Journal of Religion and Health, Vol. 24, No. 2, Summer 1985

The Placebo and the Therapeutic Uses of Faith NORMAN SAUL GOLDMAN ABSTRACT: The holistic movement in modern medicine has raised questions concerning the

very character of the religion-medicine dialogue. A truly mutual interaction between theology and medicine must require of the theologian a serious interest in and understanding of medicine if the notion of the body-mind unity is to be taken seriously from the point of view of pastoral care. This paper suggests that this discussion may be enriched by a theological analysis of the placebo, which has lately been the subject of controversy within medical circles. Finally, it is suggested that the value of the placebo reposes in its serving as a symbol of the dynamics of faith in medical care.

Introduction

Religion, and especially J u d a i s m , has historically m a i n t a i n e d a deep inv o l v e m e n t in such issues as sickness and health. T h e earliest healers were the priests and s h a m a n s who conceptualized disease in t e r m s of evil or sin. Later, when healing b e c a m e medicine, and a n a t o m y , physiology, and b i o c h e m i s t r y s u p p l a n t e d confession, repentance, and expiation, theologians b e g a n to consider the parallels t h a t m i g h t exist b e t w e e n health and salvation, healing and faith. W i t h i n this framework, we shall focus upon one p a r t i c u l a r a s p e c t of medical t r e a t m e n t which clearly e m b o d i e s the i n t e r s e c t i o n b e t w e e n religion and medicine along the axis of faith and suggestion. I t has a l w a y s been acknowledged t h a t within the p h y s i c i a n ' s p e r s o n reposed one of his m o s t powerful weapons against disease, t h a t is, the a l m o s t ineffable q u a l i t y t h a t c h a r a c t e r i z e d a positive, enriching, and special p a t i e n t - p h y s i c i a n relationship. This relationship has been described successively as a sacred one, as one of s u p r e m e t r u s t , and as an essential i n g r e d i e n t of successful t h e r a p y . Indeed, it has often been r e m a r k e d t h a t cures r e s u l t even if t h e p h y s i c i a n exploiting the power of this special relationship prescribes n o t h i n g m o r e p h a r m a c o l o g i c a l l y active t h a n a placebo. Alas, the m e r e articulation of the word " p l a c e b o " evokes s t r o n g reactions when u t t e r e d at a ward r o u n d or medical conference, or when s u g g e s t e d as a possible form of t h e r a p e u t i c intervention. L e t us begin, therefore, with a careful definition and e x p l a n a t i o n of this r a t h e r c o n t r o v e r s i a l medical concept. In reviewing the l i t e r a t u r e on the placebo, the best definition I h a v e c o m e across is t h a t offered b y A r t h u r K. Shapiro. In a v e r y t h o r o u g h c o n s i d e r a t i o n of the placebo c o n t r o v e r s y , Shapiro s u m m a r i z e s the viewpoints of t h o s e who Norman Saul Goldman, D. Min., is Coordinator and Psychiatric Liaison with the Consultation Service of the Department of Psychiatry at Sieff Government Hospital in Safed, Israel. 103

0 1985 Institutes of Religion and Health

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have taken positions in favor of placebo usage as well as of those who are against the use of placebos. In this context, Shapiro suggests t h a t the placebo be defined as: 9 any therapeutic procedure (or that component of any therapeutic procedure} which is given to have an effect on or does have an effect on a symptom, syndrome or disease, but which is objectively without specific activity for the condition being treated. 1 The placebo and its allied placebo effect may be of particular interest to the pastoral therapist, because they appear to highlight the nonspecific or the nonbiological aspects of medicine. And it is precisely this phenomenon of nonspecificity, which remains so ambiguous to the medical scientist and yet so potent a tool in the hands of the medical healer, that serves us well as a focal point in the continuing, often faltering dialogue between religion and medicine.

