Something Weird Is Going On With Placebos

For the past few decades, something strange has been happening in clinical trials. Painkillers aren't getting worse, but the placebos they're tested against appear to be getting better. In one landmark study, the advantage of pain medication over placebo shrank from 27.3% in 1996 to just 8.9% in 2013. Even stranger? This trend was found almost entirely in American trials. In this episode of The Rest Is Science, Professor Hannah Fry and Michael Stevens (Vsauce) investigate the extraordinary science of the placebo effect; how our expectations influence pain, why belief can change the way our bodies respond, and what this means for the future of medicine. Why does the way a treatment is presented matter so much? And how can simply expecting something to hurt actually make it hurt? But the placebo effect doesn't stop at medicine. From pedestrian crossing buttons that do nothing to the surprising psychology of road safety, Hannah and Michael explore just how easily our expectations can shape our experience of the world. ------------------- "For more information about Cancer Research UK, their research, breakthroughs and how you can support them, visit https://www.cancerresearchuk.org/our-research/rest-is-scienceCancer Research UK is a registered charity in England and Wales (1089464), Scotland (SC041666), the Isle of Man (1103) and Jersey (247). A company limited by guarantee. Registered company in England and Wales (4325234) and the Isle of Man (5713F). Registered address: 2 Redman Place, London, E20 1JQ." ------------------- Find The Rest Is Science all over the internet by ⁠⁠clicking here.⁠⁠ -------------------Video Producer: Adam Thornton + Oli Oakley + Jack MeekAnimator: Sam BensonVideo & Social: Bex TyrrellAssistant Producer: Lucy LipscombeProducer: Simona RataSenior Producer: Lauren Armstrong-CarterChief Digital Officer: Samuel OakleyExec Producer: Neil Fearn Learn more about your ad choices. Visit podcastchoices.com/adchoices

• 0:00Speaker 00

  Welcome to The Rest Is Science. I'm Hannah Fry.

• 0:03Speaker 01

  And I am Michael Stephens. Hannah, here's something really weird that we don't understand very well at the moment, and we haven't for like, at least 12 years. Placebos are getting better. Placebos are getting more and more effective. They are becoming effective drugs, even when people know it's a placebo. But here's the even weirder twist. It's only happening in America.

• 0:35Speaker 00

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• 2:43Speaker 00

  I beg your pardon.

• 2:45Speaker 01

  Yeah.

• 2:45Speaker 00

  Are you trying to tell me American placebos are better than American placebos?

• 2:51Speaker 01

  American placebos-

• 2:52Speaker 00

  You Americans and your patriotism, this has gone too far, Michael.

• 2:55Speaker 01

  Yeah. I mean, what does it mean about Americans that placebo are becoming so good? There's all kinds of hot takes you could have about this, about magical thinking, about faith. It's a real phenomenon that was kind of first brought into discussions back in like, 2012, 2013, when McGill University ran this like, study where they were just looked at placebo across decades. So first of all, let's, let's define what a placebo is, and we might need to rework this definition as we go forward. But a placebo is something, a treatment or a drug that has no known active pharmaceutical or biological or chemical

• 3:40Speaker 01

  effect, okay?

• 3:41Speaker 00

  Sugar pill.

• 3:42Speaker 01

  A sugar pill. The opposite of a placebo is called a verum.

• 3:47Speaker 00

  Hmm.

• 3:49Speaker 01

  I didn't know this until this morning, when I was just reading about placebos, and, and they started saying, well, compared to a verum, a placebo, blah, blah. And I'm like, what's a, what the hell is a verum? Turns out, verum is what you call a real drug that has a known biological reason for working. So for example, if I get a cut on my arm, and I pour rubbing alcohol all over it, that prevents infection in a verum way. It's real. It really kills bacteria.

• 4:18Speaker 00

  Presumably, you can still call it a verum and not really understand how it works. Like anesthesia, for example. You pin down an anesthesiologist and get them to really explain how anesthetic works. They won't be able to. They can't.

• 4:31Speaker 01

  Yeah.

• 4:32Speaker 00

  They refuse. I mean, maybe they're just refusing, but they won't. But presumably, that's still a verum because we know that it reliably, reproducibly works.

• 4:41Speaker 01

  That is the fuzzy truth of this whole thing. And I've spent years on this. I've worked with professors at McGill University on placebos. I'm even thanked in one of their published papers.

• 4:52Speaker 00

  Amazing.

• 4:53Speaker 01

  Okay. And they still are like, we don't really know how to define placebo. Because yeah, ultimately, it just means, how much do we know about why it works? And there's a limit to where we know so little about how it works that we just call it a placebo.

• 5:07Speaker 00

  Okay.

• 5:08Speaker 01

  But you're right. There are things like anesthesia, where it's like, we don't totally know what's happening, but we, we can pinpoint where we should be looking, so we're not going to call it a placebo.

• 5:19Speaker 00

  Got you. Because there's definitely a mechanism going on somewhere.

• 5:21Speaker 01

  I mean, I think that there's some even like, broader application of the word placebo, where we could say that airplanes fly because of placebo. We don't know exactly how it happens.

• 5:32Speaker 00

  As we've discussed.

