Reconstructing the Meaning Effect – The Capacity to Self-Heal Emerges from the Placebo Concept
Harald Walach, 2014
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Arguably the most important conceptual development in the area of placebo research in recent times was the redefinition of the placebo effect as an “effect due to the meaning of an intervention” (Moerman & Jonas, 2002). The placebo effect was reframed from a nuisance to a potential resource. When Martini in Germany (Martini, 1932) and Beecher in the US (Beecher, 1955; Lasagna, Mosteller, von Fel-singer, & Beecher, 1954) started discussing the placebo-effect in the 30ies and 50ies it was a conundrum. Clinical pharmacology set out with the promise to find ever more specific treatments for diseases. This project assumes that through scientific knowledge we will unravel the causal network of diseases that can then be specifically targeted through clearly designed drugs with specific, known and targeted causal pathways of efficacy. This is theory. Or shall we say poetry and fantasy? Following this theory, everything that is not causal can only be background noise and a nuisance (Grünbaum, 1989). And hence the placebo-effect, as it showed in clinical trials that were necessary to prove the specific efficacy of these interventions, was considered a nuisance and, technically speaking, error variance to be minimised. Research and clinical experience showed how powerful such effects can be in practice. The redefinition by Moerman and Jonas captured this cultural move: the placebo-effect grew from a nuisance to be avoided to a resource that can be very helpful (Walach & Jonas, 2004).
In this contribution I would like to take this development one step further and argue that this effect is actually the most important therapeutic effect of all. All so called specific effects, causal interventions etc. are only maneouvres that help marshal this most powerful therapeutically: the self-healing response. And so my thesis is that behind the placebo-effect we see self-healing at work. I am advocating a kind of figure-ground perceptual change: What has been considered the background, even background noise, namely the placebo-effect, I would hold to be the most important element. It should move to the foreground and become what it actually is: the most important component of every therapeutic system (Wampold, Minami, Tierney, Baskin, & Bhati, 2005). That does not negate that there are specific effects, like in life-saving surgeries in cases of emergencies or when resecting tumours. But they are the background that only allow the figure to emerge: the individual self-healing trajectory.
The Conceptual Problems of the Specificity-Non-Specificity Distinction
The standard paradigm of clinical pharmacology and modern medicine assumes that the way to cure is to understand the pathological cause of illness and then to intervene at the causal point of pathogenesis. This reasoning follows from the assumptions of cellular pathology introduced by Virchow in the 1850ies and followed through until today (Uexküll, 1982; Uexküll & Wesiack, 1988). The paradigmatic idea behind this notion is that the body is a causal (classical) biological machine with understandable causal relations. It turned out that this was an extremely useful abstraction from the complexities of human life when we are dealing with emergency situations and acute problems, as was the case for most of the 19th century and roughly until the 1950ies. Until then the major problems were to understand and contain the large epidemics – cholera, typhus,tubercolosis, polio, smallpox, etc. – and to provide emergency relief for the casualties of the large wars from 1914 to 1919 and from 1939 to 1945. And for all those problems it is very useful to abstract from complexities and view the human body as a causal biological machine, find the point of maximal causal disruption and treat it. The discovery of potent anesthesic substances supported this reasonipowerfulowerful way (Alkire, Hudetz, & Tononi, 2008; Woolf & Butcher, 2011). The large scale synthesis of morphine in 1827 by Merck and other opiates in its wake, as well as cocaine (Stachowske, 2002), seemed to pave the way for very powerful and reliable alteration of human conscious experience of pain and psychological well-being. So why not also for the treatment of diseases and cures for headaches, stomach pain, and the like?
Enter a new rogue and a new jester. The rogue: multicausal, complex, life-style dependent diseases and functional, psychosomatic problems taking centre stage from the middle of the 20th century onwards. The jester: systems biology and non-linear systems theory.