Holistic medicine

If there is a way to bridge the apparent gap between religion and modern medicine or between a material versus a spiritual position, t h a t bridge must be the fascinating discipline of psychosomatics, holistic medicine, or behavioral medicine, as it is sometimes called. Of course, we cannot here discuss adequately this area other than to suggest a brief description 9 Perhaps it would be most helpful to conceive of psychosomatic or holistic medicine as a movement within medical science which emphasizes the role of intrapsychic, social, and environmental influences upon disease processes. For example, recent investigations into environmental stress and physiological effects spurred by the early work of Cannon and Selye, and the psychoanalytic theories of Alexander have enlarged our perspective and understanding of the way in which we live and abuse our lives as a potential source of illness. In a magnificent autobiographical account of the evolution of his "general adaptation syndrome," Hans Selye reports t h a t as a medical student, in an era of growing scientific precision and specificity, he began to pay attention to the vague and general condition of just feeling sick. During the ensuing years, he pieced together his now-famous biological theory of stress, which pivoted upon the centrality of the pituitary-adrenal axis. For Selye, hormonal balance and hormonal activity were the mediators of what he believed to be the nonspecific components of disease. The significance of Selye's work does not end with his hypothesis of a mechanism for disease process. Selye offers us a biological metaphor for some very fundamental theological notions, such as meaning, cooperation, unity, and altruism. As he states it: It is gratifying to learn that what religions and philosophies have taught as a doctrine to guide our conduct is based upon scientifically understandable biological truths. 2

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Thus, the religious values we have been taught have evolved from what Selye defines as "intercellular altruism"--simply stated, a cooperative effort among cells because of their common goal of biological efficiency and continuity. In contrast to this state of productive coexistence, Selye characterizes cancer as one result of forgetting this principle of "collective altruism" and replacing it by individual and unrestrained cellular expansion or aggrandizement. Life's irritations, disappointments, and frustrations amount to stress, and the effectiveness of our coping mechanisms determines the outcome of these psychic forces upon our physical health. Freud, in his early work with Breuer on hysteria, began to outline the patterns of intrapsychic turmoil vis-d-vis physical symptomology. In these writings he describes a process that may continue for years until there is a final irruption or "conversion," as Freud defined it. This conversion reaction does not take place in connection with impressions that are fresh, but in connection with the patient's memories of those impressions. Quite appropriately, Freud summed up the dynamics of hysteria as suffering from reminiscence.3 The problem in more theological language m a y be apprehended as one of memory or personal myth. This is a crucial theological issue, considering that the Judeo-Christian tradition is based upon our collective memories of significant primal events and the manner in which we have transformed these events into myth. The hysteric cannot adequately respond to his painful and disorganizing memories; and, somewhere along the line, his psychic defenses fail in the successful management and repression of these memories. In treating the hysteric, one allows the patient not merely to recall but to relive those memories. Whether we speak of catharsis, abreaction, or working through, the power and significance of the ritual repetition cannot be overlooked. Indeed, it has been suggested that in our modern technological civilization there are fewer essential "transition rituals. ''4 This dearth of ritual contributes to emotional breakdown, inasmuch as the individual is left to cope with challenges of maturation bereft of the ritual's powerful integrating and sublimating capacities. Consequently, as the work of Van der Hart suggests, some psychotherapists are creating therapeutic rituals which would facilitate a working through of previously unresolved conflicts. Since life consists of a continual series of transitions, encounters, challenges, and adaptations, the individual's accumulated successes or failures contribute to the mounting level of harmful stress affecting his health. As one of several modern researchers has pointed out, life changes, varying from change of job or stormy encounter with the boss to the death of a spouse, do affect the body and may even influence such diseases as cancer.5 Some investigators are currently working on a hypothesis of disease predictability based upon the sum total of stress that can be calculated to be present in a person's daily life. 6 It appears that the stress theory is being reworked to embrace the whole person and his possible illnesses from heart disease to periodontal disease and dental caries. 7 Our objective here, however, is not to catalogue the research into the relation between psychological well-being and organic illness.

