Hellish workouts – The Nocebo effect, a self-fulfilling prophecy


Have you ever heard of the Nocebo effect? Antony Stewart discusses how the words we use could be making our workouts more painful for our participants.

The British Heart Foundation (BHF) has shared a study1 from the New England Journal of Medicine, which concluded that 90% of the side effects from statins might be caused by a thing called the Nocebo effect. Although the Placebo phenomenon is widely known in the world of medicine and beyond, its close cousin, the Nocebo effect, is less talked about. In the context of the BHF study, it was found that participants reported the same degree of commonly known side effects from the drug, regardless of whether they took the actual statin or the alternative control sugar-pill. This is not unprecedented, as there is a rich history of clinical trials that have recorded negative reactions to the prescription of sugar-pills.

A Placebo gives a medical benefit despite having no active ingredient. It is thought that the language, human interaction, process and theatre of the prescription is the thing that somehow stimulates a physical response. This prescription normally comes from a doctor; however, it can be delivered by anyone respected in a society, such as a shaman, elder or a group exercise instructor!

A Nocebo provokes a similar but opposite response. This is where the culture, language and interaction with a respected authority creates an expectation of a certain negative outcome. In this particular case, it involves (widely reported in the media) potential statin side effects.

The fitness industry itself represents a highly respected authority (most of the time) and we have a language all of our own. In recent years, I think we have begun to see a shift in the way in which we describe exercise, especially in the high-intensity exercise arena, partly but not exclusively in the boutique market and, in particular, on social media.

This is not an entirely new thing to our industry. Think ‘no pain, no gain’, a phrase that is almost 2,000 years old but was made especially famous in fitness in the 1980s by Jane Fonda! There has, however, been a creeping inflation in hyperbole in language generally in our society and this has unsurprisingly spread to fitness.

Disgusting, hideous, killer, smashed, hell are just a few of the words I found to describe potential online workouts, simply by taking a quick look at social media this morning. Interestingly, language is often used to solidify social groups, by creating a universal code that signifies who is part of the clique and who is an outsider. Maybe we are talking like this as a way to create a rapport and foster camaraderie with an existing group of individuals? Those who are new to the group, to the club or new to exercise entirely must find this incredibly intimidating!

If there is a lesson to be learned from Nocebo, are the words we are using making exercise more painful for participants? Some psychologists believe that many people avoid exercise, not because of lack of time (as is self-reported) but because humans have a natural and often understandable desire to avoid the uncomfortable. Is there an opportunity to frame the physiological and psychological changes that occur during and after exercise in a more positive light?2

As fitness professionals, we know that the endorphin high and subsequent mental and physical benefits of exercise far outweigh any temporary discomfort. Have we fallen into a pattern of Nocebo in the way in which we describe some types of exercise, creating a self-fulfilling prophecy on the body and mind? In other words, the more we describe exercise as a ‘killer’, ‘disgusting’ or ‘hideous’, are we inadvertently causing this to translate into the reality of the experience? Not a great way of ensuring that new members come back after their first class!

Scientists do not know definitively how Nocebo works. They have, however, completed enough experiments over the last 50 years to know that it certainly does. One theory is that the brain is conditioned to react to cultural, linguistic and situational cues. The more we expect something to happen because society or someone influential tells us that it will, the more likely we are to experience it.

Negative Nocebo responses are not only stimulated by words; amazingly, they can also be triggered by a whole variety of non-verbal cues! It turns out that studies show that we can encourage a Nocebo response without even speaking. As a trusted person, if we ultimately believe that something is painful, not worth it or simply won’t work, our clients are likely to pick this up3.

Think of the most successful personal trainers or group exercise instructors you know. How often have they overcome adversity partly (or hugely) with the help of exercise? These are fitness professionals who have lost significant amounts of weight or overcome injury or negative life experiences themselves. They want to share this success with others and they do this verbally and non-verbally each and every day. It is their belief in the prescription of exercise that creates the psychological effect.

Now think of the opposite of these people – those who are in the industry for their own potentially self-centred reasons and who maybe don’t rate any other form of exercise than their own style of training. Imagine the trail of Nocebo they might be leaving around your business, as they successfully predict (and therefore influence) negative reactions and outcomes from exercise.

So, what can we do to counteract the power of Nocebo in fitness? Well let me ask, how is your business depicting exercise on social media and on your website? Is it emphasising the benefits and pleasure of the experience, or the challenging nature of the workout? What language are your instructors using before, during and after class and also on their own social media channels? During class, are they explaining how and why a movement or workout gives benefits? We know that both the Placebo and Nocebo effect work best when belief is maximised. Belief is greater with deeper understanding.

In the BHF study, the participants had pre-determined expectations about statin side effects, which manifested regardless of whether the individual was selected to take the statin or was in the control group that took the sugar-pill. Maybe there was also a group who actually experienced some of the benefits of taking statins despite being in the sugar-pill group? This process is called Placebo and, in a future blog, I will be exploring how this amazing phenomenon could also be utilised to help your members achieve their goals.

Where to next? Find out how we adapted to working online with digital ain’t easy blog

Author bio

Antony Stewart is head of group exercise for Third Space clubs, as well as a DJ and dance music producer who has created tracks for the fitness industry and internationally successful dance music compilation albums. Antony has enjoyed 20+ years in the fitness industry and also worked as a senior manager for both David Lloyd and Virgin Active.

References

  1. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/november/no-difference-in-side-effects-with-a-statin-or-dummy-pill accessed 6th April 2021
  2. https://www.psychologytoday.com/us/blog/shrink/201411/the-real-reason-we-dont-exercise accessed 6th April 2021
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4804316/ accessed 6th April 2021



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