There are only two ways to live your life. One as though nothing is a miracle. The other is as though everything is a miracle. ~ Albert Einstein
Spells and medically hexing. Sounds like Voodoo, doesn’t it? In fact, without even a far stretch of the imagination, essentially, it is. Voodoo (also called Hoodoo, Voodoon), is just one of many spiritual belief systems and forms of practice that can be found around the world, rooted in the deep belief that an external power, deity, or authority has profound power over our consciousness and health, enough so that it can cause illness and death simply by believing it will. And it was the study of the suggestibility and power of ‘magic’ seen in the practice of voodoo that led Harvard Researcher Walter Cannon (also a major force in the research behind the adrenal stress response) to study the phenomenon associated with voodoo in the 1940s, which was soon after, in 1961, dubbed the nocebo effect by Harvard researcher Walter Kennedy. It has since also been referred to as ‘the evil twin’ of the placebo effect, which you have probably heard of.
Placebo – The Power of Positive Thinking
The word placebo translates literally as “I will please,” and is the phenomenon whereby the positive belief in a treatment or substance to improve health, alleviate a symptom, or cause a positive outcome, is associated with a positive outcome. It is extremely well studied, with over 2000 scientific papers demonstrating effectiveness, and thus is employed in medical research in the form of the placebo-controlled study because about 30% of the positive outcomes seen in clinical trials are thought to be based on a placebo effect. Therefore, to be considered effective, a treatment or medication must have an effect greater than the placebo used in the study, usually an inert substance or sham treatment that in some way mimics the actual treatment.
The studies that demonstrate the effectiveness and pervasiveness of the placebo effect, and its ability to be solicited in individuals, are extensive, varied, and fascinating. They include sham open heart surgery in which patients who underwent a surgical incision to the chest but had no procedure demonstrated the benefits that were expected with the actual surgery, reduced pain with analgesia when the patient is told this will not hurt much (compared to more pain, via the nocebo response, when told it will hurt), to improved effectiveness of medications based on the influence of the color of one pill compared to another.
One of the most amusing and interesting placebo studies looked at the weight and health parameters of 84 women who worked as room attendants (cleaning hotel rooms) in seven different hotels. At the outset, when questioned most stated that they got very little physical exercise beyond their cleaning tasks, which they did not feel provided adequate exercise. The experimental half of the group was then informed that their level of activity at work met the Surgeon General recommendations for an active lifestyle, whereas the control group were not told this. Although none of their behaviors or patterns of activity changed during the four-week study, at the end of the four weeks, those who were told they were getting a recommended amount of exercise lost weight, showed a decrease in blood pressure, body fat, waist-to-hip ratio, and body mass index, whereas the other group did not.
Nocebo – or Thinking Ourselves Sick
Beliefs and expectations are not only conscious, logical phenomena, they also have physical consequences, ~ Robert Hahn, author of the article The Nocebo Phenomenon
On the other hand, the nocebo effect has the power to cause pain, illness, and even death, which has been demonstrated conclusively in prominent medical journals, though is less well-researched than the placebo effect, largely because it’s not easy to get approval to do studies that can make people sick.
The term nocebo, first used in the 1960s, means “I will harm,” and if you believe harm will happen, it appears to increase your risk that it will. One dramatic example of this was seen in a study in the 1990s when researchers discovered that women who believed that they were prone to heart disease were almost four times as likely to die of heart disease as women with similar risk factors who didn't have this belief. This was regardless of their age, blood pressure, weight, and cholesterol levels. What did they share? The belief that they were likely to get sick.
Quoting Harvard professor Herbert Benson, the president of the Mind/Body Medical Institute in Boston, at which I completed a certification during my medical training, Brian Reid in his Washington Post article, “The Nocebo Effect: Placebo's Evil Twin,” writes, “There are examples of studies done on people undergoing surgery who almost want to die to re-contact a loved one. Close to 100 percent of people under those circumstances die.”
Frighteningly, the effect appears to sometimes become ‘contagious.” In a study done at a university in the UK, a group of students was instructed to inhale a sample of air, which they were told contained a ‘suspected environmental toxin’ that could cause headache, nausea, itchy skin and drowsiness. Half of the students then watched a woman inhale a sample of this air, after which she immediately appeared to exhibit those symptoms. While the sample contained regular, run-of-the-mill, uncontaminated air, students who then inhaled the air were more likely to develop these same symptoms, particularly women who had seen another student inhale it and show symptoms! This phenomenon of a nocebo illness spreading through a large group of people has been observed and is called ‘mass psychogenic illness.’
