The Curative Waters And Warnl

Poultices of Psychotherapy

ARTHUR K. SHAPIRO, M.D.

• In eighteenth century England, when theword plncebo first appeared in a medical

dictionary, there were fewer than 100 physi­cians accredited by the College of Physicians.The demand for medical treatment could notbe met and largely fell to clerics and apothe­caries, who were later incorporated into medi­cine as physicians. One such cleric was thefamous philosopher Bishop Berkeley.'

His most famous remedy was tar-water;originated in Rhode Island, this concoctionwas made by shaking a gallon of water witha quart of tar. After being allowed to standfor three days, the supernatant was pouredoff.'

Berkeley wrote metaphysical tomes aboutthe virtues of tar-water. It was widely usedby empirics, but referred to by others asquackery or the tar-teater 1Tumia of BishopBerkeley." His claims for superior salutaryeffects were based on what he described as"evidence, tests, experiments, matters of fact,the best reason, judgment and experience,"affidavits, and many years of use. Enteringinto the controversy about its employment, heproposed an experiment in which patients\vould be "put into two hospitals at the sametime of year, and provided with the samenecessities of diet and lodging: and, for fur­ther care, let the one have a tuh of tar-waterand an old woman; let the other.... what at­tendance and dmgs you please." Had this ex­periment been done, tar-water would haveproven conclusively superior to all the treat­ments of the best physicians. The reason isobvious today. Medical practice was underthe influence of humoral theories, and treat­ment was largely based on depletion, evacua-

Doctor Shapiro is from the Division of Psychiatry,Montefiore Hospital, New York 67, N. Y.

Presented at the American Psychiatric Association,Divisional meeting, November 21, 1964, Philadelphia,Pa.

]anuary-Fehmary, 1966

tion, and dehydration. Berkeley, on the otherhand, advised, especially for fevers, a largeglass of tar-water every hour.'

Berkeley, other empirics, and their op­ponents, would have been astonished by thesimplicity of the remedy-simple water.

Are we destined to be similarly astonished?Of what do the curative waters of psycho­

therapy consist?Is it more than simple suggestion, non­

specific, unintended, or placeho effects? Ifplacebo, what do we mean by the term?There is little agreement even about this.Can it be clarified?

Yes, I helieve that a definition of theplacebo can he formulated. But it will henecessary to re-examine the etymology andsemantics hecause previous histories arc in­adequate."'"

DEFl:-\ITION OF PLACEBO

The Oxford New English Dictiollary at­tributed the first definition to Hooper's 1811medical dictionary where placeho was definedas "An epithet given to any medicine adoptedmore to please than to henefit the patient."

Pepper, in a classic paper which hecame animportant reference for the history of the wordplacebo, noted that Hooper's definition actual­ly appeared eight years earlier, and cited astill older definition which appeared inQuincy's 1787 dictionary. The first definitionactually appeared, however, in Motherhy's1785 Neu: Medical Dictionary. But more im­portantly, Pepper and those who followedmisquoted this definition as "a commonplacemethod of (sic) medicine." The actual defini­tion, in Quincy, Motherby, and others, was "acommonplace method or medicine."

The distinction between "of' and "or" is im­portant. The former limits the definition tomedicine, whereas the latter includes anymedicine as well as method.

21

PSYCHOSO~fATICS

Soon thereafter, as medical theory and prac­tice changed, the term became limited tomedicine.

This continued until fifteen years ago, whenmedical dictionaries, in part by happenstance,began to limit the definition to inert sub­stances. Such interpretation has influencedthe thinking of many physicians and non­physicians who conceive of the placebo onlyas inert.

In recent medical literature and dictionariesdefinitions have been expanded.

My proposed definition, which I believefulfills historic and heuristic criteria, is as fol­lows:

A placebo is defined as any therapy (or thatcomponent of any therapy) that is deliberate­ly used for its nonspecific psychologic or psy­chophysiologic effect, or that is used for itspresumed specific effect on a patient, symp­tom, or illness, but which, unknown to patientand therapist, is without specific activity forthe condition being treated.

A placebo, when used as a control in ex­perimental studies, is defined as a substanceor procedure that is without specific activityfor the condition being evaluated.

The placebo effect is defined as the non­specific psychologic or psychophysiologiceffect produced by placebos.

In other words, a therapeutic proceduremay be given with or without knowledge thatit is a placebo. It would include treatmentsgiven in the belief that they are not placebosbut which actually are placebos by objectiveevaluation. The placebo may be inert or activeand may include, therefore, all medical treat­ment, no matter how specific or how admin­istered. It may take the form of oral andparenteral medication, topical preparations,inhalants, and all mechanical, surgical, psy­chotherapeutic, and other therapeutic tech­niques. It would include a treatment whichproduced symptoms or side effects which werenot specific for that treatment. A placebo mayor may not result in a placebo effect, and theeffect may be favorable or unfavorable-thatis, positive or negative.

PLACEBOGENESIS

If this definition can be accepted, althoughit may be difficult without the full rationale

22

which has been presented elsewhere,~-' weare confronted by the question of the etiologyof placebogenesis.

