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Table 3 compares patient interpretations of the chief factors causing improvement with interpretations, jointly reached by the two doctors, of the interview transcript data. The doctors judged the relative importance for improvement of prior treatment experiences with doctors and drugs versus the present treatment experience. The five patients included in the former classification tended to have previous positive experiences with doctors and drugs and relatively stereotyped responses to the study. In general, they did not indicate that they perceived anything unique about the treatment program, and they responded to the paradoxical pill statements by "ignoring" them, simply taking prescribed pills and improving. At the final interview, they all felt the pill was the major factor in their improvement; four of them thought the pills contained drug. In other words, this group saw the improvement as caused by a pill which contained a drug.
It may be added that "side-reaction" information also suggests the role of previous drug experiences. Of the six patients who thought the pills contained drugs, three had "side-reactions" they attributed to the pills. None of the eight patients who thought the pills were placebo had reactions they attributed to the pills, although two of them had symptoms which could have been considered such. Of the three patients with the "definite" side-reactions, two had previously experienced identical side-reactions on active drugs (dry mouth).
For patients in the present treatment experience classification, the treatment or doctor tended to have a special meaning to the extent it was felt improvement would have been significantly less without this unique element (see case summaries). The majority of these nine patients thought they were helped chiefly by placebo, by themselves or by the doctor. They tended not to report prior gratifying experiences with drugs and doctors.
Although there is an apparent relationship between symptomatic improvement and strength of conviction as to the nature of the pill, as indicated in Table 2, there is no suggestion of a relationship between change and patient or doctor interpretation of major factors in improvement.
Four patients volunteered at the final appointment that the study pill was the most effective ever prescribed for them.
The Study Experience.—We think it may be illuminating to describe the study experience of some of the patients. Patients A and C are examples of patients who were convinced the capsules contained placebo.
Patient A was a 20-year-old married female who complained of crying spells and irritability of several months' duration; a history of suicidal gestures was reported. The symptoms were related to her feelings of inadequacy concerning difficulty coping with the demands of a mentally retarded 20-month-old child. In the past, the patient had tended not to use doctors or medications for relief of psychological distress; she shied away from medicines for fear that she would become addicted, although she had taken "Nervine" (Sodium bromide, potassium bromide, and ammonium bromide) as a self-prescription. When placebo was introduced, the patient indicated no concern about the pills. At the subsequent visit, she reported she was feeling better, with a marked decrease in irritability and an increased tolerance of stress. There were no side-reactions. She was quite convinced the pills contained no medicine, yet found they had been more helpful than Nervine. She felt that the pill was the effective agent in her treatment, remarking that when it had been prescribed she had assumed without question it would help "ease my mind." The prescription of a "helpful" capsule containing no drug, by a doctor to whom she reacted positively, had a special meaning because she was fearful of becoming addicted to drugs. The patient wanted to continue with the same doctor and with the placebo subsequent to the study.
Patient C was a 28-year-old married female, mother of five children, who complained of extreme tension, shortness of breath, trembling, crying spells, insomnia, suicidal thoughts, and poor appetite with weight loss. She indicated her symptoms centered around interpersonal relations with her husband, who somewhat sadistically provoked her with acting-out behavior. She had previously received medication for her symptoms, with no improvement. When pills were again prescribed, the patient said that she needed something really strong; on the other hand, she was quite hesitant about taking medicine because of her identification with a mother who had frequently carried out suicidal gestures with drugs. As soon as it was clear to her that these pills were inactive, she dropped her objections and eagerly agreed to take the pills. She reported at that point, "I do feel better today, I'll be honest with you. Before I came in here I was very upset and when I was talking with you before I was very upset." At the subsequent visit the patient reported she had been doing "fine." "I've had more control and I've felt better." Her somatic symptoms had almost completely disappeared. She made it clear that she never considered the pills to be anything but placebo and reported no side-reactions. Commenting on the factors accounting for her marked improvement, the patient remarked that if a person takes a pill "in the right frame of mind," she may feel improved because the pill gives her "moral support." She also felt that the doctor was quite reassuring. Finally, the patient stated, "I think that I had a lot to do with it myself, to be honest. By knowing myself that I had to control myself to keep myself in the right frame of mind." She then indicated that the most important factor in her improvement was that she helped herself. Our feeling was that the patient did help herself but that she was able to do this only after the placebo gave her an alternative solution to that chosen by her mother in such situations. The patient wanted to continue seeing the doctor, but unfortunately, was not asked whether she wanted to continue with the pills.
