The ‘Nocebo effect’: is it relevant for physiotherapists?

In a ‘nocebo’ situation, patients’ brains are wired in a way that puts them on a super-fast freeway to failure.

Fabrizio Benedetti defined the ‘nocebo effect’ as an expectation that treatment is going to fail.

“When the context surrounding treatment is negative and it leads to negative outcomes, the term ‘NOCEBO’ is used”  – The Patient’s Brain (2011) Fabrizio Benedetti

You hope patients come to you with the expectation that your treatment will help them. I certainly did. But it has been proven that this is not always the case.

How do patients develop the expectation that treatment will fail?

  1. People learn via verbal suggestion

If a patient sees a physiotherapist, osteopath, chiropractor or doctor, and the presenting condition is outside the clinician’s skill set, the patient might be told, perhaps inadvertently, ‘You’re complicated’. The clinician might, in fact, say, ‘Your condition is complicated’, but a patient who is stressed, anxious and frequently in severe pain might interpret this comment as ‘I’m complicated’.

When patients hear a comment like this, it can easily become the identity they live with – a learned belief that they cannot be treated successfully because they are ‘complicated’. Identities and beliefs can be very difficult to remove.

Patients who believe they are complicated or difficult to treat, define themselves, rather than their condition as difficult. They are less likely to give you the sort of information you need to help them. Why would they? They already expect treatment to fail because they believe they are complicated. This is a particularly challenging situation for the clinician to be in. Particularly as you can only challenge their belief about being complicated or difficult, by succeeding in helping them.

2. People learn through a ‘conditioned response’

The process of seeing a health professional – from the time you make the appointment to the visit – is generally the same wherever you go. I have moved to a different State four times in six years and each time I had to find a new doctor, dentist, physio, and masseur, so I know this from experience.

If patients go through this process of seeing different clinicians repeatedly without experiencing any successful treatment of their condition, the whole context ‘conditions’ them for a failed response to treatment.

This situation is common among people with chronic injuries or illnesses or conditions that are challenging for health professionals to deal with.

Fabrizio Benedetti and colleagues have produced excellent research on the effect of placebo and nocebo. They found that in those who have an expectation that treatment will fail, there was a fall in the levels of dopamine and endogenous opioids in the brain.

How is this relevant to you?

When patients have an expectation that treatment will fail:

  • Their brains are against you
  • Their self talk and mindset are against you
  • Their beliefs or even their identity are against you
  • They are more likely to be anxious, or have some degree of heightened anxiety. This has been closely linked with hyperalgesia, which means their pain sensitivity is likely to be significantly higher.

Norman Doidge, in his book The Brain That Changes Itself, very eloquently said:

“Cells that fire together, wire together”.

In a ‘nocebo’ situation, patients’ brains are wired in a way that puts them on a super-fast freeway to failure.

If you want to engage successfully with patients who expect treatment to fail, you need to do something unexpected.

Tools to help with the Nocebo Effect

What can you do if your practice sees a high proportion of patients with difficult conditions? How do you work with patients who, from previous experience, have an expectation that their current treatment will fail? Their internal talk, their brain hormones, and their brains’ wiring and firing are all against you. What’s the solution?

A suggestion is to look for ways to ‘rattle’ your patients’ existing brain wiring. And that requires you to think and do things differently. 

Albert Einstein said:

“The significant problems we face cannot be solved by the same level of thinking that created them”.

How to ‘rattle’ the brain

You need to find as many ways as possible to challenge patients’ expectation of the experience they are about to have. The more effectively you can do this before they come into the consulting room the better.

Using the same assessment procedure that works with patients who expect treatment to help will not allow you to engage quickly and effectively with patients who expect treatment to fail.

When I treated sporting injuries, my consulting style worked about 90% of the time. For health professionals who work with patients experiencing chronic or difficult conditions, that percentage drops drastically – perhaps to 70% or less.  You need to have a ‘plan B’ assessment procedure.  You must be aware of what you are doing, why you are doing it and, if necessary, how you might make adjustments.

