Investment in the Placebo Effect
Advised Daniel Cathell in a much-consulted manual for physicians published in 1922, “It is often very satisfying to the sick to be allowed to tell, in their own way, whatever they deem important for you to know. Give to all a fair, courteous hearing, and, even though Mrs. Chatterbox, Mr. Borum, and Mrs. Lengthy’s statements are tedious, do not abruptly cut them short, but endure and listen with respectful attention, even though you are ready to drop exhausted.” The physician doomed to such recitations would have been that much more exhausted if instead of sitting in the comfort of his own quarters he made house calls one after another. In its own way, even medicine was a laborious trade. “It is, to our postmodern minds, quite incredible,” writes Edward Shorter, “that in those days patients expected the doctor to call virtually every day”—three or four days successively for the mumps, five days for a nervous condition, and so on. Clearly the physician had to spend time with his patients if they were to gain the consoling feeling that they were being attended to in the full sense of the term. The doctor had to be patient.
Compared to the postmodern physician, the attentive physician of 1922 had little in his armamentarium. Hence the use of bromides. Allowing patients to tell their story and hearing them out in full was itself a sort of bromide, which is not to say that this rite was without some therapeutic effect. On the contrary, it is probable that many complaints were alleviated by the release of telling and the consolation of being heard by a gentleman of science, especially if they were nonspecific to begin with. As is well known to drug manufacturers who conduct clinical trials only to discover that impressive numbers of placebo-takers report the benefits in question, suggestion is a potent force. “Suggestion,” concludes Shorter, “plays an enormous role in the practice of medicine, even though neither doctors nor patients like to admit it. What interests me is the declining ability of doctors today to cure by suggestion”—declining if only because they no longer have either the inclination or the luxury to devote hours on end to the passivity of listening.
Indeed, the entire model of doctors dispensing bromides (or vitamins or pink pills) and offering the sympathy of the ear seems to have been swept away by history as surely as the house call. Physicians today have at their disposal not only antibiotics and the fruits of a pharmacological revolution but an entire armory undreamed of a century ago when the ability to diagnose disease ran well ahead of the ability to treat. If physicians no longer dabble in talking cures, neither are they as powerless in the face of disease as their scientifically trained but otherwise ill-equipped predecessors. But the medical doctor’s abandonment of the rite of listening does not mean this practice has disappeared from among us. Psychotherapists, often popularly confused with medical doctors, have rushed in to fill the gap. When medical doctors with the exception of psychiatrists could or would not listen by the hour, therapists offered to do just this. Even as medicine became more powerful but less personal, psychology surged in popularity, quite as if it had taken up not only the functions of consolation abandoned by medicine but the very defense of the person. By the turn of the twenty-first century there were some 50,000 clinical psychologists among a quarter million psychotherapists of one stripe or another in the United States.
The field of clinical psychology dates to the Veterans Administration Act of 1946 but soon enough outran its original mandate (as, indeed, post-traumatic stress disorder was eventually extended to cover patients who knew no battlefield beyond that of the family). Associated as it was with the defense of the person, clinical psychology’s growth-spurt coincided with a rights revolution that overthrew the paternalism etched all too plainly into Cathell’s portrait of the physician “enduring” the narratives of his patients. Even while the Cathellian physician performs the part of the listener and radiates a comforting humanity, he is filled with cynicism at his own charade. Nicknaming those to whom he shows courtesy and classifying them as “the sick,” he doesn’t seem to acknowledge these persons as independent beings and competent agents. It was against such attitudes that the bioethical principle of autonomy was asserted.
As the discipline of bioethics came into being in tandem with the affirmation of patient rights, at its core lay recognition of the patient as a self-determining being. Following the publication of Thomas Kuhn’s Structure of Scientific Revolutions in the 1960s the notion of the paradigm shift caught on, and many would characterize the emergence of bioethics not long thereafter as a paradigm shift in its own right—a decisive emancipation from the ways of the past. Such a description risks dividing history into the bad old days and the enlightened present. Then people saw through a glass darkly; now we see things as they are. Then was deception and mystification; now is transparency. Even in the age of transparency, however, the psychotherapist operates in strict secrecy, claiming privileges of confidentiality that once invested the priest’s confessional and employing methods whose soundness has never been verified. Many would date the repudiation of the medical use of placebos to the advent of bioethics. But even as placebos were banished from medical practice, the placebo effect flourished in the therapist’s office. If a placebo effect is a benefit (1) derived from the expectation of benefit (an expectation encouraged by the receipt of clinical attention itself) and (2) registered in the form of feeling better, then psychotherapy that lavishes attention on the patient in the interest of helping him or her feel better about things will almost necessarily engage the placebo effect. Moreover, where placebo effects can be distinguished both in theory and practice from the clinical effect of drugs—hence the methodologically demanding clinical trials pitting drug against placebo—such effects are so woven into the very practice of psychotherapy as to frustrate the attempt to distinguish them from actual benefits even in theory. Psychotherapy is a playground of placebo effects.
