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The Silent Healer  the Role of Communication in Placebo Effects Jozien Bensing William Verheul 2009 Bensing  Ask for permi...
Placebo “ I will please” 2009 Bensing  Ask for permission before adopting
Structure of Presentation <ul><li>A Bit of History </li></ul><ul><li>Current Knowledge </li></ul><ul><li>Looking Forward <...
Hooper’s Medical Dictionary (1811) <ul><li>Placebo: an epithet given to any medicine adapted more to please than to benefi...
Hippocrates, 460 – 400 B.C.  <ul><li>“ some patients, though conscious that their condition is perilous, recover their hea...
Around the midst of the 17th century, the times they were a’ changing …….. Throughout history, physicians have always been...
<ul><li>Cartesian dualism </li></ul><ul><li>Mind-body dichotomy </li></ul><ul><li>Body is a machine </li></ul><ul><li>Redu...
This could be a happy marriage Unfortunately, there is a hierarchy 2009 Bensing  Ask for permission before adopting The Sc...
<ul><li>&quot;Three-quarters of badly wounded men, although they have received no morphine for hours... have so little pai...
<ul><li>1955 </li></ul><ul><li>In the JAMA, Beecher announces – based on a review of 15 clinical studies -  that on averag...
Beecher Placebo research Placebo-controlled clinical trials ? 2009 Bensing  Ask for permission before adopting
placebo-effects in RCT’s <ul><li>In biomedical research only the therapeutical effect is considered </li></ul>Hrobjartsson...
<ul><li>In biomedical research placebo-effects are often considered as noise or as a nuisance </li></ul><ul><li>However, t...
It is getting time to open the black box of the physician’s healing power White, 1988 How can we learn to understand (and ...
Structure of Presentation <ul><li>A bit of history </li></ul><ul><li>Current knowledge </li></ul><ul><li>Looking forward <...
How do patients recover? Dutch Medical Schools (p/y): 2000 clinical trials 900 PhD theses 7500 publications 2009 Bensing  ...
Placebo: a relic from the past? <ul><li>WIRED MAGAZINE: 17.09.2009 </li></ul><ul><li>    </li></ul><ul><li>Placebos Are Ge...
What do we mean with ‘placebo effects’? <ul><li>Placebo effects are the  aspecific  or  nonspecific  effects of a medical ...
The content of the placebo-concept is temporary <ul><li>If we understand the mechanisms: </li></ul><ul><li>it is no longer...
Non-specific or incidental factors can also have  negative  influences on patient outcomes Nocebo effects 2009 Bensing  As...
Are placebo effects real and robust? <ul><li>NO </li></ul><ul><li>Hrobjartsson ,  Nw Eng J Med , 2002 </li></ul><ul><li>Hr...
Where do we find placebo-effects? <ul><li>Asthma </li></ul><ul><li>Bronchitis  </li></ul><ul><li>Common cold </li></ul><ul...
What can cause placebo effects? Treatment characteristics (e.g. colour, size, shape of drug) Health care setting (e.g. hom...
Mechanisms behind placebo effects <ul><li>Classic Conditioning </li></ul><ul><li>Positive or Negative Expectancies </li></...
Mechanism 1: conditioning <ul><li>A therapy or therapeutic procedure can produce a context-effect on health outcome, when ...
Mechanism 1:  classic conditioning   The natural response of a dog on the infusion of  adrenaline  is:  elevated  blood pr...
The natural response of a dog on the infusion of  acethylcholine  is:  lowered  blood pressure Mechanism 1:  classic condi...
Amaral & Sabbatini, 1999 Mechanism 1:  classic conditioning   2009 Bensing  Ask for permission before adopting
Review placebo effects based on conditioning <ul><li>Conditioned placebo-responses have been demonstrated in human beings ...
<ul><li>A medical treatment or procedure can produce a placebo-effect because the recipient expects it to.  </li></ul><ul>...
Pain reduction based on expectancies: open versus hidden treatment With several types of painkillers, patients experience ...
Hidden vs open paradigma Colloca & Benedetti, 2005 2009 Bensing  Ask for permission before adopting
Review Open vs Hidden Treatment: <ul><li>When manipulated experimentally, open treatment is more effective than hidden tre...
