The Science of Willpower

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No Pain, No Gain: Why We Want Therapy to Be Hard and Yoga Uncomfortable

Should we try to exploit the placebo effect?

I recently came across a study that highlights one of the biggest ethical challenges facing healthcare providers and wellness professionals. We know that the placebo effect can contribute to the positive outcomes received from many different health interventions. Anything about an intervention—whether it's the color or cost of a pill, the side effects of a surgery, or the name of a psychological therapy—can make a patient expect more benefit, and actually receive more benefit.

So should we try to manipulate the placebo effect by tweaking our interventions to enhance it?

In this particular study, 57 undergraduate students were enrolled in a health-promoting intervention. They learned a breathing technique called the Maximum Pause, described by the authors as "holding the breath after a gentle exhalation, generally as long as one can, or to the point of moderate discomfort." (To help, they were instructed to pinch their nostrils while they suspended the breath.)

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The students were told that this breathing technique has many physical and mental health benefits, and they were asked to practice it once in the morning and once at night for four days. (In reality, there is not a lot of evidence that this particular technique improves anything—which is exactly why the researcher picked it. They wanted to be sure they were studying the placebo effect.)

At the end of the four days, the students answered three questions about the breathing exercise:
1. How much do you expect the breathing exercise to enhance your well-being? [EXPECTED BENEFIT]
2. How effortful is the breathing exercise? [PERCEIVED EFFORT]
3. How many times during the last 4 days did you use the breathing exercises? [ADHERENCE]

Participants also reported on two outcomes: a self-reported measure of mood, and the simple question: "Do you feel better after performing the breathing exercises?" [PERCEIVED BENEFIT]

The best predictors of feeling better and mood were the participant's expected benefit and his or her perceived effort. When both expected benefit and perceived effort were considered at the same time, only effort remained a significant predictor. Actual adherence (how often they practiced) did not add any predictive power.

In other words, the placebo effect was a function of how hard participants thought the breathing exercise was. (In fact, the correlation between effort and perceived benefit was .90, which is astronomically high.)

When I read these results, it immediately clicked with my experience teaching yoga and meditation. Although "easy" practices like relaxation, simple postures, and breath awareness meditation can be therapeutic, people often want something difficult and complicated. Many new students assume that a challenging yoga pose will do more for their back pain than an easy stretch, or that a complicated breathing exercise will do more for their stress than just breathing mindfully.

Yoga teachers and therapists end up facing the same ethical challenge that physicians have long struggled with. Is it ever appropriate to offer a "placebo" in the form of some complex pattern of breathing or movement? Should we recommend a healing practice that takes more effort than, strictly speaking, should be required? Or should we challenge the "no pain, no gain" mentality and stick with the simplest and safest practice demonstrated to have real benefits?

I myself am in the "keep it simple and safe" camp, at least for now. Although I know how important the placebo effect can be, I don't think we know enough about it to manipulate it. I'm very curious what others think, though, either from the "prescriber" side or the patient/student side.

Your thoughts?

Study mentioned:
Gaitan-Sierra C & Hyland ME (2011). Nonspecific mechanisms that enhance well-being in health-promoting behaviors. Health Psychology, 30(6), 793-6.

Kelly McGonigal is a health psychologist at Stanford University and the author of Yoga for Pain Relief: Simple Practices to Calm Your Mind and Heal Your Pain and The Willpower Instinct: How Self-Control Works, Why It Matters, and What You Can Do to Get More of It.

Kelly McGonigal, Ph.D., is a health psychologist at Stanford University.

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