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British researcher Irving Kirsch and his colleagues conducted an extensive meta-analysis of published research materials on anti-depressant medications. Their findings were published in 2008 under the title "Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration." You can find it on line at http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045
A brief overview of their method and conclusion states the following: "The researchers obtained data on all the clinical trials submitted to the FDA for the licensing of fluoxetine, venlafaxine, nefazodone, and paroxetine. They then used meta-analytic techniques to investigate whether the initial severity of depression affected the HRSD improvement scores for the drug and placebo groups in these trials. They confirmed first that the overall effect of these new generations of antidepressants was below the recommended criteria for clinical significance. Then they showed that there was virtually no difference in the improvement scores for drug and placebo in patients with moderate depression and only a small and clinically insignificant difference among patients with very severe depression."
The same year this meta-anlysis was done, 2008, Oxford University Press published the book Talking Cures and Placebo Effects by David Jopling which is the focus of this review. It would not be surprising if, before reading the book, its title led the reader to the assumption that the author was going to argue that talking cures are no better than placebos. And to a certain extent that's true. But Jopling is careful to point out that placebos have in fact been proven to be a very effective treatment option in many--some very surprising--instances. Notice that the Kirsch study above doesn't claim that anti-depression medications and placebos are equally ineffective. It states that placebos actually work as well as the anti-depressants. This is the perpsective Jopling brings to his readers' attention. It raises the question, Why take a pharmaceutical product, with all its side effects and chemical activity on the body, when a chemically inert placebo works just as well?
But what exactly is a placebo, especially when it comes to talk therapies? And how could comparison trials on the effectiveness of placebos versus talk therapy be carried out? Wouldn't a 'talk placebo' still be a type of talk therapy by necessity? If a condition is known to be placebo responsive, such as depression, should therapists and doctors avoid prescribing active medication in favour of non-active placebo pills? In other words, should a placebo be considered a legitimate treatment option?
One of the most pressing issues in psychotherapy as it relates to placebos is the question of how the interpretation (for example, of dreams) and insights (for example, into the events of the client's childhood) actually promote a client's mental and emotional improvement. A vexing problem arises when interpretations and insights aren't factually accurate or even true--when they are nothing more than explanatory fictions offered by a well-meaning or incompetent therapist. Jopling asks whether, when false interpretations and insights are accepted as true by the clients, and the client improves, is that improvement attributable to the placebo effect? And if so, then is this improvement by means of placebo interpretations and insights ethical, considering the damage done when, for example, false memories of child abuse are created by therapists? These are the sort of questions Jopling answers expertly.
This book is well-researched, clearly written, with well-structured arguments as the foundation of each chapter. Jopling offers a number of fascinating case studies in both medicine and psychotherapy where placebos have been successfully employed to treat ailing patients and clients. One of the most fascinating phenomena discussed is what Jopling calls "open placebos" where medical patients are told they are being given a non-medicinal sugar pill, they knowingly agree to take this placebo three times a day, and they none-the-less still report improvement in their conditions. What can account for this? Jopling offers several possibilities.
This is a fascinating book that, among other things, illustrates the powerful influence of wishful thinking, self-deception, confidence in an authority figure, and hope in the process of recovery from both physical and mental ailments. I highly recommend this book to anyone interested in the purely theoretical or conceptual issues surrounding placebo use, as well as to those who work 'hands-on' in the many health care and helping professions. In it you will find some intriguing and unexpected answers to the question, What makes people better?
© 2009 Peter B. Raabe
Peter B. Raabe teaches philosophy and has a private practice in philosophical counseling in North Vancouver, Canada. He is the author of the books Philosophical Counseling: Theory and Practice (Praeger, 2001), Issues in Philosophical Counseling (Praeger, 2002), and Philosophical Counselling and the Unconscious (Trivium, 2006).