Zhenzhen Zhang
DOI
10.5281/zenodo.20025552
Resource type
Journal article
Publisher
New England Journal of Traditional Chinese Medicine
Published in
New England Journal of Traditional Chinese Medicine, V(2), ISSN: 1536-8017, 2023.
Abstract：Methods to regulate the spirit in TCM have similar effects to psychological suggestion, persuasive language, and religious prayers; the outcomes of all of these practices can be attributed to the placebo effect. Modern research has revealed that the placebo effect not only impacts the mind, but also involves changes in corresponding physiological systems. Findings such as the enhancement of the functions of corresponding regions of the cerebral cortex or changes in biochemical indicators prove that the placebo effect has a physical basis. Since ancient times, TCM has emphasized regulation and treatment of the spirit, and has prioritized the impact of the mind on diseases of the human body, including the positive impacts that modern medicine refers to as placebo effects and the negative impacts known as nocebo effects. This paper provides examples of various TCM methods to regulate the spirit, with the goal of reminding fellow TCM practitioners to consciously and actively utilize these methods to maximize placebo effects while avoiding nocebo effects. In combination with the non-placebo effects of acupuncture and Chinese herbal medicine, these methods can improve clinical treatment outcomes.
More than ten years ago, a friend who practiced Western medicine candidly remarked that the therapeutic effects of TCM and acupuncture are actually psychological effects; they work if you believe in them. I debated with her for a while on this topic, thinking that she was narrow-minded and short-sighted. I brought up many research findings, trying to persuade her that the effectiveness of TCM and acupuncture was not just due to psychological effects. At last, she begrudgingly said that the studies were not double-blind and they didn’t add up to anything. Over the past few decades, in the rush to modernize TCM, TCM practitioners such as myself have bent over backwards to carry out all kinds of experiments using modern scientific research methods, equipment, and measurements to prove the scientific validity of TCM and refute claims that its effects are psychological. If we were to see some Western research that concluded that TCM treatment outcomes were simply placebo effects, we would habitually or reflexively retort that this was because they didn’t understand TCM, their study design was unreasonable, they didn’t follow TCM methods when carrying out their research, and so on. People often regard “psychological effects” and “placebo effects” as derogatory terms that belittle the value and deny the effectiveness of TCM and acupuncture.
The therapeutic outcomes of TCM and acupuncture are not purely placebo effects.
A growing body of research has proven that the effectiveness of acupuncture is realized through changes to physiological functions in the human body. For instance, in 2017, researchers performed a controlled study with 80 carpal tunnel syndrome patients that compared verum and sham acupuncture treatments. The results showed that after treatment, patients in the verumacupuncturegroup had noticeable changes in brain activity in the cerebral cortex regions that map to the second and third fingers, which corresponded to improvements in the patients’ symptoms and enhanced median nerve conductivity. The sham acupuncture group also saw improvements in symptoms, but did not have the corresponding changes in cerebral cortex activity. The researchers concluded that verum acupuncture enhanced the patients’ neurophysiology and in this regard it was superior to sham acupuncture (the placebo group). This study tells us that the clinical treatment outcomes of acupuncture include placebo effects (the sham acupuncture group also improved) as well as non-placebo effects (along with improved symptoms, cerebral cortex activity and median nerve conductivity were also enhanced; these changes in physiological function are not placebo effects)［１］. There are many other similar acupuncture studies, too many to list here.
Placebo effects are everywhere
“Placebo” is a Latin word meaning “I shall please”. Modern medicine uses placebos to study whether medical interventions or methods are truly effective when the influence of psychological effects has been ruled out. However, the placebo effect does not only exist in the medical field; practices that have persisted for over a thousand years, such as suggestion therapy, psychotherapy, religious prayer, and the ancient Chinese zhuyou prayer ritual, all share similarities with the placebo effect. They all can alleviate illness and pain to varying degrees, so regardless of how history proceeds and how science develops, these methods will not disappear. A patient with depression once told me that acupuncture enabled her to work and live like a normal person, and as a result she no longer wrestled with the question of whether to take antidepressant medication. Although her doctor once told her that acupuncture was just a placebo, she said that she didn’t care whether it was a placebo; as long as it could free her from the suffering of depression, it was an excellent treatment, and she continued to get acupuncture treatments for over ten years. She said if she had not gotten acupuncture treatments, she would have had to take antidepressant medication for her whole life.
