Kenneth Gilbert, MD

Placebo: a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any physiological effect.

Nocebo: a detrimental health effect produced by psychological or psychosomatic factors, such as negative expectations of treatment or prognosis.

The mom said very little as I interviewed her teen-aged son, but her active eyes let me know that she took in everything that had been said. By the end of the assessment I was clear that this set of complaints did not line up with any usual diagnosis and was processing my list of medical illness that can masquerade as psychiatric issues. I needed lab work to take the next step but as is often the case in this rural part of the country I anticipated that the family would not have insurance to cover it. (Details of this case have been changed in respect of personal privacy, but the situation as described represents the clinical challenge.)

I handed the mom my lab requests and had started to explain where I thought the work could be done at least cost. She folded over the lab order and placed it thoughtfully in her purse, and then mentioned to me that they appreciated my effort but the family was going to pursue “natural” therapy to see if that might be useful. She named the product they would use. I pivoted into my “we will support whatever modality you decide to use” comment, and things were left in suspension as they left without making a follow up appointment.

That evening I did a quick web search to discover just what she had been talking about when she said “natural” therapy. My web search revealed that she was referring to an apparatus operating with a name that is printed out to look very much like the logo of a recognizable nation-wide laboratory service. The apparatus consists of 2 metallic handgrip bars that vibrate slightly and a set of blue lights that dance in various patterns in front of the person. While holding onto the brass handgrips, electronic sensors are said to detect something called energy signatures, and the online explanation reports that it detects 40,000 medical abnormalities. The product website includes a small disclaimer that the product “does not diagnose, cure, prevent or treat disease.” It further notes that those with a medical condition or concern should consult an appropriate health care professional. These statements are obviously meant to protect the company from any sort of legal liability. The problem, of course, is that the individuals who are making use of this product see the ream of “data,” not the disclaimer nestled on the bottom on the homepage.

I later got in touch with the family and asked for a copy of these results. The data print out covered more than 10 pages of supposed indicators, and I specifically noticed that the printout did not include the small disclaimer that was on the website.

I strongly suspected that there was a treatable cause for this young man’s symptoms, and doubted that it should be thought of as a psychiatric syndrome. I thought that he needed something much more substantial than a read out of the “energy signatures” of his body.

At the same time, you can see the attraction to the family of the “natural” evaluation. On the one and the patient’s family has Dr Gilbert, who looks worried, says he does not really know what is going on, and orders about $400 worth of lab work during the very first appointment. On the other hand, the family has the confidence of a local unlicensed practitioner/purveyor of this product who comfortably assures the family that he can quickly and inexpensively determine the problem and recommend a set of “natural” remedies to address it. After 4 or maybe 5 treatments, or perhaps a recommended course of supplements that he will be glad to sell them at a special discount price, all will be well. His fee is a lot less than $400.

I think I can say that this fancy apparatus offers a high-tech method to create a placebo effect. Harvard researcher Ted Kaptchuk 

 and makes the point that “the placebo effect is more than positive thinking—believing a treatment or procedure will work. It’s about creating a stronger connection between the brain and body and how they work together.” He continues, placebos “have been shown to be most effective for conditions like pain management, stress-related insomnia, and cancer treatment side effects like fatigue and nausea.”

 Other researchers have shown that, properly used, placebo is not only as effective as opiates for some categories of pain, but apparently involves the same brain receptors as opiates do. Having used appropriate mind-body methods for alleviating pain, the subsequent administration of naloxone resulted in pain return just as it does when pain has been managed by opiates.

I want to be respectful of the placebo benefit, although the phrase can imply a worthless remedy, sold by a shyster. Of course, I need to stay centered in my own training and tradition as an allopathic physician. That training appropriately emphasizes the role of the scientific method to prove that something works. At the same time, I am humble enough to know there are other healing traditions that make other assumptions about causes of illness. Science is very important in my tradition, but science does not yet explain everything, and given the millions of visits that are made annually to non-allopathic healers in the United States, we have to conclude that they provide relief that is valued even if we do not understand how that happens.

