REFRESH INC.: June 2018

Monday

Conversation is a skill. Here’s how to be better at it

https://www.theladders.com/career-advice/conversation-is-a-skill-heres-how-to-be-better-at-it

Panio: Conversation is a skill, and one we are actually quite bad at.

Celeste: Yes, naturally. Knowing how to have a good conversation is not information that you can just memorize and then you’re done. As a skill, you have to practice it. You don’t go to the gym [just] once. It’s the same thing with conversation.

Panio: I experience it every day because I have eight-year-old twins. One will talk in this ear and one will talk in the other ear about totally unrelated topics, and they won’t even pause for each other.

One of the things that I thought was really intriguing [in We Need to Talk] was conversational narcissism. Maybe I just did it by bringing up the anecdote about my kids, but it’s when someone talks about something, and your [conversation] partner immediately brings up something personal or relative to them.

Celeste: Conversational narcissism is a scary term for something that just happens constantly, and the way that the researchers talk about it is a shift response or a support response. Either I can shift the attention to myself, or I can support what it is that you’re talking about.

Panio: What would a shift example be?

Celeste: If you were to say, “I have eight-year-old twins and they talk in my ear all the time,” and I would say, “God, I know what you mean. My son talks to me — ” and we start talking about my kid. As opposed to, “I have a kid, too. What is that like [for you]?” I’m bringing something up, but it’s in support of what you’re saying.

Celeste: Exactly. A conversational narcissist is the one that keeps taking the ball from the game of catch and not ever passing it back.

“Just listening to somebody is an act of love.”

Panio: Yeah. I had a fear while reading your book: “Am I doing these things? Do I have these conversational bad habits, and I’m just unaware of them?” What’s a way that I could find out? Day-to-day, your friends don’t give you feedback and say, “You know, you talk way too much about yourself.”

Celeste: Right. Or they do—when they’re ready to not be friends with you anymore.

There’s this great exercise, and it’s inspired by Pat Wagner, an expert on conversation. Make a list of the five things that people do in a conversation that annoy you the most. Maybe “interrupt you all the time,” maybe “only give yes or no answers,” whatever they are. Five things that are most annoying to you.

Then go to the people closest to you. Do not tell them what the list is. Just say, “Okay, how many of these things do I do when I’m in conversation with you?” You will usually discover that many of the things that annoy you the most when other people do them are things that you are doing.

That’s partly because a conversation, at its worst, is a power struggle.

Panio: What do you mean by that? Someone is trying to dominate the other person?

Celeste: Exactly. It’s part of that conversational narcissism. It’s this pull of attention, this tug of war. If you’re constantly trying to win that tug of war, and someone else is tugging back, that’s irritating. But that means that they’re doing what you’re doing, and that’s probably the most annoying thing you can think of.

Celeste: Yeah. I started this whole thing to learn how to be a better interviewer. Then I discovered that those exact same skills, the things that worked in the studio, worked just as well with my kid and my spouse and my boss and everybody else in my life. The essential components of what makes a good conversation are basically universal.

Panio: I don’t know if you use this word, but it seems like the implication is authenticity. People can smell it if you’re not being sincere. They just check out.

Celeste: Exactly. Kids know when you’re BS-ing them. They aren’t subtle about it at all — they’ll immediately point it out. As adults, we just get better at hiding that we’ve discovered someone is BS-ing us.

Human beings have a BS detector. We know when somebody doesn’t actually like us. We know when someone’s distracted and doesn’t want to sit there and talk to us. Look, if you don’t want to talk to somebody, just walk away. Excuse yourself and walk away.

Panio: I like having conversations, but as a pretty introverted guy, I certainly have those moments where I’m fried and tired, and I’m just like, “I can’t do this.” How do you extricate yourself with tact? Is it enough to say, “I’m so sorry, I’m just really tired. Do you mind if we talk later?”

Celeste: Yeah, absolutely. I do it all the time. I have adult ADD, so I’m constantly saying to people, “My brain is in a million places. I’m having trouble focusing. I want to hear what you’re saying, and I can’t right now. Give me a rain check, and I’ll come back to you when my brain is functioning.” I say some version of that pretty much all the time.

Or my son will come and tell me about another new video game. I’ll be like, “Dude, I can’t absorb anything you’re telling me, but I will sit here and listen if that’s what you need from me.”

