Phil. Trans. R. Soc.

B (2011) 366, 1849–1858

doi:10.1098/rstb.2010.0385

Review

Placebo studies and ritual theory:

a comparative analysis of Navajo,
acupuncture and biomedical healing
Ted J. Kaptchuk*
Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School,
330 Brookline Avenue, Boston, MA 02215, USA
Using a comparative analysis of Navajo healing ceremonials, acupuncture and biomedical treat-
ment, this essay examines placebo studies and ritual theory as mutually interpenetrating
disciplines. Healing rituals create a receptive person susceptible to the influences of authoritative
culturally sanctioned ‘powers’. The healer provides the sufferer with imaginative, emotional, sen-
sory, moral and aesthetic input derived from the palpable symbols and procedures of the ritual
process—in the process fusing the sufferer’s idiosyncratic narrative unto a universal cultural
mythos. Healing rituals involve a drama of evocation, enactment, embodiment and evaluation in a
charged atmosphere of hope and uncertainty. Experimental research into placebo effects demon-
strates that routine biomedical pharmacological and procedural interventions contain significant
ritual dimensions. This research also suggests that ritual healing not only represents changes in
affect, self-awareness and self-appraisal of behavioural capacities, but involves modulations of
symptoms through neurobiological mechanisms. Recent scientific investigations into placebo acu-
puncture suggest several ways that observations from ritual studies can be verified experimentally.
Placebo effects are often described as ‘non-specific’; the analysis presented here suggests that
placebo effects are the ‘specific’ effects of healing rituals.
Keywords: placebo effect; ritual; Navajo healing; placebo acupuncture; biomedicine

1. INTRODUCTION changes in symptoms owing to placebo treatment are

Biomedicine primarily confines its examination of the accompanied by objective changes in neurobiology [8].
placebo effect—dummy pill, bogus injection or fake sur- Such findings have led to an explosive expansion of
gery—to simulating a biomedical intervention within a placebo studies in biomedicine [9].
randomized controlled trial (RCT). This perspective is Curiously, with noteworthy exceptions [10 – 13], the
derived from the importance of placebos in RCTs. In discussion of placebo in biomedicine has not benefited
fact, the RCTwas developed to exclude the confounding from an examination of healing ceremonies. This essay
effects of imagination, will, belief or what is usually seeks to mutually expand placebo studies and ritual
called bias from the accurate assessment of medical theory. It treats the placebo effect component of bio-
treatments [1–5]. Demonstrations of efficacy beyond medical treatment as one form of a socio-cultural
placebo control in RCTs are fundamental to bio- healing ritual and finds placebo experiments to be
medicine’s claim that its treatments are based on the making valuable contribution to ritual theory.
objective physical–mechanical effects of pharmacology Rituals are repetitive ‘prescribed formal behaviours’
or physiological procedures and are not ‘merely’ rituals [14] and ‘more or less invariant sequences of . . . acts
devoid of active ingredients. Placebo controls demarcate and utterances not entirely encoded by the performer’
legitimate from illegitimate healing [6]. [15]; cf. [16]. They usually share ‘an ordering or proce-
Yet, patients frequently report relief in the placebo dure that structures them, a sense of . . . the purposive
arms of RCTs. This creates a challenge to the centrality (devoted to the achievement of a particular objective),
of proximal causality in biomedicine [7]. While some of and an awareness that they are different from ‘ordinary,
the amelioration observed in placebo groups in RCTs is everyday events’ [17]. Symbols are the smallest com-
related to the natural course of an illness and regression ponent unit of ritual that still retain specific properties
to the mean, recent sophisticated laboratory studies of of the ritual, and symbols invariably repeat the message
placebo treatment point to a genuine placebo effect of the entire ritual [14]. The ritual is embedded in an
beyond natural processes. Experiments reveal that authoritative cultural truth or mythos with an ‘overarch-
ing narrative structure’ [18]. Healing rituals take
participants ‘to the heart of a society’s cultural concepts
*[email protected] of power and potency, their sources and modes of mani-
One contribution of 17 to a Theme Issue ‘Placebo effects in festation, and [to] the persons . . . who have potency’ [19].
medicine: mechanisms and clinical implications’. In a post-enlightenment and post-Newtonian world, the
1849 This journal is q 2011 The Royal Society
1850 T. J. Kaptchuk Review. Placebo studies and ritual theory

