Bruce Grierson, New York Times :
(From previous issue)
Four years ago, Langer and her colleagues published in Psychological Science a study that came closest in spirit to the original counterclockwise study in New Hampshire. Here, too, the placebo was a health prime, a situational nudge. They had two groups of subjects go into a flight simulator. One group was told to think of themselves as Air Force pilots and given flight suits to wear while guiding a simulated flight. The other group was told that the simulator was broken and that they should just pretend to fly a plane. Afterward, they gave each group an eyesight test. The group that piloted the flight performed 40 percent better than the other group. Clearly “mind-set manipulation can counteract presumed physiological limits,” Langer said. If a certain kind of prompt could change vision, Langer thought, there was no reason, that you couldn’t try almost anything. The endgame, she has said many times since, is to “return the control of our health back to ourselves.”
Last spring, Langer and a postdoctoral researcher, Deborah Phillips, were chatting when the subject of the counterclockwise study came up. Over the more than 30 intervening years, Langer had explored many dimensions of health psychology and tested the power of the mind to ease various afflictions. Perhaps it was finally time to run the counterclockwise study again. But if they did, she wanted to raise the stakes: Could they shrink the tumors of cancer patients? Langer often says she has no clue where her ideas come from – but in this case it was crystal clear: Metastatic breast cancer killed her mother at 56, when Langer was 29.
Phillips suggested that perhaps they should start with early-stage cancers, ones perceived as more curable, but Langer was firm: It had to be a big, common killer that traditional Western medicine had no answer for. She settled on Stage 4 metastatic breast cancer. Treatment of such cases is usually framed in terms of so-called comfort care. “The medical world has given up on these people,” Langer says.
The study, which is planned for the spring, is designed to include three groups of 24 women with Stage 4 breast cancer who are in stable condition and undergoing hormonal therapy. Two groups will gather at resorts in San Miguel de Allende, Mexico, under the supervision of Langer and her staff. The experimental group will live for a week in surroundings that evoke 2003, a date when all the women were healthy and hopeful, living without a mortal threat hanging over them. They will be told to try to inhabit their former selves. Few clues of the present day will be visible inside the resorts or, for that matter, outside them. In the living areas, turn-of-the-millennium magazines will be lying around, as will DVDs of films like “Titanic” and “The Big Lebowski.” San Miguel de Allende, which has historically been a place known for its nearby healing mineral springs, is a Unesco World Heritage Site, and many of its buildings look as they did a few hundred years ago. “The whole town is a time capsule,” Langer says. (The other group at San Miguel will have the support of fellow cancer patients but will not live in the past; a third group will not experience any research intervention.)
As with the original counterclockwise experiment, subjects will be tested before and after on relevant measures – in this case the size of their tumors and the levels of circulating proteins in their blood known to be made by cancer cells – in addition to variables like mood and energy and pain levels. The experimental group will bring with them the same kinds of primes that the New Hampshire men did, like photographs of their younger selves. “We won’t make them haul their bags up the stairs,” Langer says. But otherwise they will be nudged to do all they can for themselves.
The staff will encourage the women to think anew about their circumstances in an attempt to purge any negative messages they have absorbed during their passage through in the medical system. This is crucial, Langer says, because just as the mind can make things better, it can also make things worse. The nocebo effect is the flip side of the more positive placebo effect, and she says that one of the most pernicious nocebo effects can occur when a patient is informed by her doctor that she is ill. The diagnosis itself, Langer says, primes the symptoms the patient expects to feel. “You change a word here or there, and you get vastly different results,” Langer says. She told me about a yet-to-be-published study she did in 2010 that found that breast-cancer survivors who described themselves as “in remission” were less functional and showed poorer general health and more pain than subjects who considered themselves “cured.”
So there will be no talk of cancer “victims,” nor anyone “fighting” a “chronic” disease. “When you’re saying ‘fighting,’ you’re already acknowledging the adversary is very powerful,” Langer says. ” ‘Chronic’ is understood as ‘uncontrollable’ – and that’s not something anyone can know.”