That’s one of the things I try to get through in the book — just listening to somebody is an act of love. That’s a gift. We always feel like we need to prove how smart we are, or prove how much we know, and interject what we think and give advice to other people. Sometimes the best thing you can do for that person is just listen to them. You don’t actually need to say anything at all. You can just listen.

Panio: I was really moved [when] you wrote about your friend. Her father passed away, and she was, of course, devastated. Then you weighed in about your experience losing your father. You thought you were empathizing and being a good friend, but she got really annoyed with you.

Celeste: She got angry, yeah. She said, “You win. Fine.”

Panio: Like, “Your pain is worse.”

Celeste: Exactly. For quite a while I kept thinking, “Well, she didn’t understand. I was just trying to be helpful.” I was just trying to say, “I know how you feel.”

[But] she was right. I was interjecting my story of my own struggle, when it just needed to be about her. She needed me to bear witness to the kind of man her father was. That’s all she needed.

“If you don’t know what to say, it’s an indication that you need to learn something.”

Panio: I thought you had a really astute insight — you said you were uncomfortable by her feelings or what she was expressing. I think a lot of us are. If a friend comes to us, and they’re really hurt —

Celeste: You don’t know what to say.

Panio: You don’t want to say the wrong thing. You don’t want to distract them, because that seems unfeeling. [So] everyone says, “I’ll share a moment of vulnerability for me. I’ll tell them about when my parent passed away or when something hard happened to me.”

[But] if your parent just died and your friend jumps in like, “Yeah, my dad died and it sucked,” it’s like, “Okay, but that doesn’t do anything for me right now.” Another person’s pain doesn’t achieve anything for your emotional state.

Celeste: Exactly, it does not help the other person at all. I felt uncomfortable and didn’t know what to say, [but] she didn’t need me to say anything. She just needed me to listen to her.

What’s more, the way that our brains work is that sharing that story feels really good to us.

Panio: Right. [When] we’re talking about ourselves, we get a little dopamine kick.

Celeste: Exactly. It’s activating the same pleasure center as sex and heroin and chocolate. We feel really good about it.

That gives us an unreal perspective to what just actually happened. Just because we feel good about it doesn’t mean the other person did.

Panio: Situations like those can make or break a friendship. The general advice is go talk to them and tell them how you feel, but should it be just listen or ask a few questions?

Celeste: Yeah. There’s a PBS documentary about this jazz musician Daryl Davis. In his off time, he’s made it his hobby to talk guys into leaving the KKK. He’s a black man. He’s so successful that he almost single-handedly dismantled the KKK in Maryland. When people ask him, “How on Earth do you do this?” he says, “I just listen to them. People just want to be heard. I don’t go in there to lecture them. I’m not going to tell them what they should or ought to be doing. I just listen to them.”

The other thing is that conversation is almost less about what you say than about what you hear. You will not learn a single thing from anything that you say. You already know it. The only way you’re going to learn is by listening to another person. In those moments of grief, if you don’t know what to say, it’s because you don’t fully understand how they’re feeling and what they’re going through, which means stop talking and listen. Ask questions if you need to. But if you don’t know what to say, it’s an indication that you need to learn something.

Panio: That’s good. But how do you have conversations with people with which you aggressively disagree?

This is a big topic these days, where I feel like the national discourse has almost collapsed. Everyone says you can’t talk to anyone. It’s all vilification and outrage. Some of it justified, I get it, but looking back, when I was a kid, you could still be friends and neighbors and have a civilized disagreement about some things. That seems to have just disappeared in one generation. Every study says we only get more and more polarized.

Trending: Introverts are Natural Disruptors—Here’s Why

Celeste: You’re totally right. Even during the Nixon administration, about a third of Americans said they’d be unhappy if someone from the other political party married into their family. It’s now about 80%. By some measure, we are more polarized than we were since the Civil War.

Here’s the error in logic that I don’t understand — what do you think you’re giving somebody by listening to them? You say, “This person’s a racist, so I can’t talk to them.” What benefit do you think you’re giving to them by having a conversation with them? You’re not helping them — it’s not like you’re donating to their cause. But you’re doing a lot for yourself because you can actually learn a great deal.

We do get this sense from social media that we can tailor our interactions like we tailor our Twitter feed, right?

Panio: Right. “I don’t want that in my life, so I’m just going to cut it out.”

“I consider questions to be the most powerful tool you have at your disposal.”

