4. Possible bíochernícal pathways for placebo effeds
Carecholarnines and seroronin. Catecholarnines were me
!irst hormones s:rudied carefully and shown ro respond ro
changing ernorional sutes and stress levels. Besides their effects
on heart rate, blood pressure, and other manifescicons oE me
"fighr-or-fiighr response," adr cnocortical hormones have more
recendy been shown to be linked to aire red irnmune responses
(see below).
Endorphins. Endorphins were among me fu>!
neuropeprides srudied in relation ro placebo response: early
research showed mar placebo .nalgesi2 could be r eversed by
naloxone, a known endorphin anrsgonisr. Sinee then. me
picrure has gro"Tl much more complica red as rnulriple
endorphins and cheir parhways have been rraced. Endorpbins
are now suspecred ro be involved in other pbysíologic
responses besides pain relief.
Xeuroimmune responses. Much research has r ecendy
rraced links berween me endocrine svsrern and me imrnune
s;>>tem and has shown mar imrnune funccion can be altered
experirnencally through changes in stress or relaxarion.
::--'-europepcde recepmr sires have been identified on immune
cells, illusrrating how alI of me above syseerns ma:' "talk" ro
each orher and ro me irrunune s)'scem.
Rcfcrrous
Blalocl.:JE, Srnith E.i\1: The irnrnune system: Our mobile
br:ún? lnrmunal Toda_\' 6: 115-117, 1985.
Golub ES: Conneccions berwe en me nervous, haematopoieric
and gerrn-cell sy;cems, X,¡m1" 299:483, 1082.
Grevert P. Goldsrein A: Placebo analgesia, naloxone. snd ¡:he
role of eridogenous opioids. In \\ 'hice L, T ursky B, Schwartz
GE (eds). Plarrbo: Tbeoty. rcscarcb, aud mccbanisrns. ),"e'"
York, 19.85, pp 332-350.
Kiecolr-Glaser JK., Glaser R. Srrain EC, Srout, _lC, Tarr Kl.,
Holliday j E, Speicher CE: Modularion of cellular' imrnuniry
in medical sruaems,] B(hn~: J,.Jd 9:5':'21, 1986. '
Marx J: The irnmune system "bdongs in che bOO:-", Pernsi\'e
anacomical and biocherrucal links berween me immune and
nef\·ous syStem5 help explain ho'" mood mighc inAuwce
disease suscepcibilicy, Scimcr 227:! J 90-1 J 92. 1985.
Pe¡-¡'CB, Ruff ,\IR, \.\'eber Rj, H~rl.:enbm ;\1: r<curopepcides
and meir reccprors: A psychosomacic nerwork,] lmmunol
!35:820-S26. 1985.
-------------~--
- .
dorphin leve! increased, rus immunoglobulin A was stirn-
ulated, or wharever. But we know enough coday ro W}-
derstand whv#....,2 distinzuished medical educator , Rozer ::;,
Bulgér, has said, "It is much easier now ro consider the
art of medicine as an emerging science through which me
adepr practitiorier allows or facilitares me patienr's cwn
interna! pharmacy ro dispense agents in rherapeutic corn-
binarions and arnounts ar just me righr rime."
The firsr quesrion is me rnosr irnportanr one for us as
pracritioners. but ir obviously cannor be answered by
purely biochemical or physiological research. (Indeed. re-
search thar rruly helps us understarid me placebo effect
shows me inadequacy of medicine's traditional ITÚnd-
body dualism. because no research rhar splirs me ITÚnd
and body inro sep3rare comp2rtrnenes of realiry can rell
us what we need LO know.) 1 \\ill suzzest an answer ro mis
question thar, 1 think, is supporred by me smalletsódy of
research mar is available, as well as by me experiences of
man}' thoughcful and caring physicians. The answer
comes in (\\'0 pares: a list of more specific behaviors and
a discussion of underlving artirudes and approaches.
Borh me specific behaviors and me general arrirudes
gro\\' Out of ,,·.meaning model of me placebo effecr,
which srares thar tbc patient's bealtb is 71/0.'T¡d'e~)'ro Chf7llgC
in a positive direction trben tbe 7IIcallil/g of tbe illness expcri-
mee bas bren d:allged for tbe pnticnt in u positive ¡:·u_r. To r· ,
take a cornmonplace exarnple, when l\1r. Srnith goes to :
me doctor having an experience mar rneans ro hirn, "1
rnight have caricer," and he goes a\\'a~' wirh an experience
thar means, "1 have a bad case of bronchitis and ir should
be berrer in a fe\\' davs if 1 take mese anribiotics," rhen
. we would e:-.:pect that mere is me gTearesr likelihood mar
Mr. Smirh \\-i11 feel berrer and br eathe easier, possibly
even before me antibiorics reach a rherapeuric serum con-
centr anon.
Because "rneaning " is hard (Q define or undersrand.
eh e me aning model is valuable because ir can be broken
dO\\TI into specific bies of adrice. According LO me model.
if 1 want the meaning parients artach LO rheir illness ex-
perience ro be altered in a posirive direcrion, 1 oughr ro
try ro do three rhings:
1. Gi\-e parients an explanarion for rheir i!lness mar is
both understandable and 3S reassuring as is rruth-
fullv pos-ible. .
., .\bke parienrs fe el mar rheyare surrounded bv peo-
pIe who care 300m rhem and are con cerned char
thev ger well.
3. Help parients ro feel mar rhey rhernselves are ca-
pable oi a re3sonJble degree of conerol or masrery
oyer che i!lness :md ir.ss:>-rnproms (or, if a paciem is
truly nor in conerol. rh"r omer c3ring indi\ldu3ls
can exerr me control on his or her behalf).
As Box ::!3-) sho\\'s. (Qd3~' 3r leasr sorne preliminar;.-
research exists LO documenc impro\'ed paoent ourcomes
when each of mese three mings are done. As we "'ould
expect, mere is also a good d~al of Q\'erlap among me
The Placebo Response 347
 __ _-- _---------,-----------_
·. .. .. .. _ ~---
.. ._.--_. ...._-_!..