• 5:33Speaker 01

  You ask most pilots, and they'll, they'll debate amongst themselves over it, as we've discussed. But clearly, there's something going on that isn't just, it stays up because we believe it will. That's not true either. So it isn't quite a placebo, but it's somewhere in between. And so is basically everything we believe. I found this really impressive. This is a paper, let me just look up, so Tuttle and Toyama from McGill, they published one of the first looks at the effectiveness of placebo over time. They just looked at all the research on medicines that had been done since the 90s, up until 2013. And they noticed that we were coming up with new drugs and new treatments, but yet the placebo cases also had better and better results. So in 1996,

• 6:19Speaker 01

  amongst Americans, for pain relief, so we're looking quite specific at pain relief only, actual drugs with understood mechanisms worked 27.3% better. Better means patients reported either less pain, or after treatment, they were pain-free. Okay? 27.3% better than taking a placebo.

• 6:40Speaker 00

  Can I just say, before we move on, right, I think that number is quite small.

• 6:46Speaker 01

  Yeah.

• 6:47Speaker 00

  And, and the thing is, I've always found this really strange about the idea that when you do randomized clinical trial, you know, double-blind, whatever it might be, that like, the, the gold standard of how you decide whether something is effective, and then you're comparing it against a placebo, and all it's got to do is be better than placebo. Because that 20-whatever percent that you, you've got there, I mean, presumably, most of those drugs will come with some sort of side effects, some long-term repercussions, there's a financial cost associated with it, there's all kinds of risks and so on. And like, that doesn't seem like a massive benefit to me.

• 7:22Speaker 01

  No, it isn't a massive benefit. I, I don't have from this study, numbers comparing the actual drug to no treatment at all.

• 7:31Speaker 00

  Sure.

• 7:32Speaker 01

  But the key, the key focus of this study was that in 1996, Americans looking for pain relief found that known chemical pharmaceuticals were 27.3% more effective than placebo, than a pill that was just full of sugar or some inert compound. In 2013, pain relief medications were only 8.9% better than the same placebos had been in 1996.

• 8:01Speaker 00

  Okay.

• 8:02Speaker 01

  And this problem has only gotten worse. The effectiveness of especially pain relief drugs is getting closer and closer to placebo, not because pain relief drugs are getting worse, but because placebo is getting better.

• 8:17Speaker 00

  This, okay, this is, this is, this is wild. Say that again. 8.9%?

• 8:23Speaker 01

  Yes. In a span of 17 years, placebo got so much better that actual drugs effectiveness went from being 27.3% better to just 8.9% better.

• 8:37Speaker 00

  These numbers are sta- I was staggered at 20-whatever percent. I mean, I wanted it to be 100%. I wanted it to be like, the placebo does nothing, the medication does the thing that you want it to do. That's sort of what I was expecting. But these numbers are, they're terrible, and they're going in the wrong direction.

• 8:53Speaker 01

  They're, they're really confusing. The actual medicines are still doing better. But I think that besides pain relief, the area that we find this most strongly is with antidepressants.

• 9:06Speaker 00

  Hmm.

• 9:06Speaker 01

  So, when it comes to prescribing medicine for depression, placebo causes, on average, patients to score eight points better on a specific depression survey. I forget the name of the survey, but eight points better. So that's a good result. Okay, that's an improvement. Eight points better. But the best medications we have on average cause people to rate their, their feelings 10 points higher.

• 9:37Speaker 01

  And so about eighty percent of why antidepressants today work is because of the placebo effect.

• 9:44Speaker 00

  Because you're going to see somebody because they're giving you a pill, because you feel as though somebody is helping you with your problem, irrespective of what's actually in the medication.

• 9:54Speaker 01

  Just doing something is the majority of why antidepressants work. Now, the whatever's happening in the brain and the body chemically still makes a significant difference. Ten is more than eight, you know, twenty percent matters. That's that's worth pursuing. But the question remains, why is it so close? And it's actually helpful that this is so so much closer in Americans. And the the researchers in this paper, Tuttle and Toyama, they they put two hypotheses forward that haven't really been tested well enough yet.

• 10:37Speaker 01

  But the big differences they saw between Americans and the rest of the world were two things. One was that clinical trials in America got super long. From nineteen ninety to twenty thirteen, in nineteen ninety six, the average clinical trial was four weeks long. But by twenty thirteen, it was twelve weeks long. Okay.

• 11:00Speaker 00

  Right.

• 11:00Speaker 01

  Three times longer, people were under care. The other difference is that in America, we have pharmaceutical commercials. We are surrounded by advertisements that tell us and show us how effective medications are.

• 11:18Speaker 00

  Right. So the belief in you're you feeling like you're going to get better.

• 11:22Speaker 01

  That's right. The belief in in the paper, they call it the strength of the ritual and the glamour of pharmaceuticals is so much more enchanting to Americans, that we believe in their effectiveness a lot more. And I might even say we believe in their potency more. Because even people who distrust medicine and think that it's going to actually make them worse, they at least still believe it will have an effect, one way or the other. They believe that it's potent and strong.

• 11:53Speaker 00

  Have I told you that I made a program about pain before? Have I told you this?

• 11:57Speaker 01

  Yeah, well, we did a whole episode on pain.

