Thanks for your offer of help to troubleshoot my problem. Once in a while it happens; usually it does not. I have no clue what I did, or did not do, on my keyboard that accounts for the difference. Therefore, I don’t know what I could tell you that would enable you to help me. I have discovered the software has a Safe Draft button. Perhaps that will solve my problem though I am unclear whether a single click of the button results in automatic continuous saving or whether it is necessary to click the button every so often to save one's most recent work.
Most of my family members (some of them are burdened by medical degrees) consider my recovery a placebo effect.
These family members, including those burdened with medical degrees, seem to be mired in an obsolete view of the placebo effect. Here is how Jo Marchant described that view in her New York Times bestseller
Cure: A Journey into the Science of Mind Over Body (2016): “Back in 1954, an article in the medical journal
The Lancet stated that placebos comfort the ego of ‘unintelligent and inadequate patients.’ Although doctors might not put it so bluntly today, attitudes haven’t changed much since then.” Marchant reports that around the time of the
Lancet article, governmental agencies began to require placebo-controlled trials for approval of new drugs. A new drug would not be approved unless it produced better results than an inert pill. She says the framework of placebo-controlled drug trials is the basis of modern medical practice because it allows scientific determination of which medicines work and which don't. Given this framework, she suggests that "the placebo effect is of no interest [to physicians] beyond being something to guard against in clinical trials."
Marchant devotes the first three chapters of
Cure to modern research on the placebo effect. Although she is a journalist and author, her PhD in genetics and medical microbiology equips her to evaluate the methodology used and conclusions reached in medical research studies. She dispels the view that placebos work by tricking gullible patients into believing they have less pain than they actually do. While it is true that a placebo does not work unless the patient expects it to work, she says the research shows this patient expectation leads to “measurable physical changes in the brain and body.” She provides a number of examples. For instance, a placebo can trigger the brain to produce endorphins. (The term “endorphin” is an amalgam of two words:
endogenous mo
rphine). This natural morphine relieves or stops pain but without any of the adverse side effects of exogenous morphine that is put into the body by ingestion or injection. Endorphins are just one of many chemicals that a placebo can induce the brain to produce. Marchant says a prominent placebo researcher "emphasizes that the placebo effect isn’t a single phenomenon but a ‘melting pot’ of responses, each using different ingredients from the brain’s natural pharmacy.” (Switching for a moment from Marchant to Moseley and Butler, they say “the medicine cabinet in your brain” can produce a cocktail of hormones that works throughout your body to dampen down tissue-danger messages from reaching your brain.)
Marchant is under no illusion that the placebo effect is a cure all. First, it is “limited to the natural tools that the body has available.” It can't enable a person with cystic fibrosis to "create the missing protein that their lungs need any more than an amputee can grow a new leg." Second, a placebo affects only symptoms, i.e., “things we are consciously aware of, such as pain . . . .” There is little evidence that placebos can affect things we are not consciously aware of such as cholesterol and blood sugar levels. Pain, of course, is an unpleasant conscious sensation; we feel it. So pain is a good candidate to be influenced by the placebo effect.
Schubiner is not unaware that people with an outdated view of the placebo effect have criticized his approach to treating PPD on the ground that it is “merely” a placebo. I don’t know if you have read the book that he coauthored with psychiatrist Allan Abbass titled
Hidden from View: A Clinician’s Guide to Psychophysiologic Disorders. They collaborated on the first and last chapters; Schubiner wrote chapters 2 through 4, and Abbass wrote several chapters on ISTDP. In chapter 3, Schubiner responded to the placebo criticism as follows: “[W]hen neural coding of expectations of chronic pain or other PPD symptoms is the underlying reason for the persistence of symptoms, changing the expectation (which is the definition of the placebo effect) can literally cure the disorder.”
I do think that there is a difference between placebo and Sarno's method in how it applies to the most difficult cases. Placebo implies a passive approach. Patient takes a pill, wakes up next day without pain. It does work that way for some of the TMS-ers who read the book and watch their pain disappear within a day or a month. But it is not how it worked for many people here on this forum. We had to actively re-wire our brains in order to heal our nervous systems to the point that it eliminated faulty neural paths.
My initial reaction to this was that you are wrong, but on reflection I think any differences between us likely are only semantic and turn on what the term “placebo effect” means. We learn from Lewis Carroll’s
Through the Looking Glass that words can mean whatever a person wants them to mean. Obviously it is important for people to be clear about what they mean to avoid misunderstanding. But a meaning contrary to the conventional meaning is not necessarily “wrong,” especially if the conventional meaning is out of step with modern research. I am going to try to clarify what I mean, and understand Schubiner to mean, by “placebo effect.”
Here is my transcription of what Schubiner said about the placebo effect in his Commonwealth Club lecture, with my addition of bracketed numbers for clarity regarding its four elements:
“The placebo effect consists of people [1] having an explanation for what’s wrong with them, [2] having a technique they can use, [3] having a practitioner that they trust, and [4] having hope and optimism. So when you put all those things together, you get a strong placebo effect. Placebo effect is all you need for brain-induced pain. So what I do is in a sense a placebo effect. I am helping people help themselves by harnessing the power of their own brain.”
