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Placebo Effects:

From The Perspective Of Integral Psychology

Andrew G. Reece

Naropa University

April 2010
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Abstract

This paper makes a broad survey of placebo effects in present and historical medical literature. Placebo

effects are considered from the perspective of Integral Psychology, specifically from the four-quadrant

model of holonic development. Additional sections cover the following topics: Arguments against the

validity of placebo effects, problems with identifying and measuring placebo effects, and ethical

considerations in the purposeful use of placebos in clinical practice.


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Foreword: Storytime at the Ivory Tower

This is a story about the power of stories. In a sense, storytelling is art of recounting of reality

from a particular perspective – from the way it seemed real to me, or you, or to an entire community.

Over the course of writing this particular tale, I have come to understand a paradoxical truth: that in

transmitting these stories there is a new reality, every bit as real, which is born with each new telling.

The stories of Mind, Body, Culture, and Environment, are not simply fanciful visions or subjective

opinions in a fictional frame of reference. Rather, they speak of what IS, and as their words come to

our ears, they actually serve to shape our view of the world, in and around us. I suppose I'm getting a

bit ahead of myself – telling the end before the beginning, as it were – but suffice for now to say that I

wasn't expecting to find out about this storyteller's secret when I set out to write this paper.

Originally, I had planned to write my thesis on the practice of long-distance healing, where a

healer exerts a beneficial effect on a patient from a remote location. Early on in my preliminary

research I quickly ran into the confounding problem of how to determine whether or not an observed

effect was actually brought about by the remote healer, or whether some other factor had contributed to

a patient's improvement. This soon led me to a deeper investigation of the placebo effect, a term used

to describe the curious phenomenon of the mind's ability to heal the body when it has been fooled into

thinking it has been given medical treatment, when in fact it has not. It didn't take long for me to

realize that there was a fascinating (and, not insignificantly, far-better documented) wealth of research

opportunities available within this subject alone.

Placebo effects, along with their relationship to unusual phenomena like long-distance healing,

interest me because the greater part of my adult life has been spent in environments where the

inexplicable and esoteric are seen as commonplace. For the past ten years, I have travelled the world to

study with warriors, healers, mystics, and contemplatives, along my own path of self-inquiry and

pursuit of wisdom. I currently live on a small island in southern Thailand, in a community of yogis and
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healers, where I am both a student and teacher. It has become something of a hobby of mine to look

into the scientific support for many of the theories and practices that I and my colleagues follow, many

of which originated in ancient spiritual traditions often thought to be incompatible with contemporary

scientific knowledge. In my research, I have uncovered a curious mix of authentic truth and regional

coloring; it has become my own personal aspiration to develop a spiritual practice and worldview that

is fully supported by all modes of knowing: intuitive, investigatory, spiritual, secular.

To this aim, a comprehensive study of the placebo effect seemed invaluable, and indeed, it has

so proved itself. During the course of my research for this paper, I often fancied as though I could feel

my conscious mind rewiring connections and opening new possibilities, as I learned more about what

we know, as a collective, about the capacity of the mind (both individual and collective) to influence

and even govern our biological exteriors. As with most successful inquiries, I am left with more

questions than answers – but these new questions don't seem to demand their own responses; rather,

they sit formidably astride my accumulated worldview, dangling their legs near the top of my

perspective, continually presenting the same challenges: How much of what you are experiencing right

now is a product of mind? Where is the line between objective and subjective realities? Are they

ultimately different? Does it matter?

I also consider my placebo research to be timely in another way. I have recently entered into a

new phase in my life, one in which I am attempting, as best I can, to strip bare the various assumptions

I have been carrying about myself, others, and the way the world works, and to start anew with an

open, honest, and authentic approach to rebuilding myself as an individual (as well as a part of a greater

whole). I'm not sure whether learning more about the power of placebos contributed to this new effort,

or whether the effort itself influenced my interest in them as a topic of research – I suspect the two

possibilities were and are engaged in a symbiotic relationship. Along with this new phase comes a

tremendous amount of doubt, or at least skepticism; in attempting to reformulate the way I experience
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the world, I am trying to apply the sharpest discernment I have to evaluate those beliefs and

perspectives that make up my conscious mind. Many of the things I hold most sacred – my

understanding of yoga, my belief in a higher power, my own self-image – have come under a powerful

barrage of questions and new data (much of which I accumulated as a result of this research).

From what we know about the power of the physician as a therapeutic agent in his own right,

there is good reason to believe that much of the explanation for why a sugar pill can sometimes cure

disease lies not in the fact of the pill itself, but because the physician, whom the patient trusts, has

conferred the power of his authority into the placebo substance. The pill becomes a talisman, potent

for the ability to heal that it represents. It is a short leap from there to considerations of religious and

spiritual concern – and there the questions take on a wicked double edge: Does God provide us with the

placebos, conferred with Its Holy power? Or is God the placebo, an idea imbued with the confidence,

faith, and trust we place in our teachers? And even if the latter is the case, if placebos have genuine

power to deliver, then would it really matter, as long as we manage to invest our faith fully in Buddha,

in Tao, in Brahma? Is the disillusionment of the cosmos another way of saying that post-Enlightenment

culture found out it was being given a placebo? Or is our current reliance on rational-materialism a

placebo that wards off the existential fear of death and the unknown? These are questions with which I

currently wrestle.

At the same time, somewhere in the background, I can just barely feel a certain sense of deep

ease behind all this turmoil – perhaps this core equanimity is the one thing that will emerge as a stable

truth when the smoke clears. I rather suspect it will be so. In the meantime, though, I am intensely

grateful for this opportunity to make a comprehensive study of placebo effects, not only with respect to

my life, but also to my culture, social environment, and to the world at large.
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Introduction: Medicine at a Crossroads

The burgeoning discipline of placebo research tries to understand how seemingly useless

treatments, such as sugar pills and sham surgery, can yield tangible, therapeutic results.1 Medical

science refers to these as placebo effects, from the Latin “I will please” (Evans, 2004, p. 2). Although

for much of its early status as a medical phenomenon, placebo was thought to be related mainly to the

subjective phenomenon of analgesia (Beecher, 1955; Harrington, 1999; Levine, Gordon, & Fields,

1978), it is now understood that objective, physiological effects can be generated with placebo

treatments as well.2 In a recent meta-analysis, Mark (2009), for example, reported that placebo

recipients have demonstrated significant improvements across a wide range of pathology, including

bipolar mania, chronic fatigue syndrome, ulcerative colitis, Crohn's disease, depression, erectile

dysfunction, irritable bowel syndrome, migraine, osteoarthritis, pre-menstrual syndrome, and restless

leg syndrome. The problem arising today in placebo studies is therefore not one of acknowledgment,

but rather one of comprehension: even though most scientists now recognize that the placebo effect has

both psychological and physiological significance, still efforts to develop a more inclusive, integrated

medicine have been slow in forming. These efforts have been hampered largely by a lack of a coherent

framework within which to formulate a new vision. I propose that such a framework does exist, in the

ontological model laid out in theorist Ken Wilber's Integral Psychology. Integral Psychology offers a

cogent format for a more complete understanding of the significance of placebo studies, as well as for

the field of medicine as a whole.

This paper is divided into six parts. In Part One, I provide a clearer definition of Integral

1 Some placebo use today is true to this original notion of a placebo being a sugar pill or some otherwise completely inert
substance, however a distinction is now made between “pure placebos” and “impure placebos”. (Fässler, Gnädinger,
Rosemann, & Biller-Andorno, 2009, p. 3) The latter category indicates the use of active medicine not meant to treat the
ailment for which it is being prescribed, ie. giving antibiotics to treat a viral infection. Impure placebos are used more
frequently today than their purer counterparts. (Fassler et al., 2009; Hrobjartsson & Norup, 2003; Sherman & Hickner,
2007)
2 Analgesia is the medical term for pain relief.
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Psychology and its composite parts. Part Two presents a literature review of relevant research which

supports my assertion that Integral Psychology is, in fact, a useful framework for understanding

placebo and the larger medical context. The review is divided into four sub-sections, according to

Integral theory's four-quadrant epistemological approach. (I'll elaborate on this more in the next

section). Part Three draws on the conclusions presented by each of these four perspectives, to

formulate a vision of a truly integrated medical model, based strongly on placebo research. In Part

Four, I briefly present some of the arguments put forth by skeptics, which attempt to discredit the

significance of the placebo effect. Part Five looks at a few of the most important issues facing placebo

studies today, and offers some speculation as to how future applications of the placebo effect might be

used in medicine. Finally, in Part Six I present a summary of findings, and point the reader to a handful

of important truths that may be taken from this presentation.

Before we can really get settled into our story, I first need to take a moment to introduce

Integral Psychology. Call it the flashlight I'll be pointing upward from under my chin as we all gather

'round the fire. The Integral system is its own vast network of stories, the full scope of which has

already taken up numerous volumes. As an introduction, however, the following should give us

enough to get started.

Part One: What Is Integral Psychology?

Integral Psychology is a contemporary school of thought that regards personality and behavior

as indicators of an ongoing, psycho-spiritual developmental process. Originally considered to be a

branch of Transpersonal Psychology, Integral Psychology was largely born out of the work of a single

theorist, American philosopher Ken Wilber (Visser, 2005). Wilber (2002) synthesized the spiritual

systems of the world's ancient wisdom traditions with 20th century developments in psychological

understanding, which he then used to model the full potential range of human development in an
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elaborate spectrum of consciousness. The latest version of Wilber's Integral vision now extends

considerably beyond the boundaries of traditional psychology (Wilber, 2006).

