The Placebo Nocebo Dance

People respond to genuine care and concern – empathy. There may be more to it than just care and concern, though, that makes some patients respond to treatment and others not so much.

When a physician tells me that a certain kind of treatment will very likely work for me as expected and generates some belief and hope in me, I am far more likely to respond as expected (I do like being right!). This is the placebo effect – it is real and it is powerful!

The dark side of placebo is the “nocebo” effect, a variation of which is “SNIOP” (Subject to the Negative Influence of Other People). Especially when those “other people” are authority figures – doctors, nurses, etc. – the effects can be devastating. The nocebo effect, too, is real and powerful.

Invoking Nocebo

In a recent hospital stay, I was surprised to discover how few hospital personnel have even heard of the word, nocebo. Most knew what a placebo was while none were familiar with nocebo. It’s too bad, too, because what doctors and nurses tell their patients matters to them psychologically. When a doctor tells a patient that the prognosis is bad, the immune system in the patient drops – even if the patient consciously disbelieves or doubts the physician’s prognosis. That drop hurts the patient.

Instead, physicians especially should take great care to couch their communications with patients in the frame of success language patterns. A patient with terminal cancer will not get better knowing the doctor believes they will die soon. If ANYONE has EVER survived the cancer before, the physician should tell the patient that there IS a chance of survival and recovery and that that chance may apply TO THEM. It’s not false hope – in which the doctor truly believes the patient will die soon, yet tells the patient otherwise. That’s just plain lying – and is as bad or worse than nocebo. Rather, it is simply making use of statistics, which are a physician’s friend – invoking statistics takes the onus off the doc and places it into the realm of the abstract.

What my medical team believes about my disease or condition and about me makes a huge difference to the outcome of my care. There is no neutral ground here – the beliefs of all those involved matter.

Nurses who tell a patient, “This might hurt…” or “Little stick here…” are unwittingly invoking the nocebo effect by telling the patient what to expect. When we expect pain, we tend to get it. And because we like doing things right, we’ll get LOTS of pain when we expect some. Although it sounds like a good practice to inform the patient, I wonder if something to the effect of, “Have you ever had an IV before? We’ve come a long ways since then… it’s so much easier and faster now… etc.”

The last time I was in the hospital, I was surprised how much the IV hurt. I realized that the pain may have been the result of the nurse’s setup of, “this may hurt a little bit…” Well, guess what? I got exactly what she expected of me.

Shortly after that hospitalization, I returned to the hospital with complications and was once again given an IV. I already had an expectation (a nocebo) and so was dreading the inevitable IV. This time, it was a paramedic who inserted the IV – without warning, he suddenly applied the IV – I didn’t even notice until I looked and saw the thing. When I arrived at the hospital, the staff needed to replace the IV and once again, the nurse came at me with that look – the “I’m so sorry I have to do this to you” look. “Stop that!” I told her. “I’ve had it with this nocebo stuff – just get on with it.” We spent the next 15 minutes learning about the nocebo effect, at the end of which, I had an IV in my arm again with almost no sensation at all.

Invoking Placebo

At EVERY turn, physicians especially should invoke the placebo effect for their patients. We tend to get what we expect to get, so why not expect the outcomes we want? If there is a chance, why not assume the best chance? My psyche wants to believe that I will be the exception, so why not invoke that placebo effect?

I’m not saying we should lie to make the patient feel better. False hope can be just another form of nocebo. If my physician really does believe that I have no chance against a disease or condition for which he’s treating me, his bias will taint his work – I don’t want that physician involved with my care – his belief may kill me!

The TRUTH is – if ANYONE ANYWHERE at ANY TIME has had a successful outcome, then the phrase, “You can make it through this…” is the truth and can be used to initiate or support the placebo effect in both patient and medical caregivers.

Physicians who invoke the nocebo are probably doing so as a result of their own personal doubts about their skills. I get that – I often don’t feel all that skillful. And physicians tend to be among those who resist the temptation to lie to their patients. I applaud that.

Yet, might it be okay to focus more attention on the statistics of a procedure than its risks? Might we describe a disease or condition in terms of possible positive rather than negative outcomes?

Let’s Dance

I admit it’s sometimes difficult to change the general way of things. Nurses will very likely continue to unwittingly invoke pain responses in patients due to nocebo effect. Doctors will continue to unwittingly miss opportunities to invoke placebo effect for their patients.

The responsibility for my care is not their business – it’s mine. It’s my choice to take accountability for my health and to tell professional caregivers how to treat me psychologically. They know the physical part – and that’s very good, in my opinion – I’m very happy with the great care I received from the professionals I met at the hospital. And as I spoke up and let them know how I felt about what they said and believed about me, they were quick to respond with more effective (for me) behavior patterns.

May you enjoy great health and vitality all your life.

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