Mindset Matters 4!

This article is the forth in a series about how our attitudes, beliefs and mindset can affect our health. There is a fascinating and growing body of evidence that there is a much stronger relationship between our minds and our bodies than perhaps we have been lead to believe. I hope that these articles stimulate some new thoughts and ideas for you, or perhaps shore up what you already knew. I’ve included a list of further reading at the end of each article too, for those who want to look into this in more detail.

So far we’ve looked at a number of ways your mindset can affect your health. Given everything we’ve discussed, do you think that mindset may be relevant to the healthcare you receive?

You bet!

You trust your health care professional to work in your best interest. You turn to them in a time of vulnerability. Art could be said that they can hold your life in their hands (sometimes literally).

First, let’s talk a bit about placebos. You would have heard the term, no doubt in contexts like “this medication works better than placebo”, or “the response was just placebo”. So what is it? 

All that we are is the result of what we have thought. The mind is everything. What we think we become.
— Buddha

A placebo is something that is used in a clinical trial to help test the effectiveness of a treatment. For example, if a drug is being tested, the people participating in the trial (kindly referred to as “subjects”) are typically divided into two groups through random selection. One group is then given the drug being tested, while the other group receives a completely inert pill (such as a sugar pill) that looks identical. This is the placebo. The subjects don’t know what they’re getting, and neither do the researchers running the trial. This is to remove all subjectivity from the results - if you don’t have expectations about what should happen because you don’t know which pill a subject is receiving you can’t influence the results, however unintentionally, through wishful thinking or unconscious bias. 

Placebos can also be used in trials of surgical procedures. In such a trial, subjects receiving the placebo will essentially be “cut open” as per usual, but will then have the surgical incision closed again without the actual procedure being performed. They can see the signs of a surgical procedure, but don’t know whether or not they received the actual intervention.

These processes are important because they allow us to get a good idea of what works clinically and what doesn’t. 

But here’s the interesting bit - in most trials, some of the people receiving the placebo still show results. Even though they’ve received no medication or surgery, they still get better. This is the placebo effect.

For a long time this was discounted. “Some people just get better”, or “it’s all in your head”. The effects went unexplained. I believe this comes largely from the assumption that the physical function of our bodies is separate from the operation of our minds. But as you will have gathered from the previous posts, there is a growing body of evidence that points to the fact that our mindset does indeed affect our bodies. In fact, it is now a well enough documented phenomenon that there are expert groups around the world who are currently developing guidelines about how to ethically and effectively make use of the placebo effect in clinical practice.

When the heart is at ease, the body is healthy.
— Chinese proverb

Further to this, we know that the way you regard your treatment will affect how effective it is. For example, there was a study performed years ago where post-surgical patients in recovery were given pain-killers. Some had them administered by an automatic device that periodically pumped some into their catheters. Others had the pain-killers given to them by a nurse or doctor at their bedside. The second group reported much better responses to the medication (they had less pain), even though both groups received exactly the same amount. 

There’s a dark side to this - the negative placebo, also known as the nocebo effect. This is where detrimental effects on health occur due to factors such as negative expectations of treatment or prognosis. Stories float around of people who have been diagnosed with terminal illnesses and subsequently pass away, only for it to be discovered that they received an incorrect diagnosis. I’m not sure of the veracity of these stories. More mundane examples include a definite and measurable change in the experience of pain depending on the understanding and context of the sufferer. (I’ve frequently noticed this in stories from women about their experiences of labour.)

Theories and evidence as to how placebos function are evolving. A lot of the focus in on neurology, and how our brains interact with other aspects of our physiology like our immune system to control things like inflammation and healing. There is some fascinating and promising ideas emerging from this area. I’ve included some links to specific papers, as well as an interesting article published recently in the New York Times magazine for those of you who want to read further.

So, if how you feel about any treatment you receive is important, then the quality of the relationship you have with your health care provider is pivotal. If you trust them and have confidence in their credentials and that they understand your issues, if you feel they have your best interests genuinely at heart, then it could well contribute to a positive outcome for you. They don’t have to be your best friend, but it helps if you feel comfortable with them. 

Further (and as far as I’m concerned this is very important), take note of the language and manner they use when they discuss your symptoms, diagnosis and prognosis. While you definitely want them to be honest and straightforward with you, that still leaves a huge amount of room for expressing things either positively or negatively. 

With this in mind, I believe good health practitioners don’t just hone their clinical and diagnostic skills. They also put thought into how they relate to the people who come to see them. Creating a relationship of trust, where patients can do more than just rely on their credentials as a health care practitioner, but can also feel confident that the practitioner has respect for them and an understanding of the personal nature of their particular issues, is more than just window-dressing! A good “bed-side manner” is actually important if practitioners want their patients to get positive outcomes. And thoughtless or careless exchanges can have unfortunate consequences! Consider the nocebo effect we discussed above. So people skills are vital!

As I said at the beginning, health care professionals hold your wellbeing in their hands. I think it is reasonable for us to expect more of our health care practitioners in this matter. I hold myself to this standard.

Further reading:

An interesting article about placebos is in the New York Times magazine: available here.

Benedetti F. Placebo and the new physiology of the doctor-patient relationship. Physiol. Rev. 2013 Jul;93(3):1207-46. 

Colagiuri B, Schenk LA, Kessler MD, Dorsey SG, Colloca L. The placebo effect: From concepts to genes. Neuroscience. 2015 Oct 29;307:171-90.

Dodd S, Dean OM, Vian J, Berk M. A Review of the Theoretical and Biological Understanding of the Nocebo and Placebo Phenomena. Clin Ther. 2017 Mar;39(3):469-476.

Jakovljevic M. The placebo-nocebo response: controversies and challenges from clinical and research perspective. Eur Neuropsychopharmacol. 2014 Mar;24(3):333-41. 

Meissner K, Kohls N, Colloca L. Introduction to placebo effects in medicine: mechanisms and clinical implications. Philos. Trans. R. Soc. Lond., B, Biol. Sci. 2011 Jun 27;366(1572):1783-9. 

Benedetti F. Placebo and the new physiology of the doctor-patient relationship. Physiol. Rev. 2013 Jul;93(3):1207-46. 

Beecher HK. The powerful placebo. J Am Med Assoc. 1955 Dec 24;159(17):1602-6.