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Articles:  Talk of risks, side effects may lead to nocebo effect &
 Psychotherapy, embodiment and the Dharma {Below}

Medicine Prescription

Talk of risks, side effects may lead to nocebo effect

By Bruce Borkosky, Psy.D, PA
January 5, 2021

Appropriate informed consent requires disclosure of the proposed treatment, the risks and benefits of that treatment, the risks and benefits of not proceeding, and alternatives to the treatment. This practice has become widely accepted, primarily because it supports patients’ autonomy.

However, perfect autonomy is impossible because there are always factors influencing non-rational decision-making.

Further, autonomy can sometimes conflict with nonmaleficence (do no harm). Patients can be harmed by the disclosure of risks and/or side effects because the mere mention of side effects causes patients to experience those side effects. This is a corollary to the placebo effect, called the nocebo effect.

For example, patient A is told that erectile dysfunction (ED) is a side effect of an antidepressant and develops ED even though he previously never suffered from that problem. The medication is discontinued, but the ED remains unresolved.

Nocebo effects are common and, when medications are involved, may occur more frequently than side effects caused by the specific pharmacological action of drugs.

Nocebo effects can cause unpleasant side effects, eliminate the efficacy of a beneficial treatment and increase perceived pain. Patients may discontinue needed treatments and may seek additional medical consultations. Medication changes and hospitalizations may rise, patient distress may increase and quality of life may decline. In the extreme, these negative expectations may increase the risk of suicide.

Nocebo effects can be caused by patients’ fear, anxiety, increased attention to symptoms and even direct neurobiological changes. Patients who somatize or who are anxious or depressed may be at greater risk of nocebo effects.

Minorities and other vulnerable populations may also be at greater risk.

The suggestibility of mental health patients to placebo/nocebo effects may be extreme. For example, antidepressant clinical trials consistently show placebo response rates of 30 percent to 50 percent. Similarly, clinical trials have found a drug vs. placebo effect difference of only 0.5 standard deviations.

The nocebo effect has implications for mental health professionals, not only for our informed

consent process, but when assisting other healthcare professionals. For example, health

psychologists might consider designing the informed consent process for medical practices.

Accordingly, given that the nocebo effect can potentially harm patients, increased

consideration should be afforded to this potential for harm during the informed

consent process.

The following suggestions are offered as ways to reduce the frequency and severity of nocebo effects during informed consent:

* Recognize that informing patients about side effects is not a mere presentation of “facts” but an essential component of treatment and requires clinical judgment.
* Personalize the disclosure provided according to patients’ needs (i.e., don’t use the same boilerplate “contract” with every patient).
* Frame information in a positive manner (i.e., to reduce loss aversion)
* Have a discussion with patients regarding how the anticipation or fear of an adverse reaction can become a self-fulfilling prophecy.
* Discuss the nocebo effect explicitly.
* Discuss those risks that are more common and potentially more detrimental to patients.
* Provide opportunities for those patients who desire more information – i.e., creating separate documents with more details, etc.
* Discuss with patients how side effects occur and how to guard against them.
* Avoid unintentional negative suggestions, such as trivialization (e.g., “You don’t need to worry.”), or focusing attention on symptoms (e.g., “Are you in pain today? Are you depressed today?”).
* Practice validation (involving both understanding and acceptance) and take care that the reassurance is not seen as being patronizing.
* Elicit discussion of patients’ negative expectations by encouraging question-asking and correcting any mistaken assumptions.
* Discuss any prior bad experiences with mental health professionals in treatment, evaluations or via personal contact.

An ongoing controversy in the ethics community is whether patients should be provided with all information — in the name of autonomy — or whether withholding information is sometimes permissible. Some have even argued that patients should be nudged to make “better” decisions (a la Thaler, 2009), while others are horrified by this suggestion.

The concept of the nocebo effect clarifies that not all information is helpful for all patients; as psychologists, we should be mindful of the effect our words and actions have on patient decision-making.

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Bruce Borkosky, Psy.D., has been practicing forensic psychology for 26 years. Currently working as a prison psychologist and in private practice, he regularly publishes on the law and ethics of the clinician-patient relationship. His articles may be found online at and he can be contacted at A number of relevant articles on the nocebo effect are available at


Psychotherapy, embodiment and the Dharma

By Bryant Welch, Ph.D., JD
January 5, 2021

“I don’t have any experience in applying Western psychotherapy to the Buddhist path.”
— H. H. Dalai Lama.

These are dark days. And more than anything else, the stability of the human mind will determine our outcome.