Of course, the subjects hope to get better, and everything about the setup is nudging them in that direction. So the study becomes a kind of open placebo experiment. Langer has long believed it’s possible to get people to gin up positive effects in their own body – in effect, to decide to get well. Last fall, she tested that proposition, but in reverse: She recruited a number of healthy test subjects and gave them the mission to make themselves unwell. The subjects watched videos of people coughing and sneezing. There were tissues around and those in the experimental group were encouraged to act as if they had a cold. No deception was involved: The subjects weren’t misled, for example, into thinking they were being put into a germ chamber or anything like that. This was explicitly a test to see if they could voluntarily change their immune systems in measurable ways.
In the study, which is ongoing, 40 percent of the experimental group reported cold symptoms following the experiment, while 10 percent of those in control group did. Buoyed, Langer ordered further analysis, looking for more concrete proof that they actually caught colds by testing their saliva for the IgA antibody, a sign of elevated immune-system response. In February, the results came in. All of the experimental subjects who had reported cold symptoms showed high levels of the IgA antibody.
Placebo effects have already been proven to work on the immune system. But this study could show for the first time that they work in a different way – that is, through an act of will. “As far as we know today, the placebo responses in the immune system are attributable to unconscious classical conditioning,” says the Italian neuroscientist Fabrizio Benedetti, a leading expert in placebo effects. In Benedetti’s experiments, a suggestion planted in the minds of test subjects produced physiological changes directly, the way a dinner bell might goose the salivary glands of a dog. (In one study, healthy volunteers given a placebo – a suggestion that any pain they experienced was actually beneficial to their bodies – were found to produce higher levels of natural painkillers.) “There’s no evidence that expectations play a role as well,” Benedetti says. Langer plans to further analyze the subjects’ saliva to see whether they actually have the rhinovirus and not just elevated IgA.
The implications of the open placebo – that is, we know the sugar pill is just a sugar pill, but it still works as medicine – are tantalizing. If placebo effects can be harnessed without deception, it would remove many of the ethical issues that surround placebo work. In a study published in the journal Plos One in 2010, Ted Kaptchuk, a professor of medicine at Harvard Medical School, and his colleagues administered a placebo labeled “placebo” to a test group of patients suffering from irritable bowel syndrome. Their symptoms declined significantly as compared with a no-treatment control group. “At some level everybody realizes they themselves are the placebo,” Langer says.
Langer’s cancer study has had to clear the hurdles of three human-subjects ethics boards – one from Mexico, one from Harvard’s psychology department and, for a time, one from the University of Southern California’s medical school, where until recently Debu Tripathy, an oncologist who is recruiting subjects for Langer’s study, was a professor of medicine. In June, progress stalled when the board at U.S.C. asked that the language be tweaked. “There’s so much stuff that’s totally outrageous in this world,” Langer told me at the time. “They want me to add a consent form for the people to sign saying there’s no known benefit to them. But that just introduces a nocebo effect!” (The study now has to clear the ethics board at the University of Texas M.D. Anderson Cancer Center in Houston, where Tripathy presently works.)
Like the men in New Hampshire, Langer’s cancer patients in San Miguel will pass a richly diverting week. In this case, art classes, cooking classes and writing classes will help distract them from the brute dread of their circumstances and re-engage them in life. The terror of late-stage cancer can be as debilitating as the physical reality, Tripathy says. Some sufferers, he says, show symptoms akin to PTSD. There’s strong evidence that the support of other people boosts the quality of life for cancer patients. There’s less evidence that it improves their health prospects.
I asked Tripathy whether there’s any precedent for what Langer is trying to do. “Well, there are many examples in medicine where improvement in the emotional state seems also to bring about some improvement in the disease state,” he said. “We know, for example, that Tibetan monks can meditate and lower their blood pressure. People with hypertension, they embark on behavioral changes, and you can see the improvement in the medical indexes, like fewer heart attacks. But cancer? That’s a harder thing to fathom.”