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The holistic movement provides us with enough evidence to substantiate the importance of the mind-body schema in health care. The authority of this holistic point of view, which asserts that intrapsychic unease may and does contribute toward organic pathology, however, is essential to our appreciation of the theological meaning and value of the medical concept of placebo and the placebo effect. In the post-Cartesian world of the body-mind dichotomy, physical medicine began to make tremendous strides in diagnosis, treatment, and comprehension of disease. The contributions of Virchow, for example, in pathology created an entirely new perspective, as man's unwellness was reduced to cellular pathology. And, as William James indicated, medical materialism even attempted to reduce religious experience to afflictions of the liver, the digestive tract, or the brain. Thus, Paul's visions on the road to Damascus were merely the hallucinatory symptoms of a tumor of the occipital (visual) cortex, s This approach not only embraced internal medicine but dominated early psychiatry as well. Even the work of Freud on hysteria reflected his physiological bias when he wrote about psychic trauma in terms of "summation" and "foreign body," terms that refer to physiology and germ theory2 In fact, Freud conceived his psychology to be a natural science, and even his dream theory was constructed upon the foundations of the contemporary neurophysiology. Freud had derived his psychic model from the physiological constructs laid out in his Project for a Scientific Psychology, which was written in 1895, parallel to his research and writing of The Interpretation of Dreams. In this model of dream processes, the psychic and neural agencies are virtually the same.~~ Thus, even in his most theologically relevant masterpiece, his exploration of the unconscious and what Jung believed to be its revelatory capacities, Freud remained consistently loyal to a broad psychophysiological perspective, avoiding a simplistic and dangerous reductionism. Some fifty years later, Franz Alexander, despite his pioneering work in the psychoanalytic study of organic disease, in which he posited his theory of psychogenic specificity, expressed the hope that as physiology advances, we shall be able to study the brain processes of emotion. 1~ The fact is that more than thirty years have passed since Alexander's ideas about the emotional etiology of disease. We know a great deal more about neurophysiology today. We speak in terms of interacting psychosomatic processes rather than psychogenesis. Theories of multi-factorial causation seem to express more adequately the complexity of illness and the corresponding complexity of cure. In such a multi-dimensional view it is quite feasible to find an appropriate place for religion in both its integrative intellectualizing role and in its therapeutic role, Consequently, no longer should theologians or the pastoral care staff feel like second-stringers in the modern hospital. Perhaps, as many pastoral care workers have testified, the feelings of inferiority that accompanied the chaplain in the medical center were attached to the cultic and esoteric character of the hospital in which the physician officiated as the high priest surrounded by nurses, technicians, and novices (residents and interns), creating an atmosphere further strengthened by a special vocabulary and knowledge. But today, as holistic medicine expands and increases its adherents, the

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logical conclusion would place the social sciences and theology alongside physiology. Indeed, there will be a need for creating a new set of symbols that would truly be interdisciplinary.

Theplacebo Donald E. Smith, in an article on the future of the religion and medicine dialogue, reviewed the differences and similarities between religion and psychiatry or psychology. He attempted to explain why psychology began to replace religion and salvation gave way to self-actualization as the psychiatrist became the new high priest of a new cult, a new manifestation of idolatry identified by Heschel as egoism. 12 As a consequence of training programs in pastoral psychology, the clergy have begun their return to the classical priestly role of healing. The contemporary pastoral psychologist armed with the techniques of psychotherapy is attempting to perfect his discipline by synthesizing theological perspectives into a therapeutic modality involving insight, transference, ritual and tradition, liturgy, and values. In describing the altogether mystical aura surrounding the physician, Smith reflects upon the quality of the relationship that has evolved. . . . patients . . . spend hundreds of hours exposing their most dreaded secret selves to a stranger . . . . they pay as much as $100 per hour . . . . After all this they still feel obligated to the doctor . . . . One can only conclude that what happens in the doctor-patient relationship touches something as mysterious and profound as to set aside completely normal emotions about the fees-for-services relationship. 13 The radical dependency that is often developed on the part of the patient toward his physician implies a deep inward capacity for trust. As Smith observed, certainly the patient must have faith in the healer, and it m a y even be that faith is the healing force. Of course, it is on the level of faith that we speak here of the placebo. It is not merely the manipulation of the patient's gullibility, as some critics of the placebo would have us believe, that creates the placebo effect. Rather, it is one's complete and ultimate concern for getting well which transforms either the pharmacologically inert substance or the biologically potent substance, such as the antibiotic or analgesic, into an even more potent expression of man's striving for wellness and wholeness. It is precisely in this context that we can build a conceptual framework which allows for the use of ritual and regression in the service of healing. Whether we speak of one's traditional religion, faith in God, or faith that both the patient and the physician place in the cult of medicine, the role of ritual remains potent and quite often efficacious. Even the modern center in which physicians practice these rituals and display their symbols is a form of testimony to a fundamental need for ritual. In this sense, the white coats, the ceremonious ward rounds, the compulsive routine, and the ritualized approach to the patient all give expression

