While I have been gaily writing blogs on any passing topic that piques my interest, I am all too well aware that I can only do this because I stand on the shoulders of all those osteopaths (and other manual therapists) who spend considerable time and intellectual effort doing the sterling groundwork necessary to create these courses and gain the depth of knowledge which means I have things to write about,
Nowadays I get contacted by people who have produced interesting work, but who have no platform to disseminate it, so I have decided to flesh out this site with more of the intellectual substance that we all know there is in our profession. I was very grateful to Stephen Tyreman for his guest blogs, and now I am following up with an essay by Maria Larrain, about placebo, (that very topical issue). It is adapted from a piece of work she submitted for her Masters degree in Medical Anthropology at UCL (not UCO, UCL! – although she does teach paediatrics at UCO). It brings together many current themes – narrative, a potential move towards phenomenological research rather than solely RCTs, the meaning of illness, and the importance of communication. I find particularly interesting the notion that healing occurs when
- therapist and patient inhabit the same mythical world
- the patient accepts the therapist’s power to redefine their relationship to it
Thanks to Maria for her permission to print this. I am sure you will also find food for thought here..
Meaningful Healing– Bridging the gap between the mind and the body through the placebo and nocebo response.
By Maria Larrain BSc BOst DPO PgC ACE
This article is based on an essay that I wrote for the module Ritual Healing And Therapeutic Emplotment for my MSc degree in Medical Anthropology at University College London (UCL).
Redefining placebo as the “meaning response”
The placebo and nocebo response are two sides of the same coin – how can someone report an improvement in their illness by seemingly innocuous therapeutic input? How
can someone experience worsening in symptoms by the mere suggestion of the possibility of side-effects? (1). Anthropologist Moerman (1981) argued that placebo in itself is inert and therefore cannot have a response, but that the evident neurophysiological response to what is termed ‘placebo’ as result of expectations and beliefs should be redefined to be called the ‘meaning response’ (2). Placebo has become a very complex area of inquiry since the early studies in the 1960s, involving a cross-section of disciplines aided by the advancement in neuroscience and neuro-imaging (3). The neurophysiological effect of placebo is modulated by the autonomic nervous system (ANS) and limbic system in the cerebral cortex(4). Moerman‘s theory of the ‘meaning response’ (2002) has provided a plausible biological explanation of why people heal in response to narrative and symbolic healing. (5).
3 responses to healing: autonomous, specific, and meaning
The placebo and nocebo response is interesting for anthropologists because anthropology is the study of what makes us human. 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. Moerman (2002) defined humans as having 3 adaptive responses to injury, which are innate healing processes perfected over millions of years of evolution; autonomous, specific, and the meaning response. The autonomous response is the homeostatic response, the physiological dynamic balancing act that the body does in response to an insult. The specific response is the response our body has to a cut, where blood will start coagulation and scar tissue will form through the process of inflammation. This would be the narrow biological definition of healing. The ‘meaning response’ is where cultural, social and symbolic processes interact with biological ones. This suggests that it is 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). Neither is it accurate to describe human healing as being reduced solely to biological factors, which has been the tendency in science-based healthcare. (5, 7)
The rebranding of the placebo response
Despite the old bioethical precept ‘first, do no harm’, the placebo response and its place in modern healthcare is grudgingly accepted, if not outrightly contentious (8) . The apprehension of embracing the placebo response in modern healthcare is both historical and philosophical and is bound to the ‘objectivist’ view that runs deeply in traditional Western philosophy (9). In April 2017 an international gathering of several hundreds of scientists from a variety of disciplines such as neuroscience and clinical psychology met for the first time at The Society of Interdisciplinary Placebo Studies (10). Their aim was to rebrand placebo and focus on the booming area of study on how expectations, motivations and beliefs can shape health. As neuroscientist Vitality Napadow from Massachusetts General Hospital and Harvard Medical School noted, placebo implies fakery, a sham and a desire to deceive (11). Placebo has traditionally been used as a benchmark to measure the efficacy of pharmaceutical drugs (3). The double-blinded trials are the ‘gold standard’ in medical research and the double-blinding is an acknowledgement that a drug’s efficacy can vary depending on who gives it, how it is given, 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”
Humans are susceptible to narrative that creates meaning and what anthropologists refer to as symbolic healing. Kleinman and Sung (1979) (13) distinguished between ‘disease’ as a distinct biological or psychological malfunctioning entity, while ‘illness’ was seen as the patient’s psychosocial and cultural response to disease that also included the patient’s family and social network response to it. They explored the efficacy of Taiwanese shamans and concluded that their success was because they focused on alleviating their clients ‘illness experience’ with the social and cultural meaningful use of narrative and symbols. Healing occurs when both therapist and patient inhabit the same mythical world and the patient accepts the therapist’s power to redefine the patient’s relationship to it. Anthropologists consider this as universally valid whether it is in the use of scientific medicine or the use of magic (14).
