Why Bogus "Alternative Medicine" Seems to Work
DharmaTroll
survive as nostalgic yearnings for a return to nineteenth-century-
style democratized health care (now wrapped in the banner of patients’
rights) and a dislike of bureaucratic, technologic, and specialized
treatment of disease. Likewise, the allure of the “holistic” dogmas of
alternative medicine is a descendant of the fascination with Eastern
mysticism that emerged in the sixties and seventies. Although the
philosophy and the science that underlie these holistic teachings have
been severely criticized, they retain a strong appeal for those
committed to belief in “mind-over-matter” cures, a systemic rather
than localized view of pathology, and the all-powerful ability of
nutrition to restore health (conceived of as whole-body “balance”).
Many dubious health products remain on the market primarily because
satisfied customers offer testimonials to their worth. Essentially,
they are saying, “I tried it and I got better, so it must be
effective.” But even when symptoms do improve following a treatment,
this, by itself, cannot prove that the therapy was responsible.
If the practitioner claims persecution, is ignorant of or openly
hostile to mainstream science, cannot supply a reasonable scientific
rationale for his or her methods, and promises results that go well
beyond those claimed by orthodox biomedicine, there is strong reason
to suspect that one is dealing with a quack. Appeals to other ways of
knowing or mysterious sounding “planes,” “energies,” “forces,” or
“vibrations” are other telltale signs, as is any claim to treat the
whole person rather than localized pathology.>>
Why Bogus Therapies Seem to Work
by Barry L. Beyerstein
http://www.csicop.org/SI/show/why_bogus_therapies_seem_to_work/
Volume 21.5, September / October 1997
At least ten kinds of errors and biases can convince intelligent,
honest people that cures have been achieved when they have not.
“Nothing is more dangerous than active ignorance.”
-Goethe
Those who sell therapies of any kind have an obligation to prove,
first, that their treatments are safe and, second, that they are
effective. The latter is often the more difficult task because there
are many subtle ways that honest and intelligent people (both patients
and therapists) can be led to think that a treatment has cured someone
when it has not. This is true whether we are assessing new treatments
in scientific medicine, old nostrums in folk medicine, fringe
treatments in “alternative medicine,” or the frankly magical panaceas
of faith healers.
To distinguish causal from fortuitous improvements that might follow
any intervention, a set of objective procedures has evolved for
testing putative remedies. Unless a technique, ritual, drug, or
surgical procedure can meet these requirements, it is ethically
questionable to offer it to the public, especially if money is to
change hands. Since most “alternative” therapies (i.e., ones not
accepted by scientific biomedicine) fall into this category, one must
ask why so many customers who would not purchase a toaster without
consulting Consumer Reports shell out, with trusting naivetë, large
sums for unproven, possibly dangerous, health remedies.
For many years, critics have been raising telling doubts about fringe
medical practices, but the popularity of such nostrums seems
undiminished. We must wonder why entrepreneurs’ claims in this area
should remain so refractory to contrary data. If an “alternative” or
“complementary” therapy:
1. is implausible on a priori grounds (because its implied
mechanisms or putative effects contradict well-established laws,
principles, or empirical findings in physics, chemistry, or biology),
2. lacks a scientifically acceptable rationale of its own,
3. has insufficient supporting evidence derived from adequately
controlled outcome research (i.e., double-blind, randomized, placebo-
controlled clinical trials),
4. has failed in well-controlled clinical studies done by impartial
evaluators and has been unable to rule out competing explanations for
why it might seem to work in uncontrolled settings, and,
5. should seem improbable, even to the lay person, on “commonsense”
grounds, why would so many well-educated people continue to sell and
purchase such a treatment?
The answer, I believe, lies in a combination of vigorous marketing of
unsubstantiated claims by “alternative” healers (Beyerstein and
Sampson 1996), the poor level of scientific knowledge in the public at
large (Kiernan 1995), and the “will to believe” so prevalent among
seekers attracted to the New Age movement (Basil 1988; Gross and
Levitt 1994).