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to the fundamental aspect of the healing process, which is trust in the skill and judgment of the physician and the m y t h in which both doctor and patient participate. The placebo effect, then, is the direct result of the special quality inherent in the physician-patient encounter. In reminiscing about the "pretechnological" era in medicine, Lewis Thomas, Chancellor of the SloanKettering Cancer Center, describes his father's role as a physician in terms of how he looked after his patients by simply being there. And perhaps most important of all, he stood b y . . . getting down to brass tacks, what the doctor did; he might not have anything much in that black bag, and no magic potions to serve up, and certainly nothing that he could put into or get out of a computer, but he did have his presence and that made a difference. 14 It is this healing property of the physician's being, this mysterious gift which must be retained even as biochemistry expands its range of explanations and therapeutics. This notion of presence or gift presents us with still another manifestation of the placebo effect. The placebo, as we have already noted, is the subject of vigorous debate within the medical community. Brody, in a paper that summarizes the arguments pro and con, reviews the ethical and technical objections to the placebo. 15 Basically, the problem of employing the placebo is a moral one. According to Brody, it is the problem of the physician deceiving his patient. Historically, the placebo was given to the patient as a regular medicine, and the patient was led to believe that it was a potent drug. At times, the physician chose the placebo simply in order to placate his rather troublesome patients who suffered more from emotional problems than from organic illness. In such circumstances, the physician was, indeed, guilty of deceiving his patient, a tactic that today would be considered ethical misconduct. Thus, Fletcher strongly condemns the use of placebos as a "medical lie" 16which undermines the physician-patient relationship. This relationship, which today is more of a contractual agreement than a covenant, was once based upon what Brody describes as "paternalistic assumptions." In other words, the patient transferred upon the physican those attitudes and fantasies once projected upon his own "omnipotent" father. Shapiro outlines the conditions in which employing a placebo may be indicated; included are cases in which the patient is terminal and the truth m a y be harmful, or in which there are patients with incurable or degenerative conditions where no adequate treatment is known. 17 Most writers on the subject tend to agree with Shapiro's indications, especially on the point of there being no active medication available. It would appear, then, that for most physicians, the placebo constitutes a last resort or reflects an attitude that, since there is nothing better, perhaps a little psychologic manipulation or "faith healing" will be of some value. The implication, when physicians discuss the ethical aspects of placebo usage, is that failure to use pharmacologically active materials represents a medical shortcoming. Add to this the scientific commitment to truth, and we more fully understand the major obstacles in the contemplation of placebo therapy.

