What is the difference between the “confidence cure” and a mere placebo?

The most familiar example of a confidence cure is when you go to your doctor frightened by a strange and unpleasant symptom, and your doctor compassionately chuckles and authoritatively explains that you have nothing to worry about: the condition is common and easily treatable. You have no doubt that he knows what he’s talking about. You walk away not only with the “real” medicine, but also feeling much better before you even take it.

There are many ways that the confidence cure works its magic, but an obvious one is the one I just described in my last post: the intensity of our pain is determined by the opinion of our brains, not by what’s going on in our tissues.

Pain problems freak people out

Many common painful conditions are characterized by strong patient fear and anxiety that does not get relieved, because few health professionals understand them well enough to offer credible reassurance. For instance, in the case of low back pain, patient fear is understandable, but usually way out of proportion to the severity of the problem — and not only do health professionals not know enough about low back pain to reassure them effectively, but often scare the patient by reinforcing any number of common, ominous myths about low back pain.

Reassuring a patient is not a “placebo,” per se — it’s not fake medicine, not a sugar pill. There’s a genuine therapeutic effect based on rational, informed confidence.

But placebo has a “genuine therapeutic effect,” too! In both cases, the patient has been led to believe that they are going to be fine, and that belief in turn may have a therapeutic effect. So what’s the difference? And why is it fine to aim for a confidence cure, but sugar pills are ethically dubious?

A placebo is not a long term solution — confidence is

The problem with placebo is that it’s ethically wrong to systematically lie to people … even for their own good. It’s acceptable in some situations, but not as a general rule. If you can get the same effect without lying, not only are you morally safer, but you also get a much more robust effect over time.

The therapeutic problem with “fooling” people with a pure placebo — or with a quack therapy — is that most people rarely stay fooled for long, and often end up more hurt and scared and bitter than ever before.

For instance, consider the example of a true snake oil, a therapy that is expensive and totally bogus. Initially, a placebo effect will be powered by the charisma of the therapist and the desperate hopes of the patient. But most patients have a little voice asking them: “Is this stuff crap? Did I just waste my money?” Rather than true confidence, most people who’ve spent a bunch of money on questionable therapy are watching anxiously for the first sign that they wasted their money. And of course those signs come quickly, because the therapy is bogus.

Confidence and hope rapidly turn to ashes — so much for a placebo effect!

The beauty of a real confidence cure is that you get an extremely robust therapeutic effect that is much less likely to be taken away from you later by the discovery that you were being ripped off. That’s the difference: a placebo is not a long term solution, but rational confidence based on good information is. That’s a huge difference.