Long Live the Placebo Effect?
The placebo effect has a negative reputation, but that is not entirely justified. In complementary and alternative medicine (CAM) it is also seen as the self-healing capacity of the body. What exactly is the placebo effect and how can we osteopaths make good use of it?
By Sander Kales, D.O.-MRO, M.Sc.
Much of the effect of an osteopathic treatment is due to what we unknowingly do. Up to 75 percent of the relief of pain and depression complaints after a biomedical treatment is due to the placebo effect (Dieppe 2016).
The placebo is often seen as an inert substance; a pill that contains nothing effective. The placebo effect is that which follows the administration of a substance or a procedure. A placebo treatment is therefore not only about fake pills, but also about symbols, rituals and interactions.
McQueen reviewed placebo effects and postulates that the effect decreases as disease and depression worsen (2013). Placebo effects also appeared to vary enormously with different diseases.
The reverse also applies: the same placebo effect appears to be found for treatments from different healthcare providers. That was the opinion of doctor John Lie during the NVO Migraine congress of 2018. The effect of acupuncture versus a dummy treatment in the treatment of migraine turned out to be just as large as that of osteopathy versus a dummy treatment. Lie therefore concluded that the same underlying treatment mechanisms must be at work. That there is indeed an influence of placebo on physical functioning is also apparent from the negative “placebo” effect: the nocebo (Kaptchuk 2015). In short, not the treatment but something else improves the complaints of patients.
The placebo effect can partially explained by distinguishing between disease and illness. Disease is a biological dysfunction that can be explained pathophysiologically, a disorder is a condition. A placebo treatment primarily affects the condition and not the disease, McQueen states.
Although it can do a lot for the patient, a placebo treatment only provides relief and not a cure. What is at the origin of the pain complaints, such as tumors, is not reduced.
“The severity of the symptoms is partly determined by the experience of the patient”
The healing relationship
Apparently there is such a thing as effective medication and a healing relationship. In ancient times the phenomenon of healing was already known, and often it was mostly the intention to relieve another person of his suffering. Over time this developed into Complementary and Alternative Medicine (CAM) with rituals, beliefs and treatments. Today, according to the American National Institute of Health, CAM can be subdivided into five subareas: alternative medical systems (such as acupuncture, homeopathy), biologically based therapies (dietetics, phytotherapy), manipulative and body-oriented therapies (chiropractic, osteopathy, massage), energetic therapies (therapeutic touch, Reiki) and body-mind interventions (meditation, hypnotherapy) (Staud 2011).
With the development of the medical sciences, CAM developed further as well. In its search for the effective treatments, the medical sciences eventually left behind “bloodletting” and mercury treatments, and with that healing was also forgotten. Placebo got a bad name.
The word placebo literally means: to satisfy. It comes from a Latin psalm from the 14th century the Placebo Domino: I will satisfy the Lord. Henry Beecher made this concept popular in 1955 with his book “the Placebo effect.” He stated that the placebo is a threat to medical science and is therefore unethical. In randomized controlled studies (RCTs) today, the effect of placebo’s is not measured but filtered out (Staud 2011).
“The placebo effect van be seen as the self-healing capacity of the patient”
CAM
But what applies to regular medicine does not apply to Complementary and Alternative Medicine. After all, CAM is not related to tumor treatment, but more often to the experience of complaints. Because the severity of complaints is also partly determined by the experience of the patient. In CAM, the placebo effect is therefore seen as the self-healing capacity of the patient, the third principle in osteopathy.
According to renowned CAM researcher Ernst (1995), the effect of a CAM intervention does not only consist of a specific treatment effect, but also of non-specific effects such as the placebo effect, a natural healing effect and various other phenomena. But what exactly does the placebo (treatment plus effect) consist of? Or vice versa: how is it that CAM practitioners score so well on placebo effects?
According to Stub (2017) researcher at the Integrative Health Care center in Norway, CAM is provided by health care practitioners who listen, confirm, give hope – and do this in a pleasant environment. They generally have more time than their colleagues from mainstream medicine. In addition, these health care providers believe in the effectiveness of their approach. All of these factors influence the placebo effect.
