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timtyler11y80

Are you sure that "anti placebo effect" is a good name though?

It may be that nocebo has a better claim to being an "anti-placebo effect".

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65 The Anti-Placebo Effect

by ShannonFriedman

28th Sep 2013

3 min read

65

Just about everyone is familiar with the placebo effect at this point. What I've discovered through my personal studies working with people suffering from anxiety and depression is that there is actually a significant related effect, which I have dubbed the anti-placebo effect.

Google says: pla·ce·bo ef·fect

noun

a beneficial effect, produced by a placebo drug or treatment, that cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient's belief in that treatment.

I say: anti·pla·ce·bo ef·fect

noun

a beneficial effect, produced by a treatment, that is not attributed to treatment itself or has stopped being noticed, and thus the patient does not believe in that treatment as effective.

Its easy to miss treatment working. For example, as a kid grows up, its easy to miss how their vocabulary is growing, but for someone who doesn't seem them every day, it may be immediately obvious "my how they're talking more!" In other words, an anti-placebo effect is what happens when someone is having an intervention that is causing their life to improve, but the person does not believe that they are improving.

This effect is most common with people who suffer from depression, who have biases for sad [1] and otherwise negative stimuli compared to the general population, and is also true of people suffering from anxiety from my personal client tracking. Its also important to note that this bias persists after the recovery of the depressive episode.

The reason that this is important is that those recovering from anxiety and depression have a tendency to believe that they are not doing as well as they are - due to this cognitive bias creating an anti-placebo effect for them, which results in their giving up too soon on interventions which are effective and thus not getting better and regressing to old unpleasant patterns.

It has been interesting since tracking results of my own clients [2] - I have all of them track scores at the beginning of their sessions on the site moodscope.com at the beginning of their sessions, so that we can see their progress over time with a consistent bias of the time of tracking being start of session (as opposed to other random biases such as wanting to take the quiz when in an especially good or bad mood). I also take extensive notes and track other metrics of progress.

What I've found, is that many clients hit a point after a few weeks or months, where they are questioning if they have made any progress. Because I take metrics to prepare for this, I am able to point my clients at their metrics, and say for example, that according to their self reports, their mood has increased by 50% and their productivity has doubled. What typically happens when I review score + notes with the client in question is that once they look back at how things were before compared to how they are now, they realize that they actually have made progress, and this is often followed with additional forward progress.

It is interesting to put this in perspective with the hedonic treadmill [3]. The hedonic treadmill is the supposed tendency of humans to quickly return to a relatively stable level of happiness despite major positive or negative events or life changes. What I'm finding with my studies is that it is often true for people recovering from depression when they take an overall evaluation (go meta), especially from a low point, but that when they look back at the factors that have changed, and they take the mood score test looking at different aspects of their experience on moodscope.com, they actually do have a more positive life experience when measured this way. When I point out the inconsistency, people generally determine that the moodscope.com reported experience is more accurate (especially when supplemented by going over session notes) and over time, most clients do get off the hedonic treadmill and proceed to having the meta level catch up with moodscope.com.

The good news about this for people suffering from anxiety and depression at large: If you are aware of the negative cognitive bias and anti-placebo effect, you can take steps to account for and correct this bias. One of the best ways to do this is by taking metrics along with notes that you can look at later. When you look back, look at what your overall trend is, and try to focus on that more than if you happened to have a bad day or week. If you have been progressing with a good linear regression, odds are that if you don't give up the new better patterns and habits you have created, they will continue to serve you. Although external factors to the one variable you are studying do complicate this and need to be taken into account.

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847035/

[2] http://www.depressiontoproductivity.com/your-clients-really-improve/

[3] http://en.wikipedia.org/wiki/Hedonic_treadmill

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[-]TheOtherDave11y440

The thing that made this most obvious to me was training my dog.

For example, when conditioning her out of a behavior I dislike, my intuitive approach seems to be to monitor the intensity of the behavior... I expect a steady stream of intense performances
BBBBBBBBBBBBBBBBBBBB
to become a stream of less-intense performances
bbbbbbbbbbbbbbbbbbbb
and then disappear altogether.

But in reality the intensity doesn't change much, and sometimes it even gets worse. I never get "bbb..." What declines is the frequency. That is,
BBBBBBBBBBBBBBBBBBBB
becomes
BBBBBB_BBBBBBBBB_BBB
which, from my intuitive perspective, is essentially no progress at all... I don't notice.

And then on the other end, when the behavior is almost extinguished, I get
_____B___B_______B___
which, from my perspective, is an endless series of "oh good, we got rid of this behavior -- oh, crap, now it's back again, just as bad as it ever was! This isn't working!"

