The Placebo Effect in Therapy (Part 1/2)

What is therapy and why does it work?

“Psychotherapy appears to be an unsystematic myriad of nonspecific elements mixed together in the hope that some will be effective.”¹

Here at the Dead-End of All Things

Psychotherapy is a relatively recent method for dealing with mental disorders, begun by Freud nearly 150 years ago. Since then, other bright and charismatic healers have speculated about what causes and cures mental distress. These theories, and their corresponding techniques, are wide-ranging. Therapy can look and feel wildly different depending on the orientation to which a therapist subscribes. For example:

• A classical psychoanalyst might remain silent for long stretches of the session, only emerging to offer an interpretation of the client’s hidden or repressed motives. For example: “Is it possible that this sexual frigidity toward your wife is the result of ambivalent feelings for your now-dead mother?” The goal of psychoanalysis is to make the unconscious conscious.

• A cognitive behavioral therapist might do most of the talking, draw charts and diagrams to better convey points, collect data on week-to-week changes in client mood, and assign homework. Because the goal of cognitive behavioral therapy (CBT) is to change maladaptive behavior, the therapist’s role is to point out distortions in client thought and/or emotion that underpin behavior. For example: “What you’re doing there is called generalization. You’re assuming that because you failed in one domain, you’ll fail in others. Not only is that a logical fallacy, but it also prevents you from trying anything new.”

• A Rogerian or person-centered therapist strives to have meaningful conversations about life’s biggest questions. The therapist’s goal is to maintain “unconditional positive regard” toward the client, respecting the client’s right to live their own life and make their own decisions. Carl Rogers, after whom the technique is named, is famous for saying: “The curious paradox is that when I accept myself just as I am, then I can change.”

• Interpersonal therapists focus mainly on how the client communicates in session, which is seen as a proxy for how the client communicates in life. Conversations vacillate between process and content. For example: “I noticed how you shrugged off my suggestion to start exercising. Is that dismissive attitude something you exhibit toward others, as well?”

• Adlerian therapists are particularly interested in birth order and social purpose. A Gestalt therapist might encourage clients to “lose their mind and come to their senses,” perhaps by using the empty-chair technique. An equine-assisted therapist “allows” clients to clean their horse and muck out their stables. A family therapist uses genograms (fancy family trees) to understand how a client's familial role might influence the roles they play in other situations.

In short, there are over seventy types of therapy listed on Psychology Today—the primary website for clients looking to find therapists—and each has its own method based on how it understands mental illness to be caused and cured.

Would we not, with such a diverse pool of hypotheses, expect diversity in outcomes? Should it not be clear which of these therapies is on the right track? Instead, the research has by and large suggested that none of them are significantly better than the others.² This is known as the Dodo bird verdict. (And yes, that is the bird in the title image.)

Not everyone agrees with the Dodo bird verdict, of course. Many maintain that certain techniques (e.g., CBT) work significantly better for certain conditions (e.g., anxiety). But my thoughts on this are similar to my thoughts on medication. By and large, I don’t buy it.

Sure, some medications work great for specific conditions. For example, antipsychotics reliably reduce delusions and hallucinations, the so-called “positive” symptoms of schizophrenia.³ However, most of the effectiveness of antidepressants—the most prescribed form of psychiatric medication—is due to placebo. A pill of salt would work just about as well, as long as people believed it would.

Similarly, for certain conditions—such as phobias—exposure therapy is the clear gold standard. Anything else is likely a waste of the client’s time. For most of the issues that clients bring to therapy, though, any number of therapeutic techniques can and do work—yes, even brushing a horse.

So much healing to be had…

Common Factors

The Dodo bird verdict is plausible for two reasons. First, the brain is a mystery. It’s the most complicated thing humans have ever encountered. And as any white-collar car owner knows, it’s pretty hard to fix something when you don’t know how it works.⁴

Second, therapy is hard to study. If a researcher wants to ask if such-and-such treatment is better for such-and-such condition, they must define “treatment,” “better,” and “condition” in ways that are general enough to conduct an experiment, but specific enough to do the terms justice. This would be a difficult needle to thread for intelligent people with the right incentives, let alone clinical psychology in its current form.

In my podcast with Dr. Nesse, I asked him how he would treat someone who lost desire for romantic partners as soon as desire was reciprocated. Dr. Nesse responded by saying he would need to know much more information. Exactly. Meanwhile, I raised that particular issue because it was one of four unique issues a former client had brought to therapy, none of which were replicated elsewhere in my caseload. So even the first step of an experiment—finding a common enough problem to study—is extremely difficult.⁵

Furthermore, how do I practice therapy? I genuinely have no idea. I’m an articulate guy, so I’m sure I could whip something up; and I’m sure I could make it sound nice. But if someone asked me to manualize my treatment method for an experiment, it might ruin me. I’d have to come face to face with the fact that I just sort of make things up as I go.

