Boston, March 2-4 2020
In this video, Stanford University professor, athlete, and psychologist Alia Crum, PhD, discusses how our mindset can affect health behaviors and outcomes.
Following is a transcript of her remarks. Note: TEDMED videos are produced for viewing. If at all possible, we strongly suggest watching the video. Much as we love the written word, voices and gestures carry nuanced intonation and emotion. We provide a transcript below, but these transcripts are generated with speech recognition software and light human editing, and there may be minor errors. Please double-check the actual video before quoting spoken remarks or references.
Despite continual improvements in medicine, one of the most fascinating aspects of healing remains something we've been aware of for centuries, the placebo effect. Today, I want to talk about what we know currently about the placebo effect and examine what we can do to more effectively leverage it to our advantage. The placebo effect demonstrates the sometimes surprising power of our mindset, thoughts, beliefs, and expectations to produce meaningful changes in the body.
Simply taking a sugar pill under the impression that it's a real medication can not just improve your pain, anxiety, and depression, but also reduce your blood pressure, calm your asthma, and boost your immune system. Placebo surgeries -- yes, you heard me right -- in which the doctor puts patients under anesthesia, cuts them open, and sutures them back up again without doing anything can get people back on their feet again. Placebos don't always take the form of sugar pills or procedures. Their effects aren't always so rosy. Placebo poison ivy can cause real rashes. The mere fear of side effects makes those effects more likely.
As the major threats to our health have changed from infectious diseases to chronic disease and we increasingly look to changes in our behaviors -- behaviors like exercise, diet, and stress for solutions -- what we're finding is that the benefits of those behaviors to depend on our beliefs. For example, in a study that we ran while I was at Yale, we gave people the exact same milkshake, but with two different labels. What we found is that when people believed they were consuming an indulgent high-calorie milkshake, their bodies responded as if they had consumed more calories. Over the last 30 years, placebo experts and neuropsychologists have shown that placebos don't just work by making us say we feel better. They produce a whole host of specific neurobiological effects. I could spend all day talking to you about placebo effects. But while those studies are provocative and intriguing, the more useful question is not is there a placebo effect, but what can we do as patients and providers to consciously and deliberately harness that effect to our advantage.
The shocking truth is despite being aware of the placebo effect for centuries we know relatively little about what it actually is. We know even less about what we could do to produce it on-demand. There's a good reason for this gap in our knowledge. When we develop new medications and new treatments, we spend enormous amounts of money, time, and effort trying to outperform the placebo effect.
We're stuck in an outdated model. In this model, we compare a new treatment to the placebo effect. They're set up in competition. There's only two possible outcomes for the placebo here. 1. If the drug outperforms the placebo, which by the way it's very difficult to do, only about 10% of new drugs pass this test. But if it does, the placebo effect is immediately deemed irrelevant. We start marketing the drug and prescribing the drug, and we forget about any benefit that could have occurred from just a placebo. On the other hand, if the drug or new treatment does not outperform a placebo, then the placebo is the villain. Our hopes for the new drug are dashed and millions of dollars go down the drain. Actually, it's on the order of billions of dollars that go down the drain to the tune of a familiar refrain. It was nothing more than just a placebo effect.
Now, don't get me wrong. This is a good rigorous standard for testing the efficacy of new medications. But what this model obscures, what we so often forget is that, in the practice of medicine, the reality of medicine, the placebo effect does not disappear. It remains actively involved.
When we realize this the whole meaning of the placebo effect changes. It's no longer some irrelevant or nuisance response to a sugar pill, but the scaffolding and support system on which the total effect of the treatment is placed. When we realize this, we realize we need new models that just don't compare against the placebo, but models that seek to unpack and understand its underlying components.
Let's take a trip to the doctor's office and I'll tell you about a study where we try to do just that. In this study, we have a doctor give patients a histamine skin prick test. A histamine produces an allergic reaction, a rash on the forearm that we can measure the size of that reaction as it changes over time. Six minutes after giving them the prick of histamine, the doctor applies a placebo cream, an inert cream. For half of the participants, the doctor has some good news. She says this is an antihistamine cream. It's going to make your rash and irritation go away.
For the other half, she has some not so good news. She says this is a histamine agonist. It's going to make your rash and irritation worse. What did we find? The results were quite, quite simple. When the doctor said the cream would make the rash worse, the rash was actually worse. This was ten minutes after applying the cream. When she said the cream would make the rash better, the rash was better.
