This article has been updated from an essay written for the module Ritual Healing and Therapeutic Emplotment for the MSc degree in Medical Anthropology at University College London (UCL) in 2017.
by Maria Larrain, MPhil BOst DPO PgC ACE
Redefining placebo as a “meaning response”
The placebo and nocebo response are two sides of the same coin – how can someone report an improvement in their illness from seemingly innocuous therapeutic input? How can the mere suggestion of possible side-effects worsen someone’s symptoms? (1). As argued by anthropologist Moerman (1981), placebo is inert and, therefore, cannot be responded to, but the evident neurophysiological response to the placebo effect due to expectations and beliefs needs to be renamed the ‘meaning response’ (2). From the early studies in the 1960s, placebo has evolved into a very complex field of inquiry involving a cross-section of disciplines, aided by the advancements in neuroscience and neuroimaging (3). It is thought that the neurophysiological effects of placebo are mediated by the autonomic nervous system (ANS) and limbic system in the cerebral cortex. As a result of the theory of the ‘meaning response’ proposed by Moerman (2002), it has been possible to provide a plausible biological explanation for why people heal as a result of narrative and symbolic healing experiences. (5).
3 responses to healing: autonomous, specific, and meaning
Since anthropology is concerned with studying what makes us human, the placebo and nocebo response are of interest to anthropologists. We share a common biology and nervous system, but how we respond is subject to cultural variations and it is this variation that occupies medical anthropologists. According to Moerman (2002), humans have three adaptive responses to injury, which have evolved over millions of years of evolution: autonomous, specific, and meaning-based responses. The autonomous response is the homeostatic response, the physiological dynamic balancing act in response to an insult. The specific response is the body’s response to a cut, in which blood coagulates and scar tissue forms as a result of inflammation. This is the narrow biological definition of healing. In the ‘meaning response’, cultural, social, and symbolic processes interact with biological processes. Therefore, it would be more accurate to describe human healing as an integrated experience that does not ignore biological or evolutionary factors, which has been a tendency in anthropology (6). In the same manner, it is not accurate to refer to human healing as being solely determined by biological factors, as is the common practice in science-based medicine. (5, 7)
The rebranding of the placebo response
It is grudgingly accepted, if not outright contentious, that the placebo response has a place in modern medicine, despite the old bioethical precept “first, do no harm” (8). Apprehensions about the placebo response in modern healthcare are both historical and philosophical, bound to the ‘objectivist’ view inherent in traditional Western philosophy (9). An international gathering of several hundreds of scientists from a variety of disciplines, including neuroscience and clinical psychology, was held in April 2017 at The Society of Interdisciplinary Placebo Studies (10). They were seeking to rebrand placebo and focus on the booming research area of expectations, motivations, and beliefs relating to the effect of these factors on health. According to neuroscientist Vitality Napadow of Massachusetts General Hospital and Harvard Medical School, placebo implies fakery, deception, and sham. In the past, placebos have been used as a benchmark to measure the efficacy of pharmaceuticals (3). Medical research that is conducted using double-blinded trials is the gold standard. The double-blinding process acknowledges that a drug’s effectiveness may vary depending on who administers it, how it is administered, what colour it is, and what story is being told about its efficacy or side effects (12, 5).
“Healing occurs when both therapist and patient inhabit the same mythical word, and the patient accepts the therapist’s power to redefine the patient’s relationship to it”
It is human nature to be sensitive to narratives that create meaning and what anthropologists refer to as symbolic healing. Kleinman and Sung (1979) (13) defined ‘disease’ as a distinct biological or psychological dysfunctional entity, whereas ‘illness’ was defined as the patient’s psychological and cultural response to the disease, as well as the response of the patient’s family and social network. Based upon their research, they concluded that Taiwanese shamans provided relief to their clients’ illness experiences by using narratives and symbols that were culturally and socially significant to both. Healing occurs when both the therapist and the patient inhabit the same mythical world, and the patient accepts the therapist’s power to redefine the patient’s relationship with it. Anthropologists believe that this applies whether scientific medicine or magic is used (14).
There is no way for a biomedical doctor, osteopath, or shaman to practice in a vacuum, free from the non-specific effects their narratives and symbols have on their patients. There is a large component of placebo healing through symbols in modern medicine too, or what anthropologists refer to as biomedicine (2, 7). As a symbol of the doctor’s technical skills, stethoscopes worn by doctors in hospitals have a strong cultural significance that inspires confidence in their ability to use this instrument to detect life and declare death as well as serving as a sign of their professional status. There is evidence to suggest that the doctor is the single most important factor in determining the meaningful quality of medicine and, therefore, the placebo response. The more enthusiastic the doctor, and the more committed they are to their technical skills, the more significant the placebo response (2).