dominant mythos can be thought of as an absence of ‘chantway’ rituals that remain a vital contemporary
unifying myths and its replacement with components component of Navajo healthcare [26].
of secular narratives of reason, humanism, nationalism When home remedies such as herbs or sprinkling corn
or scientific causality [20]. pollen with a prayer provide insufficient relief for a health
Although they often include narrative accounts, heal- problem, a Navajo may turn to chantway rituals. About
ing rituals are never simply enactments of plots, stories 30 distinct ceremonies, which engage between 1 and 9
or assertions of truth. Instead, they are compelling days, have been described [27]. To select a particular
multi-sensory dramas involving evocation, enactment, chant and uncover the supernatural, moral or behavioural
embodiment and evaluation [21]. Rituals and their taboo that has been transgressed, a sick person or the
sensory, affective, moral and aesthetic components family often first consults divining diagnosticians. After
transmute the mythos into an experiential reality for par- determining the trespass such as looking one’s mother-
ticipants. Metaphors and symbols, the healer’s prestige, in-law in the eye or chopping down a tree where bats
social interactions with relatives and community mem- (messengers to the Holy People) live, an appropriate
bers in the course of preparation and performance of ritual such as Hail Way, Red Ant Way, Mountain Top
the ritual, and gesture, recitation, costume, iconography, Way or Big Star Way is recommended [28]. Some families
touch, ingestion and the physical ordeal—all provide consult multiple diagnosticians because an inaccurate
vehicles for and multi-dimensional guideposts to a pro- diagnosis and incorrect treatment plan will doom the
cess that is meant to transform a patient from ritual to failure [29].
brokenness to intactness. Healing rituals are surrounded The ritual chant is a recapitulation and performance
with belief and uncertainty, positive expectancy and of the process whereby the Holy People came to give a
worry, anxiety and fear. While hope sustains the process, particular chant to the Navajo. The chant tells the
people know that healing ceremonies are sometime story of a hero who usually begins as a marginal person
unsuccessful [22,23]. Healing rituals have ‘as if ’ or and who goes through a series of unfortunate, dangerous
‘could be (subjunctivizing)’ dimensions: one performs and catastrophic episodes to be finally redeemed and
these behaviours because they may lead to relief of dis- transformed into a Holy Person. In a representative
comfort or disability. The person with an illness, episode of the Hail Way chant, after committing
family members participating in their care and healers adultery, Rainboy, originally a good-for-nothing gam-
are strongly committed to portraying a world in which bler, is blasted to pieces by the jealous husband,
healing is an open possibility [24]. Rituals create a recep- Winter Thunder, master of the rare winter thunder.
tive or ‘porous’ individual open to culturally defined Because other Thunder People and allies such as Pink
potent influences. Ritual healing usually requires the Wind and various Insect People know that the wife actu-
guidance of a healer with technical expertise and char- ally seduced Rainboy, they take pity and gather
isma to make the universal mythic world accurately Rainboy’s pieces between sacred buckskin and perform
converge, penetrate and elicit changes in the idiosyn- songs and dances to re-constitute him. Additional epi-
cratic biographic world of the patient. As will be shown sodes of dismemberments and restorations continue,
below, even scientifically validated biomedical treat- each involving a host of other supernatural beings with
ments administered by medical professionals retain new songs, prayers, dances, chants and sandpaintings
performative aspects characteristic of rituals. [28]. Eventually, Rainboy goes to live with the Holy
This essay comparatively describes three healing People, but before he departs, he teaches the Navajo
encounters: Navajo ceremonial chants, acupuncture ancestors the precise rites he learned during his travails.
treatment in the Western world and biomedical pro- The entertaining plot is merely the scaffold for the
vision of healthcare. Navajo ritual was chosen because ritual performance. The primary Navajo goal for a heal-
their ceremonies might be considered the healing ritual’s ing ceremony is to invite, cajole and even coerce various
equivalent to the giant squid axon in neurology: the Holy People to attend the ritual as participants and even-
phenomenon is readily visible even to the naked eye. tually to inhabit the famous Navajo sandpaintings made
Acupuncture was chosen because it also provides an of pulverized stones (figure 1) [31]. The ritual creates an
elaborate ritual and because, in the West, placebo acu- ‘osmosis’ that conjoins the supernatural agency active in
puncture has been the subject of a significant corpus of the cosmos with the individual patient and, to some
scientific experimentation. The third type of healing extent, to all participants and observers. ‘Specific healing
encounter, biomedical treatment, is discussed because practices are more significant than narratives relating to
biomedicine created placebo treatment and first their formation’ [31]. At the height of the chant, the
detected what it calls ‘placebo effects’. Biomedicine medicine man touches in turn the hero’s sand-painted
also gave rise to ‘placebo studies’. The essay will sum- feet and then the feet of the patient, the hero’s legs
marize comparative findings, and then examine recent and then the patient’s legs, the belly of the hero’s
experimental evidence in placebo studies. The simul- image and then the patient’s and so forth. The patient,
taneous exploration of ritual theory and placebo studies sitting on the sacred buckskin corresponding to Rain-
will expand the discourse of both fields. boy’s buckskin, is transformed. The divine presence
inhabiting the sandpainting becomes the patient. The
patient repeats, many times, after the chanter:
2. NAVAJO HEALING
The Navajo nation is the most populous American This I walk with, this I walk with
Indian tribe in the USA. While traditional Navajo cere- Now Rainboy I walk with.
monials coexist with other forms of healthcare [25], this These are his feet I walk with,
essay limits its examination to the dramatic traditional This is his body I walk with,

Phil. Trans. R. Soc. B (2011)

 Review. Placebo studies and ritual theory T. J. Kaptchuk 1851

Figure 1. Thunder People. A sandpainting of various Thunder People all of whom help to put Rainboy back into one piece.
The image represents what the healer sings and dancers perform during this episode of the Hailway Chant. The zigzags on the
Thunder People are lightening. In one hand they hold octagonal hailstones, and in the other, more lightning. They are also
travelling on black and white lightning represented by zig-zags under their feet. (Adapted from Kaptchuk & Crocher [30].)

