Friday, June 05, 2015

The Placebo Effect and Psychotherapy

What the power of positive thinking may have begun to lose by the late 1990s in terms of political stridency, it gained in terms of biomedical responsibility. More than anything else, this respectability was gained through the increasingly firm identification of positive thinking with the placebo effect. Between 1997 and 2000, there appeared no fewer than five academic books on the placebo effect (one of which I edited)…. The main argument offered by the new literature was that the placebo effect was important above all for what it taught us about self-healing. It was not just a trick; it produced real (physiologically discernible) effects….—Anne Harrington

The placebo effect depends on the art of deception (perhaps even ‘self-deception,’ as suggested in what follows). It’s certainly possible that psychotherapy, in part, relies on this, or at least an analogous process, as Jon Elster argues in Sour Grapes (1983):

“How are we to reconcile the facts—or rather impressions—that (i) there is a great deal of successful therapy, (ii) therapists believe that a good theory is essential for success and (iii) very little of the variance in therapeutic success is explained by the therapist’s choice of one theory rather than another? [I don’t think this necessarily means that ‘anything goes,’ but that’s an argument for another day.] Often the theory tells the therapist to bring about some intermediate state (analogous to the buried treasure [from La Fontaine’s fable of the laborer and his children]) as an indispensable stepping stone to the final goal of mental health (corresponding to wealth in the fable). In psychoanalysis, for instance, it is argued that the intermediate state of insight or ‘Bewusstwerden’ is required for the final goal of ‘Ichwerden’ to be realized. My suggestion is that in therapy the final goal is not realized instrumentally through the intermediate state, but as a by-product of the attempt to bring about that state. Moreover, there may be several, different intermediate states that, if pursued seriously, can lead to this outcome. Crudely put: the therapist must believe in some theory for the therapeutic activity to seem worth while, and it will not be successful unless he thinks it worth while. Therapist and patient are accomplices in a mutually beneficial folie à deux.”

So, should a psychotherapist be persuaded by the above account, can he or she remain a therapist? In other words, would this newly won knowledge undermine her attempt to practice therapy, given that she can no longer believe the “right theory” is indispensable to therapeutic success? (See chapter 8, ‘Psychotherapy—The Purest Placebo?,’ in Evans below for an extended discussion of some of the relevant issues.)

We might compare this to an earlier story told by Elster in which a therapist attempts to bring about sleep for an insomniac. Elster describes a technique in which the patient is given instructions for the following night to “note very carefully, every five minutes, all the symptoms of insomnia, such as dizziness, headaches, a dry throat. This, the therapist says, is essential if he is to be able to come up with suggestions for overcoming the insomnia. The patient, naively and obediently, does as instructed, and promptly falls asleep. Sleep has come, but as a by-product—and in this context is it essentially a by-product, since the effect would have been spoiled had the therapist told the patient about the point of the instructions.”

One thing Elster does not discuss, however, is that this “technique” does not seem repeatable: it’s a one-shot strategy, at least with a clever or even halfway intelligent patient, who will soon discover the “real” purpose of the therapist’s instructions.

References & Further Reading:
  • Benedetti, Fabrizio. Placebo Effects. New York: Oxford University Press, 2nd ed., 2014.  
  • Brown, Walter A. The Placebo Effect in Clinical Practice. New York: Oxford University Press, 2013. 
  • Elster, Jon. Sour Grapes: studies in the subversion of rationality. Cambridge, UK: Cambridge University Press, 1983: II. “States that are essentially by-products”: 43-108.   
  • Evans, Dylan. Placebo: Mind over Matter in Modern Medicine. New York: Oxford University Press, 2004.
  • Gillett, Grant R. Bioethics in the Clinic: Hippocratic Reflections. Baltimore, MD: Johns Hopkins University Press, 2004.
  • Gillett, Grant R. The Mind and Its Discontents. New York: Oxford University Press, 2nd ed., 2009.
  • Harrington, Ann. The Cure Within: A History of Mind-Body Medicine. New York: W.W. Norton & Co., 2008. 
  • Harrington, Anne, ed. The Placebo Effect: An Interdisciplinary Exploration. Cambridge, MA: Harvard University Press, 1997.
  • Kolber, Adam J. “A Limited Defense of Clinical Placebo Deception,” Yale Law & Policy Review, Vol. 26, 2007; San Diego Legal Studies Paper No. 07-87.
  • Miller, Franklin G., et al., eds. The Placebo: A Reader. Baltimore, MD: Johns Hopkins University Press, 2013.  
  • Moerman, Daniel E. Meaning, Medicine and the ‘Placebo Effect.’ Cambridge, UK: Cambridge University Press, 2002.


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