Positive psychology doesn’t have a great track record as a way to fight cancer. Indeed, when James Coyne and colleagues followed 1,093 people with advanced head-and-neck cancer over nine years, they found even the most optimistic subjects lived no longer than the most pessimistic ones.
Some cancer patients respond to interventions better than others, Tripathy notes. “But even with high-dose chemotherapy, you rarely see ‘complete response,’ which is total disappearance” of advanced breast cancer. “So if we saw anything like that, boy, that would hit the medical journals in a hurry.”
One day in Puerto Vallarta in February, Langer sat on the patio of her hillside home. An iguana the length of a celery rib scooted across a high railing, and the dogs went bananas. “That’s Ada,” Langer said. “Or is it Ida? There are two – it’s hard to tell them apart.” When the iguanas first appeared and began devouring the hibiscus, Langer was startled. Now she and Nancy feed them petals for lunch. “That’s the way it is,” she said. “You can be scared. You give it a name, and then it’s a pet.”
Langer peered out over the deep blue sea, in the direction of a lagoon, where early in her career she conducted experiments on whether dolphins were more likely to want to swim with mindful people. In the last few days, she had been exchanging emails with a writer who wanted to come stay with her for a couple of weeks, taking notes for a screenplay for a Hollywood biopic.
Langer told me that she chose San Miguel for her new counterclockwise study primarily because the town had made “an offer I couldn’t refuse.” A group of local businesspeople, convinced of the value of having Langer’s name attached to San Miguel, arranged for lodging to be made available free to Langer. They also encouraged her to build a Langer Mindfulness Institute, which will take part in research and run retreats. (A local developer donated a beautiful casa, next to his Nick Faldo-designed golf course, to serve as staff quarters for the institute.) Starting sometime next year, adults will be able to sign up for a paid, weeklong counterclockwise experience, presumably with a chance at some of the same rejuvenative benefits the New Hampshire test subjects enjoyed.
Langer says she is in conversation with health and business organizations in Australia about establishing another research facility that would also accept paying customers, who will learn to become more mindful through a variety of cognitive-behavioral techniques and exercises. She has already opened a mindfulness institute in Bangalore, India, where researchers are undertaking a study to look at whether mindfulness can stem the spread of prostate cancer.
Langer makes no apologies for the paid retreats, nor for what will be their steep price. (This, too, is calculated: In the absence of other cues, people tend to place disproportionate value on things that cost more. Dan Ariely, a psychologist at Duke, and his colleagues found that pricier placebos were more effective than cheap ones.) To my question of whether such a nakedly commercial venture will undermine her academic credibility, Langer rolled her eyes a bit. “Look, I’m not 40 years old. I’ve paid my dues, and there’s nothing wrong with making this more widely available to people, since I deeply believe it.”
Medical colleagues have asked Langer if she is setting herself up to fail with the cancer study – and perhaps underappreciating the potential setbacks to her work. It’s also possible that subjects who don’t improve could feel more demoralized by the experience. In her memoir, “Bright-sided,” the journalist Barbara Ehrenreich wrote scorchingly about the sunshine brigade that bombarded her with “positive thinking” as she suffered through breast cancer. Under those conditions, patients who don’t get better might feel as if they themselves were somehow to blame.
After a lecture in 2010, in which she’d discussed how when we talk about “fighting” cancer we actually give the disease power, a man buttonholed Langer and laid into her. His wife had died of breast cancer. “He said she had fought it, and I made it seem that it was her fault,” Langer told me.
