What is the Placebo Effect?
A placebo is something that seemingly has no therapeutic effects but can make someone think they are receiving some therapy. The placebo effect is when that thing makes us feel like we've had some benefit from it.
The closest thing I can relate this to in real life is when someone talks about someone having nits, and you immediately end up with an itchy head. We can't possibly have caught nits just through conversation, but our body makes us feel the symptoms of having them.
Placebo in Medicine
In medicine, placebos are used to measure how well a particular drug or therapy has worked. By giving some people a fake, inert drug, and some people a real drug, researchers can isolate patient improvement and if the real drug patients get better, and the fake ones don't, they can say more confidently that it was the drug that made them better and not any other factors. The patients don't know if they have the real or fake drug, so in some cases, if the patient believes that they have been given the real one, they start to feel like they're feeling better, even though they have had no active drug.
This works well in black-and-white situations as it's difficult to tell the difference between a pill that has no active ingredients, and one that does. These research principles have been used across healthcare, but in the example of acupuncture and massage, it's quite hard to fool someone into thinking they've had a needle inserted into them or had someone's hands compress their soft tissue. Historically, acupuncture has used methods such as poking someone with a cocktail stick to fool them into thinking they've had needles inserted, using a stage dagger-esque contraption to give the visual illusion a needle has been inserted, and just inserting needles in random places with non of the accuracy an acupuncturist is trained to deliver. The problem with these methods is that in the unlikely event you are fooled into thinking you've had acupuncture, you are still interacting with the body, the acupuncturist has still interacted with the body, and they are having an effect on it. You will affect blood flow and you will affect the nervous system, and you will get a response. It may not be a huge response, but large enough to make it seem like the real acupuncture isn't statistically different enough from the placebo. Special shout out to Dr Lara McClure (https://www.laramcclure.co.uk/) who allowed me to participate in using these different sham methods while teaching acupuncture students, and has enabled me to speak with experience and confidence about how inept some of these methods are as a 'sham' alternative for research purposes.
Another issue with measuring complementary therapies this way, is that lifestyle advice is usually given. The lifestyle changes suggested to a patient are designed to improve their issue and prevent reoccurrence, but you can't ethically give people placebo advice, and the advice given to a patient is an integral part of a holistic therapy such as acupuncture or massage. This has caused problems with research into complementary and alternative therapy. If you can't control the treatments strictly, the data suffers and can lead to an assumption that the placebo effect is the major mechanism in people benefiting from treatment.
A Fresh Perspective?
No one likes to be tricked into anything, and this is no different. There is a stigma that is attached to the placebo effect which has bred an association with scams or charlatans, but if we stop for a moment and think about what the placebo effect is... It's our own body making itself feel better without any external intervention, which is very impressive. If we were given the option of having medications or treatments to feel better, or to just magically feel better without those interventions, I think most people would choose the magic. An article on the WebMD website puts it slightly more eloquently...
Research on the placebo effect has focused on the relationship of mind and body. One of the most common theories is that the placebo effect is due to a person's expectations. If a person expects a pill to do something, then it's possible that the body's own chemistry can cause effects similar to what a medication might have caused. WebMD
When it's put like this, you can't deny that it is pretty fantastic, but of course, the context is paramount. If you took a pill that you thought was for anti nausea, and you stopped feeling sick, then your own body chemistry has halted that sick feeling mechanism in your body. It's done the job. However, if you have osteoarthritis and you take what you think is a pain killer, and you feel less pain, then yes less pain is wonderful, but the placebo effect will not repair the cartilage and bone, and the issue is not solved. There are also many issues surrounding consent when dealing with a placebo which is another, long conversation.
So at this point, it is worth stating a few important things. I am not suggesting that everything you see on the internet is real, nor that every therapy available is going to work for you. Equally, I'm not suggesting that acupuncture or massage are driven solely by the placebo effect. Thankfully, acupuncture (and massage perhaps to a lesser extent) has a wealth of good quality research using some different research methods to combat the issues of the placebo effect. In particular, a study that looked at brain-scanning patients while they were having acupuncture is a great example of the tangible effects acupuncture has. You can read more about that in this blog post: https://www.benelliot.co.uk/post/what-happens-in-your-brain-when-you-have-acupuncture
I do however believe that the empowerment patients get from seeking treatment, especially manual treatment, is a huge influential factor in a person getting better. Making the decision to do something proactive, parting with your own money, investing in the treatment and advice given to you, and forming a therapeutic relationship with your practitioner; all of these things are going to benefit your healing and I think are not too dissimilar to how the effects of the placebo effect are described. What proportion of any improvement is this mechanism, and what proportion is the active treatment is impossible to measure and likely varies from person to person, and issue to issue, but I believe it is there in most cases.
That said, I can't say it is always the case that this mechanism of empowerment is always needed to provide a successful treatment. There are numerous occasions where I've felt people are only coming for treatment to appease their better half for example. Probably the best example of this is when giving acupuncture to patients at St James Hospital. Men undergoing treatment for prostate cancer were able to access acupuncture to help manage the hot flushes they often had due to the hormone treatment they received. These treatments were free, so there was no subconscious expectations. There were also a number of patients who really didn't want to be there, forcibly brought along by their wifes in an effort to stop them complaining about their flushes whilst simultaneously not doing anything to help them. Some, in fact vocally rejected the idea that acupuncture could provide them with any respite whatsoever. This was a minority of course, but within those few were the ones who gained the biggest reduction in the frequency and intensity of their hot flushes. It took them a while to admit this, but were very keen to sing the praises of acupuncture thereafter. Not only did these patients not have the monetary attachment to the treatment, they also had an almost anti-placebo, strictly willing the treatment not to work.
Perhaps I'm wrong and it was all bravado or banter. After all hot flushes for anyone can be a very distressing and disruptive symptom and I'm sure there was at least a subconscious part of them that wanted the treatment to work. In any case, analysing that experience has remained with me when thinking of the placebo effect, and while it has not enabled me to draw any conclusions, it has compounded the fact that placebo is a complex matter that is not simply a hoax or a scam. The body's ability to heal itself surely counts as the most powerful medicine. I often speak to patients in my clinic in York about their treatment with the context of creating the best environment for the body to heal itself, whether it be lifestyle advice, exercises to help with muscle imbalance, regulation of the nervous system for anxiety or stress, or pain relief using acupuncture or massage. All these things create benefits and space for our bodies to heal in all sorts of ways. Does that make it placebo? Not in the dirty sense in my opinion, but there's something going on, and whatever that is can only be a good thing.
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