Therapeutic Healing and the Placebo Effect: from Qusṭā ibn Lūqā’s medicinal power of “persuasion or suggestion” to “open-label placebos”

   

None of what follows this introduction is written by yours truly, still, I thought it might be of interest to some of our readers. It concerns subject matter I hope to address now and again over the summer. Long-time readers of this blog will be aware of my abiding interest in the values and purposes of psychoanalytic theory and therapy, especially in the wake of Adolf Grünbaum’s critique of psychoanalysis,¹ as it provoked vigorous philosophical arguments and debates both about the scientific standing of psychoanalysis in general as well as specific beliefs, hypotheses, and theories within psychoanalysis in particular, some of which do not depend upon or pivot around the science question, and which I happen to believe has been resolved in favor of Freud and psychoanalytic psychology (be it Freudian, Kleinian, etc.). Psychoanalysis can thus in part be characterized as a novel science of human subjectivity (the other principal part being clinical therapeutic analysis) which encompasses fundamental properties of human nature, the constitution of the individual person or personhood, and the nature (hence philosophy) of mind. It is “novel” in the sense that it is neither simply a natural nor a social science while partaking of and transcending both, bringing to the fore, among other things, an extension of so-called folk psychology, a richer and more complex philosophy of mind, as well as model of human development and individuation. It addresses the possible and plausible reasons for as well as the prospects for the relief of, mental, existential, and physiological kinds of human pain and suffering as a mind/body therapy. It builds upon and in some respects still resembles modes of healing and “care of the psyche” found in shamanic, religious, magico-religious or alchemical, medicinal, psychological, philosophical and other traditions. And given prior attempts at integrating Marxism and psychoanalysis, I think this science of human subjectivity can, when combined with Marxist sensibilities, contribute to filling out a reasonable if not persuasive biosocialpsychological model that does justice to individual human beings, groups, and the contexts, settings, and situations they find themselves in that either enable and facilitate, constrain, or inhibit our efforts to attain human happiness (if not eudaimonia), welfare and well-being. In our follow up post, we will briefly look at the nature of the placebo effect in psychoanalysis, as well as, and perhaps more importantly, examine a psychoanalytic explanation of the psychological mechanisms underlying the placebo effect proffered by Linda A.W. Brakel.²

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“Although the modern use of the term [placebo] and an awareness of how frequently the placebo effect is a factor in treatment have a relatively short history, it has frequently been argued that the placebos have been at the heart of therapeutics during most of medicine’s history. [….] But with so much in the history of successful therapeutics retrospectively attributed to the unknowing use of placebos, it is well to be reminded that, however unaware most healers may have been, the knowing use of placebos dates back a very long way. [….] [I]n the Physical Ligatures of Qusṭā ibn Lūqā [al‐Ba῾labakkī] (ca. 820–912), the placebo effect and suggestion were given a significant place in therapeutics. [….] His Physical Ligatures was ‘a learned “high medicine” text on the empirical use of magic,’ in which he made the point, ‘on no less authority than Plato,’ that ‘the mere belief in the efficiency of a remedy will indeed help in a cure;’ and numerous manuscripts and early modern printings suggest that his work was widely read in the West. Qusṭā maintained that ‘a benefit of some drugs in some circumstances is the effect that they have on the mind, provided patients believe them to be remedies. Most of his prescriptions involved ‘the power of persuasion or suggestion;’ and he clearly recognized the placebo effect when he said that ‘the action of a medicine may be no more than the effect the suggestion has on the mind.’” — Stanley W. Jackson, Care of the Psyche: A History of Psychological Healing (Yale University Press, 1999): 281-282.

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“Given that placebos are such a powerful treatment on their own, we might ask ourselves: why are they not being used as a treatment more widely? One of the biggest barriers is an ethical dilemma. On the one hand, placebos are highly effective for certain symptoms and conditions, and can have a real therapeutic effect. On the other hand, to benefit from placebos, the predominant thinking has been that people need to be misled into believing they’re taking an active treatment. Since most medical authorities worldwide have agreed – for good reasons – that lying to patients isn’t a best practice, this reliance on deception has prevented the widespread use of placebos as treatments in and of themselves.