Now, this alone is interesting because it suggests that the physiological responses to the histamine depended on the beliefs that the patient had about the cream. In other words, our mindsets about treatments like, "This will work," or, "This is risky," are not irrelevant. They matter in shaping treatment outcomes, but where do those mindsets come from? How are they informed?
Now, obviously the words of the doctor here were a critical factor, but there could be other factors like what the doctor did or what the person thought of the doctor. In psychology, we call this the social context. Countless studies show that the social context makes and has a tremendous influence on our behavior. But can the social context get under the skin?
To test this, we changed the social context. In one scenario, we amped up the warmth of the physician. She looked the patient in the eye. She connected with them on a personal level. She didn't just ask date of birth or location of birth. She asked, "Where were you born? What was it like growing up in Ohio?" In addition, we had cues in the environment that signaled her competence. Her badge read Fellow at the Stanford Allergy Center. The room was pristine and she completed the procedure with precision.
Why warmth and competence, you might ask? Social psychologists have shown that these are the two fundamental qualities that we judge people on. Anytime we meet somebody new, we are immediately judging them for better or worse.
First, we want to know do they have good intentions to me or bad? Are they warm? But secondly, we want to know do they have the ability to enact those intentions. Are they competent?
To examine the effect of these two fundamental pillars of social interaction, we strip those qualities away. In this scenario, the doctor is not very warm at all. In fact, she's staring at the computer screen: Date of birth. Location of birth.
The next question.
We also raised some questions about her competence. Her badge reads "student doctor." Remember, it's all about perception. Her badge reads Student Doctor. The desk is messy and when she puts the blood pressure cuff on she fumbles. What did we find? What we found is that the warm and competent doctor, the one who connected with the patient, what she said about the cream made the effect even stronger. The healing effects of her positive expectations that she set were even more powerful.
But when the doctor was cold, fumbling, and pays you no attention, what we found here was that what she said about the cream made no difference at all. What does this tell us? Remember those mindsets that I said matter, mindsets like this treatment will work? It turns out the effect of those mindsets hinges on the social context in which they're shaped. The social cues embedded in the warmth and the competence add depth. They add meaning to those mindsets, making them not just this treatment will work, but this treatment will work because I'm in good hands because the doctor understands my unique and personal needs.
This brings us back to the original question: What is the placebo effect? Let's unpack it. First, there's the effect that would occur if you did nothing at all. The body has a natural ability to heal itself with time and that alone should not be discounted. But secondly, there's the effect of our mindsets, the effect of the lenses through which we're viewing and perceiving that treatment to evoke, create, and activate the healing properties in the body.
Finally, there's the effect of the social context, the medical ritual, the bedside manners, the doctor's credentials, the branding of the drugs, and the things that shape our mindsets, which in turn activate our body's natural healing abilities. When we realize this, we realize we can abandon our outdated notions of placebo effects as some mysterious or magical response to sugar pills and start reclaiming those effects for what they really are: the words we choose to use and the connections we choose to create.
We can start to ask more useful -- questions like what is the best mindset to have when diagnosed with cancer or diabetes? How can we inform patients of risks or side effects without causing unnecessary suffering? How can we create relationships and social context imbued with a sense of warmth and competence for people of all races, colors, genders, and backgrounds?
These are the questions that we're interested in at my lab at Stanford because we believe that medicine has a real opportunity here. We're talking about simple inexpensive interventions, changes in our words and actions that can produce objectively better health outcomes. My hope is that patients and providers in the healthcare system will join me in this journey and start taking these questions as seriously as we take the development of new medications. Because at the end of the day, three things are indisputable. The effects of the forces underlying placebo effects aren't irrelevant. They are alive and at play in every single medical encounter for better or for worse.
Secondly, the effects of these forces, the effects of our mindset in the social context, are not mysterious or magical. They're understandable. They can be measured, categorized, and quantified. Third, the effects of these forces are not adversaries. They are allies, critical building blocks in a hierarchy of healing that can occur.
We spent 13 years and $3 billion mapping the human genome. The early results have promised that the future of medicine will be more personalized and more optimized than ever before. It's been worth every hour and every dollar. But we've also left some really important stones unturned. An improved understanding of these forces -- the social context, the mindset of the patient, the body's natural ability to heal these forces -- can be an extraordinary resource for health and healing just as soon as our own minds are open to that possibility. Thank you!