Often when we think of the placebo effect, we think of sugar pills that have no “real” medicinal benefit but work their magic through expectation of benefit. In physical medicine, there is some reluctance to rely on psychological mechanisms for healing (even if these mechanisms trigger physiological processes, like the release of endorphins) given the taint of deception. After all, the physician is asked to “do no harm” and isn’t encouraging self-delusion a form of harm? Truth and goodness go together, right? Well, yeah, in my book – but it’s complicated.

Take psychotherapy. Psychotherapy is all about harnessing psychological mechanisms to get better. So are we to privilege some mechanisms over others? And when we try to heal ourselves, we often self-consciously rely on “belief” even though part of us knows we’re placing more faith in optimism than is warranted by the cold, harsh facts of our situation. But we also know that such faith can make a difference in getting through or getting buried.

A lot of psychological interventions instill hope, provide a plausible narrative that makes sense of one’s misery and show a credible way out. The specific narrative and techniques matter less than whether the client buys into them. Plus there are the “common factors” of therapy that make a big difference in outcomes: the experience of positive regard, empathy, collaboration, and an alliance with the therapist. Leaving out placebo effects, common factors, environmental factors (e.g., "fresh start" experiences like new job or new partner), regression to the mean and personal characteristics of the therapist and client, the specifictreatment may contribute as little as 1% to treatment outcomes (ouch!).

These thoughts were triggered by a recent meta-analysis showing the benefits of Cognitive Behavioral Therapy (CBT) to be declining as time goes on. The authors of the study speculate that this may be because CBT’s placebo effect is wearing off. Let’s face it: CBT is pretty old-hat. Yesterday it was CBT; today, it’s mindfulness. When you take away the hype, and the expectations it engenders, what’s left? Mostly the warm and fuzzies.

I’m still a big advocate of The Truth, come hell or high water. But I know that a lot of people aren’t such sticklers for Getting It Right. And for some people, belief really helps. It changes their physiology, behavior and environment – and somewhere in that sea of change, something real happens.