The Role of Patient–Practitioner Relationships in Placebo and Nocebo Phenomena

Abstract

Introduction: Placebo and nocebo effects form part of all therapeutic environments and play a significant role in the effectiveness of treatment outcomes. Patient expectancies drive these phenomena, which can be shaped through contextual factors including verbal suggestions, conditioning, and social observation. Objectives: This review seeks to identify the biopsychosocial factors of the patient– practitioner interaction that play a role in the development of placebo and nocebo effects, as well as the anthropological elements of the biodynamic process of relating that are meaningful in the development of expectancies. Methods: We conducted a narrative review of frameworks of the placebo and nocebo effect, including the impact of expectancies and interpersonal relationships in the context of healing and the clinical setting. Results: Expectancies leading to placebo and nocebo effects can be modified by macro and micro factors, such as culture and society, as well as individual psychobiological traits, respectively. The developmental sociobiological adaptations that form and consolidate mindsets and meaningful contexts play an important role in shaping patient expectancies, as well as patients’ conscious and subconscious reactions to signs and actions taking place within the clinical environment. Practitioner characteristics, like empathy, friendliness, and competence, favor the formation of positive expectancies. Caring and warm patient–practitioner interactions can enhance the therapeutic value of clinical encounters when patients’ positive expectancies are actively encouraged and engaged. Conclusion: A patient-centered approach rooted in demonstrating care and empathy can positively enhance a patient’s experience within the clinical environment and activate psychosociobiological adaptations associated with the placebo phenomenon. Pain patients could particularly benefit from non-invasive approaches for improving treatment effectiveness and quality-of-life.

Medical practice and placebo response: an inseparable bond?

“…Through experience, conditioning and learning, placebo effects often occur unconsciously but highly frequently [25]. The mere act of consulting a doctor when suffering, contributes to the placebo response as the doctor is associated with a healer's position, who will improve the patient's discomfort [26].…”

European Headache Federation recommendations for placebo and nocebo terminology

“…Appendix Table 2 Environmental factors and stimuli modifying placebo/nocebo effects Modifiable Non-modifiable Patient's expectations [13] Previous experiences [14] Pre-treatment verbal and non-verbal suggestions [15,16] Patient's personality [17] Speed of treatment titration [18] Cultural factors [19,20] Safety profile of treatment [21] Age [22] Patient-doctor relation/communication [23] Social Media and Internet information [24] Investigator/physician status [15] Gender [25] Affective and cognitive traits [26] Level of patients' education [22] Generic formulations [27,28] Genetics [29] The appearance of drugs or medical devices, e.g. packaging, color, price, drug taste, etc.…”

Narrative Medicine Meets Planetary Health: Mindsets Matter in the Anthropocene

“…In sum, there are many ways in which the study of mindsets-and the lessons already learned from placebo studies-can be applied on a larger scale. In the clinic, it is clear that expectancies are influenced by the cultural mindsets and contexts large and small [106,107]. It seems obvious that the factors which foster positive expectancies-empathy, competence, trust, warmth, assurance, respectful discourse-are of relevance at community and global levels.…”