Benefits of the placebo effect in the therapeutic relationship Mike Wall, Steve Wheeler

This paper starts by defining placebos, and describes several placebo effects observed in orthodox medicine. The authors argue that the concept of the placebo effect should not be confined to treatment and medicine alone, but should be extended to the therapeutic relationship itself. They maintain that the interpersonal skills practiced by the complementary therapist are a major factor in producing positive health outcomes. Furthermore, the personality, presentation, and demeanour of the complementary therapist are thought to play a vital part in the promotion of clients' psychological well-being. Other benefits of the placebo effect are discussed, including positive behaviour reinforcement resulting in the client's desire to return to the therapist for further consultation and treatment. The paper concludes by offering several ways in which the placebo effect can be established within the boundaries of the therapeutic relationship.

... something which pleases patients probably

also offers benefits to them...

Mike Wall BEd (Hons), RGN, DipN, RMANM

Steve Wheeler BSc (Hons), Cert Ed (FE), FAETC, MBPsS Institute of Health Studies, Faculty of Human Sciences, University of Plymouth

I N T R O D U C T I O N

Placebo is a name derived from the term 'I shall please.' According to one definition, it is 'a harmless, unmedicated treatment used for its psychological effect, often as a comparison with other treatments' (McConnell & Philipchalk 1992). Therefore, placebo is a term most generally applied to pharmacological compounds which are inactive, and administered to 'please' patients rather than to directly benefit them. Nevertheless, it could be argued that something which pleases patients probably also offers benefits to them (Grahame-Smith & Aranson 1990).

Many studies have been conducted to try to establish the reasons why inert substances such as saline should have beneficial effects on the health of the recipient. Indeed, the placebo effect is now a common contemporary issue of debate in many areas of health care. For example, the argument that placebo injections appear to be more powerful than placebo pills, and that the colour of a tablet actually makes a difference to the power of the placebo effect, are currently under debate (Cohen 1996).

We have come a long way from the days of the Wild West medicine shows where dubious travel- ling salesmen sold potions and wonder elixirs with the claims that they possessed remarkable curative properties. With the benefit of hindsight we can see that many of these promises were, predictably, unfounded, as the potions invariably consisted of lit-

tie more than coloured water. Such potions, were they in existence today, would probably be termed 'placebo' in nature. Regardless of the doubtful effects of their potions, many 'medicine men' made comfortable livings and their clients often returned for more, claiming that the potions actually worked. Arguably, a modern-day equivalent of the wonder elixir would be an injection of normal saline, or a pill containing nothing more remarkable than sac- chafin, as a control measure in a pharmaceutical trial. Unfortunately for some researchers, the placebo effect of such innocuous substances has occasionally confounded test results.

PLACEBO IN O R T H O D O X M E D I C I N E

One of the authors has observed a client who, whilst suffering from the effects of post-natal depression, and on prescription for the anti-depressant drug Prozac, made a decision to stop taking the medicine. Some time later, during a period of emotional unrest, she restarted the treatment and immediately reported feeling better. However, her doctor had previously informed her that the therapeutic value of Prozac often requires as much as a week to take full effect. It is significant that although the client was aware of the time required for the drug to become beneficial, a placebo effect occurred which resulted in the pro- motion of a feeling of well-being.

Complementary Therapies in Nursing and Midwifery ([ 996) 2, 16~ 163 �9 1996 Pearson Professional Ltd

Benefits of the placebo effect in the therapeutic relationship 161

... placebo effects

are first and foremost perceptual in nature.

... placebo effects probably derive more from the client's perception of the therapist's qualities than from the treatment itself

Placebo has also been used, with varying success, in controlled drug studies in order to establish the efficacy of certain substances (Clayton 1989). Indeed, it is within the context of this definition that much of the research relating to the placebo effect and orthodox medicine holds its roots.

