Rituals are a sequence of activities, performed in a sequestered place, and performed according to set sequence. Rituals are something we all partake in as part of living in society. We just had the centuries old ritual of going door to door wearing customs and asking for candy on October 31st. We also saw the breaking of the 108-year-old ritual of the Chicago Cubs fans saying, “There is always next year” after not winning the World Series.
Why do we have rituals? From a psychological perspective, we use this repetitive behavior systematically to help neutralize or prevent anxiety. It gives a sense of order and predictability in a very chaotic unpredictable world. (Our nervous system is an intriguing part of our body, it likes novel new things as long as there isn’t too much uncertainty that goes with it. Also because it requires a lot of energy to function, it recognizes that it needs to look for short cuts to run somethings on autopilot. Read Thinking, Fast and Slow for more on this.) Thus rituals allow us some certainty: when I do this, and then this, this will be the next thing to occur. Also, over time these rituals become very ingrained and occur with little to no thought to conserve energy. This type of ritual response can be part of a conditioned response (Classic ‘Pavlovian’ Conditioning).
Understanding this concept of the therapeutic ritual and conditioned responses helps us understand the research the shows significant pain reduction benefit, even when placebo is revealed. This study showed that even when patients knew they were receiving a drug that was a placebo they still had improvements in pain reduction.
One of the researchers, Dr. Kaptchuk reported: “It’s the benefit of being immersed in treatment: interacting with a physician or nurse, taking pills, all the rituals and symbols of our healthcare system. The body responds to that.”
So what should we as clinicians do with this type of understanding? Be comforted in knowing we can deliver pseudoscientific placebo interventions ethically? Research shows placebos work even when someone knows about it. So, ethically all you have to do is keep them informed, right? I would hope not! I think we need to look carefully at our care we deliver. Maybe the outcomes I’m getting are not due to specific effects of my treatment, but just the therapeutic ritual that surrounds it. I need to understand how to ethically enhance the therapeutic ritual surrounding an evidence based intervention that does actually have specific effects that helps individuals. I can Engage, Empathize, Educate, Enlist, and End as I provide patient-focused care.
What say you?
via Dr. Kory Zimney, DPT
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