Celeste: Exactly. “That’s a negative thing in my life, so I’m not going to have anything to do with that.”

Well, you’re not helping yourself. You’re not helping them by listening to them, you’re not helping yourself by not listening to them. At this point, we have to stop only searching for comfort. Comfortable is not a productive state. Discomfort is the state in which you actually invent and create and innovate and strategize.

Panio: Right. Dissatisfaction and discomfort underpin all of human achievement.

To your point about people being unwilling to talk, I think people often think that if they’re listening, that’s a tacit approval. That if you listen, then that’s a way of saying, “Well, maybe there’s some validity to what they’re saying,” as opposed to listening itself just being a virtue, without approval built into it.

Celeste: I think that’s one way of articulating it, but I don’t think people put that much thought into it. I think they just don’t want to do it.

Panio: I wanted to end with practical strategies that you can implement immediately. Can you give me a couple?

Celeste: Yeah. I consider questions to be the most powerful tool you have at your disposal. I was at the TED Summit, and this nuclear scientist from Japan comes up to me and he says, “I’ve watched your TED Talk a bunch of times, and I still can’t figure out how to start a conversation.” I said, “Well, where are you from in Japan?” He goes, “I’m in Kyoto.” I said, “I’ve never been to Kyoto. Is it crowded like Tokyo?” He says, “No. It’s the place with all the cherry blossoms.” I said, “But do you have packed apartments, or do people have houses with yards?” He starts describing it to me. Five or ten minutes on, I said, “That’s how you start a conversation. You ask people questions that they know the answer to, about things they care about.”

People love to talk about themselves. As long as you’re asking them questions and allowing them the opportunity to talk about something they care about, they’re going to feel great, and you’re going to feel great because you’re learning all kinds of stuff. Questions are magic.

The weird power of the placebo effect, explained

Over the last several years, doctors noticed a mystifying trend: Fewer and fewer new pain drugs were getting through double-blind placebo control trials, the gold standard for testing a drug’s effectiveness.

https://www.vox.com/science-and-health/2017/7/7/15792188/placebo-effect-explained

In these trials, neither doctors nor patients know who is on the active drug and who is taking an inert pill. At the end of the trial, the two groups are compared. If those who actually took the drug report significantly greater improvement than those on placebo, then it’s worth prescribing.

When researchers started looking closely at pain-drug clinical trials, they found that an average of 27 percent of patients in 1996 reported pain reduction from a new drug compared to placebo. In 2013, it was 9 percent.

What this showed was not that the drugs were getting worse, but that “the placebo response is growing bigger over time,” but only in the US, explains Jeffrey Mogil, the McGill University pain researcher who co-discovered the trend. And it’s not just growing stronger in pain medicine. Placebos are growing in strength in antidepressants and anti-psychotic studies as well.

“The placebo effect is the most interesting phenomenon in all of science,” Mogil says. “It’s at the precise interface of biology and psychology,” and is subject to everything from the drug ads we see to our interactions with health care providers to the length of a clinical trial.

Scientists have been studying this incredibly complex interface in great detail over the past 15 years, and they’re finding that sugar pills are stranger and more useful than we’ve previously imagined. The new science of placebo is bringing new understanding to why alternative treatments — like acupuncture and reiki — help some people. And it could also potentially allow us to one day prescribe smaller doses of pain drugs to help address the opioid crisis currently ravaging America.

Most instructively, the science finds that since we can’t separate a medicine from the placebo effect, shouldn’t we use it to our advantage?

There is no one placebo response. It’s a family of overlapping psychological phenomena.

Belief is the oldest medicine known to man.

For millennia, doctors, caregivers, and healers had known that sham treatments made for happy customers. Thomas Jefferson himself marveled at the genius behind the placebo. “One of the most successful physicians I have ever known has assured me that he used more bread pills, drops of colored water, powders of hickory ashes than of all other medicines put together,” Jefferson wrote in 1807. “It was certainly a pious fraud.”

These days, placebo — Latin for “I shall please” — is much more than a pious fraud.

As Ted Kaptchuk at Harvard, who is regarded as one of the world’s leading experts on placebo, put it to me in a recent interview, the study of the placebo effect is about “finding out what is it that’s usually not paid attention to in medicine — the intangible that we often forget when we rely on good drugs and procedures. The placebo effect is a surrogate marker for everything that surrounds a pill. And that includes rituals, symbols, doctor-patient encounters.”