Previously, most people believed that the effectiveness of medications was due to the fact that they altered our physiological and pathological mechanisms. By contrast, placebos were sugar pills or stimuli that had no effect on illness or the human body. Therefore, the placebo effect was equivalent to no effect. But recently, a placebo study carried out in Australia in 2021 revealed something interesting. Researchers connected heated electrodes to the skin of volunteers’ arms and at the same time applied Vaseline. One group of volunteers was informed that the ointment applied was an analgesic cream that could relieve the pain from the electrodes. Among these subjects, it turned out that one-third of them reported a reduction in pain. Another group of subjects was informed that the ointment was a pain-increasing cream that would amplify the severity of their pain; over half of this group felt more pain (the nocebo effect). This experiment tells us that one-third of the subjects responded to a placebo consisting of verbal cues and half of them experienced the nocebo effect［2］. The nocebo effect is a negative outcome resulting from an adverse or negative cue.
In another placebo study on IBS, researchers explicitly told volunteers with IBS that what they were taking was a sugar pill that did not contain medication, but their bodies would respond to the sugar pill. If they had a positive attitude it would be more effective, but this was not necessary. It was very important to take the pills on schedule. After three weeks, the result was that the symptom improvement rate in this group of volunteers reached 59%. In the other, non-intervention group serving as the control, the symptom improvement rate was 35%. There was a statistically significant difference between the two.［3］While the subjects clearly knew they were taking a placebo, persuasive language was still effective.
Placebo mechanism
Researchers have discovered that the placebo effect occurs due to changes in the brain. In the words of Harvard University placebo research expert Ted Kaptchuk, “The placebo effect is more than positive thinking, believing a treatment or procedure will work. It’s about creating a stronger connection between the brain and body and how they work together. “［4］Meanwhile, Robert Shmerling, another Harvard professor, said, “The placebo effect is for real and the benefits of a placebo treatment aren’t just ‘all in your head’. Measurable physiological changes can be observed in those taking a placebo, similar to those observed among people taking effective medications. In particular, blood pressure, heart rate, and various blood test results have been shown to change among subsets of research subjects who responded to a placebo. “［5］
For example, in a placebo study on pain, researchers performed functional MRI brain scans on patients with chronic pain due to knee osteoarthritis, and then repeated the brain scans on the subjects after administering a placebo. The results showed that those who felt a decrease in pain had increased activity in the medial frontal gyrus region of the brain, a region that makes up roughly one-third of the frontal lobe. The researchers believe that while the mechanisms behind the impact of placebos are not yet fully clear, they involve complex neurobiological reactions, including increased secretion of neurotransmitters such as endorphins and dopamine, and are related to increased activity in brain regions associated with emotional responses and self-awareness.［4］
The well-known classical Chinese saying “to quench thirst by looking at plums” provides evidence for the existence of ancient placebos. A New Account of the Tales of the World, written by Liu Yiqing, states: “While on a military campaign, Wu of Wei ［Cao Cao］ could not find the route to a water supply and his troops were thirsty, so he announced, “Ahead lies a large grove of plum trees loaded with fruit; they are sweet and sour, and can quench thirst.’When the soldiers heard this, their mouths all started to water. ” This record describes a time when Cao Cao was leading his troops to battle and could not find a source of water along the way. His generals and soldiers were thirsty and tired, so Cao Cao shouted to everyone that there was a grove of plum trees ahead full of luscious sweet-and-sour fruit that could alleviate their thirst. Upon hearing this, the troops all started to salivate. They bravely moved forward and fought vigorously. In the end, Cao Cao successfully defeated the enemy. Historical texts describe Cao Cao as deceitful, but we can see that he successfully applied positive psychological expectations to cause changes in people’s physiology (their mouths started to secrete saliva so they were no longer parched and thirsty). This also proves that cues and persuasive language can indeed trigger changes in physiological functions.
Based on what has been discussed above, we must acknowledge and accept that acupuncture treatment has its own unique mechanisms of action. While treatment effects are achieved via non-placebo pathways, the placebo effect inevitably plays a role to some degree. In other words, with any treatment, it is impossible to rule out psychological effects or the placebo effect.