This is his mind I walk with, Everything is supervised by the healer or hataali
This is his twelve plumes I walk with. . . (translated as medicine man, chanter or singer). He
In beauty I walk. . .living again I walk directs the proceedings and is responsible for what
It is finished in beauty. would be the equivalent of an entire Wagnerian
It is finished in beauty [30]. opera including the ‘orchestral score, every vocal
part, all the details of the settings, stage business,
For four days after the conclusion of the ceremony, the and each requirement of costume’ [27, p. 163]. For
patient is considered, by family and friends, as if he or example, the Hail Way ritual can include 433 different
she is a Holy Person and given an opportunity to songs and chants. While the chantway ritual is scripted
focus, evaluate, interpret and experience a new self. and supposedly invariant, the healer needs to be
The ritual, not the story, is what drives this transform- flexible and able to make quick decisions in relationship
ation. The ritual re-enacts—words, songs, iconography to circumstances (such as insufficient resources to
and actions—the adventure and healing episodes execute the ritual, incorrect paraphernalia discovered
originally performed by the Holy People and taught to during the ritual or an accidental taboo violation).
the Navajo. Ultimately, the healer directs the convergence of
For the Holy People to participate, the performance sacred and human reality and has to improvise a bal-
arena has to be purified and marked as sacred. The ance between ‘preoccupation with order and a
Navajo dwelling must be cleaned, fumigated and tolerance of ambiguity, a tension between the need
arranged to the tiniest detail. Douglas fir boughs, snake- for correctness and precision and the recognition of
weed and straight and crooked snake and prayer sticks, open-endedness and subjunctivity’ [32].
are placed at exact angles in relation to the four direc-
tions and sacred Navajo landmarks where the Holy
People reside. The patient, and to a lesser extent 3. ACUPUNCTURE
family and audience, are cleansed: scrubbed with Unlike the general community involvement of the
yucca soap, sweated in lodges, administered emetics, Navajo ceremony, it is usually an individual patient
sprinkled with pollen, rubbed with herbal fragrances who enters the acupuncturist’s office. For the Western
and if physically able, made to jump over fires. Moral patient, the acupuncturist’s office is both unique and
cleaning includes confessions and apologies. Once familiar. The space is filled with acupuncture charts
the chant begins, dancers, masked impersonators of and manikins, Asian art work and Chinese herbs. Juxta-
the deities, circle the patient. Different sandpaint- posed to this are the trappings of biomedicine such as
ings made of pulverized stones depict and concretely intake forms, billing information, sterile trays, cotton
embody the Holy People. The final critical sandpainting balls and diplomas. The area has distinct smells that
brings the hero into the room. Throughout the ceremony, can include Asian incense or burning mugwort, a
sounds from thunder whips, gourd rattles, basket drums, herb used to heat acupuncture points. For Western
bullroarers, talking prayersticks and eagle bone whistles patients, the authorized truths are closer to what
remind everyone of divine numinous presences. would be considered alternative cultural paradigms.
Phil. Trans. R. Soc. B (2011)
1852 T. J. Kaptchuk Review. Placebo studies and ritual theory

