Key Points

• Our goal is to tap into placebo pathways to help clients manage pain and feel better.

• Warmth, competence, rituals, and good listening skills in the massage room will help you harness placebo pathways.

I made my niece, Tricia, a strong-tasting cup of coffee. Thirty minutes later, she said, “That was one powerful cup of coffee. I’m bouncing off the walls!” But here’s the thing: It was decaf. She was experiencing a placebo effect. 

Once I told her, Tricia’s face turned red, and I couldn’t convince her that experiencing a placebo effect isn’t a bad thing. Unfortunately, negative feelings around placebos prevent most people from seeing the value of a positive placebo effect. 

Don’t be one of those people. Massage therapists can tap into a client’s placebo pathway to improve therapeutic outcomes and client expectations. 

The Placebo Effect

A traditional definition of placebo effect is a brain-body response to an inert treatment in a specific psychosocial context.¹ Did you just think of a doctor in a white coat in a lab administering a sugar pill? I did. But it’s possible to have a placebo response with a treatment that is not a sugar pill. 

Picture a nutritionist in an office handing a patient a vitamin pill (active ingredient) for a specific vitamin deficiency. The patient takes the vitamin pill and instantly feels more energy. The instant energy response was likely a placebo response, since vitamin supplementation would need time to produce an effect. 

Massage is more like a vitamin pill than a sugar pill in the sense that both the massage and the vitamin pill have “active” ingredients and are capable of producing a brain-body response. So, let’s expand the placebo definition to include active treatments that can be enhanced by placebo-related mechanisms.² 

How Do You Produce a Placebo Effect?

You produce a placebo effect through expectancy and learned associations, according to placebo researcher Darwin Guevarra, PhD.³ Expectancy means anticipating an intended beneficial effect. For example, a doctor tells their client “Azur” that a cream (actually a placebo cream) will reduce his joint pain. Azur believes the cream will help his arthritic knee, and it does. 

A learned association happens when a beneficial effect is paired with a placebo object or procedure. It’s automatic and the person is unaware. For example, “Elaine” is injected with a pain-killing medication. Later, she is given a second injection, but this time, unbeknownst to Elaine, the painkiller is a placebo (saline solution). Elaine experiences less pain after the placebo injection.  

What a Placebo Can Do

It’s notable that a saline injection can reduce pain.⁴ An even more dramatic example of a placebo effect occurred in Paris in the late 18th century when Charles Mesmer temporarily returned the sight of a blind girl using a treatment called animal magnetism, which was proven to be a placebo.⁵  

In a Harvard Health Publishing article, professor Ted Kaptchuk says, “Placebos may make you feel better, but they will not cure you.”⁶ He also goes on to say placebos “. . . have been shown to be most effective for conditions like pain management, stress-related insomnia, and cancer treatment side effects like fatigue and nausea.”⁷

Pain management is in our massage wheelhouse. Our goal is to tap into placebo pathways to help clients manage pain and feel better. Let’s apply the research.

Enhancing the Placebo Effect Through Competence and Warmth

In 2019, Lauren Howe, PhD, and her colleagues identified two key components for enhancing a placebo response in the therapeutic relationship: competence and warmth.

Howe explains, “A provider’s competence and warmth make a provider more credible, believable, and/or persuasive, which may boost the impact of the expectations they set about treatment.”⁸ Howe refers to competence and warmth as “gets it” and “gets you.” The doctor who gets it does things like conduct a thorough exam and demonstrate mastery over the subject matter. The doctor who gets you is nice and calls you by name.

We’re not doctors, but like doctors, we have placebo potential through the therapeutic relationship—and we should not let this healing potential fritter away. 

Recently, a person in persistent pain, we’ll call her “Shari,” was referred to me by another health-care provider. Here’s how I applied warmth, competence, and other research-backed findings in the massage room.

Be Warm

Shari has persistent hip pain. She has been through the gamut of diagnostics and treatments and was cleared of any life-threatening malady. Basically, she was coming to me as a last hope. No pressure, right?

When Shari came in, I smiled and introduced myself like I do with every new client. I offered her water and made sure to call her by her first name. I didn’t get a lot of warm fuzzies back from her. Later, as we talked, I realized she was on the fence about massage. Nothing worked so far, so why should this work? 

Be Competent

Shari filled out the intake and we started to talk. At the time, I didn’t realize I was actually engaged in another placebo-enhancing activity—ritual. 

Yes, filling out a massage intake is a ritual. How so? Think about your first time at a dentist, physical therapist, primary doctor, nutritionist, or almost any health-care provider—what do you do? Fill out an intake. In fact, if you weren’t asked to fill out an intake, you’d probably think twice about the quality of care you were about to receive. Intakes are a modern medicine ritual. And rituals are powerful because they induce changes in the brain via the release of feel-good hormones.⁹ We make a big deal out of our intake in our office. The form itself is comprehensive and designed to get the client to talk and tell their story. We also put ample time between clients so the therapist can get all the information they want and the client doesn’t feel rushed. 

After Shari filled out the intake, I asked questions. She talked and I listened. Besides providing me with valuable information, listening strengthened therapeutic rapport. Then, I explained my massage approach to pain relief, but Shari interrupted me. She asked, “Do you think I can feel better?”

Using Research as an Expectancy

It was a jarring and loaded question. Honestly, I had no idea if she would ever be in less pain or if massage would help her manage the pain. But here’s what I did know: Research suggests moderate pressure can reduce pain caused by certain conditions.¹⁰ So, I said yes and briefly explained the research. Her face lit up, and that’s when I finally felt a therapeutic connection.

