If you haven’t already heard, massage, bodywork, and manual therapy probably don’t work in the ways we thought they did. It’s becoming clearer that these modalities produce many (some say all) of their beneficial effects via the nervous system and the brain, and that they probably produce far fewer direct physiological changes (such as reducing lactic acid) or structural changes (such as permanently remodeling connective tissues) than we previously thought.
Though tissue-based explanations of massage and bodywork’s effects are not completely out of the picture yet (there is, for example, reasonable evidence that hands-on work can produce certain tissue effects, like viscoelastic change, improved hydration, and increased interlayer glide),1 there is a growing consensus that, as practitioners, we can be even more effective in our work by better understanding the ways our hands-on work interacts with the brain and nervous system.

Enter the Placebo

Placebo research offers us a glimpse into ways we as bodyworkers might better understand the relationship between the brain and body. Placebos can produce very tangible effects, but their results come from their psychological and neurobiological influences on the brain rather than by direct physical effects on the body. It’s long been known that the very act of receiving any treatment can have positive psychological effects, apart from any physical benefits of the treatment itself. That’s why comparisons to “sham” placebo treatments are commonly used as controls in randomized clinical trials (RCTs). By comparing the effects of the active treatment to the placebo treatment, the specific physical effects of the agent being studied can be measured separately from all of the indirect (contextual or “nonspecific”) placebo effects that come along with simply receiving a treatment.
But according to placebo researchers such as Fabrizio Benedetti, professor of physiology and neuroscience at Turin University, placebo effects are commonly misunderstood, even by health-care providers (who, he says, employ them every day, whether they know it or not). “A placebo is the entire ritual of the therapeutic act,” not just the sugar pill, says Benedetti.2 After all, sugar pill placebos only “work” when offered within the context of a therapeutic interaction. From this perspective, it is the treatment’s context itself—including the setting; the interaction between practitioner and client; the client’s expectations, beliefs, and conditioned responses; and more—that are the “active ingredients” in the placebo intervention.
Dramatic examples of therapeutic context influencing treatment outcomes abound. For example, studies of contextual placebo factors (such as setting, interaction, expectations, etc.) have shown that:
• Warmer, more empathic practitioners get better results (Images 1–2). In one 2014 study, chronic back pain patients reported a greater reduction in pain (55 percent) from placebo treatment given by an empathetic practitioner than from actual back pain treatment given by a noncommunicative practitioner (46 percent).3
• Hospital rooms with views of nature (Image 3) have lower analgesic use, shorter postoperative stays, and higher patient ratings of their nursing staff.4
• In a study of factors affecting recovery from back, knee, and shoulder injuries, the strongest predictor of successful recovery was the patient’s expectations about that recovery.5
• More patients with favorable expectations about their sciatica-related surgery had good outcomes than did those who had unfavorable expectations; even more interesting, the patients’ expectations about recovery were an even stronger predictor of success than the surgeons’.
• Practitioners’ confidence and expectations have their own placebo effects as well: when clinicians thought they were giving a placebo (when actually giving pain medication), their patients reported less relief compared to those whose doctors knew they were giving active pain medication (see “The Value of Confidence,” Massage & Bodywork, March/April 2018, page 102).6    
These examples remind us, as manual therapists, that there are many things that influence our results besides our hands-on methods themselves. Our practice room, demeanor, rapport, language, fostering of accurate expectations, and confidence in our own methods all have the power to help or hinder our work, in and of themselves.
As the examples above show, placebo responses can be related to conscious expectations, meanings, or beliefs, but those are just some of the ways placebos work. Strangely enough, you don’t have to believe in a treatment, nor trust your practitioner, to have a significant placebo response. Our brain’s conditioned responses, which are often below the level of our conscious awareness, are also triggered by placebos. One example: study participants given an immunosuppressant in flavored water continued to show immunosuppression when given that flavor of water later, even without the immunosuppressant mixed in.7 Interestingly, animals have clear placebo responses; many of these are thought to result from conditioning (think of Pavlov’s dog salivating at the ring of the placebo bell). In ways we’re often not aware of, the context, rituals, symbols, and habituated responses related to our work are having clear and potentially beneficial effects.
Of course, expectations and conditioning can work both ways—if your client expects painful or poor results, assigns a negative meaning, or has become conditioned to unsatisfying outcomes, they might experience a nocebo response: a worsening of symptoms and pain from contextual influences alone. Pain is, after all, strongly related to context and expectation (Image 4). There is evidence suggesting that nocebo effects are even easier to trigger than placebo effects, meaning it’s probably even more important for us to be aware of the potentially negative impacts of our interactions, expectations, and the context we provide.

