It’s likely you didn’t notice the effect. But if the last time you visited your doctor they spent a little more time than usual with you, there’s a good chance you felt somewhat better afterwards. “Doctors tend to be very time-pressured these days, but even just a few extra seconds can do the work,” says Liesbeth Van Vliet, assistant professor at the Department of Health, Medical and Neuropsychology at the University of Leiden. “Just sitting down or making more eye contact can make the difference. It seems that the more you like your doctor, the more empathetic the doctor is, the better the patient feels after their consultation”.

Indeed, while doctors have long been cherished by patients for their ‘bedside manner’, Van Vliet points out that what lies behind this is something of a mysterious concept. She’s part of the team at the university’s new Center for Interdisciplinary Placebo Studies, created to research a phenomena that you may have heard of, but not quite understand: the placebo effect. That’s when there are positive healthcare results but these results are not attributable to the technical medical aspects of their care. You can, for example, give someone a pill that is chemically inert. It can’t work pharmacologically, and yet work it does.

While there is now a considerable push to find out how the placebo effect operates in clinical practice it suggests that there is more to the interplay of mind and body in the body’s healing and the patient’s experience than has long been appreciated by Western medicine. While some of those investigating the phenomena say it likely operates at some intersection of epigenetics, neurobiology and psychology, it seems to be primed by a combination of the relationship between doctor and patient, the patient’s expectation—“if we are encouraged to expect a pill to work better, it will,” says Van Vliet—and conditioning, much as Pavlov’s famed dog could be primed to salivate by the ringing of a bell, once it had been conditioned to associate the sound with being fed.

So the rituals around seeing a doctor, in developed countries at least—making an appointment, travelling for consultation, undressing for examination, being given a prescription, and so on—and the imagery that surrounds those activities—white coats, stethoscopes, clipboards, those pale green walls, that distinctive hospital smell— prompt the release of feel-good neurotransmitters with increased activity in parts of the brain related to mood and emotions, but also, more simply, ready us to feel better. It’s why, too, many of the rituals around ‘healthy living’—diet, exercise, relaxation and mental wellness and so on—may also provide a placebo effect above and beyond those behaviours’ measurable effects.

“The idea that all we take from that whole process is chemicals from pills is myopic,” reckons Kathryn Hall, assistant professor of medicine at Harvard Medical School and author of Placebos (MIT Press). “That’s why I, for one, feel better the minute I make an appointment with my doctor”. Just taking a pill—even a sugar or dummy pill—has a placebo effect. Having an injection—more invasive, more ‘medical’—has a greater placebo effect than a pill. It’s been found that pharmaceutical pills can be quietly replaced with a placebo with no change in health outcomes. Indeed, the fact that prescribed drugs often have minimal pharmaceutical effect in treatment anyway—as few as one in 10 according to one study—suggests that they are in some way working in concert with the placebo effect. Now the placebo effect is limited. It won’t, for example, cure cancer or fight a bacterial infection—drugs will be required for such very bodily, biological problems. The placebo effect has no part in unscientific New Age claims that you can simply think yourself better. But studies do suggest that it’s particularly beneficial in pain management, and in those many conditions in which stress is a major part: depression, PTSD, hypertension, fatigue, IBS, asthma, diabetes, other inflammatory diseases and so on.

Unfortunately, says Jeremy Howick, there’s a strong resistance— at best a grudging reluctance— within the medical establishment to accepting the placebo effect at all. “The placebo effect just can’t be dismissed as ‘not real’ any more. In fact, we’re building sufficient knowledge about it now that, I’d argue, it’s time for a revolution in the placebo effect that sees entrepreneurs rather than academics take its potential forward into implementation,” “argues Howick, professor of empathic healthcare at the University of Leicester, UK, and author of the recently published The Power of Placebos (John Hopkins University Press).

“Placebo studies were fringe just a couple of decades ago. They were considered wacky by the mainstream,” Howick adds. “The ‘placebo effect’ still gets used by some people in a derogatory way, in part because medicine has this undue focus on the bio- mechanical idea of the body—that it’s just a very complicated machine. Studies have gradually taken it into the mainstream”.

But not quite far enough, worries Hall. “I remember my mentor saying that when he would talk about placebos there would be nervous laughter. And still, not enough people take the idea seriously,” she suggests. In part that is because, as Howick points out, “it calls into question a lot of our drug-oriented medical training”. It summons up the spirits of woo-woo, of the mystical and metaphysical—all of which medicine, with its emphasis on the scientific method, is unsurprisingly dubious about.

