Evidence from the
NOTE: Dr. Smith will be giving a seminar on integrating mind-body therapies into chiropractic at the New York Chiropractic College, publisher of Transitions, on May 3 Ė 4, 2003. Click HERE for details.
Transitions: In your excellent work, The Power of Thought to Heal: An Ontology of Personal Faith, you describe placebo as a chemically ineffective treatment, such as a sugar pill, provided to patients who believe it works ó thereby paving the way for the patientís belief itself to serve as a healing agent. How might the healthcare system best utilize placebo?
Dr. Smith: The one disease that the placebo can cure once and for all, is skepticism about mind-body medicine. It is the most incontrovertible proof of Norman Cousinsís claim that belief becomes biology. When I encounter hard-nosed skeptics in my seminars, the first thing I ask them is if they had any objections to drug companies abandoning their blind and double-blind studies in testing new drugs. (I have yet to encounter anyone who says they should.) I then explain that if the mind cannot affect the body, these kinds of studies should not be necessary. That approach usually gets their attention, if nothing else.
The best way to utilize the placebo is to convert the current health care system, which is actually a disease care system, into a one that treats the whole human being and doesnít wait until the patient is physically ill before it acts. We will need to be patient here, however, because this conversion is a monumental undertaking.
Transitions: When I taught my child to ride a bicycle he began to peddle on his own quite well ó that was, until he noticed my hand was no longer touching the bike. He promptly fell thereafter. In the same light, can you anticipate similar regressions when patients come to realize their treatments are placebos?
Dr. Smith: Your experience with your son points to my main argument against using the placebo itself as standard treatment, although there may be times when its use is indicated. The placebos donít work if the patient knows itís a placebo. But that isnít the worst of it. What I call the inherent evil in the placebos is that it necessarily involves intentional deceit, either of others, if the doctor knowingly dispenses or prescribes them, or the patient, if treating himself. There is undoubtedly some power in deceit. Just ask any crook. However, over time, it invariably undermines credibility, and that is a price no health care system can afford to pay. I donít know whether you deliberately assured your son that you were not going to let go of the bike. If you did, and subsequently let go, and he fell and hurt himself, you might have problems in the future reassuring him that you have the situation "in hand" (pun only somewhat intended). The loss of trust is far more damaging than the skinned knee.
To show how the problem surfaces in health care, we can look at a case study from Dossey cited in my dissertation (p. 26 in the e-book), in which a man was given the drug Krebiozen as a "miracle" cancer treatment. Although the drug was soon to be completely discredited, his tumors "melted like snowballs on a hot stove" after he took it. Then the man found out that Krebiozen had been discredited, and the tumors came back. Says Dossey, "At this point his doctor, acting on a hunch, administered a placebo intravenously. The man was told that plain water was a Ďnew, improvedí form of Krebiozen. Again, his cancer shrank away dramatically." Then the patient found out that the Ďnew improvedí Krebiozen was a hoax, and "he was dead within days." In this case the damage done by the loss of credibility appeared to be fatal to the patient.
We need to look at the deliberate use of placebos in two contexts: first, from that of the patient, who is willing to deceive himself in order to get well, and of the paternalistic doctor, who is willing to deceive the patient to heal him. Letís look at the latter first and extrapolate. Assume that physicians, having recognized the power of the placebo effect, begin prescribing sugar pills to unwitting patients. (We will set aside malpractice and other legal issues for the moment, and also assume that such a practice has somehow been made legal.) It would not be long before the public learned that doctors were routinely prescribing placebos. (After all, you canít keep a standard medical practice secret. Somebody would blow the whistle eventually.) Because deceit is a necessary ingredient in all placebos, it would lose its power overnight. Moreover, Esther Sternberg, a prominent researcher on mind-body medicine at the National Institute of Health, estimates that about one third of the benefit derived from actual efficacious medications comes from the placebo effect. Consequently, even the legitimate drugs would suffer a serious loss of effectiveness. I believe that this kind of deceitful paternalism by the medical profession would have catastrophic consequences. And thatís just from a medical point of view. Whatever happened to the ethical value of patient autonomy?
Regarding the deliberate taking of placebos by patients, the problem is that this project is normally doomed from the start by the fact that the patient knows itís a placebo ó and, of course, placebos donít work if the patient knows heís taking a placebo. Because self-deceit is such an anathema to me, I have had trouble making this one work. The only time I ever succeeded was when I made some warts disappear by "sending warm energy" to them, i.e., I imagined warm, pleasant, almost sexual sensations in the affected areas of my toes. When they came back in different places years later, the treatment didnít work. Other people with greater capacity for self-deceit may get more consistent results.