h~~.:,:J
... :.•.._-,.~!;~
......•
~ .

BOX ~"--5, ~~ch findings tcnding lo support thc rneaning
Ph~~r cornrnunications artentive ro "U three
,c1~d tk mcaning modelhave resulrcd in draauóc/..
impro.;~ in patienr ourcornc. Egberr et al, (196-4) suic1je(:::;:::
-.9i ¡:c.ricas. ~going elero\'e.abdominaJ surger)', H.Jf o~
rhese rec:::.-cd: rourine preoperative visit, whereas che other
half were &t7. ;¡ dcrailcd preparation hy thc s nesrhesiologisr
f(Jr L"O pU::op::;-aÓ\'c pain thev would experience, followed by
reassuranze ri-izt me pain was normal and would go .".-;¡)',
Paticnrs ""_-': =ughr specific relaxs rion exercises, instructed in
rurninc orz: in bed, and advised ro ask for pain medication if
these ':;:'t:;,-=e; ciid no! produce cornfort. Afrcr surgery me
an=hcsi,_~ :~in visired mese patients once or rwice daily
,n¿ rcpc~-.i m:: ad\'ice and e ncourug ement. The experimental
gT('''? reC;~é5<t.:ihJlf 2,
rnuch narcotic medicarioo as me
con rro] c,:.;¡>. ,;-,d me surueons, ",'hu wer e blinded ro patierit
g:-ouping:.. ~n~ thern hom~ an 2\'cr~ge of z.: days earlier. The
in\'t:sc!!2.¡_(¡-:;comrncnrcd. ","'c: believe mar our discussions
with :hi: ¡::.::rieotShave changed me rneaning of me
postcperacve siruation .. , , B~'~ti!iz:ing an active placebo acrion
"'c hzve been able te reduce cheir posroperarive pain (p. 816),
These znthors used me rerm "placebo acrion" thero.
psvchophrsiological efíects of their t01:21he;¡ling inta>7ncion.
In additioz ro chlnging the meaning of me posroperacve - .
course, their intervenrion provided pa tients with me rneans tO
control d:" pain, and introduced me elerne nts oí care and
. encour agernent, Using these rnethods, me physicians .•.-ere able
:0 produce rncasurablc improverncnr in paticn t ourcome.
Other research srudies havc a llowed us tO assess me various
elerncnrs of me mezning model in r elative isola tion. The
irnporrance of me pcrienr's belief systtm aod world view is
supported by srudies thar show that syrnprorns are more likely
10 irnprove whe n me physician carefully lisrens te patients'
accounts O: their illnesses and tries ro be sure that ;¡greemenr
exisrs berween patient and physician about me narure of me
problern (Bass et al., 1986: Headache Srudy Croup, ¡986;
Srarficld el al., 1981). The irnportance of maste~- and control
is shown when parients are taughr 10 be more active
participants in medical encounrers; me patients who tal:e more
control in me medica! interview can liso be shown tO
evenruallv .have la ter disabiliry because of rheir dise.ase
(Greenfield et al., ¡985)_ Alzhough research m;¡y require mar
differem pon:ions of me rneaning model he srudied separately,
me ideal pracrice model is obviously ro combine al! of irs
elernerns (belief system, caring, and control) in me same
parienr visit,
Rifcrma:s
Bass MJ, Euck C, Turner 1. Diekic G, Prarr G, Robinson HC:
Tht physiciln 's accons and me outcome of iUnc:s.s in fam.ily
prac¡ice.} FllnI P"II" :~:4:;-4~.¡986.
Egberl LD, Ba~l GE. \\'t:lcÍl CE. Barden ,\U-:': Reciueoon of
posroj1e;-.'ci\·~ p;lin h;- enCOUT2!!enlCnr :and instnJcoon o:
p~¡ients::\ ,rudy (ji" doctor-paoent rlpport. :\' El1gl J Mcd
_:>70:S15-8~7, 1964_
Greenfie!d S, ~plan S, ,,'are _TE:E_\:pandin? p.rienr
in'-oh'cmenr in <::lre: EffcctS on p.ri~nr outcomes, .41111 l11TtT77
.\1rd l02:520-52S, 1985.
H,,~d;l('he Srud~' Group af rhe l'ni"ersil\' oi H'e~l~rn Onurio:
