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The placebo effect is more than a pill; it’s a performance.
We often think of “placebo” as a synonym for something like a sugar pill – an inactive medicine whose effects are the result of our expectations. But you don’t need a pill to get a placebo effect. In fact, some view the interactions between a doctor and patient as the most powerful placebo of all.That’s the idea behind a recent placebo study by researchers in Israel, published (and freely accessible) in Frontiers in Psychology and discussed in the latest post on alternative medicine researcher/debunker Edzard Ernst’s blog. And I think it’s very relevant to how coaches and athletes interact, and how we think about techniques like ice baths with conflicting evidence of effectiveness.
The title of the study is “Manipulating the Placebo Response in Experimental Pain by Altering Doctor’s Performance Style”, and the corresponding author is actually a theatre director from the University of Haifa’s Theatre Department. The study used an actor to “play” a doctor with two dramatically different performance styles, to see how it would affect the effectiveness of a pain medication.The experimental design involved a pain test that required subjects to dip their hand in ice water for up to five minutes, reporting when they started to feel pain (pain threshold) and when they could no longer tolerate it (pain tolerance). After the pain test, they received an experimental pain cream (which was actually hand lotion) from the fake doctor. Then they repeated the pain test to see if there were any improvements.In one scenario, the doctor acted like a “typical” distracted doctor. As the study describes it, “remained seated at his desk throughout the encounter, continuous reading of text on the computer screen, typing, minimal eye contact, and lack of tactile interaction with the volunteer”.In the other scenario, the performance “was based on healing rituals performed by shamans and healers”. For credibility’s sake, they didn’t do any dancing or drumming or wear masks or anything like that. Instead, “the verbal part was personal, attentive to the volunteer, and used imagery in the questions and the explanations. The stage directions indicated free movement in the room, including periods of standing while speaking, frequent eye contact, and deliberate tactile interaction with the volunteer (handshake while greeting and touching of the hand while examining it after the experimental pain procedure)”. The “doctor” also expressed strong belief that the treatment would work.Many placebo studies find that there are “responders” and “non-responders,” which may be related to certain genes. In this case, they divided the results based on those who improved their pain threshold by more than 30 per cent in the second pain test.
The results? Here’s the percentage increase in pain threshold in Scenario A (the “normal” doctor) and Scenario B (the touchy-feely one):
Frontiers in Psychology
The non-responders, by definition, didn’t respond. In fact, they got worse on average. That makes me wonder if the time between the two pain tests (80 minutes) was so short that there were lingering after-effects of the first test (either physiological or mental). Otherwise, it’s hard to understand why the “pain cream” would have made things worse. Only about 15 per cent of the subjects were classified as responders, which is unusually low and also makes me think the tests might have been too close together.
Still, in the responders, there’s a big improvement in pain threshold – and, as predicted, the effect is bigger when the doctor made a stronger personal connection with the patient and expressed belief that the treatment would work.
Ernst’s take on the study is that “conventional” doctors have neglected the performance aspect of medicine – what used to be called “good bedside manner” – whereas the success of many alternative practitioners is based almost exclusively on performance (since their therapies don’t do anything). In a perfect world, we would get the best of both worlds: doctors using effective and science-backed therapies, interacting with their patients in a careful and engaged way that promotes confidence. (Of course, many doctors already do this! But it’s an area that is perhaps neglected in medical education.)
And as I mentioned at the top, I think great coaches are also great “performers” in a similar way. They form personal connections with their athletes, and are able to instill confidence that the training they’re doing (and the other training aids they’re using) are the best possible performance-boosters.
In some ways, these traits in a coach are probably more important than exactly how much rest he or she prescribes between intervals, or whether you wear compression tights after your long run. Still, like Ernst, I think it’s possible to get the best of both worlds: an evidence-based, science-backed shaman-coach.
