When the Story Is the Cure

Even the size and color of a pill tell a story about it, in turn priming your expectation of its efficacy

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Every medical technology already harbors a placebo response by virtue of its intensity. A sham surgery is more powerful than a saline injection; a saline injection is more powerful than a sugar pill. Some argue that the placebo response solves for cognitive dissonance. The more involved the intervention, the more the patient thinks, Gosh, I hope this treatment works—hence why a higher price paid for the intervention can mean a greater placebo response. Similarly, studies show the more expensive you think a bottle of wine is, the more you will enjoy it. The price of this pill or wine is a suggestion of its value, raising your expectation of its efficacy or taste. Because the brain is a prediction machine, the stated price is priming you to interpret the stimulus accordingly.

But every technology has its limits. After all, a pill is just a pill, right? Not quite. Even that small pill is inevitably wrapped up in a story that a person, a doctor, and a society tell about it. For example, a larger pill is more powerful than a smaller one. The color, too, can influence the placebo response. “Red, yellow, and orange are associated with a stimulant effect, while blue and green are related to a tranquilizing effect,” wrote researcher Dr. A. J. de Craen. If something so insignificant as the size and color of a pill can influence the placebo response, consider the potential of the millions of other factors around this theater of care: the doctor’s clothing, the office layout, the advertisements around the drug, what your friends and family say about the drug. Add all these factors up and you get the drug’s verisimilitude.

Bear with me… verisimilitude (verum, meaning truth and similitude meaning likeness) is the general believability or realness of a work of fiction. There are two types of verisimilitude. Cultural verisimilitude has a writer craft a story that aligns with the structures and boundaries of the real world (the story must be plausible within the world at large) while generic verisimilitude is the quality of realism within the story itself (is there internal consistency of character and plot). Verisimilitude is best achieved through the specificity of detail in the story. This aligns with the writerly maxim the more specific you go, the more universal the story becomes. In that tension between specificity and universality is a quality of a believability. The goal of fiction is, according to Samuel Coleridge Taylor, the suspension of disbelief, that feeling of losing yourself in a good book or movie. Verisimilitude is what allows for that suspension. It is a reflection of your confidence in the story’s reality.

Your ability to suspend your disbelief at the movie theater depends on the work's verisimilitude

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We live in a confidence economy. The power of a dollar bill comes not from an intrinsic value in the paper itself but rather from our confidence in the institutions that manage the economy; our world responds by collectively believing that bill is worth a certain amount. In the same way, confidence, achieved through good storytelling, confers economic potential, so too does storying confer medical potential in a pill. Some scholars (Irving Kirsch, most notably) argue that the bulk of Prozac’s benefit comes from a placebo response. This explains why research suggests that the efficacy of Prozac has increased over time. Nothing in the pill’s recipe or in our biology has changed. Rather, more people take Prozac now and believe in its power. We know that placebos have a strong peer pressure effect. If your neighbors take Prozac and claim great healing powers, the suggestion of its efficacy is greater, in turn raising your expectation of its powers to lift your depression. (Unfortunately, the opposite is true with the nocebo effect.)

Hope is a close cousin of expectation and may be even more powerful in harnessing a placebo response. Compared to expectation, hope is a more personal and private act; hope, too, depends on uncertainty, implying some degree of irrationality, while expectation hinges on the amount of available evidence. I can hope to be cured of cancer, but if given enough evidence I will certainly expect it. The essential difference between the two is the degree of emotionality involved. Expectation is cold, clinical, even entitled, while hope implies a warm yearning. The former is passive and the latter active. Hope aligns with belief, as belief requires the absence of proof (if there were proof of a higher spiritual being, I would no longer need to believe in that being). In one study, patients told they might not have received the active drug in the trial demonstrated the most powerful placebo response to it, suggesting that hope itself fueled the power of the drug. In other words, when facing more uncertainty, these patients had a greater hope to see a difference in themselves—and they did.

But even in the absence of evidence, hope is strengthened by confidence and confidence by verisimilitude. Clinicians must use emotion to suggest this confidence, precisely at the point where the evidence stops. “Hope is not the conviction that something will turn out well but the certainty that something makes sense, regardless of how it turns out,” wrote Vaclav Havel. In other words, hope depends on a degree of cultural and generic verisimilitude. How you convey that verisimilitude is through story.

In Biographia Literaria, Coleridge calls the suspension of disbelief an act of “poetic faith”—a beautiful synonym for the placebo response. (When I hear “poetic faith,” I think of leaping in the same way hope implies a degree of irrationality: confidence in the treatment, but also in spite of its evidence.) Consider the neurological mechanism of the placebo response observed in patients suffering from chronic pain, as discovered by the researcher Tor Wager. Pain from the body typically is processed first by the primitive regions of the brain, then disseminated forward to the prefrontal cortex, the logic center of the brain that makes humans human. When patients in pain experience symptom relief from a placebo response, fMRI brain scans show that the pain signals work backward, starting from the prefrontal cortex and working backward. In other words, fiction (this pill will help me) clashes with biological fact (my back hurts). Somewhere in that collision between the two is what you actually end up feeling.

Hope is irrational. Yes, it depends on evidence, but more so on emotion—empathy and compassion. This is perhaps why patients’ perception of empathy in their doctor quickened their ability to heal. Norman Cousins was clued into this in 1979 when he wrote, “The human body experiences a powerful gravitational pull in the direction of hope. That is why the patient’s hopes are the physician’s secret weapon. They are the hidden ingredients in any prescription.”

Of course, hope, empathy, and compassion alone are never enough. Doctors can learn from storytellers—those involved in this theater of care—while storytellers can learn from doctors. Fiction and fact thrive best in dialogue.