Placebo, Belief, and the Brain’s Emotion Regulator

Bo and Wager’s chapter on placebo effects and emotion regulation is a rich reminder that the brain is not only a signal processor—it’s also a storyteller, constantly predicting what sensations mean and what comes next. This work, now from the archives, makes a clear argument: placebo effects and cognitive emotion regulation are different routes to a similar destination—changing appraisal. In practice, that means changing the felt meaning of pain, anxiety, sadness, craving, or stress, and shifting the motivational “tilt” that drives behavior.

Placebo effects are described here as a family of responses that tap into endogenous therapeutic potential through treatment context—relationships, rituals, cues, suggestions, and learned associations. Importantly, the chapter distinguishes between placebo effects (improvements attributable to placebo-related processes) and placebo responses more broadly (which can include other changes that occur during care). The authors emphasize that what people believe about a treatment, and how they interpret their symptoms, can change emotional and motivational systems in the brain in ways that matter clinically.

Emotion regulation, on the other hand, is the deliberate, goal-driven use of attention and appraisal to influence emotion and related experiences like pain. Classic strategies such as cognitive reappraisal can work well, but they are effortful and often hardest to deploy when someone is tired, overwhelmed, depressed, or in acute distress.

This is where biofeedback and neurofeedback become especially interesting. In general terms, biofeedback and neurofeedback are training methods that provide real-time information about physiological or brain activity so a person can learn to shift their internal state through practice. The chapter’s core message—meaning and context shape emotion and symptoms—maps directly onto what happens in feedback-based training: signals become understandable, change becomes visible, and self-regulation becomes more believable.

How the Chapter Builds Its Case

This isn’t the kind of paper where you can point to one lab, one protocol, and one set of participants and say, “That’s the method.” Instead, Bo and Wager do something more like what good clinicians do in supervision: they pull together patterns across many studies and ask, What keeps showing up, and what does it mean?

So the approach here is a guided tour through three overlapping research worlds—placebo neuroscience, emotion regulation science, and clinical translation. Rather than getting lost in a forest of individual findings, the chapter organizes the evidence around a few recurring ways researchers reliably evoke placebo effects, a few standard ways they test deliberate emotion regulation, and the brain systems that tend to light up when meaning and expectation start changing experience.

Think of it as an “evidence map” for how context (what a treatment means) and skill (what a person can do on purpose) can both shift emotions and symptoms.

Placebo induction pathways

The chapter lays out multiple routes to placebo effects. Three common approaches appear repeatedly in the broader literature discussed:

1. Verbal suggestion and expectancy: Participants are told a treatment will help (e.g., reduce pain or distress), and expectation becomes the active ingredient.

2. Conditioning and learned associations: Treatment cues are repeatedly paired with real symptom relief, building an associative “this means safety/relief” response that can later be triggered by the cue alone.

3. Open-label placebo and supportive context: Placebo-like benefits can occur even without deception when the therapeutic frame emphasizes how mind–brain processes can influence symptoms, and the encounter provides credible cues, care, and structure.

The chapter’s theoretical model highlights appraisal as a hub: expectations about the future, interpretations about causes, and self-referential meaning all feed into how symptoms are experienced and acted upon. The authors also note that placebo effects often show up more strongly in symptom reports than in objective physiology, though under some conditions placebo-related processes can shift peripheral physiology and behavior over time.

Emotion regulation paradigms

To compare placebo with deliberate regulation, the chapter draws on classic emotion regulation tasks used in lab settings. In many studies, participants view negative images or experience pain while being instructed to respond naturally or to use a strategy such as reappraisal (changing the meaning of the stimulus). These paradigms allow researchers to map brain activation differences between regulation and non-regulation conditions.

Neural measurement and synthesis

A major methodological focus is neuroimaging evidence that links both placebo and regulation to overlapping neural systems. The chapter emphasizes frontoparietal control networks (including dorsolateral prefrontal regions), along with systems involved in valuation, self-referential processing, and affective meaning. The authors also discuss findings from brain stimulation studies showing that changing prefrontal excitability can alter placebo responses, offering causal support for a role of prefrontal systems in expectancy-driven modulation.