Integral theory asserts that human behavior can best be understood by employing a broad range

of analytical schema which Wilber (2006) refers to as the “AQAL” model (pronounced “AH-kwall”)

(p. 26). Wilber uses AQAL as shorthand for “all quadrants, all levels” (p. 26), indicating the model's

reliance on two primary modes of analysis – a four-quadrant epistemological grid of his own design,

and a scheme of gradated human maturation first outlined by researchers in the field of developmental

psychology. In the Integral framework, individual entities are considered as “holons” – units which are

wholes in themselves but also parts of greater wholes, such as in the relationship between atoms and

molecules, molecules and cells, and cells and organisms (Wilber, 2000, p. 7).3 Each holon, in order to

be fully understood, must be considered from at least four basic perspectives: its interior and exterior

characteristics, in conjunction with its individual and social qualities (Wilber, 2006). According to

Wilber (2006), the resulting four-quadrant grid – individual-interior, individual-exterior, collective-

interior, and collective-exterior – constitutes the minimum ways of looking at a holon in order to make

an informed statement about its overall condition (see Fig. 1). An individual born in Switzerland, for

example, has her own interior consciousness, as well as an individual body. In addition, her existence

is also undeniably affected by her being raised amidst Swiss culture (her collective-interior) and by the

social institutions (laws, government, means of transportation, media, etc.) which give her culture its

outer structure (her collective-exterior). It would be difficult, if not impossible, to relate to this

individual in her entirety, without first taking into account these four foundational perspectives.

Holons are also entities capable of maturation (Wilber, 2000). Drawing on the work of

developmental theorists including Piaget, Loevinger, Graves, Maslow, and Kegan, Wilber (2006)

described how this maturation unfolds in identifiable stages from lesser to greater complexity.
3 This is a term originally coined by Koestler (1967), to describe the organizational properties of organisms and life
systems in general.
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Figure 1. Four-quadrant schematic of the AQAL model.

This occurs over a broad range of developmental lines, among roughly two dozen distinct streams of

concern, ranging from cognitive to interpersonal to artistic and psychosexual (Wilber, 2000). An

individual might be particularly developed on a cognitive level, but significantly underdeveloped on an

emotional level (or vice-versa). The aggregate of a holon's various lines and each line's degree of

developmental maturity is referred to as the Integral “psychograph” (Wilber, 2006, p. 10, fig.1). In

addition, Integral Psychology employs various typologies (ie. Myers-Briggs, Gurdjieff's Enneagram),

as well as an awareness of the differing states of consciousness (waking, dreaming, deep sleep) to

further inform holonic development (Wilber, 2000).

This network of quadrants, levels, lines, types, and states makes up the bulk of Integral

Psychology's analytical model. Although the full scope of the Integral framework is exhaustively
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comprehensive, for the purposes of this paper consideration will be mainly given to the AQAL model's

four-quadrant approach. The story told by the four quadrants is one of specialization in service to the

big picture, and in the often-fragmented world of medical research, that kind of approach can be very

useful. As such, I will present a review of placebo-related literature in the context of the four quadrant

model – I'll go through each quadrant, one-by-one, and show how unique, indispensable research is

being done which wouldn't be available from any of the other quadrants. To better set the stage for this

analysis, this next section will begin with a historical overview of placebo use in healing contexts

around the world, up to the present-day view of placebo effects and their role in modern medicine.

Part Two: An All-Quadrant Placebo

Voltaire famously noted that “the art of medicine consists of amusing the patient while nature

cures the disease” (Andrews, 1987, p. 72). From the perspective of modern medicine, this appears to

have been largely accurate for most historical healing systems. In a comprehensive survey of herbal

remedies used in ancient Chinese, Indian, Babylonian-Assyrian, Greek, and Roman medicine,

researchers Arthur and Elaine Shapiro (1999) concluded that out of the roughly 4,785 drugs and 16,842

prescriptions accounted for, “with only a few possible but unlikely speculative exceptions, all were

placebos” (p. 13). Certainly, the administration of placebos was commonplace by the early Industrial

Era. In an 1807 journal entry, US president Thomas Jefferson wrote of a prominent physician who

assured him that “he used more bread pills, drops of coloured water and powders of hickory ash than

all other medicines put together” (Evans, 2004, p. 3). Even Richard Cabot, perhaps the most famous

American physician of the early 20th century, confessed, “I was brought up, as I suppose every

physician is, to use placebos...for acting upon a patient's symptoms through his mind” (Harrington,

2009, p. 63). In nearly all cultures and eras which have some record of healing practices, from First

Nation shamans (Znamenski, 2007) to World War II front-line medics (Beecher, 1955) to modern-day
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clinicians (Placebo: Healing the body, 2009), placebo treatments have been used as a matter of

common resource.

While the art of the placebo has existed throughout the course of recorded history, it is only

recently that we have begun to develop a more precise understanding of how it works, and for whom.

For instance, the oft-quoted statistic is that placebos are effective in about a third of any experimental

group. Beecher's (1955) seminal work on placebo effects is largely responsible for this statistic; since

its publication, actual rates of placebo efficacy have been shown to vary dramatically (Wall, 1992).

Placebo effects are nearly non-existent when treating some illnesses, such as cancer, and in other cases,

as in that of depression, placebos have been observed to be effective up to 90% of the time (Moerman

& Jonas, 2002)

Benedetti (2009) notes that the term “placebo effect” is actually now something of a misnomer,

as it is no longer considered to be a single phenomenon, but rather composed of a number of distinct

factors. Some of these factors may actually represent phenomena completely unrelated to the actual

treatment, which in one way or another may color the accuracy of a healing assessment. “Regression

to the mean”, for example (also referred to as “spontaneous remission”), describes the obvious (but

often overlooked) fact that many diseases or ailments simply get better on their own over time.

(Benedetti, 2009; Kirsch & Sapirstein, 1998) As many people seek out medical help either at or near

the height of their illness, any resulting treatment, whether active or placebo, may be aided by a natural

course of improvement. False reporting of improved or worsened conditions, either by the doctor or

the patient, can also skew assessment (Benedetti, 2009). In addition, co-treatment – the receipt of other

forms of therapy from a different source – often goes unreported and also contributes to a murky

understanding of exactly how effectively a given treatment is working (Benedetti, 2009).

These examples are among a wide range of factors potentially at play in the healing process. As

they do not relate specifically to the actual treatment in question, but yet still present the outward
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conclusion of improved health or recovery, some physicians now prefer to distinguish between a

placebo effect and a placebo response (Benedetti, 2009; Kirsch & Sapirstein, 1998). A placebo

response is any observable improvement from a placebo treatment, after the effects of all outside

factors have been accounted for. The more general “placebo effect” represents the sum total of all

improvements that occur after a placebo is administered – this can include those elements mentioned

above, such as regression to the mean, passage of time, reporting bias, et cetera (Benedetti, 2009).

Even within the more narrow context of placebo response, however, there still remains a distinct

lack of consensus as to the actual nature of the placebo mechanism. Shapiro and Shapiro (1999) wrote,

“We are not even close to selecting the significant from the multitude of variables proposed as

underlying the placebo effect” (p. 29). Today, twelve years later, the exact extent to which

psychological, neurological, cultural, and social-environmental factors are significant in creating a

placebo response is still unknown.

One reason for this lack of coherency in placebo research is due to a lack of collaboration

among different disciplines. As a result, disparate camps have arisen – some in biology, some in

psychology, some in pharmacology and even social anthropology – each of which is attempting to

evaluate the placebo effect in its own terms. In order to fully grasp the import of each groups' findings,

I believe it is first necessary to introduce a collaborative framework by which placebo researchers can

understand not only the significance of their own data, but also the synthetic wisdom available from a

inter-disciplinary view. I propose that the AQAL four-quadrant model of Integral Psychology is just

such a framework. The following section presents a review of relevant research literature intended to

illustrate more fully how the placebo effect is representative of distinct but mutually interdependent

factors, which line up nicely within the grid of the AQAL model.

My Own Best Medicine: Placebos in the Individual-Interior


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As the dominant mode of inquiry in science remains one that uses empirical, observable data to

draw conclusions, the interior consciousness of the individual is often overlooked as unimportant, even

non-existent (Begley, 2007). But the idea that one's personal conviction – call it faith, belief,

assurance, or trust – is highly important to the healing process is an ancient one, with plentiful

examples (Brody, 1999; Harrington, 2009). In more modern times, take, for instance, the 1957 case of

Mr. Wright, as reported in Dylan Evans' Placebo (1994). Wright had been diagnosed with acute

lymphoma, with just weeks left to live, when he learned of a new experimental anti-cancer drug called

krebiozen and insisted that it be given to him. Within days of taking the krebiozen injection, Wright's

tumors shrank “from the size of oranges to the size of golf balls” (Evans, p. 12), and days later he was

released from the hospital, seemingly free of malignancy. When new findings revealed that krebiozen

was actually useless, his tumors returned. At that point, his doctor lied and said that the newspapers

were wrong, and that krebiozen was actually a powerful remedy. Wright's physician gave him a

placebo injection of saline (claiming it was krebiozen) and the tumors disappeared again. Months later,

when Wright learned that the American Medical Association had issued a formal statement indicating

the worthless status of the drug, his cancer returned immediately; Wright died just days after hearing

the news.

Other dramatic, medically confounding examples have been well-documented over the past

century. A case of congential ichthyosis, a disfiguring skin disease thought to be completely incurable,

disappeared from the arm of a 16 year-old boy after a doctor used an experimental form of hypnosis

(Mason, 1952). Harrington (2009) reported the story of a woman who refused treatment for life-

threatening injuries from a car accident, and instead completely healed her wounds after a night of

intense prayer. A French man completely debilitated by multiple sclerosis achieved a total recovery

(thought to be medically impossible) after a visit to the town of Lourdes, a holy site for Christians

(Harrington, 2009). Lourdes Medical Bureau chief Patrick Thellier later remarked with evident
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surprise:

[The subject] suffered an organic infection of the multiple sclerosis type in a severe and

advanced stage of which the sudden cure during a pilgrimage to Lourdes corresponds with an

unusual and inexplicable fact to all the knowledge of science. It is impossible for medical

science to say anything more today. (Zenit International News Agency, 1999, Para. 9)

The firm conviction that a treatment will have a positive outcome can even override the effects

of a known toxic substance. Wolf (1950) reported giving two nauseous women (one of them pregnant)

ipecac, a strong emetic agent, while telling them that it would ease their discomfort. Both of them

reported immediate and lasting relief; normally, ipecac would have induced powerful vomiting within

moments of ingestion. Wolf concluded, “The above 'placebo' actions depended for their force on the

conviction of the patient that this or that effect would result” (p. 106).

