International Journal of ISSN: 2381-1803IJCAM

Complementary & Alternative Medicine
Opinion
Volume 4 Issue 2 - 2016
Placebos, CAM and Healing: P+X+Y
Paul Dieppe* and Emmylou Rahtz
Institute of Health Research, University of Exeter, UK
Received: August 18, 2016 | Published: August 23, 2016
*Corresponding author: Paul Dieppe, Institute of Health Research, University of Exeter, UK, Email:

Citation: Dieppe P, Rahtz E (2016) Placebos, CAM and Healing: P+X+Y. Int J Complement Alt Med 4(2): 00114. DOI: 10.15406/ijcam.2016.04.00114
Keywords: Complementary and Alternative Medicine; Healing; Health care; Placebo

Introduction

Complementary and Alternative Medicine (CAM) is in great demand. It is used both as a form of complementary medicine, in combination with Western biomedicine, or as an alternative, as many people find that biomedicine alone is incapable of relieving their distress and suffering [1]. They are seeking something else that they do not feel they get from biomedicine: caring and healing perhaps [2]?

Many physicians have emphasised the need for caring in health care [3-5]. It involves: doing ‘the little things’ for patients; listening; being present; sharing decisions; and having the intention to heal [3,6,7]. Central to concepts of caring and healing is a sense of connection: to other people, as in a health care or CAM consultation, but also to nature and to spirituality. In addition, people who give or receive healing often mention ‘something else’, an indefinable, metaphysical quality that helps healing happen. Arthur Frank sees healing as ‘the rest’; “the possibility of becoming whole that remains even when nothing remains for curative medicine to do” [8].

The positivist science that underpins modern biomedicine is dismissive of most forms of CAM, and of healing. It insists on the use of placebo-controlled, randomised controlled trials (RCTs) as the only means of ‘proving’ whether a CAM intervention works or not, in spite of the fact that RCTs deliberately factor out all of the contextual factors that may be particularly critical to the efficacy of CAM interventions [9]. Not surprisingly then, in RCTs many CAM interventions do not produce an effect that is deemed satisfactory by biomedical science, and we are therefore told that they ‘do not work’, or that any effect they produce is ‘just a placebo effect’.

In this article we explore the interrelationships between placebo effects, the specific effects of interventions, and caring and healing, and suggest that we need to combine the best of each to maximise benefits for our patients.

Just a placebo effect

The dismissal of CAM interventions as ‘just a placebo’ is interesting. The placebo effect, which has been investigated extensively [10-12] is not completely understood, but clearly involves a multitude of different factors. These include the manner of the interaction between the giver and receiver of health care, the context (both physical and cultural) in which the intervention is used, and the beliefs and expectations of both the therapist and their client [13]. It is also apparent that placebo effects, and their ‘evil twin’ nocebo effects, can be hugely important when it comes to the relief or worsening of symptoms like pain and depression. It has been calculated that 75% or more of the relief of pain and depression achieved with biomedicine can be attributed to the placebo effect (ibid). In other words, most of the value that conventional doctors provide in the treatment of many common conditions is ‘just a placebo effect’. Furthermore, Greville-Harris and colleagues have published evidence to suggest that nocebo effects are even more powerful than placebo effects, and that medical practitioners often unwittingly activate a strong nocebo effect during their well-meant clinical encounters [14].

So, if much biomedicine is ‘just a placebo’, and conventional doctors are often making their patients worse because of their lack of understanding of the nature and power of caring and human interactions, why be troubled by the fact that some CAM interventions may be ‘just a placebo’? Perhaps medical science should celebrate the ability of CAM practitioners to induce a powerful placebo effect, and seek to understand how both CAM and biomedical practitioners can induce placebo.

The specific effect within CAM interventions

The effect of any intervention can be divided into the characteristic or specific effect of that intervention (such as the ability of an anti-hypertensive drug to lower blood pressure) and the non-specific or incidental effects of everything else that goes on around the use of that intervention (such as the anxiety provoked by being prescribed an anti-hypertensive, resulting in an increase in blood pressure) [15]. Because RCTs cannot deal with the complex interactions between specific and non-specific effects that occur in most, if not all CAM interventions, the interventions can be dismissed as having no specific effect (‘just a placebo’). But some CAM interventions may have a real specific effect as well. In such cases we could say that the effect of a CAM intervention is:

Placebo + x (where x = the specific effect of the CAM intervention).

Healing

Some CAM practitioners call themselves healers. And just as there are a multitude of different forms of CAM intervention, there are also many different healing practices on offer to the general public. But healing is difficult to define, and it is often hard to understand exactly what a CAM practitioner who describes themselves as a healer means by the use of that terminology.

