Bonus material: Path dependency and status quo bias as ideology (31 Aug 2009)

I've got a post up at Generation Bubble about the usefulness of such concepts as path dependency and status quo bias to conservatives. Like the placebo effect, which is apparently growing stronger, the strength of these other psychological effects are probably controlled by ideology -- that is, their intensity can be manipulated by how ideas about them are repeated and ratified in the public sphere, ideas that become accepted as common sense, things that we fall back upon as natural explanations for phenomena, and natural ways to respond. These biases are real but perhaps not as inevitable as the way we report on them makes them out to be. And they are downright untrustworthy when deployed in reactionary argument.

A related thought: the rhetorical deployment of the findings of psychological research would seem to have an impact on the ongoing validity of those findings -- our psychology may change in reaction to how certain aspects of it are abused in argument.

Placebos as performance (29 June 2009)

Paul Kedrosky links to this article by Harriet Hall at the Skeptic about the placebo effect. The upshot is that placebos don't do anything physiological but instead shift a patient's awareness of their own symptoms. In the article's terms, it separates pain from suffering. So placebos are less substances than performances staged by creditable authorities (or at least people we are temporarily willing to credit, if we are delving into the world of Reiki healing or homeopathy ("the ultimate placebo because its remedies usually contain nothing but water") or macrobiotics or what have you) to persuade us that something transfiguring has taken place. Placebo effects are essentially rituals to distract us from our pain, keep us preoccupied while our body tries to repair itself.

The article mentions a recent study that intended to debunk the placebo effect:

In 2001 two Danish researchers, Asbjorn Hrobjartsson and Peter Gotzsche, published a paper entitled “Is the Placebo Powerless?” in the New England Journal of Medicine.3 They reviewed studies that included a no-treatment group, and they compared the improvement with placebos to the improvement with no treatment. They “found little evidence in general that placebos had powerful clinical effects.”
For studies with a binary outcome (improved versus not improved) there was no significant difference between the placebo and no treatment groups. For studies with continuous outcomes, there was some apparent effect of placebo; but not so for objective outcomes that could be measured by someone else, such as blood pressure, but only for subjective outcomes that depended on self-reports, such as pain. They weren’t even sure about that, however, because the effect was greater in smaller trials, indicating possible bias.

This seems to reinforce, though, the hypothesis that placebos distract us from pain, that they are in essence conjuring tricks staged by a (witch) doctor.

And some tricks are more persuasive than others:

We not only know placebos “work,” we know there is a hierarchy of effectiveness:

* Placebo surgery works better than placebo injections
* Placebo injections work better than placebo pills
* Sham acupuncture treatment works better than a placebo pill
* Capsules work better than tablets
* Big pills work better than small
* The more doses a day, the better
* The more expensive, the better
* The color of the pill makes a difference
* Telling the patient, “This will relieve your pain” works better than saying “This might help.”
In one study patients were given the same aspirin in either a brand name bottle or an unlabelled bottle; it worked better if it was labeled as a brand they recognized. Our pharmacy used to stock two different brands of allergy pills that were made in the same factory and were identical except that one was green and the other was blue. When a patient said it wasn’t working any more, we’d switch him to the other brand and it would start working again.

That's amazing to me. It's like a grammar of analgesia.

The reason I'm fascinated by the placebo effect is that it reminds us how limited instrumental thinking is -- the idea that this object has this effect. Instead, the context has enormous ramifications on our experience of things, an effect that sometimes we seek to ignore because it is impossible to control or even analyze thoroughly. As Hall points out, the pills are less important in treatment than the doctor-patient relationship. One could extrapolate and argue that this is true of objects generally. When we expect them to change how we feel, they are merely proxies for relationships, which ultimately have the most effectiveness in altering our moods. How we feel about ourselves, to a large degree, is a social construction -- is determined by how the feeling is constructed in our interactions (real or imagined) with other people.