Langer apologized to the man. “Those are good points, and I’m sorry I didn’t address them,” she said. “But let me explain to you that it’s the culture that teaches us that we have no control. I’m not blaming your wife; I’m blaming the culture.” Langer imagines a day when blame isn’t the first thing people reach for when things go awry. Instead, we will simply bring to bear the power of our own minds – which she believes will turn out to be far greater than we imagined. (Concluded)
(From previous issue)
Four years ago, Langer and her colleagues published in Psychological Science a study that came closest in spirit to the original counterclockwise study in New Hampshire. Here, too, the placebo was a health prime, a situational nudge. They had two groups of subjects go into a flight simulator. One group was told to think of themselves as Air Force pilots and given flight suits to wear while guiding a simulated flight. The other group was told that the simulator was broken and that they should just pretend to fly a plane. Afterward, they gave each group an eyesight test. The group that piloted the flight performed 40 percent better than the other group. Clearly “mind-set manipulation can counteract presumed physiological limits,” Langer said. If a certain kind of prompt could change vision, Langer thought, there was no reason, that you couldn’t try almost anything. The endgame, she has said many times since, is to “return the control of our health back to ourselves.”
Last spring, Langer and a postdoctoral researcher, Deborah Phillips, were chatting when the subject of the counterclockwise study came up. Over the more than 30 intervening years, Langer had explored many dimensions of health psychology and tested the power of the mind to ease various afflictions. Perhaps it was finally time to run the counterclockwise study again. But if they did, she wanted to raise the stakes: Could they shrink the tumors of cancer patients? Langer often says she has no clue where her ideas come from – but in this case it was crystal clear: Metastatic breast cancer killed her mother at 56, when Langer was 29.
Phillips suggested that perhaps they should start with early-stage cancers, ones perceived as more curable, but Langer was firm: It had to be a big, common killer that traditional Western medicine had no answer for. She settled on Stage 4 metastatic breast cancer. Treatment of such cases is usually framed in terms of so-called comfort care. “The medical world has given up on these people,” Langer says.
The study, which is planned for the spring, is designed to include three groups of 24 women with Stage 4 breast cancer who are in stable condition and undergoing hormonal therapy. Two groups will gather at resorts in San Miguel de Allende, Mexico, under the supervision of Langer and her staff. The experimental group will live for a week in surroundings that evoke 2003, a date when all the women were healthy and hopeful, living without a mortal threat hanging over them. They will be told to try to inhabit their former selves. Few clues of the present day will be visible inside the resorts or, for that matter, outside them. In the living areas, turn-of-the-millennium magazines will be lying around, as will DVDs of films like “Titanic” and “The Big Lebowski.” San Miguel de Allende, which has historically been a place known for its nearby healing mineral springs, is a Unesco World Heritage Site, and many of its buildings look as they did a few hundred years ago. “The whole town is a time capsule,” Langer says. (The other group at San Miguel will have the support of fellow cancer patients but will not live in the past; a third group will not experience any research intervention.)
As with the original counterclockwise experiment, subjects will be tested before and after on relevant measures – in this case the size of their tumors and the levels of circulating proteins in their blood known to be made by cancer cells – in addition to variables like mood and energy and pain levels. The experimental group will bring with them the same kinds of primes that the New Hampshire men did, like photographs of their younger selves. “We won’t make them haul their bags up the stairs,” Langer says. But otherwise they will be nudged to do all they can for themselves.
The staff will encourage the women to think anew about their circumstances in an attempt to purge any negative messages they have absorbed during their passage through in the medical system. This is crucial, Langer says, because just as the mind can make things better, it can also make things worse. The nocebo effect is the flip side of the more positive placebo effect, and she says that one of the most pernicious nocebo effects can occur when a patient is informed by her doctor that she is ill. The diagnosis itself, Langer says, primes the symptoms the patient expects to feel. “You change a word here or there, and you get vastly different results,” Langer says. She told me about a yet-to-be-published study she did in 2010 that found that breast-cancer survivors who described themselves as “in remission” were less functional and showed poorer general health and more pain than subjects who considered themselves “cured.”
So there will be no talk of cancer “victims,” nor anyone “fighting” a “chronic” disease. “When you’re saying ‘fighting,’ you’re already acknowledging the adversary is very powerful,” Langer says. ” ‘Chronic’ is understood as ‘uncontrollable’ – and that’s not something anyone can know.”