Prcuicrors oí aUlcom(: in h",d3Cht· patÍen,-, pr<:sencing tO
fami!y phnieians: ,-'. one yC:lr prospectÍ\'e srudy, Hc"dachr
2G:~8:'-:94. 10S(,.
St2fti,,:J B_ "'r,., e, H"" K, (;ro;, R_ Bick 1'5, D'Luf!off BC:
The inf1uence of pniem-practitioner af!Ttemem on outcome
of e~re, ,-in;} P,,"!;r Hw!:b ¡1:127-D 1, 1981.
rnodcl thre e caregories. Fo' exarnple, rwo m,jO~':d;~
demonsrrated that parients rerid te get berrer when ther-e ;';;f.-.
is good agreement berween me patient and me physician
: "'_
about me narure of me patienr's problern. Is this because
:::;.;.-:+ me physiciari's explanation of me problem is more un-
. . derstandable and sarisfying te me parient who is now cer-
rain mar ir is an explanarion of her or his 0::"1/ problem
and not sorne generic explanation talen off me shelf Or
is ir because me patient feels more cared about beca use
me pbysician has calen me time and energy 1:0 be sure
mar he or she understands me problem fulh-~ The arcas
of overlap are pracrically reassuring ro us, 'because ir is
har d 1:0 imagine" practirioner doing iusr on e thin¡:; on
mis lisr without at me sarne rime dcing one or rwo or.hers,·
Ir's grati~ing te reulize mar rhe overlap probably en-
harrees me placebo effecr even further.
Applying me meaning model in e;¿~ryday patienr en-
counters tales sornepracrice: even Shaw's physician prob-
ably did nor starr healing broken bones with che sound of
his voice straighr Out of medical school. ,Ve can furth er
exparid on che model by describing sorne pracrical tips
(Box 2 ~-6), As you have a chance ro warch experiericed
physicians in the ir pracrice s. you can be ale rr ro how thev
approach each patienr and which of mese srr ategies (or
others) they ernploy.
C~.
HEALlNCi AND 5TORY
The rerrn "healing 50n of person" sug-gest5 mar me phy-
sician 311 of us would lile te be is not rner elv someone
who ernploys certain skills or rools: he or she has a par-
ticular son of artirude about what he or she does, and che
artirude reflects a real personal investme nt in che \\'3)' mar
[lOX 2..;--6. 5tral~ie:; for putting the mcaning modcl into practicc
1 __ -\.sI: me parienr about other approaches he or she luS trie'd
before che offio: risic, Un.I= mese effon:s have been
h:umful or dangerous, me parient should be cornplimenred
for me 2tte!:lprs ro g:zin control over rus or her sympro=,
2. Pro,id~ brief e:rplanations of ho\\' tre.atmem is el:pected te
'\.t·ork 00 che uncierlying rnechanisms of me illness. üse your
u''1ders::L!lding of me patiem's'bdid.~'srem .pOUt me illne:s.<
and potenri2L< of me~2p:' ro inregr.ne !,our expJ2n2rions "im
me paciem's "",ode!." In " similar fashion. e:\:pbin ho","
reeorruneoded home remedies "'ork, E"en simple relDedies
such as rest, aspirin, fluids, and humidific;;cion can hendit
by in,h-iduiliz.ed e:o.:pl:ma.rions chor assure me patieot mar
you are tiling rus or her s:mproms s~riously. Finaliy, as!.:
ho\\' "'ell ;'our e:rplanatioru and prescripcons fit v.;m me
e:o.:p=curions me p3cient h.d ",hen m3king me ;;ppoinonent..
IdeneJ)' differenc.es in el:pecurions 2nd diSCU5S mem open!y,
3. If feasible, ser up 2 follow-up ';sir te learn how wel! che
rrea=ent "'-o~ked. If chis is nOt pncOcal, show concern b:'
asking me pancor te uTite or cill ro infOTro you of me
outcome..

348 Beha\lorJl.\1c::dicint:

-----,--- ..._- .. _-_._, ,-- -, - .