And it’s not just one thing. “I see the placebo effect as a kind of loose family of different phenomena that are just yoked together by this term,” says Franklin Miller, a retired NIH bioethicist who has edited a volume on the subject. “Sooner or later we’ll get rid of the term,” he says, and talk more specifically about each of its components.

The family of placebo effects ranges from the common sense to some head scratchers. Let’s start off with the simplest.

1) Regression to the mean

When people first go to a doctor or start on a clinical trial, their symptoms might be particularly bad (why else would they have sought treatment?). But in the natural course of an illness, symptoms may get better all on their own. In depression clinical studies, for instance, researchers find around one-third of patients get better without drugs or placebo. In other words, time itself is a kind of placebo that heals.

Sugar pills and active drugs can both change the way patients report symptoms.

2) Confirmation bias

A patient may hope to get better when they’re in treatment, so they will change their focus. They’ll pay closer attention to signs that they’re getting better and ignore signs that they’re getting worse. (Relatedly, there’s the Hawthorne effect: We change our behavior when we know we’re being watched.)

But as we’ve seen, the placebo effect is more than just bias. There’s also:

3) Expectations and learning

The placebo response is something we learn via cause and effect. When we take an active drug, we often feel better. That’s a memory we revisit and recreate when on placebo.

Luana Colloca, a physician and researcher at University of Maryland, has conducted a number of studies on this phenomenon. And they typically go like this: She’ll often hook up a study participant to an electroshock machine. For each strong, painful shock, she’ll flash a red light on a screen the participant is looking at. For mild shocks, she’ll flash a green light. By the end of the experiment, when the participants see the green light, they feel less pain, even when the shocks are set to the highest setting.

The lesson: We get cues about how we should respond to pain — and medicine — from our environments.

Take morphine, a powerful drug that acts directly on neurochemical receptors in the brain. You can become addicted to it. But its analgesic powers grow when we know we’re taking it, and know a caring professional is giving it to us.

Studies show that post-operative patients whose painkillers are distributed by a hidden robot pump at an undisclosed time need twice as much drug to get the same pain-relieving effect as when the drug is injected by a nurse they could see. So awareness that you’re being given something that’s supposed to relieve pain seems to impact perception of it working.

Pain relief is stronger and more immediate when morphine is injected out in the open.

The research also suggests that fake surgeries — where doctors make some incisions but don’t actually change anything — are an even stronger placebo than pills. A 2014 systematic reviewof surgery placebos found that the fake surgery led to improvements 75 percent of the time. In the case of surgeries to relieve pain, one meta-review found essentially no difference in outcomes between the real surgeries and the fake ones.

There is such thing as the nocebo effect: where negative expectations make people feel worse. Some researchers think this is what’s fueling the gluten-free diet fad. People have developed a negative expectation that eating gluten will make them feel bad. And so it does, even though they may not have any biological gluten sensitivity.

4) Pharmacological conditioning

This is where things get a little weird.

Colloca has conducted many studies where for several days, a patient will be on a drug to combat pain or deal with the symptoms of Parkinson’s disease. Then one day, she’ll surreptitiously switch the patient over to a placebo. And lo and behold, they still feel healing effects.

On that fifth day, it seems the placebo triggers a similar response in the brain as the real drug. “You can see brain locations associated with chronic pain and chronic psychiatric disease” acting like there are drugs in the system, she says. For instance, Colloca has found that individual neurons in the brains of patients with Parkinson’s disease will still respond to placebos as though they are actual anti-Parkinson’s drugs after such conditioning has taken place.

The brain can learn to associate taking a pill with relief, and produce the same brain chemicals when drug is replaced with placebo.

What’s going on here? Learning. Just like Pavlov’s dogs learned to associate the sound of a bell with food and would start to salivate in anticipation, our brains learn to associate taking a pill with relief, and start to produce the brain chemicals to kick-start that relief.

This pharmacological conditioning only works if the drug is acting on a process that the brain can do naturally. “You can condition pain relief because there are endogenous pain-relieving mechanisms,” Miller says. Painkillers activate the opioid system in the brain. Taking a pill you think is a painkiller can activate that system (to a lesser degree).

And some studies do suggest that the placebo effect’s powers may possibly move beyond the brain.

Researchers have used flavored drinks to condition an immune response to placebo.