Another area of research concerns psychiatric treatments, and in particular electro-convulsive ther- apy (ECT). In ECT, following sedation, a shock is passed through the patient's brain, briefly disrupting electrical activity. According to Breggin (1979), the only true benefits of ECT are its perceived effects. The placebo effect of ECT was investigated where patients were sedated, some receiving shock therapy and others receiving none. Subsequently, members of both groups reported feeling better. It appears then, that placebo effects are first and foremost per- ceptual in nature. That is, if patients or clients con- sider that treatment will be beneficial, they may begin to experience a feeling of well-being as a result of this belief, once they have received (or believe they have received) the treatment.

THE THERAPEUTIC RELATIONSHIP

The authors propose that the placebo effect should not be confined to medicinal or technological treatments alone, but extended to the therapeutic relationship itself. Sanderson and Carter (1994) argue that the holistic perspective aims to enable individuals to become more aware of themselves, a focus of care rather than cure of which effective communication is central. Indeed Richardson (1989) has argued that placebo effects probably derive more from the client's perception of the therapist's qualities than from the treatment itself. Fish (1979) tends to support this hypothesis by stating that the client's belief that a therapy will be beneficial, and the social influence brought to bear by the therapist, are vital placebo fac- tors in the success of any therapy. Indeed, with the increasing recognition that the placebo effect is thera- peutic in itself, Shapiro and Morris (1978) have pos- tulated that it may be the entire basis for numerous methods of psychotherapy. It may therefore be logical to assume that a supportive relationship between the therapist and the client could enhance this process.

PSYCHOLOGICAL PRINCIPLES

In psychological terms, the mechanism of the placebo effect of therapeutic relationships can be investigated in several ways. As Duck (1973, 1977) has shown, most individuals seek out personality support during the development of relationships for positive feedback to reinforce their own behaviour. We further argue that this psychological principle could apply within the early stages of therapeutic relationships and is therefore worthy of considera- tion within the field of complementary health care.

If personality support is forthcoming, interper- sonal relationships become quickly established and strengthened. Thereby, the behaviour of visiting a therapist for advice or help with a long-standing condition may be positively re-inforced if the client receives helpful, friendly and welcoming responses from the therapist. Moreover, Rokeach (1960, 1968) has argued that belief congruence is a strong factor in the acceptance of others into one's per- sonal world: the very essence of relationship devel- opment. In other words, the perception that another individual's belief system is similar to one's own will encourage self-disclosure which, when recip- rocated, will lead to a deepening of a relationship. Thus, the client perceives that the therapist has similar beliefs that positive health outcomes can be derived from complementary approaches. This may reflect upon and enhance the self-esteem and self-image of the client and thereby promote a psy- chological sense of well-being. Evidence from one study indicates that when psychological benefits are strengthened, an improvement in the self- esteem and well-being of the individual is evident, supporting the argument that the placebo effect in itself is a powerful psychological mechanism (Shapiro & Shapiro 1984).

A valuable attribute in providing a placebo bene- fit from the therapeutic relationship is that the client is more likely to continue the therapy when the envi- ronment is conducive to a supportive process. Indeed, as suggested by Di Matteo and Friedman (1982), positive feedback from a therapist, com- pared with neutral feedback given at interview, has the effect of not only fostering a more positive rating of the therapist, but also more adherence to the rec- ommended therapy. Therefore, the relationship between practitioner and client will be strengthened as a result of both prolonged contact and a sharing of ideals, such as the common objective to facilitate health and healing through complementary thera- pies.

Finally, the effect of cognitive dissonance must be taken into account. Cognitive dissonance is descriptive of the attempts by an individual to reduce psychological conflict where two opposing beliefs or opinions are simultaneously held (Festinger 1957). For example, a client may be con- vinced that his illness is insurmountable, and yet also hold that help may be forthcoming in the shape of the complementary therapist. These conflicting beliefs may clash particularly during the consulta- tion, perhaps with the result that the client wishes to please the therapist by complying with the treat- ment. This decision reinforces the belief within the client that there may be help for his condition, which in turn leads to an acceptance that the therapist will indeed provide a solution, diminishing the disso- nance. A therapeutic relationship between client and practitioner is thus established, and the placebo effect begins to emerge as a sense of well-being within the client.