Patients bring a wide assortment of complaints [33,34]. treatments. Supplemental herbal treatment can provide
They also bring their hopes, expectations, doubts, fear, additional potent regulatory influences.
anxiety and a limited knowledge of what will happen
[23,35]. Using observation and examination, the acu-
puncturist performs a formalized diagnosis. Questions 4. BIOMEDICAL TREATMENT
and examination can be unusual: do you sweat very Sitting in the waiting area, silent with hushed antici-
little or very much? What is your favourite season of pation or nervously thumbing the magazines, the
the year? What are your recurrent dreams? And favourite patient visiting a biomedical practitioner is eventually
foods? May I examine your tongue? Can I feel your called into the examination room. He or she meets the
pulse on both wrists in various depths and positions? physician, the mediator between ‘the salvational . . .
Western patients know this is different. Afterwards, the powers of science’ and sickness [39]. Despite a phys-
acupuncturists offer a diagnosis, and, in the West, an ician’s commitment to science, for the patient, the
explanation of the diagnosis. If the patient does not healer still retains some of the numinous power of a
know beforehand, by the end of the first session, he or priestly profession. But before the use of scientifically
she becomes aware of the potency of vitalistic energies based interventions can begin, patient and physician
(qi), yin-yang, wind, dampness, and fire and how they (or other biomedical practitioners) engage a stereotypi-
regulate both human health and the entire cosmos. If a cal ritual. A patient–physician connection needs to be
person’s joints especially hurts in winter, ‘stuck cold’ established to both ensure collaboration and promote
and ‘insufficient yang’ are probably the problem, if accurate diagnosis. Patient and physician engage in
they hurt in the damp weather accumulated ‘dampness’ formal behaviours including ‘practices, conventions
and ‘excess yin’ is the likely culprit [36]. The diagnosis and procedural rules’ based on established obligations
links the patient’s condition to meteorological and mac- and expectations in a context of decorousness [40].
rocosm forces and connects the patient to a wider world Wearing a sacerdotal white coat and stethoscope, the
of coherent and intentional forces [37]. The acupunc- physician is supportive and compassionate and manages
turist’s goal is to balance these forces within the to conceal any pressure to move patients through effi-
patient. Acupuncturists appeal to more ‘naturalistic’ ciently [41]. The patient shows the proper deference.
impersonal forces (e.g. yin, yang, qi, wind) compared Implicit confidentially allows for medical trust and an
with the Navajo supernatural Holy People. But for the interaction transpiring with a full ‘sensory repertoire
patient (and perhaps the acupuncturist), these naturalis- [that] conveys messages [with] manual gesticulations,
tic elements probably still pertain to what might be facial expressions, bodily postures, rapid, heavy, or
experienced as numinous spiritually charged forces. light breathing, [and] tears’ [42]. While the encounter
Like the Navajo chanter, the acupuncturist, whose train- is formally scripted, contingencies and idiosyncrasies
ing also takes many years, is the skilled mediator of the of the moment allow the physician to show his or her
troubled microcosm and all powerful macrocosms. ‘individual character, personal style, rhetorical skills
The explicit narrative acupuncturists communicate and [unique] moral and aesthetic differences’ [42].
to their patients usually concerns balancing various Any major violation of the prescribed ritual codes—‘an
‘energies’ to bring harmony to the patient [36]. But unguarded glance, a momentary change in tone of
the non-spoken implicit meta-enactment is a drama- voice, an ecological position taken or not taken can
tic ritual of ‘porousness’ and opening to the cosmic drench . . . [an encounter] with judgmental significance’
influences. Through elaborate calculations honed by and threaten the relationship [40, p. 33]. For build-
intense training and experience, the acupuncturist ing trust, sincerity is less an issue than the correct
deftly wields the needles. One needle, two three . . . up performance of the prescribed behaviours.
to 20 or so. Fingers are twirled. Penetration happens. Establishing a collaborative bond with the physician
Inserted in seemingly incomprehensible spots, the nee- moves the patient from ‘free agent to docile patient’
dles harmonize the patient’s microcosm to reflect [43]. Under the direction of the physician, the scientific
macrocosmic balance. Other supplemental forms of gaze penetrates the body. The patient changes from
touch—bleeding, scarification, cupping, even a kind of clothing to flimsy gown. So begins an incremental dra-
burning—create additional openness. All the time the matic process of ever-increasing exposure and inner
acupuncturist is concentrating like a surgeon and self- probing. The chest is heard, the abdomen is palpated
reflectively nods their head as he/she studies reactions and orifices are inspected, and the abdomen is palpated.
and makes tiny sighs of approval or disapproval to each Bits and pieces of the person’s inner being are removed
needle insertion. The acupuncturist will feel the qi and as samples of different fluids and discharges are prepared
any changes in the pulse. Occasionally, the acupunc- to go to the laboratory. Genetic samples may be sent
turist will break the silence and ask the patient if he or for decoding. Machines with thunderous Olympian
she feels a particular sensation, called ‘deqi’ or ‘feeling names—computerized axial tomography, myocardial
the qi’ [38]. The practitioner responds positively when perfusion imaging, magnetic resonance imaging, posi-
the patient says ‘yes’ and tries again if the patient says tron emission tomography—begin their cacophony of
‘no’. Some effect can be immediately anticipated and, clicks, buzzes, clangs, screeches, thumps and roars.
at the end of the session, the patient is asked whether Eventually a universal structural, physiological or psy-
he or she feels anything different. Any sensations, chophysiological abnormality ‘that conforms to a
changes or feelings the patient reports (at this session culturally sanctioned conception of disease’ is detected
or later sessions) are considered important and inter- [44]. After all the reports are returned, the physician
preted on the grid of pre-existing cultural conceptions makes a diagnosis, explains the treatment strategy and
[22]. The patient is usually told to come back for more selects a prescription from over 3000 approved
Phil. Trans. R. Soc. B (2011)
 Review. Placebo studies and ritual theory T. J. Kaptchuk 1853