The importance of meaning in healing
To facilitate healing, the therapeutic process must have meaning for the individual seeking treatment, even if they do not fully comprehend its mechanics (13, 5, 15). Through the autonomous placebo response, meaning itself can transform a person’s illness experience. Patients’ ability to create meaning from their illness experience and their healing is dependent on their understanding of themselves, their bodies, the healing system, and its symbols, and how the healer manipulates the symbols to elicit a healing response.
The therapeutic relationship
In The Lost Art of Healing, cardiologist Bernard Lown (1996) (16) bemoans the loss of doctors’ bedside skills in technology-focused medicine. He argued that a great deal of emphasis is placed on the importance of knowledge and technical skills in therapeutic encounters, while the social and cultural interaction between the healer and the patient is given less attention. There are several clinical functions healthcare systems share, including the cognitive and communicative process of explaining illness and disease through narrative and this is dependent on the healer and the patient (13). In neuroscience and physiology, we are beginning to understand how the patient’s brain and the doctor’s brain interact to produce therapeutic effects (3).
How do osteopaths regard placebo?
Placebos are powerful therapeutic tools that deserve to be brought out of the shadows, and this is especially important for manual therapists (17). For a profession such as osteopathy that describes itself as holistic, i.e., considering mind and body as interconnected, there is an element of embarrassment that the placebo response produced by interaction with the patient is of therapeutic value, if not of primary significance. A large part of this is due to how we are attempting to adapt ourselves to the biomedical paradigm. Rather than embracing the placebo effect, we blind ourselves to it throughout our research and trials, then wonder why there is no statistical difference. There is a great deal of difficulty in blinding oneself to the non-specific effects of a therapeutic encounter which is based on the physical and cognitive interaction between the practitioner and patient, where meaning is generated in the moment-to-moment experience. In contrast to randomized controlled trials, our type of healthcare is well suited to being studied using inter-subjective embodied phenomenology. Research in physiotherapy and nursing is increasingly using this method (18).However, more recent osteopathic research has followed suit with a better understanding of how to use phenomenology to study the therapeutic interaction between osteopaths and patients. In the study of cranial osteopathy, this is particularly useful (19).
Allogrooming
As a result of feeling vulnerable, our physiology is less capable of healing. A study examining the recovery of chronic lower leg wounds found that greater fear and distress prior to surgery was associated with poorer outcomes, and that depression and anxiety were predictors of delayed wound healing (20). Biological response to placebo is linked to our desire to feel cared for. In Latin, placebo means “I shall please.” It is the caring, compassionate, empathetic, and supportive role of the healer that contributes positively to our healing process. It is possible that this is an evolutionary adaptation. It has been argued by physiologist and neuroscientist Benedetti (2013) that doctor-patient relationships can be seen as a unique social interaction that developed as a result of social grooming during human evolution. It is believed that allogrooming, which involves caring for the body surfaces of others, is a function related to the cerebral cortex. To strengthen kinship bonds and later exchange grooming for food, our ancestors may have engaged in altruistic grooming and grooming exchanges.
The nocebo response
While we have evolved to respond positively to the care of others, we are also susceptible to the negative effects of carelessness and outright malice. The term ‘homeostasis’ and the phrase ‘fight or flight’ were coined by physiologist Walter B. Cannon at the turn of the 20th century (21). He may also have been the first scientist to report on the nocebo effect. He was fascinated with the physiology of emotions, and in 1942 he wrote an article about the Voodoo Death. He had been told by anthropologists about the practice of cursing people by pointing a bone at them where they subsequently died. Cannon explained the physiological effects of seemingly innocuous injuries such as cursing and magic as an extreme “fight or flight” response. In his discussion he did not address the pathway from high emotion to eventual death, but there is evidence that the body’s stress response can lower the immune system so that it becomes susceptible to disease (22). Cannon did not elaborate on whether this was the path to death, but it is possible that people cursed also experienced behavioural changes that may have affected their access to food and shelter.
The Cartesian quagmire – bringing the biological and psychosocial together
While anthropologists have been interested in the effects of symbols, beliefs, and culture on healing for decades, there has been a conceptual Cartesian quagmire that has proven difficult to escape. The field of anthropology has historically viewed biological processes and mental processes as distinct phenomena rather than as interrelated ones (23). It has been argued that ethnographers lack an understanding of the ANS or ignore its importance in human behaviour completely (24). As a result of calls for an integrated approach to anthropology (6), this concern has been addressed more recently in biosocial anthropology.
