Edited by Dr David Peters Churchill Livingstone, London, 2001 Paperback, 235 pages, £14.95
(Reviewed by David Mayor, EJOM Vol. 3 No. 6)
‘Art happens when what is seen becomes mixed with the inside of the person who is seeing it’ Chaim Potok1
What is placebo? What is not placebo? A word we all use, mostly without knowing what we are talking about, a word that may be, ultimately, undefinable. This book is a useful contribution to the ongoing debate on the existence, the meaning, the place of placebo in the participative interworld of the patient-practitioner interaction.
Based on a 1997 London conference around the theme of self-healing, its 13 chapters by some 18 authors extend the debate beyond the usual arena of clinical trials and intellectual jousting over the existence, importance and science of placebo to embrace intersubjectivity and consciousness, intention and co-creation. Inevitably, therefore, not all the contributions sit easily together, and the overall impression some may have is that the boundaries of discussion have been dissolved to such an extent that it is hard to remember that the unifying theme is this ‘thing’ called placebo.
The book is divided into the three parts of its subtitle. In the first, anthropologist Cecil Helman introduces the cultural constructs involved in placebo and nocebo, followed by a clear and concise account of placebo from a scientific viewpoint by Edzard Ernst. Next, Gunver Kienle and Helmut Kiene repeat what they have written before, questioning the very existence of the placebo effect (as originally quantitated by Beecher in his 1955 article ‘The powerful placebo’). Importantly, they differentiate between placebo as the ‘imitation of treatment’ and as ‘all those therapeutic endeavours aimed at mobilizing the body’s self-healing powers.’ They question the existence of the first, not the second, deconstruct the interpretation of placebo as ‘conditioning,’ highlight the factors that can create false impressions of placebo effects. The theoretical part of the book ends with a riveting chapter by Angela Clow on psychoneuroimmunology and preferential hemispheric specialisation in the brain: left activation and cell-mediated immunity, approach motivation, pleasure, dopamine elevation, right and humoral immunity, withdrawal, anxiety, increased noradrenalin and serotonin, correspondingly mediated by basic asymmetries in the autonomic nervous system. Her account of conditioning and its effects on immune ‘natural killer’ (NK) cells and cell-mediated cytokine ‘interleukin 2’ (IL2) is of importance to all acupuncturists - acupuncture’s effects on the immune system too are measurable in terms of the same changes. Is acupuncture a form of conditioning?
After the heady heights of theory, we are plunged into an overview of placebo in practice in the next six chapters. First James Hawkins, an independent doctor in Edinburgh, asks how we can optimise nonspecific effects in treatment, suggests some exercises and urges the reader to move from contemplation to action, stressing the importance of empathy and ‘a sense of common humanity, of going beyond the ego.’ Then David Reilly, the homeopathic doctor from Glasgow who has done so much to deepen our thinking about holistic healthcare, focuses on self-healing, in a virtually unedited transcript of his lecture at the 1997 conference. As he puts it, ‘the main aspect of the therapeutic encounter may be working the interfaces, the gaps, between our inner and outer worlds, between our conscious and our subconscious and between our inner world and our physical system.’ Robert Withers, Jungian analyst, acupuncturist and homeopath, then explores placebo using the language of psychoanalysis. His emphasis on introspection and the unspoken is a welcome antidote to an otherwise somewhat intellectual approach.
A sensitively written chapter by Janet Richardson follows. Here she unpacks a host of key themes, such as intersubjectivity in the therapeutic relationship, emotional engagement, being fully present, or being with rather than doing to. She explores our need for explanatory myth, whether as patient or practitioner, yet with recognition that none of this need be verbalised. Philip Latey, osteopath, then returns to the theme of placebo, discussing it in terms of patient responsiveness and practitioner persuasiveness, reviewing the process of long-term treatment and what factors enhance therapeutic change. Like Janet Richardson, he stresses the difference between making things happen, or allowing them. He touches on the physical ‘entrainment’ that can occur with rhythmical and repetitive manual interventions, the empathy and risk involved in such intimacy. To complete this section, Stephen Wright and Jean Sayre-Adams discuss healing and therapeutic touch. Again, they differentiate between ‘health technology,’ directive treatment, and simply being aware, with an ‘intention to heal,’ or even ‘an intention to allow...’ Again, they use this word ‘intersubjective,’ and point out that of course, if we are not separate in the healing encounter, then the directive approach of ‘I do this to you’ is no longer explanatory.
The research section of the book includes two chapters. In the first, a short one, Anton de Craen, Angelica Lampe-Schoenmaeckers and Jos Kleijnen (well known for his systematic reviews of acupuncture) reiterate the difference between effects observed in placebo control groups and the placebo effect itself. They then look at how non-specific factors interact with specific treatments, using examples from their own careful research. A long chapter by ‘applied philosopher’ John Heron follows, in which the placebo effect is considered (briefly) within the context of a ‘participatory world view.’ I am not a philosopher, and have never found John Heron easy to read. While some of the other contributors to this book clearly limit their concern to the scientific, or the clinical, in a way that is comfortable for me, or at least give a glimpse of what might occur in the gaps between when we think we know what we are doing, John Heron’s ‘participatory paradigm’ drily asserts, so he says, that we cannot have any final or absolute experience of what there is behind/beyond/beneath the relationships we co-author with our patients. Of course, in a way, this is true. But I feel uncomfortable with it. While I love the excitement and tenderness involved in the co-creation of healing and meaning that can occur during acupuncture, I only feel part of this work if the spirit, the archetypal, speaks to me, touches me, through it. The journey and the arrival cannot be so distinct for me.
The book finishes with a polished epilogue on psychoneuroimmunology and the mind-body connection by neuropsychiatrist Peter Fenwick. Boldly, he does not even mention placebo, but writes of the effects of optimism and anxiety on immune function, of ‘upward and downward causation’ and the possibility of mind as ‘a widely distributed property,’ of prayer and interconnectedness.
So the book ends on an inspirational note, for me strangely at odds with some of the other, more down to earth contributions. I would have preferred it if the editor had woven the disparate threads of this tapestry into some conclusions of his own. Yet, for all its patchwork quality, the book is considered, thought-provoking, and a fine Eurocentric foil to earlier publications on placebo, most of which have a strong North American focus.
It is clearly also very much a book of its time, part of the unfolding of contemporary ‘postmodern’ thinking on ‘constructivism’ (or co-constructivism), grappling with how to express the coming together of mind and body, or ‘energy,’ that occurs in so much of complementary medicine. I still cannot decide whether I think it is in reality a book about placebo, or a book about the essence of healing. Perhaps it does not matter. To make up your own mind, you will have to read the book itself.
Reference 1. Potok, C. (1990). The Gift of Asher Lev. Heinemann, London.
Acknowledgement I would like to acknowledge the help of my wife, herself a Jungian analyst, in discussions on the subject matter of this book and the work of Polly Young-Eisendrath.
David F Mayor David Mayor is currently preparing a textbook on Electroacupuncture for the publishers Churchill Livingstone. He has a particular interest in the placebo effects of electrotherapy.