Something Weird Is Going On With Placebos

0:00Welcome to the Rest of Science. I'm Hannah Frey. And I am Michael Stevens. 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. This episode is brought to you by Cancer Research UK. All right, here's something really cool. The earliest written description of cancer that we've ever found is from an ancient Egyptian papyrus that was around before even Cleopatra was on the throne. It described tumors being removed by a

0:52tool that they called the fire drill, which we think was used to burn off diseased tissue. Beating a disease that's so ancient and complex with over 200 different types, it's not going to happen overnight. But thanks to research, cancer treatment has advanced a lot. And Cancer Research UK is driving further innovations like cancer-sniffing robots and drugs made from gut bugs that could change the future of medicine. Over the past 50 years, Cancer Research UK's work has helped double cancer survival in the UK. And today it's continuing to save and improve lives around the world. For more information about Cancer Research UK, their research and breakthroughs, and how you can support them, visit cancerresearchuk.org slash rest is science.

1:37Hi, this is Garyllinica from Goalhangers. The rest is football. This episode is brought to you by W Wise. It's only when you start moving money between currencies that you really think about the exchange rate, the fee, and what might be hidden away in the small print. Whether you're living abroad, paying someone overseas, or just trying to manage your money across borders, you want a fair exchange rate, an easy transfer, and no surprises along the way. Wise keeps things simple. Wise is a smart way to move the currencies you need around the globe. It works in more than 160 countries and with over 40 currencies. Most transfers arrive instantly. Wise uses the mid-market exchange rate, like the one you see on Google,

2:20with no markups or hidden fees. So when money needs to move, you can see the rate, know the fee and get on with it. Join millions saving billions on hidden fees by downloading the Wise app today. Be smart, get wise, T's and C's apply. Observe the North American dad, 50s, great polo collection. He enters his vehicle information on Carvana. An offer appears in minutes. Remarkable. He squints, reads it again, smiles and says, Dang, that's a good offer. The highest form of approval. No haggling. No hassle. No one called him boss. He's still on the couch. Astonishing. Sell your car today on Carvana.com. Pickup fees may apply. I beg your pardon. Yeah. Are you trying to tell me American placebos are better than

3:17other placebos? American placebos. You Americans and your patriotism, this has gone too far, Michael. to 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 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 effect. Okay. Sugar pill. A sugar pill. The opposite of a placebo is called a verum. I didn't know this until this morning when I was just reading about placebos. And they started saying, well, compared to a verum, a placebo, blah, blah.

4:24And I'm like, 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. 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. 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. That is the fuzzy truth of this whole thing. And I've spent years on this. I've worked with

5:15professors at McGill University on placebos. I'm even thanked in one of their published papers. Amazing. 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. But you're right. There are things like anesthesia where it's like, we don't totally know what's happening, but we can pinpoint where we should be looking. So we're not going to call it a placebo. Got you. Because there's definitely a mechanism going on somewhere. I mean, I think that there's some even like broader application of the word placebo,

5:53where we could say that airplanes fly because of placebo. We don't know exactly how it happens. As we've discussed. You ask most pilots and they'll debate amongst themselves over it, as we've discussed. You ask most pilots and 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. But yet the placebo cases also had better and better results. So in 1996, amongst Americans, for pain relief, so we're looking quite specific at pain relief only, actual drugs with understood mechanisms worked 27.3% better.

6:59Better means patients reported either less pain or after treatment they were pain-free. Okay, 27.3% better than taking a placebo. Can I just say, before we move on, right? I think that number is quite small. Yeah. And the thing is, I've always found this really strange about the idea that when you do randomised clinical trial, you know, double blind, whatever it might be, like 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'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 that doesn't seem like a massive benefit to me.

7:50No, it isn't a massive benefit. I don't have from this study numbers comparing the actual drug to no treatment at all. But 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. Okay. 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. This, okay, this is, this is, this is wild.

8:48Say that again. 8.9%. 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. These numbers are staggering. 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 absolutely terrible, and they're going in the wrong direction. 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. So when it comes to prescribing medicine for depression, placebo

9:41causes, 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 feelings 10 points higher. And so about 80% of why antidepressants today work is because of the placebo effect. 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. Just doing something is the majority of why antidepressants work. Now, whatever's happening in the brain, in the body, chemically, still makes a significant

10:35difference. 10 is more than 8. 20% matters. That's worth pursuing. But the question remains, why is it so close? And it's actually helpful that this is so much closer in Americans. They put two hypotheses forward that haven't really been tested well enough yet. 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 1990 to 2013. In 1996, the average clinical trial was four weeks long. But by 2013, it was 12 weeks long. Okay. Right. 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.