So it really really helped to keep a chart of the frequency of the behavior that I can look back at and realize that actually, we've been making steady progress all along, even though it completely doesn't feel like progress at all.

After my stroke, when I was relearning to walk/talk/think, that strategy was absolutely critical to warding off despair. I charted everything, and it made a huge difference.

[-]hyporational11y50

After your stroke, what kinds of things did you chart specifically? In which areas was the progress most motivating?

[-]TheOtherDave11y170

Some examples:
How many times I could raise and lower my leg before being exhausted.
Number of steps I could take at a time.
Words I blocked on.
Number of times I became altogether unable to complete a sentence. (Though this was more approximate.)
Number of pushups I could do.
Distance I could walk.
Complexity of the hardest logic-puzzle I'd successfully solved.
How many words I could write before my hand was exhausted.
How coherently I could write (I still have somewhere a piece of paper on which I wrote the same sentence, over and over, on each line; it gradually morphs from a literally indecipherable scrawl to something indistinguishable from a normal-though-sloppy person's handwriting.)

These were, of course, at different times in my recovery.

[-]TheOtherDave11y80

Oh, and re: motivating... that's a much more difficult question to answer.

The charting techniques were "motivating" only in a prophylactic sense... they helped me resist a certain kind of "I'm not getting any better" despair that was otherwise very compelling and very _de_motivating.

Positive motivation to progress was much harder to come by, and I had a much less concrete grasp on it. I was often in a not quite apathetic, but highly disengaged state with respect to my recovery. Mostly I dealt with this by accepting it as just another intermittent deficit where I had to ride out the bad periods and take advantage of the good ones.

I think the closest I can come to describing it accurately is to say that motivation-to-progress was highly correlated with focus; when what I was doing was recovery, I was very motivated to make progress. What direction causality ran, though, I have no idea.

[-]pjeby11y120

A related concept: "change amnesia". Our general memory of our past behaviors is heavily influenced by our expected present behaviors, such that we tend not to remember how we behaved differently in the past, and have difficulty believing we were ever that dumb/lame/whatever when actually confronted with evidence (such as pictures, journal entries, etc.)

Some people have this worse than others: a couple times I've had clients who came to me with a large stack of personal problems, and three months later don't know why they're paying me because they're not getting any changes... and then when I ask about the problems they had when they started, they usually remember telling me about those problems, but don't remember having the problems any more. (As in, they don't remember experiencing the problem, and don't think that they would be the kind of person who would've had a problem like that!)

For me personally, I have a lot of trouble reconstructing how I thought about a subject, once I've self-modified on that topic, with the effect usually setting in after a few hours or overnight. (Although honestly, I've never tried such a reconstruction any sooner; the difficulty might set in within minutes for all I know.) So I can remember that I used to think in some messed-up way, and maybe even what behaviors resulted from that messed-up thinking, but actually simulating the previous mode of thinking becomes difficult and unnatural.

[-]hyporational11y30

The few times I tried, I had to quit journaling out of pure embarrassment. After a few months, pretty much the only reaction I had reading old entries was: "who the hell is this idiot?"

My past self was completely alien to me, and I couldn't even understand what the words meant. I didn't really write for comprehension, as I thought my future self would totally understand me.

[-]Kawoomba11y80

Makes you wonder how crucial that whole value-preservation thing actually is ...

[-]hyporational11y00

Hehe, a good point. I don't have such a strong reaction reading old forum posts for example, though. At least I can understand them, even if I don't agree with them.

[-]Shield11y110

Are you sure that "anti placebo effect" is a good name though? The placebo effect refers exclusively to medical treatment if I'm not entirely mistaken, and this seems to have much broader implications in basically any sort of training. It's still basically the same effect if someone refuses to notice the progress they made with say tutoring, but it has nothing to do with medicine or treatment.

Seems a bit misleading.

[-]timtyler11y80

Are you sure that "anti placebo effect" is a good name though?

It may be that nocebo has a better claim to being an "anti-placebo effect".

[-]Vaniver11y40

The placebo effect refers exclusively to medical treatment if I'm not entirely mistaken, and this seems to have much broader implications in basically any sort of training.

While the placebo effect is generally defined in a medical context, people rarely throw type errors when you talk about placebos outside of medicine. The Hawthorne Effect is the name that productivity boosts due to observation / novelty / active treatment go by, but it's seen as similar to if not the same as the placebo effect.

[-]Desrtopa11y20

I can affirm that I expected the term to refer to something different, namely an effect that causes people to do worse based on their concerns surrounding an intervention, such as in this study on intercessory prayer, where the individuals who knew they were being prayed for did worse than the other groups, possibly because they were concerned that they were so badly off that they needed people to pray for them.

