Cognitive Therapy a Placebo ?

Hi Fred,

I like the way you keep your focus, but keep learning from every dialog. I have two comments on your interesting post.

First, I think there is evidence of enough individual variance in executive function and talent for self-regulation (1) to account for people having very different experiences with monitoring and changing their thoughts, and trying to regulate undesireable feelings and impulses in this way.

The phenomenal effectiveness of Ritalin, at least in the short run, reveals that self-control can be altered. The drug doesn't just directly alter the way we feel, it alters our ability to control ourselves. The empirical question is whether and to what degree we can also alter self-control and improve self-regulation of emotional storms, obsessive thoughts, and impulsive or compulsive behaviors _without_ a drug. The problem with the claim that "we can't do this simply by monitoring and changing thinking patterns" is that it is fairly trivial. Very few people would argue with it, and very few cognitive therapists rely entirely on that kind of intervention. As far as I'm aware, cognitive therapy doesn't rely on a simplistic top-down model of cognitive processes inhibiting emotion, though it exploits that mechanism when it is relevant.

Second, the notion that any form of therapy shown to be effective can be dismissed as a general placebo effect is an odd one that doesn't seem to add much to our understanding. Placebo simply means that we do something to please someone. It has a weak sense meaning that we just report a positive change to please an observer. Someone gets a sugar pill and claims that they feel better, but there is no objective evidence to support that they have improved. In this sense, clearly anything that works is "better than placebo."

Unfortunately, placebo is also often used in a stronger but confusing sense meaning that we experience an objectively measureable psychological or physiological change without an active intervention. That is, the term "placebo" has come to refer to what some authors refer to "healer within" or "mind-body" effects where the body affects itself in a _medically_unexpected_ way. Having this name for effects just because they are unexpected makes for tremendous confusion. I think most "placebo effects" in this sense are found eventually to have medically conventional causal links in the connections between the body systems. Things like odd superstitious rituals seemingly causing warts to go away more quickly, or things like allergic responses to simulated allergens, or things like conditioned immunosupression. It is in this sense that some have compared effective therapy to "placebo."

This is closer to Beecher's original sense when he used "placebo" to try to explain the real pain-relieving effect of inert drugs that people believed were morphine. Both the weak and strong sense are important when we consider the 'placebo control' in experimental protocols, so in that context the term overlaps both.

However, I think the strong sense is better called "expectancy effects" because that emphasizes that we are responding to a perception of circumstances rather than just putting on a pretense to please someone.

The problem with the strong sense of placebo or general expectancy effect is that the conditions for expectancy effects are not well understood, or at least are not what most people assume they are. Recent research underscores this by revealing that most so-called placebo effects in placebo control trials are most often very weak or non-existent.(2,3) Yet in individual experiments, expectancy effects can be demonstrated dramatically, and overlap somewhat with hypnotic suggestion effects.(4) To reconcile these conflicting outcomes, we either have to assume that 50 years of research showing placebo effects was all "bad" or else that the "placebo control" isn't neccessarily the same thing as the expectancy effects seen in experiments that purport to demonstrate a "powerful placebo."

This means that claiming an effective therapy to be "due to placebo" or "no better than placebo" is getting the point backwards, I think. Placebo is a vague term for an often ineffective technique of giving someone an inert treatment and looking for a real response. A therapy that can be demonstrated to be effective is instead revealing some specific conditions that provide a real benefit, while sometimes comparing one "placebo" to another. The outcome research is not just telling us that "placebos" work, it is telling us something more specific about the conditions that lead to improvement.

That a study can now show one "placebo" to be more effective than another "placebo" reveals the weakness of the placebo concept and the value of the research. Finally taking us beyond Hans Eysenck's famous study and the "Dodo Hypothesis" and that whole traditional line of critique claiming that all therapy is basically the same. Clearly it isn't all the same, and it will be useful to learn how and why it
differs, and the specific role of individual differences as well as therapeutic techniques and their interactions.

(1) Barkley, R. (1997). "ADHD and the Nature of Self Control," Guilford, New York.

(2) Hrobjartsson A., Gotzsche P. C. (May 24, 2001). " Is the Placebo Powerless?— An Analysis of Clinical Trials Comparing Placebo with No Treatment." N Engl J Med 2001; 344:1594-1602.

(3) Bailar, J. C. III. (2001). "The Powerful Placebo and the Wizard of Oz." N Engl J Med 344: 1630-1632
(4) V. A. Gheorghiu, P. Netter, H. J. Eysenck, & R. Rosenthal (Eds.) "Suggestion and suggestibility: Theory and research." NY: Springer Verlag.

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