Roses, Falling Eggheads, Placebos, and the B-Word
What do poet Gertrude Stein and our interpretation of the bond have in common? In perhaps her most memorable line she wrote, “A rose is a rose is a rose,” a deceptively simple statement that has fueled academic discussions for decades. But according to Stein herself, the line referred to the fact that merely thinking or hearing a word suffices to elicit any imagery or emotions we associate with it. In other words and in spite of all those dictionaries out there, we choose to take a Humpty Dumpty approach:
‘“When I use a word,” Humpty Dumpty said in rather a scornful tone, “it means just what I choose it to mean—neither more nor less.”
(Lewis Carroll, “Through the Looking Glass”, Chapter 6)
But while I can understand the convenience of this for the speaker, it can be maddening when those in different academic disciplines and media choose to do the same thing for the same word because… Because why? Well, I think because, rightly or wrongly, we expect them to use words in a context that elicits images and emotions that complement our definition of the word. Or at least we expect them to tell us how they define the word so we may adjust our images and emotions accordingly.
In my case, I choose to define the word “bond” based on the dictionary definition as something that holds two components together. The bond may consist of something mechanical such as rope, chain or glue. Or it may be a biochemical bond, such as the attraction that holds atoms, ions, or molecules together to form cells, tissues, organs, and systems far greater than the component parts. Because we and animals are living beings held together by such bonds from which ultimately arise all our actions, thoughts, and emotions, to me it seems only natural that the bond that connects us to animals is biochemical in nature. The closer the person and animal are physically and emotionally, the more readily they consciously or subconsciously would pick up any changes and enhance those that benefit the relationship and extinguish those that do not.
While this definition of the bond makes sense to me, I discovered very early in my medical and behavioral career that many who used the b-word don’t share this definition. Either that or they share it in theory but not in actual practice. Medical and behavioral education typically ignores the existence of any interspecies biochemical bonds and their effect on animal health and behavior beyond that of a neutral conduit of the prescribed treatment. The exception to this occurs when said treatment doesn’t work; then a weak bond between person and animal may be blamed for its failure.
This got me thinking yet again about how we as animal-care professionals and companion animal owners, and those who use animals as a means to some beneficial human end (e.g., service animals, animal-assisted therapy or education) feel about how any proposed treatment could affect it. And as sometimes serendipitously happens, an article that gave me some intriguing clues appeared in my mailbox. Or rather the latest edition of Scientific American Mind with an article entitled “When Pretending is the Remedy” by Trisha Gura about the neurophysiology of the placebo effect showed up there. The article described several studies of particular importance to those who interact with animals in the aforementioned categories.
But before I delve into these I must note that, from the beginning and like the word bond, the word placebo has elicited multiple and sometimes mutually exclusive emotions and images from those in all walks of life. While some associate(d) it with the responses of feeble-minded folk easily hoodwinked buy snake oil salesmen, medical researchers long long recognize that a certain percentage of those participating in the most rigorously controlled scientific study will respond the same way to any sham treatment as those receiving the real McCoy. What differs now is that more scientists want to know how placebos work instead of dismissing them as a nuisance that increases the costs of their studies or mucks up their data.
So how do placebos work? Thanks to research conducted by Tor D. Wagner and his team at the University of Colorado at Boulder, we now know that expecting to get a pain-killer as well as actually getting one reduces people’s self-reported pain. It also turns out that this expectation and the medication itself affect different parts of the brain. Expectation of pain relief decreases activity in the brain areas associated with emotion while increasing it in the prefrontal cortex, that part associated with planning, reasoning, and problem-solving. On the other hand, pain-killers affect those brain centers associated with pain-processing. But these two events don’t occur simultaneously. The pain-reducing response to the expectation of pain-relief occurs sooner than the brain’s response to the actual medication. This led the researchers to suggest that adding the placebo effect of expectation of relief could be used to enhance the efficacy of analgesics. In addition to accelerating the time of response, it also might reduce the amount of pain medication required.
What’s interesting about these studies and their results is that they parallel discoveries made in dogs by Pavlov and others. Expectation of a perceived good (or bad—more on that later) event also stimulated parts of the dog’s brain different than those areas stimulated by the event itself. And it also triggered responses sooner than those caused by the treatment.