Review: placebo effects based on expectancies <ul><li>Many controlled studies show the influence of expectancies on health...
Mechanism 3: Affect  <ul><li>A medical treatment or procedure can produce a placebo-effect if it is administered in a warm...
support for the role of affect in placebo effects <ul><li>The placebo-response is stronger in stressed and/or anxious pati...
studies on the effects of affect <ul><li>Affective communication (warmth, empathy, nodding, eye contact) has shown to be r...
Limitations in communication research <ul><li>Much research is descriptive and correlational </li></ul><ul><li>RCT’s are c...
<ul><li>Placebo-effects exist and are genuine </li></ul><ul><li>At least 3 mechanisms are responsible: </li></ul><ul><ul><...
Structure of Presentation <ul><li>A Bit of History </li></ul><ul><li>Current Knowledge </li></ul><ul><li>Looking Forward (...
Medicine is a delicate balance between art, science and communication   (Carole Guzman) 2009 Bensing  Ask for permission b...
This could be a happy marriage Unfortunately, there is a hierarchy Art and science should be integrated 2009 Bensing  Ask ...
Neurocognitive sciences can help <ul><li>By providing knowledge about mind-body interaction </li></ul><ul><li>By introduci...
New knowledge: Neurobiological substrates of placebo effects <ul><li>Endogenuous opioids are found in placebo-responders  ...
New technologies (neuro-imaging) Collaca & Benedetti, 2005 2009 Bensing  Ask for permission before adopting
New methodologies <ul><li>Analogue patient paradigm </li></ul><ul><li>Standardized medical visits are watched by analogue ...
Coherence of skin conductance ( participating in versus watching a medical visit) 2009 Bensing  Ask for permission before ...
New methodologies <ul><li>The human mirror system acts as the neurological hardware for analogue patients’ empathy for the...
Experimental conditions (2x2) <ul><li>Positive Affect </li></ul><ul><li>Friendly and inviting welcome </li></ul><ul><li>Sh...
change in: &quot;The treatment will help against the pain&quot; Participating in visit Watching visit 2009 Bensing  Ask fo...
change in &quot;the pain will continue for a long time&quot; Participating in visit Watching visit 2009 Bensing  Ask for p...
Change in state anxiety Participating in visit Watching visit 2009 Bensing  Ask for permission before adopting
Experiences with methodology <ul><li>Intervention check: positive </li></ul><ul><li>Doctors & patients judged the videos a...
Reflection on results <ul><li>Raising expectations in itself is not sufficient to produce robust effects on patient outcom...
General conclusions <ul><li>Placebo effects exist and are genuine, no response bias </li></ul><ul><li>Three mechanisms  (c...
General Conclusions II <ul><li>Much progress has been made in the study of placebo effects in health care </li></ul><ul><l...
Let us open the black box of the physician’s healing power ! facilitating Open – closed questions EMPATHY Summarizing Eye ...
For information: [email_address] [email_address] 2009 Bensing  Ask for permission before adopting
2009 Bensing  Ask for permission before adopting
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Bensing ICCH09 Plenary PowerPoint

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This plenary took place on Monday, October 5, at 8:30 am during the International Conference on Communication in Healthcare (ICCH) 2009, in Miami Beach, Florida, USA.

The Silent Healer; The Role of Communication in the Placebo Effect

Jozien Bensing, PhD, was born in 1950 in Tilburg, the Netherlands. After finishing her formal education as clinical psychologist at Utrecht University, she started a research career at the Netherlands Institute for General Practitioners. She is founder and first president of the European Association of Communication in Health Care. In 1985 she became director of the Netherlands Institute for Health Services Research. She was appointed as full professor of Health Psychology at Utrecht University in 1991. She is a member of several councils and committees on the interface between the scientific world and healthcare, such as the Netherlands Society of Sciences, the Dutch Royal Academy of Sciences, the Dutch Health Council and the National Advisory Council on Health Research. She supervised more than 20 PhD-theses and wrote more than 200 publications, mostly on healthcare communication and related issues.