And, certainly, there is much about the placebo effect that is, at the moment, hard to comprehend. Howick may argue that, since most of our thoughts are subconscious, the way our body reacts to a positive experience—for example, an unhurried appointment with a genuinely concerned doctor who isn’t time-pressured or over-burdened with form-filling, as so many are—has, ostensibly, little to do with what we consciously think about it. But even he still sounds surprised by the fact that “there’s a placebo response even if the doctor tells you that they’re giving you a placebo treatment”.

To make that clear: as if the placebo effect wasn’t already weird, it works even when you know, categorically, that there’s no active drug in your treatment; that is, if you take what medical types call an ‘open-label non-deceptive’ drug, the body is nonetheless tricked into thinking it’s getting some healing effect. You can even undergo what’s called sham surgery—in which there’s no actual surgery—and improve your shoulder impingement or knee osteoarthritis.

Likewise, while belief can play a huge part in the effectiveness of the placebo effect, studies suggest it works even with sceptics. Fabrizio Benedetti isn’t quite sure why this is so surprising—that we often knowingly experience the placebo effect in our everyday lives is self- evident, he suggests—and draws an analogy with watching a film.

“Movies are powerful triggers of strong emotional responses, ranging from love and tears to heartache and fear,” says Benedetti, professor of neurophysiology at the University of Turin Medical School. “These reactions take place even though the viewer is aware that everything is fiction. Considering human evolution and biology, this is quite surprising, as these reactions are supposed to have evolved for social interaction and survival. The fact that they take place during movie viewing even though neither social interaction nor survival is at stake indicates that emotional and behavioural responses can be elicited unconsciously— automatically—by merely simulating situations of real life”.

Yet you can see why the medical establishment might be wary of leaping to the same conclusion; the placebo effect might be why some "alternative" medicines—typically marginalised as lacking in evidence for their efficacy—actually work for some people, and so maybe shouldn’t be as dismissed quite so readily.

“There are quacks, of course,” Howick insists. “But perhaps the fact is that ‘alternative’ medicine practitioners are just better at evoking the placebo effect. Their philosophy aligns more with the science of placebos. It’s not that they’ve used crystals. It’s that they have given more time, attention and consideration to their patients and that has a positive effect. All this calls into question a lot of the fundamental tenets of modern medicine”.

There are also what Elissa Patterson, assistant professor of psychiatry at the University of Michigan, notes as being more political reasons why the placebo effect is still pushed back out to the margins—not least that powerful pharmaceutical companies are not overly keen on the idea that we could be using fewer drugs, despite our current over-use of them, with all of their side-effects to boot.

“People in medicine are really nervous about the placebo effect because they want ideas to be evidence-based. [The general public] tend to want to align with what’s scientific, too, because of that fear of snake oil salesmen,” she says. “I’ve seen people who get better and then hedge because they’re embarrassed, even ashamed by it being explained by the placebo effect. There’s the cultural belief that those who respond to it are weak or foolish. But evidence is often marketing material from pharmaceutical companies, so there’s no big push to champion anything that doesn’t make money, and the placebo effect doesn’t”.

As Kathryn Hall puts it, “Nobody wants to rock the boat”. That’s even though regulatory bodies won’t sanction a new drug unless, as is the gold standard for drug testing, it outperforms a placebo—sugar pills and the like—in blind trials. That can not only mean that certain drugs, long known to be of benefit in ameliorating certain diseases, can’t actually be used to this end, but also that some pharmaceutical companies are no longer trying to develop treatments for the likes of chronic pain and depression—two of the most widespread and debilitating medical issues—because beating the placebo effect is too expensive and too taxing.

Indeed, as Hall points out, the very fact that the placebo effect is built into drug trials makes such trials ineffective—as expectation promotes a placebo response whether the test subject is taking an active pill or an inert one. “We have drugs that people have done amazing testing on, demonstrated how they work, shown them to be safe to go into humans and yet turn out to be no better than placebo. We have to ask why,” Hall insists. “What is it that we’re missing?”.

The implications of further research—answering the many questions being raised about the placebo effect—would likely be profound, says Patterson, bringing broad institutional change, from the way pharmaceuticals are created to the nature of doctor/ patient interactions.

“We might even just save a lot of money by giving doctors the [freedom] to administer placebos when they feel there is benefit in doing something [other than just prescribing ineffective or potentially harmful drugs] when the best course of action is to get out of the way and let healing happen,” she says. “We need to start seeing the brain’s power to heal yourself as a kind of super-power”.