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Moss, in his study of the physician's resistance to open communication with the terminal patient, raises the issue of truth in this other context. He quotes the physician in William Hamilton's play about a young woman who asks her doctor whether she is going to die. "Look, when m y word of truth to a seriously ill patient can actually hurt him physically, can even wipe out the will to live, what is truth in matters like this? ''18 Indeed, what is truth in matters like health and illness? Used wisely, it may achieve the right effect, but, used improperly, it may be damaging. Consequently, one team of researchers reported on their study of patients' acceptance of their illness and its influence upon their treatment outcomes. 19 In brief, high acceptance and trust in the healer's capacity is a contributory factor to a good prognosis. A number of years later Mills and his collaborators applied these results to the postoperative course of patients who had undergone open-heart surgery, confirming the conclusion that acceptance was a crucial variable in getting well. 20 The question of telling the truth to the patient must inevitably be applied to the placebo issue. One of the most notable figures appearing in the longstanding debate was Richard C. Cabot, the famous clinician and ethicist. While he accepted the fact that it was nearly impossible for the physician to be dogmatic vis-d-vis the "truth," Cabot tended to reject the use of placebos on the basis of its long-range consequences. That is, if the physician prescribed a placebo simply in order to placate a patient who did not require any pharmacological treatment, he was directly responsible for the perpetuation of false ideas about disease and its cure. 21 The debate surrounding the placebo also includes those physicians who are willing to include in their medical considerations a nonscientific approach. Thus, for example, Fleming argues for the judicious use of the placebo when "organic" pain is present. But when the pain is of a non-organic origin, the physician should sit down and talk with his patient. 22Jerome Frank suggests that there are three conditions in which placebo therapy m a y be appropriate: when an active agent cannot be used or is nonexistent, with patients whose anxiety aggravates their condition, and with patients for whom treatment means a pill or an injection (and who, if they don't receive it, won't return). 23 After reviewing the moral elements of the placebo argument, Brody offers a "non-deceptive" technique for placebo usage which he feels fulfills the ethical command of physician honesty. For Brody, as well as for most of the proponents of the placebo, the essential curative factor resides in the physician-patient relationship. Thus, the placebo, as Fleming, Benson, and Frank all agree, is the symbolic representation of the physician's caring role. As Benson put it: . . . from antiquity until the present era, the physician, himself, has been a significant factor in the treatment of the patient. Until recently, this was the physician's most potent tool in restoring his patient to good health. 24 However, Benson is quite specific with regard to what he describes as the conventional placebo and its deceptive administration. Salt-water injections and sugar pills employed in the classical manner are dishonest and unethical.

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The healing relationship is crucial not only to the nonspecific aspects of treatment; it is also essential to the patient's understanding of and compliance with medical advice. Blackwell, investigating the problem of poor adherence to medical advice, suggested that three factors must be present in order to improve patient compliance. These elements are: better patient comprehension of his illness and its treatment, adequate supervision, and the patient's independent involvement or self-management under medical supervision. ~5 In order to achieve this goal of patient motivation and self-management, it is important that the physician take the time to educate his patient. This investment of time, then, becomes a simultaneous period of supervision. In effect, the process of educating one's patient has the potential of creating the kind of interaction and communication that inspires faith in the physician and, correspondingly, in his medicines. An illustration of the effectiveness of good communication comes from the studies of placebo effectiveness of surgical procedures on angina pectoris. The most significant element was the surgeon's own enthusiasm for the procedure, and those surgeons classified a s " skeptics" achieved poor results from the operation. 26 Indeed, the entire subject of physicians' attitudes, expectancy, and faith raises a rather difficult problem in terms of treatment outcome. One investigator attempted to examine the intrapsychic, interpersonal, and even the symptomatic aspects of the psychiatrist's prescribing medication for his patient. Medication was defined as a "relationship equivalent. ''27 Consequently, when appropriately prescribed, medication was perceived as a symbol of the physician's interest and care; and, when improperly given, it communicated the physician's indifference. In this sense, all medications maintain a placebo effect that may be either positive or negative. Furthermore, there is a quality of ritual even in the prescribing of medication. Frank has noted that the placebo's symbolic power is derived from its being a tangible symbol of the physician's role as a healer. But even beyond its symbolic use, it seems to have a special effectiveness in terms of activating the healing of damaged tissue, when that damage is related to physiological changes connected with unfavorable emotional states. 28 Thus, placebos produce their benefits by working upon certain negative emotional states. For example, it has been observed that the value of placebo analgesia in relieving post-surgical pain lies in its success in combating the "processing" aspects of pain, such as apprehensiveness or anxiety and other emotions that may influence the sensation of pain. The role of the patient's expectation with regard to treatment outcome constitutes another major dynamic of the placebo effect. Personality types that are capable of trust in their physician respond more favorably to the placebo. Finally, we arrive once again at the core of the issue, the dimension of expectant faith and the quality of the physician-patient relationship. The results of one research project carried out in a mental hospital demonstrate the power of an effective relationship. In this study, it was disclosed that when physicians took a renewed interest in their patients, the patients began to feel better about their doctors and began to improve. Skodol and his co-workers