Conversely, when patients believe they are receiving treatment that is harmful, even if the

substance is completely inert, negative effects can result (Barsky, Saintfort, Rogers, & Borus, 2002;

Hahn, 1997). This phenomenon is called the nocebo effect, from the Latin, “I shall harm” (Evans,

1994, p. 24). The case of Mr. Wright's recurring tumors (on hearing that his medicine didn't work)

could be considered an early anecdotal example of nocebo at play. Later, it was discovered that nocebo

could be produced by conditioning as well (Ader & Cohen, 1975; Amanzio, Corazzini, Vase, &

Benedetti, 2009; Rief et al., 2009).

Although most placebo research is conducted in a pharmacological context, even placebo

surgery, once thought to be a laughable concept, has produced significant results (Cobb, Thomas,

Dillard, Merendino, & Bruce, 1959; Johnson, 1994; Linde, Gadler, Kappenberger, & Rydén, 1999). A

recent set of studies employing sham arthroscopic knee surgery showed that placebo surgery can be just

as successful as actual surgery, calling into question the efficacy or ethical justification of subjecting

patients to such invasive surgery (Moseley, Wray, Kuykendall, Willis, & Landon, 1996; Moseley et al.,
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2002).

What we broadly refer to as placebo extends even beyond the strict context of medical

treatment. Studies have shown that people who perceive their health as poor have much higher

mortality rates than people who believe they have excellent health, even when controlled for actual

health conditions (Idler & Kasl, 1991; Kaplan & Camacho, 1983). Crum and Langer (2007) conducted

a study of 84 hotel maids whose everyday work activity more than exceeded the US Surgeon General's

recommendations for daily exercise. Despite their rigorous workday, 66% of the maids reported not

exercising regularly, and 36.8% declared they did not exercise at all. Crum and Langer report:

Interestingly, the health of the room attendants reflected their perceived levels of exercise rather

than their actual levels: According to their initial physiological measures, the subjects were at

risk with respect to BP, BMI, percentage of body fat, and WHR—all important indicators of

health. These results suggest the possibility that at the onset of the study, the room attendants

were not receiving the full benefits of their exercise because they were not aware that they were

getting exercise at work. (pp. 169-170)

Langer's research team divided the maids into two groups, and gave only one of the groups an

extensive education on exactly how much exercise they were getting each day by performing their

daily work routine. These newly informed maids, along with the uninformed control group, were

instructed to continue about their work, without altering their activity. After four weeks' observation,

the uninformed group showed no significant signs of change, but the informed maids showed

significant improvements in every measure of health (weight, body fat, body-mass index, blood

pressure, and waist-hip ratio). These findings suggest that, at least in some cases, it is mental outlook

alone that determines bodily health.

The interior perspective of not only the individual patient, but also the doctor, has some bearing

on the efficacy of medication, whether real or placebo. Gracely, Dubner, Deeter, and Wolskee (1985)
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demonstrated this in a study of post-operative placebo analgesia for 60 patients recovering from

wisdom tooth surgery. Two groups of patients were informed that they would be receiving one of three

possible treatments: a powerful painkiller (fentanyl), a pain antagonist (naloxone), or a placebo. This

wasn't actually true though; doctors who administered the injections knew that one group (Group A)

would only receive either naloxone or placebo treatments (ie. no possibility of pain relief), while

subjects in the second group (Group B) could potentially receive the painkiller. Those who received

pain-enhancers and painkillers responded as expected. The people who received placebos, however,

showed surprisingly split results. Although the doctors were under strict orders not to relay their

expectations to the test subjects in any way, placebo recipients in Group A experienced far greater and

longer-lasting pain relief than did placebo recipients from Group B. Somehow, the doctors' own

internal states of knowing influenced patients' results. While the study authors speculated that the

doctors' foreknowledge could possibly have resulted in “subtle behaviors that influence patient

responsiveness,” their only clear conclusion was that “clinical analgesia depends not only on the

physiological action of the treatment administered, but also on the expectations of patient and

clinician” (p. 43).

While these data strongly suggest that personal perspective is a powerful component of the

placebo effect, it should be acknowledged that the individual does not exist within a vacuum. Culture

and society play an important part in shaping our interior landscape of belief, conviction, and attitude,

and any attempt to understand the healing process without taking into account these factors would be

incomplete. This next section will examine how the various forms of community and collective

meaning influence placebo phenomena.

Cultural Views on Healing: Collective-Interior

The most obvious collaboration in the context of medicine is that between the doctor and the

patient. The quality of the relationship that doctors form with patients has long been acknowledged as
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having therapeutic implications (Benson & Epstein, 1975; Dixon, Sweeny, & Gray, 1999; Houston,

1938). Good bedside manner is an attribute appreciated even in the common wisdom of popular

culture; in the 1911 play, “The Doctor's Dilemma,” George Bernard Shaw describes the character Dr.

Bonnington as “cheering, reassuring, healing by the mere incompatibility of disease or anxiety with his

welcome presence. Even broken bones, it is said, have been known to unite at the sound of his voice”

(1911, Act I).

From this perspective, many of the examples of placebo at work in the previous section,

ascribed to the strength of the individual's interior convictions, could just as easily be seen as having

originated from the shared relationships, exchanges, and meanings present in the medical environment.

Thomas (1987) showed that just by giving a firm, confident diagnosis, clinicians' positive interaction

with patients highly increased the likelihood of speedy recovery. Gryll and Katahn (1978) showed that

doctor-patient communication – specifically the implied meaning behind a doctor's choice of words,

and the confidence they impart to a patient – has a significant effect on placebo treatments. Patients

were given sugar pills before a dental injection, but doctors described the effects of the supposed

treatment differently, either expressing great enthusiasm for the efficacy of the treatment (“I've found

[this pill] to be very effective”), or low expectations (“I personally have not found [this pill] to be very

effective”) (p. 256). Patients who were given the enthusiastic explanation not only experienced less

actual pain, but reduced fear and anxiety related to the dental procedure as well. Gryll and Katahn

conclude, “These data argue rather strongly for paying close attention to what information patients are

given about the effects of drugs....either a warm dentist or a warm dental technician can potentiate

positive placebo effects” (p. 259).

Beyond the immediate context of doctor-patient relationship, the wider cultural imprintings of

meaning, symbolism, and value, all have been shown to play a significant part in determining the

strength of placebos. Many studies have been done, for example, on the importance of pill color. Pink,
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red, and orange pills have been shown to work best as stimulants; blue and purple pills work better as

sedatives and antidepressants (Blackwell, Bloomfield, & Buncher, 1972; de Craen, de Vries, Kleijnen,

1996; Schapira, McClelland, Griffiths, & Newell, 1970). The only known exception to the blue pill

rule is found among Italian men; Benedetti hypothesizes that this is because the Italian national soccer

team, a source of great pride and passion for many Italian men, is blue (Abumrad & Krulwich, 2007).

(Italian women responded much the same as the rest of the world.) The cultural and emotional

relationships people have to color are clearly strong enough to determine even the effectiveness of

pharmaceutical drugs.

The vehicle and route of administration makes a difference as well, based on cultural notions of

effectiveness. Hussain and Ahad (1970) noticed that sedatives in capsule form worked better than the

same dosage in pill form – in a time when capsules were a relatively new product and seen as an

advancement in technology. Placebo injections have been shown to work better than placebo pills for

blood pressure, headaches, and post-operative pain. (de Craen, Tijssen, de Gans, & Kleijnen, 2000;

Gracely, Dubner, & McGrath, 1979; Grenfell, Briggs, & Holland, 1961) Branthwaite and Cooper

(1981) even demonstrated that flashy, impressive packaging improves the power of placebos (as well as

actual medicine). Our cultural preferences for flash, color, and high technology have been shown to

modify the effectiveness of what was once thought to be straightforward pharmacology.

Our perceptions of quantity, in addition to quality, also affect our experiences with placebo

medication. In the perspective of mainstream medicine, greater quantity of medicine almost always

means stronger effects. 100mg of medicine versus 50mg of medicine is expected to have a stronger

effect. Oddly enough, this holds for placebo treatments as well. Moerman (1983) and de Craen,

Kaptchuk, Tijssen, and Kleijnen (1999) both showed that subjects who received twice the quantity of

placebo medication (four pills instead of two) reported stronger healing reactions. Despite the seeming

obviousness of this relationship, between quantity and strength, it still must be recognized that this is
Running Head: INTEGRAL PLACEBOS 19

also an artifact of our cultural assumptions about medicine. By way of contrast, the alternative medical

paradigm of homeopathy considers smaller quantities of medicine to be more potent. I think it would

be interesting to see if someone who believed in homeopathy would have an opposite experience in a

similar experiment to Moreman and de Craen et al.

Alongside these myriad curiosities, the wider convictions held by our collective belief system

about science and its ability to name and understand our world can have an impact on placebo and

healing as well. Brody (1999) remarks, “It is typical of the Western post-Enlightenment culture at a

certain time in history to believe that science can exercise power over the natural world and that it does

so in part by naming and categorizing natural phenomena” (p. 82). This acknowledgment, of our

reliance on the scientist's hold over nature, is not dissimilar to Harrington's (2009) description of the

pre-Enlightenment role of religion in exorcism: “The role of the priest was precisely delineated...he

must function as a sort of spiritual physician-cum-surgeon, first confirming the presence of the

demonic, then using his spiritual authority to expunge it” (p. 37).