Results

Because this is a synthesis chapter, the “results” are best understood as a set of converging conclusions.

1) Placebo effects reliably engage affective and motivational appraisal systems

Across conditions such as pain, anxiety, depression, craving, and neurological symptoms, placebo-related processes tend to change brain activity in systems that shape affective meaning and motivation. The chapter frames placebo as a meaning response: treatment cues and therapeutic context shift how symptoms are interpreted, what is expected, and what feels possible. These changes can alter subjective distress and, in some cases, influence longer-term trajectories through behavior (sleep, activity, self-care, social engagement).

2) Emotion regulation and placebo converge on appraisal, but differ in how they get there

Both processes are described as ways of modulating appraisal to reduce negative affect and improve well-being. Emotion regulation typically depends on explicit goals and deliberate cognitive control—often effective, but effortful. Placebo-related modulation tends to be more automatic once expectations and associations are in place, which may be an advantage under stress, fatigue, or low motivation.

3) Overlapping neural circuits: context maintenance and value construction

The chapter highlights prefrontal and frontoparietal systems (including dorsolateral prefrontal cortex) as important for maintaining context and expectations, and for modulating affective processing accordingly. Valuation-related systems and self-referential networks are also emphasized as core contributors to changes in feelings, motivation, and symptom meaning.

4) Additive effects are plausible; true synergy is not guaranteed

When placebo and other cognitive manipulations (such as distraction) are manipulated independently, some findings suggest additive benefits rather than strong synergy. The chapter argues that interactions between belief/expectancy and specific regulation strategies remain underexplored and may vary by context and implementation.

5) Clinical integration: two limitations that can be complementary

Emotion regulation can fail when effort and motivation are depleted. Placebo mechanisms can be weak when expectations are low or trust in the intervention is minimal. Integrating both—building credible, supportive contexts that increase expectancy while also teaching concrete self-regulation skills—may address motivational and cognitive barriers and help benefits persist.

Discussion

This chapter offers a clinically useful reframe: many “treatments” work not only because of what they do biologically, but also because of what they mean—and meaning is not fluff. Meaning is a set of brain computations that shape value, threat, agency, and future prediction. In that sense, placebo and emotion regulation are cousins. One often arrives through the outside-in pathway of context (rituals, relationship, cues, suggestion). The other arrives through the inside-out pathway of deliberate skill (attention, appraisal, imagination guided by goals). Both can change the same family of systems that construct feelings and motivation.

In practice, this matters because people rarely come to training or therapy as neutral observers. They come with a nervous system that has learned what helps, what fails, and what is safe. They also come with a prediction engine (the brain) that is constantly asking: Is this worth it? Will I be disappointed again? Do I have the capacity to change? The chapter’s emphasis on appraisal suggests that effective care is partly the art of shifting those predictions in grounded, ethical ways.

This is one reason biofeedback and neurofeedback fit so naturally here. The feedback loop creates a bridge between subjective experience and measurable change. For someone who struggles to “feel” regulation, a heart rhythm trace, skin conductance curve, or EEG trend can transform a vague instruction (“relax”) into something learnable (“when I breathe this way, my physiology shifts”). And when learning becomes visible, hope often becomes more plausible. That is not placebo in the dismissive sense; it is motivation built on evidence.

At the same time, the chapter reminds us to be careful: expectancy-driven improvements may show up first in self-report and may not always translate into objective physiology or functional outcomes. That is not a failure—it is a clue about sequencing. Subjective distress is often the first domino. When distress decreases, behavior becomes more flexible. When behavior shifts, physiology may follow.

The most clinically interesting idea in the chapter is the potential for a positive feedback loop: supportive contexts and credible cues can lower the barrier to initiating regulation, while repeated successful regulation experiences can strengthen expectancy and sustain benefits. This is the opposite of a “mere placebo” story. It’s a learning story.