Just as “it is often very satisfying to the sick” to pour forth what is on their minds, so the mere act of relating their troubles to an understanding therapist will tend to make patients feel better. Therapy is virtually designed for the placebo effect. As noted, it is no easy matter to differentiate the consolations of therapy even in theory from the mere sense of feeling better. Studies, and of these there are many, that find that patients receiving different modes of psychotherapy enjoy comparable benefits yield presumptive evidence that the benefits in question derive more from the happy effects of professional attention than from the specifics of this or that treatment. (Such studies also suggest that any given mode of psychotherapy tends to generate confirmation of its own value.) But in addition to respectful attention the therapist can offer many ingenious elaborations of the placebo effect. The therapist not only recognizes me as a self-determining person but helps identify the forces hindering me from achieving the self I wish for, not only refrains from judgment but assures me that the self is not subject to moral judgment at all and that those who so label me, wrong me. He or she believes in the potential for a richer existence I bear within. That all of this language is loaded; that one decade’s ethos of deferred gratification becomes another’s rhetoric of crimes against the self; that the manual of accredited mental disorders grows dramatically from edition to edition; that psychological diagnoses follow trends, as with PTSD, ADHD, bipolar disorder (now much on the rise), or the wave of imputed cases of child sexual abuse some years ago—all of this suggests that the discourse of psychological practice is epistemologically weaker and more fashion-driven than is commonly conceded; but because it rides trends, it is that much catchier and therefore that much more efficient as a conductor of placebo effects. In order for placebos to work, if only for a time, we have to trust in them, and psychologists and even their less trained brethren now seem to enjoy the kind of confidence that, as Shorter tells the story, was forfeited by postmodern physicians when they gave up the more personal mode of their merely modern predecessors.
Medical history is a museum of discarded fashions, with the tempo of fashion accelerating during the twentieth century, as in the marketing of drugs for the treatment of psychiatric conditions. Many pharmaceutical remedies for schizophrenia, including super-doses of vitamins, were enthusiastically adopted only to be abandoned after proving to be nothing but placebos. Anti-anxiety drugs followed the same pattern, with the twist that some effective agents were prescribed, wittingly or not, at placebo levels. In studies of anti-depressants the success rate of placebos is high, in some cases approaching the rate of the drug in question. Mood-altering drugs are now vigorously advertised, thus tapping directly into the dynamo of fashion. The fact is that far from being exempt from fashion, drug treatments for psychiatric problems have shown themselves to be subject to that power and borrowed charisma straight from it. In psychiatry as in medicine generally, “Therapies are initially deemed veritable panaceas by patients and enthusiastic healers who describe impressive results. With time, the results falter, skeptical healers report flagging therapeutic efficacy, and new therapies take the place of the older ones.” There is no reason to believe that psychotherapies enjoy an exemption from the influence of fashion that has played tricks with the use of psychiatric drugs. Quite the opposite. Standards of evidence are if anything less rigorous in talking therapies than in the use of drugs, which are after all subject to testing in double-blind clinical trials designed to control for the placebo effect. In talking treatments where all depends on the patient buying into the therapy, the fashionableness of the therapeutic language can be a great selling point, and an unfashionable language a patient lost. The power of fashion may bedevil psychotherapy epistemologically, but serves it otherwise. Oprah’s magazine offers tips on style along with psychological tips. If placebo controls in clinical trials “are our surest protection against fads and fashions that come and go,” the placebo effect sustains the fads and fashions of psychotherapy.
