Effects of Forms – Forms of Effects: The Use of Placebos in Medical Design
Right until the late 18th century, animal and plant products were used as medicine, as well as human body parts and fluids. (1) People believed, for example, that beans had a curative effect in kidney diseases, and because of their form, walnuts were used for treatments of the brain. (2) In those days implications of natural products were mostly drawn from their form, taste or smell.
Today some companies make again use of these old mechanisms of cognition, and transfer the concept of tautological design to their products. The pharmaceutical company Merck, for example, recently developed a heartshaped tablet named „Concor“, which activates through the perception of form the implicit mental concept behind, that a heart-shaped pill is good for the heart. The shape and colour implicits in this case very obvious, the expected effect of the tablet. Because of this fact it is interesting to ask if objects, particularly for medical contexts, can be designed in such a way, that they have an impact on the healing process of the patient.
In the field of medical design, medical staff has often to deal with patients who feel strained and are driven by negative emotions such as insecurity or anxiety. „We have long known that, when people are anxious, they tend to narrow their thought processes“. (3) But these narrowed thought processes and negative emotions disrupt the healing processes of patients. For the design of medical products that means that things under stressful situations require a lot more care, with much more attention to the details because people using them are usually not very imaginative when they are driven by their negative emotions.
The psychologist Alice Isen and her colleagues have shown that being happy broadens thought processes and fascilitates creative thinking. Isen discovered that when people were asked to solve difficult problems, they did much better when they had just been given a small gift – not much of a gift but enough to make them feel good. Isens´s results show that when people are relaxed and happy, their thought processes expand and they become more creative. (4)
These and related findings suggest the role of aesthetics in product design: Attractive things make people feel good. But how does this make something, for example, easier to use? Simple, by making it easier for people to find solutions to the problem they encounter. In other words, happy people are more effective in finding alternative solutions and, as a result, are tolerant of minor difficulties.
Throughout the field of medicine placebos are used as an aid to therapeutic suggestions. Because people believe in the curing effects of prescribed placebo products or treatments, they are more relaxed, their inner mechanism of self-healing forces is activated and their situation enhances because they feel happier at all. So could the self-healing processes of patients also be triggered by medical design objects in therapeutic situations, and if, how these things need to be designed?
Because products go far beyond their physical appearance, as they may also be identified for their mental concepts (5) (for example as signs or projections of ideals and ideas), a view on the topic of perception by the cognitive psychology may help to explore how products are perceived by humans and especially the phenomenom of the placebo effect works.
Perception generally refers to the process of recording information of an organism through its senses (see, hear, feel, taste, smell). The process consists of four steps: receive – interpret – choose and organise (cognitive processing). (6)
By gathering information of the product through our senses (receive) we not only gain physical data, but also we get indications for use, handling and other semantic informations (interpret). „Produkte aktivieren mit ihren physischen Eigenschaften, ihrer Termperatur, Form, Oberflächenkonsistenz, Größe, Verpackung, ihren Geräuschen, usw. automatisch auch eine dahinterliegende, mentale Ebene im Gehirn.“ (7)
Because of the prefrontal cortex in our brains, which is responsible for evaluation and meaning, we are able to translate product characteristics, such as for example „physical temperature heat“, into some more abstract concept like „social warmth“. With the help of our imaging techniques today, these biochemical reactions in brain areas coud be made visible. Leuchter et al. (8) , Liebermann (9) , Mayberg et. al. (10) and Wagner et al. (11) identified in their research furthermore, that the prefrontal cortex has also increased metabolic rates by the processing of placebos. Colour is one of the physical characteristics that is researched best in the field of psychology, regarding medical contexts.
Roullet and Droulers did several studies and examined pharmaceutical packaging colors in terms of drug expectancy. They found out, that red is mostly attributed to the heart condition drug (32%) and analgesics (20%). Yellow is attributed mostly to heart (23%) or dermatologic (23%) drugs. Green is related to analgesic (25%) and hepatic (21%) medicines. The blue package is affected to an analgesic drug (26%), while the brown is related to a heart condition drug (33%). The neutral package (gray) is attributed to an analgesic drug (25%). Dark tones generally induce more potent considerations: the darker the package, the more potent the drug.