There are several healing traditions that appear to rely on what allopathic medicine calls placebo:

—American Metaphysical Health Movement: Phineas P. Quimby (1802 to 1865) invented this approach to illness that is now carried on in a movement. It persists today in groups such as Christian Science, Unity, and Divine Science, all of which continue to serve a large following.

 At the time of its inception, this treatment option may well have gotten overall better results than the standard medical options of the day.

— Indigenous medicine: Notwithstanding the role that herbal preparations may play, virtually all indigenous medicine applies spiritual insights to their healing capacity through ritual and often community support.

: With no disrespect to its practitioners who have explained its theory of body energy to me, I hold that Reiki is a placebo strategy.

: chiropractic practitioners in my experience apply placebo in addition to physical manipulation and (generally excellent ) history-taking.

 Since there are thousands of chiropractic visits annually in the United States, we must acknowledge their healing benefit. Practitioners of allopathic medicine are quick to point out that there are a few individuals who are permanently paralyzed every year from an 

 Allopaths cannot be too smug in this observation, however, since by comparison, the favored allopathic treatment for headache (nonsteroidal anti-inflammatory drugs) account for about 7500 deaths per year in the United States.

Somewhere in this conversation, we have to recognize that traditional, organized religious practice brings many of the benefits we attribute to mind-body therapies. A 10-year study of individuals who stated that religion was very important in their lives had one-tenth the frequency of depression compared with those who said religion was of no importance in their lives.

 A 16-year study involving almost 150,000 women revealed that those who attended religious services more than once per week experienced 33% lower all-cause mortality compared with women who had never attended religious services.

 Religion has been providing guided imagery, as well as therapeutic suggestion, meditation, and some forms of hypnosis for as long as we can track back through recorded history. Of course, there are many problems with a psychiatrist promoting specific religions to patients, but we certainly should support our patients’ proposals to make use of their own religion as a healing modality.

Challenged to participate in multi-modal care

Let me return to my teenaged patient being assessed with flashing blue lights and vibrating grip bars. The conversation about how to proceed presented obvious challenges. I attempted to respect the potential placebo effect, but at the same time perform my medical duties in an ethical way. There was yet another layer of complexity to the conversation, because this family belongs to a religious community that selectively uses allopathic medication, but does not enroll in individual health insurance programs. If there is an expensive diagnostic course, paying for it will involve communicating the whole process to the bishops of the community, who will have to agree that the costs of assessment and treatment will be borne by the community as a whole. My experience in the past is that the bishops of a particular community can be both very wise and very unpredictable. Getting them involved in an illness with vaguely defined symptoms would be a challenge, yet once involved I had found community support to be unwavering and I have to respect the research that points out that those for whom religion is very important have substantially better long-term outcomes than those who report no active religious involvement in their lives.

The clinical challenge is to proceed in a way that is respectful of the family’s experience of the mysterious electronic apparatus, but also allows the family to recognize this is not the most productive route for their son’s illness. As of this writing the family has dispatched their son to a residential program which purports to be based on “natural” healing. But they have left me with a very specific internal dialogue about the role of allopathic physicians in a multi-modal health care world. I will expand on that dialogue in the next column with an exploration of how Cognitive Behavior Therapy is part of the conversation of how we think about ourselves.

is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

1. The power of the placebo effect: treating yourself with your mind is possible, but there is more to the placebo effect than positive thinking. Harvard Health Publishing. Accessed August 15, 2020. 

https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect

2. Colloca L. How do placebo effects and patient-clinician relationships influence behaviors and clinical outcomes? 

. Southern Methodist University Press; 1987.

4. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. 

5. Reiki(“RAY-kee”): “A Japanese form of energy healing believed to have originated in the late-19th century. Reiki centers on the manipulation of ki, the Japanese version of chi. Rei translates to God’s Wisdom or the “Higher Power" and Ki to “life force energy.” Reiki is the “spiritually guided life force energy.” Reiki is based on the belief that when spiritual energy is channeled through a reiki practitioner, the patient's spirit is healed, which in turn heals the physical body.” Medical Definition of Reiki. MedicineNet. 

https://www.medicinenet.com/script/main/art.asp?articlekey=31106

“A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation.”