In a 2012 study, participants were given a sweet drink along with a pill that contained an immune suppressant drug for a few days. Without notice, the drug was swapped with placebo on one of the trial days. And their bodies still showed a decreased immune response. Their bodies had learned to associate the sweet drink with decreased production of interleukin, a key protein in our immune systems, which is produced in many cells outside the brain.

Results like these show “we are talking about a neurobiological phenomenon,” Colloca says.

5) Social learning

When study participants see another patient get relief from a placebo treatment (like in the electroshock experiment described above), they have a greater placebo response when they’re hooked up to the machine.

6) A human connection

Irritable bowel syndrome is an incredibly hard condition to treat. People with it live with debilitating stomach cramps, and there are few effective treatments. And doctors aren’t sure of the underlying biological cause.

It’s the type of ailment that’s sometimes derided as “all in their head,” or a diagnosis given when all others fail. In the early 2000s, Harvard’s Ted Kaptchuk and colleagues conducted an experiment to see if usually intangible traits like warmth and empathy help make patients feel better.

In the experiment, 260 participants were split into three groups. One group received sham acupuncture from a practitioner who took extra time asking the patient about their life and struggles. He or she took pains to say things like, “I can understand how difficult IBS must be for you.” A second group got sham acupuncture from a practitioner who did minimal talking. A third group was just put on a waiting list for treatment.

A caring provider can create a stronger placebo response than an apathetic one.

The warm, friendly acupuncturist was able to produce better relief of symptoms. “These results indicate that such factors as warmth, empathy, duration of interaction, and the communication of positive expectation might indeed significantly affect clinical outcome,” the study concluded.

Participants in the “augmented” condition — the one in which the caregivers were extra attentive — reported better outcomes at the end of the three-week trial, compared with both participants who received treatment as normal and those waiting for treatment.

This may be the least-understood component of placebo: It’s not just about pills. It’s about the environment a pill is taken in. It’s about the person who gave it to you — and the rituals and encounters associated with them.

What placebos can, and can’t, do

Placebos seem to have the greatest power over symptoms that lie at the murky boundary between the physical and psychological.

A 2010 systematic review looked at 202 drug trials where a placebo group was compared to patients who received neither placebo nor active drug. And it found that placebos seem to move the needle on pain, nausea, asthma, and phobias, with more inconsistent results for outcomes like smoking, dementia, depression*, obesity, hypertension, insomnia, and anxiety. (*Separate literature review on depression meds does find an effect of placebo compared with no treatment.)

“It seems like placebo taps into a family of psychological and brain processes that’s very much something we evolved for,” says Tor Wager, a University of Colorado Boulder neuroscientist who has co-authored many of the key papers on the neuroscience of placebo. “Take pain as an example. If you step on something sharp, there’s pain in your foot. Now, how should you respond to it? Well, if you are running from an attack, you don’t even want to feel that. You keep going.”

Another way to think about it: Placebos tweak our experience of symptoms, not their underlying causes.

A 2011 study elegantly illustrates this. In the experiment, asthma patients were randomly sorted into three groups: One group received an inhaler with albuterol, a drug that opens the airways. Another group got an inhaler with a placebo. A third group got “sham” acupuncture (meaning the needles were withdrawn before they touched the skin). A fourth got nothing. The study authors evaluated lung function on two metrics: self-report from the patients on their asthma symptoms, and an objective measure of lung functioning.

If you go by self-report, it looks like the placebo, albuterol, and sham acupuncture are all equally effective.

The objective measure, however, shows only the albuterol improved airflow. (FEV is a measure of lung function.)

Which isn’t to say that the self-reported improvement on placebo doesn’t matter. In many illnesses, patients would love a greater opportunity to ignore their symptoms.

“In all the objectively measurable illnesses, like cancer, even heart disease, there are components of it that are not [objectively measurable],” Kaptchuk says. And it’s those symptoms that are the prime targets to treat with placebo.

Placebo can only help symptoms that can be modulated by the mind. “There are real limits to what you can condition,” Miller says. You can’t, for example, condition the cancer-killing effects of chemotherapy. Our bodies don’t produce cancer-killing chemicals.

There’s evidence that placebos actually release opioids in the brain

Over the past 15 years, scientists have made some of their most interesting discoveries looking at how placebos have a powerful impact on the brain.