Red, brown and grey packages are perceived as designed for serious illnesses. Brown, red and orange packages require some precaution of use, compared to blue, green and yellow ones. Brown- and red-packaged drugs are perceived as more costly than orange or yellow boxes. Darkhued packages (red, blue and brown conditions) are considered as acting more rapidly, more expensive, more susceptible of side effects and more curative than light-hued packages (yellow, green, orange and grey conditions). (12)
De Craen et al. published 12 studies on the influence of colours in the field of pharmaceuticals by examining different coloured placebo drugs, showing their perceptual impact, regarding effect and potency. The studies presented that the physical property of colour has big influences on the perception of the medical efficiency and the patient´s expectancies towards a perceived action of the drug.
The results showed that red, yellow and orange were associated with a stimulant effect, green and blue were associated with a tranquilising effect. Hypnotic, sedative, and anxiolytic drugs were more likely than antidepressants to be green, blue or purple. White was related to general drugs, red and scarlet for cardiovascular and blood or lymphatic system drugs. Tan, beige and burnt orange were drawn to drugs for skin deseases. In efficiency red and black drugs were perceived as strong and white as weak. Anxiety symptoms were most improved with green, depressive symptoms responded best to yellow. (13) Huskisson showed that a red placebo is as efficient as a real analgesic drug. (14)
Concluding the studies above, the drug apprearance, in terms of colour, for the packaging and the medication itself have influence in the efficiency of the treatment. In the same way, the very brand name of a drug will have a differential therpeutic effects according to its consonance (15) or its nortoriety (16). But not only the colour, also the preparation form (capsule or tablet) size and forms are other factors that affect a therapeutic outcome. Buckalew and Coffield found out that capsules are perceived stronger compared to tablets (17).
Classical tablet forms stick to a simple language of form, they are round, oval, oblong or squared. Only a few products, such as the heart tablet „Concor“, from Merck or SmithKline Beecham´s drug „Requip“ for the Parkinson disease. „Requip“ has hemispherical bulges that stick at the fingertip to compensate the impaired fine motor skills of Parkinson patients and to provide an independent use of the drug. Also for the dosage, the form of the tablet plays a major role since it can be divided via one or more score marks into a plurality of parts. (18)
So the shape of tablets gives extremely obvious hints about the use and dosage opportunities of the drug, another factor to support medical treatments is the frequency of taking drugs and also if they are cheap or expensive has a direct outcome on the therapeutic effectiveness.
„Der Effekt des verabreichten Medikaments steigt, wenn die Patienten sie viermal am Tag statt nur zweimal nehmen. Wird den Patienten gesagt, dass die Tabletten teuer sind, wirken sie besser, als wenn sie als billig dargestellt werden. Ist in die Placebo-Tabletten zudem noch ein Markenname eingraviert, steigert das die gefühlte Wertigkeit und damit die Effektivität weiter. Zwei Tabletten scheinen stärker zu wirken als eine, eine große bunte Kapsel stärker als eine Pille, besser noch als Placebos in Pillenform wirken Placebos als Injektionen und ein chirugischer Eingriff wirkt stärker als eine Injektion (je invasiver die Therapie umso größer der Placeboeffekt). Wenn der Chefarzt die Placebobehandlung verabreicht, scheint das mehr zu bewirken als wenn es ein Pfleger tut. Und wenn der Arzt oder die Ärztin noch zusätzlich mit Worten, Ritualen und Mitgefühl den Patienten ermutigt, zeigt das die allerbesten Ergebnisse.“ (19)
Not only by the appearance but also by handling the effectiveness of a treatment is supportet, because „the handling of products provides important signals to the brain for the decryption of the mental concept and further, implicit information which is not provided via visual properties“ (20).
