The importance of appropriate communication even in clinical practice

In modern medicine, the term Nocebo is used to refer to any substance or medical therapy that is harmless and devoid of intrinsic therapeutic activity, but still able to trigger negative or unwanted reactions because of the negative value that the subject attributes to the treatment.

The term Nocebo (from Latin, “I will do harm”) has been suggested by a number of authors in opposition to the term placebo, with the aim of distinguishing the pleasant effects from the harmful effects of placebo.

The main mechanisms on which the Nocebo effect develops are the classical conditioning and the expectation phenomenon as well as the psychological characteristics of the patients and the influences of the context and the situation. Negative expectations lead to a worsening of clinical conditions or the Nocebo effect (Moerman, 1981).

The worsening of clinical conditions is obviously not only the result of the relationship between the healthcare staff and the patient, but also between patient and patient, in the same department for example, or on the Internet.

In order to better understand the power of communication between healthcare professionals and patients, it is important to enter into the paradoxical assumption that informing the patient can seriously harm his or her health. The whole relationship, in this case, takes place within a framework made up of expectations and research to reassure the patient on the one hand and the duty to transmit the necessary information on the part of the healthcare professional on the other. In this situation the paradox of the communicative assumption becomes such not because of the syntax, structure of the message, but because of the semeiotics – as it is said – and semantics – meaning of what is said – intercepted and declined by the patient according to his mental constructs. The Nocebo effect finds its place mainly in these situations.

So, basically, when we talk about the Nocebo effect, what does that mean?

-Nocebo means the appearance of a symptom induced by the negative expectations of the patient himself (conscious and above all unconscious) and/or by suggestions interpreted or transmitted (involuntarily) in a negative way by and to the patient in the absence of a clinical picture of objective worsening or other type of treatment.

– The basic mechanisms include, on the one hand, Pavlovian-style conditioning learning patterns present in patients and, on the other hand, anticipatory anxiety generated by negative expectations, either personal or induced by the clinician’s verbal, paraverbal and non-verbal communication. The latter two are the most penetrating.

– Nocebo responses can occur through involuntary negative suggestions from doctors and nurses. Type information about possible complications (if poorly transmitted).

At this point, it is good to make an example using a perfectly successful search.

The scholar Walter Mischel has established, thanks to experiments and research carried out on primates and human volunteers that behavioural states are determined by situations and not, as it was believed, constitutionally acquired. He states, that a behaviour is predictable to the extent that, by entering into empathy with the emitter, one becomes aware of its motivations and emotions because, our brain, processes behavioural responses on the basis of only two elements resulting from the perceptual sum of phonetics, semantics, syntax and pragmatics, i: “If … Then”. “If there is a 37% recovery from the disease, then it means that to undergo treatment is useful” (frame, mentally easy, conditioning). Now how can the health care professional decrease the walnut tree effect on their patients? Some phrases to avoid during the healthcare-patient relationship:

– Phrases that cause uncertainty: “The treatment might work,” “Let’s try this drug!”

– General expressions: “During the examination (tomography) his brain will be cut into small slices and then analysed later!”

– Ambiguous phrases: “Soon we’ll put you to sleep and you won’t feel a thing.”

– Emphasize negative aspects: “You must absolutely avoid lifting heavy objects if you don’t want to end up paralyzed!”

– Focus your attention: “Raise your hand if you feel pain!” “Are you nauseous?”

– Symptom denial: “You don’t have to worry; he’ll only bleed a little.”

The ethical implications are therefore multiple; physicians are therapeutic agents that must use information to make the “right” decisions, to provide therapy based on knowledge of pathological processes. However, what is technically “right” may not be biomedically and ethically “good” for a particular patient at a particular stage of the disease.

Therefore, the individualisation of clinical-rehabilitation processes does not only dwell on the need to recognise the value of that patient’s life experiences, but to recognise the value of his experiences at that particular moment when he comes to medical attention, which can change in subsequent times.

[Fonte: Medicina di Frontiera, anno III, Nr. 1]

By Federica Peci

Psychologist and Scientific Journalist

In cooperation with Cerebro® Staff

Cerebro ® , an Innovativation and High-Tech Neuroscience Start-Up, which helps patients in medical practices and associated clinics through different methods and approaches to improve the perception and quality of life of each individual.