pharmaceuticals available on the market. Pills, tablets or ceremonies, acupuncture and biomedical treatment—
injections can be analgesics, anxiolytics, antihyperten- can be said to provide:
sives, hypnotics, b-blockers, antihistamines, hormones,
antibiotics, tumour shrinking agents, antidepressants — An evocation of space, time and words separate from
and so on. Medications are thought to operate according the ordinary. A unique designated arena is estab-
to the same universal chemical and physical laws that lished especially designed to create a receptive
govern all that science has already illuminated and tech- person. The patient as seeker meets the healer as
nology has built. The patient can take multiple trustworthy guide and protector. This space also
prescriptions several times a day as a repetitive ingestion provides the location of solemn pronouncements
of the scientific potion. While the patient is hopeful, of diagnosis and treatment plan. While only a pro-
patients know that there is a chance for therapeutic logue, the space and words by themselves may
failure. A period of observation, interpretation and decrease a patient’s fear and improve symptoms
additional consultation follows. If medications are not [47,48].
successful, more invasive methods and procedures — A pathway of enactment that guides and envelopes the
including surgery can be used for such purposes as cor- patient. The ritual grabs the patient’s attention and
recting anatomical abnormalities, removing tumours or provides multi-sensory compelling experiential evi-
implanting mechanical devices, joints or entire organs. dence of being embraced by universal forces. The
Despite its scientific and secular orientation, biomedical healer is the impresario and guide, the patient is
treatment and technology for the patient can still retain a supplicant and follower.
mysterious and numinous quality. Like the Navajo and — A concrete embodiment of potent forces. Healing influ-
acupuncture healing, the biomedical treatment fuses ences are directly ingested, injected, absorbed or
universal forces (which are described in scientific incorporated. The healer ensures that these forces
terms) onto a single person’s unique suffering. accurately penetrate and precisely regulate the per-
sonal world of the patient. For the patient, the rite
is tangible, immediate and physically experienced.
5. RITUAL AND HEALING — An opportunity for evaluation of a new status. Each of
Navajo ceremonies, acupuncture and biomedical these rituals give patients and healers a chance to
pharmaceuticals and procedures map the personal dislo- interpret what happened. This feedback takes
cation of illness onto culturally sanctioned universal place within pre-existing cultural preconceptions of
narratives of power. Rituals focus on ‘sharing emotional, how healing takes place. Any outcome—positive,
cognitive and attentional states and coordinating actions negative, unclear or any combination of these—is
relevant to those states’ and involve processes that generally explainable within the elaborate models
are attention grabbing, redundant, rhythmic, repeti- of each framework. If dissatisfied with the outcome,
tive, decorous, well-rehearsed and somewhat invariant patients may elect to try other systems; all three
[45]. Patients situate themselves in the ‘liminal’ space rituals described above coexist in pluralistic medical
between brokenness and intactness. With an aesthetic environments with multiple alternative options
persuasiveness and adroit craftsmanship, healers create [25,49]. If faced with failure, healers will have post
an ‘osmotic’ bridge between cultural mythos and hoc rationalizations and, if sufficiently charismatic,
idiosyncratic biography. have new opportunities to practice, fine tune and
While story, plot and explanation are important as obtain further success with their skills.
framework, it is the ritual and its symbols that forge trans-
actional processes attaching the patient’s life-world to the Rappaport’s description of ritual emphasizes the
universal order of phenomenon. The performance pro- dramatic process of ‘what happens’ to a person in a
vides the patient with a palpable and participatory ritual. Csordas proposes an alternative framework
experience of empowerment and enlarged self-identity. [50] that emphasizes the internal states a patient
The patient is opened and is persuaded [46]. Each undergoes in a healing ritual. Specifically, Csordas
ritual described is ‘emotionally saturated’ with touch, points to three stages of inward experience:
sounds, smells, kinesthesia, paraphernalia and costumes
representing ‘condensations’ or symbols of culturally cer- — A predisposition to be healed. Predisposition involves
tified power integrating explicit and implicit personal the seeking behaviour, entrance into a healing
narratives with cultural truths of ultimate agency and domain, and reaching some tentative agreement
meaning [14]. Layers of sensations and behaviours on a strategy or diagnosis. It is the first step in
address different patient sensitivities and probably work creating receptiveness and openness to universal
synergistically. The ‘patient is not passively incidental to potent forces. A subjunctive, as if, world is
the ceremonial process, but is possessed with hope, frus- established.
tration, confusion, uncertainty, understanding and — An experience of empowerment. Empowerment hap-
relief ’ [32]. While illness is accompanied by despair, pens when the coherent universal forces—deities,
worry, anxiety and pain, patients’ health seeking yin-yang or chemical–physical adjustments—infuse
behaviours represent hope (desire for improvement), the chaotic world of the patient. A multi-dimensional
potential re-moralization and an openness to new possibi- performance merges with patient hope to produce
lities, if not necessarily absolute confidence and positive concrete experiences of engagement with healing
expectations (belief in likelihood of improvement). forces. The ritual provides a direct experience of
With Rappaport’s model of ritual [21] providing a being contacted with culturally recognized healing
starting point, all three healing rituals—Navajo influences.
Phil. Trans. R. Soc. B (2011)
1854 T. J. Kaptchuk Review. Placebo studies and ritual theory