… [There is an] emerging research trend [that studies the] possible beneficial effects of placebos given without deception, also known as ‘open-label placebos’ or ‘non-deceptive placebos.’ In a foundational study in 2010, researchers at Harvard Medical School randomised patients experiencing irritable bowel syndrome (IBS) symptoms into either an open-label placebo group or a no-treatment control group – and crucially, all the patients knew which group they were in. The researchers told patients in the open-label placebo group that the placebo effect is powerful, that the body can respond automatically to taking placebo pills (similar to the classic conditioning example of Pavlov’s dogs, who salivated at the sound of the dinner bell), that a positive attitude helps but is not required, and that it is vital to take the pills faithfully for the entire 21-day study period, regardless of their belief in the pills. By the end of the study, even though the placebo pills contained no active ingredients, and despite the patients knowing they’d been taking placebos, they reported fewer IBS symptoms and more improvement in overall quality of life than patients in the no-treatment control group. [….]

So what’s really going on here? It’s not the sugar pill itself that leads to these changes in psychology and physiology, and it’s not magic either. Research in medicine and psychology on both traditional and open-label placebos suggests several mechanisms at play.

One is people’s expectations, or the positive belief that a treatment might have beneficial effects. In open-label placebo studies … people are often told that a belief in the placebo isn’t necessary, but they are encouraged to keep an open mind. Some of the clinical studies have involved volunteers for whom many other treatments have failed, and so they have added reason to hope that this experimental, slightly unorthodox treatment might work for them. Emerging research suggests that this belief might be partially responsible for the benefits. [….] Another possible mechanism is conditioning, in which the body learns to associate beneficial effects with an action or ritual. Many of us have had repeated experiences of taking pills that help reduce our symptoms – ibuprofen for a headache, NyQuil for a cold, or Pepto Bismol for an upset stomach. Over time, the body may learn to associate taking a pill with symptom relief. So the very act of taking a pill itself can catalyse the body’s own capacity for healing.

This conditioning is sometimes done explicitly in research with open-label placebos. In one clinical study, researchers asked patients recovering from spine surgery to pair their active pain medication with open-label placebos and also to take the placebo pills on their own. The placebo pills began exerting their own pain relief. Compared with the control group who received treatment as usual, patients who also took the open-label placebo pills consumed approximately 30 per cent less daily morphine in the days after surgery.

There are also other, less well-studied mechanisms that may be at play in open-label placebo effects. For example, when someone starts taking a treatment – placebo or not – they often begin paying closer attention to their own minds and bodies. Most conditions and symptoms fluctuate over time. For example, when we are experiencing a headache, even if we don’t take any medication or other action, the severity of that headache will naturally decrease over time. People who take open-label placebo pills may hope for improvement, making them more attuned to times when their symptoms subside. Other research shows that medical rituals – whether that’s taking a pill, getting an injection, or merely having a cup of tea and taking a hot bath – can evoke both expectations for healing and a conditioned response. Thus, the act of taking pills faithfully can become a healing medical ritual in and of itself.

Now that we are seeing an accumulation of evidence that open-label placebos might be helpful, researchers and clinicians are starting to think about how to apply them in practice to benefit patients. [….] Current and future research is continuing to shed light on which conditions open-label placebos might be best-suited to. As the field grows, a debate must follow: will open-label placebos ever become part of mainstream medicine? Is it better to focus efforts on convincing doctors (and patients) that open-label placebos can be effective, or should we better understand the mechanisms of open-label placebo effects and try to harness those mechanisms in conjunction with active medications and treatments, such as by boosting patient expectations? Will open-label placebos ever be more than a semi-fringe last resort for conditions and patients for whom most other treatments have failed?

Of no small consideration is the fact that, with little money to be made from prescribing sugar pills, the influential pharmaceutical industry has no incentive to promote this kind of medication over patented, privatised medications and treatments. In many ways, research on open-label placebos is still in its infancy. The next 10 years may determine the ultimate impact of this research. As the field progresses, one of us (Darwin) plans to continue to investigate and optimise open-label placebo effects on stress, anxiety and depression in both clinical and non-clinical settings.” — Darwin A. Guevarra and Kari A. Leibowitz, “Why placebo pills work even when you know they’re a placebo,” Psyche, March 9, 2022.