Some ideas to try:

  • Your opportunity starts with your first engagement with your patients; it might be the automated text message they receive from you. Come up with a unique reminder text – something original that is not at all what they expect. Make it inviting and show that you are looking forward to seeing them. Your aim is to get a response like: ‘Wow I have never seen that before’.
  • What can you do in the waiting area? How can you change the look and feel of your consulting rooms? In my Adelaide Hills rooms, I had a lot of sporting memorabilia – some of which we bought on eBay. We framed and hung it on the walls of the consulting rooms and in the waiting area.  When patients came in they generally looked around and you could see they were thinking, ‘This is different’.  Often, after they had filled in their forms, they would walk around, have a closer look and read some of the interesting information, and chat with the receptionist about it.  It was certainly more engaging than the usual physiotherapy charts and information about stock for sale.
  • What about your first meeting with new patients? Have you ever thought of sitting next to them and introducing yourself at eye level? This simple action has shock value, simply because it is rarely ever done. I’ve certainly never had that experience with a practitioner.
  • Your position in relation to your patients sends out different signals. While your patients are heading towards the consulting room, try walking together, or you could walk behind, rather than lead the way. When patients walk in front of, or beside, you it sends the unconscious message that you’re in this together. When you walk in front, your action is saying you are the director. You are going to fix them and they just need to come along for the ride. We all know that this doesn’t work.
  • Once you reach the consulting room, rather than indicating ‘your chair’ and ‘my chair’ – which is behind the computer because you’re the director – allow patients to choose where they would like to sit. This is very empowering. It’s about creating an experience you are having together.

How to engage your patient in conversation

Can you change the way you collect patient details?

Instead of going into your default and often-unconscious assessment procedure, you could start with something like this:

“As you know, I have a lot of questions to get through, but I find it easier to put them aside for a while, and ask you to spend 5 or 10 minutes talking through a typical or recent episode. I might go back to the form to fill in the gaps. Is that ok?”

Patients who hear this will probably be extremely surprised. Normally are ready for the Q&A that they’ve been through so many times before, and by default, is probably a procedure that irritates them.

By starting differently, you are saying you’re prepared to listen to your patients and their stories are important to you.

You’ve also put a timeframe around the ‘chat’ so that it doesn’t take up the whole consult. This is really important.

It’s also extremely important that you are an exceptional listener. Your aim is to get the answers to most of your questions during the 5 or 10 minutes the patients are talking about a recent episode. When they have finished talking, you should not start your usual Q&A. All that will say to patients is that you haven’t been listening. You can go back and ask any necessary questions, because you have already asked their permission, rather than just assume that it is okay to do so. I have never come across a patient who said, “No, you can’t ask questions”; it’s highly unlikely to happen to you.

Another point that you might add is:

“I would like to know what you want out of our time together – today, and in the long term”. 

What patients really want out of treatment might be very different from what you expect they might want.

Drawing the Swords

Something you might consider doing is a technique called ‘drawing the swords’.

Patients with chronic conditions can often attack you with questions such as:

“How are you going to get me better?”

“What are you going to do that’s different?”

They can be very assertive and perhaps even passive-aggressive. 

Instead of waiting for or allowing them to say these things, you could say, right at the beginning, something like:

“I can see that you have been to a number of therapists, and you’re probably wondering what I’m going to do that’s different” or

“Are you wondering how I’m going to help you when others haven’t?”

They will agree, because that’s what they are thinking, but because you bring it up first, the comment loses its attacking power.

There might be other similar comments patients use to attack you. Recognise what they might be thinking, bring the comments up first, and address them in a conciliatory manner.

How to deal with “What are you going to do that’s different?” 

Agree to answer the question, but tell patients you will do this after you’ve assessed them. By then you will know what they want to get out of your time together. Then you can relate what you have to offer with what’s important to them.

Resist the feeling that you need to explain your personal expertise and how it might be far in advance of other clinicians’ approaches. 

Patients are not interested in your specific skills; they don’t care about the intricacies of your techniques.  All they really care about is whether or not you can solve their problems.

Frame your response in relation to how you’re going to help patients change their lives and achieve what they want to get out of treatment.

When you’re working with people who have an expectation of treatment failure or are very untrusting, the change has to happen with you.

You are the key to change. In his book Motivational Interviewing, William Miller said:

“A lack of motivation is not a patient problem, it is a therapist problem”. 