Of course, the subjects hope to get better, and everything about the setup is nudging them in that direction. So the study becomes a kind of open placebo experiment. Langer has long believed it’s possible to get people to gin up positive effects in their own body – in effect, to decide to get well. Last fall, she tested that proposition, but in reverse: She recruited a number of healthy test subjects and gave them the mission to make themselves unwell. The subjects watched videos of people coughing and sneezing. There were tissues around and those in the experimental group were encouraged to act as if they had a cold. No deception was involved: The subjects weren’t misled, for example, into thinking they were being put into a germ chamber or anything like that. This was explicitly a test to see if they could voluntarily change their immune systems in measurable ways.
In the study, which is ongoing, 40 percent of the experimental group reported cold symptoms following the experiment, while 10 percent of those in control group did. Buoyed, Langer ordered further analysis, looking for more concrete proof that they actually caught colds by testing their saliva for the IgA antibody, a sign of elevated immune-system response. In February, the results came in. All of the experimental subjects who had reported cold symptoms showed high levels of the IgA antibody.
Placebo effects have already been proven to work on the immune system. But this study could show for the first time that they work in a different way – that is, through an act of will. “As far as we know today, the placebo responses in the immune system are attributable to unconscious classical conditioning,” says the Italian neuroscientist Fabrizio Benedetti, a leading expert in placebo effects. In Benedetti’s experiments, a suggestion planted in the minds of test subjects produced physiological changes directly, the way a dinner bell might goose the salivary glands of a dog. (In one study, healthy volunteers given a placebo – a suggestion that any pain they experienced was actually beneficial to their bodies – were found to produce higher levels of natural painkillers.) “There’s no evidence that expectations play a role as well,” Benedetti says. Langer plans to further analyze the subjects’ saliva to see whether they actually have the rhinovirus and not just elevated IgA.
The implications of the open placebo – that is, we know the sugar pill is just a sugar pill, but it still works as medicine – are tantalizing. If placebo effects can be harnessed without deception, it would remove many of the ethical issues that surround placebo work. In a study published in the journal Plos One in 2010, Ted Kaptchuk, a professor of medicine at Harvard Medical School, and his colleagues administered a placebo labeled “placebo” to a test group of patients suffering from irritable bowel syndrome. Their symptoms declined significantly as compared with a no-treatment control group. “At some level everybody realizes they themselves are the placebo,” Langer says.
Langer’s cancer study has had to clear the hurdles of three human-subjects ethics boards – one from Mexico, one from Harvard’s psychology department and, for a time, one from the University of Southern California’s medical school, where until recently Debu Tripathy, an oncologist who is recruiting subjects for Langer’s study, was a professor of medicine. In June, progress stalled when the board at U.S.C. asked that the language be tweaked. “There’s so much stuff that’s totally outrageous in this world,” Langer told me at the time. “They want me to add a consent form for the people to sign saying there’s no known benefit to them. But that just introduces a nocebo effect!” (The study now has to clear the ethics board at the University of Texas M.D. Anderson Cancer Center in Houston, where Tripathy presently works.)
Like the men in New Hampshire, Langer’s cancer patients in San Miguel will pass a richly diverting week. In this case, art classes, cooking classes and writing classes will help distract them from the brute dread of their circumstances and re-engage them in life. The terror of late-stage cancer can be as debilitating as the physical reality, Tripathy says. Some sufferers, he says, show symptoms akin to PTSD. There’s strong evidence that the support of other people boosts the quality of life for cancer patients. There’s less evidence that it improves their health prospects.
I asked Tripathy whether there’s any precedent for what Langer is trying to do. “Well, there are many examples in medicine where improvement in the emotional state seems also to bring about some improvement in the disease state,” he said. “We know, for example, that Tibetan monks can meditate and lower their blood pressure. People with hypertension, they embark on behavioral changes, and you can see the improvement in the medical indexes, like fewer heart attacks. But cancer? That’s a harder thing to fathom.”