 •• ~t •
the physician comes across to other people. That is why
we <need tO expand the meaning model beyond a list of
ways to behave with patients to get at sorne underlying
principies. 1 believe thar a healing son of person is sorne-
one who has a special interese in me stories of che patients'
illnesses and of che patients' lives .
.Although "srory" sounds far too unscientific to have
been a serious subjecr of medical research in me modem
era, che medical literarure in more recent ~'ears has re-
flected an increasing inreresr in chis norion. Ir is tied di-
rectly ro rneaning by recalling thar humans are, in a ve~-
basic way, narr ative crearures who rry to understand che
world by relling stories abour ir ro themselves and to each
other. (Psychologisr ] erome Bruner has gane so far as ro
say that che narrative way of knowing is che basic human
wa:-- of knowing: scienrific knowledg e is secondary and
derivarive, rnerely a more strucrured ·and formal way of
telling srories abour me world.) To undersrand what an
illness means to che patient is to understand che story thar
che patient has rold himself or herself abour me illness
and how th.is fits (or refuses to tic) within che larger un-
folding story that is che parienr's life srorv.
~1any symptoms are physical, bur suffering is never
purely physical. _-\ marathon runrier has a pain in me
lo'\\"er baek.; a chrcnic parient who was in an auto acciderir
several years ago and who has been unable ro work since
has lower back pain, The sro~' che rnarathon runrier rells
hirnself or herself is, "1 ran a grear race this rime. A lirtle
r est,' some srrerching, and fluid replacement, and those
sore muscles will be feeling grear."The sro~' me chronic
pain parient rells hirnself or herself is, "There's rhat pain
agún. Ir riever goes awa:', and ir never will go a\\"a:·. Life
was grear befor e my accidenr, now mar darnn puin wont
ler me enjov anything for even a few minutes. And nene
of rhe doctors can do a thirig ro help me." The rnarathon
runrier has a pain bur does not suffer; me chronic back
patient suffers grearly.
A healing son: of physician seeks out suffering, as well
as a lisr of signs and symproms, and wanrs to heal suffering
jusr as much as he or she wantsro cure disease and save
lives. This sorr of physician realiz.es thar me healing of
suffering may often resulr from working with me parient
ro reconsrrucr me story mar me parienr is relling hirnself
or herself abour me illness.
_-\healing óon: of physieian is eharanerized b:' 3n abid-
ing euriosity abour me stOries mar patients reU (or \I'ould
t:eU if properly encouraged to do so). George Engel, me
mosr prorrunenr e:":ponem of me biops;.-chosocial model,
has \'er\" insisrhrfulh' demonscrared che link bet:ween tl-üs
hea!ing arn~de a~d che scienrifie approach ro clinica!
medicine. T\ har mocil'ares me healing son of person 3nd .
me most asrute clinical seienusr is ultim:JreJy me same
thing. Bom hal'e a fundamental curiosiry mar leads mem
ro make ,'el\" earefu! and discriminating obsen'acions
abour cErnea!' evenrs (and me pariem's Sto~" or me med-
ical hisro~', is me firsr c1ue mar II'e ger as ro rhe eyems of
~----~-_ _._ ..•.. '''-- -- ·_-----------------------------------
interest). Borh are curious enough to be able ro lav aside
their inicial biases and prejudices and to be able 'to de-
scribe me events me)' are srudying in exact and repro-
.ducibJe fashion. .
Thus, che healing physician is sufficiently curious riot
to do whar me average physician did in one widely cited
srudy of medica! interviewing-e-interrupr che parient wi m
quesrions about specific sympwms afcer me parienr has
had only 18 seconds tO explain what he or she thinks is
going on. To me clinical scientist, curting off me fiow of
me patienr's narrative ar mar point is just as basic an error
as going inro che laborarory to look at microscope slides
and not cleaning off me lens first. .
Physicians are not saints; we have our good days and
our bad days, and we all have our personal preoccupations
that can getin me ""ay of connecting with our patienrs
on their o~<1?Lerms. The healing son of physician relies
on an abiding curiosiry ro overcome che bad days aSfa me
preoccuparions as much as is hurnanly possible. "\Ve ger
sufficieritly curious as ro what is making this person in
from of us respond to an illness in this particular \\'ay thar
we forger abour ourselves and connecr with me patíent as
a fellow human in need. \Ye do not connect 7JIe7"e~)' as a
fellow human. however; because our curiosiry is .pan: of
oür sciemific zpproach, we connecr as professionals who,
hold Out me hope tha r ~ considerable powers of modern
sciencfic medicine will be broughr ro che aid of this suf-
fering individual. Knowing whar II'e know abour neuro-
peprides, catechola ...mines, and me immune sysrem, ir is
nor so \"e~' surprising mar che bodv of a patient who fe els
connecred in LI:.i.S fashion rnight St2.::1: LO irnprove in its
funcrions as a result, And ir is not so ver:; surprising that
me story thar patienrs tell thernselves about their illness .
mizhr be a more reassuring and more self-ernpowering
story than me one rhev had told before rhis "connection
oceurred.
Phvsicians who approach parie nts in this manner have
a power ro heal, in par.: because many suffering parienrs
feel radicallv disconneaed from their farnilies, their com-
muniries, and indeed frorn cornmon hurnaniry, \;I.,11en~-ou
are siek and suffering, :'ou ma:' feel mar no one can really
understarid what you are going r.hrough or really has me
parience ro listen ro your plighi:: everyxvhere else evervday
Jife seems to be ~oins: on as usual. and \'ou alone are Out-
side of me Bo\': oi human exi5i."~nce.'But me physici:Úl
who seeks ro con..¡ec;: \\im -chesuffering paciem by hearing
and imerpreting rus or her s1."O~· seems ro ron a risk. T o
realh- ger imo me pacient's srory 1I"0uld mean, ro a large
measure, sharing a portion of mat pa'óem's suffering. If
\\"e pracrice medicine th.is \l"ay routinel~', anm't we surel:'
he;¡ded for "bU.iT10Ui::·' This fear of emocional Il..Ilner-3-
bilir:' leads man:' physicians ro pur up a scrong l\"al1 of
psychologlcal defense. w assure mar he or she nel'er 7'ea/~1'
comes ro feel me full force of me patient's suffering. Bur
1 suspecr mat: me physician on me safe side of mar \,'all
nel-er he~rs -che patienr's fl.lll Stoíy eimer, and che walled-
The Placebo Response 349
 ...• ---- _. -------.--.-----.------. -_._""" ..•. __ . '_" .• ~.,-""", . ';;;:'f" , .•.. '"",_,-