The impact of both the placebo and nocebo effects are psychobiological, and are visible using PET scans of the brain. The placebo effect increases dopamine and opioid activity, to name just a couple of the changes, leading to a sense of well-being and pain alleviation, whereas the nocebo response is associated with both reduced dopamine and opioids, and a sense of dread and, depending on the setting, increased perception of pain. Also impacted are the adrenal stress response system leading to changes in cortisol production, the immune system, and the cardiovascular system, including changes in blood pressure and heart rate. In the case of placebo, this works to our healing advantage; in the case of nocebo, not so much, and has led to heart attacks and sudden death!
If this article hasn’t grabbed your attention so far, here’s where it gets critically important to take note: The words medical professionals use when they are communicating with us may have the most powerful healing – or damaging – effect of all.
Sticks and Stones May Break Your Bones, But Words Also Matter: Medical Hexing
Words are the most powerful tool a doctor possesses,
but words, like a two-edged sword, can maim as well as heal. ~Bernard Lown
Nearly two decades ago my friend and colleague Robert Rountree, M.D. shared an important story from his medical practice. It went like this: A patient of his came in after she’d been diagnosed and treated for breast cancer. She asked him if breast cancer tended to recur, and he said sometimes, but usually not for about 10 years. Ten years later she was back in his exam room with a recurrence of breast cancer. “Doc,” she said, “Why couldn’t you have said I have 20 or more years?” He learned a lesson that some doctors never do – in most cases it’s best not to negatively prognosticate, because most often, we just don’t really know, and can be doing more harm than good.
In our culture, we have been deeply acculturated to believe that medical doctors have a tremendous level of not only knowledge, but authority, to the extent that the “Doctor as God” phenomenon is well recognized. Let’s just consider the fact that as adults, we address those we hire for services, for example, our hair stylist, plumber, even our lawyers if we have them, by our first names. Not so with our physicians. We too often inadvertently (and culturally) hand over a staggering amount of power to physicians, and moreso when we are in a medical exam setting, because of established power differentials (we’re in an exam gown, butt naked in the back while the doctor is clothed, we address the doctor with a title (Dr.) while we’re addressed often by first name, unless we’re elderly, then as Mr. or Mrs.. The greater the power differential, the greater the nocebo effect may be, so the male doctor-female patient dynamic may be especially problematic, and may partially explain why several studies have found that women seem to be more susceptible to the nocebo effect than men.
The nocebo effect is further, generally unwittingly, imposed on patients by doctors in the form of direct statements that are generally inherent to the communication style and facts that doctors have been taught, for example, “This is something you can’t recover from and you’ll just have to get used to it,” when discussing a chronic disease, or “Why are you using herbal remedies – those things never work,” when discussing unconventional approaches, as well as by fixed labels (such as the designations “high risk” “advanced maternal age” for childbearing women), indirect verbal cues, for example, a condescending verbal tone, and indirect non-verbal cues including a dismissive shrug of the shoulder or an eye-roll.
Our risk of nocebo effects is even higher when we feel more vulnerable, because we are more open to negative suggestions, vague communications, and misunderstandings. Why? All of us, when we are in an extreme situation or we feel exceptionally vulnerable go into a semi-trancelike state that makes us even more susceptible to the power of unclear communication, imposed doubt about our health and body, and negative suggestion. And in a culture where doctors have assumed and/or been ordained with priest-like power, the comparison to voodoo becomes even easier to understand.
So, any time we feel there is a threat to our health, such as a new diagnosis, surgery, or an accident or emergency, we are that much more susceptible to the nocebo effect. Apply this to the experience of a pregnant woman or a woman in labor who is given negative expectation for an outcome. An example of this happened to my first midwifery client over 30 years ago; she was told by her (male) obstetrician during a pelvic exam (an unnecessary one at that, and talk about a power differential when your spread eagle, feet in stirrups, with a stranger’s fingers in your yoni) in her first trimester that based on her slight height and build (around 5’4” and 125 pounds) and her husband’s greater height of 6’2”, she’d “never be able to push that baby out and would need a cesarean for sure.” Her innate intelligence won out, she switched to a midwife, and had a beautiful homebirth. However, nonetheless, only seconds before her baby’s head emerged, she stopped pushing, looked at me terrified, and said, “Is this baby too big for me to get out?” I reassured her that her baby’s head was well on it’s way out, that she could toss that concern away for eve, and with one more gentle deep breath and spontaneous push, her beautiful boy was born. Unfortunately, though we’d previously discussed it, she’d been burdened by this worrisome seed of doubt on some level in her psyche for her entire pregnancy.