The interesting area is the gray zone, when the patient might just deliberately refrain from reading the medical journal articles debunking megavitamin therapy, homeopathy, and other such remedies. My doctor actually encouraged me to take large amounts of vitamin C at the onset of a cold or flu ó in spite of the fact that he had undoubtedly read the studies that discredited claims by Linus Pauling and others to the contrary. Personally, I stopped megadosing on vitamin C; it just doesnít work for me. However, one of the major weaknesses of our health care system modeled on the repair shop is the assumption that all human bodies are alike. It may be possible, albeit impossible to prove, that vitamin C actually worked for Linus Pauling but not for me. There may be more differentiating me from Linus Pauling besides date of birth and a couple of Nobel prizes.
Then thereís chicken soup, a remedy long touted by generations of Jewish mothers as a cure for colds, but largely dismissed by the more recent generations of their doctor sons and daughters ó that is, until somebody actually secured funding to do a study on it. What the researchers found out was that any hot liquid speeds recovery from a cold, but chicken soup seems to work better than anything else. Líchaim! Of course, I donít know of any follow up studies on this one, nor do I know of any about the medicinal benefits of matzo balls. But there are times when you may have to admit your mother was right.
In conclusion, I would tend to agree with William Jamesís essay "The Will to Believe" on this one. James argued that there are circumstances in which it was intellectually permissible to believe something just because you wish that it be so. An example he used was the belief in a benevolent God. Because experience itself will never give us enough evidence one way or another, we have the right to hold such beliefs as true. We are not intellectually obligated to deny all propositions we cannot prove. So as a doctor, you can legitimately say that vitamin C does seem to help some people cure colds or flus, or, if it seems to help you, keep taking it. Donít take this one too far, however, and start eating cheesecake as a placebo treatment for heart disease!
Transitions: Can this be avoided?
Dr. Smith: The disenchantment people experience when they find out that your treatment is a placebo comes from the loss of the doctorís credibility that happens whenever you lie to someone. If youíre going to dispense or prescribe placebos, do so in the same manner as porcupines mate ó very carefully. And I also might add, very rarely. Donít get caught in a lie.
Transitions: Researches have taken great pains to combat problems associated with "blind" and even "double-blind" studies. For example, it was discovered that single-blind studies were skewed when the beliefs of the experimenters contaminated the study, since a doctorís enthusiastic endorsement of a cure was contagious. The patient who adopted the doctorís enthusiasm for a treatment triggered his/her own placebo effect. Why is it that researchers, who were so quick to recognize placeboís effects, were so eager to ignore them and construct studies designed to effectively eliminate them?
Dr. Smith: Iím not sure I understand your question here. Constructing studies designed to eliminate the placeboís effects is not ignoring them. On the contrary, it is recognizing and dealing with them appropriately, according to the scientific method.
What I think you are getting at is why they didnít recognize the implications of the placebo effect. A simple answer to this question is that people ordinarily find it hard to see what theyíre not looking for. Pathologists had been cursing the mold that was spoiling their bacterial cultures for years, but it took a visionary like Alexander Fleming to speculate that the same substance might also kill bacteria inside the body. Likewise, Iím sure that many neurologists had seen receptors for neurotransmitters on the spleen before David Felten saw them and asked what might be their purpose.
If you remember that philosophical materialism was accepted almost as dogma in academia for most of the Twentieth Century, you can understand why nobody would draw any broad inferences from placebo effect. If you donít ultimately believe that the mind can be a cause, then the placebo effect is just an anomaly, a peculiar quirk of nature. Because it is impossible even in theory to explain in materialist terms, nobody saw any point in investigating it.
Transitions: You cite Norman Cousinsí dramatic demonstration of the placebo effect that occurred during a high school football game in Monterey Park, California. As described, four persons had to leave their seats during the game because of severe nausea and dizziness. School officials concluded that the ill people consumed soft drinks made from tainted water. The cheerleaders made a public announcement warning people not to consume the soft drinks, and immediately, people began to faint and retch. One hundred and ninety-one persons were hospitalized and hospital emergency-room physicians reported that the symptoms of food poisoning were genuine. Laboratory analysis subsequently showed there was nothing wrong with the water. This fact no doubt figured in the subsequent and sudden improvement of all those who had become ill during the game. Are we all currently suffering from suggested diseases? To what extent?