When describing the efficacy of Cuna shamans in Panama, Lévi-Strauss (1963) (25) used parallels with psychotherapy and transference. In his account, he illustrates how mythological songs can be used to alleviate the suffering of a woman during difficult childbirth: ‘The song constitutes a purely psychological treatment, for the shaman does not touch the body of the sick woman and administers no remedy’ (p. 197) (25). A cognitive effect, as well as the fact that the woman believed in the myth and lived in a society that believed in it, was credited by him as the reason for the effectiveness of the Cuna song. Nevertheless, we know that acute stress may enhance the susceptibility to the meaning of metaphors and trigger a physiological response (25). The intention of the Cuna shaman’s song was to describe the pains of the sick woman and to identify them as mythical beings. In order to provide some order and coherence to her chaotic and disordered psychological and physical state, the shaman “re-integrate (the pains) within a whole where everything is meaningful” (p. 197) (25). As the shaman named the pain and made it meaningful to the woman, he fulfilled an important part of the meaning model of illness, which is comparable to providing a diagnosis. In essence, a diagnosis is a coherent narrative that helps both the patient and the healer to make sense of the situation. The diagnosis provides a meaningful explanation for the unruly sensations in the patient’s body as well as serving a healing function in and of itself (26, 27). As a result of the meaning response, it is more difficult to dismiss shamanic healing as superstition or suggest that its efficacy is due to pure chance.
The biopsychosocial model
The placebo response is an evolutionary adaptation that occurs in response to receiving care. In pain management, the placebo response is a valid mechanism for improving outcomes, and manual therapists must consider how their narrative can maximise this response within ethical limits (17). It is also imperative that they examine ways to reduce narratives that may lead to catastrophising and the nocebo effect. When Waddell (2009) first introduced the biopsychosocial (BPS) model into musculoskeletal medicine in The Back Pain Revolution, he asked the question of why some people recover from back pain while others become disabled by it and noted that the medicalisation of back pain was making people worse. In order to achieve a positive outcome from a BPS perspective, it is important to provide a narrative that is sensitive to the illness experience of the individual. People in pain are more likely to achieve better health outcomes if their narrative is focused on their health than if they are told a biomechanical narrative that includes explanations such as ‘leg length discrepancies’ or ‘pelvic torsions’, which medicalize benign musculoskeletal presentations and increase catastrophizing, a predictor of poor outcomes. (28).
The effect of consent and communication
Health outcomes for osteopathic patients are so greatly impacted by expectations and communication that the regulator has made it mandatory for osteopaths to improve their communication and alongside their technical skills (29). In addition, we are required to inform our patients of the possibility of adverse effects from certain techniques, such as the minimal risk of stroke associated with cervical manipulations. In modern healthcare, it is ethically imperative to have a shared decision-making process and informed consent, however, these processes can shape patient expectations, which can in turn influence the effectiveness of the therapy (12). It would be interesting to know if this process predicts reported adverse effects of cervical manipulations. It has been found that reporting of side effects is associated with negative expectations in medical nocebo studies (1). Using functional magnetic resonance imaging (fMRI), negative expectations completely abolished the analgesic effect of a potent opioid in a pharmacological study (30). Healthcare practitioners, including osteopaths, must be mindful of how they communicate adverse effects to their patients.
Curing is different from healing
Modern healthcare often fails to address the subtleties of emotion, ritual, and culture, according to Moerman (2002).His critique extended to the failure of biomedicine to address our understanding of our ecology; the understanding of cycles of relationships with others, plants, animals, and the climate. In recent years, however, biomedicine in the UK has taken a holistic turn with an increased emphasis on personalised care and social prescribing (31). This is in recognition of the social determinants of health (33).
It is important to note that biomedicine may cure but not always heal; a post-cancer patient may live with the fear of cancer returning and have experienced a life-changing event that may have affected their work, their relationships with others, and most importantly, their relationship with their body. It is often our privilege as osteopaths to assist patients during the healing process following cancer treatment. As a patient once reported, they felt supported during the medical treatment, but they felt abandoned and vulnerable once they were informed, they had been cured. In addition to feeling exhausted, they had lost trust in their body and health. Having experienced postoperative pain, they sought osteopathic care and support for this part of their healing journey. During treatment, we discussed how cancer had affected their lives and what they hoped for the future. Within a few weeks, they began to feel better and started working again and exercising, which helped restore what they had lost through the illness experience – their social relationships and their relationship with their body. When I help my patients through their healing process and assist them in ‘re-integrating themselves into a whole where everything makes sense, is my work really that different from that of a Taiwanese or Cuna shaman? Seeing myself as an osteopath through the eyes of an anthropologist, I do not believe this is the case.
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