The appeal of nonscientific medicine is largely a holdover from
popular “counterculture” sentiments of the 1960s and 1970s. Remnants
of the rebellious, “back-to-nature” leanings of that era survive as
nostalgic yearnings for a return to nineteenth-century-style
democratized health care (now wrapped in the banner of patients’
rights) and a dislike of bureaucratic, technologic, and specialized
treatment of disease (Cassileth and Brown 1988). Likewise, the allure
of the “holistic” dogmas of alternative medicine is a descendant of
the fascination with Eastern mysticism that emerged in the sixties and
seventies. Although the philosophy and the science that underlie these
holistic teachings have been severely criticized (Brandon 1985), they
retain a strong appeal for those committed to belief in “mind-over-
matter” cures, a systemic rather than localized view of pathology, and
the all-powerful ability of nutrition to restore health (conceived of
as whole-body “balance”).
Many dubious health products remain on the market primarily because
satisfied customers offer testimonials to their worth. Essentially,
they are saying, “I tried it and I got better, so it must be
effective.” But even when symptoms do improve following a treatment,
this, by itself, cannot prove that the therapy was responsible.
The Illness-Disease Distinction
Although the terms disease and illness are often used interchangeably,
for present purposes it is worth distinguishing between the two. I
shall use disease to refer to a pathological state of the organism due
to infection, tissue degeneration, trauma, toxic exposure,
carcinogenesis, etc. By illness I mean the feelings of malaise, pain,
disorientation, dysfunctionality, or other complaints that might
accompany a disease. Our subjective reaction to the raw sensations we
call symptoms is molded by cultural and psychological factors such as
beliefs, suggestions, expectations, demand characteristics, self-
serving biases, and self-deception. The experience of illness is also
affected (often unconsciously) by a host of social and psychological
payoffs that accrue to those admitted to the “sick role” by society’s
gatekeepers (i.e., health professionals). For certain individuals, the
privileged status and benefits of the sick role are sufficient to
perpetuate the experience of illness after a disease has healed, or
even to create feelings of illness in the absence of disease (Alcock
1986).
Unless we can tease apart the many factors that contribute to the
perception of being ill, personal testimonials offer no basis on which
to judge whether a putative therapy has, in fact, cured a disease.
That is why controlled clinical trials with objective physical
measures are essential in evaluating therapies of any kind.
Correlation Does Not Imply Causation
Mistaking correlation for causation is the basis of most superstitious
beliefs, including many in the area of alternative medicine. We have a
tendency to assume that when things occur together, they must be
causally connected, although obviously they need not be. For example,
there is a high correlation between the consumption of diet soft
drinks and obesity. Does this mean that artificial sweeteners cause
people to become overweight? When we count on personal experience to
test the worth of medical treatments, many factors are varying
simultaneously, making it extremely difficult to determine what is
cause and effect. Personal endorsements supply the bulk of the support
for unorthodox health products, but they are a weak currency because
of what Gilovich (1997) has called the “compared to what?” problem.
Without comparison to a similar group of sufferers, treated
identically except that the allegedly curative element is withheld,
individual recipients can never know whether they would have recovered
just as well without it.
Ten Errors and Biases
The question is, then: Why might therapists and their clients who rely
on anecdotal evidence and uncontrolled observations erroneously
conclude that inert therapies work? There are at least ten good
reasons.
The disease may have run its natural course.
Many diseases are self-limiting — providing the condition is not
chronic or fatal, the body’s own recuperative processes usually
restore the sufferer to health. Thus, before a therapy can be
acknowledged as curative, its proponents must show that the number of
patients listed as improved exceeds the proportion expected to recover
without any treatment at all (or that they recover reliably faster
than if left untreated). Unless an unconventional therapist releases
detailed records of successes and failures over a sufficiently large
number of patients with the same complaint, he or she cannot claim to
have exceeded the published norms for unaided recovery.
Many diseases are cyclical.
Arthritis, multiple sclerosis, allergies, and gastrointestinal
complaints are examples of diseases that normally “have their ups and
downs.” Naturally, sufferers tend to seek therapy during the downturn
of any given cycle. In this way, a bogus treatment will have repeated
opportunities to coincide with upturns that would have happened
anyway. Again, in the absence of appropriate control groups, consumers
and vendors alike are prone to misinterpret improvement due to normal
cyclical variation as a valid therapeutic effect.
Spontaneous remission.
Anecdotally reported cures can be due to rare but possible
“spontaneous remissions.” Even with cancers that are nearly always
lethal, tumors occasionally disappear without further treatment. One
experienced oncologist reports that he has seen twelve such events in
about six thousand cases he has treated (Silverman 1987). Alternative
therapies can receive unearned acclaim for remissions of this sort
because many desperate patients turn to them when they feel that they
have nothing left to lose. When the “alternatives” assert that they
have snatched many hopeless individuals from death’s door, they rarely
reveal what percentage of their apparently terminal clientele such
happy exceptions represent. What is needed is statistical evidence
that their “cure rates” exceed the known spontaneous remission rate
and the placebo response rate (see below) for the conditions they
treat.