The placebo effect is therefore achieved by having faith and belief in the healing process. Patients undergoing CAM therapy experience being seen as a whole. This holistic approach is perceived by patients as empowering and instructive with regard to their own recovery capacity. This contextual healing is seen as the placebo treatment. Dieppe (2016) states that mainstream medicine should applaud the ability of CAM practitioners to achieve a strong placebo and learn from it.
There is also a demonstrable neurophysiological effect with placebo effect. When undergoing a placebo treatment, Finness (2010) measured changes in brain activity. It is therefore clearer to replace placebo treatment as a concept with “mental attunement to the context of treatment”. This mental tuning gives the relief of pain.
According to Harvard brain researcher Hashmi (2018), mental attunement consists of internal (expectation) factors within the patient and external (relational) factors, regarding the therapist and the patient.
The internal relational factors consist of: patient expectations, pain beliefs, satisfaction and health beliefs. The external relational treatment factors, also referred to as non-specific factors, consist of beliefs from the osteopath, the therapeutic relationship and feedback, rituals, conditioning. Together they are also called “common factors”.
As an osteopath, how do I optimize the process of mentally tuning in?
The osteopathic therapist-patient relationship
The professional competence profile for osteopaths in the Netherlands (NVO 2014) states that an osteopath communicates effectively verbally and non-verbally to build a relationship, to conduct a conversation and to be able to report. An osteopath must learn to build a good relationship by listening, recognizing verbal and non-verbal communication, giving space, learning to recognize feelings and, in the meantime, taking into account the uniqueness of the patient.
The British Osteopathic Association (G.O.C. Standards, 2000) states that the osteopath enters into an empathetic relationship with the patient. They believe that the osteopath should be critical and able to reflect on himself. Touching creates an intimate contact and non-verbal communication is therefore important.
The German osteopath Mayer (20165) describes in her thesis that the osteopath-patient relationship consists of the following five components: the work agreement, transference-countertransference relationship, the restorative development-oriented relationship, the congruence I-other (empathic capacity) and the transpersonal relationship (self-awareness, third-person perspective). It is important to keep all five components in mind during the treatment process.
Professor Sturmberg (2013), specialist in the field of complex systems in health care, summarizes these relationships by stating that a healing relationship consists of three components: competencies (clinical wisdom, mindful, emotional self-regulation and self-confidence), processes (appreciation, connecting and surrendering) and outcomes (hope, trust, being known, PROM and PREM). You can train the competencies, observe the processes and try to get feedback (for example through peer review) and evaluate the outcomes.
In summary, one can state that an osteopathic relationship must contain a number of aspects: competencies of the osteopath, good processes (working relationship, non-verbal communication, transfer-versus-transfer, affect regulating and subject relationship) and of course the desired outcomes. These aspects may then result in an improvement of the non-specific/general treatment factors. What do these skills look like in the osteopathic process?
The diagnostic phase
The osteopath-patient relationship starts with a diagnostic phase. Within osteopathy we work with the five explanatory models of complaints according to the ECOP (Hruby, 2019). The fifth model is the biopsychosocial model. The definition according to Romano is: “The biopsychosocial approach systematically takes into account biological, psychological and social factors and their complex interaction in understanding health, disease and healthcare.”
It appears that the osteopath is inclined to focus primarily on a biomedical and a structural analysis of the demand for help in everyday practice. They are much less inclined to approach the demand for help from the biopsychosocial model (Sampath 2020). According to osteopath Abrosimoff, this leads to osteopaths having a paternalistic attitude towards their clients (“I’ll fix it”). And that attitude has a negative effect on all relational aspects that would actually increase the effect of a treatment (2020).
Thus, the concept of somatic dysfunction in osteopathy does not take into account the psychosocial dimensions of complaints. Fryer even states that this notion is outdated and reinforces the belief in a structural biomedical cause of pain. The osteopath “makes or heals” instead of “guiding the change” (2016). Osteopath and clinical psychologist Calsius notes that there is a latent danger of reducing the psychological reality of the patient to the somatic explanation paradigm of osteopathy (2018).
The treatment phase
The biopsychosocial model is non-theoretical and purely descriptive. It provides a framework for the diagnostic phase, but doesn’t give a guideline for the treatment phase. However, various osteopaths have also looked into the treatment phase.
