Nocebo Effects in Pain Treatment
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You have probably heard of the term “placebo effect,” especially as it relates to health-related treatment.
This definition from Wager and Atlas (2015) sums it up well: “Placebo effects are beneficial effects that are attributable to the brain-mind responses to the context in which a treatment is delivered rather than to the specific actions of the drug [or other treatment].” The “context” is the key here. Contextual factors in healthcare encounters can include: |
Placebo and nocebo effects take place in communication.
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- Treatment setting: Does it seem reputable and official?
- Practitioner: Does the person seem reputable and competent?
- Rationale: When the practitioner explains the treatment to the patient, does the mechanism of action seem plausible and logical?
- Expectation: Does the practitioner expect the treatment to work?
- Trust: Does the patient trust the practitioner?
Miller, Colloca, and Haptchuk (2009), who are some of the outstanding scientists in the field of placebo research, suggested that “the ‘placebo effect’ within health care should be understood as a generic name for the various direct causal pathways from clinician-patient interaction to therapeutic outcomes relating predominantly to symptomatic relief and coping with illness (p. 529)”.
They encourage people to think of placebo effects as “interpersonal healing”, because there is always an interpersonal interaction involved.
However, there is a similar interpersonal phenomenon that has thus far gotten much less attention but may be even more powerful than placebo effects (Yang et al., 2024).
These are nocebo effects.
They encourage people to think of placebo effects as “interpersonal healing”, because there is always an interpersonal interaction involved.
However, there is a similar interpersonal phenomenon that has thus far gotten much less attention but may be even more powerful than placebo effects (Yang et al., 2024).
These are nocebo effects.
What, Exactly, Are Nocebo Effects?
They are things a clinician says to a patient that makes a patient doubt whether a treatment will work, makes them feel helpless or hopeless in the face of symptoms, or makes the patient feel worse about their condition (Colloca & Barsky, 2020). Thus, the clinician or the context in which the patient is treated encourages them to not engage in treatment or, worse, to engage in activities and ways of thinking that exacerbate symptoms rather than helping to relieve them.
When it comes to back pain and other chronic pain conditions, nocebo effects can be extremely detrimental. Even in the course of diagnosing a condition, clinicians can do harm.
For example, when clinicians tell patients with back pain “your spine is so worn out!”, the patients then start acting in ways that protect their back from movement (Bonfim et al., 2021)—which is exactly the opposite of what people with back pain should be doing (Lin et al., 2020).
This example points to a major problem with a lot of healthcare practitioners’ training: It is overly focused on a biomedical model that equates structural irregularities with pain.
This association has been proven false so many times (see Brinjikji et al., 2015, and Kasch et al., 2022 for recent reviews), but the belief persists on both the side of patients and clinicians.
Thus, searching for structural changes on imaging studies, and pointing out all of the spine’s “faults”, becomes the norm. Blaming those "faults" for a patient's pain, the doctor recommends surgery, which may result in placebo pain reduction, at least in the short term (Harris, 2016).
However, when no structural abnormalities can be found, clinicians may say things like:
When it comes to back pain and other chronic pain conditions, nocebo effects can be extremely detrimental. Even in the course of diagnosing a condition, clinicians can do harm.
For example, when clinicians tell patients with back pain “your spine is so worn out!”, the patients then start acting in ways that protect their back from movement (Bonfim et al., 2021)—which is exactly the opposite of what people with back pain should be doing (Lin et al., 2020).
This example points to a major problem with a lot of healthcare practitioners’ training: It is overly focused on a biomedical model that equates structural irregularities with pain.
This association has been proven false so many times (see Brinjikji et al., 2015, and Kasch et al., 2022 for recent reviews), but the belief persists on both the side of patients and clinicians.
Thus, searching for structural changes on imaging studies, and pointing out all of the spine’s “faults”, becomes the norm. Blaming those "faults" for a patient's pain, the doctor recommends surgery, which may result in placebo pain reduction, at least in the short term (Harris, 2016).
However, when no structural abnormalities can be found, clinicians may say things like:
- "There’s no reason for your pain"
- "There’s nothing we can do for you"
- "You’ll just have to live with it"
Those words have real power in a healthcare context. They sound utterly hopeless. They point to the patient being a powerless victim to their pain. That's the negative power of nocebo effects.
Can Nocebo Effects Be Avoided?
Even when a diagnosis or reason for a person’s pain are not initially obvious to a clinician, there is no need to make the patient feel at fault for, or hopeless in the face of, that situation. In addition, though, a clinician’s lack of training in the biopsychosocial model is certainly not their own fault. When it comes to back pain and other forms for chronic pain, clinicians’ training and available treatment options have not at all caught up with current research (see Hauber 2025, Chapter 1; Sharma et al., 2024; van Dijk et al., 2023).
Person-centered communication is a key method to counter that gap between evidence and training/practice. A patient’s healing can begin when clinicians take the time to learn how to communicate effectively, putting the patients’ needs and emotions first (Braeuninger-Weimer et al., 2019), even when the clinician can’t say exactly what’s causing a person’s pain to persist.
In fact, clinicians’ empathy reduces patients’ pain (Ellingsen et al., 2023; Licciardone et al., 2024), and patients find it beneficial when clinicians acknowledge the emotional content of what patients say (Vase et al., 2014).
Similarly, the therapeutic alliance, which includes person-centered listening, communicative competence, and social connectedness with the patient, has also been shown to reduce pain intensity (Ferreira et al., 2013; Fuentes et al., 2014; Montag et al., 2024)
Thus, when it comes to reducing the potential negative effects of nocebo, person-centered communication appears to be a good first step (Caliskan et al., 2024; Evers et al., 2018).
All referenced articles appear at the bottom of this page.
Person-centered communication is a key method to counter that gap between evidence and training/practice. A patient’s healing can begin when clinicians take the time to learn how to communicate effectively, putting the patients’ needs and emotions first (Braeuninger-Weimer et al., 2019), even when the clinician can’t say exactly what’s causing a person’s pain to persist.
In fact, clinicians’ empathy reduces patients’ pain (Ellingsen et al., 2023; Licciardone et al., 2024), and patients find it beneficial when clinicians acknowledge the emotional content of what patients say (Vase et al., 2014).
Similarly, the therapeutic alliance, which includes person-centered listening, communicative competence, and social connectedness with the patient, has also been shown to reduce pain intensity (Ferreira et al., 2013; Fuentes et al., 2014; Montag et al., 2024)
Thus, when it comes to reducing the potential negative effects of nocebo, person-centered communication appears to be a good first step (Caliskan et al., 2024; Evers et al., 2018).
All referenced articles appear at the bottom of this page.
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