• 11:59Speaker 00

  We did, we did. But the key thing that really stuck out to me is that I went to go to Oxford to go and meet, she's called the Queen of Pain, Irene Tracey. And what her experiments do is she puts people into FMRI scanners while she subjects them to measured amounts of torture, essentially. The conclusion of her lab is that pain is not an an objective quality that your body is measuring. It's not, it's not sort of, you know, it doesn't come with units because actually it is constructed within your brain. It is it is a version of reality that your brain decides on once it puts all the information together, not a hard signal that you're getting from elsewhere.

• 12:44Speaker 01

  That's exactly right. And it really teases out a significant difference around what where placebos work and where they don't. If I cut my arm really badly and I treat it with an antiseptic, like rubbing alcohol or something, it that really does kill the bacteria and we know why. But if I wash it with a prayer, it's much more likely to become infected. However, however, if I wash it with a prayer, it really is likely to hurt less than if I do nothing, depending on how much I believe in that prayer. So infection is less well treated by placebo than pain.

• 13:29Speaker 00

  Which makes sense.

• 13:30Speaker 01

  Okay. Broken bones are less well treated by placebo than depression.

• 13:35Speaker 00

  Mm hmm.

• 13:37Speaker 01

  However, it's not entirely black and white. And that gets to like the deeper mechanisms behind what our bodies do on their own and letting the body do what it would normally do. And to see why, let's let's look at the theories around like why placebo might work in the first place. There are basically two main explanations. One is classical conditioning, meaning we learn that things get better when we do something. So when we do something, we already feel better. The other is about expectancy. It's sort of related, but this one says that at this deep level, a lot of symptoms

• 14:19Speaker 01

  like pain, like mental anguish, a lot of those symptoms exist in order to signal for help, to either signal us that we need help or to signal others that we need help. A child who falls on their own outside might start crying in order to get the attention of an adult. But once the adult gets there and soothes them, soothes them, they stop crying, but they don't necessarily feel any better. Their their scrapes, their bruises, their broken bones haven't been mended, but they've accomplished step one, which is to get help. So the symptom of I'm going to cry, I'm going to feel this immense pain that makes me cry, or that makes me walk and move in a different way that that catches other people's

• 15:02Speaker 01

  attention so that they know that I'm heart hurt, that's not as necessary anymore. So those symptoms go away. They've done their job. They've gotten attention.

• 15:09Speaker 00

  So then the way that you're describing that is that actually one, you know, the point that you were making earlier about antidepressants is that like just feeling like someone is helping you is sort of part of the battle.

• 15:24Speaker 01

  That's right. That's right. Just feeling like someone's helping you and you're helping yourself. So what's what's even more, I think, mind blowing to me is that not only are placebos getting better, but labeled placebos are getting better. There's been a lot more research lately on giving people a placebo and just telling them that it is one. It used to be that, you know, the the key was that people needed to not know if they were taking a real drug or if they were taking something that that looked maybe real but wasn't. There was a study that came out of Harvard Medical School, I'd say maybe about ten years

• 16:07Speaker 01

  ago, that I it's one of my favorite. I'm going to get to my actual favorite a little bit later, but this one's like a close second. So they looked at migraines. And here's here's what they did. They they took a bunch of patients who suffered from migraines and they gave them envelopes that contained pills to take, I don't know, every day, three times a day. I forget, I forget what the regimen was. But there were three types of envelopes. Your envelope either said Maxalt, which is an actual migraine drug, or it said placebo. Or the third case was that your envelope said Maxalt or placebo, we won't tell. Okay.

• 16:52Speaker 01

  So some people thought they were getting a placebo, some thought they were getting the medication, and some thought, they don't know.

• 17:00Speaker 00

  So can I guess which order the the results came back in? Because my guess would be Maxalt's number one is the thing that actually does something, followed by the envelope where you're where you can't tell, followed by the placebo. That would be my guess. And there'd be big jumps between them.

• 17:16Speaker 01

  And you're you're pretty correct, but I haven't actually described every single variable that they tweaked in the study. Also, I should say there was technically a fourth group, which had no treatment at all. They didn't even get an envelope and they were the worst. So through through this trial, they actually reported that their pain increased by an average of somewhere between ten and twenty percent. Every other person in the group reported a reduction in in migraine pain. But yeah, you're right. You're right. The the people who received an envelope that said placebo had a little bit of a reduction, which is still way significant compared to those who said, I my pain is like twenty percent worse than it was before and I got nothing. The people who got the unspecified envelope, they were a bit better.

• 18:01Speaker 01

  The people who got the actual medication labeled envelope were the best. But there's another wrinkle to this, which is that what the envelope said wasn't necessarily true.

• 18:13Speaker 00

  Cheeky.

• 18:14Speaker 01

  Yes.

• 18:15Speaker 00

  Did they know that?

• 18:16Speaker 01

  They did not know that. So it was 50/50 whether the envelope was true or not.

• 18:23Speaker 00

  Oh, that's great.

• 18:24Speaker 01

  Let me rephrase that. What I mean is that, that when you got an envelope, 50% chance it was placebo, 50% it was the real medicine. So-

• 18:32Speaker 00

  Irrespective of what it said on the outside.

• 18:34Speaker 01

  Exactly. So half of the people who got the envelope that said, this is a placebo, actually received the real medicine. Half the people who got the one that said, this is the real medicine, got placebo, and half of the people that got the, we're not going to tell you, got one or the other.

• 18:49Speaker 00

  So in a way, actually, theirs was the only true envelope.