Now imagine the vulnerability of a women laboring in the hospital who is told the same “You’ll never get that baby out.” It’s practically a self-fulfilling prophecy and perhaps a greater contributing factor to our national cesarean section rate of 34% than has been recognized and studied.
While it’s important to be entirely truthful, and not withhold information from patients, most of the time, with rare exception, we just don't know how long someone has. And the phenomenon of being “scared to death” and “worried sick” seem to bear out in our physiology. So, every time a doctor makes a pronouncement that your illness is incurable, that you just should ‘live with it,” that “there’s nothing you can do,” that you are relegated to a life of chronic disease and medication, that you have a limited rate of survival from a more serious disease – you are essentially being hexed just like in voodoo. And it’s pretty much how doctors have learned to communicate with patients, so there’s a good chance that you – or someone you love – will experience some level of medical hexing at some time. If you’ve been diagnosed with a “chronic illness” such as diabetes, Hashimoto’s or another autoimmune disease, depression, anxiety, or any number of conditions, chances are you’ve already experienced the ‘jinx.’
Words have biological consequences, but health care providers are largely ignorant of the impact our words are having. Meynen et al., in an article in the American Journal of Bioethics in 2012 stated that the “The physician’s words not only describe reality, but they modify and create reality.”
It’s not just sticks and stones that can break our bones. Words can harm.
Think Sick, Stay Sick?
To some extent, the placebo and nocebo effects demonstrate that the body does what the mind expects, that we can “expect” ourselves into sickness. The medical literature is rife with examples.
So many of the women who contact me via the internet about their health concerns, some of who become my patients, have been struggling with symptoms for so long, they’ve forgotten to focus on what it feels like to be healthy. When I ask, “What does being healthy look like to you?” I am sometimes met with a continued list of symptoms as if the question itself didn’t even register. Most women have never considered what health “looks like” to them. Some have wrapped their identity in the blanket of their symptoms, illness, and diagnosis. An example that was recently brought to my attention was women with Polycystic Ovarian Syndrome (PCOS) referring to themselves as “Cysters” (as in sisters, the pun being that previous definitions of this condition included the presence of ovarian cysts, though ironically, these often are present in women with PCOS).
While commiserating in diagnosis-based Facebook and other groups can initially reduce one’s feelings of isolation and distress, it can also reinforce and amplify a disease mindset, so it’s important to check in with yourself on how you feel when engaging with the group. In fact, one might say that even receiving a diagnosis, though important for determining treatment, can have a nocebo effects. I’ve seen this in Functional Medicine practices, where someone goes into the doctor with some gas and bloating and comes out with a laundry list of diagnoses – SIBO, Candida, adrenal fatigue, mitochondrial dysfunction, estrogen dominance to name a few of the most common. While again, these can be instructive, this new long list can make someone who previously felt overall generally well, now feel like they are the walking wounded, or as patients have confided after such visits, “I’m a lot sicker than I thought.”
To some extent chronic illness, partly as a result of inflammation and activation of the HPA Axis (the Stress Response) which is very common, can impact the brain in such a way as to cause us to lean in a negative direction – a phenomenon known as ‘negativity bias.’ But it’s important to try to kick the sick mentality, if possible. I suggest to my patients as part of changing their mindset to a wellness one next you’re tempted to give a litany of symptoms to a colleague, friend, or family member who asks you how you’re doing, consider reframing your usual response from a litany of ‘sick symptoms’ to: ‘getting better all the time.’
Stress, Nocebo, and the “You Zone”
Interestingly, the nocebo and plabeo effects play a role in whether stress impacts our health. While I have written a great deal on the potentially harmful impact of stress on our health on many levels from mood and mental focus to weight, hormones, and immunity, what I have more accurately described in my articles and latest book is the impact of distress on our health. While we’ve largely been led to believe that stress can kill, stress itself, it turns out, has numerous positive stimulating effects on our immunity, mental focus, well-being, productivity, and performance. In Kelly McGonigal’s book, fabulously called The Upside of Stress, she illustrates in detail that it is not merely stress that has a negative impact on our health, but our perception of stress as beneficial or harmful. When assessed statistically, our rates of death from disease don’t go up just because we’re under stress, how we interpret and perceive that stress plays the greater role in determining outcome (health, death). You can read more about her important findings here in her book, watch her Ted Talk, or learn more in my book, The Adrenal Thyroid Revolution, in which I give you tools for staying in what I call The You Zone – your stress “sweet spot” – without crossing into distress.
