How do you prescribe placebo?
Sometimes my patients say, “I think the medication is working, but it’s probably just placebo.” I have never understood that “just.” The placebo effect is the most compelling mind-body phenomenon we have. It demonstrates, robustly and repeatedly, that a belief in the efficacy of a treatment helps make the treatment effective.
Traditionally, for placebo to work, the person needs to think they are taking the active medication; the effect depends on their belief that science-based medicine can cure. In trials, participants consent to being “blind” to their treatment, but in a regular clinical setting, that would be unethical.
With open-label placebo (OLP), people know they are receiving placebo. The effect now relies on their belief that belief can heal. It represents a paradigm shift from mechanistic to multi-dimensional. It heralds the healing of the mind-body split that has plagued dominant culture since the 1600s.
There are a few small studies of OLP as a treatment for depression, with mixed results. The results of Kelley 2012 “do not support the hypothesis that open-label placebo is effective for [depression].” Nitzan 2020 does “support the possibility that OLP is an effective treatment for… depressed patients.” And Hahn 2022 says, “OLP treatment had a beneficial effect on perceived sadness.” Outside of mental health, OLP has been studied in irritable bowel syndrome (Kaptchuk 2010), back pain (Carvalho 2016), and asthma (Wechsler 2010) with preliminarily promising results. Often patients’ subjective perception of distress improves with OLP treatment even if objective measurements do not.
I have studied the OLP literature, on depression and other conditions, but I’m not going to belabor it here because the studies were not conducted in the same way that I prescribe OLP.
Studies are necessarily standardized, meaning all patients undergo the same protocol. But OLP must be highly personalized, tailored specifically and meaningfully to the individual using it. OLP also relies heavily on the quality of the relationship between the practitioner and the patient, which cannot be fully cultivated in a study. Finally, the participants were not selected based on their belief that belief effects healing. Trying to make it work for people who don’t believe in it will fail by definition.
A good candidate for OLP is someone who is open to the idea that a placebo is a symbol that works in subtle ways to support a desired outcome. When I introduced the idea of OLP to one of my patients, he said, “Right, how could it not work?” So yeah, he was a pretty good candidate. But you don’t have to have 100% confidence in it, just openness. Doubt is normal and welcomed.
There are limits to what OLP can do, just like any other treatment. I am not out here saying that placebo can cure cancer. I have seen this type of absolutist “mind over matter” stance harm some of my patients, leading them to forgo effective medical treatments or blame themselves when their illness persists. I am devoted to using OLP in a way that is realistic and grounded. In the spirit of full transparency, I currently use placebo mainly to augment existing psychiatric medications or to treat people with relatively mild symptoms.
So what does the OLP treatment process actually entail? We start with four questions:
What does a healed state look and feel like?
What do you believe has the power to heal?
What is something ingestible that symbolically represents that power?
What ritual can we build around the symbol to make it more potent?
The resulting placebos and rituals are as varied as the humans I work with. In the process of exploring these questions, I learn so much about who you are and what you value. And hopefully, you come to trust me to co-navigate this adventure at your side.