This has been reviewed fullyG.s and can besummarized briefly as follows:

The reaction of patients to placebos cannotbe reliably correlated with their personality,sex, intelligence, age, psychiatric diagnosis,projective tests, suggestibility, or the severityand chronicity of their illness. The factormost frequently reported to be characteristicof placebo reactors is manifest, unelaborated,or free-floating anxiety. Other important fac­tors in the patient include: the physician­patient relationship; confidence in, previousexperience with, the fame and popularity ofthe doctor and treatment; expectation of re­lief; defense mechanisms and their manipula­tion; motivation, learning, and conditioning;opportunity for catharsis; reduction of guilt;cultural factors; and various situational vari­ables.

IATROPL\CEBOGEl'I.'ESIS

Another important mechanism is iatroplace­bogenics,s.9 a term describing the study ofplacebo effects produced by physicians.

Iatroplacebogenesis can be direct or in­direct. Direct includes diverse phenomenasuch as the therapist's attitudes toward or in­terest in the patient, the treatment, and theresults.

DIREGr lATROPLACEBOGENESIS

Interest in the patient refers to the thera­pist's warmth, friendliness, liking, sympathy,empathy, disinterest, rejection, and hostility.

Interest in treatment refers to the physi­cian's faith, belief, enthusiasm, conviction,commitment, optimism, positive and negativeexpectations, skepticism, disbelief, and pessi­mism.

Interest in results refers to data distortioncaused by random observer effects and by in­tentional or unintentional nonrandom ob­server bias.

All of these interests have been demon­strated in many studies to be associated withsuccessful treatment and placebo effects.

The primary and direct effect of the healer'sinterest in the patient is on reduction of guilt.It is also associated with increased potentialsfor learning, conditioning, suggestibility, ca-

Volume VII

CURATIVE \vATERS-SHAPIRO

tharsis, and it stimulates other factors whichhave been correlated with placebo effects.

The primary and direct effect of the thera­pist's interest in the treatment is the mobiliza­tion of the patient's hope and optimism. Thisfactor also has a direct effect on guilt reduc­tion.

The direct effect of an interest in results ison nonrandom intentional or nonintentionalobserver bias. Data are influenced, com­municated, distorted, and then used to con­firm hypotheses.

All of these factors may now interact withthe potential specific effects of varioustherapies.

INDIRECf fATROPLACEBOGENESfS

Indirect iatroplacebogenesis,8,9 on the otherhand, has not been considered in the litera­ture,

The physician's interest may be indirect,subtle, and paradoxical. An interest in atheory and method of treatment, as opposedto an interest in the patient, may produceplacebo effects. This occurs when the patientdisplaces the interest from the therapy to him­self and experiences the physician's interestin his treatment as a personal one. Thus,placebo effects are produced or augmentedwhen the physician is prestigious, dedicated tohis theory and therapy, especially if it is ofhis own innovation, or if he is a recent con­vert; and when the therapies are elaborate,detailed, expensive, time-consuming, fashion­able, esoteric, and dangerous,

Although the placebo effect is probably amultidetermined phenomenon, iatroplacebo­genesis may parsimoniously help explain manyobservations about the placebo effect.

None of the foregoing sounds as simple asBerkeley's curative tar-water. Yet Berkeley's

January-Febmary, 1966

problems were not simple to Berkeley, nor tohis fellow cleric and empiric, John Wesley,the founder of Methodism. For cancer, Wes­ley advised "a Mellow apple, cut off the Top,take out the Core, fill the hole with hogs­grease; then cover it with the Top and roastthe Apple thoroughly. Take off the Paring,heat the Pap well, spread it thick on Linnen,and lay it warm on the Sore, putting a Blad­der over it. Change this every twelve ortwenty-four hours."l

Not too bad a cure, actually, if we considerthat what was called cancer during the eigh­teenth century was sometimes a neoplasm butmore often a nonspecific inflammation. Ofcourse, the essential ingredient in the concoc­tion was the warmth of the poultice.1

In conclusion, we may ask again, of whatdo the curative waters and warm poultices ofpsychotherapy consist?

REFEREKCES

1. King, L, S,: The Medical World of the 18thCentunJ. Chicago: The University of ChicagoPress, 1958.

2. Holmes, O. W.: Medical Essays. Cambridge,~Iass.: The Riverside Press, 1891.

3. Shapiro, A. K.: An historic and heuristic defini­tion of the placebo. Psychiatry, 27 :52, 1964.

4. Shapiro, A. K.: A rejoinder. Psychiatry, 27:178,1964.

5, Shapiro, A. K.: Semantics of the placebo, Sub­mitted for publication.

6, Shapiro, A. K,: Factors contributing to theplacebo effect: their implications for psycho­therapy. Am. ], PsycllOth" XVIII:73, 1964.

7. Shapiro, A, K.: Etiological factors in placebo('(feel. I.A.M.A" 187:712, 1964,

8. Shapiro, A. K.: Placebogenics and iatroplacebo­genics. Med, Times, 92:1037, 1964.

9. Shapiro, A. K.: Iatroplacebogenics. Paper pre­sented at the American Psychiatric Association,Divisional meeting, November 20, 1964. Phila­delphia; and to he submitted for puhlication,

35 Ellst 85th StreetXcIV York 28, New York

23