[-]Lethalmud11y00

Maybe Nocebo?

http://en.wikipedia.org/wiki/Nocebo

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[-]ShannonFriedman11y00

Here's my answer to that: http://lesswrong.com/lw/iqr/the_antiplacebo_effect/9tiw

[-]Zaine11y00

In the placebo effect, you try something, see results, and believe those results derived from what you tried, when in fact what you tried could not possibly have had any effect whatsoever; the observed results are then attributed to one's beliefs that the tried thing had the capacity for effecting change.

The above refers to a different phenomenon: one tries something, doesn't see results, and believes what they tried had no effect, when in fact what they tried did have results.

In the placebo effect, one's beliefs effect change. In the phenomenon Shannon refers to, change occurs regardless of one's beliefs.

Interestingly, when I presented the above description of the placebo effect to someone and asked for what they would expect of the opposite, they replied, "Change happens and they don't believe it." I would think the term, "Opposite-Placebo Effect" or "Opposite of the Placebo Effect" a better descriptor, as 'anti-' implies simple negation rather than a flipping of observed effects.

This could of course just be an issue of differing perspectives on what is or isn't an intuitive moniker.

[-]kalium11y60

Actually the placebo effect is a statistical term covering the entire improvement seen in the placebo branch of a trial. Part of the effect comes from beliefs, yes. But there are other causes. For instance, people tend to enroll in clinical trials when their health is at a local minimum, and reversion to the mean can account for a good chunk of their improvement.

[-]Zaine11y00

I didn't know this, and if there are other instances, would like to know all of them. Thank you!

[-]RolfAndreassen11y60

people suffering from anxiety from my personal client tracking.

This phrase probably does not carry the intended meaning.

[-]ShannonFriedman11y00

LOL, indeed :)

[-]Viliam_Bur11y40

I have noticed this kind of effect on myself -- I start doing something... the improvement is very slow... I convince myself that the improvement is zero... so I stop doing it... so I never finish it... which I take as a proof that my improvement was zero.

Having unrealistic expectations makes it even worse, because the higher expectation the more disappointment with slow progress.

Probably the correct solution would be: just record your improvements. I imagine something like beeminder, just without the deadlines: create a graph for something, enter data points, see the visualization, celebrate when you reach some goal.

[-]4hodmt11y180

Beeminder without the deadlines is Beeminder with the weekly rate set to zero.

[-]A1987dM11y40

Or even just a text file and a gnuplot script, for that matter.

[-]hyporational11y40

I've had personal experience with this phenomenom, but never associated it with the hedonic treadmill.

I think this has also something to do with you current emotional state determining which episodic memories you recall. When you feel good, you remember all the good stuff, when you feel bad, all the bad things pile up. I've found it's really difficult to remember what it was like being depressed when I'm well. That has lead to stupidly quitting medication a couple of times. Is there a name for this effect?

EDIT: In my case the improvement with medication was dramatic, so it wasn't just a case of not noticing slow progress. My point was the anti-placebo effect probably consists of many different kinds of known cognitive failure modes, and it might be helpful to recognize them. In the problem that I describe, the difficulty is in retrieving memories that don't fit the emotional context. The hedonic treadmill effect is another type of an effect that fits the category.

[-]ShannonFriedman11y30

What you're describing sounds like the results from the anti-placebo effect, although I didn't go so far as naming that. Basically, you don't realize its working (anti-placebo effect), and then you stop and regress (what you're pointing to). Since you've figured this out, you should have a much easier time avoiding it with the next intervention you try, especially if you track the metrics you're most interested in seeing changes in.

One place that things get tricky is that your negative reinforcement loops can get started while you're still tracking metrics - as an example, perhaps you're doing great, and then you have one bad day, and then you make the false assumption that the bad day means that you will continue having bad days and that none of the other progress is real. If you adopt that belief, then even your mood tracking will decline, so its important to be reality checking as much as possible along the way, and to remind yourself that one bad day is not as big a deal as weeks of good days, and that will help you stay on track. Here's a video of me role playing the two attitudes that might be helpful.

Not quite on topic, but same principle - replace getting the work task done with having succeeded in improving on the metric you've been tracking for several consecutive weeks, and imagine how the optimistic person would respond to a down day, with that attitude, v.s. the overwhelmed/depressed role play person.

[-]hyporational11y00

Edited the original to clarify. The video link didn't work, it's here, pretty descriptive of the basic attitudes. Changing attitudes to me feels like changing beliefs, you can't simply choose them by tricks of imagination. Medication helped with that. These days my problem is more simple avolition than depression, any non pharma tips on that? (I'm a physician.)