— A concrete perception of transformation. Perceptions sources of agency in the cosmos. It also retains implicit
of relief and recovery come from bodily experi- moral dimensions such as the social legitimation of the
ences, emotional adjustments, new behavioural sickness role, the support of proper lifestyle behaviours
options, cognitive interpretations and moral and the ethical integrity required of the physician. The
renewal. The truth of performance is not so acupuncturist inhabits a place somewhere between the
much a belief but is felt with unimpeachable Navajo and physician. Yin-yang theories can be only
experiences. secular but easily can have an explicit religion, moral
or a meaning-centred praxis framework. No less
Taken together Rappaport’s and Csordas’ models than biomedicine, practitioners can support healthy
suggest that for the patient, healing is a performative behaviours and encourage reframing of self-awareness.
process that is accompanied by a series of shifting Furthermore, early classical Chinese texts and well-
internal states. Both of these scholars would agree known historical cases describe the importance of
that the healing ritual with its dramatic narrative and ritual performance and charismatic healers [36,52,53].
compelling aesthetics has a ‘performative efficacy’: In its attempt to look scientific, contemporary
the participatory experience of the ritual itself auto- Asian textbooks in China play down this ‘non-specific’
matically shifts perceptions, emotions, meaning and effect and, in fact, the patient–physician relationship
self-awareness [17,19]. can be extremely curtailed [33,54,55]. Unknowingly,
Notwithstanding their similarities, the Navajo, acu- acupuncture in the West has adopted and maybe
puncture and biomedical treatments are distinct in rescued the now disappearing old-fashioned Western-
many ways. Besides the details of the ritual, and from a style intimate patient–practitioner relationship but
biomedical viewpoint the relative proportion of ‘specific’ mistakenly seeing it as a unique Eastern ‘holistic’
effective material-physical causal agents, the internal practice [37].
self-awareness on the relevance of ritual in all three
practices is profoundly different. For the traditional
Navajo, or the Navajo who, at least temporarily, adopts 6. RITUAL AND THEATRE
the traditional framework, there is no separation of Healing rituals have been described as performance in
ritual and the healing. Healing is the enactment or per- this essay, and, indeed, one helpful way of thinking
formance. The Navajo would not be likely to make use about rituals is in contrast with theatre, especially
of the word ‘ritual’, but instead would speak of healing tragedy. An examination of their similarities suggests
ceremonies or chants. Any component of the Navajo cer- the potential persuasive power of healing rituals. Both
emony that, from a biomedical perspective, might have tragedy and healing are about difficult life problems.
specific, ‘proximal’ or ‘non-ritual’ causality—herbs, Both involve an aesthetic of narrative and symbols
sweat lodges, fasting—would be considered to have and prescribed enactments that depend on skilled
‘numinous’ power that helps to cajole the Holy People. craftsmanship and artistry. Like patients, to echo Aris-
Ceremony is the self-defining mechanism of the healing totle, the audience of tragedy experiences emotional
and its correct enactment is the primary recognized agitation (e.g. fear and dread) and physical arousal
vehicle of healing. Ritual is explicitly religious and (e.g. tears, coldness and shuddering) [56]. Through
moral: healing ceremonies, religion, morality and art evocative and crafted enactment, both theatre and heal-
are fused into a single unity. For the biomedical phys- ing entice us into a subjunctive (as if or ‘could be’)
ician, the ritual is much more problematic: a central world of open possibilities [15,24]. The truth of theatre
pillar of biomedicine is the banishment, through the and healing rituals is lived ‘not in the sense that their
apparatus of the RCT, of any therapy that is primarily truth value is certified by logic or argument but in the
reliant on ritual. While the ritual of the patient– sense that they are taken into the imagination and
physician relationship is recognized for its supportive lived with, if only for a time’ [18]. For both the simu-
value in official pronouncements, its purpose is to lation becomes authentic, the imaginative becomes
foster cooperation and adherence for the ‘real’, specific reality and the illusion becomes palpable.
or non-ritual treatment. Pharmaceutical treatment, Uncertainty is involved in both theatre and ritual
procedures and surgery are recognized for their instru- healing. While a drama is scripted before any perform-
mental causality, and discussion of their performative ance and has an inevitable outcome, the audience
aspects is generally marginalized. The ideology of accepts the representation as uncertain [21]. As we
biomedicine places ritual (or placebo effects) to the have noted, medical rituals necessarily have built-in
margin where, at best, it has a subordinate role as uncertainties. And these uncertainties are tempered
the ‘art’ as opposed to the ‘science’ of medicine [51]. by hope and openness as the audience and patients
The ritual is submerged and implicit and devoid of both look for a successful resolution of either social
religious or an explicit belief-system but rather is based conflicts or health disturbances.
on what is self-described as non-cultural and universal But theatre and healing are not identical and a com-
‘evidence-based knowledge’. In fact, the official elimin- parison of differences suggests some reasons why
ation of ritual as a concept within biomedicine may healing rituals are ultimately more persuasive than
partially infuse biomedical procedure with an additional drama. While actors in theatre and healers in rituals
charged symbolic ‘power’. Despite the scientific ethos, connect audiences and patients to the deepest truths
for patients and perhaps for physicians, biomedicine and core behaviours of a culture, the stakes are much
goes beyond technical expertise and retains aspects of higher for patients. In theatre, audience and actors
a healing ritual albeit with a secular mythos. It can are separate, while, in ritual, the patient and healer
evoke the awe and inspiration of touching ultimate are at once both actor and audience. In rituals, patients
Phil. Trans. R. Soc. B (2011)
 Review. Placebo studies and ritual theory T. J. Kaptchuk 1855