If we look into books written for the general market by therapists, books which after all constitute examples of therapeutic language in action, we had better be prepared to suspend ordinary standards of evidence. A chapter in the celebrity psychologist Phil McGraw’s Life Strategies is characteristically entitled “There Is No Reality, Only Perception.” A universe where perception is reality constitutes both an alternative to our own and a uniquely favorable medium for something as subjective as the placebo effect. As in this case, the authors of self-help manuals (many of them, like McGraw, PhD’s) are willing to say in print the sort of things others wisely keep behind closed doors, and the self-help genre is a theater of placebo effects, filled with vacuous language tricked up to console or inspire. The literal meaning of “placebo,” “I will please,” could stand as the motto of many a self-help author, concerned as they are to ingratiate themselves by every possible means to their readers, whom they insist on addressing in the second person. As if the delegation of the role of the comforter to the psychologist were being dramatized, the self-help author reminds us that even in a world implacably hostile to the authentic self, he or she stands by us like a true friend. If there is no empirical basis for the effects ascribed to an inert pill in a clinical trial, neither is there an empirical foundation for many of the authors’ postulates, such as the existence of this authentic self or the possibility of reprogramming the self I now have.
A notoriously cynical use of a placebo was in the Tuskegee Syphilis Experiment, launched a decade after Cathell’s Book on the Physician Himself with the aim of providing medical science with data about the effects of untreated tertiary syphilis. In the hope of claiming bodies for the autopsy table, the architects of the Tuskegee study recruited some hundreds of syphilis-infected black field workers from Macon County, Alabama under the pretense of treating their “bad blood.” Once well in the study’s net, the men were in fact treated only with iron tonic and aspirin, the latter of which, being new to them, seemed a wonder drug. When an actual wonder drug, penicillin, came onto the market after the study had already acquired its own inertia, they were not only denied it but prevented from getting it. While the authorities behind the Tuskegee study may have convinced themselves that their placebos were the very best sort of placebos inasmuch as they did the men a bit of good instead of being merely inactive, and that the study did the men no harm by denying treatment of a disease for which no good treatment existed, both rationalizations crumbled as they were overtaken by history. In any case those in charge of the study were guilty of drawing in the field workers with false promises and systematically deceiving them for decades thereafter. In the Tuskegee Syphilis Experiment the deceptions to which the medical use of placebos lends itself appear in the most glaring light.
By the time the Tuskegee infamy was exposed in the press in 1972, concern over the abuse of human subjects in medical research was such that safeguards of the subjects’ rights and interests were already being put in place. Two years later appeared a paper on “The Ethics of Giving Placebos” in Scientific American, to be followed in short order by a study of Lying, both by Sissela Bok. At the center of the bioethics revolution that began before and crested after Tuskegee came to light was the principle of informed consent, and it is a measure of commitment to this principle that subjects in randomized clinical trials now had to be notified that they might receive placebos.
With the invocation of fuzzy if appealing constructs from “potential” all the way up to “authentic self,” therapists have devised a way to use the placebo effect free from the moral taint attaching to medical deceptions. In contrast to an experimenter knowingly administering a substance of little or no medical value to a duped subject as in Tuskegee, therapists do not seek to fool patients into believing in their own potential, or whatnot. They may tell themselves that the benefits of psychological counsel cannot possibly fall under the placebo effect because the placebo effect depends on deception, and they do not use deception. They may believe that the placebo effect kicks in only with the use of drugs, and because they do not prescribe drugs, they cannot possibly be invoking the placebo effect. Nevertheless, if the placebo effect refers to a perceived benefit that stems from the power of suggestion and the expectation of benefit alone, some of the benefits derived from an encounter as tailor-made for suggestion as the therapeutic transaction almost necessarily come under that heading, even if the transaction satisfies every bioethical requirement. Arguably, it was the ability to tap straight into the power of suggestion with a clear conscience, in the conviction that no ethical rule was being broken—indeed, that the therapeutic encounter uniquely respects and cherishes the autonomy of the patient—which cleared the way for the dramatic expansion of the psychological market over the decades since the principles of bioethics were first set down.
In the light of history it is clear that a seismic shift in the medical landscape took place in the second half of the twentieth century, more or less in tandem with the social revolution that broke out in the 1960s. Even as medicine acquired power that physicians early in the century could only have dreamed of, the physician’s right to the patient’s trust was sharply questioned (the abuse of trust in the Tuskegee experiment being fresh in everyone’s mind), and medicine itself became more impersonal and system-like. No sooner had the word “alienation” come into vogue than many learned what it was to feel alienated from the powerful institution of medicine. Doctors had less time to spend with patients. Around the same time, however, psychotherapy boomed. “Credibility,” the word of the hour, was invested in psychotherapy even as it was withdrawn from other institutions. Not only did psychotherapists spend time with their patients as doctors now rarely did, but, enjoying a credit that few others were able to command, were well positioned to exercise the power of suggestion. At a time when the notion that American society is sick had the status of Jane Austen’s “truth universally acknowledged,” the therapist claimed a special believability, and belief is the soul of the placebo effect.