In 2003 Jozien Bensing became the first non-American to receive the international George Engel Award for “outstanding research contributing to the theory, practice and teaching of effective healthcare communication and related skills” from the American Academy on Physician and Patient
(now AACH). In 2004 she received a royal decoration (‘Officer of the Order of Orange Nassau’) for her work in translating scientific knowledge into public. She received the prestigious SPINOZA-award for her research on doctor-patient communication in 2006; in 2007 she was chosen to become a member of the Royal Netherlands Academy of Sciences, which consists of the top-200 most prestigious Dutch scientists.

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  • Hier een lijst met klachten waarbij placebo effecten zijn aangetoond
  • Transcript of "Bensing ICCH09 Plenary PowerPoint"

    1. 1. The Silent Healer the Role of Communication in Placebo Effects Jozien Bensing William Verheul 2009 Bensing Ask for permission before adopting
    2. 2. Placebo “ I will please” 2009 Bensing Ask for permission before adopting
    3. 3. Structure of Presentation <ul><li>A Bit of History </li></ul><ul><li>Current Knowledge </li></ul><ul><li>Looking Forward </li></ul>2009 Bensing Ask for permission before adopting
    4. 4. Hooper’s Medical Dictionary (1811) <ul><li>Placebo: an epithet given to any medicine adapted more to please than to benefit the patient </li></ul>2009 Bensing Ask for permission before adopting
    5. 5. Hippocrates, 460 – 400 B.C. <ul><li>“ some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician” </li></ul>precepts VI 2009 Bensing Ask for permission before adopting
    6. 6. Around the midst of the 17th century, the times they were a’ changing …….. Throughout history, physicians have always been well aware of the healing power of a comforting attitude Acknowledgment: Hanneke de Haes 2009 Bensing Ask for permission before adopting Jan Steen, 1650 W. Chandler, 1785
    7. 7. <ul><li>Cartesian dualism </li></ul><ul><li>Mind-body dichotomy </li></ul><ul><li>Body is a machine </li></ul><ul><li>Reductionistic approach </li></ul>René Descartes 1596 - 1650 Strategic Decision! Mind: domain of church Body: domain of physicians 2009 Bensing Ask for permission before adopting
    8. 8. This could be a happy marriage Unfortunately, there is a hierarchy 2009 Bensing Ask for permission before adopting The Science of Medicine The Art of Medicine
    9. 9. <ul><li>&quot;Three-quarters of badly wounded men, although they have received no morphine for hours... have so little pain that they do not want pain relief medication, even though the questions raised remind them that such is available for the asking.” </li></ul><ul><li>Pain in Men Wounded in Battle (1946) </li></ul>Henry Knowles Beecher 1904 - 1976 2009 Bensing Ask for permission before adopting
    10. 10. <ul><li>1955 </li></ul><ul><li>In the JAMA, Beecher announces – based on a review of 15 clinical studies - that on average 35 percent of a drug’s or a doctor’s succes is due to the patient’s expectation of a desired outcome, or the “placebo effect”: </li></ul><ul><li>“ The powerful Placebo” </li></ul>Henry Knowles Beecher 2009 Bensing Ask for permission before adopting
    11. 11. Beecher Placebo research Placebo-controlled clinical trials ? 2009 Bensing Ask for permission before adopting
    12. 12. placebo-effects in RCT’s <ul><li>In biomedical research only the therapeutical effect is considered </li></ul>Hrobjartsson et al, 2002 2009 Bensing Ask for permission before adopting Therapeutical effect control placebo intervention
    13. 13. <ul><li>In biomedical research placebo-effects are often considered as noise or as a nuisance </li></ul><ul><li>However, these are a fascinating target for scientific inquiry </li></ul>Hrobjartsson et al, 2002 placebo-effects: noise or focus? 2009 Bensing Ask for permission before adopting control placebo intervention placebo effect
    14. 14. It is getting time to open the black box of the physician’s healing power White, 1988 How can we learn to understand (and thus enhance) placebo-effects? 2009 Bensing Ask for permission before adopting
