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Pain, placebo, embodied cognition, and the YouTube black hole

By Dr Alan Bowman

A confession about how I spend my lunch breaks

Have you ever fell down the YouTube black hole? On a recent lunch break I decided to watch a Ted Talk from the excellent Mick Thacker. He talks elegantly about the predictive processing model of pain. It’s a complex but important model for pain clinicians to dig into, and his video is well worth a watch.

From there, the YouTube algorithm supplied me with the recommendation of “how to learn a language in six months”. Over-ambitiously, I pressed play. Immediately my attention was captured by another thumbnail – “how coffee transformed my life”. Coffee transforms my life every morning, so I clicked it.

Twenty clicks later, I was watching people run down a hill chasing after a wheel of cheese. My lunch break was over. Welcome to the YouTube black hole.

To end somewhere very different to where you started happens to me every time I log into YouTube. For me, it’s also a central part of being a Pain Geek, and that’s a good thing. In this blog I’ll be sharing how I find reading along with Laura, Christine and the rest of the Pain Geeks across the world, and where it takes me (spoiler – it takes me all over!).

I will never “complete” learning about pain management

I’ve been a part of the Pain Geeks community for almost a year now. Each month I will read along with the suggested papers, books, poems, and artwork, and then I get itchy. I learn something new, but from that learning explodes more questions. I need to scratch that itch, so off I go down another black hole, hoovering up literature in search of more answers. I'm a bit like a cat with a ball of wool that keeps rolling away from me. To catch up with it is not the point – I will never “complete” learning about pain management.

Regardless, there is a lot to gain from chasing the important questions. Your eyes open, your view widens, and you grow a little.

Here’s what I mean…

Sugar pills

A recent topic we’ve been digging into as a group is about pain and the placebo / nocebo effect. In brief, placebo effects are those that are caused by an intervention that has no specific “mechanism of action” for the intended outcome. A well-trodden example of this is the notion of giving people “sugar pills” that don’t contain anything medicinal, yet still produce an effect.

For example, patients with dental pain who are given an inactive substance with no medicinal or pain-relieving properties (e.g., salt water) can experience the same amount of relief as patients given a pain-relieving drug by their dentist (link). Expectation plays a part here – the expectation of pain relief can produce pain relief. This works in the opposite direction too; expecting increased pain can intensify pain levels – the nocebo effect.

It's a fascinating area and I enjoyed reading through the papers by Rossettini et al and Benedetti et al that received the Pain Geeks treatment over the summer. I was particularly drawn to the conclusion that how we are when delivering pain management (e.g., communication style, empathy, prosody, non-verbals) and where we are (e.g., the room, the space, the environment) may contain a multitude of modifiable placebic and nocebic factors, the sum of which may tilt outcomes for the people we support, for better or worse. And then the itch began again, and I ventured further down the black hole.

How do we make pain management less nocebic?

My immediate reaction after reflecting on this reading was “how do we make pain management less nocebic? What is a placebic healthcare environment?”

I thought back to the pain management services I have worked in across my career. The old hospitals, the wipe-clean floors, the tube lights. For many it is an alien environment that at best can feel jarring and at worst, abjectly traumatic. I couldn’t shake the feeling that we need to move chronic pain management out of hospitals for good, as they may be laden with nocebic environmental factors that contribute to subjective pain experience.

In my search to put some data to this train of thought, I was reminded of an old but commonly cited paper by Roger Ulrich, who examined hospital records of people recovering from surgery. One group of patients recovered quickly, had fewer negative evaluative medical notes on record, and required fewer painkillers than the second group (link). The distinguishing factor? One group had hospital beds positioned in front of natural green space. The other group was positioned in front of a brick wall. I’ll let you guess which was which. Environment and context matter.

Beyond the brick wall

With that said, when you look over the brick wall, there are people. There are some brilliant, dedicated people, who care deeply about those they help. Across professions, the clinicians that stick in my mind as making the biggest difference to people living with chronic pain were those with warmth, kindness, the patience to listen deeply, and to connect on a human level with the attendees of their clinic. And so deeper down the black hole I went. What is it about the relationship between a clinician and a patient/client/service user that is special? Is it just “being nice”, and if it is more than this, what on earth is it? Placebo, or something else?

