The Prescription You Didn’t Know You Were Writing

The Prescription You Didn’t Know You Were Writing

By Ronald Rosen, MD, CWSP, CMD

I signed up for a one-week course in clinical hypnosis expecting to learn new procedural skills, something distinct and perhaps even a bit theatrical. Instead, I came away with a more practical realization: I didn’t need to formally “do hypnosis” to influence outcomes. I was already doing it—every day, in every patient encounter—just not with intention.

Like most clinicians, I had been underusing one of the most powerful tools in medicine: suggestion.

In post-acute and long-term care, where we manage chronic symptoms, functional decline, and complex medication regimens, the way we communicate is not just bedside manner—it is part of the treatment itself. Every explanation, every framing of a diagnosis or therapy, carries embedded cues that shape patient expectations. And those expectations, in turn, influence outcomes in measurable ways.

More Than Words

When we prescribe a medication, we are also prescribing a narrative. Consider the difference:

• “We can try this, but it may not help much.”
• “This has helped many patients like you feel more comfortable and move more easily.”

Both statements are honest. Only one increases the likelihood of benefit.

Expectation is not abstract; it is biologically active. Research has shown that positive therapeutic framing can engage endogenous opioid pathways, modulate dopamine release, and alter activity in brain regions involved in pain and symptom perception.¹ As described by Tor D. Wager and Lauren Y. Atlas, “Placebo effects can be as large as the effects of accepted drug treatments or larger and can reduce disability and increase quality of life over a period of months or longer.”¹ They further note that “multiple studies have shown that placebo analgesia can be blocked by the opioid antagonist naloxone.”

A Familiar Clinical Moment

An 82-year-old resident with osteoarthritis is struggling to participate in therapy because of knee pain.

One clinician says, “We’ll start with acetaminophen. It’s safe, though it may not do much at this point.”

Another says, “This works by calming pain signals in your joints. Many people notice that, within a few days, movement becomes easier and therapy feels more manageable.”

Same medication. Same patient. Different trajectory.

The second approach does not rely on exaggeration or false reassurance. It simply aligns the treatment plan with a constructive expectation—one that can enhance adherence, engagement, and ultimately, outcomes.

Understanding the Placebo Response

The placebo effect is often dismissed as incidental or even irrelevant. In reality, it reflects a set of well-described neurobiological processes.

Work by researchers such as Fabrizio Benedetti has demonstrated that placebo responses can activate endogenous opioids, influence dopaminergic pathways, and produce measurable changes in symptom perception.²

In conditions such as pain, depression, and functional disorders, the placebo component of treatment can be substantial. Analyses by Irving Kirsch and others suggest that in mild-to-moderate depression, the difference between active medication and placebo is often modest—highlighting the significant role of expectation and context in therapeutic response.³ Similarly, gabapentinoids for certain chronic pain syndromes and even widely used agents like acetaminophen for osteoarthritis have, in some trials, shown only marginal benefit over placebo.³ This does not render them ineffective but underscores how strongly outcomes are shaped by context and expectation.

The effectiveness of placebos is not an argument against treatment. It is a reminder that treatment effectiveness is not solely pharmacologic. Context, expectation, and clinician communication contribute to therapeutic response.

Even When Patients Know

One of the more surprising findings in recent years is that placebo effects can persist even when patients are told they are receiving a placebo.⁴

In studies of “open-label placebo,” patients who were explicitly informed that their treatment contained no active medication still experienced meaningful and sustained symptom improvement. The therapeutic ritual—combined with a credible explanation of mind-body interaction—appears sufficient to generate benefit.

For clinicians, this underscores an important point: belief and expectation are not all-or-nothing phenomena. They can be cultivated ethically, without deception.

The Other Side: Nocebo

If expectations can improve outcomes, they can also worsen them.

The nocebo effect—negative outcomes driven by negative expectations—is particularly relevant in long-term care, where patients are often vulnerable, medically complex, and attuned to clinician cues.

Consider how easily we may contribute to it by:

• Emphasizing rare side effects without context
• Expressing uncertainty in ways that undermine confidence
• Framing treatments as unlikely to work

A statement such as, “This medication can cause dizziness, nausea, and fatigue,” may be accurate, but it also primes the patient to experience those symptoms.

A more balanced approach—“Most people tolerate this well; if anything feels off, let us know, and we’ll adjust quickly”—conveys the same information without amplifying risk.

Not “Just a Placebo”

Using suggestion effectively is not the same as giving a placebo.

We are not substituting inert treatments for real ones. We are optimizing the delivery of evidence-based care by aligning it with constructive expectations.

In this sense, suggestion acts as a force multiplier by:

• Enhancing medication response
• Improving participation in therapy
• Reducing perceived symptom burden
• Supporting adherence

In the PALTC setting, where small gains in function or comfort can have a meaningful impact, these effects are far from trivial.

Practical Takeaways

• Be deliberate in how treatments are introduced
• Emphasize realistic but positive expectations
• Avoid amplifying side effects inadvertently
• Align messaging across the care team
• Recognize that communication is a clinical intervention

Closing Thought

We often think of prescriptions as medications or therapies. But every interaction carries an additional, less visible prescription—one that shapes how patients experience their illness and their care.

The question is not whether we are influencing outcomes through suggestion. It is whether we are doing so intentionally.

Selected References

1.    Wager TD, Atlas LY. The neuroscience of placebo effects. Annu Rev Neurosci.
2.    Benedetti F. Placebo Effects: Understanding the Mechanisms in Health and Disease.
3.    Kirsch I. The Emperor’s New Drugs: Exploding the Antidepressant Myth.
4.    Kaptchuk TJ, et al. Placebos without deception: A randomized controlled trial in IBS. PLoS ONE.
5.    Colloca L, Barsky AJ. Placebo and nocebo effects. N Engl J Med.
6.    Wager TD, Atlas LY. The neuroscience of placebo effects. Annu Rev Neurosci.

Dr. Rosen is a geriatrician at Mass General Brigham and a hospice and palliative medicine physician at Care Dimensions Hospice and Palliative Care. He is a certified wound specialist and serves on the PALTmed Core Curriculum faculty.