are self-revelatory and engage in a back-and-forth are administered unaware buprenorphine, tramadol,
exchange involving intimacy and trust. The theatre audi- ketorolac and metamizol for pain control by hidden
ence is more passive and can always touch the chair or infusion, these powerful analgesics have significantly
notice the stage and switch to awareness of the illusion. less effect than when they are provided openly in full
They can return to pre-theatre reality when the drama view of the patient [60]. Another study demonstrated
ends. In healing rituals, patients and healers anticipate that diazepam (valium) provided unknowingly to the
and hope for permanent (or at least temporary) change patient has no effects on post-operative anxiety; only
and rarely find moments to escape the awareness of a pre- if accompanied by the ritual of treatment does the
carious predicament. The arousal is deeper. Patients are drug work [61]. Such experiments suggest that ritual
active and search for clues that the performance is real is an active component of biomedical treatment,
[23]. Theatre demands a limited and temporary degree especially when patient-centred subjective symptoms
of absorption, while healing ritual demands a much are the measured outcome [62].
greater degree of commitment and surrendering the
self [57]. While theatre and ritual both touch existential,
affective and behavioural self-appraisal, healing ritual 8. RESEARCH INTO THE RITUAL OF
often emphasizes potential changes in physical discom- ACUPUNCTURE
fort, disability and disfigurement. A theatre audience Placebo acupuncture study has become a multi-
can passively accept, reject or consider the theatre’s disciplinary subcategory of placebo research. This
drama, patients have much more at stake. Ultimately, research can help illuminate the potential utility of
theatre is for pleasure and, and what Aristotle calls cath- connecting placebo studies and ritual theory. Placebo
arsis, while healing involves the concrete and immediate acupuncture research has been made possible with
life-worlds. the development and validation of placebo acupunc-
ture devices where patients experience a penetrating
needle (over non-acupuncture points), but in actuality
7. BIOMEDICAL RESEARCH OF PLACEBO the needle retracts or telescopes up the shaft of the
EFFECTS needle handle [63]. These experiments offer helpful
Scientific research does not usually consider ritual insights into healing rituals.
within its scope of research. Rituals come in too One such placebo experiment was an RCT that
many varieties with too many variables to easily allow randomly treated 270 patients with chronic arm pain
rigorous controls and experimental manipulation. with either placebo acupuncture or placebo pill and
Analysing the effects of the images or songs of the found that placebo acupuncture was significantly
Thunder Gods will never become a high priority for better in reducing pain over time, but placebo pills
biomedicine. The closest biomedicine comes to the offered more benefits in improving pain-disturbed
study of ritual is with placebo studies. Recent reviews sleep [64]. Subsequently, a functional magnetic reson-
elsewhere [8,58] make a systematic presentation of ance imaging (fMRI) study examining the same
recent scientific research unnecessary in this essay. placebo needle demonstrated that healthy volunteers
But to briefly summarize, placebo research has clearly given calibrated thermal pain and treated with placebo
described psychological mechanisms—e.g. expec- acupuncture had significantly less pain compared with
tations, conditioning, anxiety reduction, learning, those who received the same thermal pain without
memory, motivation, somatic focus and reward—that treatment. Importantly, volunteers treated with the
contribute to a response to a ‘simulated’ treatment. placebo needle demonstrated unique activation of ros-
More recent research has begun to describe how the tral anterior cingulate cortex, which is involved in
appearance of treatment elicits quantifiable changes emotion modulations, and a pronounced activation
in neurotransmitters, hormones, immune regulators in the right anterior insula, which is involved with bridg-
and regionally specific brain activity that could influ- ing sensations to emotions [65]. A subsequent study
ence peripheral disease processes through plausible using positron emission tomography (PET) and a
physiological mechanisms [9,59]. In particular, the radioactive tracer to measure endorphins followed
effects of placebo treatment in various illnesses have patients with fibromyalgia receiving eight weeks of pla-
been linked, at least, to activation of the opioid, dopa- cebo acupuncture treatment [66]. Placebo acupuncture
minergic and serotonergic systems [8]. It has become increased endorphin release.
clear that the performance of healing, without any bio- Later, components of placebo acupuncture treatment
medically defined active ingredients, unleashes were disassembled and incrementally combined and
endogenous chemicals with salubrious effects. Impor- compared in a six-week three-arm RCT of 262 patients
tantly, one research programme—the ‘hidden drug with irritable bowel syndrome (IBS) [67]. In group 1,
versus open drug paradigm’ as developed by Benedetti patients received no treatment but had to respond to a
and colleagues [60]—demonstrates that even when large battery of research questions at baseline, midpoint
active medications are used, the ritual of treatment and endpoint. Twenty-eight per cent of these patients
can be a significant component of biomedical treat- reported adequate relief on a validated IBS measure.
ment outcome. In these experiments, researchers This could have been due to the sympathetic attention
administer potent drugs intravenously in a manner from the research team, natural fluctuations or regression
that the patient remains uninformed about the drug’s to the mean. Group 2 received the same questionnaires
provision and compares this outcome to the situation plus fake acupuncture and a ‘limited’ business like
where the patient is fully informed about the drug patient–healer interaction. Acupuncturists told partici-
administration. Such studies show that when patients pants that the RCT was testing acupuncture so they
Phil. Trans. R. Soc. B (2011)
1856 T. J. Kaptchuk Review. Placebo studies and ritual theory