The osteopath can modulate the autonomic nervous system, based on tone and lifestyle stressors change (Kolb 2020). However, this falls within the biomedical paternalistic “I will make it” approach.
According to the osteopath Barrington, touching during an osteopathic treatment has a number of facets: supportive, preparatory, informative, caring, therapeutic intervention, awareness of information, safety and exchange (2014). Touching therefore contains many relational aspects that can promote the treatment relationship and thus also ensure the non-specific treatment effect.
It is then necessary to integrate osteopathic touching with verbal communication, to make transference and resistance phenomena transparent. Mayer (2015) conducted qualitative interviews with osteopaths and showed that the person who sees himself as a mediator between the patient and his “healthy” parts, places less emphasis on verbal communication than the therapist who sees himself as a supervisor of the process.
“By paying more attention to the factors that contribute to the osteopath-patient relationship, we can increase our effectiveness”
Resume
The osteopathic intervention has a number of effects, including the placebo, or the mental alignment with the treatment. The osteopathic treatment does not contain a separate biopsychosocial approach, but it does arise from the treatment relationship. Touch is an important aspect of this. This touch requires more verbal communication and awareness of the relational factors. By paying more attention to the factors that contribute to the osteopath-patient relationship, we can increase our effectiveness.
The NVO congress will elaborate on the biopsychosocial working method of the osteopath, and includes the following speakers:
Joeri Calsius, osteopath and clinical psychologist, presents a conceptual model for integrated bodywork from a somato-psychic perspective.
Hedda Lausberg, neurologist and psychiatrist, has worked out non-verbal communication so that there are concrete tools that contribute to improved patient contact.
Eva Banninger, professor of clinical psychology, shows through video contribution what happens in transfer-opposite transfer phenomena (see recent newsletter).
From the Mental Health Care (GGZ), Rogier Hoenders will show the limits but especially the possibilities for an integrated approach.
Red flags: disorder or serious pathology.
Yellow flags: psychosocial indicators that show an increased risk for progression to longer-term distress, inability and pain.
Blue flags: work and employer perception of health and work.
Black flags: context and environment, such as other people, systems and policies
Orange flags: psychiatric symptoms.
Abrosimoff M, Rajendran De, “Tell me your story” – How osteopaths apply the BPD model when managing low back pain – A qualitative study, International Journal of Osteopathic Medicine (2020).
Barrington, Contacting with Clarity – The communicative purposes of osteopathic touch, 2014, Master of Osteopathy, Unitec New Zealand.
Bialosky 2017, Placebo Mechanisms or Manual Therapy: A Sheep in Wolf’s Clothing? J Orthop Sports Phys Ther 2017; 47 (5): 301-304. doi: 10.2519 / jospt.2017.0604.
Calsius, Experiential Bodywork Course, Panta Rhei, 2018.
Clarke, R.J., Depression, Anxiety and Positive Outlook among patients presenting to an osteopathic training clinic: A prospective survey, Master of Osteopathy, Unitec Institute of Technology, 2010.
Dieppe, P., & Rahtz, E. (2016). Placebos, CAM and Healing: P + X + Y. Int J Complement Alt Med, 4 (2), 00114.
Dugailly, P.M., Fassin, S., Maroye, L., Evers, L., Klein, P., & Feipel, V. (2014). Effect of a general osteopathic treatment on body satisfaction, global self-perception and anxiety: A randomized trial in asymptomatic female students. International journal of Osteopathic medicine, 17 (2), 94-101.
Ernst, E., & Resch, K. L. (1995). Concept of true and perceived placebo effects. Bmj, 311 (7004), 551-553.
Finniss, D.G., Kaptchuk, T.J., Miller, F., & Benedetti, F. (2010). Placebo effects: biological, clinical and ethical advances. Lancet, 375 (9715), 686.
General Osteopathic Council, Standard of Proficiency, 2000.
Greco, C.M., Yu, L., Johnston, K.L., Dodds, N.E., Morone, N.E., Glick, R.M., & Colditz, J. (2016). Measuring nonspecific factors in treatment: item banks that assess the healthcare experience and attitudes from the patient’s perspective. Quality of Life Research, 25 (7), 1625-1634.
Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. 2010; 90: 1099–1110.] Phys Ther.
