“An error is the more dangerous the more truth it contains.”
– Henri-Frédéric Amiel
Ah placebo! Along with natural history and regression to the mean, it is one of the positive non-specific effects of any intervention. Some people think that I don’t like placebo which is ridiculous. That would be like saying I don’t like natural history! I will be the first to admit that you cannot avoid placebo (all treatments involve some sort of placebo) and by all means you should do everything you can to enhance its effects.
But I believe that you should enhance those effects INTENTIONALLY. I call this “placebo-fu”. Unfortunately, most providers get their placebo effects ACCIDENTALLY which, in my opinion, is lazy, misleading, and suboptimal. Regardless of whether or not your effects are specific or non-specific, misunderstanding the mechanism of action is like firing blindly into the dark. You should recognize the placebo that is always in play and manipulate it to give the greatest effect.
Before I go much further, remember that non-specific effects treat non-specific diagnoses. In other words, you’re not curing a cancerous tumor with placebo. But you might reduce a cancer patient’s anxiety or perceived pain. Of course if anxiety treatment is ALL the patient needs, then that patient needs to see a mental health professional, not a surgeon or physical therapist. Placebo, in isolation, might be effective for RONPDD, however.
By definition, the placebo effect is not unique to an intervention. In other words it is “not specific” to the intervention. (Do you see where that term comes from?) That means that you can get those same effects from ANYTHING as long as the context is correct. Interventions that automatically and unintentionally get ALL of their effects this way are inaccurately called “placebos” (placebo is an effect not an intervention).
So let’s talk about strengthening your placebo-fu. A good starting point would be the 5 “E”s as described by the Institute for Healthcare Communication. Robert Jamison wrote a very good piece on this for IASP back in 2011. At the end, I’m going to add “Placebo Theatre” to the framework.
The 5 “E”s
Be engaging with your patient. Make eye contact, be warm and inviting (don’t get creepy), show interest, etc. Body language goes a long way here. Don’t stand towering over them. Sit down, relax. Keep it loose and friendly. Add some appropriate humor.
Of course you need to be jotting notes on your computer, but make sure to sit forward, nod as they talk, repeat things back for clarity. I will admit, if I have a suspected “high stress case”, I won’t even bring my computer into the exam room. However, I rarely need to do this because my placebo-fu is strong.
Show that you understand and care about the case in front of you. Remember that when interacting with someone, anyone, the primary thing that they want is to be understood. Try to fulfill that first. Employ active listening strategies by asking clarifying questions. Relay back to them what they are describing. Allow them to correct you so that the two of you can come to a consensus as to what they perceive they are dealing with, physically and emotionally. Don’t educate yet. Just listen and understand. If you don’t understand their position, you cannot even begin to educate them.
The first step of educating another person is to understand their starting point – that is what you established with your active listening. What do they believe is going on and why? What are their concerns? Now you know your starting point. You allowed them to educate you and made sure that you understood what they were trying to say. Now it’s your turn to educate them and make sure that they understand what you are trying to say.
Once you and the patient have come to a consensus as to their concerns and your understanding of the core problems to address, you must form an alliance. This is the “Therapeutic Alliance”. The patient must buy in to the story and agree to proceed. You must lay out options for the patient to choose from. “Here is what I can offer you.” Let THEM make the decision on what to do next.
They may adamantly not want anything on your list. In this case, you should neither force your plan of care nor just do whatever they want. They simply need another provider and that is ok. The stronger your placebo-fu, the less likely this will happen. Understand that two providers may have identical recommendations except one is able to achieve buy in while the other is not. This happens all the time.
Draw your session to a nice tidy end. Have a definitive plan of what you will do and what the patient will do. Give reasonable expectations. Explain what to expect if things are working well, and what to expect if things are not working well. Lay out what will be recommended if things are not turning out as they should. Let them know that things are rarely black and white and this is ok.
“All the world’s a stage, and all the men and women merely players: they have their exits and their entrances; and one man in his time plays many parts, his acts being seven ages.”
– Bill Shakespeare, personal friend of the author
So this is my addition to the 5 “E”s: Placebo Theatre. This is “The Show” of healthcare. It begins with the patient’s original understanding of what your profession does and continues all the way through completion of care. The marketing of “techniques” by others adds to the theatre. Let’s break this down so we can add it to our placebo-fu.