This perceptual effectiveness of a treatment to kick-off self-healing processes can even be increased by a person that cares, and speaks to you about the medication and the application of the product. The factors of appearance, handling and meaning are necessary for the impact of placebo products. But which products are meant by placebo and what can the placebo effect be used for?
The Latin word „Placebo“ literally means „I will please“ and first appeared 1811 in a medical dictionary, which described the term as „an ephithet given to any medicine adopted more to please than to benefit the patient“ (21). „Placebos were widespread in medicine until the 20th century and they were sometimes endorsed as necessary deceptions“ (22). Analogously „Nocebo“ from the Latin verb „nocere“ describes the negative effects, deteriorating a condition of a patient, after a sham treatment. The widest known form of a placebo today is the orally taken tablet, which just consists of milk sugar. However, placebos are not only confined to the area of tablets but also include other interventions like injections (of saline) or sham surgerys. So the placebo can be described as a pharmacologically inert substance or treatment with no effect on our metabolism.
Henry K. Beecher published the first metaanalysis on this theme, an article named „The Powerful Placebo“ in 1955. He examined over 1000 patients in 15 different studies and concluded that 35% of the patients reached a satisfyfing improvement of their complaints through the use of Placebos. He found out that placebos are most effective when the stress (anxiety or pain) is greatest. Beechers results became the basis for placebo research and were supported by further subsequent psychological studies on the placebo effect, which reformed also the clinical research by the so-called „double blind“ technique for drugs which is used until today as a standard of pharmaceutical studies for drug testing. By the „double blind“ technique two treatment groups – one with the placebo treatment, the other group with a real treatment are compared. The groups are not informed if they get a sham or a real preparation. (23)
The placebo response refers to the improvement of symptoms in a person, that has received a sham treatment and expected an effect. To understand the placebo phenomenon as whole, the placebo response is further explored because it contains psycho-neurological relationships. Until today no sound medical explanation could be found to declare the reason for the placebo effect and reactions but the phenomenom of the placebo effect points to the importance of perception and the brain´s role in our physical health.
„Am besten sind Placeboeffekte in der Schmerztherapie (Rückenleiden, Arthritis, Rheuma, Kopfschmerzenund bei Angstzuständen, Asthma, Allergien, Neurodermitis, Bluthochdruck, Husten, Magengeschwüren, Depressionen) zu studieren. Schlafstörungen sund so gut wie placeboresistent, Epilepsie ist es völlig. Bewusstheit ist die Voraussetzugn und die Krankheit muss Körperfunktionen betreffen die unter Einfluß des Zentralnervensystems stehen. Schmerz lässt sich bei etwa 35 Prozent der Patienten durch Placebos bessern, Magengeschwüre bei 50 Prozent, Rheuma und Arthritis bei bis zu 80 Prozent.“ (24)
Obviously the self-healing processes can not be used for every kind of illness. Mainly in the field of pain therapy, as well as in the field of psychologial deseases the use of placebos is used best in daily practice. To explain the placebo effect four concepts are used by the placebo science: the concept of natural history, the concept of expectations, the concept of conditioning and the concept of meaning. By the natural history the spontaneous course of a natural healing is meant. „Eine Behandlung, die zu einem Zeitpunkt hoher Schmerzintensität appliziert wird, kann eine heilende Wirkung vortäuschen, denn es ist naheliegend dass die Beschwerden zu einem späteren Zeitpunkt sowieso geringer sein werden.“ (25)
An expectation is the anticipation of a future state. The placebo response arises from the fact that the patient has in mind that an intervention will work. This will affect the treatment as it corresponds to the patient´s expectations and his hope.
Conditioning means educating to a specific response through a particular stimulus. Pavlov studied that an involuntary response can be triggered by exercise through a neutral stimulus that would not cause this reaction without conditioning. The Studies has become known as „Pavlov´s dog“ (26).
„Das gesamte Immunsystem kann durch den Prozess der Konditionierung beeinflusst werden, indem mit dem konditionierten Reiz nur noch Placebos verabreicht werden.“ (27) The conditional stimulus is very open and can be triggered by the entire context of the drug application (tablet, injection, presence of the physician, white doctor dress). The plaster is a simple example of such a conditioned stimulus since it is coupled by prior experience, and the reaction to pain relief.