“When I first started studying placebo effects, it kind of seemed like magic — for some reason, your brain mimicked a drug response,” Wager says. “The biggest change in this field in the last 15 years is that neuroscientists are beginning to uncover the underlying neural mechanisms that create the placebo response.”

Placebos, researchers have found, actually prompt the release of opioids and other endorphins (chemicals that reduce pain) in the brain. Other findings:

Drugs that negate the effects of opioids — such as naloxone — also counteract the placebo effect, which shows that placebos are indeed playing on the brain’s natural pain management circuitry.
The periaqueductal gray matter, a region of the brain key for pain management, shows increased activity under placebo. Regions of the spinal cord that respond to pain show decreased activity under placebo, which suggests either the sensation of pain or our perception of it is diminished under placebo.
Patients with Alzheimer’s disease start to show a diminished placebo response. It’s probably due to the degradation of their frontal lobes, the area of the brain that helps direct our subjective experience of the world.

Our understanding of all this is far from complete, Wager says. For one, researchers still don’t completely understand how the brain processes pain. A lot of the brain regions implicated in the placebo response also play a role in emotions. So we don’t yet know if placebo is actually reducing our sensation of pain, or just our interpretation of it. (Also, as with a lot of neuroscience studies, a brain area might “light up” in an experiment, but it’s really, really hard to know what exactly is going on.)

“So really, what we should be concluding from those studies is something like ‘placebo affects the pain you report,’” Wager says. “What does pain mean to you? That’s a decision that’s made in your brain in different circuits, and that’s essential to placebo.”

You can tell people they’re taking a sugar pill for their illness, and they’ll still feel better

Kaptchuk has studied the placebo effect for decades, and something always bothered him: deception. Placebo studies have long relied on double-blind procedures. It ensures scientific rigor but keeps patients in the dark about what they’re actually taking.

“About five years ago, I said to myself, ‘I’m really tired [of] doing research that people say is about deception and tricking people,’” he says.

So he wanted to see: Could he induce a placebo response even when he told patients they were on placebo?

His own randomized controlled trials found that giving patients open-label placebos — sugar pills that the doctors admit are sugar pills — improved symptoms of certain chronic conditions that are among the hardest for doctors to treat, including irritable bowel syndrome and lower back pain. And he wonders if chronic fatigue — a hard-to-define, hard-to-treat, but still debilitating condition — will be a good future target for this research.

“Our patients tell us it’s nuts,” he says. “The doctors think it’s nuts. And we just do it. And we’ve been getting good results.”

Kaptchuk’s work adds a few new mysteries to the placebo effect. For one, he says that the placebo effect doesn’t require patient expectations for a positive outcome to work. “All my patients are people who have been to many doctors before. They don’t have positive expectations about getting better,” he says. “They’ve been to 10 doctors already.”

Colloca has a different interpretation of his results. She says there’s a difference between belief and expectation, so while the patients may not believe the pill will work, they still unconsciously expect it to.

That’s because, she says, they still have a deep-seated conditioned memory for what it means to take a pill. They have a conditioned memory for what it means to be in the care of another person. And that memory is indeed an expectation that can kick-start the analgesic effect in the brain. They don’t have to be aware it’s happening.

Some doctors wonder if placebos can be integrated into mainstream medicine

The researchers I spoke to for this story are overall optimistic that these discoveries can be used in the clinical settings. There’s a lot of work left to do here, and certainly some of the findings are easier to implement than others. For instance, we could start with reminding doctors that they can relieve pain simply by being warm and caring to their patients.

Colloca wonders if the placebo effect can also be harnessed so that the millions living with chronic pain can feel the same therapeutic effects with a lower dosage of opioid treatments that are both ineffective and deadly.

The NIH’s Miller says it’s too soon to start prescribing placebos, or using the effect, to decrease the dosage of a drug. For one, most of these studies are short-term and conducted with healthy volunteers, not actual patients.

“There’s still lot we don’t know,” he says. Like side effects: Just as a placebo can mimic a drug, it can also mimic a side effect. “We haven’t done the kinds of studies that will indicate that you can maintain therapeutic benefit at lower side effect burden.”

More broadly, Kaptchuk says, for years researchers have seen the placebo as a hurdle to clear to produce good medicine. But placebo is not just a hurdle. “It’s basically the water that medicine swims in,” he says. “I would like to see the bottom line of my research change the art of medicine into the science of medicine.”