PSYCHOLOGY AND PHYSICAL THERAPY

are suggestions that should be considered only within the contexts of the ethical and professional framework that all regulated therapists operate by, that is, eliciting a placebo effect on the basis of false infor- mation, for example ‘this cream will help the bone tissue heal’ is clearly unethical.

It is tempting to speculate that in the future when we have a greater under- standing of mind-body links, generally, and placebo effects specifically, medical ethics may be revised. That is, it may be considered unethical not to communicate in a positive style, even to be ‘economical

SOME RECOMMENDATIONS Contrary to popular myth, in clinical and therapeutic settings, the placebo effect is rarely manifested in the form of a single direct response to the administration of an inert tablet. It is probably very rare that a doctor gives a patient a couple of sugar pills and says, “You’ll be better in a week.” It is in fact evident from the research in part one of this article, that the placebo effect may be elicited, or compromised, by a variety of factors, many of which are under the direct control of the practitioner. It could even be argued that all therapeu- tic settings are ‘armed’ with a potential placebo effect, and that this effect may be either facilitated or compromised by sever- al practitioner-specific factors. In relation to this, some recommendations and cau- tions are briefly described below.

■ A therapist who conveys confidence in their ability to bring about a positive outcome may, by doing so, augment any treatment with a therapeutically signifi- cant placebo effect. Such confidence should not be deceptive, for example

process. These beliefs are based both on the patient’s own experience of injury and rehabilitation (see below), and information from third parties. The prac- titioner, as a third party, should seek to inform the patient using terminology that encourages positive belief effects (he or she may also help the patient reinterpret any negative beliefs based on previous experience). For example, the phrase “I am going to use ultrasound therapy as it has been found effective in injuries similar to yours” is likely to pro- mote more positive belief effects than “we could give ultrasound a try...”

indicating that a two-week recovery period is possible when in fact a six- week recovery period is both likely and desirable, but should convey at least the potential for positive outcomes even if these are not entirely certain.

with the truth’, in a clinical setting, aware of the potentially negative influence of uncertain or pessimistic communications. It would not be overly controversial to suggest that the history of medicine demonstrates that the ethics of practice may vary with changes in the immediate cultural/political, technological and sci- entific environment.

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■ Practitioners should ensure that their overt behaviours and statements are not likely to elicit an anxiety response in their patients. For example, a look of concern on the face of the practitioner at initial consultation may be seen as an empathic and helpful sign by a patient; whereas a look of worry may elicit con- siderable anxiety and reduce confidence in outcomes.

■ The patient’s beliefs in the likelihood of positive therapeutic outcomes may be a major factor in the rehabilitation

■ As well as potentially reducing the patient’s anxiety, use of techniques/ technology (eg. ultrasound, anti-inflam- matory gel, manipulation) that the patient has found effective in previous clinical settings might elicit a condi- tioned placebo response. This may hold true even if the practitioner would not necessarily choose to employ such an approach him/herself in the present context. Although not discussed explic- itly in either of our two papers on the issue, it is frequently suggested in the placebo effect literature that classical conditioning, the subconscious and ongoing association between a stimulus and a response, may account for a sig- nificant percentage of placebo effects. Even in the absence of a conditioned response, use of previously successful techniques may significantly reduce the client’s anxiety about their current injury and the potential efficacy of any new treatment.

■ Adopting a professional and smart appearance and demeanor may also elic- it a conditioned placebo response. This factor, that is the idea that how we dress and appear can dramatically influ- ence the outcomes of the therapeutic process, is in our experience one of the most contentious aspects of this topic. On delivering this information in semi- nars and practicum, the first author of the present paper has often been greet- ed with complete disbelief! However, from our very first experience in life we associate such signals with health and well-being and it is evident that many experienced practitioners appreciate the legitimacy of this idea. Not surprisingly, the literature suggests that white is a preferable colour to wear.

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