New research suggests that physical wellbeing extends well beyond nutrition, behavior, or mental attitude. It hinges on conviction.
At the University of Florida, Russell Price, who lives with Parkinson's disease, has surgery to place a deep brain stimulation (DBS) lead, which sends electrical pulses to the brain regions governing movement, a treatment proven to bring meaningful symptom relief to properly chosen patients. Some additional progress in certain patients may stem purely from anticipating improvement, a phenomenon known as the placebo effect. "This isn't anything mystical," notes neurologist Michael Okun.
A pilgrim doubted he could reach the Chapel of Grace. Walking was torture, never mind covering the 70 miles that thousands of devotees journey each year to view a sacred wooden figure: the Black Madonna of Altötting.
Richard Mödl had fractured his heel shortly before, but in 2003 he was resolved to finish his inaugural pilgrimage from Regensburg to Altötting, Germany. He reasoned that if discomfort overwhelmed him, he could always catch a ride. Yet his trust in the Virgin Mary's capacity to guide him was unwavering. So he walked. And walked.
Now 74, Mödl radiates a warm smile and a lean, wiry physique that seems built to withstand a charging rhino. Ever since his foot mended, he has completed the pilgrimage 12 additional times, becoming a devoted advocate for its life-changing influence.
Mödl is not unusual in his conviction. Whether it arrives as a brush with the Holy Spirit at a Florida tent revival or a sacred bath in the Ganges, belief-driven healing surrounds us. Studies indicate that consistent religious attendance may strengthen immunity, reduce blood pressure, and extend longevity.
Faith in a higher power is far from the only form of belief capable of producing seemingly inexplicable improvement. Six thousand miles from Altötting, another individual encountered what appeared to be medical magic.
Mike Pauletich first sensed trouble in 2004. His baseball throw drifted off target, and his arm ached. His hand trembled slightly, and, most peculiar of all, his wife pointed out that he had stopped smiling altogether.
Assuming he had carpal tunnel syndrome, he visited a physician. However, his faulty aim wasn't tied to his arm, and his missing smile wasn't because his arm hurt. At 42, Pauletich was diagnosed with early onset Parkinson's disease. His physician warned that within a decade he would be unable to walk, stand, or feed himself.
Pauletich didn't decline as steeply as predicted, yet for years he battled both the illness and depression, as speaking and writing grew increasingly difficult. Then, in 2011, he approached Ceregene, a firm trialing a novel gene therapy. Parkinson's arises from the progressive death of the neurotransmitter dopamine. Prior work in monkeys had shown that injections of a protein called neurturin could slow disease progression by shielding and potentially mending damaged dopamine-secreting neurons. Ceregene's experimental approach involved boring two openings, one in each brain hemisphere, through a patient's skull and delivering the drug straight to the target zones.
Pauletich's recovery following the surgery was striking. Before joining the trial, he had difficulty moving. He had to repeatedly clarify to clients of his technology firm that his garbled speech wasn't from alcohol. After the procedure, his tremors vanished, his movement grew steadier, and his speech sharpened considerably. (Today his condition is barely detectable.) His study physician, Kathleen Poston, was stunned. In strict medical terms, Parkinson's had never been reversed in humans; the best realistic outcome was a deceleration of progression, and even that was uncommon.
In April 2013, Ceregene released the trial findings: Neurturin had not succeeded. Patients administered the drug did not fare significantly better than those in a control arm who had undergone a placebo procedure, a sham operation in which a physician drilled small indentations into the skull to mimic real surgery. Ceregene was acquired by another firm in 2013, and its neurturin research for Parkinson's was discontinued.
Poston was devastated. Yet upon examining the data, she spotted something that gave her pause. Mike Pauletich had not received the actual surgery. He had received the placebo.