Beware of the Internet (and Over-Testing)
It’s important to take care, also, in this age of rapid internet access to health information, not to ‘psych’ ourselves into sickness. As Benjamin Osteroff states in his thoughtful article about his father’s death, “The volume of medical information available today provides as much of an opportunity for unnecessary anxiety as it does for a patient to practice due diligence.” And Meynen, from the above-mentioned article stated that nocebo effect “shows us that mere information about potential harm is likely to be harmful itself.”
Indeed, I’ve received numerous worried emails from individuals who’ve had some form of Functional Medicine testing, whether self-ordered online or from a health practitioner, ranging from food IgG (“allergy testing”) to genetic testing for “SNPs” such as the MTHFR, the results of which can include statements such as having this genetic change may increase your risk of miscarriage, heart disease, and stroke, have not only caused them great anxiety and even fear, but that have often erroneously led to years of avoiding a long list of foods to which they were not truly ever allergic, supplements to take, and worries which may be entirely unnecessary and unfounded.
While I do have many patients with true food intolerances, for example, when it comes to food and the nocebo effect, I’ve more than once wondered whether some of the symptoms so many of us experience after eating otherwise healthy foods isn’t in part due to a mass nocebo effect – those of us interested in integrative health are bathed in a continual sea of information about what can harm us. One double-blind study, designed to evaluate a controversial method of food allergy testing, compared the effect of injecting the foods to be evaluated with the effect of injecting plain saline solution. The patients in the plain saline injection group were made aware that allergic type responses could occur and might include itching of the nose, watery or burning eyes, plugged ears, tight or scratchy throat, nausea, dizziness, sleepiness, and depression. The proportion of patients who experienced symptoms was similar in both groups, and furthermore, a ‘‘neutralizing’’ injection, given to eliminate the reactions, were also equally effective regardless of which injection they’d initially received. This study thus showed both a nocebo and placebo effect!
Is it possible that more of our health symptoms than we realize are a result of the barrage of health negative information overload we’re experiencing? I wonder. After all, the nocebo hypothesis states that negative expectations can cause symptoms and sickness, and cultural beliefs contribute to the nocebo effects. It’s worth considering our mindset about how we’re approaching our health and the health information (and sometimes misinformation) we’re exposing ourselves to. Consider, for example, the impact of worrying about your food possibly inducing symptoms the entire time you’re taking in your meal? Perhaps this is a realistic expectation based on symptoms you’ve previously experienced from certain foods. But are we certain it’s just the food causing the response? Or can mindset and beliefs contribute? And how might we feel differently if we ate with greater receptivity to our foods and trusted our body to be able to digest them better? Are we feeding ourselves too many food–unfriendly thoughts?
Break the Spell and Reclaim Your Power
I’m not saying that having a placebo mindset will cause miracles to happen. Life, health, and illness are more complicated than that. But we do know that getting stuck in “negativity bias” can impede healing. So why stay stuck there?
If you’ve been struggling with symptoms and have already ‘tried everything,’ you may have begun to doubt your ability to improve or recover and that persistent belief could contribute to the nocebo effect. So, telling tell yourself on a regular basis “nothing ever works for me,” “I’m never going to get better,” “I guess I’m just stuck with this and am always going to feel this way,” is hexing yourself! Perhaps in this situation, the recommendation of “fake it ‘til you make it” when it comes to your beliefs, may have some value. Similarly, if you’re doubtful of the potential effectiveness of your therapies, or excessively worried about the side effects of medications, foods, or supplements, it’s possible that you’ll be more likely to experience those side effects, and studies have shown that if you think the treatment is likely to fail, it more likely will.
We can create our own self-fulfilling prophecies one way or the other – so why not be our own placebo instead of nocebo!
