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The Nocebo Effect: How Your Power of Suggestion May Harm Your Clients

by Jonathan and Matt

Did you know that your negative words could be harming a client during the session?

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We have the ability to help shape bodies. We have the privilege of helping people. That’s what we do. It’s why we wake up in the morning and it’s what makes us smile as we rest our face on the pillow at night.

We are trainers, coaches, and therapists. We help people.

What we don’t do, what we should never do, is cause harm. No matter the circumstance, no matter the scenario, we don’t purposely hurt the people that trust us to guide them.

So what if we told you that despite your best efforts, despite your best intentions, you might be doing just that? You’re hurting your clients, your patients. We’re going to show you how to stop.

The Power of Suggestion

Judgmental language is like a grenade. Words like “fat, scrawny, or weak” are words that harm. Words like “damaged” or “broken,” phrases such as “you’re going to be injured,” or “you don’t move right” can destroy what you are trying to build.

“Judgmental language is like a grenade.” – Click to Tweet

Somewhere in the evolution of fitness, we have made our clients fearful of movement, avoidant of positions, caused dread in their postures. Our intentions were good, but our results were not.

What we say can harm our clients.

Thanks to the work of many great thinkers and researchers, we understand that pain is an experience, a response to the perception of threat. Like sight, hearing, and taste, anything that can change your perception has the ability to influence experience.

Our brains aren’t biological self-storage units, holding memories and experiences like a box holding mementos in your attic. Our brains are active participants in constructing the very feelings and perceptions that you undergo every moment.

The Placebo Effect

The placebo effect can be a part of this experience. It isn’t an inert force, an imagined response to a sugar pill, or a delusion of the mind playing tricks on the body. The placebo effect is a real and quantifiable thing. It’s the response of our nervous and endocrine systems to our interactions with the environment around us — our internal expectations, desires, and emotions.

It’s the physical changes to the way that the brain produces, and in turn experiences pain. It’s why your client’s physiology responds to your words as a trainer.

Consider a well-known study in the New England Journal of Medicine1 which found that a fake surgery for knee arthritis was just as effective as a real surgery. Or this study in the Journal PLOS One2 that offered fake pills – placebos – to a group of Irritable Bowel sufferers who knew ahead of time that they would be taking a placebo. Even with that knowledge, the pills still worked just as well as “real” medicine simply because it was suggested that they could.

The Nocebo Effect

Now consider the opposite. What happens if our words suggest harm? What happens when we don’t tell you the pills will make you feel better, but instead that they’ll make you feel worse? This is called “The Nocebo Effect.” This is called harm.

Through similar mechanisms, the nocebo effect is the “Yin” to the “Yang” of the placebo effect. Where words, thoughts and suggestions reduce pain in placebos, negative words, thoughts of harm, and suggestions of injury produce or increase pain in the nocebo.

Consider a study on the effects of a powerful painkiller in the journal Science Translational Medicine, where suggesting that the pill would harm caused the drug to not work. Consider an authoritative review of the nocebo effect in the journal Pain, which concluded that the influence of nocebo was as strong as the influence of placebo. Now recall that placebos can work as well as surgeries in some cases to eliminate pain and return function.

Think of your client’s response if they’re told their squat is dysfunctional, that they’re going to hurt their knees. Even this suggestion of future pain or injury can alter this client’s perception in subtle and cumulative ways, making them more likely to experience pain if they move in a way that they were warned against.

Positive Coaching

Let’s be clear: coaching form still matters. There may be disagreements amongst professionals as to what constitutes ideal form, but it’s still true that consistent use of poor form during exercise is inefficient and may influence pain or produce tissue damage.

“Good form” is a term we use to describe preferred ways to move dependent on the task. It isn’t a law for which no variation is allowable. If you see your client moving in a way that you don’t like, change it, but don’t pathologize it.

The client performs a few sloppy reps of a deadlift, moving almost entirely at the low back. Telling the client that they’re going to “blow a disc” or hurt their back sends a direct message about the integrity of their spine — weak, brittle, fragile, just waiting for injury.

Instead, coach in the positive. Encourage hip movement. Explain the role and the power of the hips, legs, and back. Cue their strengths, shift focus away from negative language and toward performance goals.

We can teach our clients to trust or fear their bodies. All it takes is a suggestion, a word.

If we hope to empower our clients to take control of their health, we must abandon the language of defects and dysfunctions. What you say and how you say it can have real and lasting impacts on your clients’ lives.

“We shape bodies. And through the power of suggestion we also shape minds.” – Click to Tweet

Further Reading

How to Analyze Fitness Research (free Ebook) – Jonathan Fass

The Real Reason That You Still Have Back Pain – Armi Legge

The 10 Drugs That Trainers Must Know About – Dr. Spencer Nadolsky

References

1. Moseley, J.B., O’Malley, K., Petersen, N.J., Menke, T.J., Brody, B.A., Kuykendall, D.H. et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002; 347: 81–88

2. Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, et al. (2010) Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS ONE 5(12): e15591. doi:10.1371/journal.pone.0015591

3. . Bingel, V. Wanigasekera, K. Wiech, R. Ni Mhuircheartaigh, M. C. Lee, M. Ploner, I. Tracey, The Effect of Treatment Expectation on Drug Efficacy: Imaging the Analgesic Benefit of the Opioid Remifentanil. Sci. Transl. Med. 3,70ra14 (2011)

4. Petersen GL, Finnerup NB, Colloca L, Amanzio M, Price DD, Jensen TS, Vase L. The magnitude of nocebo effects in pain: A meta-analysis. PAIN August 2014 (Vol. 155, Issue 8, Pages 1426-1434, DOI: 10.1016/j.pain.2014.04.016)

About the Author
Jonathan and Matt

Matthew Danziger is an independent personal trainer working in the NYC area and Long Island. He is currently pursuing his degree in massage therapy. Matt can be found writing about movement, pain, manual therapy, and fitness on his blog at True Movement or stirring up trouble on social media. Jonathan Fass is currently the Private Physical Therapist and Sports Manager of His Royal Highness Prince Alwaleed bin Talal, billionaire investor, philanthropist, and humanitarian. He is a graduate of the first Doctoral Class in the City University of New York’s Physical Therapy program, and attended his Orthopedic Physical Therapy Residency at the University of Delaware, one of the top-ranked physical therapy programs in the nation. Jonathan is the former co-host of “The FitCast,” and now has his own podcast, “The Strength of Evidence” which he promises will have all-new episodes soon. You can also find him at www.JonathanFass.com, which he also promises to update…soon. You can follow him on Twitter at https://twitter.com/JonFass and Facebook at https://www.facebook.com/jon.fass. He actually updates those. Sometimes he posts pictures of cats, too.