My sense, then, is that the erosion of the doctor-patient bond to which Edward Shorter refers and the burgeoning of the market for psychotherapy occurred not just at the same time but together. Even as medicine underwent the narrowest scrutiny at the hands of the new discipline of bioethics, psychotherapy received a kind of plenary grant of credulity, supporting which was and is a conception of the therapist as a priest of health whose office is a confessional. The counsel dispensed in the therapist’s office is accordingly wrapped in a semi-religious secrecy, in contrast to doctrines like human potential or the authentic self that fly in full view in any bookstore you like. The confidentiality of therapy serves not only to shield the patient but to protect the therapist’s theories and practices from the sort of scrutiny to which words and deeds are generally liable in our contentious world.
And yet the epistemological embarrassment of the placebo effect is hardly a secret. That the therapeutic benefits of psychoanalysis might derive from nothing more solid than the placebo effect was recognized almost a century ago by Freud himself, though he purported to answer this potentially annihilating objection to his method. As for psychotherapy in general, it is well known that over the years evidentiary support has lagged behind the practice of that art. The hospitality of therapy to the placebo effect was conceded fifty years ago. Wrote David Rosenthal and Jerome Frank in a 1956 paper on “Psychotherapy and the Placebo Effect”:
It is by now generally recognized that all forms of psychotherapy yield successful results with some patients and that these successes depend to an undetermined extent on factors common to many types of relationship between patient and therapist. This poses a knotty problem for proponents of various specific forms of psychotherapy who are convinced that their successes result from their particular theory or technique and wish to convince others of this. . . . Certain general aspects of the psychotherapeutic relationship seems very similar to those responsible for the so-called placebo effect, which is well known to investigators of the therapeutic efficacy of medications.
A candid admission. In the intervening half century the double-blind clinical trial became the norm of verification, and experience has shown that “for afflictions that have a strong psychological component, like pain, anxiety, and depression, the placebo response rates are often high, making it more difficult to prove a drug’s efficacy” in such trials. And if it isn’t common knowledge that of all medical or quasi-medical treatments, “psychotherapy, whether provided by psychiatrists, psychologists, social workers, nurse therapists, clerics, or other professionals, is the treatment most subject to placebo effects,” it ought to be. Yet even critical minds seem reluctant to question the basis of psychological treatments that minister directly to the placebo effect.
Why don’t medical doctors in particular, familiar as they are with the trickery of placebo effects in drug trials, call the psychotherapists on their claims? Perhaps because they are too busy or don’t care or think it comes too close to criticizing a fellow medical doctor or think engaging in argument beneath the dignity of a medical doctor or don’t want to intrude into a confessional or believe psychotherapy to be, if of doubtful good, at least harmless. But recall that physicians decades ago defaulted the listening and consoling functions of their profession to psychology. They are not about to reverse this arrangement. “The inrush of ‘science’ . . . has crowded out some of the doctor’s former empathy and ability to communicate concern.” The rhetorical effect of this streamlining of medicine has been to charter psychotherapy as a complement to medicine, or a sort of complementary medicine in its own right. Not only has psychology has taken empathy and the communication of concern as its very mandate, it has embraced and exploited the placebo effect that no longer has an acknowledged place in medicine beyond the modest supporting role of a control in a clinical trial.
Bioethics is governed by such august terms as moral norms, moral virtues, moral principles, moral ideals, moral excellence (all of which appear prominently in Beauchamp and Childress’s Principles of Biomedical Ethics). In the therapist’s office language like this will appear in scare quotes if at all, its nullification probably contributing to the soothing effect of therapy. As was noted fifty years ago, in and of itself the “undemanding attitude” of the psychotherapist is likely to activate the placebo effect. Not only do psychotherapists not speak for moral norms (now reduced to a puerile if vicious blame game), some are willing to dismiss moral evaluations as a pious fraud and a menace to authenticity. Take up anything written by a therapist for the mass market and you will probably find morality portrayed just so—as a lie perpetrated by the world to keep us from discovering our true selves. Morality itself is thus identified as a radical threat to one of the animating ideals of the bioethics revolution: human self-determination. Perhaps so many find therapists specially believable because they present themselves as uniquely exemplifying the guiding bioethical principles of beneficence, nonmaleficence, and respect for autonomy all at once.
