My personal opinion on deception and placebos
In my life I have been a professional magician, hypnotherapist, cognitive-behavioral psychotherapist, physician, psychiatrist and brain-behavior neuroscientist. When I was at UCLA I did fellowships in geriatric psychiatry and neurobehavior. I applied for and obtained funding to do dementia research and my work was published in respectable journals.
As a magician I learned how easy it is to fool someone. If you understand what people pay attention to and what kind of information their brains are prepared to digest, then you can easily communicate with them in a way that deceives them. Or, you can communicate in a way that alters their behavior. You can do both these things by communicating with someone in a way that is suggestive.
The first thing I learned when studying how to do hypnotherapy was that you can’t totally control someone’s mind with suggestion but you can get them to loosen up and do what they may have been predisposed to want to do, or at least be OK with doing, in the first place. That is when I realized that the person’s expectation is fundamental to the process. I thought back to being a magician and realized that the person’s expectation is indeed important. All you are really doing is taking someone to a place they wanted to go anyways. You can do this because following directions from an authority and/or being influenced by social cues are species specific behaviors. It is how Homo sapiens are programmed to interact.
A magician and a hypnotist figure out how the brain evolved to function and then play it like it was a piano.
When I was a resident psychiatrist I trained with a type of therapy known as cognitive-behavioral psychotherapy (CBT). This is the first talking therapy that was scientifically demonstrated to be effective. It is a time-limited therapy in which you focus on thoughts you have that are connected to behavior you are doing. The idea is to reconstruct your thoughts about a behavior. The hope is that by practicing this you can get control of your thoughts and behaviors and reduce your anxiety and depression.
Interestingly, when functional brain imaging became available they studied this type of talking therapy with images to see what parts of the brain were active. They compared this activity to that seen when on medication for the same condition.
Guess what?
The CBT affected the same parts of the brain as did the medications. A depressed patient often has reduction of activity in the frontal lobe of the brain and this is correlated with a reduction in serotonin and norepinephrine function. Prozac improves these defects and so does cognitive-behavioral (talking) therapy.(1)
Wow!
As an aside, it works best when you do both together.
When I became a psychiatrist, I found myself in the middle of a war between those that thought talking therapy was the best and those that thought biological therapies were the best.
I did both and loved both.
In addition to cognitive-behavioral psychotherapy I also trained to do electro-convulsive therapy (ECT). I can tell you that they are both fantastic treatments. This led me to the question, “How can therapies that are so different treat the same condition?”
The only answer I could imagine was that there must be something about brain science that we have yet to figure out. Therefore, I wanted to study the brain. The basic science researchers are usually the ones doing this and I was already on the path to being a clinical researcher. I had to find a way to study the brain while doing clinical medicine.
I developed a relationship with Dr. Marco Amadeo who was a geriatric psychiatrist. When I told him I liked working with the elderly and was most interested in doing brain research he said in his distinctive Italian accent, “Goooo to UCLA.”
I went to UCLA and studied with Jeffrey Cummings, Gary Small, Bruce Miller, Andrew Leuchter and the late great Frank Benson. Drs. Benson and Cummings had studied under Norman Geschwind in Boston. He is famous for creating the field of behavioral neurology. He would study brain lesions and correlate that with behavioral alterations. He was interested in finding out how the brain worked. He did not have access to functional brain imaging at the time and relied on autopsies. In the 90s when I was at UCLA we began using functional brain imaging machines (PET, SPECT, fMRI and QEEG) to correlate brain injury with behavior in living subjects. It was quite an exciting time to be a clinical neuroscientist.
We would look at which parts of the brain were functionally impaired in people with strokes, Alzheimer disease or fronto-temporal dementia and carefully assess their behavior. We wanted to see the correlation between the area of damage and how that related to behavioral symptoms. We wanted to know how the brain works.
For example, I was able to determine that apathy is not the same thing as depression.(2) Apathy involves different anatomical structures and functional pathways in the brain. This kind of research is called brain-behavior research.
That is my background.
Now, the question is, “Can you change brain function through non-pharmacologic means using only suggestion and expectation?”
Here are my thoughts.
My mother used to always say, “It ain’t what you say but the way that you say it.”
You do not need to lie to someone in order to get them to do what you want them to do. Truth telling or lying does not matter. It is all in how you communicate. The manner of the communication needs to be compatible with your brain’s software. The suggestion and expectation have to be in the correct programming language. Your brain does not evaluate incoming information to see if it is logically or scientifically accurate. Your brain guesses based on how, or who, the information is coming in, or from. If the incoming language is coded correctly your brain will trust it and be influenced by it.
For example, when you read a paragraph where the letters within the words are rearranged you can still read the paragraph with relative ease. Often you don’t even notice that the letters are rearranged. It is because our brains respond more to expectancy and suggestion than to the objective structure of the letters. If it is on a familiar medium and familiar font and given to you by a familiar person and the subject is familiar your brain will accept the information. If it was given to you by Count Dracula in a dark room and written in an unusual way it will be much more difficult to decipher what is on the page. You will be more critical and more able to notice misspellings or ambiguous words. You will be less influenced by what this paragraph is saying. In both situations there was no deception.
“It ain’t what you say it’s the way that you say it.”
Another example is the way that psychotherapy research has unfolded in the past 20 years. In the early 90s they found a way to objectively study CBT. For a while CBT was known as the only psychotherapy that we knew worked and all the others were suspect. Subsequently, psychotherapy after psychotherapy was studied in similar ways and found to work. All these various and different therapies had a wide range of philosophy as to why they should work. At this point in time it is safe to say that pretty much any psychotherapy from any orientation will work. It is also safe to say that the philosophy is not the active ingredient. And none of these therapies use deception.
How is that?
If you really study all these various therapies and look for the way they play the brain with suggestion and expectancy, you will find they are all pretty similar.
“It ain’t what you say it’s the way that you say it.”
Hypnotherapy is the easiest example to talk about. It works best with a fully informed subject who wants to do it. The subject can even practice and get better at allowing themselves to follow the story line from the hypnotist. I can hypnotize around 80% of the population and tell them that their arm is numb and when I stick them with a needle they will feel nothing. The story line the hypnotist is telling is much less important compared with the suggestion and expectancy involved.
When you study alternative medicine and look at each therapy from this point of view you will quickly see that they are all very similar. They are all about HOW and not WHAT the practitioner is communicating.
You can say to a patient, “I am sending you to a Homeopath who will tell you a story about an essence being in the water. This story is made up but cleverly designed to get your brain to produce natural pain killers through the placebo effect. If you voluntarily allow yourself to follow the homeopath’s suggestion, then you will experience less pain.”
This is what I mean when I claim that the placebo effect does not require deception. To make this work the doctor has to genuinely convey that he believes this will work and the patient has to have a genuine expectation that this will work. Therefore, in order to do it right the doctor has to understand the science of placebo medicine and be able to select patients appropriately. He also must communicate in the correct manner.
–Morgan Levy, MD
Deception and Placebos
Controversies
References
1. Functional neuroimaging in mental disorders Philip K McGuire and Kazunori Matsumoto World Psychiatry. 2004 Feb; 3(1): 6–11.
2. Apathy is not depression. Levy ML1, Cummings JL, Fairbanks LA, Masterman D, Miller BL, Craig AH, Paulsen JS, Litvan I. J Neuropsychiatry Clin Neurosci. 1998 Summer;10(3):314-9.
Dr. Levy does speaking engagements to both professional and non-professional groups on a sliding scale. Read his bio and contact him at: Morgan L. Levy, MD
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