Hashmi, J.A. (2018). Placebo effect: Theory, mechanisms and teleological roots. In International review of neurobiology (Vol. 139, pp. 233-253). Academic Press.
Hruby, R.J., Tozzi, P., (2017). The five osteopathic models: Rationale, application, integration: from an evidence-based to a person-centered osteopathy.
Kaptchuk, T. J., & Miller, F. G. (2015). Placebo effects in medicine. N Engl J Med, 373 (1), 8-9.
Kendall, N., Linton, S.J., and Main, C.J. 1997 Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long term disability and work loss. Accident rehabilitation and Compensation Insurance of New Zealand and the National Health Committee, Wellington, New Zealand.
Kolb, W.H., McDevitt, A.W., Young, J., & Shamus, E. (2020). The evolution of manual therapy education: what are we waiting for?
Mayer, Sharon, Towards a relational understanding of embodied therapeutic relationships: a qualitative study of body-focused practitioner’s experiences, 2015.
McQueen, D., Cohen, S., St John-Smith, P., & Rampes, H. (2013). Rethinking placebo in psychiatry: the range of placebo effects. Advances in psychiatric treatment, 19 (3), 162-170.
Miciak, Maxi, A review of the psychotherapeutic common factor model and its application in physical therapy: the need to consider general effects in physical therapy practice; Scand J Caring Sci; 2012; 26; 394–403.
NFP, Professional Competence Profile of Psychomatic Physical Therapy, KNGF-NFP, May 2009 edition.
Novy, Regina, Therapist-Patient-Relationship in Osteopathy; How do osteopaths form their relationship to patients? A qualitative study, Master Thesis Danube University Krems at the Wiener Schule für Osteopathy (Vienna School of Osteopathy), Vienna, May 2007.
NVO, Professional profile Osteopathy, version 2014.
Sampath, K.K., Darlow, B., Tumilty, S., Shillito, W., Hanses, M., Devan, H., & Thomson, O. P. (2020). Barriers and facilitators experienced by osteopaths in implementing a biopsychosocial (BPD) framework of care when managing people with musculoskeletal pain – A mixed methods systematic review protocol. International Journal of Osteopathic Medicine.
Staud, R. (2011). Effectiveness of CAM therapy: understanding the evidence. Rheumatic Disease Clinics, 37 (1), 9-17.
Stub, T., Foss, N., & Liodden, I. (2017). “Placebo effect is probably what we refer to as patient healing power”: A qualitative pilot study examining how Norwegian complementary therapists reflect on their practice. BMC complementary and alternative medicine, 17 (1), 1-10.
Sturmberg, Joachim P., and Carmel Martin, eds. Handbook of systems and complexity in health. Springer Science & Business Media, 2013.
Association of Haptotherapists (VVH) Professional competence profile GZ-Haptotherapeut version 2010.
Zellner, Katrin, Übertragung und Gegenübertragung – Phänomene einer gegenseitigen therapeutischen Beziehung! Eine Hinführung auf das Theme Patients-Therapists-Beziehung mit Bezug zur Osteopathy, Thesis Osteopathy Schule Deutschland, Berlin, 31.08.2014
Zhang, W., & Doherty, M. (2018). Efficacy paradox and proportional contextual effect (PCE). Clinical Immunology, 186, 82-86.
Zilcha-Mano, S., Roose, S. P., Brown, P. J., & Rutherford, B. R. (2019). Not just nonspecific factors: the roles of alliance and expectancy in treatment, and their neurobiological underpinnings. Frontiers in behavioral neuroscience, 12, 293.
x
In the Netherlands, the psychosomatic physical therapist goes one step further from the osteopath according to his professional competence profile (2009). They see themselves as an instrument in the client’s treatment process. The therapeutic relationship refers to the dialogically embodied contact between client and therapist. This vision requires continuous reflection during the entire treatment process, both on one’s own actions (self-reflection) and on the client’s reaction. Feeling (intuition and experience), empathy and sympathy are required elements in the attitude of the psychosomatic physical therapist (NFP 2009).The psychosomatic physical therapist examines for red, blue, black and yellow flags, identifies implicit problems and assesses whether the client can actively participate in the process.This flag system has been postulated by Kendall (1997), among others. The system is a means to map the psychosocial landscape of the patient.