Indeed, the power of physicians to heal, simply by virtue of their medical authority, is alive and

well in the minds of many people today. Take, for example, the recent study done on sufferers of

irritable bowel syndrome at Massachusetts General Hospital (Kaptchuk et al., 2008). There were three

arms of the trial: the control group, which consisted of patients under observation, but who were not

receiving any special care or treatment; a placebo treatment group, which received sham acupuncture

twice per week; and a placebo-plus-care group. Members of the third group followed the same sham

acupuncture regimen, but also received a full 45-minute consultation with their doctor, who encouraged

them to share what they felt their disease meant, and what sort of story they had to tell about it. After

three weeks, 44% of subjects who were given placebo treatment only showed marked signs of

improvement, compared to 35% of observation-only patients, supporting basic assumptions about


Running Head: INTEGRAL PLACEBOS 20

placebo efficacy.4 Subjects in the placebo-plus-care group, however, showed an overall improvement

rate of 62%, a result that ranks as “comparable with the responder rate in clinical trials of drugs

currently used in the treatment of irritable bowel syndrome” (p.6). This indication, that quality time

spent between doctor and patient can, in some cases, successfully treat disease as well as an established

course of medication, seems laden with significance in a healthcare system where doctors are pressured

to limit face-to-face interactions with patients to seven minutes or less (Salgo, 2006).

Clearly, then, the cultural background which frames our encounters with medicine is another

distinctly powerful element at play here. In a sense, the placebo effect has spawned a greater

understanding of not only the mind's own hidden powers of healing, but also insight into the way that

medicine itself, once thought of as a model for objective, irrefutable scientific process, is in fact highly

susceptible to culturally-dependent values and meaning. This is not to say, of course, that the value of

medicine is completely determined by subjective impressions – even in the case of placebo treatments,

studies have demonstrated a clear neuro-physiological basis for this remarkable mechanism. The next

section will address how placebo effects happen in the quadrant of the individual-exterior – the human

body.

No Brain, No Pain: Individual-Exterior Neurological Correlates

Just as personal and cultural history is responsible for the belief or mental attitude of the

placebo responder, there are also corresponding effects that occur in the physical body that serve as

testament to the power of individual belief and expectation. This information is relatively new, and still

forthcoming; up until the late 1970s, the prevailing view was that the placebo effect (if it existed at all)

took place largely in the subjective sphere, and that the physiology of the individual remained

unaffected, even if one's conviction in the power of a treatment made it seem to work. Today, we know

4The often-observed improvement that occurs in a small percentage of trial participants simply by virtue of their subjective
impressions related to being part of a trial is known as the Hawthorne Effect, and is another variable that is considered in the
effect vs. response debate in placebo studies (Parsons, 1974).
Running Head: INTEGRAL PLACEBOS 21

that this is not entirely accurate – it has been well-established that thought both expresses and

determines neurological activity. Science journalist Jonah Lehrer writes, “There is nothing inherently

mysterious about a psychological thought impacting the activity of neurons. That's what thoughts do”

(2008, Para. 3). Particularly in the fields of immunology and pain research, scientists have

demonstrated numerous times that there are undeniably placebo effects happening in the body as well

as the mind. From what we know today, there are two primary ways we can consider the placebo effect

at work in the physical body (the individual-exterior quadrant): first, as an effect born of behavioral

conditioning, and second, as a stimulating agent of neuro-chemical systems.

Ader and Cohen's (1975) experiment with rats and immunosuppresants was the first to show

that physiological placebo (or, in this case, nocebo) responses could be elicited through conditioning.

By giving rats sugar water laced with cyclophosphamide, Ader conditioned their bodies' immune

systems to be negatively affected upon the biological stimulus of the ingestion of sugar water. Even

after the chemical itself was removed from the water, rats with prior conditioning continued to have

weaker immune systems than others newly introduced to the sugar water. This proved to be a twist on

classic conditioning studies, as no overt psychological mechanisms were used in the conditioning

process, rather the rats' bodies themselves became conditioned without any conscious efforts on the

parts of the rats themselves. Numerous studies since then have verified this conditioning potential in

both animals and humans (Amanzio & Benedetti, 1999; Buske-Kirschbaum et al., 1992; Goebel et al.,

2002).

In one particularly representative case of placebo conditioning, Benedetti exposed human

volunteers to painful electric shocks (kellyneill, 2009). He then administered an inert saline injection,

but told subjects it was a powerful painkiller. On the next round of shocks, the current was reduced by

60% (check stat) without subjects' knowledge. Subjects accordingly registered lower pain responses,

all the while believing that this was because the painkiller was working, and not because the strength of
Running Head: INTEGRAL PLACEBOS 22

the shock had been lowered. On the next round, the electrical current was turned back up to its original

power, and yet subjects continued to report lower levels of pain. Benedetti used this experiment to

show that placebo effects can be strongly augmented by behavioral conditioning.

In addition to the conditioned response evident in some placebo mechanisms, the mind's

subjective experience of healing runs side-by-side with a network of neuro-physiological processes.

Levine et al. (1978) demonstrated that pain relief from placebos could be disrupted by administering

naloxone, an opiod5 antagonist. This finding was the first to strongly suggest a neurological

mechanism at work – if placebo relief could be blocked by a neurochemical substance, then placebo

effects must at least in part be taking place in the brain. Although the initial experiment design had

several possible weaknesses, it has since been replicated with better controls in place, with the same

results (Benedetti, 1996; Grevert et al., 1983; Levine & Gordon, 1984).

Further research has turned up extensive evidence for placebo effects as acting along opiod-

receptive neural pathways (Amanzio & Benedetti, 1999; Petrovic, Kalso, Petersson, & Ingvar, 2002),

as well as a variety of non-opiod networks (Benedetti, 1996; (Fabrizio Benedetti et al., 1995); Brody,

1999; de la Fuente-Fernandez, 2001). These data indicate that placebo effects work along a diverse

array of neurological and physiological pathways, even beyond the confines of the brain and into the

vast neurological network of the body entire. Moyers (as cited in Brody, 1999) acknowledged this in

concluding that “the mind is part of a communication network throughout the brain and body” (p. 85).

Brody's (1999) comments regarding the ubiquity of peptide receptors6 further elucidate this point:

If identical peptide molecules are found to be active in the brain, the intestine, and the immune

system, and cells in all three tissues have receptors for the same peptide, then it seems quite

arbitrary to insist that a process goes on in the brain which is qualitatively different from

processes which occur elsewhere in the body. (p. 85)


5 Opiods are a class of pain-blocking neurotransmitters.
6 A neural network responsible for regulating immune function
Running Head: INTEGRAL PLACEBOS 23

It has been further speculated that by mapping these specific pathways, it may be possible to

glean some insight via neurophysiology into the major psychological mechanisms responsible for

placebo efficacy in the subjective realm. Brody (1999) notes that peptide receptors are clustered most

heavily in the parts of the brain linked to generating emotion, and are least present in the cerebral

cortex (the center primarily associated with cognition), suggesting that “the placebo response is

principally linked to the patient's emotional reaction to a healing encounter and that it effectively

bypasses the patient's cognitive processes” (p. 86). Wager et al. (2004) and Lehrer (2008), on the other

hand, have observed placebo effects which seem to diminish activity in the emotional areas of the

brain, and increase it in cognitive areas. This issue remains a source of dispute, and one in which

further research is clearly needed.

Most recently, focus on placebo neurophysiology has shifted to phenomena observed in the

spinal cord. Matre (2006) and Goffaux, Redmond, Rainville, and Marchand (2007) both presented

evidence suggestive of spinal pain processing modulation during placebo analgesic effects. Eippert,

Finsterbusch, Bingel, and Buchel (2009) recently demonstrated via fMRI conclusive data showing that

placebo effects, at least in the realm of analgesia, occur first in the spinal cord's processing of pain

signals on their way to the brain.

These data suggest a robust and highly inclusive framework for placebo activity in neurological

corridors. Over the past 30 years, research has demonstrated that a) subjective belief that a placebo

remedy is effective stimulates clear neurological effects, b) these effects are not limited to a single

response network (ie. pain relief, immune function, or mood regulation), and c) placebo activity is seen

not only in the brain, but extensive to the entire central nervous system (both brain and spinal cord). In

addition, certain researchers have made initial forays into the possibility that physiological data on

placebos may, in time, be able to actually inform us regarding the way placebos work in the subjective,

psychological domain, and not simply the other way around. (Brody, 1999; Wager et al., 2004) The
Running Head: INTEGRAL PLACEBOS 24

physical realm of the individual-interior quadrant has contributed valuable information to our overall

understanding of the mind-body relationship. The final piece to consider in this four-quadrant analysis

is related to the physical realm on a macroscopic level – the collective-exterior. This next section

examines how the material components of societal systems – namely, technological and economic

conditions – can influence our understanding of the placebo effect.

Modern Medicine's Ever-Growing Toolshed: Placebos In The Collective-Exterior

The collective-exterior quadrant deals exclusively with a society's exterior makeup, including

technological, economic, political, and institutional means. The growth of modern medicine has been

largely dependent on advances in this quadrant. A hospital can treat more patients with a wider range

of illness than a local physician, or an apothecary, ever could have. Ambulances and helicopters can

transport sick individuals to medical care with greater haste, and the laws of air and ground traffic

make special allowances for them to do so. Specific to our story, the many advances and discoveries

made in the neuro-physiological arena of placebo research have been entirely dependent on the level of

development of the systems in this quadrant. We can only know as much as we have the ability to

observe. In addition, the behavioral framework under which scientists conduct their experimentation

also plays a factor in determining the degree of accuracy and clarity of testing results. In this section

we will examine how the development and refinement of experimental methodology has affected our

understanding of placebo, as well as how brain imaging technology has improved our ability to

observe, on a minute level, the ways in which placebos transform the physical body.

