THE PLACEBO EFFECT PART 2

■ Employing an empathic approach and spending time, for example, listening to the client’s case history or worries, may allow the therapist to allay anxiety and increase the patient’s confidence. Many authorities believe that the basis for the success of several alternative therapies is that the practitioner spends longer simply talking with the patient than is common in conventional medical prac- tice. Some go even further to suggest that such therapies are successful in whole due to the powerful placebo effects elicited as a result of the practi- tioner taking the time to develop rele- vant belief systems.

SOME CAUTIONARY NOTES Several points above may be seen to imply that merely by eliciting the appropriate belief, a practitioner can bring about significant clinical outcomes. This may be the case in some situations, but is cer- tainly not the whole story. Evans (1) in dis- cussing the claims of Kirsch and Sapirstein (3) that 75% of the effect of anti-depres- sant medicine is placebo, makes a very astute point. Even if this claim is warrant- ed, the remaining 25% of the anti-depres- sant intervention that is pharmacologically active remains a clinically significant and vital component of

the treatment. For

example, if the rate of recovery, in this case from clinical depression, is reported on a five point scale of: 5 = impaired self care 4 = cannot work 3 = definitely impaired 2 = mild functional impairment 1 = normal functioning

Then the seemingly minor 25% proportion of the therapy provided by the active com- ponent of the treatment could make the difference between ‘impaired self care’ and ‘cannot work’, or between ‘mild functional impairment’ and ‘normal functioning’, both significant differences to the patient. Placed in the sports rehabilitation context, such an effect could be the difference between an athlete sitting in the grandstand or playing in an important game. We recommend that, whenever possible, practitioners utilise the potentially additive effects of psychological (placebo) and biological (eg. pharmacologi- cally or physiologically active treatments) processes utilised concurrently, as opposed to placebos used alone.

Focusing only on the injured limb or tissue www.sportex.net

may be counter-productive, for example, Jeffels and Foster (4), suggested that an over-emphasis on the patient’s pain by, for example, asking them to rate it on a scale of 1 - 10 before and after the intervention, may produce an over-expectancy of pain and actually increase anxiety. Howe (5) suggests (placebo-induced) reduction in swelling may eliminate pain that marks an injury. So, the patient and medical staff may be given the false impression that the injury has resolved, and therefore increase the risk of a more serious injury if participation resumes prematurely. Howe (5) therefore suggests, to facilitate the performer’s return to fit- ness, it is important for the sports medicine team to recognise that the placebo effect may be operating.

Should you use the placebo effect in a sit- uation where no other option is possible (for example, Beecher (6) successfully used injections of a saline solution after running out of morphine while operating on injured soldiers), or in which it seems appropriate. A common example is telling a child that dock leaves will cure the sting of a sting- ing nettle, Humphrey (7) ensures that this fact is not later revealed to the patient. Firstly, placebo effects rarely work twice, if the patient knows that the first instance was in fact a placebo effect (evidence sug- gests that if a patient is suspicious having been deceived once, the effectiveness of an otherwise reliable intervention may be reduced).

Secondly, despite the fact that

the placebo effect is powerful, it is rarely a comfort to a patient to discover that their recovery was not due to a recognised med- ical intervention but due to being misled by a trusted practitioner.

SUMMARY Having talked to many rehabilitation prac- titioners, athletes, coaches and medical professionals over several years, it is fair to say that, to some, the recommendations above are second nature, while to others they may seem recklessly unscientific. If, after reading these two articles, you feel the latter is the case, our apologies for fail- ing to support our recommendations with sufficient evidence. However, in writing this article we were able to review only a tiny percentage of the research findings relating to the placebo effect and to present only a fairly superficial synopsis of recommenda- tions based on these. For greater informa- tion, we strongly recommend that the scep- tical and the non-sceptical among you read

Dylan Evans’ (1) ‘Placebo: the belief effect’. This text is not - as is often the case with many volumes on mind/body issues - a strongly argued case for the placebo effect, but a balanced and systematic review of the empirical evidence relating to this some- what counter-intuitive phenomenon.

THE AUTHORS

Dr Chris Beedie is a member of the British Psychological Society (BPS) and the British Association of Sport and Exercise Sciences (BASES). He is senior lecturer in Sport and Exercise Psychology, and programme director for the BA/BSc programme in Sport and Exercise Psychology, at Canterbury Christ Church University College, Canterbury, Kent. His academic interest and peer-reviewed publications focus on the effects of emo- tion, mood, and mind-body interactions on human performance. His consultancy work focuses on training practitioners in the field of health, fitness and sport, to better utilise psychological principles in their practice.

James Hopker is a member of the British Association of Sports Rehabilitators and Athletic Trainers. He graduated from St. Mary’s, Twickenham in 1998 and is now a lecturer on the BSc. Sports Therapy, Health and Fitness degree at the University of Kent, Medway, Chatham, Kent. He also runs a suc- cessful Sports Injury and Rehabilitation Clinic at the university and provides training and injury prevention consultancy for ath- letes, sports teams and organisations.

References 1. Evans D. Placebo: the belief effect. Harper Collins 2003. ISBN 0007126123 2. Ogden J. Health Psychology: A textbook. Open University Press 2004. ISBN 0335214711 3. Kirsch I, Sapirstein G. Listening to Prozac but hearing placebo. A meta-analysis of antidepres- sant medication. Prevention and Treatment 1998;1(2):1-15 4. Jeffels K, Foster N. Can aspects of physio- therapists communication influence patients’ pain experiences? A systematic review. Physical Therapy Reviews 2003;8: 197-210 5. Howe D. Sport, Professionalism and Pain: ethnographies of injury and risk. Routledge 2003. ISBN 0415247306 6. Beecher HK. The powerful placebo. Journal of the American Medical Association 1955:159(17):1602-1606 7. Humphrey N. The mind made flesh: Essays from the frontier of evolution and psychology. Oxford University Press 2004. ISBN 0192802275

● Although beyond the scope of the present paper, research has indicated that anxiety may also be placebo responsive. See Evans (2003) for discussion.

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