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Placebo and nocebo effects

…what to tell your patients?

  • Stimulate placebo effects without exaggerating
  • Avoid frightening metaphors and do not create negative expectations
  • Tailor information to the specific patient, condition and treatment

Explaining possible placebo and nocebo effects to patients can increase the effectiveness of treatment. It is, however, important to tailor the information to the specific patient, complaints and treatment. It is essential to not unnecessarily frighten the patient while explaining possible negative effects or side effects. This is a selection of advice from 27 prominent experts in the fields of psychology, neurology, communication sciences, sociology and sports sciences.

Explain

Therapists can use the terms ‘placebo’ and ‘nocebo’, according to the experts. Nevertheless, they do call for clearly explaining to the patient what these terms mean, how they can affect the treatment, and how these effects can be distinguished from actual treatment effects or side effects. It does not matter whether therapists clarify this in conversation, using videos or in a folder, as long as it matches the patient’s preferences.

Training the therapist

The experts argue that therapists should be trained in using effective communication to stimulate or avoid placebo and nocebo effects. They should also be guided on how to tailor information to an individual patient. Ideally, basic and advanced professional education institutions fit this training into their existing curriculum, but it could also be featured in courses regarding ethics or communication skills for instance. 

Delphi study

The authors used a Delphi study design including three steps. First, all 27 experts completed a questionnaire with open questions to collect all existing scientific information. From this, the authors derived 158 individual items that the experts scored on a scale from zero to ten (0 = completely disagree; 10 = completely agree). The final step was to conduct a meeting with all experts to discuss the highest ranked items, and definitive advices were formulated. 

> From: Evers et al., Psychother Psychosom 90 (2021) 49-56 . All rights reserved to The Author(s). Click here for the online summary. Translation by Annette Wiertz

Expert opinion by Sanneke Don, MSc

There is a growing interest, both in the scientific field as well as in daily practice, for placebo- and nocebo-related effects. These effects can be explained from a neuroscientific perspective. As therapists we can respond to this in a positive way by the design of our treatment facilities and the treatment itself. It is very probable that we as therapists, and our relationship with the client are the most important factors in the development of placebo-related effects. These can originate from for instance empathic listening, building on a good relationship with the client, taking sufficient time and using positive verbal and nonverbal communication.

The study of Andrea Evers and colleagues goes one step further by emphasising the importance of explaining these neuroscientific effects. It can for instance be helpful if someone understands that the complaints can increase by consulting Doctor Google (after all, the internet is a source of many nocebos). It can also be important for people to understand that complaints can increase under the influence of fear or stress, or decrease when people seek distraction or undergo a treatment of which they have positive expectations. This is not all that different from what we discuss with people during pain education or psychoeducation. 

However, specifically explaining placebo and nocebo mechanisms goes a little further, as people literally receive education on how these effects originate in the body, in which it is explicitly recommended to use the terms ‘placebo’ and ‘nocebo’. It is not clear yet what the best way is to do this within physiotherapy, because no studies have been conducted yet in a physiotherapeutic setting. We follow future studies with great interest and will share potential new developments with you once they arise. 

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