The fact that the placebo response lies beyond the effect of the treatment itself demonstrates the complexity of this effect. In another batch of contemporary studies, Ted J. Kapchuck, director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center in Boston, and Harvard researcher and psychologist Irving Bosh treated asthmatic patients with a known effective drug (i.e., albuterol) or saline inhalers, sham acupuncture, or nothing. Following this, patient respiratory scores determined via testing revealed that 20% of those receiving the drug improved compared to 7% of those receiving the placebo or no treatment. That seemed pretty straight forward until the researchers asked all of the patients to rank their respiratory discomfort on a scale of 0-10. When they did that, all except those who received no treatment reported a 50% improvement. This further supported the notion that response to treatment consists of the placebo effect and the drug or other technological component. A comparable study of subjective and mechanical evaluations of lameness in dogs with osteoarthritis showed a similar effect. (Michael Conzemius, DVM, PhD and Richard B. Evans, PhD. Caregiver placebo effect for dogs with lameness from arthritis. J Am Vet Med Asso 2012; 241: 1314-1319.)
Both the human and animal studies indirectly create the same dilemma, how to answer the question, “When push comes to shove, which do we trust more: the patient’s or caregiver’s evaluation of the patient’s response based on the patient’s quality of life, or some technological test result?”
Next we turn to the apparent source of those expectations regarding the effect of any treatment: clinician interactions with patients and patient care-givers. In this human study, once again the test group—composed of sufferers from irritable bowel syndrome (IBS) which also increasingly affects dogs and cats—received either sham or no treatment. What differed is that those in the sham-treatment group received either minimal or quality empathetic interaction with the caregiver. Those who received no treatment reported a 28% improvement compared to 44% of those who received minimal clinician communication. Meanwhile 62% of those for whom quality interaction was part of the treatment reported improvement of their symptoms.
The researchers then eliminated any deception by telling patients up-front that they would receive a placebo “that previous studies demonstrated produced significant improvement in IBS symptoms through mind-body self-healing processes”. Once again patients who received this treatment reported reduction in symptoms and an increased sense of well-being compared to those who did not.
Even more fascinating and another take-home message here: the clinicians who engaged in mindful, supportive communication with their patients prior to the actual treatment experienced the same brain changes as patients who anticipated the treatment’s success. Another way to think of this is that empathic communication put them on the same wavelength; they formed a neurophysiological bond with the patient that enabled them to enhance the patient’s ability to heal.
But what about placebos evil twin, the nocebo effect? A review of drug studies by Winifried Hӓuser of the Technical University of Munich also demonstrates that there’s a downside to expectations that arise from interactions with trusted sources. His review revealed that placebos caused half of the negative effects associated with the actual drug, a phenomenon he called the nocebo effect. He maintained, and the above and other studies on the positive effects of the placebo effect appear to support this, that warnings to patients or their caregivers could contribute to this. Naturally no one suggests that such possible negative consequences shouldn’t be shared. But once again, the need to be mindful of how this is done was stressed. Practitioners so terrified of lawsuits who practice defensive medicine to the point patients or caregivers believe it will be a miracle if they survive the diagnostic procedure or treatment may reduce their patient’s ability to do exactly that.
Think about these experiments and what they tell us, as members of animal-care professions, those prescribing the use of animals to help people, and private individuals dealing with our own animals, about the human-animal bond. We live in a society in which we easily may convince ourselves that quality communication with another person, let alone an animal, pales compared to just doing something. Why waste valuable time thinking and talking about medical or behavioral changes until we feel confident about what we’re going to do and why and can communicate that message to any animals involved via verbal and nonverbal communication that’s meaningful to them?
Because it’s not a waste of time. How we interact with animals before we begin any treatment will affect their response to it. If we feel clueless and apathetic and don’t care to remedy that situation before commencing the treatment, those are the expectations we’ll communicate to the animals, i.e. none. If anything about the proposed treatment makes us feel anxious and we don’t address those fears up-front, such is the nature of our half of the neurophysiological bond we offer our animals. If we feel confident about the treatment and our and the animals’ ability to accomplish it, communicating those expectations via our body language will jump-start the healing process.
The placebo studies offer tantalizing glimpses of their role in mind-body self-healing and the role caregivers play in enhancing that effect. At the same time they remind us of the role empathy and trust play in formation of a bond strong and flexible enough to support this kind of two-way communication. So while Humpty Dumpty and others may choose to define the human-animal bond strictly in terms of what animals do that affects us, there’s a lot to be said for defining it in terms of all the conscious and subconscious ways we continuously affect each other. Only by getting out of the me-mode and into the us-one can we use the bond to ensure the well-being of human and animal alike.