Review: 2017 Placebo Symposium in Sydney
by Rebecca Barnett
Question: How do you know if you’ve actually attended a Placebo Symposium?
Answer: Everyone in your acquaintance feels obliged to ask if you got any benefit.
But it definitely wasn’t all just in my head. I really did attend a Placebo Symposium in November, jointly convened by the Pain Management Research Institute at Sydney University and the IASP Placebo Special Interest Group.
And, yes, I genuinely benefited.
Most formal definitions of the word placebo include the terms “inert” or “chemically inactive”.
Damien Finniss, Chair of the IASP placebo special interest group, opened the event by laying down the gauntlet and striking at the very heart of these sorts of classical definitions of placebo. Here is the frame he provided for the whole event (based on Dan Moerman’s book, Meaning, Medicine and the Placebo Effect, which is available for FREE download):
- Placebos are not inert
- When we give a placebo, we stimulate a therapeutic ritual (psychosocial context)
- This therapeutic ritual initiates, modulates and maintains multiple endogenous pathways that improve symptoms
- Therefore, you do not need to give a placebo to elicit a placebo effect (i.e. to turn on placebo mechanisms)
- Placebo effects are part of routine clinical care (and life).
So began a two-day exploration which consistently challenged the classical notion that placebo refers to something inactive or inert, positing an alternate understanding that placebo is not actually about administering an inert substance but rather about maximising the therapeutic ritual which can lead to measurable changes in the patient’s brain (for example, specific neurotransmitter and hormone release).
The focus of the symposium was unashamedly clinical: how to harness placebo mechanisms to improve clinical outcomes. This obviously meant that there was also quite a lot of discussion about placebo’s evil step-sibling, nocebo, and how to minimise and manage negative expectations.
It’s difficult to know how to best encapsulate the stunning range of presentations and perspectives at the Symposium in a brief review. There were sessions on:
- the precise biological mechanisms of placebo effects
- reshaping and enhancing expectations in clinical practice
- how to manage negative expectations
- nocebo-induced side effects and how to avoid them; and
- how to enhance placebo without deception.
Claire Ashton-James Presentation
Perhaps unsurprisingly, the presentation that really stood out for me was the one that challenged my comfortable assumptions the most. Social psychologist, Claire Ashton-James, presented a provocatively titled session “Trustworthiness – is it actually that important?”
Obviously, perceived clinician trustworthiness does indeed play an important role in inducing both placebo and nocebo effects so no huge surprises there. Trust reduces pain and distress in response to nociception. For example, more trust correlated with less experimental pain in this study of Feelings of Clinician-Patient Similarity and Trust Influence Pain by Elizabeth A. Reynolds Losin et al.
Trustworthiness arises from a context-dependent combination of warmth (does my therapist care about me) and competence (can my therapist care for me?). For example, the perceived competence of a surgeon is much more strongly correlated with trustworthiness than perceived warmth due to the nature of the intervention. Or another example of the influence of context: you probably don’t need your paramedic to invest a lot of energy in building rapport when they’re busy controlling blood loss from a severed femoral artery.
Importantly, when perceived clinician competence is uncertain, high levels of perceived warmth may actually be detrimental to trust. So, if you’re going to be warm, you’d better make damn sure you’re also competent!
The kicker for me, though, was Claire’s discussion of affective reassurance and cognitive reassurance in the management of chronic pain. It might surprise you to hear that affective reassurance (warmth, rapport, showing empathy) has been associated with less improvement in chronic pain patients. Cognitive reassurance (providing explanations and education) has better outcomes for chronic pain.
In other words, the way we give support to chronic pain clients is crucial. Is it possible that massage therapists have become overly invested in empathy because of the cultural, social and clinical context in which we provide treatment? Is there an opportunity here for massage therapists to become much more involved in coaching and client education as a dimension of clinical care rather than resorting to needles, cups and tape to “save our hands”?
Claire also emphasised the importance of what she terms the “meet the therapist moment”: how therapists need to elicit trust almost instantaneously to maximise placebo effects. Her discussion of this was loaded with strategies to enhance client expectations in the “meet the therapist moment”.
Other personal symposium highlights included Claudia Carvalho’s presentation on enhancing placebo effects without deception (she discussed her clinical trial of unblinded placebos for low back pain) and Stewart Dunn’s story about 8-second man, a salutary lesson in how to break bad news (it ends with an unexpected and deeply counter-intuitive twist). Intrigued? You’ll have to pop off and watch his presentation online to experience the wonder of 8-second man’s schtick.
Watch For Yourself For A Limited Time
The good news is that the sessions are all available for free on a trial subscription. I really hope I have done enough now to whet your appetite.
How is Placebo Relevant to Massage Therapists?
So why should massage therapists care about placebo effects? Here are some of the things that I think are clinically relevant to us:
- Placebo (contextual/meaning) effects are part of every clinical encounter so we might as well maximise placebo to enhance clinical outcomes.
- Placebo is not a dirty word. You can enhance placebo effects in an ethical manner/without deception.
- Nocebo is faster to develop than placebo so we need to be especially careful about what we say and frame information in positive terms as much as possible.
- Single case stories are more convincing and powerful mediators of patient expectation than quoting evidence from systematic reviews and RCTs (I reckon most massage therapists would view this as good news … so why aren’t we publishing more case studies then?)
- Time invested in listening and engaging with the beliefs, fears, values and expectations of clients generates better outcomes. It’s a bit priceless. Massage therapists are in the box seat to do this. We don’t have to be using our hands to initiate therapeutic effects!
- The goal of therapy is to facilitate self-management. Creating dependence on passive treatment creates worse outcomes.
The only thing that would have improved my experience of the placebo symposium would be an army of massage therapists in attendance. There was only two of us there to fly the flag for massage therapy – a measly one percent of the delegates – and we mixed with pain specialists, psychologists, anaesthetists, occupational therapists, GPs, researchers and academics. How can we expect to work more closely with other health professionals if we don’t get our faces into the crowd at these sorts of events?
Next time, you’re coming along with me for the rather glorious ride.
Editor: For another viewpoint on the Symposium, read Bronnie Lennox-Thompson’s review. It doesn’t include details on what she and Rebecca chatted about over lunch but an interesting read nonetheless.
About the Author
As Secretary of AMT, Rebecca Barnett has been at the coalface of professional advocacy for 11 years. Her proudest achievements include the release of the AMT Code of Practice in 2013 and the establishment of AMT’s classified massage therapy research database. She’s still not sure whether to be proud of, or horrified by, those nine stressful months of negotiation with Medibank Private back in 2014. The resulting baby was one that only a private health insurer could love. She is devoted to neologism and foodstuffs with the same specific gravity as havarti cheese but she is ambivalent about semi-colons.