Dr. Smith: What you are talking about here is what Dr. John Sarno, Professor of Clinical Rehabilitation Medicine at NYU and long-time advocate of mind-body medicine in treating back pain, calls the "nocebo effect," i.e., the thoughts and beliefs that work on the same principle as the placebo effect, but which cause disease or other harm. Sarno claims that many of the costly, painful, surgical operations performed to cure back pain are both ineffective and unnecessary, because even severe back pain can have psychogenic causes.
Knowing what we do now about the stress response, any false beliefs that contribute to unnecessary chronic stress in our lives can be nocebos. I canít prove it, but I would almost be willing to bet that words and thoughts spread colds and flus just as much as sneezes do. As we continue to learn more about the intricate and intimate relationship between the immune, nervous, and endocrine systems, I believe we will find more and more links between immune activity ó or inactivity ó and the nervous system. A widely accepted theory of cancer, the surveillance theory, holds that the body creates malignant cells all the time. Cancer occurs when the normal immune activity that destroys these cells is somehow interrupted or incapacitated. The same could hold true for viruses, or at least some viruses.
Transitions: In the portion of your work that discusses placebo effect, you argue that thoughts do in fact heal. That is, that some kinds of thoughts, namely the belief in the efficacy of a cure, can and does heal. Will we ever arrive at a point whereby disease may be reasonably blamed on counter-productive thinking?
Dr. Smith: I think we already have. The problem is that nocebo effect described above is not likely to stem from a single belief, but whole belief systems, particularly those that comprise what psychologist Claude Steiner called a life script. These negative beliefs, adopted by people in childhood to cope with varying degrees of childhood trauma, underlie (usually subconsciously) our entire cognitive-behavioral structure. Norman Cousins said "Belief becomes biology." Caroline Myss more accurately says "Biography becomes biology." Deepak Chopra also agrees implicitly, in saying that the psychogenic pathogens are primarily memories.
Transitions: You write that placebos tend to work best under social conditions as summarized in Michael Murphyís book, The Future of the Body. Such conditions include the physicianís interest in the patient, the patientís interest in the physicianís treatment, the treatmentís reputed success, and relatively large patient groups. Can you anticipate a "science of placebo therapy" wherein patients will be screened for appropriate placebos, and where a variety of placebos may be offered them that attempt to meet optimal social conditions, as those alluded to above?
Dr. Smith: In a way, yes, but mostly no. The best way to get a placebo to work is to convince the patient that it is otherwise efficacious. The best way to do that is to have a solid body of evidence to back up the claim, in other words, proof that it isnít a placebo to begin with. You might conceivably spin a convincing fable about a placebo, as the doctor did with Krebiozen in the case I mentioned earlier. But the whole plot unraveled when the patient discovered the truth. Lies may work in the short run, but over time the price, in terms of lost credibility is way too high.
Donít forget that about a third of the healing power of real cures is the placebo effect, which is definitely significant. As I see it, the best way to employ "placebo effect therapy" is to do whatever you can to inspire patient confidence in therapies that actually work.
Transitions: Psychoneuroimmunology is the emerging science that takes into account the interaction between the nervous, endocrine, and immune systems. What are its strengths and blind spots?
Dr. Smith: Its strengths are in the possibilities for therapies of all kinds that will almost certainly emerge as a result of it, including conventional surgical procedures and pharmacology. But like the placebo effect, its demonstration of a link between disease and the brain opens up a whole new paradigm for health care, one in which the patients assume much greater responsibility for health and health care practitioners of all sorts work collaboratively with each other to help the patient.
Today, our health care system uses the repair shop as its model. Take your car to a mechanic, your TV to an electronics technician, and your body to a doctor. The object of the game is to turn around as many units (people) in as short a time as possible. Spend only the time with the patient that is necessary to diagnose the physical condition. If it takes over five minutes, the doctor is presumed to be wasting time. Everyone is assumed to have standard parts, and we are all basically the same. The "adult dose" of a drug is the same whether you are a 275-pound linebacker or a retired, 80-year-old, 97-pound great-grandmother.
The connection between the brain and health will eventually force the system to deal with the mind, and the great variations among human beings that this entails. Providing health care will involve diagnosing the whole person. Iím not saying that the repair shop model is going to be replaced by that of the group therapy session or of religious practice. However, the health care practitioner will have to learn to behave more like a gardener, who is accustomed to dealing with living things, than a mechanic. This may take visits of longer than five minutes. To optimize patient outcomes, they will have to take the time to get to know the patient a little better as well as work collaboratively with psychotherapists and maybe even the clergy.