For clinical practitioners of acupuncture, it is necessary to consider combining the true therapeutic effects of acupuncture with the placebo effect to the greatest extent possible in order to maximize the impact of the treatment. At the same time, one must avoid the nocebo effect, which, as previously mentioned, is the opposite of the placebo effect. If we understand placebo effects as positive cues that produce positive outcomes, then nocebo effects are negative cues that produce negative outcomes. If patients hear that acupuncture is painful, then when they get acupuncture they will be extremely nervous and feel as if the stimulus from every needle is indeed very painful. This is the nocebo effect. Similarly, in the aforementioned Vaseline experiment, among those who were told that the ointment would increase their pain, over half of the volunteers truly did feel that their pain got worse.
The TCM spirit, the brain, and placebos
We can easily see that all forms of placebo and nocebo, such as language and visual cues like rumors, instructions, and prayers, exert their effects through the brain. The brain is governed by what we in TCM call the “spirit”. According to TCM, essence, qi, and spirit are the basis for the normal physiological functions of the human body. The activities of the brain and spirit are directing and influencing the various activities in our bodies. From the moment a patient walks into the clinic until they leave, the mental activities and behavior of the patient and practitioner are constantly being directed by the brain and spirit.
There are many descriptions and definitions of the spirit in TCM; here we confine ourselves to the mind, consciousness, and thought as referred to by the phrase “the brain is the mansion of the original spirit”, which comes from Li Shizhen’s Compendium of Materia Medica. This includes some of the functions that TCM attributes to the Heart as discussed in Nei Jing,which states that “the heart is the sovereign of all organs and is the source of spirit light”, “when the heart remembers something, this is called reflection; where reflections are stored is called the will”. To put it simply, the spirit in TCM encompasses all the mental activities discussed in modern medicine.
Below, I have attempted to describe how to amplify the placebo effect in a clinical context by regulating the spirit and thereby positively activating the spirit in the brain, while simultaneously reducing the negative activity of the spirit, also known as the nocebo effect.
Regulating the spirit in treatment
1. Using spirit in intakes: Chapter eight of Ling Shu, entitled “The Spirit as Foundation”, states that “this is why those who use needles must observe the patient’s condition in order to know if their essence, spirit, ethereal soul, and corporeal soul are present or have been lost”. This means that when in clinical practice, we must observe the patient’s spirit to see if they exhibit spiritedness (eyes and face are bright and lustrous), diminished spirit (apathetic expression and dull eyes), or spiritlessness (absentminded, inappropriate responses to questions). We can understand the patient’s mental state by observing their eyes and facial expressions. At the same time, we must listen carefully to the patient’s narrative and inquire about the details of their symptoms, giving the patient the impression that our spirit is focused only on them. Every one of us has experienced going to the doctor: after a long wait, the doctor only spends ten minutes with you and then sends you on your way. This kind of experience makes patients feel that the doctor was not focused on listening to what they said. They may feel that since the doctor’s spirit was not present and he did not sincerely address their illness, the prescription he wrote may not be effective. This state of mind may cause patients to experience the nocebo effect.
2. Using the spirit in acupuncture: Chapter 25 of Su Wen, entitled “On the Preservation of Life and the Body”, says that “true acupuncture requires one to first treat the spirit”. The first chapter of Ling Shu, “Nine Needles and Twelve Sources”, also reminds us that “the spirit is in the minute details; focus the senses upon that which is diseased”. This means that the most important and fundamental part of acupuncture treatment is to treat the spirit, to regulate the patient’s mental state. We should focus on the patient’s spirit and not miss a single detail.
To this end, I frequently use spirit-calming points; many years of clinical experience tell us that no matter what disease a patient may have, there are always mental factors involved. Mental stress may cause physical discomfort, such as depression accompanied by cervical pain. Or perhaps aphysical illness causes mental distress, such as a hip joint replacement that leads to insomnia and anxiety. When I treat patients, if I am needling the front of the body, in nine out of ten cases I use points that treat the spirit such as Yintang, Shenting ［GV-24］, and the Four Gates. If I am needling the back, I often use Dazhui ［GV-14］ and the back transport points for the heart, liver, and spleen to regulate the spirit.
