The concept of placebo is predicated on the opposition between active and inert, deploying this opposition to assert that an action or substance with no inherent active principle can have a paradoxical effect “as if” it were active.1 My thesis is that there is no such thing as the inert in human affairs, relationships, or experience. Think of the apparently simple retort of the bullied child that “sticks and stone may break my bones but names can never hurt me.” Contrary to this retort, names can indeed hurt. They are not inert, but carry an actual force identifiable as hate or disdain. And what of the retort itself? Is it a vain, desperate, and ultimately inert act of self-protection, effective only insofar as it taps into the “as if” logic of the placebo? I think not, though like any remedy it must be applied under the right conditions and with the understanding that it may not be uniformly effective in the degree to which it buffers the noxious influence of name-calling with an equivalent, self-confident force of self-esteem. There is also, however, an easily overlooked element of materiality in the retort. That is its rhythm: the fact that it is phrased in trochaic meter. It is not only that meter adds the force of incantation or song, but that it directly engages the embodied existential immediacy of the situation, contributing an element of jauntiness encompassing not only tone of voice but posture and gesture.
The notion of materiality as I have just used it is of value in reflecting on the impossibility of the inert. Consider water – presumably a substance more inert even than the classic sugar pill of placebo research – from the standpoint of a Navajo indigenous healer, a Road Man of the Native American Church who was also a college instructor of Navajo culture: “Water is the most powerful medicine.” He elaborated that when a person is ill the most basic thing they need is water, and it is what one thinks of first to give an afflicted person. All of life is based on water, which it needs to survive and thrive. The insistence on water being a powerful medicine is all the more compelling given that it is expressed by a Road Man who administers peyote, the sacred cactus whose mescaline and related alkaloids render the idea of inertness massively irrelevant. So in what sense can we understand water as a medicine and not inert? First, this is a matter of adequate hydration. Second, however, the act of giving in itself is not inert insofar as it conveys a sense of care along with the material substance being given. Here the process of recognizing the power of water as medicine is identical with investing water with the power of care. It is consecrated in the sense used by anthropologist R.R. Marrett, who defined sacrament as investing a natural function with supernatural authority.2 Ritual in general and sacraments in particular are purposive and not passive, not a matter of routine and repetition, but of vigilance and a summons to exertion. They are not inert.
The uses of rhinoceros horn offers an example that taps a more complex series of relations between care/commercialization, specific/non-specific, and active/inert. Currently, of the thirty once-living rhinoceros species, all five that remain are near extinction because of poaching. Over the centuries rhinoceros horn has been used in Traditional Chinese Medicine to treat a broad range of conditions including fever, rheumatism, gout, snakebites, hallucinations, nightmares, typhoid, and headaches.3-8 Though studies indicate the horn is not entirely inert, in the last decade an explosion of horn use has taken place in Vietnam, where new uses have been introduced including as a palliative treatment, and possibly a cure for cancer. This popular usage corresponds to rapid increase in the proportion of wealthy people who can access the substance, combined with the quickly rising cancer rate in a country with still-inadequate health care. Rhinoceros horn has also become commonly used to support an extravagant lifestyle, reputedly allowing people to drink more and curing hangovers due to its traditional attribution of enhancing liver function. Indeed, rhino horn powder mixed with rice wine is described as the drink of millionaires. The false notion that rhinoceros horn is used as an aphrodisiac in Asia appears to be the fabrication of mid-20th century Western writers, but ironically under the influence of such writers there now does appear to be a trend for such usage in Vietnam,4,5,7 one that is “more effective than Viagra in allow men to have sex for two to four hours.”9 A generous conclusion would be that the traditional medical system is evolving, and a critical one would be that traditional medicine is being distorted and exploited. One is hard pressed not to conclude that this phenomenon bears some similarity to off-label prescribing in our own society. How could a placebo effect for one condition not be enhanced by the proven effectiveness of the same substance for another condition? Finally, there is the ironic trend in which the Vietnamese market has been infused with fake rhinoceros horn – the placebo form of the placebo.
