Expectation as Medicine: How Belief Enhances Real Treatments

Minutes before surgery, a surgeon tells a patient, “You’re going to bounce back faster than most.” Weeks later, she’s back on her feet ahead of schedule, despite the procedure and medication being identical to everyone else’s care. What changed? Her belief. This is the power of expectation acting alongside real medicine, not instead of it.

What Is the “Expectation Effect”?

This is more than a fancy word for placebo. It’s how what you expect for better or worse helps or hinders a real treatment. Expecting relief can amplify a drug’s effectiveness; expecting harm (a nocebo effect) can make side effects worse. Telling people about a painkiller’s power can double its impact, while highlighting negatives can nearly erase its benefit. One brain‑imaging study found that people who expected strong pain relief from an opioid experienced twice the benefit compared to those who didn’t; expecting the opposite found the drug virtually ineffective (Bingel et al., 2011).

What Happens in the Brain and Body?

Expectations don’t just stay in your head; they cascade through your body. Neurologically, the prefrontal cortex sets up expectations, which trigger the descending pain‑control system (involving the anterior cingulate cortex and brainstem), causing the release of natural opioids (Ossipov et al., 2010).

Open‐label placebos, where patients know they’re taking a placebo still work. They activate reward and pain control circuits, release endorphins, reduce cortisol, and in Parkinson’s cases, even boost dopamine release in the brain (Bernstein et al., 2021). Meta‑analyses show they consistently improve self‑reported symptoms, though not objective (Fendel et al., 2024).

Real-World Cases That Make This Concrete

• Side effects: Expectations matter. Simply informing patients about side effects can more than double the likelihood they’ll experience them. Those expecting severe effects in hormone blocking breast cancer treatment were 1.8 times more likely to report them (Webster & Rubin, 2021).

  
  

• Acceptability in the UK: Surveys find that both the public and GPs in the UK are open to the idea of open‑label placebos, especially where they can help reduce over-prescribing, for example, with antibiotics (Krockow et al., 2023).

Why Expectation Still Isn’t Mainstream in Practice

According to (Day One: Placebo Workshop: Translational Research Domains and Key Questions, 2024), trials have aimed to remove placebo effects to isolate a drug’s “pure” effect. That has taught clinicians to dismiss expectation as noise, rather than seeing it as part of the therapeutic mix.

There's also a cultural divide. In Western medicine, mind and body have long been treated separately. Although doctors know reassurance helps, they’re rarely trained or given time to use words to biologically support healing.

The Path Forward Expectation as Therapy

The future points to expectation as an ally in treatment, not a sideshow. Some promising directions:

• Clinician communication training: Simple phrases like “Many patients tolerate this well” can significantly ease patient anxiety.

• Therapeutic environments and rituals: Techniques like calming audio during surgery or brief visualisation before treatment may subtly reinforce the expectation of healing.

• Personalising belief: In future, health records might note how best to frame information to support a patient’s mindset. Some patients may get open-label placebos or mind-based encouragement alongside treatments.

• Ethical placebos: Approaches such as dose extending placebos (interspersed with real meds) or digital tools that reinforce positive beliefs may become part of standard care.

Conclusion

Think back to that patient who bounced back early after surgery. Her belief wasn’t a placebo; it was part of her recovery. Growing evidence shows that expectation doesn’t replace medicine; it complements it.

No, this doesn’t lessen the value of drugs, surgeries or therapies. It enhances them. In the future, treatment plans might always include “how to believe effectively.” Because healing isn’t just physical, it’s psychological. And maybe the strongest prescription is the one that comes with confidence, not just milligrams.

References

Bernstein, M. H., Fuchs, N., Rosenfield, M., Weiss, A.-P., Blease, C., Locher, C., Magill, M., Rich, J., & Beaudoin, F. L. (2021). Treating Pain With Open-Label Placebos: A Qualitative Study With Post-Surgical Pain Patients. The Journal of Pain, 22(11), 1518–1529. https://doi.org/10.1016/j.jpain.2021.05.001

Bingel, U., Wanigasekera, V., Wiech, K., Ni Mhuircheartaigh, R., Lee, M. C., Ploner, M., & Tracey, I. (2011). The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Science Translational Medicine, 3(70), 70ra14. https://doi.org/10.1126/scitranslmed.3001244

Day One: Placebo Workshop: Translational Research Domains and Key Questions. (2024, July 11). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/news/media/2024/day-one-placebo-workshop-translational-research-domains-and-key-questions

Fendel, J. C., Tiersch, C., Sölder, P., Gaab, J., & Schmidt, S. (2024). Effects of open-label placebos across outcomes and populations: An updated systematic review and meta-analysis of randomized controlled trials. https://doi.org/10.21203/rs.3.rs-5216072/v1

Krockow, E. M., Emerson, T. E., Youssef, E., Scott, S., & Tromans, S. (2023). Evidencing general acceptability of open-label placebo use for tackling overtreatment in primary care: a mixed methods study. BMC Medicine, 21(1). https://doi.org/10.1186/s12916-023-03074-4

Ossipov, M. H., Dussor, G. O., & Porreca, F. (2010). Central modulation of pain. Journal of Clinical Investigation, 120(11), 3779–3787. https://doi.org/10.1172/jci43766

Webster, R. K., & Rubin, G. J. (2021). Predicting Expectations of Side-Effects for Those Which Are Warned Versus Not Warned About in Patient Information Leaflets. Annals of Behavioural Medicine. https://doi.org/10.1093/abm/kaab015