In a manner of speaking, both Pauletich and Mödl took part in a performance, one that humanity has enacted for millennia, whenever we seek out healers hoping they'll restore us. And just as a compelling theatrical performance can pull us in until reality blurs, the theater of healing is crafted to draw us in by forging powerful expectations in our minds. These expectations fuel the so-called placebo effect, which can influence physical processes in our bodies. Researchers have acknowledged the placebo effect for generations and employed it as a control in medication trials. Now they are viewing placebos as a portal to the neurochemical pathways linking mind and body, conviction and experience.
What transforms a belief into something potent enough to heal? Returning to the theater: a vital element of an uplifting performance is the staging and attire. When Pauletich noted improvement in his symptoms, it wasn't solely because of the indentations he could feel in his skull or what his physicians had said about the operation. It was the entire tableau he had experienced: the physicians in white coats, stethoscopes draped over their necks; the nurses, examinations, screenings, possibly even the mediocre tunes in the waiting area. Doctors often refer to these trappings surrounding hospitals as the theater of medicine.
For over 75 years, Jones Benally has practiced healing on Arizona's Navajo Reservation, addressing both physical and emotional suffering to ease his patient's discomfort and worry. He conducts his work in a hogan (pictured)—and also in hospitals and elder-care facilities. His daughter and sons are studying his methods to continue the lineage.
This staging extends to many facets of treatment and can function beneath conscious awareness. Costly placebos outperform cheap ones. Placebos in branded packaging outperform those labeled generic. Placebo suppositories prove more effective in France, while the English favor swallowing their placebos. Frequently, sham injections outperform sham pills. Yet sham surgeries appear to be the most potent of all.
Remarkably, placebos can remain effective even when recipients know they are placebos. This was documented in a landmark 2010 paper by Ted Kaptchuk, a researcher at Harvard Medical School, and colleagues. After 21 days on a placebo, individuals with irritable bowel syndrome experienced significant improvement compared with those given nothing, despite being informed beforehand (and reminded afterward) that they were receiving placebos.
The study demonstrated that a caring patient-practitioner relationship was central to fostering belief in a positive outcome. Patients were taught about the influence of placebos and an optimistic outlook. They were informed that the placebo pills had been demonstrated, through rigorous clinical trials, to trigger meaningful self-healing responses. They were directed to take the pills consistently, without skipping any doses.
"Dealing with expectation is very tricky," says Kaptchuk, who has spent his life studying placebo effects. "We're dealing with very imprecise measuring of a very imprecise phenomenon. And a lot of it's nonconscious."
Karin Jensen, a former colleague of Kaptchuk who now directs her own laboratory at the Karolinska Institute in Stockholm, Sweden, devised an experiment to test whether subliminal cues could condition subjects to experience a placebo effect.
During the conditioning phase, participants watched alternating faces flash on a screen. Jensen chose faces because our brains excel at rapidly identifying them. Half of the participants received subliminal cues: the faces appeared for just milliseconds, too brief to consciously distinguish. For the remaining participants, the facial cues remained visible long enough for conscious recognition.
Throughout this initial phase, varying heat stimuli were applied to the participants' arms in tandem with the facial cues: more heat paired with the first face, less heat paired with the second. In the subsequent testing phase, participants, including those exposed only to the rapid subliminal cues, reported greater pain upon seeing the first face, even though the heat stimuli remained moderate and identical for both faces. The participants had thus developed an unconscious association between greater pain and the first face.
The experiment demonstrated that a placebo response can be conditioned subliminally. Jensen emphasizes that minute cues upon entering a hospital, many of which operate below awareness, trigger bodily responses in a similar fashion.
"Part of healing is nonconscious—something that happens instinctually," she says. At the Mayo Clinic in Rochester, Minnesota, neuroradiologist David Kallmes injects medical bone cement into a patient's spine to stabilize a painful vertebral compression fracture. A study directed by Kallmes at the clinic showed pain relief was almost the same one month later in a control group that received sham procedures. "Shocking to most people," Kallmes said of the results. "Surprising to me."
Hospitals represent just one common setting for the theater of belief. Hundreds of alternative medical practices draw on our expectations, including homeopathy, acupuncture, traditional Chinese medicines, urine therapy, cow dung tablets, human blood facials, vitamin infusions, sound healing, to list a few, all with varying degrees of established efficacy.