Discussion of the placebo is intertwined with how ritual healing works, fundamental to which is the “psychotherapy analogy”: the idea that ritual healing works in an indigenous setting as psychotherapy works in a Euro-American setting, and can be understood as that culture’s equivalent of psychotherapy.10-11 One practice of ritual healing to which the psychotherapy analogy applies is exorcism in the Roman Catholic Church, a liturgical rite intended to relieve affliction due to possession by evil spirits, performed by a priest under permission from a bishop. In the past decade Catholic exorcism has acquired a more prominent profile in the public sphere than at any time since the beginning of the Enlightenment. The Church accepts psychiatry insofar as, officially, mental illness must be professionally ruled out prior to recognizing a problem as due to demonic affliction.
This relation between psychiatry and religion is relevant to an understanding of placebo. The 2006 theology dissertation of an American priest who serves as his diocesan exorcist addresses the relation between the exorcist and psychiatrist by categorizing mental health professionals into three categories: those who completely reject the use of exorcism in any circumstance and dismiss it as medieval “hocus pocus;” a “placebo” group who regard exorcism as potentially to be a simple solution or a “quick fix;” and a category, “well-regarded by exorcists, [is] that of medical practitioners, including psychologists and psychiatrists, who are willing to work alongside exorcists and theologians in caring for the possessed and other people otherwise affected by demonical forces.”12 The palpable distress experienced by those who seek the help of exorcists is not only assessed in terms of the presence or absence of demonic activity but also in terms of the presence or absence of mental illness.
Psychiatrists and psychologists who are both practicing Catholics and convinced in the ontological reality of evil spirits consult and assist exorcists. One such Catholic psychiatrist, who holds a medical school faculty position in psychiatry as well as a clinical position in the affiliated mental hospital, responded to an article in a Catholic magazine written by the dean of his medical school. The dean, himself a Catholic, argued that what in biblical times was defined as demonic possession corresponds to what today is understood to be mental illness. My interlocutor agreed with everything except the obsolescence of evil spirits, and argued that evil spirits are, in his phrase “ontological entities.” When I asked if his position was not a challenge to rationality, he invoked Aquinas on the synthesis of faith and reason.
This leads to a series of peculiar questions. If possession is understood to be mental illness in actuality, would that mean exorcism must by definition be understood as placebo? Would that conclusion be reversed if exorcism was redefined as a form of psychotherapy? If demons were ontological entities, would that allow exorcism to be defined as active rather than inert? If a mentally ill person was possessed and then healed by exorcism, would its effect on the possession be understood as active while its effect on the psychiatric disorder be understood as placebo? Are we justified in describing the demonic spirit as a nocebo – an inert, immaterial entity capable of causing harm to humans? Are we justified in describing the rite of exorcism as a placebo – an inert, symbolic performance? It is out of the question to say that the afflicted are not really suffering and therefore exorcism as an inert treatment is only alleviating a non-effect. Exorcists and their assisting mental health professionals seriously endeavor to distinguish cases of psychiatric disorder and demonic possession, and moreover to consider whether an individual can be said to be both mentally ill and possessed. One exorcist has written that the criterion of demonization is that there is a kind of “surplus” in the sense that the affliction “goes beyond” what is typical of psychiatric disorder.13 This suggests that there may be a phenomenological surplus distinctive to the Roman Catholic cultural milieu which is expressed, enacted, and experienced in specifically Catholic terms. In other words, following the premise that each culture engenders the problems for which it then creates solutions, the possession/exorcism complex may be such a phenomenon.
Finally, contrary to what one might expect, exorcism is not understood as a one-shot magic bullet, or a miracle technique. It is typically an ongoing process requiring multiple sessions, and it is said that a complete liberation from demonic influence can require 5-7 years if a person if truly possessed. It is not so much that this “incremental efficacy”10 makes exorcism analogous to extended psychotherapy as that the impossibility of the inert does not require healing to be dramatic and miraculous. What guarantees the impossibility of the inert is not only meaning but care. Meaning and care are invested in the medicine or treatment. From the side of the patient, care makes an impression, and I choose this word precisely because it bears both a material and mental sense. The degree of this impression is in turn contingent on the nature and extent of the afflicted person’s engagement in the process of becoming well, an element that can never be completely controlled for in a clinical trial. Care, investment, impression, and engagement are the human phenomena that need to be isolated and elaborated, because they are the active ingredients of the placebo effect, the agents that guarantee the impossibility of the inert.