Randomized Blindness

Twentieth-century medicine witnessed the emergence of a novel application of placebo, in the

development and standardization of the double-blind clinical trial (Harrington, 2009; Shapiro &

Shapiro, 1999). For a trial to qualify as double-blind, neither the subject nor the administering

physician can have foreknowledge of whether the treatment being given is a placebo or an active
Running Head: INTEGRAL PLACEBOS 25

treatment. The double-blind method ensures both that testers will not be able to betray their knowledge

of the treatment contents (which, in doing so, could potentially influence the subject's perception), and

that patients are not primed to have a certain quality of experience. Results, therefore, are far more

reliable than single-blinded or un-blinded experiments.7

Researchers also narrow down the range of possible explanations for trial outcomes by

randomizing, as best as possible, the demographic and medical backgrounds of trial participants. For

example, let's say a trial for hypertension medication is conducted with the only requirement being that

trial participants have high blood pressure. The trial results seem to indicate that the drug was effective

in lowering blood pressure, but then it is noticed that, for whatever reason, all the trial participants just

happened to be under 45 years of age, and a large number of them were Asian. This means that all we

can really say about the drug is that it seems to work for an under-45 population, and quite possibly the

results may be significant only for people of Asian ethnicity. Both the selection process as well as the

treatment administration should be randomized to eliminate as much potential bias as possible. A

properly randomized selection process is the best way to ensure that a representative sampling across as

many factors as possible will be present during the trial. Randomization procedures combined with

double-blind testing have been combined in the randomized clinical trial (RCT), commonly considered

the gold standard for medical research today. As placebo effects are observable in all but the most

dramatic forms of illness or injury (cancer and broken bones, for example), they have taken a place of

primary importance in RCTs as the benchmarks against which new treatments are tested.

Observational Technology

The available technology of a given era quite literally determines how well any medical

phenomenon can be understood, as observation is limited by the quality of tools of measurement. In

the early years of placebo research, researchers' ability to see into the inner workings of the brain was
7 See Gracely, Dubner, Deeter, and Wolskee (1985) for an example of revealed bias when trials only include subject
single-blinding.
Running Head: INTEGRAL PLACEBOS 26

extremely limited, as digital imaging techniques were still decades away from being invented. As a

result, the placebo effect was thought to be primarily a subjective phenomenon, limited entirely to the

subject's perception, and divorced from the actual physiological goings-on of the body. (Beecher, 1955)

Later, the emergence of physiological and neurological imaging techniques such as positron emission

tomography (PET) and functional magnetic resonance imaging (fMRI) led to a greater understanding

of exactly what a placebo effect looked like, as now scientists could see its effects both in the body as

well as observe its impact on the psychology of their subjects (Kong et al., 2006; Lieberman et al.,

2004; Petrovic et al., 2002; Wager et al., 2004).8 While Benedetti (2009) acknowledges that “modern

brain imaging techniques have been fundamental in the understanding of placebo analgesia” (p. 80),

still for the most part, the importance of this quadrant is often overlooked, even taken for granted, when

assessing the varied factors at play in our understanding of the placebo effect, and of medicine as a

whole. Indeed, the social framework and technology base under which we operate is of foundational

importance to our clear perception of mind-body interactions and their medical implications.

Although each of the four quadrants is able to inform us in their own unique capacity, I would

contend that only in examining the placebo phenomenon from an all-quadrant view can we most fully

comprehend its significance to the fields of medicine and health. Particularly from the arena of placebo

research, a growing number of physicians and researchers are calling for a more inclusive model of

medical treatment. Based on the results and implications of placebo research as outlined in this

chapter, in the following chapter I will argue for the necessity of transitioning towards a truly integrated

medical model.

8 In layman's terms, PET scans work by injecting a short-lived radioactive substance into the bloodstream, which
eventually gets to the brain. The scanner picks up on the glow given off from the radioactive decay, and makes a picture
with it. FMRI, on the other hand, measures the change of blood flow to different areas of the brain and spinal cord.
Where there's blood flow, there's increased neural activity, so an image of these changes gives a fair idea of what's
happening in the brain at a given moment.
Running Head: INTEGRAL PLACEBOS 27

Part Three: An Integral Placebo

Integral theory insists that it is not just a good idea to look at a thing from its four fundamental

perspectives, but rather it is imperative that we do so. One simply cannot claim to speak authoritatively

on a subject without a good sense for the reality – the story – of each of its four quadrants. Wilber

(2000) writes, “In our quest for an integral holism...we want to honor all four quadrants, and not

merely privilege one of them in a reductionism blatant or subtle” (p. 72). This truth is clearly reflected

here in the placebo literature – the findings of neurological activity in the brain and spinal cord are

meaningless without knowing about the subjective perceptions that trigger these neural pathways.

Looking at placebo from a purely subjective individual standpoint doesn't really take into account the

way that cultural background can shape our understandings and conceptions, which in turn make us

more or less susceptible to placebo effects under certain circumstances. The degree to which our

collective technology base has grown over time is intimately linked with our ability to see the placebo

for what it is when experimenting in the individual quadrants. And so on and on it goes – the

livelihood of placebo research in any one quadrant is dependent on all the others, and to do anything

but acknowledge this fully is just asking for trouble.

This is an important truth that applies far beyond the field of placebo research. After all, what

do we know about how well medicine works, other than from comparisons to placebo effects? In the

United States, the current standard set by the Food and Drug Administration (FDA) is that any new

drug must have performed better than placebo in two separate authenticated clinical trials in order to be

considered for distribution to the public (Silberman, 2009). But seeing placebo effects through the lens

of the four quadrants, it becomes obvious that there isn't just one effect at play, but many.

Pharmaceutical companies, in order to come up with viable products, are essentially competing against

the healing power of everything involved in the process besides actual pharmacological substances,

from the personalities of the individuals involved in clinical trials, to the cultural biases implicit in
Running Head: INTEGRAL PLACEBOS 28

participants' expectations, to the degree to which available technology can distinguish between real and

artificial results.

Two important results come out of the way that this system currently operates. First, the more

that is known about the placebo effect, the more the exact importance and effectiveness (or, in some

cases, ineffectiveness) of active medical treatments can be measured and understood. At the same time,

the more we find out about what makes a placebo powerful, the more we find out about a core set of

phenomena that are present to some degree in every treatment of every medical patient. The exact

degree to which placebo effects are present in drug treatments varies considerably, but some studies are

starting to indicate that the percentage is much higher than anyone had previously thought. All of

which is to say that as physicians become more knowledgeable about placebos, they become better,

more honest, and more efficient healers. In this section, I will lay out an argument for why it is

important, even vital, for the future of medicine, to adopt an integral, all-quadrant, placebo-inclusive

approach.

If You Can't Beat 'Em, Join 'Em

The placebo effect has basically taken on the position of an adversary to medical researchers

and pharmaceutical companies. This attitude, however, is based on old, outdated thinking which

assumed that placebos were acting purely at a subjective level, and that they could not be responsible

for any genuine physiological effects in the body. As reviewed in Part Two, there is now extensive

evidence for the fact that some aspects of the placebo effect are real, that they stimulate definite

neurological activity and can generate observable shifts in the physical body.

Perhaps more significant is recent evidence that suggests some aspects of placebo effects,

specifically related to the degree of caring present in the physician's attitude towards the patient, are as

important and successful for treating some disease as even the best pharmaceutical solutions. Recall

Kaptchuk et al. (2008), which strongly suggested that bedside manner, an interpersonal placebo of
Running Head: INTEGRAL PLACEBOS 29

sorts, is in itself a powerful healing treatment. Compared to Sherman and Hickner's (2007) findings

that only 51% of doctors surveyed believed that the doctor-patient relationship is of psychological and

physiological help to the patient, this disparity suggests an enormous potential healing resource in

methods and treatments which are currently relegated by the medical community to the taboo category

of “mere placebo”.

Furthermore, new evidence has emerged in recent years that indicates that, in several high-

profile situations, these supposedly “mere” placebo effects have been mistaken (or purposely

mislabeled) as effects of active medication. Specifically, Kirsch and Sapirstein (1998) determined that

popular antidepressants actually had never performed much better than placebo in clinical trials, yet

were made available on the market anyway due to a convenient mixture of technicalities and half

truths. Kirsch and Saperstein used the US Freedom of Information Act to request all of the clinical

trials that pharmaceutical companies had submitted to the FDA for the six most widely-used

antidepressants from 1987 to 1999. The resulting meta-analysis revealed a mean drug-placebo

improvement difference far below clinical significance (1.8 points versus the required 3.0 points to

qualify as clinically significant on the Hamilton Rating Scale of Depression). Said in another way,

none of the antidepressants on the market during this period had demonstrated improvements at a level

which would be considered meaningful in a real-world setting, but were allowed to go out for public

consumption due to their statistical (not clinical) victory over placebo treatment. In another article,

Kirsch (2005) noted that antidepressant drug responses only were able to attribute about 25% of their

effectiveness to the actual drug under trial, with nearly 50% of the response being related to some

aspect of the placebo effect.

Data like these cast a curious light on the role of regulatory bodies in medicine, such as the FDA

– why would these organizations allow a drug to be purported as useful or effective if the actual

evidence failed to support such a claim? In fact, internal memos from the FDA show that this is a
Running Head: INTEGRAL PLACEBOS 30

matter of some debate, even within the organization, as is evidenced by this 1998 communication from

Paul Leber, then director of the FDA Division of Neuropharmacological Drug Products, regarding

citaprolam, a major antidepressant.