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also carried out an investigation into the factor of "expectant faith" in terms of patients' relatedness to their physicians in a therapeutic community within a psychiatric hospital. When there were conflicts between patient and physician, there was also a negative influence upon the treatment outcome. The authors suggested that a negotiated approach to inpatient treatment may increase patient self-esteem, sense of responsibility, and capacity for trust visd-vis the hospital staff. 29 Further substantiation of the role of faith can be derived from the analysis of the role of expectancy in placebo effectiveness carried out by two psychologists, Ross and Olsen2 ~ They demonstrated experimentally that placebo responses were correlated either positively or negatively in relation to induced expectancy. Perhaps the most vocal adherents of the placebo are those proponents of the holistic movement in modern medicine. Kenneth Pelletier is one such advocate who urges that we place more emphasis on considering the ways by which the placebo effect can be systematically enhanced. Pelletier takes the position that the placebo is at the heart of all healing rituals and that through it the patient can see how potent and effective his own self-healing capacity can be. Therefore, in any revised approach to placebo treatment, the real or core aspect of the placebo effect would be the patient's informed and accepting attitude, which embraces a profound appreciation for his own intrinsic powers of healing. As Norman Cousins so aptly phrased it: 9 the placebo, then, is an emissary between the will to live and the body. But the emissary is expendable. The mind can carry out its functions without the illusions of material intervention9 The placebo is the doctor who resides within. 31 This internalized "doctor" or self-healing capacity has been highlighted in the work of Carl Simonton, who has introduced placebo techniques, such as guided imagery in the treatment of cancer. Patients were able to visualize their malignancies as symbolic devils, while they fantasized their medications at war with these personified cancer cells. Many patients suffering from advanced cancer survived up to twice as long as would have been expected. A major area of placebo effectiveness is that of pain relief. And pain is more than a physical indication of illness signaling that something is wrong somewhere in our bodies. Pain is demoralizing and dehumanizing, entangling the sufferer, who becomes totally involved with his pain. It overwhelms him, occupies him, invades and obsesses him. We see, as we observe Ivan's torment in Tolstoy's short story, The Death of Ivan Ilyich, how pain begins to create a subjective barrier between the sufferer and those around him, so that even his physician would say something like, "Yes, you sick people are always like that," when Ivan imploringly describes his pain. Anyone who has carefully observed individuals in pain recalls that its torment does not merely distract; it demands complete participation in it and identification with it. When we speak of the psychosocial aspects of pain, we come closer to appreciating its meaning than if we merely describe its neurological processes. It is larger than pain receptors and dorsal horn cells; it is also intrapsychic and idiosyncratic. In this more personal sense, pain tells us something about who we are and

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what we fear. Consequently, pain and the control of pain are of interest to the theologian. In one such investigation of pain control involving a study of 107 dental patients who had undergone extraction of their wisdom teeth, their level of postoperative pain was subjectively rated. Of these patients in a double-blind study of the placebo, 39% reported significant pain reduction in response to administration of the placebo. 32 Aside from the placebo effect of medications or inert substances, it appears that, at times, surgery in itself has a placebo effect. For example, Beecher reports upon this use of surgery and notes that for many years physicians discussed the surgical treatment of pelvic inflammatory disease in the following manner: "You just open up the belly and let in a little light and air." In the same study of placebo surgery, Beecher reviewed the use of ligation of the internal mammary arteries for the management of the pain associated with angina pectoris. Beecher concludes that a sham operation consisting merely of incision of the skin was equally as effective in pain control. 33 In pursuing the investigation of placebo analgesia, researchers have come across the intriguing hypothesis that this placebo effect may be mediated by endorphins or endogenous opiate-like substances which exist in highest concentrations in the brainstem, reticular formation, thalamus, and limbic system. These areas are responsible for both the perception of pain and our affective responses to pain, and help to explain why different individuals react to pain in different ways. Our current understanding of the mechanism of endorphins indicates that the body does have an endogenous pain-controlling system that is in part mediated by endogenous opiates. This system is not activated by the ordinary painful stimuli, but may be brought into action by certain non-pain sensory endings, as demonstrated by emotional excitement and/or intense motor activity. This system may be continuously operative in such pathological conditions as congenital absence of pain. One investigator has applied the endorphin hypothesis to acupuncture analgesia, which is widely used in China as a method of surgical analgesia, and concludes that electro-acupuncture hypalgesia (EAH) is, indeed, mediated by endorphins. 34 It appears that there are actually two different types of endogenously generated analgesia: a purely psychogenic mechanism that we might call faith analgesia which is associated with hypnosis and possibly the placebo effect, and endorphin-mediated analgesia of the acupuncture type and implicated in phenomena of trance or altered states of consciousness. 35 It would seem, therefore, that there is some way in which both categories of endogenously produced analgesia are related to transformations of an intrapsychic character. In studying a religious sect that has experienced both types of analgesia in relation to fire handling and snake holding, Kane has recorded the physiological effects of these mountain believers, who in a trance state have touched hot stove pipes, blow torches, and open flames. 36 It was then postulated that endorphins act upon opiate receptors in the brain and spinal cord that are associated with sensations of euphoria and analgesia,