If we translate this into day-to-day care, a few principles stand out:

• Build the therapeutic frame as a collaboration in self-regulation, not a passive rescue mission.

• Use structured rituals and consistent session flow to create stable cues for safety and engagement.

• Pair context with skills: breathing, attention training, imagery, cognitive reappraisal, and feedback-based practice.

• Track changes in function, not only feelings: sleep, social re-engagement, activity tolerance, concentration, irritability recovery time.

Underneath all of these is the chapter’s central theme: appraisal changes the brain’s construction of affect, and that changes what people can do next.

Brendan’s perspective

I want to name something that clinicians often feel but research designs don’t always capture: in real practice, treatments are not single ingredients. They are living ecosystems.

A tightly controlled placebo design is like trying to understand cooking by isolating salt. You can learn a lot about salt—but no one eats salt for dinner. In neurofeedback and biofeedback, the “meal” includes the protocol, yes, but also the room, the cadence of sessions, the therapist’s regulation, the client’s learning history, the small wins, the graphs, and the story that forms around those graphs.

Specific and non-specific is a spectrum

There’s a phrase that shows up in research debates like a bad magic trick: specific versus non-specific effects—as if we can sort everything neatly into two boxes. Real clinical change rarely behaves that way. It’s usually a continuum.

At one end are highly specific ingredients: a targeted contingency, a frequency band goal, a training threshold, a medication dose, a stimulus parameter. At the other end are broad context ingredients: trust, credibility, expectation, therapeutic alliance, the feeling of being understood, the ritual of care. Most outcomes live somewhere in the middle, with the “active dose” distributed across both.

What matters clinically is not pretending one end doesn’t exist. It’s learning to measure and refine the specific ingredients while also shaping the context ethically—because context is often the bridge that helps someone engage long enough for the specific learning to take root.

That is exactly why this Bo and Wager chapter resonates. Their model treats context as a genuine causal factor. It’s not an embarrassing confound to be eliminated. It’s a mechanism to be understood, shaped, and used ethically.

Clinical reality: multi-component interventions are the norm

Here’s a common clinical sequence I see:

Someone arrives saying, “I can’t calm down,” or “I know the coping skills, but I can’t access them when it matters.” They are not failing at psychology. They are bumping into biology plus history plus context. In those moments, the nervous system is not a student with a notebook—it’s a smoke alarm.

This is where feedback-based training can function as scaffolding. Not because the brain is gullible, but because the brain is learnable. The first goal is often not “deep regulation.” It is proof of influence: evidence that internal state is not purely random.

With HRV biofeedback, that proof may come from paced breathing around 0.1 Hz (often close to six breaths per minute), watching coherence increase, and noticing that the body’s “threat posture” softens. With electrodermal measures, it may be recognizing the micro-surge of arousal before irritability spills over. With neurofeedback, it may be the first time a client sees that focused calm has a signature—and that they can nudge it.

And here’s the key: those experiences are not separate from expectancy. They create expectancy. They reshape appraisal: Maybe my system can change. Maybe I can practice.

Research design versus lived learning

Many studies (especially in early neurofeedback research) unintentionally do something that the chapter warns against: they strip away the very factors that make learning durable.

• Session rituals vary.

• Provider interaction is minimized.

• Participants receive limited coaching, because coaching is seen as a confound.

• Outcomes focus on symptom ratings over short windows.

But learning-based interventions need time, pattern, and reinforcement. The chapter notes that placebo-related benefits can sometimes last weeks or longer, and that changes may be mediated by behavior over time. Neurofeedback is similar. When someone starts sleeping better, making different choices, or recovering faster after stress, those functional changes become the real “dose” that continues between sessions.

So yes, we need rigorous trials. And we also need ecological designs that respect what makes self-regulation training work in the first place.

Hope, belief, and agency: the ethical use of expectancy

Theme 5 matters to me because “placebo” is often heard as “it’s all in your head,” which can feel like a quiet insult. I prefer a different message:

Your brain is a prediction machine. Treatment changes predictions. Changing predictions changes physiology, motivation, and emotion. That is not imaginary—it’s neuroscience.