Also, I think that advertisements attempt to work in the same way as placebos, staging a performance that shifts our perceptions, so that inert products suddenly have magical effects. Cigarettes suddenly do make us manly; beer suddenly does "taste cold." If that's the case, then we need to trust the authority of advertisements to let them work. Authority could be established just through the sheer brute force of salience, spending tons of money to make a product prominent in the media. Ubiquity becomes its own argument for quality. But we may consent to believe in the authority of marketing, simply because it feels better to be fooled -- much in the same way we suspend disbelief to enjoy magic shows or novels or Michael Bay films. It's no accident that many of the earliest advertisements were for patent medicines -- the ads lay the groundwork for the medicines to "work."

The depressing conclusion I draw from this is that ads, as much as they seem contemptible, fulfill an important function in authorizing pleasure, conditioning us to its possibility, and staging the ritual that allows it to occur. They foster "expectancy" effects, whereby what we expect to happen seems to happen. Granting ads credibility makes it easier for us to find pleasure, but of a degraded sort -- they supply simulacrum relationships that supplant our need for real ones. Another way of putting that: Ads allow for a kind of pleasure revolving around objects that perhaps crowds out other forms of pleasure that demand more from us but are ultimately more satisfying. With our willing consent, they teach us to enjoy ourselves in superficial, highly contingent ways and prompt us to forget that other more durable and self-nourishing ways exist.

"Nocebos" and WebMD disease (26 Nov 2008)

One of my hypotheses is that consumer behavior is anchored in the placebo effect, and advertising serves the vital function of supplying the mind with material to work with, just enough to make belief plausible enough to achieve desirable effects. We just have to grant ads the authority we give to actual experts, like doctors. It seems as though we do this readily, without much profound consideration of what should constitute actual expertise. (I'm supposed to buy a certain kind of tea because Dodgers manager Joe Torre drinks it.) We are basically culpable in our being seduced by ads; we're not somehow tricked into belief against our will. It's beneficial to believe, because it promises us placebo magic. Skepticism can turn out to be a costly failure of imagination, especially when we just need to imagine we can feel better to actually achieve it.

Consumerism supplies imaginary solutions to problems that marketing has convinced us to reconceptualize as purchasing decisions. Making the choice to buy masks whatever underlying problem spurred the "retail therapy" in the first place. Whether or not the good has any actual demonstrable effect on anything -- whether or not we even use it -- is beside the point. An example: I downloaded a bunch of Genesis albums the other day, but I can assure you that I will never listen to most of them. But there was still something satisfying about filling a hole in my music collection, even if that hole wasn't actually a problem. It wasn't like I was suffering for want of hearing Trespass. But acquiring things is a simple way of making myself feel like I have taken some sort of action. Marketing, I guess, functions by making sure I am always aware of that sweet simplicity.

Anyway, I've seen a few articles lately that explore the dark side of the placebo effect, where the benefits of belief turn into liabilities. Last week, the WSJ reported on "nocebos":

Research has shown that expecting to feel ill can bring illness on in some instances, particularly when stress is involved. The technical term is the "nocebo effect," and it's placebo's evil twin. "It's not a psychiatric disorder -- it's the way the mind works," says Arthur Barsky, director of Psychiatric Research at Brigham and Women's Hospital in Boston.
Nocebos can even be fatal. In one classic example, women in the multi-decade Framingham Heart study who thought they were at risk for heart attacks were 3.7 times as likely to die of coronary conditions as women who didn't have such fears -- regardless of whether they smoked or had other risk factors.
Research deliberately causing nocebos has been limited (after all, it's kind of cruel). But in one 1960s test, when hospital patients were given sugar water and told it would make them vomit, 80% of them did.

This is a scary look at what the socially distributed notion of authority can accomplish. Even internal movements of our consciousness, which seem to be generated from within, are apparently easily shaped, once we commit ourselves to participation and belief. Back up would-be authority figures with institutional heft, and they can basically create your reality, down to the level of nausea you feel.

Doctors may unwittingly foster placebo or nocebo effects by how enthusiastically or warily they discuss medication. "Physician communication with patients is the closest thing to magic. It gets communicated in incredibly subtle ways—a flash in the eye, a smile, a spring in the step," says Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn.