• 18:52Speaker 01

  Exactly. Theirs was the only true envelope. And this is where things get really juicy.

• 18:57Speaker 00

  Yeah, because by doing that, what they've, what they've managed to do is to disentangle the effect of the medication versus placebo from your perception of whether you're getting the medication or placebo.

• 19:08Speaker 01

  That's right. They've given people different perceptions, but they've also given them different medicines. As you correctly guessed, people who received the actual medication did better. But if we just look at people who received the actual medication, one group did better than all the others. And it wasn't people who got the real medication and thought they were getting the real medication. It also was not people who got the real medication but thought they were getting a placebo. The best results, the lowest reduction in migraine pain, and the highest chance of being migraine-free after the trial came from people who got the real medicine, but were told, we're not going to tell you. You might not be getting it, or you might.

• 19:52Speaker 00

  That's amazing. Wait, what's the justification for that? Why, why? Because you're questioning yourself. You're like, oh, I think I am feeling, yes, I'm definitely feeling better. I'm feeling, no, I'm really feeling, I'm definitely feeling better.

• 20:04Speaker 01

  Very clever. That's exactly the hypothesis that is, I think, currently the favorite. And it's the fact that the medicine does work, okay? But if you tell people that they may not be getting the real medicine, they become hyper vigilant. And they go, how do I feel? Do I think I'm getting the placebo or not? I don't know. I, hmm, let me think. And they might, they might journal about it more. They, they check in on themselves more often. They pay more attention. And in some way, that, that results in a better outcome.

• 20:35Speaker 00

  See, this is something that I've always, you know, knowing how effective placebos are, right? Knowing that, you know, two pills works better than one. Red pills work better than blue pills. Injections of placebos work better than, than tablets of placebos and so on. I've, I've often thought that there had been times in my life or the life of people that I care about, where I would really love to give them a placebo. But unfortunately, you can't go into a doctor and say, okay, could you prescribe me a placebo? Could you prescribe me a placebo, please? Because I think that broadly it's unethical, um, from the perspective of the doctor rather than from the perspective of me. But what you're saying, I mean, this, this, this works pretty well, that you could go into a doctor and say,

• 21:15Speaker 00

  I'm going to tell you what's wrong with me. You should prescribe me something and then not tell me whether it's real or not. I leave the decision in your hands.

• 21:24Speaker 01

  Yeah. And, and I will, I will try to guess whether you gave me the active pharmaceutical or not. That that, in, in cases of, of pain, in cases of, of depression, that has shown to be the most effective treatment. Treat them with real pharmaceuticals, but leave it unknown to them whether they're getting it or not.

• 21:48Speaker 00

  Amazing.

• 21:48Speaker 01

  So just stress in general inhibits our body's ability to do what it needs to do to get better. And so if someone feels like they are being cared for, that they're being attended to, the body can take a break from, from being stressed and focus on releasing the natural opioids that make you feel better and then doing its thing. Um, the immune system can be given more resources, more energy to fight, um, and, and to help you get better. And we've talked about that before, I believe, on the podcast. There are like placebos you can sort of self-administer. And again, this is getting to the question of like, what counts as a placebo?

• 22:30Speaker 01

  But often if someone does something that, that medical science cannot prove will work, but the person believes will work, or even might work, the result can be really good. That's one of the main reasons telling people to change their diets or exercise more or be more social helps with almost everything. Because it might, we don't know exactly how this is going to help you with what's, what's troubling you. But if you change up your lifestyle a little bit, you are, you know, you're doing something.

• 23:01Speaker 00

  Doing something.

• 23:03Speaker 01

  So your body goes, all right, something's been, and when I say body, I mean, basically your brain goes, you're doing something. Okay, we're going to freak out a little bit less. Maybe this will work. Or maybe you do, do, you truly believe it'll work, which means your body focuses less on the worry and more on fixing itself. So yoga, exercise, spending social-

• 23:24Speaker 00

  Meditation.

• 23:25Speaker 01

  Meditation. Exactly. And, you know, there may truly be, in a lot of cases, a, a extremely scientific biological connection between why meditation helps with your IBS, okay? But some of it could be, uh, if we ever, you know, find the answer, it might just be that the meditation meant that your brain was able to put more resources into healing and, and, and fewer resources into generating the symptoms that made you concerned to try to get you to do something. You did something, okay? Fine. That's all we wanted you to do. And now there's going to be less pain.

• 24:03Speaker 00

  I do think that it's important that we make this distinction. There's certain ailments where doing something is definitely the right thing. But I think that what's really interesting is that, uh, ever since medical science really like got going and demonstrated how much it's capable of saving people's lives, I think that sometimes there is a bias towards doing something just to feel like you're doing something. So the example that I, that I think about a lot here is, there was a big study about prostate cancer. So early-stage prostate cancer in, uh, in men, obviously, let me start again. So early stages of prostate cancer, they had a number of different patients, all caught at roughly the same stages, and they split them into three groups.

• 24:48Speaker 00

  And the first group, they went in for surgery to remove the cancer, which I think is actually, a lot of people's instinct is to say, get this, get this thing out of my body immediately. I don't want it anywhere near me. The second group, they just did radiotherapy to try and shrink the cancer to keep it under control. And then the third group, they did nothing. So not even a placebo, just nothing. Just keep an eye on the levels, just watch and wait essentially to see what would happen. And the thing is, with this particular study, um, they followed people over a long period of time, over a number of years. What is extraordinary is that there was actually no difference in survival between the three groups.