There’s an ethical way to harness expectancy in neurofeedback. It looks like this:

• Be transparent about uncertainty and individual variability.

• Emphasize skill-building over promises.

• Use data as feedback, not as a verdict.

• Celebrate functional change (sleep, attention, irritability recovery, pain tolerance) more than perfect waveforms.

In practice, the “meaning response” becomes a clinical tool when it is grounded in observable learning. A session trend that shows steadier regulation over time is not a marketing line; it’s a mirror. And mirrors build agency.

Translating the chapter into EEG neurofeedback choices

This chapter isn’t an EEG protocol paper, but it gives a powerful lens for protocol selection: pick targets that support appraisal flexibility, attentional stability, and physiological downshift—and pair them with a story the client can believe.

A few practical examples (always individualized and adjusted to the person’s presentation):

• For hyperarousal and anxiety-prone vigilance, many clinicians start with stabilization-oriented training such as SMR (often 12–15 Hz) at central sites (commonly C3, Cz or C4), combined with inhibition of excessive fast activity that correlates with tension and rumination. The clinical goal is not “relaxation” as a personality trait; it’s creating a nervous system that can release the brakes.

• For stress recovery and cognitive-emotional flexibility, alpha-supportive approaches (often in the 8–12 Hz range) at posterior or parietal sites may be used to nudge the system toward a calmer baseline. When paired with breathing or imagery, this can turn regulation from a lecture into a felt experience.

• For some presentations, frontal midline theta training (often around 4–7 Hz at midline frontal sites) may be explored as a way to support sustained attention and internal steadiness, particularly when worry and distractibility are part of the picture.

• For mood-related patterns where motivational systems feel “offline,” approaches that target approach-related engagement and cognitive flexibility are sometimes considered, including careful work around frontal patterns and state training that supports activation without agitation.

The common thread is not a single frequency band. It’s the pairing of state training with meaning: “We’re practicing a state that helps your system interpret signals differently.” That is appraisal in action.

Integrating context on purpose

If placebo and emotion regulation both work partly through appraisal, then neurofeedback should include an explicit appraisal plan.

That might include:

• A brief pre-session check-in that names the goal state (calm, focused, grounded) in concrete terms.

• A consistent start ritual (breathing, body scan, settling), so the environment itself becomes a cue for safety.

• Skill prompts during training (gentle attention shifts, imagery, reappraisal phrases) that are tested and refined based on what the signals do.

• A short post-session reflection that links physiology to experience: “What did you notice when the feedback shifted?”

In other words: we’re not only training a waveform. We’re training a relationship to internal experience.

And that’s the hopeful punchline of this chapter for me: belief and biology are not competitors. They are dance partners. When we choreograph that dance with honesty, data, and compassion, self-regulation becomes less like a heroic act of willpower and more like a skill the nervous system can learn.

Conclusion

Bo and Wager’s chapter brings placebo and emotion regulation under a shared roof: appraisal. Placebo effects arise through treatment context, learned associations, and expectations that shift how symptoms are interpreted and how the future is predicted. Emotion regulation arrives through deliberate goals and strategies that reshape meaning from the inside out. Both can change overlapping neural systems involved in value, attention, and affective meaning—systems that often determine whether someone feels stuck or able to move forward.

For clinical work, the message is quietly radical: context is not a nuisance variable. It is part of the intervention. When supportive cues and credible rituals reduce the barrier to beginning regulation, and when regulation practice produces visible learning, a positive feedback loop can emerge—less distress, more agency, better function, and a system that becomes increasingly trainable over time.

If there’s a final take-home message here, it’s this: when belief is paired with real skill acquisition, the brain’s capacity for self-regulation stops being a theory and starts becoming a lived experience.

References

Bo, K., & Wager, T. D. (2024). Placebo effects and emotion regulation: Conceptual and neural similarities and differences. Chapter manuscript provided in the uploaded PDF.