Neither biomedical doctor, nor osteopath or shaman, practice in a vacuum able to escape the non-specific effect they have on their patient as result of their narratives and symbols, or techniques. Modern medicine, or what anthropologists call biomedicine, has a large component of placebo healing through symbols (2, 7). Symbols such as the stethoscope worn around the neck by doctors in hospitals carry with them a cultural significance that inspires confidence in the doctor’s technical skills in the use of instruments to detect life and declare death, as well as carrying a sign of professional status. There is evidence that the single factor that shapes the meaningful quality of medicine and hence the placebo response is the doctor. The more enthusiastic the doctor, and the more committed they are in their technical skills, the greater the placebo response(2).
The importance of meaning in healing
For healing to take place there has to be meaning to the therapeutic process for the person seeking treatment, even though they may not understand the mechanics of exactly how it works (13, 5, 15). The meaning itself has therapeutic potency to transform a person’s illness experience through the autonomous placebo response. How a patient creates meaning of their illness experience and their healing is subject to their understanding of themselves, their body, the healing system and its symbols, and their understanding of 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 the technology-focused practice of medicine. Knowledge and technical skills are seen as the most important aspects in the therapeutic encounter, while the social and cultural interaction between the healer and patient is less valued.
One of the clinical functions healthcare systems have in common is the cognitive and communicative process that is used to explain illness and disease in the form of narrative, and this is dependent on the healer and the patient (13). Neuroscience and physiology are beginning to understand the complex interplay between the patient’s brain and the doctor’s brain where the key elements of therapeutic effect are produced (3).
How do osteopaths regard placebo?
Placebo is a powerful therapeutic tool that deserves to come out of the shadows and this is particularly relevant for manual therapists (17). Ironically for a profession like osteopathy that describes itself as ‘holistic’, i.e. sees mind and body as interconnected, there is a degree of embarrassment that the placebo response produced in the interaction with the patient is of therapeutic value, if not the biggest value. This is bound to how we try and accommodate ourselves to the biomedical paradigm. Rather than embracing the placebo response, we try to blind ourselves to it in our research and trials and then wonder why there is often no statistical difference. In a therapeutic encounter that is dependent on the physical and cognitive interaction between practitioner and patient, where the meaning is created in the moment-to-moment experience, it is nearly impossible to blind yourself to its non-specific effects. Our type of healthcare lends itself to be studied using inter-subjective embodied phenomenology as a research tool rather than RCTs. It is a method that is increasingly being used in physiotherapy and nursing research (18).
When feeling vulnerable our physiology is less able to heal. Studies examining post-operative wound healing 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 in adults with chronic lower leg wounds (19). Placebo means “I shall please” in Latin, but the biological response to it is bound to our desire to feel cared for. We respond positively to the caring, compassionate, empathetic and supportive role of the healer. This may be an evolutionary adaptation. Neuroscientist and physiologist Benedetti (2013) (3) argues that the doctor-patient relationship is a unique social interaction that emerged during evolution as result of social grooming. The caring of body surfaces and particularly the skin of others, known as allogrooming, is a function related to the cerebral cortex. Our ancestors may have used the altruistic exchange of grooming and being groomed as a way of strengthening kinship bonds and later exchanging grooming for food.
The nocebo response
If we have evolved to respond positively to the care from others, we are also susceptible to the negative effects of carelessness or downright malevolence. Physiologist Walter B. Cannon first coined the concept of ‘homeostasis’ and ‘fight and flight’ (20). He may also have been the first scientist to report on the nocebo response. He was concerned with the physiology of emotions, and in 1942 he wrote an essay about Voodoo Death, having heard from anthropologists about the practice of cursing people by pointing a bone at them where the subjects subsequently died. Cannon explained the physiological effects on health from seemingly innocuous injuries such as cursing and magic as an extreme “fight or flight” response. His discussion did not include the pathway from high emotion to eventual death, but it is possible for the immune system to be lowered by the body’s stress response to make it susceptible to disease (21). If this was the pathway to death, Cannon did not elaborate, but it is conceivable that people cursed also experienced behavioural changes in themselves and their community that may have affected access to food and shelter.