• 25:33Speaker 00

  No difference at all.

• 25:34Speaker 01

  Huh.

• 25:35Speaker 00

  Which, which sounds crazy.

• 25:37Speaker 01

  Yeah.

• 25:39Speaker 00

  But the thing is, is that prostate cancer in particular is one of those cancers where it can be extremely slow growing. Your body can hold on to it for many, many years before it ever really causes you any problem. I mean, you still need to take it seriously. Don't get me wrong here, all right? You still need to take it seriously. The people who were in the watch and see group were still monitored, and if it then became aggressive, they then would have interventions later. But overall, across the three groups, there was no difference in survival, uh, in, in, uh, the chance of people surviving. However, so many people in the group that had gone in and done surgery just to feel like they were doing something,

• 26:16Speaker 00

  essentially paid the price with, I mean, really their quality of life for no benefit whatsoever, uh, in terms of their chances of survival. A similar thing happened in, uh, in South Korea with thyroid cancer, where they introduced a screening program that would detect early cases of thyroid cancer. And thyroid cancer, to treat it, I mean, it's really nasty, right? It's all in the neck. It's like, there's lots of, can be really sort of quite, it's, it's not a very nice procedure at all. It's like difficult to recover from and so on. Anyway, when they introduced the screening program, there was, again, no difference

• 26:56Speaker 00

  in the survival of patients from thyroid cancer. Basically, they didn't save anybody's lives. But the number of surgeries that they had introduced, because people found out they had something in their bodies and they wanted it cut out and got rid of, went through the roof. So, you know, I, I do think that this idea, I'm always like a little bit cautious of this idea of like, just do something. That just do something doesn't necessarily mean just do a medical intervention. And I think, I think sometimes our instincts are, because science and medicine is so like proven, our instincts are to really go for, go for like the, the most extreme, especially in America, actually, for the sort of the biggest medical intervention. And actually, I think, I think sort of what you're saying as well here

• 27:39Speaker 00

  is like, actually, sometimes just doing something, not necessarily something extreme, is good enough.

• 27:46Speaker 01

  Yeah. And that, that kind of brings us to the question of, you know, what do we do with this knowledge? Like, what can doctors and, and patients do? We say do something. What do we know about the something that can affect its efficacy? Well, back to the question of the glamour and the ritual of it, we know that the more,

• 28:13Speaker 01

  I'm not sure what word to use here, the more serious the something is, the more effective the results. So we know that a pain pill will be more effective. It will cause people to feel better if it's given to them by a doctor wearing a lab coat and a stethoscope and injected from a syringe than if the exact same medicine or placebo is given through like one of those chalky kind of compressed pills, which is like apparently the like least impressive kind of pill. It basically goes like tablet, okay? Like a, like a chewable vitamin for a kid, like a chalky one, like a Tums.

• 28:56Speaker 01

  Next up is like a capsule. Those people go, dang, and they really are more effective. Yeah.

• 29:01Speaker 00

  It's fancy.

• 29:01Speaker 01

  And then the top is an injection. An injection makes people go, okay, this is, people care about me. They're doing something that requires a phlebotomist. And it's like, I, whoa, I've got, I've got like a wound afterwards. Like, how could this not work? All right. So let's, let's take a quick break. And when we come back, I want to talk about the different varieties of placebo.

• 29:33Speaker 01

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• 30:36Speaker 03

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• 31:04Speaker 04

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• 31:40Speaker 01

  Okay, welcome back. So we've been talking about placebos. There are names for the different types of placebos and our relationships to them. So a placebo is when the patient does not know for sure what they're receiving, but what they are receiving is something with no actively known mechanism of action. Okay? If the patient knows that they're getting something that is basically just a sugar pill, it's called a nocebo, spelled K-N-O-W-E-B-O. They know.

• 32:17Speaker 00

  Because you know it.

• 32:17Speaker 01

  Knowledge. They know. Which is a terrible name, because of course, it sounds very much like nocebo, which is spelled N-O-cebo. And a nocebo, in that spelling, is kind of the opposite of a placebo. It's when something that is harmless actually causes pain or a deterioration in how you feel because you expect it to harm you. And if you want to look at the work that I've done with placebos and nocebos, go check out the Minefield episode on the power of suggestion. And then we did another one on touch. This was one of the weirdest, like, one of the weirdest feelings I ever got in an episode. We brought

• 32:58Speaker 01

  people into a lab and we told them that we were, I think we told them that we wanted to test this kind of like laser that was supposed to scan under the skin or something, but we wanted to make sure that it didn't cause too much pain. So people thought that they were there to just tell us when it got too painful. And of course, it wasn't real. It was a flashlight and a laser pointer installed in this like overhead projector, but made to look like a serious piece of new medical equipment. And we brought people in and we really gave them like a lot of kind of ritual and like medical layering to make it seem serious. We put like Vaseline.

• 33:40Speaker 00

  Just like the grown-up version of magic cream, right?