    15. 15. Structure of Presentation <ul><li>A bit of history </li></ul><ul><li>Current knowledge </li></ul><ul><li>Looking forward </li></ul>2009 Bensing Ask for permission before adopting
    16. 16. How do patients recover? Dutch Medical Schools (p/y): 2000 clinical trials 900 PhD theses 7500 publications 2009 Bensing Ask for permission before adopting Natural course Biomedical treatment Placebo (context) effects Health outcome
    17. 17. Placebo: a relic from the past? <ul><li>WIRED MAGAZINE: 17.09.2009 </li></ul><ul><li> </li></ul><ul><li>Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why. </li></ul><ul><li>Steve Silberman </li></ul>2009 Bensing Ask for permission before adopting
    18. 18. What do we mean with ‘placebo effects’? <ul><li>Placebo effects are the aspecific or nonspecific effects of a medical treatment on patients’ health or wellbeing (Shapiro & Shapiro, 1997) </li></ul><ul><li>Placebo effects are the incidental factors of a treatment to be discerned from the characteristic factors of a treatment ( Grünbaum, 1986; Hrobjartsson, 2002) </li></ul><ul><li>Placebo effects are the genuine psychological or physiological effects, which are attributable to receiving a substance or undergoing a procedure, but are not due to the inherent powers of that substance or procedure (Stewart-Williams et al. 2004) </li></ul>2009 Bensing Ask for permission before adopting
    19. 19. The content of the placebo-concept is temporary <ul><li>If we understand the mechanisms: </li></ul><ul><li>it is no longer non-specific or a-specific we learn to understand how it exactly works </li></ul><ul><li>It is no longer incidental we can apply it in a planned and systematic way </li></ul><ul><li>We can make it an integrated part of medical treatment and teaching medicine </li></ul>2009 Bensing Ask for permission before adopting
    20. 20. Non-specific or incidental factors can also have negative influences on patient outcomes Nocebo effects 2009 Bensing Ask for permission before adopting
    21. 21. Are placebo effects real and robust? <ul><li>NO </li></ul><ul><li>Hrobjartsson , Nw Eng J Med , 2002 </li></ul><ul><li>Hrobjartsson , J Int Med , 2004 </li></ul><ul><li>Hrobjartsson , J Clin Epid , 2006 </li></ul><ul><li>YES </li></ul><ul><li>DiBlasi , Lancet , 2001 </li></ul><ul><li>Vase , Pain , 2002 </li></ul><ul><li>Guess , BMJ-books , 2002 </li></ul><ul><li>Sauro , J Psychosom Res , 2003 </li></ul><ul><li>Hyland, Clinical Medicine , 2003 </li></ul><ul><li>Wager , Science , 2004 </li></ul><ul><li>Stewart-Williams , Psych Bull , 2004 </li></ul><ul><li>Collaca , Nature , 2005 </li></ul><ul><li>Wampold , J Clin Psy, 2007 </li></ul><ul><li>Price , Ann Psych Rev , 2008 </li></ul>Placebo-effects are always demonstrated in those studies where placebo-effects can be expected to exist 2009 Bensing Ask for permission before adopting
    22. 22. Where do we find placebo-effects? <ul><li>Asthma </li></ul><ul><li>Bronchitis </li></ul><ul><li>Common cold </li></ul><ul><li>Coughing </li></ul><ul><li>Heart failure </li></ul><ul><li>Hypertension </li></ul><ul><li>Herpes simplex </li></ul><ul><li>Parkinson </li></ul><ul><li>Rheumatoïd arthritis </li></ul><ul><li>etcetera </li></ul><ul><li>Anxiety </li></ul><ul><li>Depression </li></ul><ul><li>Schizofrenia </li></ul><ul><li>Psychoneuroses </li></ul><ul><li>Stress disorders </li></ul><ul><li>Psychosomatic disorders </li></ul><ul><li>Medically Unexplained Symptoms </li></ul><ul><li>Pain </li></ul>2009 Bensing Ask for permission before adopting
    23. 23. What can cause placebo effects? Treatment characteristics (e.g. colour, size, shape of drug) Health care setting (e.g. home, hospital, room layout) Patient characteristics (e.g. illness / treatment beliefs, anxiety, adherence) Patient-practitioner relationship (e.g. compassion, reassurance, suggestion) Practitioners characteristics (e.g. status, sex, illness and treatment beliefs) DiBlasi et al, Lancet, 2001 2009 Bensing Ask for permission before adopting
