If I had understood placebo and nocebo early in my career, I would have been a much better therapist
Early in my massage career, I denied the potential impacts of placebo in my work and was unaware of nocebo. I took credit for positive results and blamed negative results on clients not correctly following my advice. If I had understood placebo and nocebo back then, I would have been a much better therapist.
Like yin and yang, placebo and nocebo are similar yet opposites, and they are important aspects of every therapeutic encounter.
• Placebo is a neurological response that increases the potential positive effects of an intervention.
• Nocebo is a neurological response that increases the potential negative effects of an intervention.
Neither placebo nor nocebo requires conscious awareness of what is happening, nor any specific knowledge. Both have been documented in many different animal species, though for ethical reasons much more research examining placebo has been conducted.1
“It is worth knowing that there is not a single but many placebo effects, with different mechanisms across different systems, medical conditions and therapeutic interventions. For example, brain mechanisms of expectation, anxiety and reward are all involved, as well as a variety of learning phenomena. There is also some experimental evidence of different genetic variants in placebo responsiveness … Overall, there is today compelling evidence that placebos and drugs share common biochemical pathways and activate the same receptor pathways, which suggests possible interference between social stimuli and therapeutic rituals on one hand and pharmacological agents on the other. The same holds true for the nocebo effect, the opposite phenomenon of placebo.”2
Further, “The study of the placebo effect and of its evil twin, the nocebo effect, is basically the study of the therapeutic ritual around the patient, and it plays a crucial role in the therapeutic outcome.”3
Whatever we experience, even physiological responses that we are not aware of, induces various types of learning that can impact how we respond to similar stimuli in the future. Pavlov’s experiments with dogs salivating to the sound of a bell is a classic example.
At the University of Calgary, Melanie Noel, PhD, RPsych, has found that painful experiences and parental anxiety early in life contribute to negative learning experiences and increase the odds of developing chronic pain later. However, adding a positive aspect to the experience after the pain was experienced, or specific praise—such as, “You were so brave when you held still”—can reduce negative impacts or even reframe the experience as positive.
Professors David Butler and Lorimer Moseley of the University of South Australia, also founders of the Neuro Orthopaedic Institute, describe placeboic things as “safety in me” (SIMs) and noceboic things as “danger in me” (DIMs). The idea is to consider all things that may contribute to a sense of safety or danger, even if the client isn’t conscious of it, then work with them to minimize DIMS and emphasize SIMS.4 Here are some examples that apply to massage businesses:
|SIMS (Safety in Me)—Placebo||DIMS (Danger in Me)—Nocebo|
|Sounds||Relaxing, enjoyable music||Loud, unexpected, unpleasant noise|
|Light||Appropriate light level||Too bright, too dark; otherwise unpleasant|
|Temperature||Consistent, comfortable temperature||Too hot, too cold, or too uneven|
|Smells||Little or no odors, no strong scents||Weird or unexpected odors, strong smells|
|Environment||Clean, organized, well-maintained||Not very clean or organized, in poor repair|
|Parking||Well-lit, convenient parking||Inconvenient parking, poor outdoor light at night|
|Therapist||Professional appearance and attitude||Unkempt appearance, body odor, poor attitude|
|Expectations||“This is going to be great!”||“This is going to hurt so bad.”|
|Beliefs||“They really listen to me.”||“They don’t believe me.”|
Massage therapists have some control over all of these factors. Some are relatively easy to address at any time, while others are best addressed when selecting a place to practice. Expectations and beliefs can change based on how we interact with clients. Client education provides opportunities to shift clients towards more positive beliefs and expectations, and positive experiences support them.
It is important to note that referrals to mental health professionals or physical therapists is appropriate when working with people who have chronic pain. There are many aspects of chronic pain that contribute to mental health problems such as depression and anxiety, but it’s also possible that mental health factors are contributing to their pain.
Therapies such as graded motor imagery, mirror therapy, cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT), and other approaches that require advanced training and licensure might be critical to improving long-term quality of life and happiness of people with chronic pain.
Well-intended attempts to address a client’s “emotions” can easily backfire. All massage therapists should refer patients with “emotional issues” to mental health professionals. It can make a world of difference.
The client’s experiences form an internal narrative, the story of their life. Prior bad experiences may predispose them to have worse future experiences. Massage therapy educator Michael Hamm, LMT, CCST. posed this question: “How do we navigate our role in gently guiding their narrative to be more healthy and less nocebo?”
One answer is this: “Be the best warm, helpful, engaged human with a skill set to offer that you can be. Be patient and use all your acute, well-honed listening skills, as best you possibly can.”5
In “The Placebo Effect in Manual Therapy”6, Brian Fulton, RMT, offers many helpful examples. Here are a few:
• Clients who have had negative prior experiences may respond well to different methods, or to combining familiar methods with approaches they haven’t experienced before.
• Changing up your routine, altering the intensity, or adjusting the speed of your work may give better results.
• Always offer hope, encourage positive self-talk, and project confidence in a positive outcome.
• Minimize noceboic language in client education, obtaining informed consent, and during sessions.
• Offer alternatives if the client is not enjoying or responding well to the current approach.
• Keep your appointments, remain on-time, and make sure your client feels important.
• Set realistic goals and explain your plan and strategy for them.
• Ask open-ended questions and then listen to clients’ answers. Follow up to make certain you understood their answers.
• Don’t be afraid to admit you don’t know something. No one expects you to be perfect, and this honesty earns trust.
As should be apparent after reading this article, both placebo and nocebo effects can be stimulated by what you say, what you do, client beliefs and more. Pay good attention to all aspects of your massage practice for better client outcomes.
Jason Erickson, BCTMB, CPT, co-owns and practices at Eagan Massage Center. A former chronic pain patient, Jason is an internationally recognized continuing education provider teaching classes on pain science, dermoneuromodulation, sports massage, research literacy and more. His articles and podcast appearances are widely featured. For current information on his CE classes, visit healthartes.com. Read his article, “10 Steps to Succeeding in Your Massage Business Role.”
1. Wall, P. “Pain: The Science of Suffering (Maps of the Mind).” Columbia University Press. 2000.
2. Frisaldi E, Shaibani A, Benedetti F. Understanding the mechanisms of placebo and nocebo effects. Swiss Medical Weekly. 2020; Sept. 1;150:w20340. doi: 10.4414/smw.2020.20340. PMID: 32920787.
3. Benedetti F. Placebo-induced improvements: how therapeutic rituals affect the patient’s brain. Journal of Acupuncture & Meridian Studies. 2012; Jun;5(3):97-103. doi: 10.1016/j.jams.2012.03.001. Epub 2012 Apr 10. PMID: 22682270.
4. Butler D, Moseley L. “Explain Pain Supercharged.” NOI Group. 2017.
5. Jacobs D., “Dermo Neuro Modulating: Manual Treatment for Peripheral Nerves and Especially Cutaneous Nerves.” Tellwell Talent. 2016.
6. Fulton, B. “The Placebo Effect in Manual Therapy: Improving Clinical Outcomes in Your Practice.” Handspring Publishing. 2015.