Those four words may be the hardest thing in medicine to answer, because the person saying them is not lying—they really did improve. And sometimes the thing they improved on is an unfounded, or even fictional, belief system, which means the improvement now feels like proof. This is the self-deception Trivers describes, packaged differently—it's the psychoanalysis problem again: the theory was wrong, and the patients improved anyway.
For example, some people latch onto an extremely rigorous diet with a spurious rationale, and yet end up stabilizing a prior eating problem, bingeing pattern, or weight problem. Often what makes the diet "work" is not the theory but the frame: the diet becomes a ritual, a commitment device, sometimes even a moral identity. Strong belief in the diet's narrative can increase adherence, especially when it is reinforced by "spiritual" practices, authoritative texts, a charismatic leader, and enthusiastic support from fellow adherents. The resulting improvement may have little to do with the supposed mechanism ("toxins," "energy," "impurity," and the like) and much to do with ordinary behavioural ingredients: reduced ultra-processed food, fewer calories, more routine, more attention to quantities and timing, and stronger social accountability. The distinguishing features of the theory may be fictional, while the behaviour change is real.
This should look familiar. It is Jerome Frank's four elements again, which I set out earlier—the confiding relationship, the healing setting, the theory that explains the suffering, the ritual both parties believe in—with faith consolidating them and a community standing around the whole affair. Some strict diets supply every one of them, in a kitchen. Whether the toxins are real is beside the point; the toxins were never doing the work.
In psychotherapy, patients' early positive expectations are associated with better outcomes, and placebo research shows that ritual and a warm practitioner relationship can produce real symptom change. In some settings, even open-label placebos—interventions people are told are inert—can still help. Benefit does not necessarily require the theory to be true. In some cases it does not even require deception.
It is tempting to treat these forays into unfounded belief as harmless whenever they produce visible gains. But there is a dark side, and much of it is similar to religion's dark side. Some dietary regimens are medically dangerous; some aggravate eating disorders; and some cultivate a loyalty to the framework that discourages critical thinking. Social media can intensify the problem, especially when health-focused communities reward purity, rigidity, and bodily control.
When a person's identity becomes fused with a belief system, they may reject better treatments even when those treatments are clearly indicated—especially if a setback is interpreted as evidence of insufficient "faith," insufficient purity, or insufficient devotion. This is the same closed loop I described with faith healing, where the person who is not cured is left to conclude that they did not believe hard enough. The harms here are not merely theoretical. In patients with curable cancers, complementary medicine use has been associated with greater refusal of conventional treatment and worse survival, with the excess mortality appearing to be mediated by delay or refusal of effective care.
These frameworks also often come packaged with community. People who join one cluster of unusual health beliefs can sometimes be pulled, by social gravity, into neighbouring clusters: new spiritual doctrines, anti-vaccine attitudes, conspiratorial styles of explanation, and monetized ecosystems of coaching, supplements, retreats, and memberships. The pattern is not inevitable, but it is real enough to take seriously.
We mostly hear from the success stories. The people for whom the diet failed, or harmed them, or simply became an expensive obsession, rarely become public evangelists. The community's narrative therefore skews toward "miracles," while the quiet attrition and collateral damage remain largely invisible.
Finally, just as in religions, the next step is often proselytizing. People who believe they have found salvation—whether dietary, medical, or spiritual—tend to recruit. They may pressure friends and family to "convert," and disparage outsiders as ignorant, impure, or closed-minded. In the context of fad diets and alternative medicine, that can do real harm to public health.
So the point is not that unfounded belief never helps. It often does—but it helps through the same common human machinery that makes religion work: structure, community, ritual, meaning, and the confident expectation of a cure. And it smuggles in risks that are easy to deny and hard to reverse once the belief has become an emblem of belonging. The deepest problem is the one we started with: the benefit is real, and it gets misread as proof that the belief was true all along. It never was—and it never had to be.
References
Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473–485. https://doi.org/10.1037/pst0000169
A meta-analysis pooling many clinical samples, finding that patients who begin therapy with more optimistic expectations about their treatment tend to achieve modestly better outcomes. The association is consistent, though not large. It is one of the more direct pieces of evidence that expectancy is an active ingredient rather than a bystander.
Johnson, S. B., Park, H. S., Gross, C. P., & Yu, J. B. (2018). Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncology, 4(10), 1375–1381. https://doi.org/10.1001/jamaoncol.2018.2487
A cohort study of patients with four curable cancers—breast, prostate, lung, and colorectal—finding that those who used complementary medicine were more likely to refuse at least one component of proven conventional treatment, and had roughly double the risk of death. The excess mortality was statistically mediated by that refusal. The authors are careful to note that the data show what the refusal cost, not why patients refused.
Kaptchuk, T. J., Kelley, J. M., Conboy, L. A., Davis, R. B., Kerr, C. E., Jacobson, E. E., Kirsch, I., Schyner, R. N., Nam, B. H., Nguyen, L. T., Park, M., Rivers, A. L., McManus, C., Kokkotou, E., Drossman, D. A., Goldman, P., & Lembo, A. J. (2008). Components of placebo effect: Randomised controlled trial in patients with irritable bowel syndrome. BMJ, 336(7651), 999–1003. https://doi.org/10.1136/bmj.39524.439618.25
A randomized controlled trial in irritable bowel syndrome that experimentally separates the placebo response into three layers: assessment and observation, a therapeutic ritual, and a warm, attentive patient–practitioner relationship. Each layer added incremental symptom relief, with the relationship contributing the most. Ritual and relationship do real work independent of any specific mechanism.
Kaptchuk, T. J., Friedlander, E., Kelley, J. M., Sanchez, M. N., Kokkotou, E., Singer, J. P., Kowalczykowski, M., Miller, F. G., Kirsch, I., & Lembo, A. J. (2010). Placebos without deception: A randomized controlled trial in irritable bowel syndrome. PLoS ONE, 5(12), e15591. https://doi.org/10.1371/journal.pone.0015591
A randomized controlled trial testing "open-label" placebos—pills the patients were explicitly told were inert and contained no active medication. Even so, the placebo group improved more than those given no treatment at all. The result suggests that the benefit of ritual and expectation need not require deception, which complicates any simple account of what a placebo is.
Trivers, R. (2011). The folly of fools: The logic of deceit and self-deception in human life. Basic Books.
An evolutionary theory of deception and self-deception, arguing that the most effective deception often begins with deceiving oneself, because sincere belief makes the performance more convincing. A chapter applies the logic directly to religion. It explains why a genuinely felt benefit hardens so readily into the conviction that the underlying theory must be true.
Ward, C., & Voas, D. (2011). The emergence of conspirituality. Journal of Contemporary Religion, 26(1), 103–121. https://doi.org/10.1080/13537903.2011.539846
The paper that coined the term "conspirituality" for the convergence of alternative spirituality and wellness culture with conspiracy belief. The authors trace how these once-separate worlds increasingly overlap, particularly online. Joining one cluster of unusual health beliefs can pull a person toward neighbouring ones.
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