    24. 24. Mechanisms behind placebo effects <ul><li>Classic Conditioning </li></ul><ul><li>Positive or Negative Expectancies </li></ul><ul><li>Positive or Negative Affect </li></ul>These mechanisms are interlinked in many ways Van Dulmen & Bensing, 2001 2009 Bensing Ask for permission before adopting
    25. 25. Mechanism 1: conditioning <ul><li>A therapy or therapeutic procedure can produce a context-effect on health outcome, when it is associated – consciously or unconsciously – with previous experiences </li></ul><ul><li>These experiences (and thus the health outcmes) can be either positive or negative </li></ul>2009 Bensing Ask for permission before adopting
    26. 26. Mechanism 1: classic conditioning The natural response of a dog on the infusion of adrenaline is: elevated blood pressure Amaral & Sabbatini, 1999 2009 Bensing Ask for permission before adopting
    27. 27. The natural response of a dog on the infusion of acethylcholine is: lowered blood pressure Mechanism 1: classic conditioning 2009 Bensing Ask for permission before adopting
    28. 28. Amaral & Sabbatini, 1999 Mechanism 1: classic conditioning 2009 Bensing Ask for permission before adopting
    29. 29. Review placebo effects based on conditioning <ul><li>Conditioned placebo-responses have been demonstrated in human beings and in animals </li></ul><ul><li>The effects in humans include pain relief, immunosuppression (MS), the production of hormones (Parkinson) a.o. </li></ul><ul><li>Conditioning seems to be ‘hardwired’ in the brain </li></ul><ul><li>Conditioning can take place unconsciously and consciously </li></ul><ul><li>CAVEAT! If consciously, it is related to expectancies </li></ul>Stewart-Wiliams, 2004, Price, 2008 2009 Bensing Ask for permission before adopting
    30. 30. <ul><li>A medical treatment or procedure can produce a placebo-effect because the recipient expects it to. </li></ul><ul><li>Expectancies may be seen as: </li></ul><ul><ul><li>the patients’ beliefs about the efficacy of treatment (outcome expectancies) and </li></ul></ul><ul><ul><li>the patients’ beliefs about their abilities to cope with the disease and its treatment (self-efficacy). </li></ul></ul>Mechanism 2: expectancies Crow, 1999, Stewart-Williams, 2004 2009 Bensing Ask for permission before adopting
    31. 31. Pain reduction based on expectancies: open versus hidden treatment With several types of painkillers, patients experience more pain relief if they know the painkiller is administrated Price, 2008 2009 Bensing Ask for permission before adopting
    32. 32. Hidden vs open paradigma Colloca & Benedetti, 2005 2009 Bensing Ask for permission before adopting
    33. 33. Review Open vs Hidden Treatment: <ul><li>When manipulated experimentally, open treatment is more effective than hidden treatment </li></ul><ul><li>Expectations seem to play an important role in producing these context effects </li></ul><ul><li>These effects can be influenced both by previous experiences and/or verbal suggestion </li></ul><ul><ul><li>Amanzio et al. 2001, Benedetti et al.2003, Colloca et al. 2004, Levine & Gordon 1984 </li></ul></ul>2009 Bensing Ask for permission before adopting
    34. 34. Review: placebo effects based on expectancies <ul><li>Many controlled studies show the influence of expectancies on health outcomes </li></ul><ul><li>There is a clear neurobiological substrate, meaning that these effects are genuine, not only response bias </li></ul><ul><li>CAVEAT! In most studies no distinction is being made between positive words (raising expectations) and positive affect (a warm and friendly doctor) </li></ul>2009 Bensing Ask for permission before adopting
    35. 35. Mechanism 3: Affect <ul><li>A medical treatment or procedure can produce a placebo-effect if it is administered in a warm and empathic way. </li></ul><ul><li>This may serve a number of functions: </li></ul><ul><ul><li>Stress reduction </li></ul></ul><ul><ul><li>Anxiety reduction </li></ul></ul><ul><ul><li>Social support </li></ul></ul><ul><li>Its influence on health outcome is sometimes direct (relaxation), but also via moderators like self disclosure, self care, adherence, etc. </li></ul>DiBlasi, 2001, Kelley,1997, Epstein, 2007, Price, 2008, Street, 2009 2009 Bensing Ask for permission before adopting