The authority figure -- the social relation -- is what counts. Often, apparently, the medicine is just the trace of that.

I'm tempted to get sidetracked into a consideration of whether such induced feelings are "authentic" or not, though I suppose death is about as authentic an effect as can be achieved. But it's probably irrelevant to the degree that all "symptoms" are in some way "induced" by something. If we attempt to ignore or downplay the "induced" aspects of consciousness, what would be left to be real? The article makes clear how when you ask someone for symptoms, they generally will supply them.

"People's expectations play a very important role in how they react to all medications," says Richard Kradin, a physician and psychoanalyst at Massachusetts General Hospital in Boston, and author of "The Placebo Response and the Power of Unconscious Healing." He notes that about 25% of patients who get completely inert placebos in clinical trials complain of side effects -- typically headaches, drowsiness and dizziness.

If the stage is set for us to be self-aware in that way, our minds will make something happen. This has led me to be against biofeedback. The more I know about what is happening with my body, the more I think is wrong with me and the worse I feel. Is there a way to have no expectations at all? Is there a way to achieve total health ignorance? Would preventive care prevent me from feeling good?

The NYT followed with this article on research Microsoft carried out that suggests, to the surprise of absolutely no one, "that self-diagnosis by search engine frequently leads Web searchers to conclude the worst about what ails them."

Such findings evoke the debate about whether the internet can create and propagate new mental illnesses by making the very concepts behind them more prevalent and accessible. (This Atlantic story, which I am always looking for excuses to link to, explores that question.)

Patent medicine as paradigm (1 December 2006)

The early history of advertising is dominated by patent medicines -- proprietary nostrums of dubious efficacy whose curative powers often rely on whether the placebo effect takes hold (that is if opium wasn't a primary ingredient). Not only do these products target a universal human vulnerability, but they testify to our eternally renewable capacity for hope and faith in the face of hard reality. When commercial interests seized some of the power away from the church to cater to our unfortunate awareness of our physical and spiritual fraility, patent medicines quickly came to the forefront, the most efficient means for reifying human anxiety and capitalizing on it. The patent medicine was often nothing in itself, just a brand name, and ads were necessary to build up the products' aura of effectiveness -- consuming a patent medicine was essentially swallowing the ad copy, literally.

The brand name itself generates a placebo effect; its value lies in the often spurious belief it can inspire. The power of a brand also rests in its reputational history, its fashion value, and the manner in which it signals the capital invested in it; but there's still that leap of faith that lets you consume the brand in lieu of the object that's branded -- that lets you eat the cheeseburger but taste McDonald's, that lets the name affect the way something tastes as though it were an added spice. That requires both suspension of disbelief and an investment of one's imagination. With old-time patent medicines, the degree to which one was seduced by the ads probably had a lot to do with how effective one eventually felt the medicine was; if one cooperated with the promoters and optimistically seized upon the ads' suspect promises, one was likely to have a better experience of the product. For the consumerist economy, skeptics need not apply.

Patent medicines seemed to me paradigmatic of consumerism in general, one of the quintessential consumer products, doing to health and the survival instinct what pornography does for sex and the libido: if we are willing to be seduced by products and open ourselves to the sweet nothings of commercials, we can use them to construct a pleasing fantasy world independent of the product's apparent function. The incantatory, repetitive nature of advertisements collectively seems ultimately suited to lulling us into that passive and pleasing state of receptivity, in which we suspend disbelief and want to believe in the tangential effects products are alleged to have on our essential being -- a car really can change our personality, having a beer really is relaxing, makeup really is glamorous, cough drops really do provide relief.

This led me to suspect that ads and popular entertainment work in mutually reinforcing ways -- both want to convince us that suspending disbelief, embracing that as a kind of optimism and imaginative investment, is pleasing for its own sake, and both use similar tactics (humor, suspense, acute irrationalism, non sequitur, genre convention; encouaging absorption in a comfortably formulaic and highly structured plot) to accomplish that aim. Slowly we become convinced that consuming something (entertainment, a branded product) is equivalent to doing something -- that our imaginative investment in a product makes us creative, more alive. By believing completely in the fiction, we demonstrate the superiority of our imagination while at the same time reaping the benefits of it; ads and popular culture exercise our imagination, and the exercise feels good. Why bother with the perversity of resisting?

