During the next visit, the patient may report that he has discovered something that works and that he feels 25% in control of his life and the problem controls only 75%. After praising the patient for this accomplishment, your follow-up question might be, “Do you think it would be possible to try that technique even more often in the future?” or “Do you think, now that you have done such a good job of finding one thing that works, that you might think of another?” Patients may want to keep a formal written diary of their progress. By using this approach, the patient may eventually be able to report that his sense of control has risen to more than 50%. Usually that will produce a substantially improved quality of life.34,35
Story
A further implication of the meaning model is the value of explicit “story work” with patients with chronic complex problems. Since most people attach meaning to important events in their lives by implicitly or explicitly constructing narratives about the events, story work allows the physician and patient to work together with the issue of meaning. Steps in working with the patient include:
Ask for your patient’s story about the illness or problem, including its root causes, its present effect on his life, and how he imagines the rest of life unfolding with the problem. This may be done with take-home written assignments between visits to conserve office time.
Analyze the meaning of the story with the patient, looking especially at the negatives that seem to produce unnecessary suffering, such as guilt over the presumed cause of the illness or lack of improvement in the future.
Encourage the patient to begin imaginatively constructing alternative elements to the story, especially happier endings. These are much more powerful when generated by the patient and less effective when the physician suggests them.
Work with the patient to identify changes in day-to-day activities that might reflect and further cement the reality of the revised story in the patient’s life.
A similar approach is typically employed for chronic pain patients, but it is valuable to make the story work explicit.36 At the start of treatment, these patients typically see only 2 possible stories: a future in which their pain magically disappears completely or one of unremitting suffering. It may take much supportive work to facilitate the construction of an alternative story in which the patient can imagine the possibility of feeling less pain and achieving important life goals despite never being completely cured. Often the patients have been so overwhelmed by the pain experience, and the search for a cure, they have simply lost sight of those other goals; the main element of story work is getting them back in touch with those goals. Once the patient has successfully constructed that alternative story, other elements of management (long-term medication use, physical therapy, vocational rehabilitation, depression management, and so forth) often quickly fall into place.
Conclusions
From a research standpoint, many of the proposed interventions are unfortunately sloppy. One would wish to validate an empirical hypothesis such as the meaning model by distinguishing whether a better health outcome is caused by an alteration in meaning or by some other factor. The chronic pain patient who constructs a better story of ongoing life with pain is likely to be much more compliant with other therapeutic recommendations. Did the improved outcome result from the change in meaning, from greater adherence to effective modalities such as physical therapy, or both? Although progress on the research front is expected, it may well come more slowly than we would like.
But this detriment for research purposes is a plus for therapeutics. Clinicians often do not care whether a patient is feeling better because of the pill prescribed, the care and compassion shown, greater adherence, or all of them combined, as long as improvement occurs and the patient is more satisfied. The ease with which elements of the placebo response become comingled with other therapeutic endeavors makes it a more useful tool.
Because of the therapeutic usefulness of the placebo response and the way that it is intertwined with other elements of everyday practice it would seem that family practice investigators would be especially skilled at addressing the research difficulties. This review should encourage more attention to the placebo response and promote a higher priority to its research among primary care investigators and multidisciplinary research teams.
Acknowledgments
This article was partially based on some preliminary work supported by the Fetzer Institute, Kalamazoo, Michigan. The author is grateful for the suggestions of several anonymous peer reviewers for The Journal of Family Practice.