were not allowed to engage the patients in conversation. — Biomedical treatment with powerful medications
In this group, patients registered 44 per cent adequate has a ritual component that is clinically significant.
relief. Group 3 received the same questionnaires and — As with pharmaceuticals, each type of ritual, for
fake acupuncture, but the acupuncturists now engaged example, fake needles versus fake pills, has a
patients in a highly organized ritual which included an unique outcome.
augmented patient–healer interaction that included — Components of rituals can be disaggregated and
taking medical and psychosocial histories and demon- incrementally combined in a manner analogous to
strations of compassion, support, attentive-listening, a dose response. For example, adjusting com-
20 s of thoughtful silence and expressions of confidence. ponents of a ritual could make it more or less
Patients reported 62 per cent adequate relief. The study persuasive.
showed that components of the ritual of acupuncture — When engaged in a ritual, patients do not abandon
could be incrementally added—sympathetic general practical sensibilities. Hope, openness and posi-
questioning , sympathetic general questioning þ fake tive expectancy are tempered with uncertainty
treatment , sympathetic general questioning þ fake and realistic assessment.
treatment þ supportive patient–practitioner relation- — Different healers can have different effects on
ship—in a manner analogous to being dose dependent. patients even when they perform an identical
The effect of the augmented placebo was as large and prospectively defined precise scripted interaction.
significant as any pharmaceutical ever tested for IBS.
An analysis of biomarkers in the serum of all patients At a minimum, healing rituals provide an opportu-
revealed that changes in immunological biomarkers nity to reshape and recalibrate selective attention
were associated with symptom improvement and pro- [71– 73]. In a more expanded model, rituals trigger
vides a possible molecular signature of response to specific neurobiological pathways that specifically
placebo [68]. modulate bodily sensations, symptoms and emotions.
Within this placebo-IBS RCT, a nested qualitative It seems that if the mind can be persuaded, the body
study of 27 patients, involving interviews by a medical can sometimes act accordingly. Placebo studies may
anthropologist at baseline, midpoint and endpoint was be one avenue to connect biology of healing with a
implemented [23]. The study found that patients who social science of ritual. Both placebo and ritual effects
entered the trial had already seen countless specialists, are examples of how environmental cues and learning
were desperate, did not have positive expectations but processes activate psychobiological mechanisms of
rather consistently expressed hope and an openness to healing.
see what could happen. Improvement varied widely
from dramatic changes in social relationship to con-
crete steady improvement in symptoms and capacity 10. LIMITATIONS
to function. An analysis of psychological character- This essay is, at least partially, guilty of reductionism.
istics in the entire large three-arm RCT found that As a part of biomedicine and a scientific discipline,
patients in the augmented patient– healer relationship placebo studies try to deal with the universal and gen-
who were extroverted and open to new experiences eralizable concepts. In some ways, placebo studies try
were especially likely to respond to the augmented to treat placebo effects as a kind of specific psychobio-
ministration [69]. Interestingly, the impact of the logical drug-like intervention, quantifiable and
trial on patients varied significantly among the four measurable. From the perspective of ritual theory
acupuncturists even though each followed a scripted and anthropology, this approach can be seen as an
procedure that was videotaped to check for fidelity to avoidance of the particular. For example, this essay
treatment protocols. Could this be a measure of the has insinuated that Navajo chants may have some
unique charisma of each practitioner? A subsequent rough equivalence to the clanging of a CT scan.
RCT of 450 patients with knee osteoarthritis also From a more nuanced anthropological perspective,
examined placebo acupuncture in the context of an this assertion clearly distorts the meaning of chants
augmented versus a neutral patient – practitioner and CT scans. Navajo chants are explicit articulated
relationship. Again it was found that a more persuasive cultural rhymes and enactments that have been
clinical interaction positively affected clinical out- shared across generations of families and the wider
comes [70]. community. They are a part of the fabric of the
peoples’ lives. CT scans are large doughnut-shaped
X-ray machines producing cross-sectional views of
9. PLACEBO STUDIES ILLUMINATE RITUAL the body used by physicians with the explicit purpose
THEORY of diagnosis of disease. A person only encounters a
Taken as a whole, the study of placebos illuminates CT scan when sick. Both chant and CT scan probably
theory in several concrete ways. Minimally what has produce awe and anticipation, yet it is also likely that
been found includes: chants and scans are non-equivalent in meanings,
experiences and impact. Maybe one day, science will
— Rituals have neurobiological correlates. This suggests be able to learn whether their neurocircuitry is similar
that patient improvement is not only report bias or or different. But will reductionist neuroscience ever
desire to please the healer but represents changes in tell us the whole story? This essay has spoken in
neurobiology. Specific areas of the brain are activated broad sweeps. The author sees this as a step in
and specific neurotransmitters and immune markers making links between placebo studies and ritual
may be released. theory. An important next step would be expanding
Phil. Trans. R. Soc. B (2011)
 Review. Placebo studies and ritual theory T. J. Kaptchuk 1857

mix-method research methodologies that somehow 15 Seligman, A. D., Weller, R. B., Puett, M. J. & Simon, B.
merge the biomedical need for the universal and the 2007 Ritual and its consequences. New York, NY: Oxford
anthropological requirement for the particular. University Press.
16 Bell, C. 1997 Ritual: perspectives and dimensions.
New York, NY: Oxford University Press.
17 Tambiah, S. J. 1981 A performative approach to ritual.
Proc. Br. Acad. 65, 113 –169.
11. CONCLUSION
18 Kirmayer, L. J. 1993 Healing and the invention of meta-
For biomedicine, the ‘placebo effect’ has been primar- phor: the effectiveness of symbols revisited. Cult. Med.
ily of interest as a non-specific process that needs to be Psychiatry 17, 161 –195. (doi:10.1007/BF01379325)
controlled. In contrast, for ritual theory, the placebo 19 Tambiah, S. J. 1977 The cosmological and performative
effect is the specific effect of a healing ritual. Combin- significance of a Thai cult of healing through media-
ing placebo studies with ritual theory can help provide tion. Cult. Med. Psychiatry 1, 97– 132. (doi:10.1007/
a conceptual shift to counteract the ideological deval- BF00114812)
uation of ritual in biomedicine. The linkage of ritual 20 Taylor, C. 2007 A secular age. Cambridge, MA: Harvard
theory and placebo studies can expand the discourse University Press.
of both fields. 21 Rappaport, R. A. 1999 Ritual and religion in the making of
humanity. Cambridge, UK: Cambridge University Press.
This work was supported by NCCAM-NIH grants no. K24 22 Li, B. O., Kirmayer, L. J. & Groleau, D. 2010 Thera-
AT004095, P01AT002048, R01 AT001414-01 and R01 peutic process and perceived helpfulness on Dang-Ki
AT004662. All opinions are exclusively those of the author. (Chinese shamanism) from the symbolic healing per-
The feedback of Franklin Miller, Luana Colloca and Janet spective. Cult. Med. Psychiatry 24, 56– 105.
Littell was extremely helpful. 23 Kaptchuk, T. J., Shaw, J., Kerr, C. E., Conboy, L. A.,
Kelley, J. M., Lembo, A. J., Csordas, T. J. & Jacobson,
E. E. 2009 ‘Maybe I made up the whole thing:’ placebos
and patients’ experiences in a randomized controlled
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