I believe it is useful for the prescriber, patient, and 3rd-party payer to know...that citaprolam's

antidepressant effects were not detected in every controlled clinical trial intended to

demonstrate those effects. I am aware that clinical studies often fail to document the efficacy of

effective drugs, but I doubt that the public, or even the majority of the medical community, is

aware of this fact....The Office Director is inclined toward the view that the provision of such

information is of no practical value to either the patient or prescriber. I disagree... (Leber, 1998)

However commendable the perspective laid out in this memo, the FDA practice of protecting

questionable drugs continues. When the Washington Post ran a 2004 story on the apparent lack of

evidence for antidepressant drugs being effective for children, it reported the following:

The Food and Drug Administration has repeatedly urged antidepressant manufacturers not to

disclose to physicians and the public that some clinical trials of the medications in children

found the drugs were no better than sugar pills, according to documents and testimony released

at a congressional hearing yesterday.

Regulators suppressed the negative information on the grounds that it might scare

families and physicians away from the drugs, according to testimony by drug company

executives. (Vedantam)

This effort to maintain the public's belief in medicine, despite failed trial results, implies that the

FDA understood that the belief itself was more important than whether or not the drugs actually

worked. This is tantamount to acknowledging that it is the power of belief – or, said another way, the

power of placebo – more than the power of any single medicine, that is at the heart of the medical

system.
Running Head: INTEGRAL PLACEBOS 31

University of Michigan-Dearborn anthropologist Daniel Moerman echoed these sentiments in a

2000 New York Times article, saying:

If you can create a more effective healing practice based on the manipulation of meaning, then

you're going to heal more people. Is it some sort of failure if it isn't due to a pill? The

important thing is you've made somebody better. (Talbot, 2000)

With the stark irony of the FDA's position in mind, along with substantial evidence showing

that not only are placebos important and useful, but that doctors believe in them and use them in their

clinical practice, it seems to be an eminently reasonable suggestion that placebos be embraced, rather

than combated, in our official approach to medicine.

Integral Placebo, Integral Medicine

In order to effectively integrate the power of the placebo into modern medicine, first the concept

of the placebo effect must be considered from an Integral, all-quadrant standpoint. Placebos, as we

have seen, are far more than simple variations on Jefferson's “bread pills [and] drops of colored water”

(Evans, 2004, p. 3) Rather, the placebo effect stretches to include elements of personal conviction,

belief systems, and personality (the placebos of the individual-interior), as well as the ways culture and

society shape and support those systems (the effect of the collective-interior). The actual pill given to

the patient, be it active or inert, is in large part simply a condensed symbol of meaning related to the

much bigger quadrants of the subjective interior from which it gains its authority. The physician, too,

becomes a representative of the intersection of the quadrants of medicine and healing, one who has

some understanding and ability to manipulate the truth of each individual domain. Unpacking the

placebo in this way reveals that a fully integrated understanding of placebo effects leads to an integral

approach to medicine as a whole.

There are some signs that seem to indicate physicians are already looking for more holistic

ways to approach their trade, ways that include the fullness of the four quadrants' perspectives.
Running Head: INTEGRAL PLACEBOS 32

Thomas' (1987) clinical research showed a demonstrable, significant improvement in patients who had

positive, caring physicians. Kaptchuk and Jacobson (personal communication, December 10, 2009) are

currently making an anthropological assessment of their 2008 work with IBS patients, to look for fresh

insights on their already-strong data regarding the importance of doctor-patient relationships. Brody

(1999) focused on the importance of qualitative and ethnographic research methods to understand

disease. In Sherman and Hickner (2007), 74% of Chicago physicians interviewed said they felt that

emotional health was an important factor in not only psychological health but physiological health as

well; 65% also felt social support systems were of psychological and physiological help to patients

recovering from illness. That medical physicians are stressing a need for social support groups,

emotional health, cultural understanding of disease and illness, and a caring bedside manner, seems

significant in a culture which has become conditioned to expect that a cure for everything exists in the

form of a pill or a surgical procedure.

The Integral approach, however, would stress that it is equally as important to address the

objective sphere of medicine as well. No real success can be gained by a reversal of trends, to go from

the starkly objective landscape of physical medicine, over completely to the warm and caring world of

the emotional interior of doctor-patient relationships. Both objective and subjective must be considered

equally and appropriately in an integral model. The 2000 New York Times article, “The Placebo

Prescription,” articulates the proposed role of placebos in bridging this divide, wondering,

What if they started thinking of placebos as a way of bridging the gap between the magnificent

but sometimes cold efficiency of modern American medicine and the unproven but evidently

comforting remedies prescribed by homeopaths and herbalists?” (Talbot, para. 14)

To accept the placebo effect openly as a viable part of medical treatment is to make the first

steps in establishing a truly integral medicine, one that goes beyond the borders of objective-exterior

priority which assumes medicine starts and ends within the perimeter of the physical body. In Part
Running Head: INTEGRAL PLACEBOS 33

Five, we will look at some of the current discussion surrounding just how this might eventually happen.

First, though, I would be remiss in this presentation if I were to ignore the storytellers on the other side,

so to speak – the objections of those who remain skeptical about the usefulness, and even the very

existence, of the placebo effect. Part Four gives voice to these objections, as well as to my own

opinion about the validity of their claims.

Part Four: The Case Against Placebos

Despite the overwhelming evidence now available to medical science, which points to the tenable

reality of placebo effects, there continues to be a small but persuasive minority which considers the

placebo effect to be grossly overstated in its importance, or, even not to exist at all. This section will

briefly outline the arguments against the placebo effect, as well as the evidence their proponents use to

support their claims.

One such argument stems from the valid assertion that the placebo effect isn't really an effect at

all, but many phenomena rolled into one. Many of these phenomena can be understood or explained by

other known issues – regression to the mean, reporting bias, outside factors at play, etc. (Benedetti,

2009). Other effects observed after placebo treatment, such as feelings of relief, are subjective and

cannot really be determined in a specific cause-effect relationship (palMD, 2009). After all these things

have been accounted for, placebo skeptics say at the very least it is important to acknowledge that any

actual placebo responses would constitute a small percentage of the overall pool of phenomena

currently referred to as the placebo effect (Goldacre, 2008).

Some even go so far as to say that placebo effects don't exist at all. Hrobjartsson and Gotzsche

(2001) conducted a meta-analysis of 114 clinical trials and found overall that results from groups which

received placebos were not significantly greater than those from no-treatment groups, with small

exceptions made for some subjective measures, such as pain relief. While this report served as a
Running Head: INTEGRAL PLACEBOS 34

rallying call for many placebo skeptics, significant criticisms were later leveled at its findings,

including the fact that overall findings combined results from trials for both objective and subjective

illnesses. Placebos tend not to work reliably on difficult physical conditions such as cancer or anemia,

so by including studies which focused on these illnesses in a meta-analysis along with more placebo-

prone ailments like asthma, skin rashes, and depression, it has been suggested that the authors' findings

should more properly be characterized as having demonstrated that placebos do work, but primarily for

illnesses with a significant subjective component (Guterl, 2001).

Nunn (2009) argued instead against the existence of a placebo effect, on grounds of the many

failed attempts to define exactly what a placebo is. If, Nunn questions, placebo are inert substances,

then how can they have active effects? If they are treatments with non-specific effects, then how can

you observe the effects – wouldn't that then make the effects observed specific? The set of paradoxes

proposed by placebo definitions prompted Nunn to question its actual existence: “Nobody who came

and saw the placebo has conquered its definition....If something cannot be defined and does not make

sense no matter how it is viewed, it’s time to ask if it’s really there at all” (Nunn, p. 1015).

I personally have not been convinced by those who claim the placebo effect doesn't exist.

Hrobjartsson and Gotzsche's (2001) study seems to actually indicate the reality of placebo effects when

the data are carefully examined. I do agree that it is useful to be clear in differentiating known factors

which complicate trial findings (regression to the mean, reporting bias, etc.) from actual placebo

responses (if in fact they do exist), and to this end I think that to lump all apparent but non-specific

healing phenomena under a single category is somewhat misleading. This, however, is not to say that

in the final analysis, all of the healing effects observed over the course of a recovery period will be

explained away by concrete phenomena. I do think it is possible that an actual, yet-unidentified healing

mechanism does exist which relies heavily on the patient's subjective (conscious and subconscious)

relationship to the healer, the healing environment, and the treatment itself, and that some day we will
Running Head: INTEGRAL PLACEBOS 35

better understand how to employ this mechanism.

This will only be determined as our technological capacity to observe and analyze healing

processes continues to grow, much as our understanding of placebos now far surpasses the meager

knowledge available at the onset of their inclusion into standard medical practice, earlier in the 20th

century. For now, I think it's enough to acknowledge that there is a set of powerful, still poorly-

understood healing effects that can be induced through certain means, including simulated treatments,

strong doctor-patient relationships, and cultural attitudes towards medicine, and that this should be

applied to our best advantage.

Part Five: Prescriptions for the Future

In this next section I will look at the future potential of the placebo in its own right: how can the

power of the placebo be effectively harnessed by modern medicine, not simply, as one journalist put it,

“statistical noise competing with the active drug” (Silberman, 2009, para. 54), but as an effective and

openly-acknowledged treatment in its own right. In order to answer this question, we first need to look

at the major issues facing placebo research today.

The More and More Powerful Placebo

Steve Silberman's article in the September 2009 issue of WIRED magazine, titled “Placebos Are

Getting More Effective, Drug Makers Are Desparate To Know Why”, addresses the increasing body of

research literature which suggests that the placebo effect is somehow getting stronger. Admittedly, it is

somewhat misleading to claim that placebo effects are actually growing; Bell's (2009) response to

Silberman notes that this statement is really “another way of saying that the difference between placebo

and the drug is getting smaller” (para. 9). That distinction having been made, the exact reasons for this

seeming increase are still unclear, although several theories exist why this may be happening.