On the down side, I see the system failing to grasp immediately the radical changes that this new science implies. I recently attended a symposium put on by the Mind-body Medical Institute (MBMI) of the Harvard Medical School. Although the attendees were a diverse mixture of physicians, nurses, psychotherapists, and clergy, I was the only philosopher there. Many of the participants were far more off the deep end than I philosophically, talking about "energy medicine," whatever that is. However, the presenters were pretty much all "hard-nosed, reductionist scientists. For them, the link between the brain and the body was the end of the story. Psychoneuroimmunology is really nothing more than neuroimmunology, as the psyche is seen as identical to the brain. Nobody seemed interested in the equally important link between the mind and the brain.
This is not to say that there is no hope here. During one of the breaks, I asked Dr. Herbert Benson, discoverer of the relaxation response and director of the MBMI, if there was a place for philosophical discussion in all this. He agreed that the philosophical question of mind-brain identity is an important one, even in health care. If the mind and brain really are identical, as the philosophical materialist would claim, then the best way to use psychoneuroimmunology is to develop better drugs, surgery, or some other form of physio-chemical manipulation, i.e., apply the repair shop model to it. On the other hand, if the mind is a real entity that is not identical to the brain, but can causally affect it, then maybe the best tool to micromanage the brain is the mind. As the John Nash character in the film A Beautiful Mind said, with respect to managing schizophrenia, controlling the mind may be simply a matter of "not indulging certain appetites." The simple exercise of free will, which is absent in the materialist model, may be the most powerful therapy ever developed.
However, for this to happen, the philosophers and the health care scientists will have to begin talking with each other. Health care scientists will have to become aware that many of the assumptions that underlie their practice are really philosophical and not scientific in the sense of having been proven by controlled studies and experiments. Philosophers will have to come down from their ivory tower and begin turning their attention to real problems of real people, instead of writing analytical papers intended primarily for each other. I myself am working to bridge this gap, but there are times when I feel like the Lone Ranger.
Transitions: Your work described psychoneuroimmunology's early beginnings. You discussed how Dr. David Feltenís discovery of nerve fibers in the spleen established a mental/neural component to immune function, and to overall health. Taking into account this direct link between the system that thinks and the one that heals, are we properly benefiting from this discovered link?
Dr. Smith: In one sense, yes. Felten and other researchers havenít stopped working. I am fortunate enough to have personally conversed with Felten, as he is now teaching at the University of California at Irvineís medical school, which is about fifteen miles from my home. He is doing some great follow-up work. For example, as we speak his group is conducting a study comparing the various mind-body therapies in reversing heart disease. So far, he tells me Norman Cousinsís laughter therapy is the front runner. Felten and others, such as George Stafano at Duke University, Esther Sternberg at the National Institute of Health, and several people at Harvardís MBMI, including Herbert Benson, are getting right down to the molecular biological level in their research in this field. For example, they have discovered that nitric oxide (not nitrous oxide, or laughing gas) plays a pivotal role in the nervous systemís regulation of immune responses. Others such as Harvardís Ari Goldberger are integrating Chaos Theory into the picture, something I myself intend to do in my upcoming paper on psychokinesis in the brain.
However, in another sense the answer is no. Our modern health care system is so vast and bureaucratic, and the repair shop model is so entrenched, that the political, economic, and organizational changes involved in capitalizing on these new discoveries will be painfully slow. Letís face it, thereís nowhere near as much money to be made in mind-body medicine as there is in physical medicine. Much of it is preventive, which will never have the urgency of treating an existing illness. Also, health care practitioners, who feel totally responsible for the outcome, are understandably reluctant to give up the necessary control of the process to the patient, especially when the patients themselves resist taking on the newfound responsibilities for their own health. The model of the health care practitioner as the repair technician will have to give way to the health care practitioner as teacher and coach. This is monumental retraining job, to say the least. I plan to remain employed as a teacher in the field for the rest of my natural life, which, with luck, will span over 30 years. The job may or may not be done even by then.
Transitions: Medical science, through its field of psychoneuroimmunology, has shown us that the nervous system (and brain) can be an agent in the maintenance and recovery of health. It fails, however, to bridge the gap that continues to exist between brain activities, on the one hand, and thoughts and emotions, on the other. That is, it appears some aspect of our thinking has led us to a state of ill health, even though we may consciously believe we want to be healthy. In our effort to regain health, are we not simply seeking to trade in a negative unconscious placebo for a positive conscious one?