In order to reclaim our power, we must develop a sense of health self-efficacy and agency – that is, the core belief that we can have a positive effect on our own lives, wellness, and healing, and that our efforts do make a difference. Or to quote Nas, a rapper from my hometown (shout out to Queens, NY:)
I know I can, be what I wanna’ be, if I work hard at it, I’ll be where I wanna’ be…
Can every illness be 100% cured with positive thinking? I’m sure that’s not the case, nor do I believe that positive thinking will prevent every illness, accident, and tough life experience. Illness and injury are part of the journey of being human for some – indeed, many – and while I wouldn’t wish it on anyone, the reality is, it’s part of life and sometime even a great teacher.
Neither am I suggesting abandoning common sense and good treatment – including conventional therapies – in the name of faith. Some of us will need a cesarean or other form of surgery, a cancer treatment, a thyroid or other medication and I’m sure I speak for many when I say I’m so glad they exist and available. Should you ever face such a situation, the scientific and medical evidence seems clear: expecting the best possible outcome, having confidence in your ability to heal and the efficacy of the healing tools you’re employing will, statistically, increase that likelihood of treatment benefit. Indeed, the placebo effect can enhance immune, hormonal, neurological, and other physiologic functions.
Importantly, we must break the spell of seeing doctors as gods, as having greater power over or wisdom about our bodies than we do. It’s an illusion based on centuries of medical hegemony, not truth. Right now I could give you a list of at least 15 medical “whoopsies” from the last decade alone that have led to massive practice and policy changes in health care – from unnecessary intervention and suffering for patients from overuse of antibiotics leading to fatal infections, overuse of labor induction leading to unnecessary cesarean sections for mothers and problematically high rates of premature births with massive consequences for babies and families, inappropriate timing of pap smears for young women leading to overly aggressive treatment of cervical cellular changes and HPV which in turn led to eventual problems maintaining pregnancies and giving birth naturally for numerous women, to the…and the list goes on.
Medicine is not infallible. Guidelines are not set in stone. Prognoses are not divine. And doctors are not gods. Let’s stop giving over our power as if they are, and instead work in healing collaborations. Please repeat this to yourself if you are a medical care provider, including an Integrative or Functional Medicine doctor – we’re all just human.
You have the right to a provider with a healing attitude within the context of being honest, direct, and giving you the whole picture and all the information you need to make the best decisions for yourself; your health and even life may depend on it. In fact, trusting a doctor is considered to generate positive placebo effects. So, if your doctor isn’t instilling a sense of trust, or your doctor is instilling a negative belief about your ability to heal, either have the courageous conversation that you need with him or her to be more uplifting, healing, and supportive, or change practitioners. This nocebo stuff is no joke and staying in a bad relationship just to be polite is not in your best interest. It can, in fact, be deadly. And a trusting one can be therapeutic on many levels.
A New Mindset
If you personally are stuck in a ‘nocebo mindset’, whether because that was instilled in you by a practitioner, or an experience that left you filled with self-doubt, hit the pause button for a minute. I mean right now. Grab a piece of paper and ask yourself/notice:
- What are my beliefs about my body’s ability to heal?
- Do I believe in the therapies I’m trying?
- How about my practitioners?
- What’s the story I tell myself or the meaning I ascribe to my symptoms?
- What (or who) triggers my doubts about healing or the treatments I’m using?
- What do I truly believe about my body’s innate healing capacity?
Harkening back to the opening quote of this article, what if we were, as Albert Einstein suggested is possible, to shift our expectations to allow for a miracle mindset? The medical profession, from which most of the healing and disease beliefs we have been instilled with since childhood arise, has led us to believe that our bodies are lemons or machines that are going to chronically break down, that disease is inevitable, that the only ‘real solutions’ and ‘right answers’ are pharmaceuticals, surgery and other potentially invasive interventions, and that science always trumps nature. We do not, as a culture, hold and nourish the belief that the body has an innate healing capacity, and that we can enhance and support, or dampen and destroy this capacity, with our thoughts, feelings, and beliefs. Yet the science on the placebo and nocebo effects leaves no doubt that this is the case and that we have a choice as to whether we believe in our ability to get well – whether through natural approaches, drugs, or surgeries – the outcomes of all of which are influenced by our beliefs.
In my book, The Adrenal Thyroid Revolution, I make a statement that I often share with my patients because I have seen the incredible healing capacity of the body, women’s power to give birth, and the power of the mind and our beliefs on our wellness. It goes like this:
Your body has the capacity to heal beyond what you’ve ever been led to believe.
Digest that for a minute. Turn it over in your mind. Let is sink into your being. It’s a powerful dose of medicine you can give to yourself every day, whatever the healing journey you’re on.