The first and most obvious reason, writes Silberman (2009) is that drug companies have done
Running Head: INTEGRAL PLACEBOS 36

such an effective job at marketing their products, that consumer confidence translates into a higher

expectation among clinical trial participants that their treatment will be effective. The second possible

cause for higher placebo rates relates to the greater lengths which pharmaceutical companies need to go

in order to find trial participants who are “therapeutic virgins” – individuals who are not already taking

some form of medication (Silberman, 2009, para. 45). This search has led companies farther and

farther abroad, as more and more individuals in First World countries turn to medication as a long-term

solution for physical and psychological ailments. Doctors in remote regions who are paid to fill trial

rosters may end up including patients with milder symptoms (who would thus be more likely to

respond to placebos) than would normally be acceptable. And individuals in poorer regions with little

or no access to healthcare not only might have stronger hopes for improvement upon going into clinical

trials, but in addition the standard of healthcare in clinical trials is often far superior to that found in any

normal medical facility in impoverished areas; the high quality of in-trial care alone could explain a

certain degree of improvement noted in placebo arms of trials.

Bell (2009) and Silberman (2009) both stressed that a major, although unverified, reason for the

seeming increase in placebo effects may be the continual improvement of study design and quality

control. Silberman pointed out ratings from clinical trial observers using standardized tests actually

varied significantly between different testing sites. This, wrote Silberman, “was like finding out that

the judges in a tight race each had a different idea about the placement of the finish line” (2009, para.

22). Bell cites Schulz, Chalmers, Hayes and Altman (1995), who demonstrated that studies of higher

methodological design significantly reduced errors and biases in estimates of treatment effects. Bell

writes, “So one reason why the placebo effect might be increasing is that studies are just more rigorous

these days” (2009, para. 12). Although speculative, this simple explanation for the placebo effect's

seeming growth also seems to me to be worthy of consideration.

Whatever the actual reasons may be, drug makers of late have been beset with increasing
Running Head: INTEGRAL PLACEBOS 37

tendencies for both new and previously approved drugs to fail against placebo in clinical trials. Major

pharmaceutical companies, including Merck, Pfizer, and Eli Lily, have canceled trial research for new

drugs meant to treat a wide range of illnesses, including schizophrenia, Parkinson's disease, depression,

rheumatoid arthritis, and Crohn's disease, after they failed to outperform placebos (Myers, 2009;

Silberman, 2009). Even tried and true brands such as the antidepressant Prozac are now consistently

failing to beat placebos. Silberman (2009) writes, “Some products that have been on the market for

decades, like Prozac, are faltering in more recent follow-up tests....If these same drugs were vetted now,

the FDA might not approve some of them” (para. 8). From a four-quadrant standpoint, it would seem

that these curious and sometimes confusing data are problematic principally because of a lack of

attendance to the collective-exterior – the behavioral patterns and technological capabilities of the

medical discipline which determine in a very real way the degree to which any particular phenomenon

can be studied.

You Say Pla-SEE-Bo, I Say Pla-SAY-Bo

In addition to overall trends showing a rise in placebo effects across the board, new research

indicates that placebo rates differ based on the geographic region in which trials are conducted.

Arthritis patients in South America have been shown to have significantly higher placebo response

rates than in Eastern Europe, for example (Myers, 2009). Moerman (2000) found considerable cultural

variation in placebo efficacy rates, noting that placebos for ulcer disease in Brazil were less than 20%

as effective as the world average (7% vs. 36%), while rates in Germany were twice as high as the rest

of the world. Among hypertension studies, however, placebo recipients in Germany showed the least

improvement out of the entire international trial pool, and only “middling” results for anxiety

treatments (Moerman, 2000, p. 63). Although Moerman suspects these differences are due to cultural

attitudes towards different diseases, no concrete evidence has been found to support this hypothesis.

(Although as discussed in Part Two, extensive evidence exists to show that cultural influence in general
Running Head: INTEGRAL PLACEBOS 38

plays a powerful role in determining placebo responses to medicine.)

These data are poignant reminders of the importance of the collective-interior, a world of

cultures within cultures, where even one's allegiance to a sports team can effect the outcome of medical

treatment. The extent to which these factors play an influential role in placebo studies is still rather

poorly understood, and strongly calls for further research in the area of psychosocial influences on

medical treatment. Keeping in mind these unanswered questions about the nature of placebo effects, I

will now turn to the main issue concerning the future of placebos as medical resources: Knowing how

powerful an ally the placebo effect can be to conventional medical treatment, is there a way to employ

placebos as treatments in their own right, in a safe and ethical way? The second half of this section is

devoted toward identifying and understanding the different perspectives which are vocal in the ongoing

debate surrounding this question.

The Search For An Ethical Placebo

The success of placebos seems to rely on the patient believing that they are effective remedies.

This raises an important ethical issue in the ongoing debate over whether it is possible to use placebos

in clinical practice in a meaningful way; while most medical professionals acknowledge the reality of

the placebo effect, many have also expressed discomfort with the idea of deliberately deceiving

patients, even if there may be a fair chance that a placebo treatment will help. Nordenberg (2000)

quotes Dr. Michael Kirsch, writing on placebo ethics:

If using placebos therapeutically is ethical and reasonable, shouldn't we encourage judges to

render extralegal activist rulings, winegrowers to bottle `placebo' vintages, curators to display

masterpiece look-alikes misleadingly, and journalists and newscasters to sanitize news?...In

such a world, all of us would be groping for truth in a hall of mirrors. (p. 5)

Much of this concern is grounded in the established standards of medical care that have been

developed by the global medical community over the past century. One modern version of the
Running Head: INTEGRAL PLACEBOS 39

Hippocratic Oath, for example, specifically requires that no treatment be carried out without a patient's

“valid informed consent” (US Army, para. 10), effectively eliminating the possibility of using placebos

covertly. The Helsinki Declaration, a medical code of ethics adopted by the World Medical Assembly

in 1964, affirms that “every patient...should be assured of the best proven diagnostic and therapeutic

method” (Vollman & Winau, 1996, p. 1449), which puts a placebo treatment in the challenging position

of being able to prove that it can be equally or more effective than a given pharmacological or surgical

treatment. This conflict, between the motivation to use whatever treatment may be necessary to effect

healing – including placebos – and the physician's desire to be in complete ethical integrity, on the

other, has led to paradoxical attitudes among doctors. In a 2003 survey of Danish physicians, for

example, 86% of all respondents reported having given patients placebos at least once within the last

year, but only 46% found the clinical use of placebos ethically acceptable (Hrobjartsson & Norup,

2003). The study's authors go on to specify that “of the respondents who found placebo treatments

unethical, 50% reported they still had prescribed them” (p. 160). Other surveys conducted in different

countries, including Israel, Switzerland, and the United States, report similarly contradictory

sentiments, revealing the reality of a medical community in deep conflict with itself over appropriate

placebo usage (Fässler et al., 2009; Nitzan & Lichtenberg, 2004; Sherman & Hickner, 2007).

More specific than the general debate over the use of placebos, another contentious issue arises

regarding the motivation behind a physician's administration of a placebo treatment. The American

Medical Association (2007), while allowing their conditional clinical use9, explicitly forbids issuing

9 The current position of the American Medical Association (AMA) on placebo use in clinical settings is one open but
flexible disclosure. The AMA Code of Ethics states: “Physicians may use placebos for diagnosis or treatment only if the
patient is informed of and agrees to its use” (AMA, 2007, para. 2). Some leeway is provided within this context, however,
as physicians are permitted to conceal the exact details of placebo use. The AMA guidelines continue:
A placebo may still be effective if the patient knows it will be used but cannot identify it and does not
know the precise timing of its use. A physician should enlist the patient’s cooperation by explaining that a better
understanding of the medical condition could be achieved by evaluating the effects of different medications,
including the placebo. The physician need neither identify the placebo nor seek specific consent before its
administration. In this way, the physician respects the patient’s autonomy and fosters a trusting relationship, while
the patient still may benefit from the placebo effect. (AMA, 2007, para. 2)
Running Head: INTEGRAL PLACEBOS 40

placebos “merely to mollify a difficult patient” (para. 3), although this seems to be a prohibition

directed at sham medication, as opposed to other “placebo-like effects” (para. 3) brought about by an

attentive bedside manner, which are, in fact, encouraged. Physicians around the world appear to

interpret placebo-usage guidelines in different ways, in many cases acting in outright defiance of the

spirit of such codes of conduct. For example, Sherman and Hickner's (2007) aforementioned survey of

practicing doctors in the Chicago area reported almost half of all respondents having knowingly given

patients placebo remedies. Only 11% of those who reported placebo use, however, prescribed placebos

“after all clinically indicated treatment possibilities were exhausted”, with another 6% having given

them with the intent “to control pain” (p. 8). The rest of the physicians who gave reasons for their use

of placebos were arguably in violation of AMA standards, including 18% who prescribed placebos “to

calm the patient”, 15% who did so “after ‘unjustified’ demand for medication”, and 6% who simply

wanted “to get the patient to stop complaining” (p. 8). In a similar vein, 63% of Swiss doctors

surveyed provided placebos “to conform with the requests of the patient” (Fassler et al., 2009, p. 5);

43% of Israeli doctors surveyed reported offering placebos to patients “after 'unjustified' demand for

medication”, and 11% did so “to get patient to stop complaining” (Nitzan & Lichtenberg, 2004, p. 945).

Particularly in surveys conducted outside the United States, most physicians actually told their patients

that placebo treatments were real drugs or therapies (Fassler et al., 2009; Nitzan & Lichtenberg, 2004).