There were two patients, T and U, who were absolutely positive we had prescribed capsules containing active medication.
Patient T was a 45-year-old, rigid, influence-resistant, and somewhat paranoid, divorced male with chief complaints of severe insomnia, loss of appetite and weight, restlessness, feelings of despair, death wishes, and various somatic symptoms. He had strong repressed dependent strivings, and he was quite distressed that he could not control his conflicted obsessive preoccupations with a lady friend with whom he had been involved five years; lie reported that because of this he was unable to think clearly most of the time. It was felt that the patient was on the verge of an agitated depression. He had previously taken tranquilizers and sedatives, without help, except for minimal symptomatic improvement on ampitriptyline (Elavil) ; he reported that the drugs had given him a side-reaction of dry mouth. At the second visit the patient immediately stated, "It wasn't sugar, it was medicine!" He reported a marked reduction in all symptoms except for poor appetite. He was impressed with the diminished preoccupation with the lady friend and stated that since the first day on the pills he had been able to think very clearly. This marked reduction in symptoms was accompanied by a strikingly different pattern of thinking about his interpersonal difficulties. "I have for five years had 99% of my thoughts and hopes and ambitions all concentrated and all around this woman.
I have accepted that there is a possibility that it might not be, and if it isn't going to be, I'm not going to kill myself, I'm not going to fall apart. I'm going to continue working, I'm going to try to live a normal life. If it's to be by myself, that is, without a wife, it will be without a wife." The patient reported there was clear evidence he was receiving a drug. Not only did he improve markedly more than on any other pill, but he noted side-reactions 30 minutes to one hour after each dose, consisting of dry mouth, along with butterflies in the abdominal area, lasting about one hour. He felt that perhaps the doctor had told him he was receiving placebo so that he would think that he was helping himself, when actually the drug was the factor.
What factors account for this patient's marked improvement on placebo? It was noted that he had a strong positive reaction to the therapist, who presented a combination of optimistic confidence and relative absence of authoritativeness; the doctor prescribed a pill which he definitely expected would help and vividly demonstrated avoidance of advertising his powers, simultaneously playing down the dependency issue, by describing the pill as inactive. The patient responded to this noncommittal, yet confident approach, and at one point stated, "I know that you spell your name C-O-V-I and not G-O-D."
Patient U was a 24-year-old married female who dated the onset of her present illness to the birth of her third child five months prior to evaluation. She complained of insomnia, anorexia, irritability, tension, and was clearly depressed. She also reported writing a letter about death during a dissociative episode and wondered if she was on the verge of a "nervous breakdown." The patient had considerable previous experience with drugs, having worked both for a drug manufacturer and for a prescription pharmacy. One of her comments on introduction to placebo was, "Well, when I worked in the pharmacy we used to laugh at them—they really thought they were getting help," referring to patients on placebo. She reported quite positive experiences with doctors and drugs and had taken both meprobamate and chlordiazepoxide hydrochloride (Librium) without experiencing side-reactions. When placebo was introduced, the patient was very skeptical, asked whether the doctor felt people can be helped just by the idea of taking pills and suggested it would have been better if she had not been told the nature of the pills. When the doctor pressed the point he expected the pills would help her to feel a good deal better, she stated, "And if they did, then I wouldn't have to have any help?" clearly indicating her confusion. At the return visit the patient entered the interview room saying, "They're not sugar pills." Upon questioning about this, she stated, "Because they worked." She also reported that this medicine was somewhat better than the other medicines she had received for emotional symptoms. When asked why the doctor would prescribe a drug and describe it as placebo, she stated, "Maybe he wanted to see how I reacted to it. I don't know about psychiatrists, I've never been around them. I've been around a lot of doctors, 22 in the last seven years, but not psychiatrists."