Are Placebo Effects Real?

Many practitioners I’ve talked to while preparing this article aren’t sure they like the idea of “using placebos” in their work. Placebos are often thought of as being deceptive, illusory, or fake. It is true that participants in a placebo-controlled RCT don’t usually know whether they are getting placebos or are (willingly but unknowingly) subject to ruses, tricks, and set-ups.
But placebos don’t need to involve trickery nor deception to be effective. Since all treatments happen within some sort of psychosocial context, and that context has an influence on the recipients (for better or for worse), placebo effects could accurately be said to accompany all “real” treatments, not just simulated ones. For example, IV-drip morphine given without a person’s knowledge (Image 5) is 50 percent less effective than when the recipient knows they’re getting it: the patient’s overt knowledge that they’re getting morphine is the contextual “placebo” in this case, and in this case, it doubles the drug’s effectiveness.8
And contextual or placebo effects themselves are not always solely subjective: among other objectively measurable biological effects (such as hormonal changes or immune system activity), placebos have a well-documented ability to trigger the release of natural pain-relieving cannabinoids and endorphins (endogenous opiates). Placebos can also increase dopamine in the brain’s reward centers, which also helps lower anxiety, increase rapport, and reinforce positive expectations.9

The Limits of Placebo Power

Even though placebos can seem to have almost magical powers (especially if we believe the sometimes-exaggerated claims that are often made for them in the health-care marketplace), decades of research, debate, and review have mapped out both the power and the limitations of placebos’ mechanisms and effects.
Because placebos work at the level of the brain, they have their greatest effects on symptoms that straddle the overlapping area between the psychological and the biological. Systematic reviews of placebo studies have identified pain, depression, phobias, asthma, and nausea as conditions that significantly respond to placebo; smoking, dementia, obesity, hypertension, insomnia, and anxiety also show some responses to placebo, but with less consistency.10 As Ted Kaptchuk, director of Harvard’s Program in Placebo Studies, says, “Placebos only affect what the brain can modulate. It’s not going to shrink a tumor. It’s not going to deal with malaria. But it will deal with pain, fatigue, and nausea. Or will deal with feeling malaise. But it’s not going to deal with killing bacteria. That doesn’t happen on the level of the brain.”11
Another way to think about this is that placebos have much clearer subjective effects than objective effects—they work primarily by changing the way people feel, or the meaning they ascribe to their symptom, but they do not by themselves directly “cure” any underlying pathophysiology, nor eliminate the biological causes of a symptom (except perhaps indirectly, such as by lowering overall stress). Placebos might help with the pain of a broken bone, but they won’t directly heal the fracture itself. Not every placebo works on every person, and though there are significant exceptions, many placebo effects don’t last as long as effects from physical treatments. And, since some (like conditioning) involve a kind of learning, many placebos require repetition to be sustainable. Their subjective, unpredictable, ephemeral, and personal nature is part of why some remain skeptical about the usefulness of placebo effects, and describe them as illusions, or not “real.”12
The use of “real” in this way is probably more than semantics. It likely reveals a paradigm clash between two very different worldviews: one that, in its most extreme expression, values and trusts objectivity and physicality over the less-tangible nature of subjectivity, psychology, and personal experience; and the opposite point of view that puts the “personal reality” of direct experience first, sometimes before scientific method, research findings, or even “consensus reality.”
In defense of the first view (objectivity), there are good reasons to mistrust subjective perceptions, especially within a research or evidence-based context, where reproducibility, substantiation, quantification, and precision are crucial. Personal experience is, after all, subject to bias, confusion, illusion, perceptual filters, and distortion.
And yet (the other side of the conversation goes), as bodyworkers, the reasons our clients come to us for hands-on work are almost always subjective by their very nature. Changing the way someone subjectively feels can be significant, especially if “wanting to feel better” is the client’s primary desire. Pain, for example, is a subjective experience, fully known only to the person in pain, since pain often has no objectively verifiable signs. And yet, the inner experience of pain can be more “real” to the person in pain than any competing outer realities. Furthermore (this point of view would continue), to suggest that someone’s pain or relief from pain is not “real” is like saying it’s “all in your head,” and so runs the risk of invalidating the client’s suffering, and thus inadvertently causing nocebo effects by inducing doubt, confusion, isolation, hopelessness, or further anguish.
In other words, from this second point of view, though placebo effects may not always be physically “real,” the question is, does that really matter? Isn’t it sometimes enough (in fact, isn’t it sometimes great) that our clients can feel better from their treatments’ context and interaction alone? Or that we can leverage what we learn from placebos and contextual effects to help all our ministrations be even more effective?
Both views are of course true, and necessary. “The placebo effect is the most interesting phenomenon in all of science,” says Jeffrey Mogil, a McGill University pain researcher. “It’s at the precise interface of biology and psychology.”13