The exact mechanisms responsible for spontaneous remissions are
not well understood, but much research is being devoted to revealing
and possibly harnessing processes in the immune system or elsewhere
that are responsible for these unexpected turnarounds. The relatively
new field of psychoneuroimmunology studies how psychological variables
affect the nervous, glandular, and immune systems in ways that might
affect susceptibility to and recovery from disease (Ader and Cohen
1993; Mestel 1994). If thoughts, emotions, desires, beliefs, etc., are
physical states of the brain, there is nothing inherently mystical in
the notion that these neural processes could affect glandular, immune,
and other cellular processes throughout the body. Via the limbic
system of the brain, the hypothalamic pituitary axis, and the
autonomic nervous system, psychological variables can have widespread
physiological effects that can have positive or negative impacts upon
health. While research has confirmed that such effects exist, it must
be remembered that they are fairly small, accounting for perhaps a few
percent of the variance in disease statistics.
The placebo effect.
A major reason why bogus remedies are credited with subjective,
and occasionally objective, improvements is the ubiquitous placebo
effect (Roberts, Kewman, and Hovell 1993; Ulett 1996). The history of
medicine is strewn with examples of what, with hindsight, seem like
crackpot procedures that were once enthusiastically endorsed by
physicians and patients alike (Skrabanek and McCormick 1990; Barrett
and Jarvis 1993). Misattributions of this sort arise from the false
assumption that a change in symptoms following a treatment must have
been a specific consequence of that procedure. Through a combination
of suggestion, belief, expectancy, cognitive reinterpretation, and
diversion of attention, patients given biologically useless treatments
can often experience measurable relief. Some placebo responses produce
actual changes in the physical condition; others are subjective
changes that make patients feel better although there has been no
objective change in the underlying pathology.
Through repeated contact with valid therapeutic procedures, we all
develop, much like Pavlov’s dogs, conditioned responses in various
physiological systems. Later, these responses can be triggered by the
setting, rituals, paraphernalia, and verbal cues that signal the act
of “being treated.” Among other things, placebos can cause release of
the body’s own morphinelike pain killers, the endorphins (Ulett 1996,
ch. 3). Because these learned responses can be palliative, even when a
treatment itself is physiologically unrelated to the source of the
complaint, putative therapies must be tested against a placebo control
group — similar patients who receive a sham treatment that resembles
the “real” one except that the suspected active ingredient is
withheld.
It is essential that the patients in such tests be randomly
assigned to their respective groups and that they be “blind” with
respect to their active versus placebo status. Because the power of
what psychologists call expectancy and compliance effects (see below)
is so strong, the therapists must also be blind as to individual
patients’ group membership. Hence the term double blind — the gold
standard of outcome research. Such precautions are required because
barely perceptible cues, unintentionally conveyed by treatment
providers who are not blinded, can bias test results. Likewise, those
who assess the treatment’s effects must also be blind, for there is a
large literature on “experimenter bias” showing that honest and well-
trained professionals can unconsciously “read in” the outcomes they
expect when they attempt to assess complex phenomena (Rosenthal 1966;
Chapman and Chapman 1967).
When the clinical trial is completed, the blinds can be broken to
allow statistical comparison of active, placebo, and no-treatment
groups. Only if the improvements observed in the active treatment
group exceed those in the two control groups by a statistically
significant amount can the therapy claim legitimacy.
Some allegedly cured symptoms are psychosomatic to begin with.
A constant difficulty in trying to measure therapeutic
effectiveness is that many physical complaints can both arise from
psychosocial distress and be alleviated by support and reassurance. At
first glance, these symptoms (at various times called “psychosomatic,”
“hysterical,” or “neurasthenic”) resemble those of recognized medical
syndromes (Shorter 1992; Merskey 1995). Although there are many
“secondary gains” (psychological, social, and economic) that accrue to
those who slip into “the sick role” in this way, we need not accuse
them of conscious malingering to point out that their symptoms are
nonetheless maintained by subtle psychosocial processes.