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respectively. As a result of investigations such as these, pastoral theologians m a y begin to wonder whether there can be a therapeutic advantage to religious-trance experiences that may function as a means of alleviating stress. There are, however, several features that must be satisfied in order for us to accept the thesis that endorphins could be involved in mechanisms producing trance states. First, there must be a means by which the body is equipped to reduce pain. Second, there must be a mechanism for activating this means of reducing pain. Third, this mechanism should function as a natural component of normal physiology. Fourth, the type of behaviors associated with trance states can activate this system of euphoria-analgesia. Henry suggests that this behavior associated with trance states is motivated by the power of suggestion: that is, knowledge or awareness on the part of the individual that if he participates in a particular rite, an altered state of consciousness m a y be achieved. In addition, any necessary reinforcement may be provided b y t h e onlookers or the congregation. ~7 This theory can be applied to our placebo model, in which the direct participant--the patient--is supported in his belief or faith by the reinforcement of the healing team {physician, chaplain, nurses}. Preliminary considerations of the interactions between medication and relationships, endorphins and trance states, healing and faith, point to a fertile area of exploration for both the physician and the theologian. As Sidney Jourard reflected upon these correlates: 9 there is a growing reason to suspect that hope, purpose, meaning and direction in life produce and maintain wellness, even in the face of stress, whereas demoralization by events and conditions of daily existence helps people become ill. 3s Perhaps it is precisely upon this plane that the religion and health dialogue must continue. At one time theology and psychology were separate and often antagonistic disciplines. Psychoanalysis, it was believed, had raised issues that posed a serious threat to theology and the religious community. Freud had written critically of religion as a form of collective neurosis. But today close collaboration exists between religion and psychiatry, while psychoanalysis, especially, has become a bridge between the two perspectives. Today many seminaries offer psychological training as part of their preparation for the ministry or the rabbinate. Likewise, a number of clergy conduct regular counseling sessions as a part of their ministry. However, what about the pastoral care expert in the medical center? Is it sufficient for him to know only of psychotherapy or counseling in order for him to be of assistance in the spiritual or emotional support of the hospitalized patient? As we are beginning to realize, the holistic movement has created an ambiance of genuine dialogue. More and more physicians are making an effort to learn more about psychology and religion. Indeed, many medical schools offer courses in medical ethics taught by theologians. One m a y wonder, however, how many medical courses or courses in human biology are offered b y theological seminaries as part of a pastoral care program. While no one ex-

