Neuroanthropology

For a greater understanding of the encultured brain and body…

Moerman’s Placebo

Posted by dlende on April 15, 2008

I have been wanting to write a post about the placebo effect for some time, after finding a wonderful YouTube video about getting drunk without being drunk. And then today I saw a very different “placebo effect” that also drives home Dan Moerman’s point when he says that the placebo effect is better thought of as “the meaning response.” (Moerman is an anthropologist, of course.)

The video, How to Get Drunk Without Drinking, shows Derren Brown demonstrating “a method I used at university which allows people to recreate any drug state, adrenaline, alcohol, you name it, without actually taking the drug.” (If it doesn’t play, you can go directly to the YouTube version.) What is so striking about the video is Brown’s use of imagination, embodiment, practice, suggestion, and memory to accomplish the effect, and the ability of the brain to then switch between such different states so quickly. It’s also quite funny!

The other piece, The Cure by Sarah Manguso, is adapted from her forthcoming memoir The Two Kinds of Decay. Manguso writes of being twenty-one, her life in danger from an auto-immune disease, and her desire to make love to someone. Her own antibodies were attacking her body, as she wryly notes, “trying to destroy my nervous system — a misperception that caused me a lot of trouble.” She returned to college with a huge tube sticking out of her chest, a necessary part of the regular blood treatments she needed.

“My blood was removed and cleaned and put back more than 50 times. After that, my hematologist tried another treatment: massive gamma-globulin infusions. The second infusion kept me going for three months, and it was decided I wouldn’t have to have my plasma replaced again. My neurologist said I’d turned a corner, so after 11 1/2 months, my central line was pulled.”

“I believed, though, that I would stop secreting antibodies only after I had sexual intercourse. And though I looked worse than I ever had in my life, thanks to the steroids — I was fat and swollen, covered in acne, and had a gruesomely round face — I thought my legendarily promiscuous musician friend might still be interested.”

Manguso relates in simple yet elegant prose, “Finally, getting up from the bench we’d been sitting on, my friend said, ‘Your place?’ And we went to my dorm room, which was a single suite I had all to myself, with my own bathroom, because my neurologist had written a note to the university. We sat on my futon, drinking out of a plastic bottle of vodka. Eventually he said, ‘Do you have any other rooms in this place?’ and walked me to the bedroom, and lay me on my bed, and had intercourse with me. Then he asked me about the scabs on my chest from where the line had just been pulled out and listened to the things I told him, and held me very tightly.”

The two friends then wrote letters over the years. “Our letters were intimate, but I didn’t get around to explaining to him that I recovered from my disease only because he had selflessly had intercourse with an ugly version of a girl he once had a crush on. A little less than seven years after I was cured of my disease through the mystical power of intercourse, my friend died of a sudden illness. I never told him about my magical cure, his sweet medicine. And I wish I could have saved his life. I hope he knew somehow that he had saved mine.”

Daniel Moerman has a 2002 paper with Wayne Jonas entitled “Deconstructing the Placebo Effect and Finding the Meaning Response” (pdf version). As they declare quite rightly in the beginning of their paper, “The one thing of which we can be absolutely certain is that placebos do not cause placebo effects. Placebos are inert and don’t cause anything.”

Having discarded that rather large red herring, Moerman and Jonas redefine the placebo effect as the meaning response. These placebo responses comprise the “physiological or psychological effects of meaning in the origins or treatment of illness.” These are not “non-specific” effects—meanings are concrete and “are often quite specific in principle after they are understood.” The two authors then back up their argument with examples from surgery, pharmacological treatment, and more.

Moerman and Jonas bring up culture, for culture, “rich skeins of connected understandings, metaphors and signs,” plays a fundamental role in meaning. We can also add human’s penchant for magical thinking, whether described psychologically, explored personally in Joan Didion’s The Year of Magical Thinking (as much a reflection on grief as magic), or examined in-depth in the classic anthropological text Witchcraft, Oracles and Magic among the Azande by E.E. Evans-Pritchard.

Moerman and Jonas end their article by writing, “we have impoverished the meaning of our medicine to a degree that it simply doesn’t work as well as it might.”

In contrast, Derren Brown’s magical drunk and Sarah Manguso’s magical intercourse stand as direct testament to the power of meaning.

11 Responses to “Moerman’s Placebo”

  1. dlende said

    Here is a link to Science-Based Medicine’s post “Studying Placebo Effects,” which covers recent research explicitly on placebo effects. My reading? One third of the effect due just to entering the study; most robust effect comes from the doctor-patient relationship. But this is still at quite a distance from what Moerman means, and what happens in our everday lives.

    http://www.sciencebasedmedicine.org/?p=90

  2. Dan Moerman said

    I was delighted to see this blog. My work on the meaning response has been very difficult to do, and has had a rather dismal reception. The book got great reviews, but there is little critical commentary, and no one has really picked up the ideas and tried to move with them; or if they have, I haven’t seen it. It has been more popular abroad (Italy, for example; I don’t know why). But it is of course very hard for people to escape from the mechanical metaphors that we are drenched in. (Yesterday I read something that told me my brain was like a hard disk, except that something was like software. . . and I had to stop reading; I think I had a disk crash, with no backup.) Everyone knows that it’s the aspirin that stops the headache (it does play a part), but the brand name on the tablet, and the tablet itself, are at least as important as the acetylsalicylic acid. Although the whole idea is hardest on physicians (who have the most to gain, but also the most to lose) they are more likely than anthropologists to at least learn from the idea. It’s also apparently impossible for people to change language: to give up a nonsensical notion like the “placebo effect” (even more silly than, say, the “king of America” — we actually did once have a king of America. . . the last being George III). They can’t do it.