The conflation of production and consumption operates on many levels, from planning an evening around watching TV shows to the elaboration of theory which argues a consumer actually produces the product he consumes through his unique manner of consuming it. ("When I listen to Bad Company, I'm resisting its cliches about the rocker as outlaw while using them to interrogate the cultural system that both demonizes and lionizes the performer as icon" or "By putting myself in the place of the characters on Veronica Mars, I am imaginatively reproducing the show in my mind, producing conclusions that the show's creators could not have expected me to come to.") To a certain extent such elisions between production and consumption are inevitable; resources are consumed in the production of anything. But when we regard cultural consumption as the consumer's production of emotional states within himself, we have shifted the locus of meaningful work away from society -- from the shared world of experience in which we enrich and validate what one another achieve -- to our interior consciousness.

Anyway, what started me thinking about patent medicines was this articleby Zachary Seward in yesterday's Wall Street Journal about the recent craze for resveratrol, a substance found in red wine that has apparently prolonged the life of lab rats in recent studies. Resveratrol's rise from obscurity to mass-market supplement seems a modernized version of the old patent medicine story, with some new wrinkles. First, rather than rely on medicine show hucksterism and bald-faced lies, newfangled cure-alls rely on the journalistic abuse of scientific studies to generate hype. The most optimistic implications are extrapolated from the limited conclusions of a study because this will give readers' imaginations the most substantive meat to feast on. These studies provide the germ of scientific fact upon which a fantasy of control over our own mortality can be elaborated and marketed. Then, skirting FDA regulation and the intermediaries of medical professionals, the herbal product can be marketed directly to consumers:

More than a dozen supplements featuring resveratrol are sold in health-food stores and online. But dietary supplements are only lightly regulated by the Food and Drug Administration, and manufacturers don't have to demonstrate efficacy in order to market a product.
Despite those caveats, several retailers report a large jump in sales of resveratrol supplements. Whole Foods Market Inc., the national health-foods chain, sold out of its resveratrol product at many stores earlier this month, though a spokeswoman declined to give sales figures.
Bill Sardi, founder and president of Resveratrol Partners LLC, which since 2003 has marketed online a supplement derived from giant knotweed, a Chinese plant, says, "I'm having to place rush orders from China because this thing is wild." Mr. Sardi says his company sold as many boxes of its product, Longevinex, in the week after the first study appeared in the journal Nature as it did in the previous six months. Vitacost.com Inc., a large online retailer in Boynton Beach, Fla., says sales of its resveratrol supplements increased tenfold in that week. Source Naturals Inc., another supplement maker, says it has seen a "large jump" in sales of its resveratrol product.

Whether or not it really works is irrelevant to the story, as irrelevant as whether or not Huck Finn or Sherlock Holmes really existed. That its efficacy remains undetermined means only that it engages consumers on a more imaginative level than, say, Nexium. It provides an occasion for the exercise of faith and optimism, which we are always reminded are extremely positive qualities, for their own sake. In the absence of proof there blossoms the possibility for any number of pleasing stories; hence a tactic very familiar from patent medicine ads -- the testimonial:

William S. Gruss, a cardiologist whose image, signature and testimonial -- "there's absolutely no risk" -- are featured prominently in Revatrol's marketing, says Renaissance paid him but declines to say how much.
"Am I going to live longer because of Revatrol? I'll let you know," says Dr. Gruss. "But if it turned out not to live up to all of its promises, well then, no harm done."

No harm done? What about the millions of dollars wasted on a placebo? But if the placebo effect has worked, people are likely happy to have paid for the privilege. Essentially, using patent medicines or unproven herbal supplements is an experiential good, the same way going to Disneyland or the James Bond movie are. So the return on money spent on Revatrol won't be measured in terms of how many years it extends your life but how much of a sense of control it gives you, how much it permits you to tell stories to yourself that make you happy.