I confess that I already had a position on this before reading the papers. The importance of the therapeutic relationship is something that is subject to much reflection, discussion, and practice from day one of our training. There is debate within the field about why it matters. One position is that psychotherapies have specific “mechanisms of action” embedded within them that are responsible for therapeutic improvement. It is the technique, above all else, that matters. Another position is that whilst specific change techniques may contribute to therapeutic improvement, this is dwarfed by the much larger contribution that “common factors” make to therapy (i.e., factors that are shared across all therapies regardless of their specific orientation, philosophy, or change methods). This has led some therapists to suggest that all psychotherapies can produce equivalent outcomes – the “Dodo Bird debate”, as it has been named, inspired by a line from chapter three of Alice’s Adventures in Wonderland – “Everybody has won, and all must have prizes”.

I’ve always been a fan of sitting on the fence when it comes to debates that are positioned in a dichotomous way; an effort to sift through the grey. I value the specific therapy methods I’ve gathered across my career, but the importance of a genuine therapeutic relationship carries at least as much, if not more weight for me.

Getting in sync

But then the itch came back, and I had to read again. The story can’t just end there. The therapeutic relationship is likely to be important to good psychotherapy outcomes, but why?

If we take the readings on placebo/nocebo mentioned above, then we may draw the conclusion that the relationship is a placebo. It creates a context, a set of expectancies, that create change in the absence of any direct mechanism for action. In other words, the therapeutic relationship is an “inert” part of psychotherapy and other forms of healthcare.

Is there, could there be, a direct mechanism of action contained within the therapy relationship?

We are now at the wheel of cheese, miles away from where we started. I took a deep breath and turned my eye to the embodied cognition literature.

The legacy of mind-body dualism, left by philosopher René Descartes, conceives that the mind and body are separate. From this angle, cognition arises out of brain mechanisms exclusively. We have hardware, and we have software. This view is now the source of much debate.

Embodied cognition approaches take a different position; that we are a whole organism that cannot be divided neatly into “body” and “mind” compartments, much in the same way we can’t separate out the gin from the tonic once the drink is made. Bodily mechanisms are intertwined with thought in a multi-modal and dynamic way; mental experiences can also be physical experiences.

This position has some potentially important implications for psychotherapy and pain management. It may also offer some tentative answers to the question of whether the therapeutic relationship has specific mechanisms for action that cultivate change.

In their recent paper, Mende and Schmidt (2021) offer an exploration of embodied cognition within psychotherapy and highlight two important points. Firstly, synchronisation between two or more people is important. Musicians and sports teams that have a high degree of physical synchronisation between the members perform better. This finding also seems to play out in psychotherapy. Greater levels of physical synchronisation between therapist and client have been associated with better therapy outcomes and lower therapy dropout rates.

Mende and Schmidt’s second point is that the role of synchronisation may not just be limited to physical movements. It is possible that neural synchronisation (i.e., the harmony of brain activity between two or more interacting people) is relevant and can influence outcome. It is too early to tell, but the research methods required to start investigating these questions exist. Early non-clinical studies using hyperscanning methods (simultaneously measuring real-time brain activity between two or more people) have demonstrated proof of concept; voluntary neural synchronisation between two people has been demonstrated.

Much of this is consistent with some of the fundamental theories of psychological therapy, particularly those that are “relational” i.e., emphasise the importance of attunement and intersubjectivity. To select just one example, in her excellent book, “Understanding and Treating Chronic Shame”, DeYoung defines shame as “an experience of one’s felt sense of self disintegrating in relation to a dysregulating other”. To help individuals work through and come to terms with chronic shame, the safe presence of a regulating other (such as a therapist) is the intervention (not an add-on to the intervention, it is the active ingredient in and of itself). This requires empathy, emotional attunement, intersubjective dialogue, and yes, embodied synchronisation.

The bigger picture I am getting at here, is that we may be doing a disservice to the therapy relationship by assuming it is placebic in nature. There are theoretical accounts of why and what the “active ingredients” may be. Cutting edge philosophy and neuroscience (embodied cognition) research is starting to add data to the theory, and we in doing so we are deepening our understanding of what exactly happens when two people connect in a healthcare context.

What does this mean for pain management? I’m aware that my musings towards the end of this blog are psychotherapy-centric, and psychology is only one piece of the pain management pie. My view is that the lessons we can learn from embodied cognition literature and the therapeutic relationship have mileage regardless of profession. We do not deliver care in a relational vacuum.

The bottom of the black hole

We started with two papers on the placebo effect, and here we are at the end, thinking about embodied cognition.

More questions.

More curiosity.

The ball of wool keeps rolling.

Learning together with Pain Geeks is an informative, eye-opening, challenging process, which often leaves you asking more questions than you started with, and far more PDF’s on your hard drive than you planned on having.

I wouldn’t have it any other way. You end up somewhere different to where you started.

With this comes a wider, more nuanced, more detailed view of the problem of pain. That can only be a good thing, even if you never reach the bottom of the black hole!

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