Scary Words and the Nocebo Effect.
Most people have heard of the placebo effect, but not many know about its evil twin, the nocebo effect. Interestingly, not even Apple knows what nocebo is because an ugly red line appears underneath the word on my laptop each time I spell it out. Placebo is derived from Latin, meaning ‘I shall please’. Nocebo is the opposite, ‘I shall harm’.
A placebo is an inert substance or treatment given to a control group in medical studies to provide a baseline to which researchers can compare the effectiveness of the drug being tested. A positive effect occurring in someone from this group is the placebo effect. An adverse effect caused by this same inert substance or treatment is the nocebo effect. These effects are still poorly understood but seem to result from a patient’s perceptions and expectations of how the treatment will affect them.
Nocebo is less researched than placebo but we know that approximately 25 percent of participants in the control group of clinical trials experience negative side effects from placebo when warned about them. In one particular experiment patients given saline and told it was chemotherapy actually lost hair and vomited.
My favorite story regarding nocebo is about a seriously depressed man who decided he’d had enough. He ingested a whole bottle of anti-depressants as a means to end his life. He then changed his mind and got himself to the emergency room. Hyperventilating and with his blood pressure skyrocketing, he collapsed on the floor convinced he was dying. But blood tests failed to find any drug in his system. After investigating, the doctors learned he was part of the control group of a drug trial and had been taking a placebo. He overdosed on sugar pills!
In another experiment patients with prostate disease were given a drug to help relieve symptoms. Half the group was told that erectile dysfunction was a possible side effect and the other half was kept in the dark. In the first group, forty-four percent experienced ED compared to just fifteen percent of the uninformed group.
If I’m taking that drug, I don’t want to know about the side effects, thank you.
You may wonder how this phenomenon relates to massage therapy.
The words we use and the environment we create play a crucial role in the outcomes of our treatments. Our patients trust us. Without meaning to we could be sabotaging our treatments by using scary words.
Think of some of the things said by therapists: ‘your rib is out’, ‘your L4 is stuck’, ‘you’ve got scar tissue’, ‘your back is riddled with trigger points’, ‘your hamstrings are weak, your glutes aren’t firing’ and the list goes on. Using biomechanical language with negative connotations is not good for inspiring the patient’s confidence and leads to poor outcomes.
Consider this scenario: a therapist informs a patient his ‘pelvis is out’ because of a ‘weak core’ and is the cause of his low-back pain. The patient believes this because the therapist has an air of authority and seems to be an expert. The walls of the treatment room are adorned with diplomas, special education certificates and autographed pictures of local sports heroes. All of this adds to the credibility of the therapist’s words. The patient leaves the session convinced he needs to be careful how he moves lest he causes his pelvis to ‘go out’ again. He now has a fear of movement – kinesiophobia.
Well folks, it is impossible for a pelvis to ‘go out’. These scary words are more harmful than helpful. This poor guy has just been noceboed (I just made up a word).
Now that we have a better understanding of nocebo it makes more sense to use a different approach. The patient should be told that back pain is a normal occurrence and usually resolves on its own with time. Movement should be encouraged and confidence instilled by telling him he is strong and the body has an amazing capacity for self-healing. And most importantly, avoid scary words.
Because of the dramatic effects nocebo can produce, this is a topic therapists and anyone seeking therapy should be more aware of. We should all be looking for more ‘I shall please’ and less ‘I shall harm’.
Thanks for reading. Now you know more about nocebo than all of your friends. And hopefully one day Apple will be more informed and remove this ugly red line from underneath the word.