Placebo or Symbolic Effect?

In a recent study imaging the brains of patients with major depression, some of the patients had positive therapeutic responses but did not receive the anti-depressant. “We were just looking at the placebo group as a control group,” noted Dr. Leuchther, author of the study. “It was really quite a surprise to us to see significant changes in brain function in those who received placebo, activity comparable to those patients who had received antidepressants for several weeks.”

Although sham surgery is rarely used, in a trial of arhroscopic surgery for osteoarthritis of the knees, there was no difference in pain improvement between those getting actual procedures and those simply receiving incisions and sutures (Moseley et al, 2002)

Arthroscopy allows inspection of a joint cavity via an illuminated fiberoptic scope. Fragments of degenerated cartilage thought to be causing inflamation and pain are removed. Prior to this study, arthroscopic knee surgery was considered standard practice and nearly three-quarters of a million such surgeries were performed annually in the U.S. In the trial one group of patients had the surgery while another group was anesthetized and given three stab wounds to the skin with a scalpel. Both groups showed comparable levels of improvement with respect to knee pain. The researchers concluded that the billions of dollars spent on such procedures might be put to better use.

The placebo effect has been characterized as something to control and minimize in clinical research because it confounds studies, something to cultivate in clinical practice, and something present in all healing encounters. These distinctions are too often collapsed into a black box containing those healing elements that are not well understood. One person’s placebo may be another’s active treatment.

The word placebo is Latin for “I shall please.” In Chaucer’s Canterbury Tales written in the fourteenth century there is the story of an old two-faced lecher named January who wants to marry a young girl; he discusses this plan with a man named Placebo, who advises that whatever he wants to do is fine and wise. In the 19th century this sense of the word had been adopted by physicians for any medicine adapted more to please than to benefit the patient.

The actual intervention that elicits the placebo effect may be words, gestures, pills, devices and, as in the case of arthroscopy, even surgery.

Assuming that the placebo response is highly polymorphic in human populations it is reasonable to expect that pluralistic healing modalities trigger a placebo response. What has been disparagingly called the placebo effect and relegated to the category of a nuisance in research studies, is in fact an evolutionarily adaptive trait, for the individual and the social group. Opportunities for catalyzing a placebo response by triggers to the mind, body and senses and diverse, which explains why patients are choosing to use multiple healthcare systems interactively.

The old language of placebo restricts our ability to think about complex healing, and I would propose that we rename it the symbolic effect. Researchers increasingly require more subtle ways to examine and describe the variety of catalysts involved in self-healing. The full range of human experience may catalyze a placebo response, and it does this through the power of symbolization and meaning to the patient. Rehearsing or visualizing is a mode of directly producing an outcome. A symbol has both conscious and unconscious dimensions, many of which can never be known. A symbol is open-ended, polyvalent, and has an inherent capacity to bring together that which has been torn asunder. Symbols are powerful agents of "wholemaking."

The Individuation Process

Individuation is a term that Carl Jung invented. It lacks poetry, but if you are searching for meaning in your life you are individuating. It is the process of you becoming yourself – that which you were put on the face of the earth to achieve. It was Jung’s genius to realize that every person is born as unique in his or her personality as in a physical structure. The shape of your ears, the color of your eyes and your hair, the contours of your body, your thumb print -- these are unique to you. It should not be a big surprise to find out that your psychology, your personality, are equally unique. To discover your uniqueness, this is the individuation process.

Søren Kierkegaard, a 19th century Danish philosopher and theologian wrote about faith in God, the institution of the Christian Church, Christian ethics and theology, and the emotions and feelings of individuals when faced with life choices. He summed up the individuation process (though he never used that term), when he wrote that there are three kinds of men in the world. Simple man comes home after work and thinks about what is for dinner. Complex man comes home after work and ponders the imponderables of the world. Enlightened man comes home after work and thinks: What is for dinner? It looks like a round trip.

Similarly, a Zen proverb says: The simple man sees the mountains as mountains, the rivers as rivers and sky as sky. Then one loses one’s way and the mountains are no longer mountains, the river is no longer just a river, and the sky is no longer sky. This is that awful, in-between stage in which we worry everything to death and read into all about us. Then, for the man who has had satori, the mountains are again mountains, the river is a river, and sky is sky. This is other language for the individuation process.

My first analyst in Los Angeles, Fritz Kunkel, used to say there are three kinds of people in the world: red blooded people, pale blooded people, and gold blooded people. These are all ways of talking about individuation.

What is Progress?

Lewis Mumford wrote a wonderful book on modern civilization and the growth of our cities. He did not believe that we were making much progress in a true sense. There has been enormous change in the past 100 years, but has our consciousness progressed? Mumford noted that the 12th century gave us cloisters and Thomas Acquinas. The 18th century gave us no cloisters, but indoor plumbing, and Voltaire. The 20th century gave us no cloisters, plumbing, and Norman Vincent Peale. Perhaps today we would substitute mega-churches. I believe this was said tongue-in-cheek, but it speaks in an interesting way to the illusion of progress. How do we measure progress, as individuals and as a culture?