Positive psychology doesn’t have a great track record as a way to fight cancer. Indeed, when James Coyne and colleagues followed 1,093 people with advanced head-and-neck cancer over nine years, they found even the most optimistic subjects lived no longer than the most pessimistic ones.
Some cancer patients respond to interventions better than others, Tripathy notes. “But even with high-dose chemotherapy, you rarely see ‘complete response,’ which is total disappearance” of advanced breast cancer. “So if we saw anything like that, boy, that would hit the medical journals in a hurry.”
One day in Puerto Vallarta in February, Langer sat on the patio of her hillside home. An iguana the length of a celery rib scooted across a high railing, and the dogs went bananas. “That’s Ada,” Langer said. “Or is it Ida? There are two – it’s hard to tell them apart.” When the iguanas first appeared and began devouring the hibiscus, Langer was startled. Now she and Nancy feed them petals for lunch. “That’s the way it is,” she said. “You can be scared. You give it a name, and then it’s a pet.”
Langer peered out over the deep blue sea, in the direction of a lagoon, where early in her career she conducted experiments on whether dolphins were more likely to want to swim with mindful people. In the last few days, she had been exchanging emails with a writer who wanted to come stay with her for a couple of weeks, taking notes for a screenplay for a Hollywood biopic.
Langer told me that she chose San Miguel for her new counterclockwise study primarily because the town had made “an offer I couldn’t refuse.” A group of local businesspeople, convinced of the value of having Langer’s name attached to San Miguel, arranged for lodging to be made available free to Langer. They also encouraged her to build a Langer Mindfulness Institute, which will take part in research and run retreats. (A local developer donated a beautiful casa, next to his Nick Faldo-designed golf course, to serve as staff quarters for the institute.) Starting sometime next year, adults will be able to sign up for a paid, weeklong counterclockwise experience, presumably with a chance at some of the same rejuvenative benefits the New Hampshire test subjects enjoyed.
Langer says she is in conversation with health and business organizations in Australia about establishing another research facility that would also accept paying customers, who will learn to become more mindful through a variety of cognitive-behavioral techniques and exercises. She has already opened a mindfulness institute in Bangalore, India, where researchers are undertaking a study to look at whether mindfulness can stem the spread of prostate cancer.
Langer makes no apologies for the paid retreats, nor for what will be their steep price. (This, too, is calculated: In the absence of other cues, people tend to place disproportionate value on things that cost more. Dan Ariely, a psychologist at Duke, and his colleagues found that pricier placebos were more effective than cheap ones.) To my question of whether such a nakedly commercial venture will undermine her academic credibility, Langer rolled her eyes a bit. “Look, I’m not 40 years old. I’ve paid my dues, and there’s nothing wrong with making this more widely available to people, since I deeply believe it.”
Medical colleagues have asked Langer if she is setting herself up to fail with the cancer study – and perhaps underappreciating the potential setbacks to her work. It’s also possible that subjects who don’t improve could feel more demoralized by the experience. In her memoir, “Bright-sided,” the journalist Barbara Ehrenreich wrote scorchingly about the sunshine brigade that bombarded her with “positive thinking” as she suffered through breast cancer. Under those conditions, patients who don’t get better might feel as if they themselves were somehow to blame.
After a lecture in 2010, in which she’d discussed how when we talk about “fighting” cancer we actually give the disease power, a man buttonholed Langer and laid into her. His wife had died of breast cancer. “He said she had fought it, and I made it seem that it was her fault,” Langer told me.
Langer apologized to the man. “Those are good points, and I’m sorry I didn’t address them,” she said. “But let me explain to you that it’s the culture that teaches us that we have no control. I’m not blaming your wife; I’m blaming the culture.” Langer imagines a day when blame isn’t the first thing people reach for when things go awry. Instead, we will simply bring to bear the power of our own minds – which she believes will turn out to be far greater than we imagined. (Concluded)