I’ve got some basic tools and techniques, of course, such as silence and word mirroring. I’m familiar with many concepts, such as ambivalence, resistance, and transference. I even have an overarching theory—evolution, hello—to narrow and guide my hypotheses, which is more than most therapists can say. But there’s no way I could write down what I do and feel confident that someone following it was delivering the same—or even similar-enough—therapy.

Despite these difficulties, thousands of studies have attempted to compare the effectiveness of various therapeutic techniques. Clinical psychology has asked no other question—which therapy is best?—with such fervor. I think it’s fair to say that if significant and reliable differences existed, researchers would have found them by now. They haven’t.⁶

Research has, however, established therapy as a moderately effective solution to a wide range of mental problems. Perhaps a better question to ask at this point, then, is why does therapy work at all? If all or most techniques deliver some benefit, then clearly something they share is responsible—for example, a safe environment, a collaborative relationship with a supposed expert, the structure of weekly or biweekly sessions, and, of course, the expectation that therapy will work. I.e., placebo.

Three positive changes could take place if the field of clinical psychology recognized the centrality of these “common factors:”

1. Common factors could form the backbone of therapeutic training, making such training worthwhile. Graduate schools could focus on, say, the ingredients of a collaborative relationship, or what makes an environment safe, instead of harping on differences between therapeutic techniques that don’t matter.

2. Clients could move on from pointless questions such as “what’s the difference between CBT and psychoanalysis again?” or “what does LCSW stand for?” and focus instead on questions likely to make a difference, such as:

   1. Do I think I will like this therapist?

   2. Does it seem as if they will understand me?

   3. Have others had good experiences with them?

   4. Are they affordable, close by, and compatible with my schedule?

3. Research could begin illuminating the mechanisms of common factors, thus paving the way for better therapies. Why is it, for exampe, that a safe environment promotes behavioral change? What underlies a strong therapeutic alliance?⁷ Mainly: what would a therapy look like that adopted everything that made a difference and discarded everything that didn’t?

By and large, the field is still focused on distinctions without a difference, but there is some movement toward a common-factors approach, and I am hopeful that a sea-change is on the horizon.⁸ Of course, by focusing on why therapy works and how it could work better, we are liable to forget that therapy is only one option for helping people feel better—and a new one at that.

The View From 30,000 feet

I like history because it often changes the landscape of current possibilities in liberating ways. For example, I recently stopped using Q-tips because it occurred to me that most people in the past never used them and were fine. That realization added some options to my list for what to do with earwax (to include nothing) and shrank the number of items I own for removing it (to zero).

What does a historical perspective say about therapy? First, that mental illness has been around for a long time, meaning therapy—unlike Q-tips—isn’t entirely an artificial solution to an artificial problem.⁹ But it is somewhat. Mental illness existed well before modern environments, but modern environments have undoubtedly exacerbated some conditions (e.g., ADHD, schizophrenia) even as they have alleviated others.

Second, the historical perspective recognizes psychotherapy as a relatively new technology. For most of human history, mental illness was handled in other ways. Does this realization adjust the landscape of possibilities in the same way as my Q-tip revelation? I think so. At the very least, it raises the possibility that some historical methods were equivalent to or better than contemporary ones. Even as a therapist, I’m not so sure that therapy and medication are better solutions to mental anguish than religion, community, necessity, exercise in natural settings, and so on.

It is also probable that our current frontline treatments of therapy and medication share similarities—common factors—with methods of the past. The placebo effect is undoubtedly one of them. Indeed, as the Shapiros argue, “The panorama of treatments since antiquity provides ample support for the conviction that, until recently, the history of medical treatment is essentially the history of the placebo effect.”¹⁰

But is this “until recently” as true for mental health as it is for medicine? Is it fair to say that while humans once relied almost exclusively on placebo for psychic relief, they don’t need it as much anymore because psychotherapies have come such a long way? No.

Believe it or not, it was common medical practice in the 18^th and 19^th centuries to bleed and cup patients with a fever, or to administer mercury or arsenic for syphilis. These practices were ongoing in many parts of the world when Freud first hung his shingle. Yet, while we have dramatically improved upon these medical practices, psychoanalysis is still going strong. And hey, I’m not knocking psychodynamic treatments. Plenty of research has found them to be effective—if not more so—than clinical psychology’s golden child, CBT.

