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Placebo and Nocebo Effects in Psychiatry and Beyond

Original Research ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Psychiatry | doi: 10.3389/fpsyt.2019.00464

The use of Expectancy and Empathy when Communicating with Patients with Advanced Breast Cancer; an Observational Study of Clinician-Patient Consultations

 Liesbeth M. Van Vliet1, 2, 3*, Anneke L. Francke2, 4, Maartje m. meijers1, 2, Janine Westendorp2, Hinke Hoffstädt2,  Andrea W. Evers3, 5, 6, Elsken van der Wall7, Paul de Jong8,  Kaya J. Peerdeman1, 3, Jacqueline Stouthard9 and sandra van dulmen10, 11, 12
  • 1Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Netherlands
  • 2Netherlands Institute for Health Services Research, Netherlands
  • 3Leiden Institute for Brain and Cognition (LIBC), Netherlands
  • 4Amsterdam Public Health Research Institute, VU Medical Center, Netherlands
  • 5Health, Medical and Neuropsychology Unit, Institute of Psychology,, Leiden University, Netherlands
  • 6Department of Psychiatry, Leiden University Medical Center, Netherlands
  • 7Department of Medical Oncology, University Medical Center Utrecht, Netherlands
  • 8St. Antonius Ziekenhuis, Netherlands
  • 9The Netherlands Cancer Institute (NKI), Netherlands
  • 10Radboud Institute for Health Sciences, Department of Primary and Community Care, Netherlands Institute for Health Services Research, Netherlands
  • 11Radboud University Nijmegen Medical Centre, Netherlands
  • 12Faculty of Health and Social Sciences, University of South-Eastern Norway, Norway

Information-provision about prognosis, treatments and side-effects is important in advanced cancer, yet also associated with impaired patient well-being. To counter potential detrimental effects, communication strategies based on placebo and nocebo effect mechanisms might be promising to apply in daily practice. This study aimed to provide more insight into how often and how oncologists use expectancy- and empathy-expressions in consultations with patients with advanced breast cancer.
45 consultations between oncologists and patients were audiotaped. To determine how often expectancy- and empathy-expressions were used, a coding scheme was created. Most consultations (n=33) were coded and discussed by two coders, the remaining 13 by one coder. To determine how expectancy- and empathy-expressions were used, principles of inductive content analysis were followed.
Discussed evaluation (i.e. scan) results were good (n=26,58%) or uncertain (n=12,27%) and less often bad (n=7,15%). Uncertain expectations about prognosis, treatment outcomes and side-effects occurred in 13,38, and 27 consultations (29%,85%,56%); followed by negative expectations in 8,26, and 28 consultations (18%,58%, 62%); and positive expectations in 6,34, and 17 consultations (13%,76%, 38%). When oncologists provided expectancy-expressions, they tapped into three different dimensions; relational, personal, explicit. Positive expectations emphasized the doctor-patient relationship, while negative expectations focused on the severity of the illness, and uncertainty was characterized by a balance between (potential) negative outcomes and hope. Observed generic or specific empathy-expressions were regularly provided, most frequently understanding (n=29,64% of consultations), respecting (n=17,38%), supporting (n=16,36%), and exploring (n=16,36%). A lack of empathy occurred less often and contained among others not responding to patients’ emotional concerns (n=13,27% of consultations), interrupting (n=7,16%), and an absence of understanding (n=4,9%).
In consultations with mainly positive or uncertain medical outcomes, oncologists predominantly made use of uncertain expectations (hope for the best, prepare for the worst) and used several empathic behaviors. Replication studies, e.g. in these and other medical situations, are needed. Follow-up studies should test the effect of specific communication strategies on patient outcomes, to counter potential negative effects of information-provision. Studies should focus on uncertain situations. Ultimately, specific placebo and nocebo effect inspired communication strategies can be harnessed in clinical care to improve patient outcomes.

Keywords: Communication, Placebo Effect, Nocebo effect, Empathy, expectancy, Cancer, Palliative Care, Observational studies

Received: 19 Mar 2019; Accepted: 12 Jun 2019.

Edited by:

Paul Enck, University of Tübingen, Germany

Reviewed by:

Andreas Dinkel, Technical University of Munich, Germany
Johannes A. Laferton, University of Marburg, Germany  

Copyright: © 2019 Van Vliet, Francke, meijers, Westendorp, Hoffstädt, Evers, van der Wall, de Jong, Peerdeman, Stouthard and van dulmen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Liesbeth M. Van Vliet, Leiden University, Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden, 2311 EZ, Netherlands,