Tanya Luhrmann, an anthropologist at Stanford University who has devoted much of her career to comprehending people's encounters with God, observes:
"Belief is natural. It comes partly from the way our minds are hardwired"
She maintains that belief-based healing demands not only a compelling narrative but also the engagement of an attentive listener, someone with the capacity to make what is imagined feel tangible. When narrative and imagination align, the outcomes can be remarkable.
"Humans have the capacity to change their experience," she says. "These are skills, and we can learn them."
I'd learned of the belief-based healing practiced by the brujos, or witch doctors, of Catemaco, in the state of Veracruz on Mexico's eastern coast. They are notably theatrical healers, fusing shamanic traditions with Roman Catholicism much as Christians did a millennium ago. I'd heard tales of enormous, pentagram-shaped bonfires and frenzied dancers who douse you with spit as a blessing. Definitely worth a trip.
However, when I arrived in Catemaco and made my way to a modern brujo's office, I encountered no fires or shrieking shamans. Far from the dark, bat-infested cave I had imagined, the waiting area was actually a neat little living room that smelled of disinfectant. Plastic amulets and glass crystals lined the shelves. About 10 people sat in chairs, reading magazines or watching soccer on TV. As witch doctors go, the brujo who greeted me looked more doctor than witch. Dressed all in white, he sported a neat mustache and short, heavily gelled hair. Half his office was taken up by an altar packed with crucifixes, statues of saints, flowers, and hundreds of blinking, colored lights.
I'd come for a simple limpia, a cleansing of my spirit. The brujo grabbed an egg, a few sprigs of basil, and a couple of plastic squirt bottles filled with what he said were envy blockers, bad-energy protection, and a liquid that makes wealth. Everything was orderly and sanitized. After a short interview, he got down to the business of my spirit, squirting me liberally with pungent oils and rubbing an egg over my body before cracking it open into a glass of water and examining the contents.
I was familiar with this routine—it's common among brujos in Mexico. What surprised me was the lack of pomp or mumbo jumbo. It was more clinical than ceremonial. The brujo asked about my knees and lower back (both fine) and informed me that the egg indicated I might be in for some pain in the future. Like a radiologist explaining features on an x-ray, he noted several bubbles around the egg white in the glass: a sign that someone close to me was jealous and wished me ill. Then he offered, for an extra fee, to protect me from future harm. I declined; we shook hands. I left feeling a sense of anticlimax, as if I had somehow missed something. Where was the theater?
It was only when I was back on the street that I began to understand. Twenty years ago you could still find "authentic" dancing, spitting witch doctors in Catemaco (and they still show up for tourists and festivals). But expectation is a moving target. Over the past generation, conventional medicine has become the norm in Catemaco. Spitting and waving chicken feathers inspired confidence before, but most brujos today have adapted to the times, mixing white lab coats and antiseptic spray with their mysticism to tap into their modern patients' expectations: the theater of medicine. My brujo made eye contact and smiled warmly, like a skillful, caring medical doctor.
And I have to say, I did feel a little better.
JASON TREAT, NGM STAFF; KELSEY NOWAKOWSKI ART: STUDIO MUTI. SOURCES: IRENE TRACEY, UNIVERSITY OF OXFORD; FABRIZIO BENEDETTI, UNIVERSITY OF TURIN
So how does the theater of medicine actually work? How does a belief literally heal?
One part of the puzzle involves conditioning, as Jensen has shown. Recall Pavlov's dog, which drooled every time it heard a bell. That happened because Pavlov conditioned the animal to connect food with the sound. Scientists have been able to train the immune systems of rats by pairing sweet liquids with cyclosporine A, a drug that blocks the function of immune cells to keep patients from rejecting transplanted organs. Every time the rat has a sweet drink, it also gets the drug. But after enough trials, the drug is unnecessary: The sweet drink alone is enough to shut down the rat's immune response.
