I've given placebo a lot of thought. I've studied Benedetti's book, The Patient's Brain: The neuroscience behind the doctor-patient relationship, in detail. I think it's great.
Patients with pain are tired of waiting for the medical profession and other health care professions to assimilate pain science. They are banding together into societies and organizations and foundations. They are asking pain researchers to talk directly to them, to explain to them why they hurt so bad, how they might help themselves.
In February Catherine Bushnell is going to do exactly that. She will present a webinar, Out-Thinking Pain: How the Mind can Control Pain. Anyone who wants can register for this. I think it's even free.
I wrote a bit on the topic here, earlier, the confusion that surrounds the idea of placebo.
I just don't think it should be that confusing.
Now, to the topic at hand:
Let's consider a metaphor.
People equate pain with fire. Understandably! Pain is painful. It burns. Burns are painful. They hurt. The fire of burning pain. I get it.
What if pain resolution required starting a new fire? A fire of a different kind?
The objective would be to turn pain to ashes. Burn up the pain itself. Let a fire roar through the nervous system backwards, and burn pain right out of the humanantigravitysuit, metaphorically speaking. It makes sense to me, now that I've tasted the experience of being in pain, for myself. It didn't feel good. I had to mount an offensive, and fortunately, it was a success. I wrote at length about it in the Killing Pain series.
A fire deliberately set so as to burn off pain needs fuel. Firewood. An intact and hopefully "normal" nervous system has natural capacity. It has descending modulation. This is intrinsic - a whole stack of good seasoned split wood is there in everyone, i.e., central nervous systems know how to make opioids and all sorts of other lovely things that kill pain. All such a fire needs is a light and some kindling, some dry bark or crumpled paper or something.
The way the human brain works, if it is too focused on pain itself, it won't be able to accumulate enough dry kindling. Dry kindling, in this new metaphor, is the ability to distract oneself sufficiently to keep going in spite of having pain.
A fire can't be started just any old where. You need a place, a context, a shelter from the rain, a hearth. A therapy clinic, and a therapist who knows something about burning off pain, can provide an appropriate context for playing with fire, safely.
Then... then... you need a match.
Placebo is an expectation, a hope, a connection to something, a drive to seek and find support. In humans, it can be as simple as a phone call to a health care provider. It does not have to be anything fancy, or deceiving. Placebo is a match.
Without the match, nothing else works. It all just sits there.
In fact, if any single thing is not there, resolution won't occur.
All the components of a fire are necessary for it to complete, burn out, and leave behind a pile of ash. A pile of pain relief.
Think about it.
Someone to blow the flame to life?
What about manual therapy? I think, for the purpose of this metaphor, manual therapy would be an outside person who physically handles the person in pain, and by so doing, blows gently on the flame to get it going. It isn't always necessary, and sometimes the therapist (depending on what it is they think they're supposed to be doing) might blow too hard and kill the flame instead of helping the flame to kill the pain.
But in small judicious amounts, done carefully in the moment by a therapist skilled in noticing and tracking responses in nervous systems, responding appropriately, willing to take his or her time, manual therapy can help fan the flame so it can take off.