.',
.- .. } . o''.' _~.~, "'"" _
.v:
:.-:,~t.:..:p:.-r'."; ,.:
~'~:~';.~_-.-"_'.:¡,,.,..
,._' -.C;..·.·j,·::.;,·.•',·.~.:·:·~
~.... .•.•·:~,·.'
- _':.,,' '"i _

".

Expcctations hclp determine outcornc in any clinical scttinc. Courtrsy o; thc :--..·.¡;¡;:>Ola;
K¡¿~,,' F"unc<lt¡"" Inc.
Lcstniru: liov: lo slist»: peticnt cxpccteiion s vrill "dí' you bccotnc "a "c¿/in§: sor. o': pcrson ...

m phvsicisn probably cannor connc.: \\~Ó the suffering SVMMARY

parienr in :l \\'~~. Ó3l: the patierit would experience as hu-
man and caring. Ironicallv the psvchologically well-de- \\-e have seen whv. rnind-bodv . dualism has rurned Out 1:0
fended physicisn !my 105:: a g:ood de:;! of trie po-ver ,0 be inadequare for a modern undersranding of scienrific
heal, medicine (including the sciemific findings mal: are surn-
1 conclude L'1:l¡: me onlv answer. :;' we would all be mariz ed in Boxeó; :::;-3
and ::3--1-). Engels biopsycho-
healing sorts of physicians; is mal: we have 1:0 form our- social model is now being raughr 35 me ro me alrernarive

selves inro a cornpas sio nate cornrnurrirv of wculd-be old dualismo [Q r emind us that inforrnaticn is constantlv
healers.T rnusr be secure in me knowledze mal: jf 1 come flo\\ing berween me biological, psychological, and social
to suffer as" r esult of opening mvse lf up ;:0 me suffering levels of org;¡Tliz."Don o; me human s~·srem. Accor dirig ro
of m~' patie nrs. m~' colleagues will ~t tnere ro listen ro this berrer mcdel. a placebo erteq is a specia) son of fee d-
me, 5Up?(J:-~ me, ~:;ld help me p:::¡ ¡::-:¡',:l:;Íl. iusr ~151 pTO- bs ckloc>p.l:,¡{ú;:¡1;;t:i0:: frorn
is rransierred the social level

pose ro b(.' Új'c~" ¡'Uf m~'pnricnt-, Tl.i- ~< quite ~; differe nt [.¡}1f phvsicien-psrien; t;;COU;I:t,. within lLS cultura] COTI-
irnaze or (he COl;;;11Unit\' of medical ~~;3c:ice than has tra- text) and me psycholozica! leve! .rhe meaning of ill- me
dit:ipn:illih.e~l'i- 2~üme~: In rhe past. we were rrained (by ness experierice for me patient) via various biochem.ical
exa"iTIiiI. 'jf_n_Q¡ (:.~. explicir rules) W assurne me pose of and neuroimrnunolog-ical pathwavs. evenruallv r esul cing
obiec~_'scie-nti,,:s. and ro alwavs appecr ro be srrorig arid in chanzes a,
- orranic me -
and celiular levcl.
sclf-sufticicrn. ncvcr ;l(il11i,,¡n~ ~m:' \--..::;~~~,.bilir:·ro eith er That ;tecn2ck loo? will he prc'sent cach 'Lime we en-
our p<lóerrro:rJf·edch·omer.-TheilCed LO ser-a more posirive counter a parient. lf wc want LO be healing so rts of pe.-
exarnple oí mutual cornpassion musr. obviously. sean in sonso we can use our scienrific knowledg e and our ínter-
rncdical SC;-;(,(l~. :.\ g:o()d rule (<Ir ~'d: :::':jch::,:r, of medicine per soris l skills 1:0 25~\.:;-e the PT.:~Ht'sr like lihood that our
is. "Alwavs crea! rnedical srudcnts or residenrs under vcur encounrer ,"'ill add (O me parients irinare hea ling re-
supervision in che ma nrier rh.u. lare r o n. yO\l would like sources. as we ll as tO me pO\\'er of wharever rechnical in-
ro see them tr ear rhcir paticnts." rervenrions we utilize.

