PER BORGÅ ON PLACEBO EFFECTS

This is an excerpt from a report I wrote from the conference "Voices on Future Psychiatry", that took place in Falun, Sweden, in August, 2000.

Per Borgå from Stockholm is a Swedish professor in psychiatry, but he started his career as a psychiatrist working in Tanzania. He has come to the conference to talk about the placebo effect as a neglected factor in the work of treatment. First, however, he takes his chance to make a reservation against the recently published Stockholm report on the over-mortality in somatic diseases of mentally ill persons. In a study, that is not published yet, Per Borgå has looked upon the mortality of the 30 000 patients, that were hospitalised in Swedish mental hospitals and psychiatric clinics a certain day in 1979. He has found that the resting expected life time of this group has increased from 1982 to 1994.

"The results of my study are, thus, contradictory to the results in the Stockholm report", says Per Borgå. "But it is clear, that this group has an over-mortality, compared to the entire Swedish population."

When Per Borgå comes to his mere subject, everybody in the Lugnet arena is listening intensively. The placebo effect, i e that one can be cured by a pharmacum, even though this does not contain any active substance, has been considered a disturbing moment within medical science.

"Studies of clinical effects seem to look like this", says Per Borgå and shows us an overhead transparency with three columns in a diagram. "To the left, we have placebo, i e the patients in the study that were helped by pills without active substance. In the middle, we have drug 1, an old well tried med, and as we can see, this column is a little higher. To the right, we have the new drug 2, and that column is even a few per cents higher."

"Usually, the conclusions are, that the old drug is more effective than placebo, and the new drug is even more effective. The researchers focus upon these small parts of the columns, where they are superior to placebo, and try to optimise the pharmacological effects in that little part. But they neglect that most of the effects even from the pills with active substances are placebo effects - they see this as a disturbing moment."

In Per Borgå's opinion, a lucky therapeutic outcome can depend on three different factors, alone or in combination with each other. First, it can be the specific effects of the substance, that makes the cure. Second, it can be the placebo effect. Third, it can be the natural course of the disease - people overcome their colds, for example, using various types of house cures.

"Following an anthropological view, the placebo effect can be connected to what usually is called 'the frame of the treatment'," says Per Borgå. "Or, with Michael Balint's words: 'The doctor is the cure'."

"In these clinical studies of meds, one can follow the placebo effect," says Per Borgå. "And then, it is obvious that the placebo effect is not constant: it varies from one study to another, and from one doctor to another."

"A researcher named Norman has looked upon patients suffering from gastric ulcer and found a variance of the placebo effect from 10 to 90 per cents, depending on which doctor that treated them. He also made a follow-up study of the same patients, where he found, that the patients who had benefited from placebo had a more benign course and a better prognosis than these who had benefited from the active substance."

What is central in the placebo function is our need for an intervening external power, no matter if this external power is the doctor, God or different spirits. Per Borgå returns to the anthropological perspective, and discerns some important differences between the Tanzanian culture and the Scandinavian.

"The culture of Tanzania is a group-centred culture, where the individual's identity is given by the group, and where it is the group that is responsible for bringing back the deviant. Concerning social deviations, shame is the central issue," says Per Borgå. "This is a culture, that is often seen in developmental countries. In this culture, externalisation is common, i e that causal explanations of e g diseased are located outside the individual."

"The Scandinavians, on their side, are more of 'themselves enough'. We have a culture of guilt, that is more individualistic, and we locate the causes to diseases inside the individual. What is typical for our view of diseases is the micro perspective, whilst the important thing in the culture of shame is the perspective of relations - both the relations to family members and relatives who are alive and to the spirits of the ancestors."

"This means, that in the Tanzanian culture, the social network is involved in a natural way, when someone gets mentally ill," says Per Borgå. "When one is implicated in the case of disease, it also becomes natural, that this person is involved in the cure. This is done through the rite."

Generally, the rite is something that is used in life crises and traumatic crises, and it works by alleviating anxiety and mobilising curing factors. This happens, since the rite provides a system of explanations and introduces a conformity to law, a division into stages, thereby counteracting chaos. It relieves guilt and creates positive expectations. In the rite, a collective support is provided, whereby the network is strengthened. The rite also gives opportunity to emotional katharsis.

"Thus, the placebo effect is optimised in the good rite," says Per Borgå. "This is most clear in healing through faith. But there are also evil rites, with nocebo effects, which is the opposite of placebo. Here, voodoo is the most clear example, where the rite can cause the death of other human beings."

"Also in psychiatry, there are evil rites," says Per Borgå. "Iatrogenic states like institutionalisation can be nocebo effects. The diagnosing can also sometimes, under disadvantageous conditions, have nocebo effects."

In Per Borgå's view, the symptoms reported by the patient and the treatment are two elements of a communication. In order to optimise the placebo effects in the treatment, it is important to integrate the treatment with meds in the total treatment of the patient, in his opinion.

"If the placebo effects are to be optimised in psychiatry of the future, we must utilise the good rites," says Per Borgå. "We have to be sensitive to patients and their families, and we must strengthen the social networks of the patients. In the treatment discussions, we must strive for consensus, albeit we can't always reach it, and everybody must be considered being right in his opinion. We must build upon involvement and responsibility, we must give room for emotional katharsis, and we must collaborate with biological medicine. The evil rites of psychiatry, that we have been told of here, must be omitted: those that discerns the patient from his or her network, those that strive for professional control and preferential right of interpretation, and those that dichotomise between biological medicine and social reality."



©Gustaf Berglund