It would be nice to know how much of imagined SSRI poop out doesn't actually happen. Unfortunately there aren't similar tracking tools in finnish to give to my patients. Maybe pen and paper should suffice.

[-]ShannonFriedman11y00

Yes, a lot of it has do to with having the parts of your mind that are action oriented not in alignment with the ones that want to have fun. If you're in that state for a long time, or in any way that ingrains the patterns hard, eventually you get to more extreme states like lack of interest in anything.

I use non-medication techniques to get people out of these states as my profession. You might find this audio helpful.

[-]CronoDAS11y20

I'm reminded of the peak-end heuristic; the times that you're miserable are often far more dramatic and available than the times that you're not, so when you think of how you've been feeling over a period of time, you get a biased result.

[-]katydee11y20

Very interesting post. I'd like to hear more about what sorts of situations tend to produce these effects, as it sounds like information that could potentially be quite valuable.

[-]Dentin11y20

(Posting feedback as requested) Shannon - the only real problem I see in my sleep-deprived stupor is the very last sentence, which seems out of place and partially constructed.

[-]EvelynM11y10

This effect isn't limited to people with anxiety and depression. People losing weight also experience it: http://www.3fatchicks.com/forum/metabolic-research-center/146593-paper-towel-theory.html

It's hard to be objective about yourself. Using tools to gain objectivity is a good thing.

I agree anti-placebo isn't a a good name. It's more like a distorted or cloudy mirror (don't see yourself clearly). but that doesn't capture the difficulty of remembering precisely how you were a long time before, to capture changes that happen at a slow rate.

Having a good name for this, will help people to pass along the idea. Thanks Shannon.

[-]ShannonFriedman11y20

The way that I came up with the name, was that someone was suggesting that my taking metrics might create a placebo effect, where people would believe that they were doing better than they actually were.

So, my response to this was that I was not trying to create a placebo effect, but rather, to avoid a placebo effect in the opposite direction.

So while I agree with you that this effect is not an opposite (why I referred to it as related instead of reverse), I do think that it is the opposite of what a lot of people fear - that they are experiencing a placebo effect.

In short, people being afraid of having a placebo effect is often how this effect comes to be - they don't want to create false hope and then have it dissipate, so instead they refuse to believe or acknowledge real positive results when they see them.

So, I would say that the title is reasonable regarding people's expectations, but not in the precise using of the term placebo sense. Personally, I think that expectations are more important for titling. Fewer people will pay attention to a precisely named definition that they know nothing about, whereas calling it the anti-placebo effect grabs attention - specifically the attention of people who have this bias.

[-]hyporational11y10

I wonder if there are superstimuli for appreciating gradual progression that impair our sensitivity to do so. Video games come to mind.

[-]Viliam_Bur11y50

The whole internet thing -- you click something and you expect to get results within seconds.

Train your expectations with this... and then try to accomplish something in real life. Even if it takes days, it feels like eternity. If it takes months, it might as well happen after Singularity.

[-]Decius11y00

Mindhacking idea: fudge the historical results such that the trend line always appears positive, and use that as a primary intervention. This requires either violating informed consent (a bad thing) or exercising doublethink or another method of self-deception.

[-]CronoDAS11y00

When I saw "anti-placebo effect" I thought of this instead...

Edit: Beaten to it.

[-]tgb11y00

Dark arts for a good use? Modify the surveys to show them having even more progress than they did so they get even more self-confidence. Don't worry, they won't notice!

[-]Dorikka11y00

Except that if one did, things might go very, very badly for you.

[-]RomeoStevens11y00

I have been supplementing rhodiola rosea and your example is the exact thing it promises, a halving of depressive symptoms along with other benefits. I'm not sure if it's working.

[-]ShannonFriedman11y20

Yeah, hard to know in retrospect, I would love to hear more about your results in as much as you can tell. For future such attempts where you're trying something like this, I recommend taking a baseline on a mood tracking site for a week or two before starting, if you can manage it, and then tracking for at least however long they claim it takes to get results. I also recommend just generally taking baselines, maybe every couple to few months - that way, even if you don't want to mood track all the time, you at least have some reasonable random sampling to look back on to see how you're doing over time. When you track, its ideal if you find a way to have uniform bias - so always take the test at the same time each day for example, or randomize the time if you're doing many data points and can handle noise - one problem with mood tracking is that people tend to take it when they are feeling especially good or especially bad or generally motivated by extreme mood, so its good if you can find a way to minimize that particular bias.

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