The placebo effect's conditioned response in reaction to pain is to release brain chemicals—endorphins, or opium-like painkillers—synthesized in the body. In the 1970s two San Francisco neuroscientists interested in how those internal opioids control pain made a discovery during an experiment with patients who had just had their wisdom teeth pulled.
Among Peru's Ashaninka communities, healing ceremonies rely on steam from simmering herbs. Young Mircyla Prado Pintallo, just 11 years old, is being trained in the role of vaporadora. After the patient breathes in the vapor, Mircyla will interpret the leaves to assess the ritual's success and may recommend additional herbs to restore the patient's wellbeing.
The researchers first compared the response of a placebo group to the response of another group that received naloxone, a drug that cancels out the ameliorating effect of opioids. None of the subjects received or expected to receive morphine—and all of them felt miserable. Then the scientists redesigned the experiment, telling the patients that some of them would receive morphine, some a placebo, and some naloxone. No one, including the researchers, knew who would receive what. This time, some of the patients felt better, even though they didn't receive morphine. Their expectation of potential relief triggered the release of endorphins in their bodies, and those endorphins reduced the pain. But as soon as they got naloxone, they were in pain again. The drug wiped out the action of the endorphins that the placebo response had released.
Howard Fields, an emeritus professor at the University of California, San Francisco and one of the authors of the study, says:
"Without the expectation of pain relief, you can't have a placebo effect"
Since that experiment, conditioning has been used to study the effects of belief on the release of other drugs produced by the body, including serotonin, dopamine, and some cannabinoids, which can work in a way similar to the psychoactive ingredient in marijuana. But it wasn't until the early 2000s that scientists could watch how these effects play out in the brain. Tor Wager, then a Ph.D. student at the University of Michigan, put subjects in a brain scanner. He applied cream to both of each subject's wrists, then strapped on electrodes that could deliver painful shocks or heat. He told the subjects that one of the creams could ameliorate pain, but the creams, in fact, were the same, and neither had any inherent pain-reducing qualities. After several rounds of conditioning, the subjects learned to feel less pain on the wrist coated with the "pain relieving" cream; on the last run, strong shocks felt no worse than a light pinch. A typical conditioned placebo response.
The most interesting part was what the brain scans showed. Normal pain sensations begin at an injury and travel in a split second up through the spine to a network of brain areas that recognize the sensation as pain. A placebo response travels in the opposite direction, beginning in the brain. An expectation of healing in the prefrontal cortex sends signals to parts of the brain stem, which creates opioids and releases them down to the spinal cord. We don't imagine we're not in pain. We self-medicate, literally, by expecting the relief we've been conditioned to receive.
"The right belief and the right experience work together," says Wager, now a professor at the University of Colorado Boulder and director of a neuroscience lab there. "And that's the recipe."
The recipe of belief and experience is finding its way out of the lab and into clinical practice as well. Christopher Spevak is a pain and addiction doctor at the Walter Reed National Military Medical Center in Bethesda, Maryland. Every day he sees active service members and veterans with severe injuries, sometimes just days or weeks after they have left the battlefield. This offers him an opportunity to use expectation and conditioning to tap into internal opioids to stave off, or at least mitigate, long-term pain.
When Spevak first meets patients, he doesn't ask about their injuries or their medical histories—he has all that on file. Instead he asks them about themselves. He might learn that in childhood a person had a favorite eucalyptus tree outside his house or loved peppermint candies. Eventually, if Spevak prescribes opioid painkillers, every time the patient takes one, he also has eucalyptus oil to smell or a peppermint to eat—whatever stimulus Spevak knows will resonate. Over time, just as with Jensen's quick-flash faces or Wager's skin cream (or for that matter, Pavlov's bell), patients start linking the sensory experience to the drugs. After a while, Spevak cuts down on the drug and just provides the sounds or smells. The patient's brain can go to an internal pharmacy for the needed drugs.
The Mind's Internal Pharmacy
Ritual and Collective Faith
Driving off negative energy and malevolent spirits with fire, Hmong shaman Ploua Her presides over a yearly healing rite to safeguard Wang Lue Her's household. Following the fire ritual, a goat, pigs, and chickens will be offered as sacrifice and later shared among the assembled family members.