If, as Shorter observes, physicians hesitate to acknowledge the role of suggestion in medicine, psychotherapy deals liberally, almost openly in suggestion. But the strictly private transaction between Mr. Borum and the Cathellian physician hardly bears comparison with the massive social investment in placebo effects in an era when psychology has its own category in the Yellow Pages and insurance plans cover visits to the therapist. The things in which we invest in common as a polity must presumably meet a higher standard than those we buy into as private citizens. In my view a good as obviously laced with suggestion, indeed as difficult to distinguish from suggestion, as psychological counsel fails that standard. Much as I would not care to see the caricature of morality made a public principle, neither would I care to give public authorization to the practice of suggestion and the cultivation of the placebo effect.
Some might say that if psychotherapy trades on the placebo effect, so be it—that in this realm whatever makes the patient feel better, works. I would answer that psychotherapy became institutionalized in American life to the point of being covered in insurance plans by advertising itself as an art with a foundation in science, not as a channel for the placebo effect. History suggests that all kinds of things help people feel better: potions, relics, waters, confession, leeches, purgatives, tonics, autosuggestion, the laying on of hands, any of the million and one treatments purveyed through the ages by healers playing on the placebo effect whether they knew it or not. Of course to consult history is to deny the assumption, now a fashion in its own right, that the consumer society stands above history, emancipated from the ignorance that was the plague of the past. With some 250 varieties of psychotherapy already on the market a quarter of a century ago, and with fads like encounter groups, orgone therapy, Rolfing, and a Bartholomew Fair of similar wares continually going into and out of existence, their forms limited only by human invention and the life-span of fashion, it would be amazing if patients with psychological ailments could find nothing that made them feel better, at least temporarily. But for a citizen the question is not whether this or that therapy makes Smith feel better. It is whether making Smith feel better is enough to warrant the investment of public trust.
 Edward Shorter, Doctors and Their Patients: A Social History (New Brunswick: Transaction, 1991), p. 158.
 Doctors and Their Patients, p. 160.
 Doctors and Their Patients, p. 151.
 “Medical ethics enjoyed a remarkable degree of continuity from the days of Hippocrates until the middle of the twentieth century. Developments in the biological and health sciences then led to critical reflection . . .” Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, Fifth Edition (Oxford: Oxford University Press, 2001), p. 1. Cf. Orwell’s 1984: “The history books say that life before the Revolution was completely different from what it is now.”
 Paul J. Edelson, “Patient, Heal Thyself,” Hastings Center Report, September-October 1998.
 Arthur K. Shapiro and Elaine Shapiro, The Powerful Placebo: From Ancient Priest to Modern Physician (Baltimore: Johns Hopkins University Press, 1997), p. 95. My information about psychiatric drugs comes from this source.
 Paul Leber, “The Placebo Control in Clinical Trials,” Psychopharmacology Bulletin 22 (1986): 32.
 On the pop psychology movement, see my Fool’s Paradise: The Unreal World of Pop Psychology (Chicago: Ivan R. Dee, 2005).
 Adolf Grünbaum, “Empirical Evaluations of Theoretical Explanations of Psychotherapeutic Efficacy: A Response to Greenwood,” Philosophy of Science 63 (1996): 622-41. See also John D. Greenwood, “Placebo Control Treatments and the Evaluation of Psychotherapy: A Reply to Grünbaum and Erwin,” Philosophy of Science 64 (1997): 497-510.
 David Rosenthal and Jerome Frank, “Psychotherapy and the Placebo Effect,” Psychological Bulletin 53 (1956): 294.
 Martin Enserink, “Can the Placebo Be the Cure?” Science, 9 April 1999: 238.
 The Powerful Placebo, p. 85.
 Doctors and Their Patients, p. 201.
 Rosenthal and Jerome Frank, “Psychotherapy and the Placebo Effect”: 296.
 The Powerful Placebo, p. 103.
Stewart Justman is the author of Fool’s Paradise: The Unreal World of Pop Psychology.