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Key concepts about placebo I wish every reader understood 

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

One of the hardest parts of my job is The Redundancy Problem: topics that I need to cover to some degree on many pages around PainScience.com, and then also keep that coverage up-to-date. It’s a content maintenance nightmare for me.

For example, suppose I’ve made the same point about placebo 27 similar-but-different ways in 27 different books and articles (which I probably have)… and then something about that point changes! Maybe some new evidence changes my mind about it. Maybe I just think of a much better way to make the same point! Now I’ve got 27 updates to do … 😬

That kind of word-juggling act is a major part of managing PainScience.com.moreYou would not believe how many hours I’ve logged over the years with lots of text editor windows open at once, painstakingly comparing similar text, feverishly copying and pasting, trying to fit the same key points into each passage, or checking to make sure obsolete information is purged from all of them. It can get really dizzying! No joke, this is one of the main reasons I have an array of three 27" computer displaysshow — because I need a lot of virtual desk space for that kind of editing!

So, whenever possible, I just re-use the exact same text. It feels a bit like cheating, but it’s just the only sane thing to do. And so I do it, if a passage is legitimately relevant in many places, and doesn’t need any modification to fit in.

There are several points about placebo that qualify, things I wish every reader was aware of, but I can’t expect everyone to go and read about it in detail either. I need to summarize them frequently. And so I’ve created a short chapter about placebo that can be reproduced, verbatim. Any time I want to change it, I just edit a single file, and the text is automagically updated everywhere. Magic! Working smart, not hard!

And here it is …

Key points about placebo

A placebo is relief from belief: people often feel better simply because they believe they have been treated. More precisely, it is the appearance or illusion of a treatment effect that is not actually attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is over-hyped.

This is a standard section in most of my books, summarizing several key points about placebo that are important context for a thorough discussion of evidence-based treatment options. I do not support any of these points here — for readers who want to know more, there’s a more detailed article about placebo.

  • Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can collectively create the appearance of an effective treatment. Placebo is complicated!
  • Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve pain than most symptoms, because pain is entirely a product of the brain. However …
  • Placebo is not a magical mind-over-pain superpower, and it can’t affect injury and organic pathology, only the experience of them to a limited extent.
  • Placebo can backfire. When a placebo effect wears off — as it often does — people often fear that they must be really screwed. Placebo turns to nocebo, placebo’s evil twin (feeling worse because of belief).
  • Placebo potency is driven by whatever impresses the patient with the seriousness and legitimacy of a treatment: risks, costs, size, intensity, technology and even odd minutiae like the colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is all about putting on a show.
  • One of the best ways to impress people is with novel and intense sensations, because the patient can feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are sensation-enhanced placebos (“interactive therapy theatre”).
  • Placebo has been hijacked and re-branded for its public relations value to alternative medicine. “The power of placebo” is widely used as a justification for therapy that can’t beat a placebo.
  • Placebo does not work when you know it’s a placebo, contrary to what many people have heard (based on a couple bad scientific papers). The idea of “placebo without deception” is bullshit.
  • Many snake oils supposedly work on animals, and if animals are immune to placebo then the treatment must be legit. But animals (and their biased human observers) are definitely not immune to placebo.

Is it okay to pay for a placebo?

Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And placebo can work! So why not? This is an extremely common sentiment.

I have no problem with people paying for a placebo as long as their eyes are wide open, but the wider your eyes get the less likely the benefit. And there are very strict limits to what placebo can do. And paying for things is never completely harmless.

Treatments with unknown efficacy but some plausibility and low risks are the least objectionable placboes to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual effect, and I’m willing to pay a little for that chance. But, for me, the plausibility has to be there.

Comic strip of a man standing in front of shelves full of bottles and boxes. On the left, the products are labelled “Placebos.” On the right, they are labelled “Fast-acting, extra-strength placebos.” The caption: “Hmm, better go with these.”

Cartoon by Loren Fishman, HumoresqueCartoons.com.

Above all, what I want readers to take away from this is that placebo is not therapy. It’s mostly just an over-rated curve ball that accounts for an awful lot of temporary “success” stories.