Clean and Professional Presentation
Where is the clinic located? How does the reception area present itself? What are YOU wearing? Keep in mind that you are fitting into a role as a “mere player”. It is your “costume”. I wear sneakers, golf slacks, and a polo shirt every day in the office. It says relaxed rehab professional who knows exercise. Wearing a shirt and tie would be off-putting to the patients I see. Your patients may expect something different from you. Or you may want to convey something different than I do. For example, a white lab coat has an effect. The point is, be intentional about it.
A little clarification. I’m not talking CONSTRUCT validity – The thing actually does what it claims to do the way it claims to do it. I am talking about FACE validity – The thing LOOKS LIKE it does what it claims to do the way it claims to do it. Don’t get me wrong, construct validity is where the specific effects of a treatment come into play. But face validity is what gives you the placebo (something we want to enhance). It is little more than a convincing explanation.
Example: Apply load to an injured tendon to make it heal BETTER? We know this is true (has construct validity) but it lacks face validity – it is counterintuitive. Through proper education, you can increase the face validity which will increase the non-specific effects of the intervention. This is practicing placebo-fu.
Don’t look like a bumbling idiot unable to perform a special test or demonstrate an exercise. Be purposeful and deliberate. Now, that doesn’t mean feign knowledge that you don’t have. As a matter of fact, confidently explaining a scientific lack of understanding can build a huge rapport with your patient – they know that you aren’t trying to bullshit them. Your placebo-fu is growing…
Have a “system”. And no, I don’t mean that you need to use a SYSTEM™. You just need to have some kind of algorithm to your approach. Classically medical providers learn to use a differential diagnostic procedure (a process of elimination) as their approach. The 5 “E”s I described above are a system for patient communication. Your physical exam should also follow a pathway of some sort. So should the implementation of you plan of care.
Patients love this! It gives the impression that you are being thorough. Hopefully it means that you actually are.
One of the most common complaints that physical therapists hear from patients regarding their visit with their physician: “They didn’t even touch my ______!” Now you and I both know that you get pretty much everything you need in order to make a diagnosis just from the subjective, but you need to touch your patient. Just poke the spot. First, the patient believes that you now somehow understand them better because you “felt it”. Second, what if you feel a huge, hard, lump?
But there is something else. Physical contact is comforting to MOST patients (be careful of those of us with Asperger tendencies). It conveys a sense of caring and empathy (see above). No, I’m not talking about manual therapy. I’m simply talking about placing your hand on the patient as you talk to them. Give reassuring contact. Place your hand on their upper back as you guide them to the next exercise. Touch the muscle that you want them to contract. Not because it does anything specific. Because it is comforting and reassuring. And because placebo-fu.
Now I have been describing placebo-fu – the INTENTIONAL application of placebo. ACCIDENTAL application is NOT placebo-fu. Look at everything you just read above. How many of you already do all of these things but never noticed it? The 5 “E”s look like simple compassion – something most physical therapists already exhibit. Now look at the Placebo Theatre:
- Are you and your clinic clean and professional?
- Can you “sell” your interventions through a convincing explanation that “makes sense” (even if it’s bullshit)?
- Are you confident in what you do?
- Do you use some kind of systematic approach?
- Do the creators of your intervention or system market this to the general public?
- Does your intervention involve physical contact?
Good news! You are enhancing placebo!
Bad news. That may be all that you are doing and it is likely accidental. If you are unintentionally relying on the automatic placebo effects of an intervention, then you are just being lazy. Also, you may accidentally steal self-efficacy of the patient by getting them to believe in magic. As my friend Cory Blickenstaff says, “That’s no bueno.”
Your accidental placebo effect can be a crutch. Get rid of it. Take control over what you do.
Remember, the goal here is not to provide placebos in isolation. The goal is to have a specific effect. Take an intervention with a known specific effect and slather on a whole lotta placebo enhancement. That is placebo-fu.
Can’t think of anything specific to address? Well, if nothing else, after any injury, real or perceived, the patient will become deconditioned. We know this is not helpful for any diagnosis. Systematically address that with a healthy dose of reassurance and compassion.
You know, rehabilitate them…
- Placebo is a good thing, just not in isolation
- Practice “placebo-fu” by intentionally enhancing potential placebo effects
- Take an intervention with a known specific effect and slather on a whole lotta placebo enhancement
- Systematically build your patients up with exercise and a healthy dose of reassurance and compassion
The featured image on this post is “Shaolin Kung Fu” by larique via Flickr.
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