I start with a quote from Prof. Fabrizio Benedetti, professor of neuroscience at the University of Turin, which I have already reported in my article Healing Words and Empathy: Psychology or Neurobiology?
…Alongside the positive effects of placebo there can also be negative effects (nocebo effect). This can occur when communication is hasty is overly ambiguous and laden with negative suggestions that in the patient’s brain result in a feeling of threat to one’s health.”
(Nature Medicine 2011 / Prof. Fabrizio Benedetti / Univ. Torino / National Institute of Neuroscience).
Why do I want to start here? Because Prof. Benedetti is one of the world’s leading experiments in the placebo effect and because he has demonstrated with scientific studies the impact, positive or negative, that communication can have on patients. In the case of communication preceding the administration of a therapy he even calls it a “ritual” that, depending on HOW it is carried out, generates different results, activating and engaging different parts of the brain.
What really is the placebo effect and how is it generated?
The term placebo comes from Latin and, specifically, from the first person singular of the verb piacere, i.e., I will please.
In the medical field, placebo refers to a drug preparation without specific active ingredients that is administered as if it had them.
Placebo effects are the psycho-neuro-biobehavioral effects resulting from a patient’s perception, interpretation, and response to a therapeutic context (psychosocial and environmental). They can be incidental/random or intentionally determined and are produced through 3 mechanisms:
- conditioning
- increased expectations
- reduction of stress and anxiety
In addition to the mechanisms for producing placebo effects, it is interesting to see together what are the determinants, that is, those factors that influence them substantially:
- environmental factors
- the individual factors of the patient and the practitioner
- The interaction and communication between the health professional and the patient
- the care process
- the nature of the disease
Environmental factors have to do with everything from the physical environment, more or less welcoming, brightness, colors, spaces, materials, noise, waiting room seating… but also external environmental factors related to weather;
Individual factors that affect both the patient and the physician/health professional, i.e., subjective factors related to other situations that affect the mood, the way of making meanings and/or decisions… of every human being.
The interaction and communication between the physician/health professional and the patient because that is where the trust necessary in building the physician-patient relationship and therapeutic alliance is created (or not created);
The process of caring that begins long before the doctor’s visit; it begins when the patient crosses the threshold of the hospital, clinic or doctor’s office or, even earlier, when he or she enters the parking lot (when there is one) of the facility or, even earlier, when the patient or a family member or caregiver calls on the phone to make the appointment or when the ambulance arrives at the emergency room…
So in the factor concerning the process of caring, all actors are involved, not just the doctor. And, by virtue of the fact that in communication there is an assumption that says, “The meaning of a message is given by the reaction it elicits,” it is not enough to listen or to welcome or to understand or to presume to do so; it is necessary to demonstrate this to the person concerned so that he or she feels heard, welcomed or understood. Every little gesture, done or not done, every single word, based on HOW it is said, can and does make a difference.
The nature of the disease certainly has a bearing on possible placebo or nocebo effects, including those of communication. It is equally true that even in the face of inauspicious diagnoses not everyone reacts in the same way.
One study (Lipowski, cited in PsychOncology. Biological bases, clinical aspects and therapeutic approaches by R. Torta and A. Mussa, Centro Scientifico Ed. Turin, 1997), in fact, found that patients attribute different meanings:
- Sickness understood as a sense of punishment
- Enemy to fight against
- Loss of one’s sexual identity and professional, family and social role
- Value and opportunity for personal growth
- Challenge aimed at one’s mental resources
- Relief in patients who had already reduced expectations toward life
- Weakness of the organism
In summary, the conditioning elements closely related to the people involved, for better or worse, as we have seen, are: the patient’s perception and the meanings he or she attaches to the personal situation he or she is experiencing and to what he or she sees and hears around him or her; the pre-existing beliefs, hopes, and expectations of both the patient and the physician; and the development of trust.
On all these elements, communication can and does have tremendous power to build that doctor-patient relationship that supports the patient, “empowers” him (I apologize for the made-up but effective word) by increasing his ability to face his illness with courage and hope, taking him by the hand and accompanying him on his journey, even when the destination may not be recovery.
About the placebo or nocebo effect of communication, Sigmund Freud said:
Through words each of us can give
someone else maximum happiness
or bring him or her to utter despair….
Words arouse emotions and are the means
by which we generally influence our fellow human beings.
Thank you,
Emanuela
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