When you read about the placebo effect, you invariably learn that it is due to a change in the patient’s expectation, specifically, to experience improvement in symptoms and function. Yes, indeed. The question remains, though, how an expectation of improvement leads to actual improvement. After all, an expectation is a belief, and it is not immediately clear how a change in belief leads to, for example, a brighter mood, better work performance, improved sleep and appetite, accepting an invitation for dinner with a friend, etc.
My main task today is to explain how we as clinicians can leverage our patients’ initial expectation of improvement into actual improvement that is more robust and occurs in more patients than it otherwise would if we just let the placebo effect unfold on its own. After all, the placebo response does not universally occur and, when it does occur, it is fragile, that is, it can be easily derailed through the patients’ historical and habitual negative cognitions and other maladaptive strategies rearing their ugly heads, and through our clinical interventions that may inadvertently undermine the placebo effect. We can, instead, approach the placebo effect as a clinical tool that we can, if not directly deploy at will, then intentionally set the conditions for its flourishing. We can do this through a series of interventions I call The Placebo ZigZag. Before I can describe the ZigZag, however, I must first explain how an expectation of improvement leads to actual improvement. Only through learning the mechanisms of change that occur in the placebo effect will we be able to use it for our patients’ clinical benefit. The placebo effect should become, in effect, another regularly deployed tool we pull from our clinical armamentarium. Let’s begin.
The mechanisms through which the placebo effect works its magic include the following:
- Change in salience within the attentional field: A depressed person tends to pay attention to objects and events that reflect, confirm, and strengthen their depressed state. It’s easy for a depressed person to spend their entire day attending and listing (and then showing me or you their list) all the situations that show that the world is going to hell in a handbasket. Indeed, the world is going to hell in a handbasket. It always is and always will. There is never a shortage of pain, suffering, failure, and threat, including existential threat. A person, however, who comes to believe that they are already improving or about to start improving may start to notice different types of events, ones that fill them with hope and a renewed belief in the goodness of their fellow human beings.
- Interpretational biases: Anxious people, for example, have a tendency to interpret many situations as threatening, even ones that less anxious people would judge as neutral or as a mixture of positives and negatives. A person in possession of an expectation of improvement is more likely to interpret previously threatening situations as less threatening or, additionally, as being of manageable proportions, that is, the person now comes to believe that their coping capacities are adequate to face and manage the threat.
- Change in behavior: A depressed or anxious person is more likely to isolate themselves – a depressed person because of their lack of positive hedonic response to here-to-for rewarding situations and an anxious person because of their need for security and avoidance of potential threats. A person with the belief that they are improving, however, is more likely to break out of their isolation and, thus, place themselves into situations that are reinforcing. For example, a depressed, isolated person misses out on the positive interactions with family or friends, having a delicious meal at a new restaurant, or seeing a new exciting show or art exhibit. The reward-seeking behaviors slowly extinguish, forming a vicious cycle of increasing isolation and fixedness (stabilization) of the isolation. These individuals also end up missing out on, for example, being part of a group of like-minded individuals passionate and working together on some project or cause. Being part of these types of groups is particularly beneficial to depressed or anxious persons because the enthusiasm of the group members, the working on a good cause, and the opportunity to be distracted from one’s own petty but compelling fears, grudges, and preoccupations that breed hopelessness provides layers of health-inducing, virtuous-cycle-inducing rewards.
- Self-fulfilling prophecy: A person who expects to improve is likely to improve through the mechanisms outlined above. And as they notice the positive changes that follow their positive expectations, they are confirmed in their positive expectation, and they form a confirmation bias towards further improvement. Just as feedback loops among attention, beliefs, behaviors and emotions interact on the way down to deepen depression or anxiety, they also interact, this time beneficially, on the way back to health. This is especially true if we as clinicians know how to nurture these virtuous cycles and, separately, how not to undermine them inadvertently through lack of understanding.
With this as background, let me now share some ways of speaking with patients that can nurture the placebo effect, that is, the self-reinforcing changes leading to health and healing. You are free to accept, reject, or alter the following conversational approaches as you see fit. (Also, I’d love it if you wrote me and shared some of your conversational or other approaches you use to help guide a patient’s developing expectations.)
- [If patient tells me her friend responded well to Prozac]: “Prozac is an excellent choice of medication. It is a powerful medication and works well for many, many people with depression.”
- “By virtue of its effectiveness, it does have some side effects, which I’ll explain in a moment. Often, these are signs that the medication is beginning to work. Most of the time, a person starting on Prozac can put up with these unwanted effects. Sometimes, though, we need to consider perhaps decreasing or stopping the dose. I’ll make sure you know just what to do if you have any of these experiences.”
- “Now, let me switch gears and tell you about what I call the ZigZag effect. It’s an approach to help you get well more quickly. I call it the ZigZag because as the medication is working to help you, you are working to help the medication, so it can help you that much more. One mistake a person with depression can make, especially after a period of being isolated, is to think they have to be almost 100% better before doing the things they liked to do before their depression. But with the ZigZag approach, when you feel even 5% better, you take some little step to become more active. So, as the Prozac gives you a “Zig” you give it a “Zag” back. Back and forth, you and the medicine work together to get you back on your feet. You can think of the medicine as opening an opportunity for you to get back to doing satisfying things in your life again.”
- “Before you leave today, I’d like to ask you what little positive change you can make that won’t be too stressful and most fun. We can brainstorm together and come up with a concrete plan. How does all this sound?”
- “Then a little later, as you notice yourself feeling better, you will want to add more beneficial activities.
- “As you can imagine, we psychiatrists have a lot of tricks up our sleeves, a lot of therapies and exercises available to help you get to feel great again. I’m just raising this with you now, so you know these opportunities exist. For example, some people like to add meditation to their daily routine. That may be something good for you too, because it’s very effective for anxiety. We can discuss all these options as we continue to meet.”
Until next time,
“When I read the ghastly lines of tragedy darkly penned into my life, I turn and notice that the pen in my hand is wet.”
Craig D. Lounsbrough
“If you expect the battle to be insurmountable, you’ve met the enemy. It’s you.”
Khang Kijarro Nguyen
“Dare to believe in the reality of your assumption and watch the world play its part relative to its fulfillment.”
“As you grow older, you will discover that you have two hands, one for helping yourself, the other for helping others.”