162 Complementary Therapies in Nursing and Midwifery

... there is a

dearth of evidence with

regards to the

effect that the

therapist may

have as a placebo

upon the client.

RESEARCH INTO PLACEBO EFFECTS

While there is an abundance of research relating to the placebo effect as part of efficacy trials with certain substances and treatments, there is a dearth of evi- dence with regards to the effect that the therapist may have as a placebo upon the client. The notion of 'ther- apist as placebo' seems to maintain a lower profile than the more conventional aspects of the concept.

Within the context of complementary health care, placebo effects could be considered a contentious issue. There are those who would argue that the ben- efits of the therapies are based solely on the placebo effect (Lynoe 1990). However, there is no substan- tive evidence to support this hypothesis, and those seeking to establish the effect of the various com- pounds and manipulative approaches utilized in the complementary health field may yet provide evi- dence to refute it.

Regardless, we would maintain that some of the evidence to date may support the argument that the relationship created between the therapist and the client may be achieved by the utilization of a range of positive interpersonal skills that can produce a placebo benefit in themselves. Indeed, whilst there is a dearth of research regarding the benefit that the therapist can have as a placebo by the utilization of a range of conducive interpersonal skills, the recogni- tion of this fact is certainly growing (Lundth 1987).

While the placebo effect of medication is well recognized, with the move towards technology- based specialization we have come to discount the effect that the personality of the therapist can have in relationship to a placebo benefit. The benefit and subsequent healing value is founded upon letting the patient or client know that we care about their concerns (Bessinger 1993). More attention is now being directed to conscious spiritual aspects as a basis for health and physical well-being, bringing into question our former understanding of the rela- tionship between the five senses and human health (Seaward 1994).

CREATING A THERAPEUTIC ENVIRONMENT

it is quality time that can potentiate placebo benefits by creating a psychological environment that is con- ducive to 'pleasing the client'.

This process may be even further advanced by providing a physical environment which is of an aes- thetically pleasing nature, thus enhancing an holistic perspective (Passant 1990). Thus, by creating an environment which is more conducive to establish- ing a therapeutic relationship with the client, the therapist may be able to significantly influence the client's response to therapy.

CONCLUSIONS

Placebo effects are almost certainly derived from the perceptions of the recipient. Effects are often enhanced by the qualities of the therapist, particu- larly where interest and concern are shown for the client. Underpinning psychological processes indi- cate that therapeutic relationships can be built on the foundations of personality support and shared beliefs about the nature and objectives of comple- mentary therapy. Furthermore, the effect of cogni- tive dissonance may play an important part within some clients in engendering the expectancy that the therapeutic relationship will produce positive health outcomes.

Creating an environment conducive to establish- ing an effective therapeutic relationship is of paramount importance. Time, in particular, is needed with which to establish a good working rela- tionship in order for the placebo effect to occur. This can further be enhanced by offering a pleasing envi- ronment within which to provide consultation and therapy, and the practice of friendly, approachable,

and empathetic interpersonal skills. In conclusion, we feel it would be appropriate to

cite the writing of another author in the field, who states and places our own views quite succinctly:

'A sceptical approach to complementary thera- pies should be tempered with the recognition of the power of the mind over matter, and that a sympathetic bedside manner can be extremely significant in many illnesses' (Lynn 1996).

Creating an

environment

conducive to

establishing an

effective therapeutic

relationship is o f

paramount

importance.

Clients always note the degree to which a therapist is ready to stay in touch with what is being communi- cated (Casement 1994). Generally the complemen- tary therapist may spend more time over the initial consultation period than corresponding orthodox practitioners, with one study suggesting that the average medical consultation is six minutes in dura- tion (Balint 1964). While this evidence is somewhat dated, we would suggest that the demands placed upon orthodox practitioners in the 1990s leaves little room for improvement. Many complementary thera- pists may spend some time in what is seen as a meaningful consultation period, while others may only offer a minimal amount of time. We argue that

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The mark

of your ignorance is the depth o f your bel ief in injustice

and tragedy. What the caterpillar

calls the end of the world, the master calls a

butterfly.

(Richard Bach)