Definition of Chiropractic. World Federation of Chiropractic. 

https://www.wfc.org/website/index.php?option=com_content&view=article&id=90&Itemid=110

7. Perrine J. The Dangers of Neck Adjustment. 

 April 16, 2007. Accessed September 15, 2020. 9/15/2020. 

https://www.self.com/story/chiropractors-causing-strokes

 M, et al. Religiosity and major depression in adults at high risk. 

9.Li S, Stampfer M, Williams D, et al. Association of religious service attendance with mortality among women. 

Articles

A psychiatrist steeped in the scientific method considers the healing power of the placebo effect.

Acknowledging the Place of Placebo

I passed the boards in 1985. That means I am grandfathered into a system that required you to pass the boards once and then never made you take them again. To those who chafe under 

Maintenance of Certification requirements

, that may seem idyllic. But let me tell you, I am intensely aware of all that I have had to learn since residency.

Think for a moment about what residency was like in the early 1980s. Is it possible to imagine a psychiatric residency that existed before Prozac was invented? Along with my fellow trainees, I had no idea what a computerized tomography (CT) scan or magnetic resonance imaging (MRI) might be. Our residency director had to fight hard to incorporate the radical approach to therapy called cognitive behavioral therapy (CBT). As trainees, we were certainly expected to have read all 182 pages of the DSM-II (the DSM 5 comes to 816 pages without the glossary and tables in the back), and I recall I was the only member of the residency group who was not in psychoanalysis. Consider those facts for a moment, and you will have some idea of how psychiatry has changed since I entered the field and how much I have had to learn.

As a psychiatric grandfather, I am the product of sweeping advances, as well as some therapeutic catastrophes, that have happened over the lifetime of my generation. I was already in practice when posttraumatic stress disorder (PTSD) was rarely considered a psychiatric diagnosis, except in cases of military combat. Medical marijuana was considered an anarchist’s fantasy. The idea of multi-generational 

 was a common topic of academic study, and the services and institutions that had been established to treat the victims of that trauma collapsed under the weight of multiple lawsuits. I was only in mid-career when the American Psychiatric Association (APA) figured out that being gay was not a mental illness. The flowering of so-called second-generation antipsychotics started with risperidone, and I can remember when $7 a tablet seemed utterly beyond comprehension and forever out of reach of my patients on Medicaid. For four-fifths of my years as a psychiatrist, I was paid at 60% of the rate that primary care doctors received, because the idea of parity was considered impossibly idealistic. Even the insurance offered by the APA to its own members did not cover psychiatric services at parity, and when I wrote to the insurance manager to point that out, I was told that it was just impossible to imagine such a policy.

I learned some things about psychiatry almost as soon as I could walk. I have very clear childhood memories of walking past the units for disturbed males at Kalamazoo State Hospital. These 3-story buildings had open porches facing the road and behind each porch were dozens of mostly naked men groaning and shouting. I was 3 years old, holding on tightly to my mother’s hand as we walked to visit my grandmother who was, thankfully, usually on the quiet women’s unit. It was years before her life was changed by the miracle of Stellazine, but she never left the state hospital.

