Placebo and Permission to Change

Technical note: this post has a soundtrack - please play the YouTube video embedded below and move on to reading. It is the first time I'm testing this - it could require that you visit the Substack page if the music doesn't start in your email client.

You see, the mystery of placebo response is puzzling me for years. And I'm not referring only to people who get better after having a sugar pill. I also mean things like reversing drug response. It's a wild area.

I'm puzzled; many others are frustrated. Elucidating biochemical response by thought alone is a known confounding factor of clinical trials. Evidence-based medicine requires properly designed (randomized, double-blind) trials before anybody can say that a treatment works. In other words, it becomes frustrating - in developing any therapy, you compete with a placebo. 

I'm puzzled; many others are frustrated; Wayne Jonas (a US-based scientist and physician) seemed annoyed. Two years ago, he looked at the placebo from the perspective of his practice and published an opinion article entitled "The Myth of the Placebo Response." He argued empathically that the proper name for the effect is "healing response." And he called to factor this response in the treatment course instead of voraciously eliminating it. Let me read you a paragraph from his paper (BTW, you need to check his article for references to each claim, there are plenty):

Once the myth of the placebo response is removed, I, as a physician, can draw on research on the mechanisms of the meaning response to produce an evidence-based healing response for my patients. For example, I would now have evidence for using the following approaches in my day-to-day practice with any treatment, no matter what its efficacy is. I would try to use more frequent dosing rather than less frequent dosing—up to a limit. I would seek to deliver therapies in the most powerful therapeutic settings such as hospitals and clinics rather than at home. I would try and match the appearance, such as size and color, to the desired effect expected by the patient and their culture. I would attend to the style and route of administration of a treatment. I would take the time to deliver therapies in a warm and caring way and with confidence in their power to heal. I would explore what therapies my patient believes in and try to align and accommodate my treatment to that belief, provided it was safe. I would make sure I understand the mechanisms of a treatment so that I can believe in the treatment I am delivering. I would seek to align all beliefs—that of the patient, the doctor, the family, and the culture. I would add a safe and easy to use conditioned stimulus alongside the specific therapy. I would use a well-known brand or a new and exciting treatment claimed to have success. I would let the patient know what to expect. I would seek to use an electronic device to deliver and track the treatment when possible. I would always incorporate reassurance, relaxation, suggestion, and reassurance into the treatment. I would spend the time to listen and understand the patient and, when possible, touch them with empathy and reassurance. More recently, the evidence shows that I can simply explain to the patient about the likely benefit of any treatment for its potential in healing and recovery, and most remarkably, I can do this with any treatment, whether its specific effect has been proven or not.

Can you see where Jonas is going with it? 

Now, Luca Dellanna (a complexity researcher) came up with a placebo definition that sums Jonas' sentiment quite nicely "Placebo is a permission to change.

Let it sink in.

We can imagine a future where all physicians would be equipped to follow Jonas' dream. Many of them already are, but their intuition and wisdom are hard to teach and pass to others. 

But maybe we can learn from other fields. Specifically, I wonder if we couldn't learn from the principles of psychedelic-assisted psychotherapy. 

Consider that the same MDMA used as a party drug is spectacularly successful in treating PTSD. The critical difference between just a trip and a therapeutic outcome is the protocol of use - something that Timothy Leary popularized as "set and setting." The drug itself doesn't heal; it merely opens the path. Patients still need to permit themselves to change. 

Now, let's connect a few dots. We know that depression is independently associated with increased mortality, for example, in the case of breast cancer. There seems to be growing evidence that psychotherapy decreases oncology patients' mortality, at least for patients with a diagnosed mental disorder. Small studies show improvements in mood in cancer patients after a single dose of psilocybin. We are not that far from experiments that will show a reduced mortality rate in oncology patients after administering psilocybin or other psychedelic substances as part of psychotherapy. 

Do I say that psychotherapy should be a standard part of healthcare, irrespectively of the condition? Nope. It's an impractical idea.

Do I say that we need psychedelics to be a standard part of healthcare? Nope, especially that one can engineer a placebo to trigger a psychedelic experience without any chemistry

But I think that based on our knowledge of human behavior, the structure of the human psyche, and modern technology (so it is scalable), we could engineer healing response to the level unknown to modern medicine. And then we can make THAT a standard part of any medical intervention.