• 33:42Speaker 01

  Yeah, exactly. We put a magic cream on them, but I think was just Vaseline, but it came out of like an aluminum canister. And we were like, okay, we had them fill out a whole survey about their medical history and what medications they were taking. We had a nurse there. We had like a real like EMT there. And we had like a dial and before I cranked it up, I'd have to ask other researchers, like, "Do you think it's okay to go from four to five?" And we'd ask the patient, you know, "Are you ready?" And we acted a bit concerned and we really checked in on them a lot. And sometimes I'd be like, "Oh, we need to get a heart rate check on this person." And that freaked people out. So, some of them, we would reach level two and they would recoil away. They'd pull away

• 34:27Speaker 01

  because it hurt too much. And it burned them. And the debriefing, when we said, "Okay, so look, it was just a flashlight the whole time," they felt kind of embarrassed, but also like really amazed at just how powerful suggestion is.

• 34:45Speaker 00

  Yeah. But I mean, it makes perfect sense if you're that worked up, if you're really sort of in that mental state where you're bracing yourself or something. It does make sense.

• 34:53Speaker 01

  Yeah. Yeah, it really does.

• 34:55Speaker 00

  I feel like a lot of people could, you know, can really see themselves in that story.

• 35:01Speaker 01

  I mean, I would totally be in that story. I wouldn't even do the experiment. But that's a nocebo. That's when something with no action, that's harmless, causes a bad symptom. So, related to the placebo response, the ways in which nothing can actually help us out or harm us, is the Tinkerbell effect. A phenomenon where something becomes more real because we believe in it. It's named after Tinkerbell and Peter Pan, where, you know.

• 35:34Speaker 00

  I've heard of her.

• 35:34Speaker 01

  You have to believe in her for her to exist. I think in the stage show, you know, the audience has to like clap or, you know, they're asked to believe and believe in Tinkerbell and then she appears. Don't quote me on that because I'm not a big Peter fan, a Peter Pan scholar. Peter fan. Peter fan. Is that what Peter Pan fans call themselves?

• 35:57Speaker 00

  You're not a big Peter fan. They should do.

• 35:58Speaker 01

  Peter Pan's, they should. I will, I should read Peter Pan. But the point is, the Tinkerbell effect is obviously related to placebo. It's related to why, like, medical procedures and things that are dressed up in the paraphernalia of medicine. And today, especially neuroscience can be so effective, even if they shouldn't be or we don't know why. It's because if we believe in it enough, a lot of it can become true. And it sounds a little woo-woo, like, if you believe in it, it'll come true. But there are specific cases where it's quite clear that it works. One is.

• 36:32Speaker 00

  This is scientifically backed, right? This is, this is not, I mean, it might sound woo-woo on the surface, but there's like a lot of hard evidence that this is actually how the brain works.

• 36:41Speaker 01

  That's right. I mean, look, if I, if I believe that I can fly by flapping my arms, no matter how strongly I believe that, it probably won't work. But when it comes to something like how successful a school is, okay, how successful their, their teachers, their methodologies, their, their schedule, how effective those are, it really seems to have less to do with what exactly they implement and a lot more to do with how much they believe in its effectiveness, how excited the staff, the administration, the teachers are in, "Here's how we do things here." That is what correlates with successful schools, with a happy staff, happy students, and good test results, and good results later in life

• 37:26Speaker 01

  for the students. It isn't so much that like, "Oh, thank goodness, the, the government implemented this specific regimen." It's more, the school chooses what works for them and they all collectively believe in it. And the staff believes in it so much that the kids start to feel like, "Man, you guys really care. And you know what you're doing. And like, I'm glad to be a part of this."

• 37:49Speaker 00

  I mean, we talked before about, about self-efficacy, which is like the individual version of this and how important that is at success, in mathematics in particular, but in lots of different school subjects. But actually, and it's measurable and it's, you know, this is like a repeatable, testable phenomenon. If you believe that you are able to do something, your chances of doing it increase. Like, just that alone, right? Which I think is, is wild.

• 38:19Speaker 01

  I wanted to first talk about the reverse Tinkerbell effect because there are also things that only exist when we don't believe in them.

• 38:31Speaker 00

  Go on.

• 38:32Speaker 01

  Which is a funny, this is a fun thing. I talk about this a lot because when you bring this up, people go, what could that possibly be? So here's an example.

• 38:39Speaker 00

  I'm trying to think of a single one. Wait, can we make it a guessing game? Can we make it a guessing game?

• 38:43Speaker 01

  Well, yeah, you know what? I bet if you, if you guess, you'll probably find some that may be reverse Tinker Bells. But yeah, tell me, tell me what you think.

• 38:50Speaker 00

  Okay, wait, let's have a think.

• 38:52Speaker 01

  Because I've only got one example that's been like quite rigorously studied.

• 38:56Speaker 00

  Okay, so if you don't believe in it, then it exists.

• 38:59Speaker 01

  Then it exists. And if you do believe in it, it starts to not exist.

• 39:06Speaker 00

  Oh, gosh. Go on, give me a clue. Give me a clue as your example.

• 39:09Speaker 01

  Safety.

• 39:10Speaker 00

  If you don't believe in it, then it becomes true. Go on, tell me.

• 39:16Speaker 01

  The, the only example I've found that's been really carefully looked at is whether people believe it is safe to drive or not. The safer people believe it is to drive, the less safe it becomes to drive because they think it's safe. I don't need to worry too much. I can be a little bit, you know, offensive in my driving. No, why, why wear a seatbelt? Driving is safe. And suddenly it becomes less safe. But if people think that driving is not safe, they do not believe in it's safety, then it becomes safer because they all are being so much more vigilant and careful.