350 Behavioral vledicine

 ;
out which effecrs come from che medicine and which come
from che psychological reassurance of jusr taking a pill.
].D, is a 67-year-old retired insurance manager who has Patienr: But rhere's just one of me.
a long hisrory of occasional asthrna. .More recently, he had Pbysician: The "'ay we can handle that is by asking me
pharrnacist ro cede each borde with acode nurnber, and
sorne chesr pain, was rnonirored overnighr in me hospital,
he'lI keep che only key. We can put enough capsules in each
and was shown ro have an irregular heartbeat that the
borde ro las, you 1 week. You keep J diary of how much
cardiologisr recomrnended rreating with rnedication.
shortness of breath vou h ave: each niehr hefore ¡roinCTro
JD:s primary physician, Dr. Salter, has becorne ITuS-
bed you can wrire d~\\'Il a nurnber fr~rn 1 ro 1O,-\\'irh 1O
rrared in managing chis new problern, because ].D, has beinz a reallv zood dav and 1 beinz me worst asthrna \'OU
for years taken theophylline, a bronchodilaror, ro prevem ha ve~ever had,- Then, ~fter, ler's sa\~, S weeks, we'll bre'::tJ..:
artacks of asthrna. The theophylline causes the heart ro che code and see which weeks vou tock me meoph:-lIine
beat faster and may help ro rrigger sorne episodes of me and which weeks :-ou rook che placebo,
irregular heartbeat, bur each time she mes tO zer T.D, to Patient: I'm srill not sure whar mar rells us.
cut back on me cheoph~-Iline, he beco mes s; short of Pbvsician: If me nurnbers are hicher on me weeks that \-0\1
breath so quickly that he rerurns ro a full dose. Dr. Salter ~ook me theophylline. we ve pro,'ed your point: we ~o\\'
have sorne scienzitic evidence that you need me
is aware that sorne of me resulrs of me pulrnonary func-
theophyiline ro funcrion well, Then we can agree ro ke ep
~vtion tests recentlv . done do not show me sort of reactive up your dose levels. and look for sorne other \\'a:' to handle
- airways mar one would expecr in a parienr who needs high
your hearr irregulariry.
doses of theophvlline, and she suspects thar j.Dv's de- Patient: Yeah.
pendence on theophylline is more emocional than phys- Pbvsician: Bu. suppose thar me nurnbers rurn Out ro be no
ical.] ,D, has becorne quite angI)- when she mentions this, differenr en me theophylline weeks and me placebo weeks,
and she feels thar their relarionship has become strained. o
Then we. woul have preved whar 1 suspecc=-rhae irs takinz
On me next visir, Dr. Salter and _T.D, have me follow- me pill mar ¡'¡';:l;,;e,you feel relaxed and able (Q br earhe e¡¡~\:
, ,

mz conversanon: and no, me actual theophylline in me pill. '