Dr. Smith: Yes, but I wish it were that simple. There doesnít seem to be any one-to-one correspondence between a specific nocebo belief and a specific disease, as is the case of the placebo effect. The thoughts and beliefs that cause disease are those which are deeply engrained in our character. Weeding them out is like uprooting well-established dandelions. You chop the top off, and then they come back. Then you dig a little, get down to the root, and they still come back. To get rid of them entirely, you have to dig a hole two feet wide and a foot and a half deep. As Dean Ornish says in his book on reversing heart disease, using the mind to regain health often entails a total transformation of the soul, similar to that of the alcoholic or addict in a 12-step program.
Transitions: Norman Cousinís book, Head First, discusses the important role that emotions play in peopleís health:
He goes on to say:
It appears that the body/emotion relationship describes a "chicken-or-the-egg" scenario. For example, peopleís emotional states are governed by their state of health, and yet, research appears to say that health is largely a function of oneís emotions. Your comments?
Dr. Smith: You have touched on what is for me the most fascinating question in all human existence. The same can be said about life itself. Peopleís emotional state is governed by what is going on in their life, and yet common sense, along with the research, tells us that our emotions affect what happens in our lives. A good place to watch the dynamics of this process is in the "momentum" in a sporting event. A team can be in a serious slump, with little hope of winning, when a good play or lucky break, such as a double-play, a fumble recovered, or a pass intercepted, breathes new life into a disheartened team and carries them on to victory. Similarly, the failure to make a touchdown from the 2-yard line followed by a missed field goal can take the life out of a team and seal their fate. What had seemed impossible only a few moments earlier starts to happen with lightning rapidity.
The death of a loved one not properly mourned, for example, can send a person into a downward spiral of drinking, irresponsibility, financial problems, health problems, and possibly even death. Or, the person might reach a point of despair beyond what he can tolerate and bring himself to that long-dreaded AA meeting. There he discloses his despair and confesses his weaknesses that led up to it. After that, he makes a commitment to trust the Void, the Great Unseen Higher Power, to give him the strength to turn his life around. As if by magic, he finds that strength within himself, and become a better man than he ever could have been before the tragic events that initiated his downward spiral. And it doesnít always take that long.
Among the recent discoveries in mind-body medicine is that religious faith and practice really do promote health. Whether you believe in God or not, the ability to have faith in the Unseen offers a source of inspiration that can never be taken away from you. You can always draw strength from it regardless of what you have experienced precisely because it is a faith commitment that is not based on experience. It is an unconditional source of strength precisely because it is Unknown. Tapping into it can turn the downward spiral into an upward one, and before you know it, you have rediscovered your soul. You may, and probably will, lose faith again, but you can always return to it.
Transitions: Your work discusses scientific investigations into brain functions, and how their results suggest the brain actually functions as a gland, secreting, combining, and regulating the levels of chemicals, such as endorphins and enkephalins, that serve not only to control pain but also to regulate the immune system and tumor growth. This view appears consistent with Candace Pertís Molecules of Emotion approach to disease. Where do we go from here?
Dr. Smith: Towards what is now called a "holistic" model of health care, in which the role of thoughts, beliefs, and emotions are taken into consideration along with physical conditions in defining health and disease. Eventually, I believe it will in turn lead to considering the individualís relationships with other people, the outside world, and even the Eternal.
Transitions: In the end, one cannot help feeling there is an element of artifice in placebos. Discovery of the artifice makes the placebo less effective. How will healthcare take the necessary leap whereby it abandons techniques associated with unwitting placebo healing, and instead, taps into powerful psychosomatic healing systems revealed to us by placebo?
Dr. Smith: The real value of the placebo effect is that it will eventually force a paradigm shift in modern medicine. The "leap" you are talking about is the willingness to admit that mechanistic medicine is not the only answer. Along with other discoveries, such as psychoneuroimmunology, it will force the system to recognize the patient as an organism, not a machine, and very likely find ways to deal with diseases that are "incurable" by mechanistic methods. As of now, the therapies of mind-body medicine are in their infancy, and, compared to "modern" conventional medicine, relatively primitive. Like the viewers of TV mini-series, weíll just have to stay tuned to see what happens in the next episode.
Copyright © Transitions magazine 2002. Reprinted with permission of the publisher, Transitions magazine, a publication of the New York Chiropractic College.