    36. 36. support for the role of affect in placebo effects <ul><li>The placebo-response is stronger in stressed and/or anxious patients (Wasan, 2006) </li></ul><ul><li>The placebo-response is stronger in clinical pain than in experimental pain (Price, 1997, 2008) </li></ul><ul><li>‘ desire for relief’ is an important factor apart from ‘expectancies’ (Harrington, 1997) </li></ul><ul><li>The processing of negative emotions shares neural networks with pain responses (Eisenberger, 2004) </li></ul>2009 Bensing Ask for permission before adopting
    37. 37. studies on the effects of affect <ul><li>Affective communication (warmth, empathy, nodding, eye contact) has shown to be related to several patient outcomes, including: </li></ul><ul><ul><li>satisfaction, </li></ul></ul><ul><ul><li>adherence </li></ul></ul><ul><ul><li>health outcomes (Hb1ac, blood pressure) </li></ul></ul>Stewart, 1995, DiBlasi et al, 2001, Beck et al, 2002, Griffin, 2004, Rao, 2007 2009 Bensing Ask for permission before adopting
    38. 38. Limitations in communication research <ul><li>Much research is descriptive and correlational </li></ul><ul><li>RCT’s are conducted, but communication is often used as a container concept </li></ul><ul><li>Rigorous experiments testing specified communication elements are difficult to perform </li></ul><ul><ul><li>it is unethical to confront real patients in clinical situations with negative affect (cold, impersonal communication) </li></ul></ul><ul><ul><li>Communication is per se interactive, thus difficult to standardize </li></ul></ul><ul><ul><li>Researchers are reluctant to adopt a reductionistic approach </li></ul></ul>2009 Bensing Ask for permission before adopting
    39. 39. <ul><li>Placebo-effects exist and are genuine </li></ul><ul><li>At least 3 mechanisms are responsible: </li></ul><ul><ul><li>Conditioning </li></ul></ul><ul><ul><li>Expectancies </li></ul></ul><ul><ul><li>Affect </li></ul></ul><ul><li>Communication seems to play an important role </li></ul><ul><li>But can we really prove how? </li></ul>What do we know about placebo-effects? 2009 Bensing Ask for permission before adopting control placebo intervention placebo effect
    40. 40. Structure of Presentation <ul><li>A Bit of History </li></ul><ul><li>Current Knowledge </li></ul><ul><li>Looking Forward (back to the future) </li></ul>2009 Bensing Ask for permission before adopting
    41. 41. Medicine is a delicate balance between art, science and communication (Carole Guzman) 2009 Bensing Ask for permission before adopting
    42. 42. This could be a happy marriage Unfortunately, there is a hierarchy Art and science should be integrated 2009 Bensing Ask for permission before adopting The Science of Medicine The Art of Medicine
    43. 43. Neurocognitive sciences can help <ul><li>By providing knowledge about mind-body interaction </li></ul><ul><li>By introducing new technologies </li></ul><ul><li>By inspiring new methodologies </li></ul>2009 Bensing Ask for permission before adopting
    44. 44. New knowledge: Neurobiological substrates of placebo effects <ul><li>Endogenuous opioids are found in placebo-responders ( Benedetti, 1999) </li></ul><ul><li>Placebo-induced release of endogenous opioids has been obtained by using in vivo receptor binding with positron emission tomography ( Zubieta, 2005) </li></ul><ul><li>Similar regions in the cerebral cortex and in the brainstem are affected by both a placebo and a painkiller (remifentanil) ( Petrovic, 2002) </li></ul>; 2009 Bensing Ask for permission before adopting
    45. 45. New technologies (neuro-imaging) Collaca & Benedetti, 2005 2009 Bensing Ask for permission before adopting
    46. 46. New methodologies <ul><li>Analogue patient paradigm </li></ul><ul><li>Standardized medical visits are watched by analogue patients </li></ul><ul><li>The assumption is that watching a videotaped consultation produces the same effects as participating in this consultation </li></ul>Fogarty, 1999, Schmid Mast, 2005, 2007, 2008, Eide, 2008 2009 Bensing Ask for permission before adopting
    47. 47. Coherence of skin conductance ( participating in versus watching a medical visit) 2009 Bensing Ask for permission before adopting