Pbvsician: 1\1r, D" we've talked before about our differing
views on ~ medicine, 1 rhink \'OU azree with me thar we
, want ro be sure that vour hearr irrezularirv doesnt zer anv
worse and 1.figger ocher hearr problerns, _-\t the sam~ time: I
azree with vou fullv thar \'OU cant enjov lire and function
like a norr¡{al hum~n being if you 're s'h¿rr of brearh or have
LO \\'orry each minute wherher you will be,
Paiient: Yeah. I guess that sums ir up,
Pbvsicinn: \Vell, whar do you S3:; that m: 0:' ro be like
scientists in fizurinc Out where ro zo frorn here?
Patient: \\11.n d~ vou -mean, doctor: -
Pbvsician: \VeD, I've read in me rnedical journals abour a new
rechnique thar sorne docrors are USi..¡1!! rhar sort of makes
each parienr into rus O"'TI research srudv,
Patient: How do ~'ou do thar?
Physicioll: The problem \\'e are !J'\'lng tO soh-e is mn ~'ou fed
me need tO take a full dose of meoph~-lline eo be able tO
brea me, and 1 ha\'e a suspicion ch3r rhe need i,
p~'chological. Cerrainl:' man~- people \\'ho ~et ~n.-..:iousor
\\'orried breame f:lse as a result.
P,7,imr: 1 loo,,' :'ou ,hink eha;:, but \\'h1r ~()od ¿oeo' ir do me'
:~JI 1 loO\\' is rlue I ~et shon of brcam, ;In':; i: ~(\~5 J\\'~\' ii 1
;:ake m:' mtophl'ilin-e, -,
Parienr: 1 guess I "té jiow whar vou're aiming a t.
Pbvsician: ::---;0\\', because this involves using a placebo, 1 wanr
ro handle ir iusr lile a rezular research mal: me fancv narne
me exnerts use iot whar ~\'e're doinz is an ,,'~ of 1 s~d\-."
Al! people who ,!~ up ior a erial gi-\'e whar's called '
inforrned conseriz. and thev sre-¡rold exacrlv how me srudv is
goin~ ro be OO¡-,é,Onlv a~e; mey know alí me facts do thev
then agoee or reruse ro be a pare of me srudv, 1 don',
routinely use :;t'!y placebos in my medica] practice because I
donr believe ir. deceiving m:' parients about what theyre
takinz. Bur if :'0'1 understand whar we are doing her e and
what me C2?~=; have i..nthern, then youre not being
deceived. and we can go ahead so long as you agree.
Paticnt: \'-elI. 1 ;;§:7ee, I¡ seerns like me besr \\'ay ro find Out
whar's reallv goi..ng on, doesri'r ir: Excepr 1 wonder if 1 can
rnake ir through a whole week with iust placebos; I'm sure
1'11be pufti.'lg ar:O \\'heezing a\\'ay b~' me second or rh.ird
da\',
Pby.riciflll: \ \ -e can ::lsi!y alrer m3t, Suppose t:hae \\'e di\;ded
me srud:' inteo 5 -.:12:- period, inseead of l-\\'eek periods,
Thae makes i-¡ ;! üde harder ro incerp~ec me numbers, bur
'\"e C:Jfj deaJ \\~::.~ d:~L.
PI?iicllf: Ho\\' ;Ú)()~.: ~-.iJy ptrjl)ds~
PI:\',-iiiil/i: J do,,': ':..:"_in~:
!.h:H \'.-ould \\"ür;,; !.lcC:Jusei-¡could r¡;kt

Pbr,'icioll: That's where we can be scie"Dhc :=r:d !:!,e,sorne solid 1 or .2 d2~'S fa; :úl &.e s~eophy!!ine ·~O ge~ ou~ or your
proof mae meor;: is me righr one, Suppose \\'e- r:Jlk ro ~-our bloodsrream, Ii \\'e used roo shorr a rime, \'ou'd ha\'e roo
pharmacis¡ and he makes up sorne differenc borrJes oí much meoph:-'Iline in ,'our sysrem \I'hen :'ou \\'~re ~ctu:lll:,'
C3psules, Sorne borues \\'iJl ha\'e ~'our "usu¡¡1dose of r~ki,i1'; me p]:¡cebo cJpsules 3nd nor c:nough \\'hen you \I'ere
meoph:-Jline in e3ch capsule, but other h()rrle~ ",i!1 h:l\'e jmr uking ¡he ,heo?:-:~'nin",
sugar, so mey \\'on'e have an)' effece on che lungs direccly, Pflri('//r: Okay, Fi,'c da:.-s i-¡is,
PoriC71r: Isn'e mar \\'hae me~' call 3 pbcebo:
Pi.:L'iái1l1: Ex~ceh"" In J 1l1i:die;¡1J'cSe:lrch St1.JJ:', i;', ()fren ehe Three m(lil~h, bte;- [ne cOn\'er5JOOn cominues:
c::se mae h:¡]f che pcopk gcr :lli aca\'e pill ~nd blf gee me
placebo 01' sugar pil!. and ,,"hile mt srud:' i, goin~ on, Pby"iciol/: \ \ -ell_ ,\ Ir, D .. ¡-"e h~d a chance (('\ go o\'er me
nobod:- loO\l'S \\'hich is \I'hich, Th:H lees ,he scientisrs figure numhers, anc m¿ ph:mnacisr h3S broken ehe code (or me,