• 39:51Speaker 00

  That's such a good example. I mean, you see those situations where, where traffic lights are out for, for some reason, and suddenly everyone is like so unbelievably careful.

• 40:02Speaker 01

  Traffic lights go out sometimes where I live, and that's when there's like the safest driving I've ever seen in my life. Everyone's courteous, they're polite, they're paying attention, they're waving, and they're, they're driving at a good speed. But as soon as those stoplights are there, they're like, boom, I'm gonna do what I want, because I can offload my concerns to the, the lights.

• 40:23Speaker 00

  It's no longer my problem.

• 40:24Speaker 01

  And that's when mistakes get made. I think helmet safety also has been studied in this way, where once you start requiring children to wear helmets when they ride their bikes, accidents can actually go up because kids start to feel like, well, I can make that jump, I'm wearing a helmet. But if they don't have any protective gear on, they're like, I'm not gonna do that.

• 40:46Speaker 00

  Yeah. Yeah. Just be way more cautious.

• 40:49Speaker 01

  Some famous examples of the placebo effect outside of medicine are placebo buttons. We're all familiar with these, like the cross, crosswalk button at an intersection. You're like, does this really do anything?

• 41:05Speaker 00

  Do they not work in America? They definitely work in the UK. They definitely work here.

• 41:09Speaker 01

  Whether or not a pedestrian crossing signal button works is a bit of a mystery. I think the ones in the UK are probably real. I think the ones where I live, here in Colorado, are real. But in places like New York City, it's almost just like there so that people get less frustrated and feel like they're in control. I've heard, I mean, I've read that in, in a lot of really busy municipalities, they might only work during the day. They might only work at night, when there aren't expected to be very many pedestrians. So they don't bother putting a walk signal in unless someone pushes the button to request one. But during the day, it's just part of the regular routine, but they put the button there anyway. Same goes for...

• 41:51Speaker 00

  I have read in elevators that where, that the idea of actually people dangling from the sky in a metal box was actually extremely stressful. And that was why they put in the, the closed door, open door buttons, just to make people feel like they had a little bit more control.

• 42:07Speaker 01

  That's right. It makes them feel better. And I also was reading about, and again, I can't give you any like names of actual office buildings where this happens, but it's quite common for an office thermostat to only kind of, if, if at all, actually affect the temperature of the office. I think what's more common than just having a completely placebo ineffective thermostat is a thermostat that can be altered anywhere from like 90 Fahrenheit down to 60. So I don't know, that's like 16 to 27. I've literally just made up those numbers. But anyway, and it might actually signal the like main HVAC unit to

• 42:49Speaker 01

  do something, but it might only have the ability to sway the temperature maybe two degrees Celsius one way or the other, even if you've moved it all the way down, you know, 10, 20 degrees Fahrenheit, for example. It'll just, it'll just do a little change, but it makes people feel like they've done something and they feel better. I've even been testing on, how do we, how do we make it so that when people in a specific office change the thermostat, can we get the sound of a fan to start? So they think something's happening more than really has to be happening. Because that sound of that fan, it's been studied, really makes people feel a lot more comfortable with the temperature.

• 43:25Speaker 00

  Does it?

• 43:26Speaker 01

  Because they think it's at least being changed. It's going to get better. I can now focus on not how I'm feeling, but on the work I have to do, or whatever. Finally, I thought this was funny. With, when, with audio technicians at like concerts, when they're working on a mic check with the artist, there's a button that's called the DFA slider or the DFA fader. DFA stands for does F all, where F is a curse word. And it's, it's knobs or sliders or buttons that are specifically programmed to do nothing. But they're there. So when the artist says, hey, I need, I need, I need my, you know, what do they call it? My monitor to be higher.

• 44:07Speaker 00

  That's so funny.

• 44:08Speaker 01

  But if you do that, it's gonna cause feedback, but you also want the artist to be happy. You take that DFA fader and you push it up and you go, how about now? And they try it and they go, no, more. And you go, okay. And you push this button, which does nothing, but they see you do it. And you ask, is that better? Eventually they'll say, yeah, that's good. Thank you so much. And they stop complaining and they feel comfortable and confident to do the performance. But you've just been pushing the does F all button.

• 44:32Speaker 00

  That is, that is so amazing. And it also really, I mean, it resonates with something that we do in TV a lot. Have you ever heard of the strawberry filter?

• 44:47Speaker 01

  No.

• 44:48Speaker 00

  Okay, so this is, I feel slightly, I'm a bit nervous about saying it out loud, right? Because then we'll never be able to use it. But essentially what happens is when you get some people that you're interviewing, someone who needs to be on camera for some reason, who has a very clear idea in their own minds of what they want the show to be, what they want the sequence to be. This is for factual TV, right? Maybe it'll be a scientist who's just like extremely nervous and wants to like tell you every single little bit of detail that you know you'll never be able to include. Or sometimes it'll be like, you know, a company who you're visiting, who wants to put their most boring snore fest CEO in an interview, so that they can like look really important. You're like, okay,

• 45:33Speaker 00

  thank you, Mr. Snore Fest, but we actually want to go and film this really cool thing that's going on over here.

• 45:37Speaker 01

  Yeah.