From our reviews of the literature [16] and work with self-professed healers [17], we conclude that people generally conceptualise healing as some sort of change for the better that involves the (re)-acquisition of peace of mind or of a sense of wholeness and integrity, often in spite of the continuation of a disease process and some of its consequences [8]. So healing is differentiated from curing, and is characterised by concepts of integration of mind, body and spirit (or soul), as opposed to a purely physical elimination of disease. In addition, healing sometimes involves some anomalous experience, or noetic event, and may be described as involving metaphysical as well as physical elements.

Narratives of healing include at least two types of change. The first describes changes for the better that evolve over a relatively long time period, in which the ‘healee’ or client slowly improves and finds ways of living well and flourishing in spite of, or because of, disease and illness; these can be described as ‘healing journeys’. Alternatively, some people experience relatively sudden changes in perception or understanding of their illness, with immediate alleviation of symptoms, what might be called a ‘healing moment’, and something that is akin to a religious experience [17]. There are, no doubt, other healing responses that fall somewhere between these extremes; and many journeys may be initiated or punctuated by moments.

We know less about the factors that facilitate healing than we do about the placebo response, but it does not seem unreasonable to presume that many of the same factors that contribute to placebo responses (human interactions, context, beliefs and expectations) also allow healing to be activated. Healers themselves often talk of some form of universal energy or force that is channelled to the advantage of the client, or of unblocking faulty energy flow within the individual [7,18,19]. The concept of energy and energy flow as a critical element of the maintenance of good health is one that is important to almost all health systems (Traditional Chinese Medicine, Ayurveda etc.) with the exception of Western biomedicine, which dismisses it because it cannot measure that form of energy. Metaphysical concepts are commonplace among CAM and healing professionals. Healers also talk about the importance of their interaction with their clients, and they commonly use language that is anathema to biomedicine, such as ‘healing intention’ and the need for ‘unconditional love’ for the client.

The ‘evidence base’ to support the concept of healing suffers from exactly the same problem as that in other CAM interventions- the belief within medical science that RCT based evidence is the only sort that we can rely on. The literature contains a lot of highly convincing anecdotal evidence, but is not strong on science. But many RCTs of healing have been done, and intriguingly a recent meta-analysis reported significant evidence for a healing response amongst in vitro systems, such as cell cultures and tissue samples [20]. This suggests that the placebo response cannot be the whole explanation of healing, and that something else may be at work as well; perhaps something like energy channelling or healing intention. So we could conceptualise healing as:

Placebo + y (where y = a metaphysical or ‘energy channelling’ factor)

Placebo + x + y

We can imagine an evolutionary process that began, in the earliest stages, with simple healing, perhaps in the form of the intention of one person to make another human feel better. Over time this would evolve into a system like CAM, with treatments, rituals and beliefs. With the advent of medical science, this system was further refined, retaining, for example, willow bark in the form of aspirin. But when biomedicine rightly relinquished interventions like mercury and blood-letting, it also de-prioritised healing and useful placebo effects. As scientific Western biomedicine has evolved, it has increasingly concentrated on the specific effect of an intervention alone – it only bothers with ‘x’, dismisses placebo effects as relatively unimportant, and tends to ignore the idea of healing completely: if science cannot measure it, it cannot exist. Positivists like to say that alternative medicine is a misnomer, because medicine that works is simply called medicine. But this is only true of the specific mechanisms, not of placebo effects and potential metaphysical effects.

Biomedicine - just ‘x’?

So far we have concluded that placebo is an important element of all types of health care intervention, and that any specific effect of an intervention that assists the placebo effect can be described as placebo+ x. In addition, we have suggested that there may be ‘something else’ going on when patient-practitioner interactions activate healing responses, that we have called placebo+ y. But surely the best health care professionals, be they CAM or biomedical practitioners, can use all of these elements, and help their patients by use of interventions that combine them: placebo+ x + y.

Conclusion

We believe that each of the different factors within an intervention that can lead to an improvement in the condition of the receiver of the intervention should be combined for maximum efficacy. We think that both biomedical and CAM practitioners need to learn how to maximise the placebo effect, as well as gaining an understanding of those behaviours that might help induce a healing response, through attention to issues such as presence, a caring approach and focussed attention with good intention, alongside using whatever specific interventions they can that will not cause harm. Therefore, we propose:

p + x + y (where p = placebo effects, x = specific treatment effects, and y = a metaphysical, healing factor)

Acknowledgement

PD would like to acknowledge the support of the Institute of Integrative Health (www.TIIH.org>) who have provided him with a scholarship to pursue studies of healing in collaboration with ER and others.

PD would like to acknowledge the support of the Institute of Integrative Health (www.TIIH.org) who have provided him with a scholarship to pursue studies of healing in collaboration with ER and others.

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