Ethical Placebos?

This is where ethical considerations come into the conversation. One placebo-related concern is that by causing someone to feel better in the short term, or by reinforcing what some would see as too much faith in the power of belief alone, placebo-only treatment might delay or replace crucial medication, treatment, or behavior changes that could help with longer-term recovery (for example, not taking one’s prescribed psychiatric medication, or, in a higher-stakes scenario, dropping out of cancer treatments in favor of a remedy no more effective than a placebo). For these reasons, it’s important not to limit ourselves to only our clients’ subjective reports, nor to forgo medical evaluation and care whenever indicated.
And of course, deceiving our clients in any way, even if we think it in their best interest, is clearly on the wrong side of the ethical divide. (Some would also include using explanations for our work that aren’t scientifically accepted as a kind of unethical “deception,” though there is not a consensus on this view.)
The ethical considerations about placebos aren’t as simple as “don’t use placebos,” or “always use placebos.” Since every therapeutic intervention has a psychosocial context, placebo (or nocebo) effects are already part of every therapeutic interaction. The question then is, how can we stay aware of their implications and power to best serve our clients?
Part of the answer is that we already use many different placebo and contextual effects all the time—for example, whenever we are paying attention to client interactions and the relational context of our work. Most importantly, when we don’t pay attention to placebo factors, we run the risk of inducing nocebo effects.  
Placebos’ effects can seem mysterious, even magical. But “placebo” is not just one thing, and as we learn more about its constituent mechanisms, its mystery is being gradually whittled away. “I see the placebo effect as a kind of loose family of different phenomena that are just yoked together by this term,” says Franklin Miller, senior faculty member in the Department of Bioethics, National Institutes of Health (NIH). “Sooner or later we’ll get rid of the term,” he says, and talk more specifically about each of its components.14
Understanding how these various placebo and nocebo mechanisms function is helping many practitioners be even more effective in their work—not by fooling their clients with fake remedies, but by more intentionally leveraging the power of trust, expectation, ritual, anxiety reduction, and learning, and by including both the objective and subjective impacts of their work into their values and their thinking. After all, you and everything you do already have placebo effects—wouldn’t you rather your effects be beneficial ones?

Placebos You Already Use (and Could Use Even Better)

Placebos (or contextual effects) derive their power from many well-studied therapeutic phenomena. Some of these include:


Rapport
• Listen
• Empathize
• Remember that the interaction itself can be therapeutic
Authority and Trust
• Only say things you believe
• Keep appointments and agreements
• Don’t be afraid to say I don’t know

Conditioning
• Your clients have habituated responses to all aspects of their visit to you
• Keep in mind that your workspace itself has effects
• Repetition, routine, and ritual can strengthen beneficial contextual responses
Expectation
• Reassure, reframe, and educate
• Practice realistic and honest optimism
• Communicate that what you offer has value

Further Information and Learning
• Fabrizio Benedetti: Placebo Effects: Understanding the Mechanisms in Health and Disease. Oxford University Press, 2nd edition, 2014.
• Brian Fulton: The Placebo Effect in Manual Therapy: Improving Clinical Outcomes in Your Practice. Handspring Publications, 2015.