    I have given talks to medical audiences; once a neurology grand rounds at a major University hospital. Grand rounds sounds grand, but basically it was a brown bag lunch. People in blue with fluffy headdresses eating their egg salad sandwiches twittered among themselves. I started talking in my doctor-audience mode, showing all the data in powerpoint slides. The tittering quieted down. I showed them the brand name aspirin working better than generic aspirin, and that four placebo tablets a day worked better than two. I showed them the effective placebo surgery (I thought the case of the pacemakers inserted but not turned on working almost as well as the regular pacemakers made a particular impact). I showed them the highly effective laser revascularization surgery for class iii and iv angina, with the lasers turned off, with powerful effects (improvement to class i or ii) a year later. And I showed them the pet scans and the fMRIs of brains of people receiving drugs, and of others receiving placebos lighting up the same way. That brain lighting up business is a real crowd-pleaser. Yada yada. And then I’m done. And there is silence in the room. Silence. Some senior deanlet asks an irrelevant question. The silence is now louder. And it’s one o’clock, and everyone has to go back to work, in the puffy blue hats. And everyone puts back on his or her armor of mechanisms, tosses meaning into the trash with the brown bag, and, thank God!, everything is normal again.

    • Tom Steffora said

      Dr. Moerman, so cool to see your response here. As a newly graduated psychotherapist who just wrote his thesis on the placebo effect/endogenous healing (citing your work several times), and someone who is about to begin a research study on immersive memory techniques for the treatment of chronic pain, I want to say thank you for everything you have done. I would be very interested to ask you several more questions about your findings if you were available to do so. my email is steffora@charter.net . I have also witnessed the response you describe from the medical community and that is why, as a therapist, I’m trying to work with meaning response in spite of their ignoring of the phenomenon.

  3. [...] discuss the higher price=perceived better taste phenomenon. Is it just something about wine? Or a placebo effect? After all, higher priced drugs work better than lower priced drugs, even if they are [...]

  4. [...] we’ve discussed here, meditation can make the brain more compassionate. The placebo effect is better conceived as a meaning response. Beauty centers on experience and relationships, not [...]

  5. dlende said

    Another piece of research on the placebo effect, which compares double-blind studies where subjects know they have a high chance of getting a placebo versus studies where subjects know they have a low chance. Guess what? High expectations lead to greater placebo effects, but also more side effects! http://www.iq.harvard.edu/blog/sss/archives/2008/05/placebo_effects.shtml

    Also, The Christian Science Monitor provides a nice summary on research that shows the placebo effect has physiological effects, and cannot be reduced to psychological beliefs alone. Here’s the piece: http://www.csmonitor.com/2005/0831/p14s01-stss.html
    The original work by Jon-Kar Zubieta appeared in The Journal of Neuroscience, where they argue that the neurological areas “engaged by the placebo may be part of a general circuit underlying the voluntary regulation of affective response.” See here: http://www.jneurosci.org/cgi/content/full/25/45/10390

    Mind Hacks has also just posted a consideration of recent work on the placebo, with plenty of links: http://www.mindhacks.com/blog/2008/05/placebo_is_not_what_.html

  6. dlende said

    Mind Hacks has some more detail on Dan Moerman’s book Meaning, Medicine and the Placebo Effect, including a nice graph and some considerations of Moerman’s meaning response: http://www.mindhacks.com/blog/2008/06/the_meaning_response.html

  7. dlende said

    Salon has a recent article, Why “Placebo” Is Not a Dirty Word by Robert Burton. The tag? “Yes, alternative medicine works mostly by the power of suggestion. But so do a lot of conventional treatments.”

  8. dlende said

    Wired tells us that placebos appear to work better in children: http://blog.wired.com/wiredscience/2008/08/paging-dr-pan-p.html

  9. dlende said

    Mind Hacks links to a BBS radio program on placebos, a ” wonderful trip through the history and science of what we know about this most psychological of treatments.”

    http://www.mindhacks.com/blog/2008/08/placebo_interactiv.html

  10. dlende said

    Some more materials on placebo:

    Somatosphere, The Prevalent Placebo

    BrainHealthHacks, The Neuroscience behind Hope

    Pure Pedantry, The Ethics of Using Placebos

    Biology of Mind, Exercise and the Placebo Effect

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