11:46Right. So the belief in you feeling like you're going to get better. That's right. The belief 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. Have I told you that I made a program about pain before? Have I told you this? Yeah. Well, we did a whole episode on pain. We did. We did. But the key thing that really

12:30stuck out to me is that I went to go to Oxford to go and meet, she's called the Queen of Pain, Irene Tracy. 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 objective quality that your body is measuring. It doesn't come with units because actually it is constructed within your brain. 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. That's exactly right. And it really teases out a significant difference around where placebos work and where they don't. If I cut my arm really badly and I treat it with an antiseptic, like rubbing

13:26alcohol or something, 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, 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. Which makes sense. Broken bones are less well-treated by placebo than depression. 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 look at the theories around like why placebo might work in the first place.

14:22There 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 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, they stop crying, but they don't necessarily feel any better. Their scrapes, their bruises, their broken bones haven't been mended,

15:17but 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 catches other people's 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. So then the way that you're describing that is that actually the point that you were making earlier about antidepressants is that just feeling like someone is helping you is sort of part of the battle. That's right. Just feeling like someone's helping you and you're helping yourself. What's even more, I think, mind-blowing to me is that not only are placebos getting better, but labeled placebos are getting better.

16:11There'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 the key was that people needed to not know if they were taking a real drug or if they were taking something that looked maybe real but wasn't. There was a study that came out of Harvard Medical School, I'd say maybe about 10 years ago, that – 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 what they did. 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

16:57forget 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. So some people thought they were getting a placebo. Some thought they were getting the medication and some thought they don't know. So can I guess which order the results came back in? Because my guess would be Maxwell's number one is the thing that actually does something followed by the envelope where you can't tell, followed by the placebo. That would be my guess. And there'd be big jumps between them. And you're pretty correct, but I haven't actually described every single variable

17:48that 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 this trial, they actually reported that their pain increased by an average of somewhere between 10 and 20%. Every other person in the group reported a reduction in migraine pain. But yeah, you're right. You're right. 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, my pain is like 20% worse than it was before, and I got nothing. The people who got the unspecified envelope, they were a bit better. The people who got the actual medication labeled envelope were the best. But there's another wrinkle to this, which is that

18:36what the envelope said wasn't necessarily true. Cheeky. Yes. Did they know that? They did not know that. So it was 50-50 whether the envelope was true or not. Oh, that's great. Let me rephrase that. What I mean is that when you got an envelope, 50% chance it was placebo, 50% it was the real medicine. So half of the people- Irrespective of what it said on the outside. 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. So in a way, actually, theirs was the only true envelope.

19:20Exactly. Theirs was the only true envelope. And this is where things get really juicy. Yeah, because by doing that, 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 the placebo. 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.

20:06The 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. 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. 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 hypervigilant and they go, how do I feel? Do I think I'm getting the placebo or not? I don't know. Let me think. And they might journal about it more. They check in on themselves more often. They pay more attention. And in some way, that results in a better outcome. See, this is something that I've always, you know, knowing how effective placebos are,

21:06knowing that, you know, two pills works better than one, red pills work better than blue pills, injections of placebos work better than tablets of placebos and so on. I've often thought that there have 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, please? Because I think that broadly it's unethical from the perspective of the doctor rather than from the perspective of me. But what you're saying, I mean, this works pretty well that you could go into a doctor and say, 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. In cases of pain, in cases of depression, that has shown to be the most effective treatment.

22:09Treat them with real pharmaceuticals, but leave it unknown to them whether they're getting it or not. Amazing. 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 being stressed and focus on releasing the natural opioids that make you feel better and doing its thing. The immune system can be given more resources, more energy to fight 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.