Notes

1. Fascia: The Tensional Network of the Human Body, eds. Robert Schleip et al. (Edinburgh: Elsevier, 2012); A. Stecco et al., “Ultrasonography in Myofascial Neck Pain: Randomized Clinical Trial for Diagnosis and Follow-Up,” Surgical and Radiologic Anatomy 36, no. 3 (April 2014): 243–53.
2. F. Benedetti, “Drugs and Placebos: What’s the Difference?,” EMBO Reports 15, no. 4: 329–32.
3. J. Fuentes et al., “Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with Chronic Low Back Pain: An Experimental Controlled Study,” Physical Therapy 94, no. 4 (April 2014): 477–89; T. J. Kaptchuk et al., “Components of Placebo Effect: Randomised Controlled Trial in Patients with Irritable Bowel Syndrome,” BMJ 336, no. 7651 (May 2008): 999–1003.
4. M. Schweitzer et al., “Healing Spaces: Elements of Environmental Design that Make an Impact on Health,” Journal of Alternative and Complementary Medicine 10, supplement 1 (2004): S71–83.
5. S. Booth-Kewley et al., “A Prospective Study of Factors Affecting Recovery from Musculoskeletal Injuries,” Journal of Occupational Rehabilitation 24, no. 2 (June 2014): 287–96.
6. R. H. Gracely et al., “Clinicians’ Expectations Influence Placebo Analgesia,” The Lancet 1, no. 8419 (1985): 43.
7. R. Ader and N. Cohen, “Behaviorally Conditioned Immunosuppression,” Psychosomatic Medicine 37, no. 4 (Jul–Aug 1975): 333–40.
8. Fabrizio Benedetti, Placebo Effects (Oxford: Oxford University Press, 2004).
9. Raúl de la Fuente-Fernández and A. Jon Stoessl, “The Biochemical Bases of the Placebo Effect,” Science and Engineering Ethics 10, no. 1 (2004): 143–50; F. Benedetti, “Placebo and Endogenous Mechanisms of Analgesia,” Handbook of Experimental Pharmacology 177, no. 177 (February 2007): 393–413.
10. A. Hróbjartsson and P. C. Gøtzsche, “Placebo Interventions for all Clinical Conditions,” Cochrane Database of Systematic Reviews (January 2010), https://doi.org/10.1002/14651858.CD003974.pub3.
11. Brian Resnik, “A Radical New Hypothesis in Medicine: Give Patients Drugs They Know Don’t Work,” Vox, last updated June 2, 2017, accessed May 2018, www.vox.com/science-and-health/2017/6/1/15711814/open-label-placebo-kaptchuk.
12. Paul Ingraham, “Placebo Power Hype,” PainScience.com, last updated December 18, 2017, accessed May 2018, www.painscience.com/articles/placebo-power-hype.php.
13. Brian Resnik, “The Weird Power of the Placebo Effect, Explained,” Vox, July 7, 2017, accessed May 2018, www.vox.com/science-and-health/2017/7/7/15792188/placebo-effect-explained.
14. Brian Resnik, “The Weird Power of the Placebo Effect, Explained.”
Special thanks to Brian Fulton, RMT, for ongoing discussion and reference suggestions, and particularly for his definitive book, The Placebo Effect in Manual Therapy: Improving Clinical Outcomes in Your Practice (Handspring Publishing, 2015).

Til Luchau is the author of Advanced Myofascial Techniques (Handspring Publishing, 2016), a Certified Advanced Rolfer, practice coach, and a member of the Advanced-Trainings.com faculty, which offers online learning and in-person seminars throughout the United States and abroad. He invites questions or comments via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.