Regarding element 3, Scubiner and Abbass emphasize in chapter 1 of
Hidden from View: “As a foundation for this clinical work [of treating PPD], creating trust with your patient is always key. . . . Such a therapeutic relationship with your patient is a necessary ingredient at each step.” I think the reasoning behind this statement is that unless a patient trusts that the practitioner knows what he or she is talking about and is trying his or her best to help the patient, the patient will not truly accept the practitioner’s element 1 explanation of what is wrong and element 2 technique to use to fix it, nor will the patient have element 4 hope and optimism the technique will work. In sum, when all four elements are in place, the patient expects the treatment to work. That is what Schubiner meant, I think, in the chapter 3 quotation above about changing the patient's expectation being a cure for PPD.
Randomized-controlled drug trials certainly involve a passive element 2 technique (ignoring the act of swallowing a pill because that is insignificant). But I don’t see passivity as essential to the placebo effect.
Schubiner’s element 1 explanation of what is wrong is that PPD symptoms are caused by neural pathways, not something physical. In chapter 4, titled Cognitive and Behavioral Interventions, Schubiner lays out a smorgasbord of treatment techniques for patients to use. He introduces them with this statement: “If patients accept the diagnosis that there is nothing physically wrong, their pain, and the accompanying tension, fear, withdrawal, and helplessness can be reduced. Then they can
work on reducing the automatic, natural, fearful reactions to pain and other PPD symptoms that are reinforcing the neural pathways that are the current cause of the symptoms.” (Emphasis added.) The phrase “work on” foretells that the techniques are not going to be passive.
The techniques he lays out in the rest of the chapter come under the following headings: Symptom Tracking—Noticing Antecedents, Reappraisal of PPD Symptoms and Reduction of Fear, Conceiving of PPD as a Bully, Use Top-Down Cognitive Interventions (e.g., “there is nothing wrong with me.”), Meditation and Mindfulness Practice, Compassion for Self, Expressive Writing, Emotional Awareness, Examining Life Situations, and Resume Life. As you no doubt are aware, these are hardly passive techniques.
(I’ll end here with an aside. Element 3 of having a practitioner that one trusts does not necessarily require direct contact. I trusted what Sarno said in
Healing Back Pain about why my back hurt and what technique I needed to use to fix that. I now trust Moseley’s Explain Pain books and the neuroimmune interface research papers that I have read and relied on to stop more than a decade right knee pain along with several other pains.)
Placebo concept does not explain well why for many people TMS returns and becomes a game of whack-a-mole. It takes a focused effort to recondition our brains to the point that they no longer produce misfiring of the pain signals.
I like your whack-a-mole metaphor for TMS that returns. I think, however, that element 1 of the placebo effect can fully explain the whack-a-mole problem. In
Hidden from View, Schubiner provides sample scripts that clinicians can use with their PPD patients. Here is part of one of them:
“All pain occurs in the brain, whether it is due to a structural disorder or not. Pain occurs when our brain activates an alarm or danger signal. Both physical injuries and emotional injuries activate the same danger signal, which triggers pain. . . . When pain occurs (whether due to an injury or a neural pathway process), the brain learns the neural pathways associated with that pain. These neural pathways can become persistent, can be turned off, or can come and go depending on whether the danger signal in the brain is activated. People exposed to stressful life events are more likely to have a danger/alarm mechanism that is sensitive and activates pain and other symptoms.” (Emphasis added.)
This script is over-simplified for my taste. If I were writing a script for myself, it would be less brain-centric and go into more detail and complexity, including the neuroimmune interface which involves peripheral and spinal neurons as well as brain neurons. But that is just me. Schubiner surely knows from experience what will and will not “sell” with patients.
I want to focus on the sentence in the above sample script that I italicized: TMS pain can persist, can be turned off, or can come and go depending on whether the danger signal in the brain is activated—or as I would say it, depending on whether your brain determines, after evaluating the incoming tissue-danger messages in light of everything stored in your long-term memory, that you really have actual or potential tissue damage. There is nothing about the four elements of the placebo effect that says TMS pain can’t recur. To the contrary, the fact that the pain can recur is part of the element 1 explanation of what is wrong. After a person ends an episode of TMS triggered by emotional stress through applying some combination of Schubiner’s chapter 4 techniques to use, there is no guarantee that he or she will never again be emotionally stressed enough to again trigger TMS. In addition, emotional stress that triggers TMS might prime a person’s danger receptors and/or neural danger-transmission system to become more sensitive so that even lesser emotional stress in the future can result in another TMS episode. That is not inconsistent with the concept of the placebo effect.
I hope the foregoing clarifies what I mean and think Schubiner means by the term “placebo effect.”