"We have triple amputees, quadruple amputees, who are on no opioids," Spevak says of his Iraq and Afghanistan veteran patients. "Yet we have older Vietnam vets who've been on high doses of morphine for low back pain for the past 30 years."
Two years ago Leonie Koban, a member of Tor Wager's lab, spearheaded a novel placebo study. The scientists were well aware of the roles of conditioning and theater in channeling expectations. They wanted to test the effect of a third element influencing experiences of pain: other believers.
As in many previous tests of the placebo effect, the researchers delivered a burning sensation to their subjects' arms and asked the subjects to rate how strong it was. But this time they introduced an extra variable. The volunteers looked at a screen and saw a series of hash marks representing how previous participants had rated their pain. For the same stimulus, the subjects reported feeling higher or lower levels of pain based on what they were told previous participants had felt.
The result was not surprising. In the 1950s, a series of tests called the Asch experiments showed that subjects can give answers they know to be wrong in order to conform with the group. What shocked Koban and Wager was the sheer strength of the social influence: The effect was larger than might be expected after conditioning. Tests of the subjects' skin conductance responses—involuntary changes in how the body is conducting electricity, often used in lie detection—showed that they were not just reporting what they thought the researchers wanted to hear; they were actually responding less to pain. Studies with fMRI machines implicated a separate, complementary network of brain activity that kicks in when conventional placebos are enhanced by peer pressure. Koban goes so far as to say that social information might be more powerful in altering the experience of pain than both conditioning and subconscious cues.
"Information we take from our social relationships has really profound influences, [not only] on emotional experiences but also on health-related outcomes such as pain and healing," Koban says.
"And we are only beginning to understand these influences and how we can harness them."
Luana Colloca, a placebo specialist at the University of Maryland, Baltimore, alongside her colleagues, has identified yet another trigger of this puzzling phenomenon: our perception of how others feel pain. In this study, participants were conditioned to rate a heat stimulus as more intense when it appeared alongside an image of a distressed face, even though the actual heat remained moderate. An MRI scanner documents the brain's reaction to the paired stimuli.
The impact of the social group could help explain why religion might in a very literal sense be what Karl Marx defined as "the opium of the people": It can tap into the ability to access our own store of beliefs and expectations, especially when we're surrounded by other believers who are doing the same.
Nowhere is the power of group belief more evident than in religious pilgrimages—whether it's the annual Catholic trek to Lourdes, in France, the annual hajj pilgrimage of Muslims to Mecca, in Saudi Arabia, or, largest of all, the Maha Kumbh Mela, occurring every 12 years. The latest Kumbh Mela, in February 2013, drew an estimated 70 million Hindus to the Indian city of Allahabad.
Or the pilgrimage to Altötting where I met Richard Mödl. The first documented healing in Altötting was in 1489, when a drowned boy was said to have been miraculously brought back to life. Today the Black Madonna there attracts about a million visitors a year.
The pilgrims I joined on a cold Bavarian morning in 2016 had already been walking since 3 a.m. After pausing for breakfast, everyone was chatting happily, waiting for the signal to begin walking again, in the rain. I had been nervous about the trip because of ankle surgery I'd had three months before. But in that merry throng of believers, my pain faded away.
"Everyone is here for their own reasons, but they are all here for each other just as much," said Marcus Brunner, a cheery priest and 27-year veteran of the walk. "The group carries you, and you carry the group all together."
When we arrived in the Chapel of Grace, we found it covered inside and out with ex-votos—pictures representing miracles spanning hundreds of years and showing every imaginable ailment. Propped against the walls were crutches and canes left behind through the ages by parishioners and pilgrims whose suffering was relieved by the Black Madonna. The expectation of healing continues unabated.
"There is a different way of thinking here," said Thomas Zauner, a psychotherapist and deacon who had moved to Altötting in order to seek a supportive community for his developmentally disabled child. "Prayer seems to actually work."
