On Psychotherapy

What makes us better? A new study calls into question our understanding of change

A recent study about a so called “honest placebo” has received a good deal of attention. This study is particularly intriguing because unlike other studies of placebo interventions the participants clearly knew they were being given a placebo, yet still benefited from receiving the placebo. This reseach makes us stop and question our understanding of what make us better, gives us relief from symptoms, and helps us change.

The study, led by Ted Kaptchuk at Harvard Medical School’s Osher Research Center and colleagues from Beth Israel Deaconess Medical Center (BIDMC) appeared on December 22 in PLoS ONE, an on-line journal, found that placebos worked nearly twice as well as no intervention in relieving irritable bowel syndrome (IBS) symptoms, despite the fact that patients in the control group receiving the placebo were clearly told they were receiving a placebo. The investigators stated that they went out of their way to be clear with patients that they were receiving sugar pills. The authors stated that, “Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had ‘placebo’ printed on the bottle,” and further notied, “We told the patients that they didn’t have to even believe in the placebo effect. Just take the pills.” What is particularly startling about this study is that the placebo effect was quite powerful. The authors noted that those in the placebo group did as well as those who typically receive the most effective medications for IBS.

The investigators were cautious in interpreting their results, stressing that they only conducted one study, and that it was time limited, lasted for 3 weeks. Clearly their cautions are important: this is only one brief study, looking at one disorder. However, the study does raise intriguing questions about how and why people benefit from treatment. The authors hypothesized that possibly the ritual of taking medication may have accounted for the benefits of the placebo.

It is a short leap from this study to thinking about how and why mental health treatment, psychotherapy in particular, helps patients. There is a consistent body of research supporting the benefits of therapy, but there is no definitive answer or answers to how and why therapy works. In fact, there is an increasingly strident debate about what accounts for change: the specific strategies and methods associated with a given model, (Evidence Based Therapy) or the non-specific ingredients of therapy (empathy, hope, the client-therapist reliance). Advocates of Evidence Based Therapy assert that there is evidence that certain models and techniques are more effective, often Cognitive Behavioral Therapy. The American Psychological Association is a major proponent of evidenced based therapy and recently developed a website highlighting evidence based treatments http://www.div12.org/PsychologicalTreatments/disorders.html). On the other side, are a group of research (mostly psychologists as well) who argue that the claims of evidenced based therapy are greatly overblown and that the non-specific ingredients (primarily the therapeutic relationship) are what account for change (see for example the work of John Norcoss, Scott Miller and others; Miller’s website offers an accessible understanding of this view: http://www.scottdmiller.com/).

While one limited study clearly cannot resolve this debate it does force us to think more about how and why change/symptom relief occurs, and how/why different interventions work. In fact, the researchers note that previously it was assumed that placebos worked because people thought they were getting something that would help them. Their work clearly challenges our assumptions about how and why placebos work, further calling into question what accounts for change/symptom relief.

It is possible that rituals, in this study medical rituals (doing things that are associated with making one better), may be an ingredient in accounting for change/symptom relief. While there is far from definitive evidence to support this idea, this study reinforces the notion that we need to be more modest in our claims that we understand why and how change occurs. It also clearly suggests that we need to work to better understand what brings about change/symptom relief.