The Placebo Response 351

 _____ ••
.' I'Ve gm me answers here in this envelope, which 1 haven't"
open ed yet.
Paiimt: 1"''03['5 on th.is chart?
P:')'.ricion: I've divided up me 8 weeks inro me 11 S-day
periods that correspond te me 11 bordes of medicine me
pharrnacist g2ve you. Then 1 averagcd your daily breathing
sccres for each of me S-dav periods, So for each 5-da~'
period \'OU see 2 lerrer aud then che a\'erage breathing scor e
íor me 5 d2\'S.
Paucut: 1 se e, So now we 'roll me drums and open me
erivelope, right:
Pbvsicinn: 1 didn 't bring a drum, bur you can go ahead. For
each period, thar is each lerrer, you can read off ro me
whether ir's a "P" period or a "T" periodo I'll wrire ir up in
th e blank spaces here with a marker as you read thern,
Paricnt: \ \ 'ell, son of 2 gun. bur J guess )"ou preved your point,
doctor. Ther es the worst period, F, where the average was
onlv 6.2, and thar was when 1 was t3king theophylline. And
me best period, H, with a 8.4 average, was a "P' pr.;;Jod, I
wouldri't have believed it if 1 hadri'r seen this,
Pbvsician: J think you are on me money, ,\1r. D .. -\5 1 glance
down me charro 1 can't see an:' connecricn berween me
breathinp scores and me Tror P periods, You'd have te do
'sorne fan CI·starisrical analvses ro pro\'e ir exactlv, bu, the
¡nttem se erns clear ro me,
P,"¡;C<17: \\'ell, m~:goed news is mar 1 don'r h ave ro make m:'
heartbear 2ny worse with medicines mar ar e ba.3 for it, but
whar do 1 do now? 1 feel a bir of panic at me idea of going
home and no¡ taking an:' capsules at all, when each time 1
rried ir in che pasr my asthrna gOL really bad.
Pbvsi.inn: 1 can offer three suggestions, and vou can pick
whichever sounds bets te you. First, you can go horne and
trv ro qui; cold rurkey. Rernember thar ~'ou now know a ior
more abour you!" medicines and vour breathing. Taking a
pili lJJf!OIH sornething very difíerenr te you now tha n ir used
<o. So you may never have any asthrna chis time if you
sirnplv stOp.
Pa¡j(7lr: \,'eIL you·m2y be righL
p}:-,'.riál1l:: ,\11' secohd sug¡restion is mar \\'e couJd send \·ou tO a
p5\"Cholo~st mar 1 kn""o~\·. who's especia!Jy gooe 2C r~hx3rion
rechn.iques, You could learn sorne quid memods of
rel2x:!tion and self-hypnosis, You could use mose rnemods
in place of me capsules. lf you st2rred lO (eel a Linle short of·
351 Beha\'ioral Medicine
• __ ._. o •••• ._. __ •••• '_' ._ • __ ' _. __ , •• _.~ ••
, ~: ~ •• ~'.;'.:.1: .•.••...
':"':""-"'~~"-"'.
~__ .
. ,-
.. -:-1_ '.¡ ")"
brea th, fullr relaxing could easily stop any arrack be fore ir
really goe going, And with pracrice you'd fee] really
confidenr mar you couJd control your artacks.
Paticnt: 1 dóri't know. I've never be en one for mese
newfangled treatrnerits.
Pbvsician: IVell, it's jusr one suggestion, althcugh I've se en
other patients like vou do r eally \\"el! with memo .\1:' thir d
suzzesrion will sound funnv, bu¡ think ir over anvwav,
\'\~\'e preved thar me placebo capsules \\"o;k \\"eiJ fo'r you
in keeping :'our br eathing under control. \\'e could 3Sh: che:
pharmacisr ro go ahead and rnake up more borrles of those
sarne placebo capsules, and you could cake one three rimes 3
d av just lile vou did durina our research srudy.
Paticut: \\ "hoa' During me srudy 1 didn 'e know which rirriesI
was on placebos. I'd feel rid.iculous popping ~ capsule in ro
m)" rnouth when I knew thar ir \\'3S a durnmv.
Pbvsician: 1 know ir sounds silly, bur think of ir r.his wav. Our
r esearch srudy showed mar basicallv your minJ \\'2S plaving
tricks with ~·ou in the past, making you t.hink :·ou ne ede d
theophylline when your lungs did all righr without thar
chemical in your sysrern. Arn 1 righrc
Paticnt: \\'ell, 1 cari'r den:' that now.
Pbvsician: Don'r ~·ou se e 'mar if ~'our mind can affe.cr ~·ou thar
\\'2\', vou can take charze of ir and US~ ir ro :'our 0\\'11
ad\'ant2ge' Be for e, your rnind helpe d vou tO breathe e~,ily
bv sending a reassurinz messJge ro "OUT body wherieve r vou
rock a capsule: "1 can relax now, because me medicine is
her e." :\'0"', suppose that you rock mese s.irne placebo
~""c.apsules, and each rime vou rook one. vou said ro your self
sornething like. "I'rn taking charge of my br eathinz bv
concrolling ir in a \\'a~' mar isnt dang erous ro my heart." J
beben mar youd ger exactiy me sarne good e ffect. arid vou
wouldri't have ro fe el silly becauscwhat vou are relling
.vourself is eX3C1:h'
. true.
Patient: You know. doctor, you rnav iust have sornething the r e.
Pbvsician: So whar do ~'ou think of m~: suggestioDs:
Patient: Suppose \\'e do mis, J can r2ke sorne more of rIlose
placebo capsuJes ¡'or a te\\" more \\'eeks. nI chink o"er your
suggestions abou: rel;;x.tion cre2t:f!1enc.s.:\b\'be after some
more time h2S gene by 1"11be read;' to see t.he psycholog1sL
O. ma:'be e\'er:-JUng v;iU be 1Íne on its OWTI. and I can iusr
qui¡ taking me C2psules \\'imou¡ 3n;' problems,
Ph_rsiciol1: Thar seems like a g-re2r plan, :'liT. D.