I shared Shari’s response with Guevarra and he agreed the research I relayed to Shari may have served as an expectancy that promoted a belief that the massage might help. 

Not wanting to overpromise, I also explained to Shari that there’s usually no magic bullet to pain relief and that pain management is not a straight line. There will be ups and downs. Unintentionally, I had stumbled into a category called placebo extenders—a way to lengthen the effect of a placebo.

Extending a Placebo Effect

Guevarra explains that a placebo stops working when a person stops believing the placebo will work.¹¹ By telling Shari to expect ups and downs, she would accept times when the pain was higher as part of a normal process, and, hopefully, would not lose faith in the treatment.  

As I worked on Shari, I located her pain areas. Using a scale from 1 to 10, I applied pressure and we worked at 4 pressure to reduce the pain to 2 pressure. Shari experienced a reduction in pain while she was on the table and after she got off the table. 

After she was dressed, I grabbed a massage textbook and showed her the muscles I massaged. The point was not to go on about my massage approach. It was to connect massage with medical knowledge and anatomy, and further demonstrate competence. Shari left knowing how to apply medium pressure on herself, and I waited for her follow-up report.

The Placebo Effect Results

Two days later Shari emailed me: “I just wanted to let you know that the massage definitely lessened the pain! I had the best two nights of sleep since I got the massage! I’m really happy with the results so far.”

I was ecstatic, but my celebration wasn’t long-lived. When she came back 10 days later, she was in pain again. Nevertheless, two days of reduced pain after 18 months of persistent pain was something. 

There was no way for me to know whether the massage itself, a placebo effect, or both helped Shari with pain reduction for two days. So, I proceeded as if both did. For the next session, I added relaxation massage using medium pressure on nonpainful areas of her body. I also told her about the research that demonstrated a parasympathetic response from medium-pressure massage, hoping that research would serve as an expectancy.¹²

After the massage, Shari felt better. She was also in a good mood and made another appointment. Going forward, I’ll continue to pay close attention to her responses and strengthen placebo enhancers that seem to be working. You can see my Shari updates at makethemostofmassage.com.

Our Placebo Future in the Massage Room

I’ll be the first to admit working for a placebo effect in the massage room is still more of an art than a science. There is no placebo-effect procedural manual. But there is hope on the horizon. 

In 2020, Guevarra and his colleagues performed a nondeceptive placebo experiment. Participants agreed to view pictures that would evoke negative emotions. Self-reporting and neural measures were used to determine degrees of emotional distress.¹³

In the beginning of the experiment, participants were divided into two groups. One group was given a placebo nasal spray they were told would help with clarifying the imaging. The other group was given the same placebo nasal spray but told it was a placebo. The placebo group was also educated about how placebos could benefit them. Here’s the amazing thing: The group who knew the nasal spray was a placebo experienced less emotional distress.¹⁴

The explanation of the placebo effect became the expectancy. In other words, you can be told a placebo is a placebo and it will work if you are persuaded to believe it will work.¹⁵ 

Warmth, competence, rituals, and good listening skills in the massage room will help you harness placebo pathways. As for my niece and her negative reaction to her placebo experience, I will make sure not to substitute decaf coffee for caffeinated coffee without her consent. 

Notes

1. Darwin A. Guevarra, “Harnessing Placebo Effects to Regulate Emotions,” forthcoming, Handbook of Emotion Regulation, 3rd ed. (Guevarra, Kross, & Moser, 2023), https://psyarxiv.com/7c8z2/download.

2. Guevarra, “Harnessing Placebo Effects to Regulate Emotions.”

3. Interview with Darwin A. Guevarra, January 4, 2023.

4. Marius Henriksen, “Saline Injections vs Education and Exercise in Knee Osteoarthritis (DISCO),” www.clinicaltrials.gov/ct2/show/NCT03843931. 

5. Ethan Kross, Chatter: The Voice in Our Head (Penguin Random House, 2021).

6. Harvard Health Publishing, “The Power of the Placebo Effect,” December 13, 2021, www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect.

7. Harvard Health Publishing, “The Power of the Placebo Effect.”

8. Lauren C. Howe, “When Your Doctor ‘Gets It’ and ‘Gets You’: The Critical Role of Competence and Warmth in the Patient–Provider Interaction,” Frontiers in Psychiatry 10 (2019): 475.

9. Fabrizio Benedetti et al., “The Placebo Response: How Words and Rituals Change Brain Circuitry,” Physiology News Magazine, winter 2009, no. 77, www.physoc.org/magazine-articles/the-placebo-response-how-words-and-rituals-change-brain-circuitry.

10. Tiffany Fields, “Massage Therapy Research,” Epub (August 1, 2014), https://pubmed.ncbi.nlm.nih.gov/25172313.

11. Interview with Darwin A. Guevarra, January 4, 2023.

12. Tiffany Fields, “Massage Therapy Research.”

13. Darwin A. Guevarra et al., “Placebos Without Deception Reduce Self-Report and Neural Measures of Emotional Distress,” Nature Communications 11 (2020): 3,785, https://doi.org/10.1038/s41467-020-17654-y. 

14. Guevarra et al., “Placebos Without Deception Reduce Self-Report and Neural Measures of Emotional Distress.”

15. Interview with Darwin A. Guevarra, January 4, 2023.