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A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 87 (for example, not taking one's prescribed psychiatric medication, or, in a higher-stakes scenario, dropping out of cancer treatments in favor of a remedy no more effective than a placebo). For these reasons, it's important not to limit ourselves to only our clients' subjective reports, nor to forgo medical evaluation and care whenever indicated. And of course, deceiving our clients in any way, even if we think it in their best interest, is clearly on the wrong side of the ethical divide. (Some would also include using explanations for our work that aren't scientifi cally accepted as a kind of unethical "deception," though there is not a consensus on this view.) The ethical considerations about placebos aren't as simple as "don't use placebos," or "always use placebos." Since every therapeutic intervention has a psychosocial context, placebo (or nocebo) effects are already part of every therapeutic interaction. The question then is, how can we stay aware of their implications and power to best serve our clients? Part of the answer is that we already use many different placebo and contextual effects all the time—for example, whenever we are paying attention to client interactions and the relational context of our work. Most importantly, when we don't pay attention to placebo factors, we run the risk of inducing nocebo effects. Placebos' effects can seem mysterious, even magical. But "placebo" is not just one thing, and as we learn more about its constituent mechanisms, its mystery is being gradually whittled away. "I see the placebo effect as a kind of loose family of different phenomena that are just yoked together by this term," says Franklin Miller, senior faculty member in the Department of Bioethics, National Institutes of Health (NIH). "Sooner or later we'll get rid of the term," he says, and talk more specifi cally about each of its components. 14 Understanding how these various placebo and nocebo mechanisms function is helping many practitioners be even more effective in their work—not by fooling their clients with fake remedies, but by more intentionally leveraging the power of trust, expectation, ritual, anxiety reduction, and learning, and by including both the objective and subjective impacts of their work into their values and their thinking. After all, you and everything you do already have placebo effects—wouldn't you rather your effects be benefi cial ones? Notes 1. Fascia: The Tensional Network of the Human Body, eds. Robert Schleip et al. (Edinburgh: Elsevier, 2012); A. Stecco et al., "Ultrasonography in Myofascial Neck Pain: Randomized Clinical Trial for Diagnosis and Follow-Up," Surgical and Radiologic Anatomy 36, no. 3 (April 2014): 243–53. 2. F. Benedetti, "Drugs and Placebos: What's the Difference?," EMBO Reports 15, no. 4: 329–32. 3. J. Fuentes et al., "Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients with Chronic Low Back Pain: An Experimental Controlled Study," Physical Therapy 94, no. 4 (April 2014): 477–89; T. J. Kaptchuk et al., "Components of Placebo Effect: Randomised Controlled Trial in Patients with Irritable Bowel Syndrome," BMJ 336, no. 7651 (May 2008): 999–1003. 4. M. Schweitzer et al., "Healing Spaces: Elements of Environmental Design that Make an Impact on Health," Journal of Alternative and Complementary Medicine 10, supplement 1 (2004): S71–83. 5. S. Booth-Kewley et al., "A Prospective Study of Factors Affecting Recovery from Musculoskeletal Injuries," Journal of Occupational Rehabilitation 24, no. 2 (June 2014): 287–96. 6. R. H. Gracely et al., "Clinicians' Expectations Infl uence Placebo Analgesia," The Lancet 1, no. 8419 (1985): 43. 7. R. Ader and N. Cohen, "Behaviorally Conditioned Immunosuppression," Psychosomatic Medicine 37, no. 4 (Jul–Aug 1975): 333–40. 8. Fabrizio Benedetti, Placebo Effects (Oxford: Oxford University Press, 2004). 9. Raúl de la Fuente-Fernández and A. Jon Stoessl, "The Biochemical Bases of the Placebo Effect," Science and Engineering Ethics 10, no. 1 (2004): 143–50; F. Benedetti, "Placebo and Endogenous Mechanisms of Analgesia," Handbook of Experimental Pharmacology 177, no. 177 (February 2007): 393–413. 10. A. Hróbjartsson and P. C. Gøtzsche, "Placebo Interventions for all Clinical Conditions," Cochrane Database of Systematic Reviews (January 2010), https://doi.org/10.1002/14651858.CD003974.pub3. 11. Brian Resnik, "A Radical New Hypothesis in Medicine: Give Patients Drugs They Know Don't Work," Vox, last updated June 2, 2017, accessed May 2018, www. vox.com/science-and-health/2017/6/1/15711814/ open-label-placebo-kaptchuk. 12. Paul Ingraham, "Placebo Power Hype," PainScience.com, last updated December 18, 2017, accessed May 2018, www.painscience. com/articles/placebo-power-hype.php. 13. Brian Resnik, "The Weird Power of the Placebo Effect, Explained," Vox, July 7, 2017, accessed May 2018, www.vox.com/science-and- health/2017/7/7/15792188/placebo-effect-explained. 14. Brian Resnik, "The Weird Power of the Placebo Effect, Explained." Special thanks to Brian Fulton, RMT, for ongoing discussion and reference suggestions, and particularly for his defi nitive book, The Placebo Effect in Manual Therapy: Improving Clinical Outcomes in Your Practice (Handspring Publishing, 2015). Til Luchau is the author of Advanced Myofascial Techniques (Handspring Publishing, 2016), a Certifi ed Advanced Rolfer, practice coach, and a member of the Advanced-Trainings. com faculty, which offers online learning and in-person seminars throughout the United States and abroad. He invites questions or comments via info@advanced-trainings.com and Advanced-Trainings.com's Facebook page. Watch Til Luchau's technique videos and read his past articles in Massage & Bodywork's digital edition, available at www.massageandbodyworkdigital.com, www.abmp.com, and on Advanced-Trainings.com's Facebook page. "Are You a Placebo?"