    48. 48. New methodologies <ul><li>The human mirror system acts as the neurological hardware for analogue patients’ empathy for the patient </li></ul><ul><li>This methodology has shown to be able to evoke discriminating reactions in response to different communication-stimuli </li></ul><ul><li>Which opens the possibility of testing the effects of different communication elements on patient outcomes </li></ul>Fogarty, 1999, Schmid Mast, 2005, 2007, 2008 2009 Bensing Ask for permission before adopting
    49. 49. Experimental conditions (2x2) <ul><li>Positive Affect </li></ul><ul><li>Friendly and inviting welcome </li></ul><ul><li>Showing empathy </li></ul><ul><li>Eye contact & body posture </li></ul><ul><li>Negative Affect </li></ul><ul><li>Formal and cold welcome </li></ul><ul><li>No empathic statements </li></ul><ul><li>Little eye contact and diverted body posture </li></ul><ul><li>Positive Expectancies </li></ul><ul><li>Positive about the type of drugs </li></ul><ul><li>Positive about expected effect on pain </li></ul><ul><li>Negative Expectancies </li></ul><ul><li>Drug is mentioned in a neutral way </li></ul><ul><li>Hesitation about expected effect </li></ul>2009 Bensing Ask for permission before adopting
    50. 50. change in: &quot;The treatment will help against the pain&quot; Participating in visit Watching visit 2009 Bensing Ask for permission before adopting
    51. 51. change in &quot;the pain will continue for a long time&quot; Participating in visit Watching visit 2009 Bensing Ask for permission before adopting
    52. 52. Change in state anxiety Participating in visit Watching visit 2009 Bensing Ask for permission before adopting
    53. 53. Experiences with methodology <ul><li>Intervention check: positive </li></ul><ul><li>Doctors & patients judged the videos as realistic </li></ul><ul><li>The women had no problems ‘playing their role’ of a patient with severe period pain </li></ul><ul><li>Most women had no problems with identifying themselves with the patient on video </li></ul>2009 Bensing Ask for permission before adopting
    54. 54. Reflection on results <ul><li>Raising expectations in itself is not sufficient to produce robust effects on patient outcomes </li></ul><ul><li>Showing positive affect in itself is not sufficient to produce robust effects on patient oucomes </li></ul><ul><li>It is the combination that works! </li></ul><ul><li>Nocebo effects are evident as well </li></ul>2009 Bensing Ask for permission before adopting
    55. 55. General conclusions <ul><li>Placebo effects exist and are genuine, no response bias </li></ul><ul><li>Three mechanisms (conditioning, expectancies and showing affect) seem to be responsible </li></ul><ul><li>All three mechanisms have shown a neurobiological substrate, which takes placebo research out of the hazy area </li></ul><ul><li>Placebo effects are often interlinked but can be manipulated in experimental designs </li></ul><ul><li>Communication plays a major role </li></ul>2009 Bensing Ask for permission before adopting
    56. 56. General Conclusions II <ul><li>Much progress has been made in the study of placebo effects in health care </li></ul><ul><li>Thanks to: </li></ul><ul><ul><li>Multi- and Interdisciplinary efforts </li></ul></ul><ul><ul><li>New technologies </li></ul></ul><ul><ul><li>New methodologies </li></ul></ul><ul><ul><li>Rigorous experimental testing </li></ul></ul><ul><li>But many new questions arise, eg. About the specific role of different communication elements </li></ul><ul><li>An exciting research domain is developing really fast </li></ul>2009 Bensing Ask for permission before adopting
    57. 57. Let us open the black box of the physician’s healing power ! facilitating Open – closed questions EMPATHY Summarizing Eye contact Nodding Tailoring I nterruptions Expectancies Explicit vs implicit Information Being Positive - Neutral Experiences 2009 Bensing Ask for permission before adopting
    58. 58. For information: [email_address] [email_address] 2009 Bensing Ask for permission before adopting
    59. 59. 2009 Bensing Ask for permission before adopting
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