The Cartesian quagmire – and how to marry the biological with the psychosocial
Although anthropologists have been concerned with the effect of symbols, beliefs and culture in healing for decades, there has been a conceptual Cartesian quagmire that has been difficult to escape. There has been a tendency in anthropology to see the biological and mental processes as distinct rather than integrated variables (22). Ethnographers were criticised for lacking understanding of the ANS, or completely ignoring its significance in human behavior (23). Anthropologist Lévi-Strauss (1963) (24) used parallels with psychotherapy and the mechanism of transference when he addressed the efficacy of Cuna shamans in Panama. He depicted how they would use mythical songs to help a woman get through a 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) (24). He credited the efficacy of the Cuna song to the cognitive effect, the fact that the woman believed in the myth and lived in a society which believed in it. However, we know that acute stress may enhance the susceptibility to the meaning of metaphors and create a physiological response (25). The principal aim of the Cuna shaman’s song was to describe the pains to the sick woman and name them as mythical beings. Providing some coherence and order to her chaotic and disordered mental and physical state, the shaman ‘re-integrate (the pains) within a whole where everything is meaningful’ (p. 197) (24). By naming the pains and making them meaningful to the woman, the shaman was fulfilling a social function that is essential to the meaning model of illness, which is comparable to giving a diagnosis. A diagnosis is in essence a coherent story that constitutes a narrative that makes sense to both patient and healer. A diagnosis provides a meaningful explanation to the unruly sensations in the patient’s body and has an important healing function in itself (26). The meaning response makes it harder to dismiss shamanic healing as superstition and its efficacy a result of pure chance.
The biopsychosocial model
As I mentioned earlier, the placebo response is an evolutionary adapted response to being cared for. In pain management, the placebo response is a valid mechanism to improve outcomes and it is imperative that manual therapists consider how their narrative can maximise this response within ethical limitations (17). Likewise they should consider how narrative that is likely to create catastrophising and the nocebo response could be reduced. When Waddell 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 pointed out that the medicalisation of back pain was making people worse (27). A good outcome from a BPS perspective is dependent on a narrative that takes people’s illness experience into consideration. A positive health-focused narrative is more likely to improve the condition of people in pain than a biomechanical narrative that includes explanations such as ‘leg length discrepancies’ or ‘pelvic torsions’, which medicalise benign musculoskeletal presentations and are likely to increase catastrophising, which is a predictor of poor outcomes (27).
The effect of consent and communication
Expectations and communication are such significant factors in health outcomes for osteopathic patients that the regulator has made it mandatory for osteopaths to work on their communication skills as well as their technical skills (28). We are also required to inform our patients of the chances of adverse effects from certain techniques, such as the minimal chances of causing a stroke with a cervical manipulation. It is an ethical imperative in modern healthcare to have shared decision-making and informed consent, but this process can shape the patient’s expectations, which can in turn influence the therapeutic outcome (12). It would be interesting to know if this process is a predictor of reported adverse effects of cervical manipulations. This has been the case with medical nocebo studies, where reporting of side-effects was associated with negative expectations (1). Expectations are so powerful for the therapeutic outcome, that in a pharmacological study using functional magnetic resonance imaging (fMRI), negative expectations were shown to completely abolish the analgesic effect of a potent opioid (29). As healthcare practitioners we have to be mindful how we communicate adverse effects to our patients.
Curing is different from healing
Moerman (2002) (2) argues that the subtleties of emotion, ritual and culture are often not addressed in medical healthcare. Neither is the understanding of our ecology; the understanding of cycles of relationships with others, plants, animals and climate. Biomedicine may cure but not always heal; a post-cancer patient may live with the fear of cancer returning and have had a life-changing event that may have affected their work, their relationship with others and most importantly their relationship with their body. As an osteopath I have been privileged to help people through the healing process after cancer treatment. One woman told me that when the medical treatment was happening she felt supported through the process, but it was afterwards, when she was told she was cured, that she had a sense of abandonment and trepidation. She was exhausted and had lost trust in her body and her own health. She wanted support for this part of her healing and she was in pain. We talked a lot during treatment about how cancer had affected her life and what she hoped for the future. After a few weeks she felt better and she started working again and exercising, which helped re-establish what she had lost through her illness experience – her social relationships and the relationship to her body. In a sense, by helping my patient through her healing process and helping to ‘re-integrate within a whole where everything is meaningful’, is my work really that different to a Taiwanese or Cuna shaman’s? Seeing myself as an osteopath through the eyes of an anthropologist, I don’t think so.
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