22:57But often if someone does something 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 gonna help you with what's troubling you, but if you change up your lifestyle a little bit, you are, you know, you're doing something, doing something. So your body goes, all right, something's being your, 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

23:41maybe 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- Meditation, diet. Meditation, exactly. And there may truly be, in a lot of cases, a extremely scientific biological connection between why meditation helps with your IBS. Okay. But some of it could be, if we ever find the answer, it might just be that the meditation meant that your brain was able to put more resources into healing 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. I do think that it's important that we make this distinction. There's certain

24:33ailments where doing something is definitely the right thing. But I think that what's really interesting is that ever since medical science really 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 think about a lot here is there was a big study about prostate cancer. So early stage prostate cancer 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. 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

25:25thing out of my body immediately i don't want it anywhere near me uh 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, 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, no difference at all, which sounds crazy yeah um but the thing is is that prostate cancer in particular is one of those cancers where it can be extremely slow growing

26:13your 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 in in 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, essentially paid the price with their quality of life for no benefit whatsoever in terms of their chances of survival. A similar thing happened in South Korea with thyroid cancer

27:02where 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 not a very nice procedure at all it's like difficult to recover from so anyway when they introduced this screening program there was again no difference 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 do think that this idea, I'm always like a little

27:41bit 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 is like, actually, sometimes just doing something, not necessarily something extreme is good enough. 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

28:29something that can affect its efficacy? Well, back to the question of the glamour and the ritual of it, we know that the more, 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. Next up is like a capsule.

29:25Those people go, dang, and they really are more effective. Yeah. 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, whoa, I've got like a wound afterwards. Like, how could this not work? All right, so let's take a quick break. And when we come back, I want to talk about the different varieties of placebo. Flowing ad budget on metrics that look great till the CFO sees them, that's bull's bend. And marketers are calling it out in Dashboard Confessions. I remember telling my boss, it'll be good for the brand when leads were slow. Yeah, it wasn't. Cut the bull spend. LinkedIn lets you target by company, job title, and more.

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31:07Great tasting hydration no matter where you're going. Shop now online or at retailers nationwide. Gatorade, hydrates better than water. Is it in you? Symptoms noted are signs of mild to moderate dehydration. Consult a healthcare professional if symptoms persist. 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.

32:03They know. Because you know it. 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 Mind Field 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 people into a lab and we told them that we were, I think we told them that we

32:50wanted 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. Just like the grown up version of magic cream, right? Yeah, exactly. We put a magic cream on them that I think was just Vaseline, but it came out of like

33:35an 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 because it hurt too much and it burned them. And the debriefing when we said, okay, so look, it was

34:22just a flashlight the whole time. They felt kind of embarrassed, but also like really amazed at just how powerful suggestion is. 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 for something, it does make sense. Yeah. Yeah, it really does. I feel like a lot of people could, you know, can really see themselves in that story. 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 have to believe in her for her to exist. I think in the stage

35:26show, you know, the audience has to like clap or, you know, they're asked to believe and believe in Tinkerbell. And then she, she appears. Don't, don't quote me on that. Cause I'm not a big Peter fan, a Peter Pan scholar, Peter fan, Peter fan. Is that what Peter fans call themselves? You're not a big Peter Fan. They should do. 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 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

36:11little 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. Well, this is scientifically backed, right? 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. That's right. I mean, look, if I believe that I can fly by flapping my arms, no matter how strongly I teachers, their methodologies, 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

37:06successful schools, with a happy staff, happy students and good test results and good results later in life for the students. It isn't so much that like, oh, thank goodness 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. I mean, we talked before about self-efficacy, which is like the individual version of this and how important that is in mathematics in particular, but in lots of different school subjects. It's measurable and this is a repeatable,

37:53testable phenomenon. If you believe that you are able to do something, your chances of doing it increase. Just that alone, Which I think is wild. 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. Go on. 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. I know. I'm trying to think of a single one. Wait, can we make it a guessing game? Can we make it a guessing game? Well, yeah. You know what? I bet if you guess, you'll probably find some that may be reverse Tinkerbells. But yeah, tell me what you think.

38:38Okay, wait. Let's have a think. I've only got one example that's been quite rigorously studied. Okay. So if you don't believe in it, then it exists. And if you do believe in it, it starts to not exist. Oh, gosh. Go on. Give me a clue. Give me a clue as your example. Safety. If you don't believe in it, then it becomes true. Go on. Tell me. 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 offensive in my driving. No, why wear a seatbelt? Driving is safe. And suddenly it becomes less safe. But if people think that driving is not safe,

39:32they do not believe in its safety, then it becomes safer because they all are being so much more vigilant and careful. That's such a good example. I mean, you see those situations where traffic lights are out for some reason, and suddenly everyone is like so unbelievably careful. Exactly. 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 driving at a good speed. But as soon as those stoplights are there, they're like, boom, I'm going to do what I want because I can offload my concerns to the lights. It's no longer my problem. And that's when mistakes get made. helmets when they ride their bikes, accidents can actually go up because kids start to feel like,