• 45:38Speaker 00

  So what you do is you go, great, let's do this. But so that you, you're like really enthusiastic, but so that all the crew know not to try their hardest and do pickups and retakes, you just say, oh, should we use the strawberry filter on this film? And then everyone knows that you're never gonna use it. Yeah.

• 45:54Speaker 01

  So that's code for it doesn't matter. Okay, like...

• 45:57Speaker 00

  It's code for like, we're doing this to make them feel comfortable. Yeah, we don't care.

• 46:02Speaker 01

  Wow.

• 46:04Speaker 00

  Because if you don't say it, then you can end up doing, like the sound deal will be like, oh, there was a plane going overhead on that one. Could you pick up that question? And then like, the camera person will be like, oh no, I lost focus. Let's pick it up. And you'll be there for blooming ages. Whereas if you just say, guys, yeah, let's strawberry filter it. And then you just get, get out of the way really quickly.

• 46:22Speaker 01

  Then they know not to have any problems. Just let it finish. Wow. But yeah, you'll have to change that code word because it'll become popular. Like I remember one of the, the phrases that I don't think is used as much now, you'll have to tell me if you work in production, is that especially if you were a PA who was out there doing crowd control because you were shooting something and onlookers might come by and say, what are you guys shooting? The answer was always mayonnaise commercial. That's what you said. Because supposedly it was boring enough that onlookers and look loo would just go, oh, okay, well.

• 46:56Speaker 00

  Yeah, we say, we say for the Open University. That's what we say.

• 46:59Speaker 01

  Oh, that's good.

• 47:00Speaker 00

  Even though actually I've made some for the Open University. I think they're so good. I adore them.

• 47:06Speaker 01

  Oh, I didn't even know that it was a thing. I just thought it was like a really generic sounding, like, oh, okay, well, there's not gonna be any celebs in that. No reason to try to watch or get closer.

• 47:16Speaker 00

  Mayonnaise commercial is hilarious.

• 47:18Speaker 01

  Mayonnaise commercial is funny, but I feel like, one, I feel like it's kind of known, especially in LA. People know that if they're told mayonnaise commercial, that's not true, that it's probably something really sexy. Like, oh no, it's, you know, Paul Rudd is doing, like he's juggling Jada Pinkett Smith or something, right? Like, I gotta, I gotta see. But also, a mayonnaise commercial sounds kind of interesting. Like, I don't know, I might see that on TV someday and I'd love to be able to say, I was there. I saw that house. I saw, I saw that actor.

• 47:46Speaker 00

  Okay, I thought of a, I did think of a reverse, I did think of a reverse Tinker Bell.

• 47:50Speaker 01

  Oh, tell me.

• 47:52Speaker 00

  I was thinking the entire time, bluntly. So it's gotta be like, you think good, it is bad, right? Or you think bad, it goes good. It's like gotta be the opposite of what you think. So what about the stock market?

• 48:03Speaker 01

  Yeah.

• 48:03Speaker 00

  Right? That like, if you think, oh no, wait, is that actually, that's the same as Tinker Bell?

• 48:08Speaker 01

  The stock market is usually given as an example of the regular Tinker Bell effect.

• 48:12Speaker 00

  Damn it.

• 48:12Speaker 01

  Like, how important is the Dow Jones Industrial Average? Well, if we all think it's really important, then we start acting like it's important, which means it's important. And when it goes down, then people start making decisions that change things and yeah.

• 48:25Speaker 00

  You know what? I think we should leave this as a challenge for the listener.

• 48:29Speaker 01

  We should. We should. Yeah.

• 48:31Speaker 00

  We want, we want more reverse Tinker Bell examples, please.

• 48:33Speaker 01

  Yeah, there aren't enough out there. We've definitely done more work in understanding the Tinker Bell effect. But the reverse has been a lot harder to pin down. But I think it's a great exercise to reflect on civilization. Like what, what, how, how, how does reality become real because we believe in it? It's almost a cliche at this point, but how do things become not real when we believe in them? That's mind blowing.

• 48:59Speaker 00

  That is mind blowing. I like that a lot. I like that a lot. You have blown our minds yet again, Michael, as you, as you always do.

• 49:06Speaker 01

  Or was it just placebo? Did you just, you just hear my voice, you associate it with, with having cool thoughts. And so you think it must have been a good episode.

• 49:14Speaker 00

  Settle in and you're happy. By the way, to be clear, if we don't call this, if we don't call this, this episode based on the fact that Americans are getting better placebos than everyone else, if we don't call this make placebos great again, I'm, I'm really gonna be...

• 49:28Speaker 06

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• 49:59Speaker 07

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• 50:29Speaker 08

  Everyone's got a hard question about AI. Your job, your kids, where it's going. Anthropic was built to surface those questions and share what it finds along the way, because there's hope in hard questions. Ask yours at claud.ai/spotify and keep thinking. That's claud.ai/spotify.

• 50:52Speaker 00

  Annoyed.

• 50:53Speaker 01

  But it's like, it's all in the mind in many cases.

• 50:56Speaker 00

  And after this episode, they've become no seebo's, but spelt the other way.

• 51:01Speaker 01

  That's right. It's the mystery that truly cures us.

• 51:06Speaker 00

  All right. We'll be back later in the week with an episode of Film Notes as ever, and back next week with another main. Until then.

• 51:12Speaker 01

  See you guys later.