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“… [M]any remarkable healings of the past that had been attributed to magic, to miracles, to faith, or imagination in the nineteenth and early twentieth centuries came to be considered the results of suggestion, and more recently these same healings have been attributed to the placebo effect. Saying that suggestive effects are nothing but placebo effects, or vice versa, seems an acknowledgment that these two phenomena overlap one another. At the very least the suggestion of help is usually an element in the use of placebo. Further, among the factors that [Arthur K.] Shapiro³ views as significant in the placebo effect are faith, hopeful expectations, the healer’s manner and attitude, and the doctor-patient relationship, all of which have been considered significant for successful suggestion in healing contexts.” — Stanley W. Jackson, Care of the Psyche: A History of Psychological Healing (Yale University Press, 1999): 282

   

Notes

1. Adolf Grünbaum, The Foundations of Psychoanalysis: A Philosophical Critique (University of California Press, 1984). The best counter-arguments to Grünbaum are found in many of the titles in section 1 of my bibliography on psychoanalytic psychology and therapy. For one of the later rounds of this exchange, see the edited volume below by Boag, Brakel, and Talvite.
2. See her chapter, “The Placebo Effect: psychoanalytic theory can help explain the phenomenon,” in Brakel’s Unconscious Knowing and Other Essays in Psycho-Philosophical Analysis (Oxford University Press, 2010): 137-146.
3. Arthur K. Shapiro, “The Placebo Effect in the History of Medical Treatment,” American Journal of Psychiatry, 1959, 116: 298-304.

References & Further Reading

• Benedetti, Fabrizio. Placebo Effects (Oxford University Press, 2nd ed., 2014).
• Boag, Simon, Linda A.W. Brakel, and Vesa Talvitie, eds. Philosophy, Science and Psychoanalysis: A Critical Meeting (Routledge, 2018 [Karnac Books, 2025]).
• Brakel, Linda A.W. “The Placebo Effect: psychoanalytic theory can help explain the phenomenon,” in Brakel’s Unconscious Knowing and Other Essays in Psycho-Philosophical Analysis (Oxford University Press, 2010): 137-146.
• Brown, Walter A. The Placebo Effect in Clinical Practice (Oxford University Press, 2013).
• Evans, Dylan. Placebo: Mind over Matter in Modern Medicine (Oxford University Press, 2004).
• Guevarra, Darwin A. and Kari A. Leibowitz, “Why placebo pills work even when you know they’re a placebo,” Psyche, March 9, 2022.
• Harrington, Ann. The Cure Within: A History of Mind-Body Medicine (W.W. Norton & Co., 2008).
• Harrington, Anne, ed. The Placebo Effect: An Interdisciplinary Exploration (Harvard University Press, 1997).
• Jackson, Stanley W. Care of the Psyche: A History of Psychological Healing (Yale University Press, 1999).
• Jopling, David A. Talking Cures and Placebo Effects (Oxford University Press, 2008).
• Kolber, Adam J. “A Limited Defense of Clinical Placebo Deception,” Yale Law & Policy Review, Vol. 26, 2007; San Diego Legal Studies Paper No. 07-87.
• Miller, Franklin G., et al., eds. The Placebo: A Reader (Johns Hopkins University Press, 2013).
• Moerman, Daniel E. Meaning, Medicine and the ‘Placebo Effect.’ (Cambridge University Press, 2002).
• Shapiro, Arthur K. and Elaine Shapiro. The Powerful Placebo: From Ancient Priest to Modern Physician (Johns Hopkins University Press, 1997).
• Wilcox, Judith and John M. Riddle, “Qusṭā ibn Lūqā’s Physical Ligatures and the Recognition of the Placebo Effect,” Medieval Encounters, 1994: I: 1-48.

 Relevant Bibliographies

• Addiction
• Biological Psychiatry, Sullied Psychology and Pharmaceutical Reason
• Buddhism and Psychoanalysis
• Dreams and Dreaming
• The Emotions
• Human Nature, Personhood, and Personal Identity
• Notes on Science and the Sciences
• Psychoanalytic Psychology Beyond the Color Line
• Psychoanalytic Psychology and Therapy
• Public Health: Social Epidemiology, Ethics, and Law