It makes sense that medical and mental histories diverged. Humans eventually figured out what the deal was with syphilis. Identifying it as a bacterial infection allowed us to recognize a cure when we stumbled upon one. For psychosis, though—or even everyday sadness—we don’t know what’s going on. The mechanisms are invisible to us. So even if we stumble upon something that seems to work, as happened with the very first antidepressants, we don’t know why. Or what could be improved. Or how much is placebo. Which is why I’d much rather have syphilis than depression.¹¹

In the absence of mechanistic knowledge, therapeutic techniques continue to proliferate. Anyone can say “this is therapeutic” and begin a cottage industry around the claim. On the one hand, there’s no real way to dispute it. On the other, they’re probably right. Thousands of things are potentially therapeutic, from receiving a compliment to being tied up and whipped. The problem is that we have no way to anticipate, organize, or compare them.

For example, at some point during her captivity to the Comanche tribe from 1836-1838, Rachel Plummer stumbled upon an effective treatment for her…let’s call it ‘adjustment disorder.’ This treatment happened to be getting lost in a cave overnight. She wrote of the experience: “The impressions made upon my mind in this cave, have since served as a healing balm to my wounded soul.”¹²

Ought we add Cave Therapy to Psychology Today’s list? The domain name cavetherapy.com is open, just saying…

End of Part I

All these threads—from the Dodo bird verdict to the historical view—suggest we should be cautious about viewing therapy and medication as the panaceas they are assumed to be.

In A Hunter-Gatherer’s Guide to the 21^st Century, Heying and Weinstein note that “The benefits [of new technologies] are obvious, but the hazards aren’t.”¹³ Freud’s introduction of the “talking cure,” and the proliferation of various techniques since, have probably been net-positive for the average person’s mental health. But there have been negatives, too. Mental health is increasingly behind a paywall, dispensed by experts, and accompanied by medication. The costs of these developments loom larger when a person recognizes that, well, psychotherapy is not penicillin.

Another subtle but potentially pivotal change has taken place in the treatment of mental distress: it has become a scientific enterprise. While the benefits of this are obvious, the hazards—such as the dismissal of social, cultural, religious, personal, natural, creative, and even magical forms of healing—are not. Under the guidance of a field desperate to be scientific, clients of the mental industry rarely perceive alternate approaches to healing, which nevertheless predominated throughout most of human history. The therapist’s office is indeed constructed from the remnants of the family home, the church, the rotary club, and the proverbial bowling alley.

In Part II, I describe the active—and for the most part unacknowledged—role that placebo plays in therapy, despite the growing insistence from both client and therapist that the process be scientific. That it make sense.

Thanks for reading and stay tuned.

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References

Bergin, A. E., & Garfield, S. L. (Eds.). (2021). Handbook of psychotherapy and behavior change (7th ed.). Wiley.

Harrington, A. (Ed.). (1999). The placebo effect: An interdisciplinary exploration (Vol. 8). Harvard University Press.

Parker, J. W., & Plummer, R. (1926). The Rachel Plummer Narrative: A Stirring Narrative of Adventure, Hardship and Privation in the Early Days of Texas, Depicting Struggles with the Indians and Other Adventures...

1. Shapiro, A. K., & Shapiro, E. (1997). The placebo: Is it much ado about nothing? In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 23). Harvard University Press.

2. As Wampold et al. put it, “None of the [data] yielded effects that vaguely approached the heterogeneity expected if there were true differences among bona fide psychotherapies.” (p. 205)

3. By contrast, medication is not all effective for reducing the “negative” symptoms of schizophrenia, such as flattened affect. In fact, medication tends to flatten affect more.

4. I won’t bore the reader with this quote in the text anymore, but recall Anne Harrington in Mind Fixers: “...current brain science still has little understanding of the biological foundations of many—indeed most—everyday mental activities. This being the case, how could current psychiatry possibly expect to have a mature understanding of how such activities become disordered—and may possibly be reordered?” (p. 276)

5. The American Psychiatric Association has done its best to capture and organize the diverse presentation of psychic misery in the Diagnostic and Statistical Manual of Mental Disorders, but despite including more diagnoses with every edition, the DSM has nothing to say about most client issues I work with.

6. Chapter 5 of Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change does an excellent job of summarizing the research on psychotherapeutic effectiveness.

7. To be fair, some are asking these questions. See, again, Chapter 5 of Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change.

8. I am also hopeful that the absence of clarity in much clinical research, from comparing the effectiveness of various therapies to the influence of genes on mental illness, will motivate more people to rely on an evolutionary framework. Mental health is complicated, and for many of its mysteries, we need to return to solid footing before we can move forward again.

9. Q-tips are primarily a solution to the artificial problem of earwax compression. In the modern world, people wear all sorts of earbuds and earplugs, but without this compression, earwax could be safely left alone. Of course, modern standards for hygiene play a part in earwax removal, too.

10. Shapiro, A. K., & Shapiro, E. (1997). The placebo: Is it much ado about nothing? In A. Harrington (Ed.), The placebo effect: An interdisciplinary exploration (pp. 13). Harvard University Press.

11. To be clear, I’d prefer neither.

12. Parker & Plummer (1926), p. 73.

13. p. 98.