40:27well, 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 going to do that. Yeah. Yeah. Just be way more cautious. Some famous examples of the placebo effect outside of medicine are placebo buttons. We're all familiar with these, like the crosswalk button at an intersection. You're like, does this really do anything? Do they not work in America? They definitely work in the UK. They definitely work here. 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

41:16control. I've heard, I mean, I've read that 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- I have read in elevators 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 closed door, open door buttons, just to make people feel like they had a little bit more control. That's right. It makes them feel better.

41:56And I also was reading about, and again, I can't give you any names of actual office buildings where this happens, but it's quite common for an office thermostat to only kind of, 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 literally just made up those numbers. But anyway, and it might actually signal the like main HVAC unit to 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

42:45way down, you know, 10, 20 degrees Fahrenheit, for example. 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 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 that's been studied really makes people feel a lot more comfortable with the temperature 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 audio technicians

43:26at 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 knobs or sliders or buttons that are specifically programmed to do nothing, but they're there. So when the artist says, hey, I need my, you know, what do they call it? My monitor to be higher. That's so funny. But if you do that, it's going to 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.

44:12And they stop complaining and they feel comfortable and confident to do the performance, but you've just been pushing the does F all button. 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? No. 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 will be a scientist who's just like extremely nervous and wants to like tell you every single little bit of detail

45:03that you know you'll never be able to include. 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 thank you mr snore fest but we actually want to go and film this really cool thing that's going on over here yeah so what you do is you go great let's do this but so that you um 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 you use the strawberry filter on this one and then everyone knows you're never going to use it yeah so that's code for it doesn't matter. Okay. Like it's code for like, we're doing this to make them feel comfortable.

45:49Yeah. We don't care. Wow. 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. Can 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's draw refilter it um then you just get get out the way really quickly 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

46:24if 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 lookaloo would just go, oh, okay, well. Yeah, we say for the open university. That's what we say. Oh, that's good. Even though actually I've made some for the open university. I think they're so good. I adore them. 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 going to be any celebs in that. No reason to try to watch or get closer.

47:03Mayonnaise commercial is hilarious. 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 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 Like I gotta, I gotta see. But also a Manning's 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. Okay. I thought of a, I did think of

47:35a reverse. I did think of a reverse Tinkerbell. Oh, tell me. 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 got to be the opposite of what you think. So what about the stock market? Yeah. Right? That like, if you think, oh, no, wait, is that actually, that's the same as Tinkerbell? The stock market is usually given as an example of the regular Tinkerbell effect. Damn it. 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.

48:12And yeah. You know what? I think we should leave this as a challenge for the listener. We should. We want more reverse Tinkerbell examples, please. Yeah, there aren't enough out there. We've definitely done more work in understanding the Tinkerbell 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, 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. That is mind-blowing. I like that a lot. I like that a lot. You have blown our minds yet again, Michael, as you always do. Or was it just placebo? Did you just hear my voice, you associate it with having cool thoughts,

48:59and so you think it must have been a good episode? Settle in and you're happy. By the way, to be clear, if we don't call 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 really going to be... There's the economy you read about in the headlines. And then there's the one taking shape inside companies every day. I'm Christine Anderson, and this is Inside Blackstone. From the technologies transforming industries to big trends shaping the economy, our goal is pretty simple. Fun, engaging conversations that make complex topics more accessible. Tune in every Tuesday and subscribe to Inside Blackstone wherever you get your podcasts.

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50:12Excludes membership fees. See Walmart Plus terms and Sam's Club terms for more info. The Viore Core Short moves with you. With everyday versatility and classic athletic fit. It's the one short for everything your day brings. Invest in your happiness and get 20% off your first purchase at Viore.com slash 420. That's V-U-O-R-I dot com slash K-O-R-E 2-0. Exclusions apply. Visit the website for full terms and conditions. Annoyed. But it's like, it's all terms and conditions. Annoyed. But it's like, it's all in the mind in many cases. And after this episode, they become nocebos, but spelt the other way. That's right. It's the mystery that truly cures us. All right. We'll be back later in the week with an episode of Film Notes as ever,

51:02and back next week with another main. Until then. See you guys later.