Before inserting the needle, I use my pressing hand to gently palpate the point, silently focusing both my own and the patient’s spirit on that spot. In chapter 67 of Ling Shu, entitled “Application of Needles”, it is said that “their spirit is easily excited and their qi easily moves”. If the spirits of both practitioner and patient are wandering and unsettled, the qi will not stay below the needle. Chapter 54 of Su Wen, “Explanation of Needles”, states that “it is necessary to keep one’s spirit upright, observe the patient’s eyes and control their spirit; this makes the qi circulate more easily”. Therefore, one must guide the patient’s spirit in order for the qi obtained by needling to flow smoothly. At this time, insert the needle quickly and the discomfort caused by needling will soon disappear. For important points, explain to the patient what effects the point will have on them at the same time as you stimulate the needle. Persuasive language will activate the patient’s positive expectations; this not only helps to reassure the patient, but can also produce better outcomes. What you say should be short and simple; you should not be overly talkative or flaunt your knowledge, or else what you say may backfire. Of course, competency in essential acupuncture skills like point prescriptions, needling, and obtaining qi are the most important factors affecting treatment outcomes; one cannot put the cart before the horse.
3. Using the spirit when prescribing herbal formulas: For the same reasons we choose “spirit” points in acupuncture, we can also use medicinals that regulate the “spirit” to treat patterns like liver depression, qi depression, dual vacuity of heart and spleen, noninteraction of heart and kidney, and spleen-stomach disharmony. Medicinals such as bupleurum (chái hú), white peony (bái sháo), dragon bone (lóng gǔ), mother-of-pearl (zhēn zhū mǔ), medicated leaven (shén qǔ), root poria (fú shén), spiny jujube kernel (suān zǎo rén), biota seed (bǎi zǐ rén), polygala (yuǎn zhì), silk tree bark (hé huān pí), and flowery knotweed stem (yè jiāo téng) can often be used to good effect.
Finally, it is worth mentioning that some research reports have shown that the therapeutic effects of acupuncture are not placebo effects. The effects of acupuncture were inversely correlated with patients’ expectations; that is to say, patients with higher expectations had worse treatment outcomes. There was a positive correlation between therapeutic effects and the patient-provider relationship.［6］The results of this study serve as a warning for us not to overly exaggerate the effectiveness of acupuncture and cause patients to expect too much. At the same time, this study also tells us that establishing a positive patient-provider relationship can help enhance treatment outcomes.
In summary
this paper uses modern medical placebo research findings to rediscover and highlight the importance of the placebo effect. Instead of denying that the placebo effect exists in the clinical practice of acupuncture, I have found that the effects of regulating the spirit in TCM diagnosis and treatment align closely with the placebo effect. Therefore, in the clinical practice of TCM, I suggest actively and assertively applying methods that treat the spirit. By regulating the spirit, one can improve treatment outcomes, enabling patients to benefit from both non-placebo and placebo aspects of the treatment and thus accelerating relief and recovery from their illness. While this paper simply describes methods to regulate the spirit using examples from acupuncture and herbal medicine, it is intended to start a discussion, inspiring practitioners to extrapolate and connect ideas from their own experience.
Author information
Zhenzhen Zhang TCM practitioner. ProfessorDr. Executive Associate Editor of New England Journal of Traditional Chinese Medicine，hang has 40 years of clinical experience, practicing and teaching in China, Japan and the United States. Dr. Zhang has been a professor and clinical mentor for New England acupuncture practitioners in Newton, Massachusetts for more than 20 years, and as a physician at the Women’s Health Center at Salem Hospital in Danvers, Massachusetts.
References
(1)Daryl Austin, Why do placebos work? Scientists identify key brain pathway https://www.science.org/content/article/why-do-placebos-work-scientists-identify-key-brain-pathway
(2)Yumi Maeda， et.al，”Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture” Brain, Volume 140, Issue 4, April 2017, Pages 914-927, https://doi.org/10.1093/brain/awx015）
(3)Ted J. Kaptchuk,et. al, Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome https://doi.org/10.1371/journal.pone.0015591. ）
(4)The power of the placebo effect Dec 132021 https://www.health.harvard.edu/mental-health/the-power-of-the-placebo-effect
(5)Robert H Shmerling, The placebo effect amazing and real（https://www.health.harvard.edu/blog/the-placebo-effect-amazing-and-real-201511028544））
(6)Dominicus W. So, Acupuncture Outcomes, Expectations, Patient-Provider Relationship, and the Placebo Effect: Implications for Health Promotion
