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High expectations

What counts as evidence that therapy is effective?

First of all, I believe any type of intervention to improve mental health - from the conventional to the esoteric - whether talking to a counsellor, psychoanalysis, CBT, yoga, reiki, confessing to a priest, meditation, the horoscope, tarot reading, acupuncture, past-life regression, choral singing, can have a positive impact, some of the time, with some people.

If I were to make this vague term 'some' more explicit, I would state it this way: "40% of people will respond to any given intervention". The intervention does not need to be evidence-based or coached in scientific-sounding rhetoric.

This is the placebo effect in action (from the Latin 'placere', to please). Although the term is usually used dismissively - it's just a placebo - I think that the phenomenon is worth a little more attention. Placebo means that the positive expectations of the client, meeting the encouraging and hopeful stance of the practitioner can create a powerful mental alchemy, whereby psychological and neurobiological resources are mobilised in the service of healing.

Several things are happening here at once and I will try to unpack them.

When we have positive expectations the brain releases dopamine even before the event. Dopamine essentially signals "pay attention - something good is about to happen to you". Dopamine is incredibly motivating - we know this by studying people where dopamine signalling is too high or too low. Extremely high dopamine levels are involved in mania. Those who suffer from bipolar affective disorder report incredible levels of energy, inspiration and productivity during manic states. Ideas come rushing in; there is no inhibition to creativity; desires are acted upon, pleasure is intense. At the other extreme end, reduced levels of dopamine signalling lead to reduced mobility physically and mentally.

Coupled with expectation, the element of surprise when we try something for the first time allows us a different perspective. We are not bringing well-worn neural pathways to this encounter - we need to attend to it differently and we tend to use the right hemisphere. Most interventions tend to be most powerful before we have habituated (got used to) their procedures. Once we settle into a routine, we tend to process it more with the left hemisphere and experience it as a set of known and rehearsed procedures. In other words, there may be a law of diminished returns at play, whereby more is not necessarily better, particularly if it's more of the same thing, failing to maintain the element of discovery and novelty.

Being in the presence of someone whom we experience as wiser, more knowing, more spiritual, or even magical in some way - can also mobilise us in positive ways, particularly if this person looks upon us with benevolence, interest and a desire to be of service. When we are in trouble, this means that what we are experiencing is outside our window of tolerance, and we are no longer able to regulate our emotions without external input. The care-seeking system is activated. Think of a child who falls and hurts her leg and calls for mother to 'kiss it better'. If there is trust between mother and the child, then the kiss will have a powerful soothing effect, reducing the experience of pain.

Trust in relationship (or secure attachment) also allows a quicker transfer of information. Researchers have shown that when epistemic trust is present children (even toddlers) learn faster. Epistemic trust is established when the child feels acknowledged and 'seen' in some way.

So there are two things here: the perceived qualities and status of the 'healer', and secondly their availability to attend to us and our concerns. Practitioners of any persuasion put a lot of effort into honing their skills and knowledge, as well as developing what is called presence, or bedside manner. Presence is hard to define but easy to recognise. It is about making a client the focus of your attention, carefully and sensitively inquiring into their world, sharing your understanding tentatively. Presence is about stillness, eye contact, rhythmic attunement and a soothing, warm and well-modulated tone. Charm, playfulness and humour are involved. Presence also speaks through aesthetic elements such as clothing that inspires associations with professionalism or spirituality (depending on what is being offered).

To be effective, practitioners have to believe in the potency of their system of belief and methodology, the way Dumbo has to belief that his feather is helping him fly. It is very hard to be hopeful and persuasive if you are coming from a cynical place. You have to wholeheartedly buy into your own system. You have to believe that you have had the best training and that you are part of a long tradition of especially skilled healers. You nurture the memory of your mentors and the higher status these mentors or teachers, the more you can bask in their aura and believe that some of their special skills and wisdom have rubbed off on you. You write articles to display your knowledge and intellectual prowess.

Effective practitioners are not necessarily the best researchers. Research requires a completely different mindset - one of cultivated scepticism and a willingness to kill your own cherished beliefs if they do not stand up to careful testing. Practitioners are not always willing to examine the weaker aspects of their system and methodology because this can make them more hesitant and uncertain.

What all approaches have in common, besides relationship, is that they offer an overarching story to explain symptoms of distress, in addition to the fact that someone is willing to attend with care, concern and compassion to this distress. Every narrative about the origin of psychological suffering will have its receptive audience, people whose beliefs and intuitions 'match' different paradigms. So the stories in themselves have a healing quality in as much as they help us make sense of our suffering, put it into perspective and connect it to something universal. The stories do not need to be true in the scientific sense of factually true, but they do need to be 'true' in a psychological sense, in a way that holds up a mirror to our soul.

I am not proposing a relativistic 'anything goes' attitude. I think we always need to be careful about the people whom we invest with the status of guru, and also about the ideas and practices that we allow to influence us. Ideas - when presented in a dogma lattice that provides a ready-made framework that cannot be argued with, adjusted, challenged or thought about - become ideologies. Ideologies are by necessity over-simplified stories about reality. Ideologies can have internal coherence (tight logic) but may be actually not particularly useful.

Practitioners who attend to those who suffer may get drunk on their status and power and forget that they are only powerful because others are willing to invest trust, love and power into them. There are endless stories of abuse of power (sexual, psychological, financial) at the hands of narcissistic gurus or healers. But sometimes the 'magic' of the placebo effect can be channelled and put to good use. It may be less intrusive or less likely to cause side effects than the chemical option.

On my introductory list two approaches make effectiveness claims based on research: meditation and CBT (cognitive behavioural therapy). Even though the researchers in these fields have put a lot of care and thought into designing 'tests' to support evidence claims, in any treatment activity involving human beings it is very hard to control for the placebo effect. First of all, participants are always aware that they are receiving the treatment vs not receiving it. Secondly, the professionals motivated intresting these treatments are already convinced that they are effective. Simply being part of a trial involves a great deal of excitement and anticipation (I am part of a new, groundbreaking approach). The initiators of the treatments and the research tend to be charismatic individuals (think of Jon Kabat-Zinn or Aaron Beck) who can inspire others to follow them and persuade funding agencies to give them money. Thirdly, when these approaches are translated into naturalistic settings the effects are diminished because the conditions are always less than the ideal conditions in the experimental design. By conditions, I mean staff and skill, ambience, and length of time for treatment. And once the 'buzz' has worn off a particular intervention, once everybody is doing, and we are all used to reading about it this further diminishes the magic.

So my advice is to focus more on finding the right person rather than the right treatment. Whatever field they might be in - there are always people who are genuine about wanting to serve others, who are compassionate, wise, caring and also humble and aware of their own limitations. They might not be the most dazzling stars on the firmament. They may not have written the most fashionable books, or have featured on TV or be at the helm of the most dazzling research facility. But they will work for you rather than exploit your need for care and connection.

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