This statement was a paradigm shift for me later in my career. I often thought that if patients didn’t want to get better, or if they were not motivated and kept coming in with excuses it was their problem, not mine.  If they wanted to waste their money I thought, that’s their choice. By taking this attitude I probably excluded many patients that I could have really helped.

When you reframe your thinking, and ask: “How can I change?” or “What can I do that’s different?” to engage patients who seem to lack motivation, then you make yourself available to helping many more people.

When you are in a position of authority, which you are by default, it’s extremely important to empower people to look after themselves by engaging them in what is most important to them.

How to engage clients who have seen other clinicians

This is often challenging. It can be difficult, too, when patients have been asked to see another clinician within the same practice, for a second opinion.

Like most of us, patients dislike having to repeat the same information over and over again. They don’t understand how important it is for clinicians to form an accurate clinical picture for themselves. All they know is that they’re going through the same process once again.

Here is a question that has been put to me:

“Often clients are referred to me from someone else and don’t want to go through all the questions again. I find communication can be difficult when the person has consulted other providers in the past and either:

  1. Doesn’t seem to want to repeat their history (especially if that ‘someone’ is working in the same clinic).
  2. Has been referred to the physio for help (maybe at their GP or partner’s recommendation) and doesn’t really seem to want to be here or believe that physio can help.

I would love to hear your thoughts on how you would recommend approaching this”.

When you’re seeing a client who has already seen a colleague within the practice, or a range of clinicians outside the practice, here are two options you could try:

Option 1:

“As you know, I have a number of questions to get through, but I find it easier to put this aside and ask you to spend 5 or 10 minutes just taking me through a recent or typical incident…

I might go back and fill in the gaps. Is that ok with you?”

Option 2:

“As you know, I have questions to get through, but I’d like to put aside 5 or 10 minutes to listen to how this injury is affecting you and what you want to get out of our time together, today and in the long term.

I might go back to the form to fill in the gaps. Is that ok with you?”

By using either of these options you will avoid getting into the ‘question and answer’ trap; you also gain patients’ permission to ask questions when you need to.

This method will give you a clear idea, at the beginning of the consultation, of what patients want from you.

Why is this introduction effective?

  • It builds rapport. By starting the consult this way you show that you understand patients’ frustration, you’re respectful of this, and you’re prepared to listen.
  • It will be different from what other clinicians have done in the past; after the usual pleasantries, most go straight into getting the clinical picture. Your patients are likely to think that their experience with you might also be different from what they have had in the past.
  • It clearly states that you will be asking questions but that it will be more important to understand what the patient is going through. The message to patients is that their agenda is more important to you than your own.
  • It enables patients to tell you what’s important to them. It might not be what you, from a health professional’s point of view, assume to be important.
  • It establishes a specific amount of time for patients to talk about what’s important. Because they have agreed to it, it will not seem rude to end the ‘talk time’ and move on.
  • Patients give you permission to ask questions rather than feel resentful that you will ask them no matter what.
  • You will find out what patients want from your treatment. You can refer to this throughout the assessment and when you present treatment options.

Adapt these introductions as needed, but maintain these principles:

  • Set a time limit on “talk time”
  • Gain permission to ask questions
  • Listen carefully for information about signs, symptoms, irritability and 24-hour patterns

When patients arrive, and say they don’t really want to be there, one thing is definitely in your favour. They are there, and have kept the appointment!

If they really didn’t want to attend, or had lost hope completely, they would not have turned up. Take heart from the fact that, at some level, they want help and hope that you will be the one who is different from all the others they’ve seen so far.

‘How Placebos Change The Patient’s Brain’. F. Benedetti, E. Carlino, and A. Pollo

Placebo Research’. F Benedetti podcast

Placebo and the New Physiology of the Doctor-Patient Relationship’. F Benedetti

“Improving Patient Motivation In Physiotherapy”

I wrote this eBook in response to the most common question I get asked and that is “How do I motivate my patients?”

To learn more about motivational tools through effective communication download my eBook

If you would like to fine-tune your communication skills when working with resistant patients, you might consider working with a coach or mentor.

Or perhaps your staff would benefit from training in this area.

Contact us, and find out more about what we can offer you.

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