In parallel with sea changes within the discipline of psychiatry, my own life has been blessed with a career that spanned many different settings. In all these settings, I've been a front-line clinician, always loving the challenge of seeing patients myself but never interested in academic psychiatry or administration. Shortly out of residency, I served on the staff of a state hospital and briefly as medical director, and later as an international graduate trainee in the British Health System. I lived in a village in West Africa and organized a health program for all the villages in the district. I have been employed as a contract psychiatrist in a state prison system (see the columns “Working on the Inside” from that segment of my life) and been self-employed in solo office practice, specializing in trauma—ie the folks who other psychiatrists refused to see because they would not deal with self-injury. I have worked as an inpatient psychiatrist who was on call every third night and expected to make rounds 7 days a week. I carried a practice of several hundred adults with intellectual disabilities living in 16 bed community housing settings—about two-thirds of whom carried a second diagnosis of psychiatric disorder. For several years I managed dual diagnosis clients in a major substance abuse program. I was a contract psychiatrist for a residential program that housed persons with serious mental illness, folks who 3 generations previously would have been confined to the chronic ward of the state hospital where my grandmother had lived. These opportunities have been woven into my life, almost always alongside at least 1 contract as the psychiatrist for a community mental health agency.

I retired once when I was 55. It might be more accurate to say I was driven out by the heavy-handed ways that managed care constrained pharmacy costs. My retirement did not last, and I returned to work, even though I had had a brain bleed at age 64 and was still having visual hallucinations. I retired again when I was 70, but again I have been drawn back into psychiatry. I continue to work today, albeit mostly via telepsychiatry connections. The technology allows me to work despite the fact that the brain bleed left me with right hemianopsia, so I am not able to drive a car to the clinics where I work.

I am a person who is always curious, and for some reason a 

 article, reporting work done by the Harvard researcher Ted Kaptchuk, led me to reflect on all the ways that body and mind are linked.

 As psychiatrists, we often send our patients to practitioners of CBT, which is the disciplined evocation of mind-body connections. Our training prepares us to think in terms of the allopathic principles of scientific intervention and the mechanics of the brain. The stated purpose of our professional organization is to promote “scientific psychiatry” and it is eager to claim allopathic parity with the other “scientific” branches of medicine, such as cancer surgery or procedural radiology. Perhaps because of that interest in being recognized as fully allopathic, in our day-to-day work we mostly ignore all the ways we know mind and body are linked.

I am proposing to organize a series of columns that tracks the mind-body relationship. This reflection for me started with Ted Kaptchuk’s research on placebo effect.

 I have extended it in my own mind to think about how it is relevant in the way we conceptualize what is going on when thousands of people knowingly ingest fentanyl and similarly dangerous substances as part of their recreational choices. I believe we can also appropriate work of some cardiologists, who have begun to explore the implications of mind-body linkages.

As a way to begin the reflection, please consider with me the problem of high placebo rates in recent drug trials.

 Notwithstanding legitimate concerns that among paid trial participants, there may be some who were convincingly claiming illness as a ticket to get into the program, placebo rates of30 to 40%

seem striking. Drug companies value these studies because they certify that their medication is worth hundreds of dollars a month, as opposed to self-healing, which would presumably cost the patient nothing. Among those who are considered by researchers to be “placebo responders,” there many who are really improved. They experienced good or great benefit from the treatment. The drug trial protocol will dismiss this placebo effect as a problem to overcome. Of course, the drug company wants to draw our focus to the benefit beyond the placebo effect, because they want to prove the effectiveness of their product in order to make a profit There would be no profit in proving that placebo effect works.

If we as a community of outpatient psychiatrists want to know how to get people who are disabled back on their feet and well again, should we not be very interested in something that works 50% of the time at a price the patient can afford? From my perspective that question holds a lot of interest. I hope you will join me in coming months as I pursue this and similar reflections on how we think about ourselves.

1. Greenberg, G. What if the Placebo Effect Isn't a Trick? 

. Nov 7, 2018: Page 50. Accessed 10/1/2020.

2. The Power of the Placebo Effect: Treating Yourself With Your Mind Is Possible, but There Is More to the Placebo Effect Than Positive Thinking. 

. May, 2017. Updated August 9, 2019. Accessed September 25, 2020.

3. Sonawalla SB, Rosenbaum JF. Placebo response in depression. Dialogues 

A Psychiatrist Looks Back on His Career and Considers the Role of the Placebo Effect in Treatment.




Author | Kenneth Gilbert, MD

Articles

Acknowledging the Place of Placebo

Reflections on How We Think About Ourselves