These survey data indicate that both official and colloquial views on placebo usage are

extremely varied and difficult to reconcile. In general, however, in the discussion over how to properly

integrate placebos into modern medicine, there are two fundamental approaches to the issue: either

physicians can fully inform patients that they are being administered a placebo remedy, or they can

choose to cover up this truth, using varying degrees of concealment. To many, the concealment option

seems more intuitively in line with the nature of the placebo effect – that the patient must believe the

treatment is real in order for the effect to be activated. The problem with this approach is that such
Running Head: INTEGRAL PLACEBOS 41

deliberate concealment necessarily needs operate clandestinely under an official stance of open and

informed medical practice, as to formally permit the misleading of patients obviously would create a

whole host of legal and ethical concerns. 10

The other possibility for an ethical placebo – the open-label approach – is at once the least-

controversial and most-paradoxical solution. Presenting a placebo treatment as open-label means

making the inactive nature of the remedy explicit to patients or consumers. Little research has been

conducted on open-label placebos thus far, most probably because they present such a counter-intuitive

possibility to researchers. If the placebo effect relies on the subject not knowing a placebo is a placebo,

then were the subject fully informed, by definition a placebo should be rendered useless.

To my knowledge, only two studies have been conducted on open-label placebos, and neither

one provided definitive results. Park and Covi (1965) ran a study on 14 neurotic patients who were

given sugar pills over the course of a week, and who were told that “many people with your kind of

condition have also been helped by what are sometimes called 'sugar pills,' and we feel that a so-called

sugar pill may help you, too” (para. 14). Although its results seemed to show an average significant

improvement across trial participants, in light of its small sample size, and conducted over such a short

period of time, and without being replicated by subsequent independent follow-up, this study amounts

at most to an interesting footnote in placebo research. Sandler, Glesne, and Geller (2008) published a

10 To date, US courts have been somewhat ambivalent about the purposeful reliance on placebo effects in commercial
medical products. A 2006 federal district court ruling (and subsequent 2008 appellate court upholding) decided against QT,
Inc., a company which sold “Q-Ray” bracelets purported to have healing effects, but which were determined by a 2002
Mayo Clinic study to work no better than a placebo (Bratton et al., 2002; Sachdev, 2008). The appellate judges noted in
their opinion statement that the defendants invoked the reality of the placebo effect as part of their appeal, with the
argument that “the placebo effect vindicates their claims, even though they are false—indeed, especially because they are
false, as the placebo effect depends on deceit” (Easterbrook, Bauer, & Williams, 2008, p. 6). Although the judges came
down harshly on the defendants for fraudulent marketing practices, it is interesting to note that they did not completely
discount the theoretical validity of the placebo argument:
The Federal Trade Commission Act condemns material falsehoods in promoting consumer products; the
statute lacks an exception for “beneficial deceit.” We appreciate the possibility that a vague claim—along the lines
of “this bracelet will reduce your pain without the side effects of drugs”—could be rendered true by the placebo
effect. To this extent we are skeptical about language in FTC v. Pantron I Corp., 33 F.3d 1088 (9th Cir. 1994),
suggesting that placebo effects always are worthless to consumers. (Easterbrook et al., 2008, p. 6)
Running Head: INTEGRAL PLACEBOS 42

more robust study some 40 years later, on the use of placebos to enhance doses of medication for

children suffering from Attention Deficit Hyperactivity Disorder (ADHD). The study yielded

promising results – children who received half their normal dose of medication, plus a placebo

“booster” (and who were told ahead of time that the pill was not a real drug) responded similarly to

those who received a full dose of their normal medication. Still, this study is technically one which

evaluates placebos as drug performance enhancers, rather than as fully independent treatments in their

own right. It currently remains to be seen whether an open-label placebo treatment can independently

perform comparably to an active drug in a robust clinical trial setting.

To summarize this section, it is clear that each of the placebo effect's four quadrants holds

numerous questions and possibilities for future research. More importantly, there is a distinct shift

away from a focus on the biological roots of health and healing (the individual-exterior quadrant), and

towards the subtler influences of personal belief, community values, and societal development

represented in the other three quadrants. For example, the apparent strengthening of the placebo effect

over time seems to be largely correlated with improvements in research technology, as well as patterns

of behavior in clinical trials – the domain of the collective-exterior. Closed-label placebos challenge

the medical profession's ethical comfort zone – the collective-interior – and open-label placebos raise

questions about exactly how patients' belief systems and understanding interact with the healing power

of simulated treatments – the individual-interior. With these complex issues looming on the horizon of

future placebo research, it seems all the more practical to contain them within a coherent framework for

understanding and integration – a framework such as the quadrant model of Integral Psychology.

Part Seven: Conclusion

Amidst the many references, stories, and ideas presented in this paper, if there is a core message

to take away from its reading, I would propose that it relates to a progression of three truths. Well,
Running Head: INTEGRAL PLACEBOS 43

three and a half, to be exact. First, to speak of what we know about the placebo effect is to speak of

what we know about medicine; second, we really don't know much about the placebo effect; and third,

in order to know more, we need to turn to other paradigms of logic, examination, and inquiry, outside

the boundaries of conventional science – paradigms including, but not limited to, integral and

transpersonal studies. In closing, I will spend a brief moment reviewing the case for each of these

statements. (The half truth I'll save for last.)

Truth #1: To know placebo is to know medicine

Modern medical research follows a simple formula in determining what should and shouldn't be

accepted as a part of its practice. Using the best methodological and technological approach possbile, a

randomized clinical trial is designed and carried out, meant to test a new drug, procedure, or treatment.

If, at the end of the trial, the treatment in question has demonstrated conclusively that it works better

than a placebo, then it becomes a good candidate for acceptance into the medical canon. That's a bit of

an oversimplification – the same test will need to be run numerous times, and ideally be verified

independently by other researchers, in order to be fully accepted – but nevertheless, results from

clinical trials make up the innermost core of medical science.

But at the core of the core, there exists a crucial determining factor: the relative success or

failure of any treatment when compared to placebo treatment. The security of this relationship,

however, is dependent on the degree to which we can trust our assessment of the placebo effect. If a

new drug is determined to be 30% more effective than placebo, then it would appear to be a legitimate

treatment. But if we were to find out some time later that we had incorrectly measured the placebo

effect, and that it was in fact 30% stronger than it initially appeared (thus making it equally effective as

the active treatment), then that same drug we once would have accepted as genuine medicine would

now be considered a failure. This is the essence of the first truth: the better we can evaluate the placebo

effect in research and clinical settings, the better we will be able to evaluate the usefulness of proposed
Running Head: INTEGRAL PLACEBOS 44

new medicines, and, thus, medical science overall. I find it a particularly striking irony, that the more

our scientific endeavors produce technology capable of greatly refined observation, the more we see

the gaps and misunderstandings in our vision of science to date.

Truth #2: We really don't know much

As mentioned in Part Five, Silberman's (2009) article, along with Kirsch et al. (2008) and

others, imply that exactly these sorts of miscalculations mentioned in the previous section are now

coming to light. Pharmaceutical companies are terrified because more and more of their drugs are

failing to win out over placebos. There is credible evidence that placebo rates can vary wildly for the

same clinical research, based on geography, culture, and study design. Recalling the findings presented

in the Individual-Exterior section of Part Two, researchers have now found neurological networks in

the brain and the spine that carry real messages of relief and healing, specifically activated by placebo

stimuli. Some of these findings were literally published just weeks ago at the time of this writing.

After 60 years of serious research in the field, there are still at least as many questions as we have

answers, and the questions now seem to suggest stranger and stranger truths about the way our minds,

bodies, and environment co-exist. Remember, these three truths are progressive, they build upon one

another. If the second truth acknowledges that we are floundering in our nascent understanding of

placebos, then to tie it to this first truth is to admit that we are equally at a loss to understand the larger

principles of medicine, health, and healing.

Truth #3: To know more, science needs outside help

To be fair, scientific inquiry has always excelled at validating the details, rather than the big

pictures. That's what science is designed to do. When enough details have been amassed, however,

there comes a point when a bigger picture is called for, in order to make sense of the many specifics.11

In the particular case of placebo studies, and, perhaps, for medicine as a whole, the four-quadrant
11 Whence the current thrust in recent decades for a grand, unified theory that brings order and relationship to the
seemingly disparate truths of Newtonian mechanics, quantum physics, and relativity, for example.
Running Head: INTEGRAL PLACEBOS 45

framework of Integral Psychology seems like a great place to start for creating greater order and

cohesive understanding. The four quadrants represent only a small part of the entire Integral vision,

and while a deeper investigation of such possibilities is unfortunately beyond the scope of this paper,

there are many further layers of subtlety and nuance that could apply here to medical research as well.

Whether it be Integral Psychology or some other inclusive, integrative epistemological framework, it

seems that some new alliance will need to be forged in the near future, one which bridges the strict but

precise orthodoxy of investigative science, and the broader ontological impressions of modern

psychology and philosophy. While the latter without the former may struggle to bring its ideas into

pragmatic application, the former without the latter seems doomed to a self-imploding course of ever-

increasing precision alongside ever-decreasing meaning.

The Half Truth: Holding it all lightly

Fortunately, this story ends on a happier note – or if not happier, then at least a lighter one.

If there is anything I have learned from my research into the placebo effect, it is that there are no truths

which can be held self-evident. (No, not even that one.) The combined wisdom from Integral

Psychology and placebo research provides clear evidence that what we think we know to be real is

actually founded upon a tenuous network of circumstance. Even the definition of the placebo effect

itself is based on elements which will inevitably shift, reorganize, and refine themselves in time. What

is “real” takes on a different meaning according to personal perspective, cultural framework,

physiological context, and technological sophistication – all of which are both illusions and undeniable

realities at the same time! This is the final half-truth – the truth of the two simultaneous and

contradictory poles of knowing – and it is in this paradox that I find the ability to hold this and every

other truth a bit more lightly. All stories make new realities, as I hope I've been successful in

demonstrating with this one; at the same time, there are other stories being told at this very moment,

and they too hold their own truths.


Running Head: INTEGRAL PLACEBOS 46

In closing, and as a thanks for reading, I offer you, the Reader, this benediction:

May the story of your own body be full of health,

May the tale of your own inner world be filled with joyful adventure.

May this ancient weaver's art

Aided by the knowledge of modern sages

Be passed on to benefit every future story!

END
Running Head: INTEGRAL PLACEBOS 47

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