- A longer version of this essay was presented to the Robert Wood Johnson Seminar on Healing and Placebo: Medicine, Religion and Ritual, Harvard Medical School in 2014. Research on Navajo healing was funded by the National Institute of Mental Health and approved by the IRB at Case Western Reserve University. Research on Roman Catholic exorcism was funded by the Social Science Research Council and approved by the IRB at the University of California, San Diego.
- Marrett, R. Sacraments of Simple Folk. Oxford: Clarendon Press, 1933.
- Rhino Horn Use: Fact vs. Fiction. 2010 http://www.pbs.org/wnet/nature/episodes/rhinoceros/rhino-horn-use-fact-vs-fiction/1178/
- Ellis, R. Poaching for Traditional Chinese Medicine. EAZA Rhino Campaign 2005-6. http://www.savetherhino.org/rhino_info/threats_to_rhino/poaching_for_traditional_chinese_medicine
- Milliken, T., Shaw, J. The South Africa – Viet Nam Rhino Horn Trade Nexus: A deadly combination of institutional lapses, corrupt wildlife industry professionals and Asian crime syndicates. TRAFFIC, Johannesburg, South Africa, 2012.
- Do, H. B., Dang, Q. C., Bui X. D., Do, T. D., Pham, V. H., Vu, N. L., Pham, D. M., Phan, K. M., Doan, T. N., Nguyen, T., Tran, T. Medicinal plants and animals in Vietnam, Volume II (first edition). National Institute of Medicinal Materials, House for Science and Technology of Hanoi, Viet Nam, 2006.
- But, P., Tam, Y-K, Lung, L-C. Ethnopharmacology of Rhinoceros Horn 1: Antipyretic Effects of Rhinoceros Horn and Other Animal Horns. J. Ethnopharmacology, 30: 1990, 157—168.
- But, P., Lung, L-C, Tam, Y-K. Ethnopharmacology of rhinoceros horn. II: antipyretic effects of prescriptions containing rhinoceros horn or water buffalo horn. Journal of Ethnopharmacology, 33:1991, 45—50.
- Guilford, G. Why Does a Rhino Horn Cost $300,000? Because Vietnam Thinks It Cures Cancer and Hangovers, 2013. http://www.theatlantic.com/business/archive/2013/05/why-does-a-rhino-horn-cost-300-000-because-vietnam-thinks-it-cures-cancer-and-hangovers/275881/
- Csordas, T.J. The Sacred Self: A Cultural Phenomenology of Charismatic Healing. Berkeley: University of California Press 1994.
- Csordas, T.J. Body/Meaning/Healing. New York: Palgrave 2002.
- Grob, J. A Major Revision of the Discipline on Exorcism: A Comparative Study of the Liturgical Laws in the 1614 and 1998 Rites of Exorcism. Dissertation submitted to the Faculty of Canon Law, Saint Paul University in partial fulfillment of the requirements for the degree of Doctor of Canon Law. 2006: 115—16.
- Dermine, F-M. Carismatici, sensitivi e medium. I confini della mentalità magica. Bologna: ESD-Edizioni Studio Domenicano, 2010.
Thomas J. Csordas is the Dr. James Y. Chan Presidential Chair in Global Health, Distinguished Professor in the Department of Anthropology, Director of the Global Health Program, and Co- Director of the Global Health Institute at the University of California, San Diego. He has conducted ethnographic research among Charismatic Catholics, Navajo Indians, adolescent psychiatric patients in New Mexico, and Catholic exorcists in the United States and Italy. Among his publications are The Sacred Self: A Cultural Phenomenology of Charismatic Healing (1994); Embodiment and Experience: The Existential Ground of Culture and Self (1994); Language, Charisma, and Creativity: Ritual Life in the Catholic Charismatic Renewal (1997); Body/Meaning/Healing (2002); and Transnational Transcendence: Essays on Religion and Globalization (2009).