The concept of meaning may be a starting point for the design of placebos in medical contexts. Daniel Moermann, a Medical anthropologist states: „We do not respond primarily to the object, but to the importance we attach to the situation, and this is influenced by many factors, individual as well as situation-specific“ (28). Also for the american physician and medical ethicist Howard Brody the placeboeffect is a „a change in the body (or, in the unity of body and mind) due to a symbolic meaning ascribed to an event or object in a healing context.“ (29)
In 2001 the designer Anthony Dunne and Fiona Raby started a placebo project which should investigate how physical effects of electromagnetic fields from electronic devices could be made perceivable. Through the project people should be more sensitized for electromagnetic fields, in particular, of mobile phones and computers, in their own living environment. Using a series of eight different furniture prototypes, working as placebos, Dunne and Raby gave the test persons over the duration time of the experiment, a psychological tool in form of a piece of abstract furniture to visualize the invisible electromagnetic fields of electrical equipments in familiar living environments and to protect people against electrical radiation. In Advance the persons were not informed that the products had no „effect“ at all. After the experiment the people were informed that the furniture just works as a placebo. (30)
The project reveiled, that users could identify easily by the placebo products how much electromagnetic radiation was in their every day private living environments. The furniture gave them the feeling to be protected from the radiation and to precisely control it. After the experiment Dunne and Raby could find out in interviews, that the users had experienced a significant increase in their psychological comfort during the project. With the furniture in their environment they felt better and healthier, even though they were not sure about the effectiveness of the objects, and could not check whether the furniture actually had an influence on electromagnetic fields or not.
The studies, especially of de Craen et al., indicated how important visualized properties of placebos are for the effectiveness of the medication. Huskisson even showed that a red placebo, because of its colour, is as efficient as a real analgesic drug for improving pain.
That colour may support a product in a positive way and has impact on its perception is also known in the field of design, stated by various colour theories (Newton, Goethe, Runge, Itten, Kandinksi, Newman, etc.). Goethe´s colour theory is, in terms of placebo design especially interesting, because he equated colour to energy – energy that affects the body on a physical and a psychological way. For him colour is energy which can not be interpreted with the rational mind, but has directly impact to the emotional center of the nervous system, better the mind, and effects us in such a way, that body functions start to work because of the colour stimulus. An improtant finding from Goethe is that each colour, with its specific character (between light and dark) has influence on our mental perception. (31)
Colour and shape work strongly together to be perceived as direct notes for medication, as they may show their effects and how often they have to been taken. For many products today the way they are perceived is not used in an optimal way.
As Zimmer showed, not only the colour or shape is important for the effectiveness of a placebo but also the whole context, means the therapeutic situation, as well as the interactions between medical staff and patients. In terms of the example of tablets, the act of taking could be designed more meaningful, maybe through the kind of wrapping or the dosing possibilities to affect the patient´s attention and to make him believe that the tablets will help him. Furthermore the form of the provided informations for tablets (the package leaflet and the conversation with the doctor) could be designed in such a way that it supports the medication, because the negative effects that may accure are mentioned but not highlighted, whereas the positive effects of the tablets are emphasised (today it is done the other way around). At this point there is much potential to strengthen drugs with the help of placebo effects.
Drawing conclusions from the project of Dune and Raby, giving meaning to things and their contexts could be an important point for the design of medical artefacts, to create future products and therapy situations that help to kick-off the self-healing mechanisms which support the well-being and comfort of patients. Here further design criteria may be established to design also abstract concepts like „Aufgehobensein“ or „Wirkungsweise“ to encourage communication and interactions. Therefore the method of design experiments could be a helpful tool, where developed prototypes can be tested in therapeutic situations, like the so-called double-blind tests for drugs.
The overall message of a placebo designs should be: The placebo takes care of you.
So it seems most important to develop artefacts, interactions and situations that deepen trust and improve confidence.
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