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pects a return to the ancient world, in which priest and healer were one individual, we are witnessing the growth of church-clinics wherein an interdisciplinary team attends each referral.39 The dialogue cannot overlook the placebo phenomenon--that is, the medical event in which the healing of the body as well as of the psyche can occur in response to an individual's faith and spirit. To quote Jourard once again: Events, relationships or transactions which give a person a sense of identity, of worth, of hope and purpose in existence are "inspiriting" while those that make a person feel unimportant, worthless, hopeless, low in self-esteem, isolated, and frustrated and those that make him feel that existence is absurd and meaningless are "dispiriting. ''t~ In agreement with the aforementioned, it has been observed t h a t when the element of hope is destroyed, the body's resistance to disease lessens and the probability of cure is diminished. 4, Consequently, a fully holistic approach to the patient must involve those levels of being wherein the arousal of faith is possible--not simply faith in the physician and his medication, but faith in the self as well. This, perhaps, is the special task of the chaplain or the "theologian in white." Oddly, some chaplains object to wearing white coats like the physicians, perhaps out of embarrassment or an unconscious and archaic sense of competition or a secret feeling of envy before the high priest of medical science. Nevertheless, there is a profound reason for the chaplain to wear the white coat. By wearing the same garb as the physician, he presents himself as an equal member of the healing team who participates in the mystique, the cult, and the ritual forms of the hospital. It is a cult not in competition with one's denominational rites, but a different expression of the classic Judeo-Christian concern for healing and everything associated with life and its preservation as a sacred deed. Thus, the chaplain appearing at ward rounds and clinical conferences is merely expressing his interest in and commitment to the body and its theological significance. As we have noted, there may be some technical difficulties in developing such a theology of the body as a component of theology of person. After all, can one be expected to appreciate the complexity of medicine without mastering its basic sciences, such as anatomy, biochemistry, or physiology? J u s t as theology once had to negotiate new alliances with anthropology, archaeology, history, and the behavioral sciences, today religion may be confronted by a newcomer. If we have accepted the contributions of psychoanalysis and existential psychiatry, we m a y need to consider still another aspect of this condition referred to as dis-ease--namely, its psychophysiology. Tomorrow we may yet speak of the physiology of faith, as psychology and neurophysiology form new and imperceptible boundaries. We may, therefore, wish to entertain the possibility of providing a broader education in human biology for the pastoral care specialist. Over the years one m a y have noticed that various pastoral journals carried articles on pharmacology, brain physiology, and hypnosis. Perhaps these early references to

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the biological aspects of the person represent the beginnings of our a t t e m p t to increase our understanding of human physiology and explore its relationships to spirit, faith, and healing.

Conclusion Tillich has written that man's ultimate concern must be expressed symbolically because symbolic language alone is able to express the ultimate. It is in this vein that the placebo is of greatest relevance to the collaborative effort between theology and medicine, because as a prescribed medication it is symbolic of the physician's therapeutic powers, and as a pharmacologically inert substance it is symbolic of the power of faith, while it.s actual effect is to mobilize the patient's own inner resources of healing. Continuing in the spirit of Tillich's discussion of symbols, the placebo (as a symbol) points beyond itself to something else. It also participates in that to which it points and opens up levels of reality that are otherwise closed to us. Thus, the placebo reminds the physician as well as the patient that while biochemistry m a y a t t e m p t to explain how some processes occur, it fails to answer the question why--which remains a mystery. And it is this m y s t e r y of healing that creates awe in all of us, physician and theologian alike. A final word of caution, because there is danger in new movements and new ideas, the danger of inculcating the heady feelings of having all the right answers, of discovering a panacea. Studies in the effects of the placebo are interesting and sobering, but like everything else in our fragile world they provide us with only limited results. The "wonder" drugs like penicillin have fallen to the emasculating effects of resistant strains of bacteria, and new p2:otocols in chemotherapy are, at times, found to be carcinogenic in themselves. The placebo and the role of faith have their places in the modern health care center, but they must not be distorted out of proportion. The s t u d y of the placebo and its theological implications supports the idea that the clergy m u s t be partners in the physicians' work, or, more theologically stated, both the chaplain and the doctor are partners in God's work. Once Abraham J o s h u a Heschel, speaking before the American Medical Association, expressed the complex relationship between religious and medicine with the simplicity and charm that have been the hallmark of his theological style. "Religion is medicine in the form of a prayer; medicine is prayer in the form of a deed. ''42 His words seem to befit our discussion here; they are a preface to our research, a guide for our labors, and a summation of our efforts.

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