Trying to understand the mind as we psychologists do is a humbling task. And trying to find ways to have a salutary effect on human suffering and irrational behavior based on that understanding is even more daunting. To me, this endeavor is the noblest enterprise imaginable and it is why I am so grateful for our profession.

I have been practicing now for 50 years. Serendipitously, along the way, I have been fortunate enough to have had some unique perspectives on this struggle to confront the complexities of the mind, the vicissitudes that have facilitated it and those that have maddeningly hindered it.

As difficult as these times are, especially in America, I have never been more excited or hopeful about the opportunities and horizons that I see emerging all around me to help alleviate the human suffering we treat in psychotherapy.

In part, this optimism may be because I practice in the San Francisco Bay Area. Still, the germs that are sprouting here are visible in other psychology communities around the country. It is essentially a story of diversity and what the illumination of different mindsets can reveal about the otherwise elusive nature of our subject and what we need to do to enhance our ability to alleviate our suffering and the terrible things it causes us to do.

Creativity and progress are based on cross-fertilization, either within the individual mind or the community at large. If it takes a village to raise a single child, harnessing the human mind for a happier existence will undoubtedly require an entire planet. Most profoundly, it has been our success, partial. However, in removing fear-based systems of thought that serve as yokes on the freedom and the diversity of many of the very different mindsets, we need to maximize the fruits of our inquiry into the nature of the mind in all its complexity.

In the 1980s, psychological inquiry and the diversity it requires were suppressed by the medical monopolists of that era. They had for decades kept psychologists and others from participating fully in the exploration and treatment of the mind. Psychology successfully overturned significant aspects of that problem and our inquiry has improved with those developments.

A greater hindrance to our tapping into the mysteries of the human mind has been our systematic exclusion of huge classes of human minds based merely on the fact they are different from the ruling regime and its orthodoxy, be it by gender, sexual orientation, race or cultural origin. But the lesson for which I am most grateful to psychology is that if I can persevere through my initial fear of something new or “different,” regardless of its nature, I am enriched in the deepest parts of my being. My understanding and perspective on the mind are expanded and my connectedness to my world strengthened and more secure. Most selfishly, my work is better, and I enjoy it more.

What has been most frustrating about the progress we have made to date has been the

extent to which the victims of the most intense human suffering themselves have had to

shape the progress we have made. When I went to graduate school in the early 1970s, it

was almost as if human trauma did not exist. For the first time, with Vietnam and the

women’s movement, voices of severe trauma refused to be silenced in their insistence

on the reality of their suffering. Human trauma, long strikingly overlooked by the menta

l health establishment, could no longer be dismissed.

With the increased recognition of human trauma, still very partial though it is, it has become difficult to deny the significance of the human body itself in the work we do. “Embodiment” techniques that become fully integrated into traditional psychotherapy, as many other psychologists are learning, provide the single most helpful breakthrough in the opportunity to increase the therapeutic agency of what we do in psychotherapy that has occurred in my lifetime.

Bodily awareness of the most personal and visceral nature of human experience is the most direct and powerful tool I have experienced in facilitating greater psychological awareness and psychological change in therapy. Neither the insight of the psychodynamic therapist nor the cognitive restructuring of the CBT therapist can be very effective if it does not take place in an embodied awareness.

But there is another fold in this therapeutic progression of which I am speaking that is crucial to understanding my renewed enthusiasm for this therapeutic enterprise.

International and cultural barriers have also been challenged during my lifetime. I had been a dilettante in Eastern contemplative practices for almost 40 years. But with the recent Tibetan diaspora caused by the Chinese attempt to obliterate the Tibetan culture and the psychological insights it had developed over millennia, hundreds if not thousands of Eastern scholars have come to our country, many settling in the Bay Area.

What they have brought to us is truly stunning. They provide an understanding of different dimensions and perspectives on the mind; they bring ways of accessing and experiencing those dimensions. Long inaccurately portrayed in Western culture, with more direct contact with these scholars themselves, these misunderstandings break down the extraordinary insights, often counterintuitive, are empirically observable and usually confirmed by Western science.

The contemplative practices these teachings teach do not preach about reality as with religion. Instead, they help one’s mind hold steady so the microscope that is our mind can stop shaking when it looks at both the world and at the mind itself. In this condition, things look very different. It provides an invaluable tool for psychotherapy.

When we integrate these tools of traditional Western psychotherapy, increased awareness of the importance of embodiment, and the contemplative tradition, we have a much more therapeutically powerful and effective tool than any of these modalities alone.

And that I find exciting.

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Bryant Welch, Ph.D., JD, is a clinical psychologist practicing in Sausalito, CA. His email address is

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