The Role of Patient-Practitioner Relationships in Placebo and Nocebo Phenomena

Abstract

Introduction: Placebo and nocebo effects form part of all therapeutic environments and play a significant role in the effectiveness of treatment outcomes. Patient expectancies drive these phenomena, which can be shaped through contextual factors including verbal suggestions, conditioning, and social observation.

Objectives: This review seeks to identify the biopsychosocial factors of the patient-practitioner interaction that play a role in the development of placebo and nocebo effects, as well as the anthropological elements of the biodynamic process of relating that are meaningful in the development of expectancies.

Methods: We conducted a narrative review of frameworks of the placebo and nocebo effect, including the impact of expectancies and interpersonal relationships in the context of healing and the clinical setting.

Results: Expectancies leading to placebo and nocebo effects can be modified by macro and micro factors, such as culture and society, as well as individual psychobiological traits, respectively. The developmental sociobiological adaptations that form and consolidate mindsets and meaningful contexts play an important role in shaping patient expectancies, as well as patients' conscious and subconscious reactions to signs and actions taking place within the clinical environment. Practitioner characteristics, like empathy, friendliness, and competence, favor the formation of positive expectancies. Caring and warm patient-practitioner interactions can enhance the therapeutic value of clinical encounters when patients' positive expectancies are actively encouraged and engaged.

Conclusion: A patient-centered approach rooted in demonstrating care and empathy can positively enhance a patient's experience within the clinical environment and activate psychosociobiological adaptations associated with the placebo phenomenon. Pain patients could particularly benefit from non-invasive approaches for improving treatment effectiveness and quality-of-life.

Keywords: Adaptation; Affect attunement; Anthropology; Emotional resonance; Expectancy; Nocebo effects; Placebo effects; Psychosociobiological factors.

Fig. 1

Sociobiological and behavioral organization of placebo and nocebo effects. Like a socio-ecological model of human behavior and development, placebo and nocebo effects are preceded and modeled by many sociopsychobiological factors that influence patients’ expectancies. On a macro scale, the environment, society, and culture play a very important role as they become one of the first filters of reality and day-to-day experience of human beings. Societal and cultural factors influence how an individual perceives disease, well-being, treatments, and even the figure of the physician. Since they can directly affect how a person is able to identify, cope, and function with illnesses, even those originating from genetic traits, psychobiological factors were located a level under the sociocultural tier. Placebo and nocebo effects are the product of a dynamic relational process with external forces that provide meaning and context to health, disease, the patient–practitioner relationship, and the therapeutic process. These meaningful contexts are influenced by an individual’s priming and experience, and help shape the formation of expectancies, mindsets and the relevance of signs and symbols. At the center of all of these multi-layered factors lie the mechanisms of the placebo and nocebo effect. At the periphery, we find external vehicles and facilitators of messages that convey important information within the patient–practitioner interaction.

Fig. 2

The patient–practitioner interaction as a vehicle for the dynamic exchange of sociobiological information in the context of health and illness. A patient-centered process of relating sets the foundation for interpersonal healing to occur, and in doing so, it has the power to positively modify the expectancies that could influence a patient’s health and clinical outcomes. This dyadic concept of the placebo phenomenon encompasses how a practitioner establishes a context of healing and well-being. The placebo and nocebo phenomena can be provoked and prevented, respectively, through a positive therapeutic alliance.