“Alternative” healers cater to these members of the “worried well”
who are mistakenly convinced that they are ill. Their complaints are
instances of somatization, the tendency to express psychological
concerns in a language of symptoms like those of organic diseases
(Alcock 1986; Shorter 1992). The “alternatives” offer comfort to these
individuals who for psychological reasons need others to believe there
are organic etiologies for their symptoms. Often with the aid of
pseudoscientific diagnostic devices, fringe practitioners reinforce
the somatizer’s conviction that the cold-hearted, narrow-minded
medical establishment, which can find nothing physically amiss, is
both incompetent and unfair in refusing to acknowledge a very real
organic condition. A large portion of those diagnosed with “chronic
fatigue,” “environmental sensitivity syndrome,” and various stress
disorders (not to mention many suing because of the allegedly harmful
effects of silicone breast implants) look very much like classic
somatizers (Stewart 1990; Huber 1991; Rosenbaum 1997). When, through
the role-governed rituals of “delivering treatment,” fringe therapists
supply the reassurance, sense of belonging, and existential support
their clients seek, this is obviously worthwhile, but all this need
not be foreign to scientific practitioners who have much more to offer
besides. The downside is that catering to the desire for medical
diagnoses for psychological complaints promotes pseudoscientific and
magical thinking while unduly inflating the success rates of medical
quacks. Saddest of all, it perpetuates the anachronistic feeling that
there is something shameful or illegitimate about psychological
problems.
Symptomatic relief versus cure.
Short of an outright cure, alleviating pain and discomfort is what
sick people value most. Many allegedly curative treatments offered by
alternative practitioners, while unable to affect the disease process
itself, do make the illness more bearable, but for psychological
reasons. Pain is one example. Much research shows that pain is partly
a sensation like seeing or hearing and partly an emotion (Melzack
1973). It has been found repeatedly that successfully reducing the
emotional component of pain leaves the sensory portion surprisingly
tolerable. Thus, suffering can often be reduced by psychological
means, even if the underlying pathology is untouched. Anything that
can allay anxiety, redirect attention, reduce arousal, foster a sense
of control, or lead to cognitive reinterpretation of symptoms can
alleviate the agony component of pain. Modern pain clinics put these
strategies to good use every day (Smith, Merskey, and Gross 1980).
Whenever patients suffer less, this is all to the good, but we must be
careful that purely symptomatic relief does not divert people from
proven remedies until it is too late for them to be effective.
Many consumers of alternative therapies hedge their bets.
In an attempt to appeal to a wider clientele, many unorthodox
healers have begun to refer to themselves as “complementary” rather
than “alternative.” Instead of ministering primarily to the
ideologically committed or those who have been told there is nothing
more that conventional medicine can do for them, the “alternatives”
have begun to advertise that they can enhance conventional biomedical
treatments. They accept that orthodox practitioners can alleviate
specific symptoms but contend that alternative medicine treats the
real causes of disease — dubious dietary imbalances or environmental
sensitivities, disrupted energy fields, or even unresolved conflicts
from previous incarnations. If improvement follows the combined
delivery of “complementary” and scientifically based treatments, the
fringe practice often gets a disproportionate share of the credit.
Misdiagnosis (by self or by a physician).
In this era of media obsession with health, many people can be
induced to think they have diseases they do not have. When these
healthy folk receive the oddly unwelcome news from orthodox physicians
that they have no organic signs of disease, they often gravitate to
alternative practitioners who can almost always find some kind of
“imbalance” to treat. If “recovery” follows, another convert is born.
Of course, scientifically trained physicians are not infallible,
and a mistaken diagnosis, followed by a trip to a shrine or an
alternative healer, can lead to a glowing testimonial for curing a
grave condition that never existed. Other times, the diagnosis may be
correct but the time course, which is inherently hard to predict,
might prove inaccurate. If a patient with a terminal condition
undergoes alternative treatments and succumbs later than the
conventional doctor predicted, the alternative procedure may receive
credit for prolonging life when, in fact, there was merely an unduly
pessimistic prognosis — survival was longer than the expected norm,
but within the range of normal statistical variation for the disease.
Derivative benefits.
Alternative healers often have forceful, charismatic personalities
(O'Connor 1987). To the extent that patients are swept up by the
messianic aspects of alternative medicine, psychological uplift may
ensue. If an enthusiastic, upbeat healer manages to elevate the
patient’s mood and expectations, this optimism can lead to greater
compliance with, and hence effectiveness of, any orthodox treatments
he or she may also be receiving. This expectant attitude can also
motivate people to eat and sleep better and to exercise and socialize
more. These, by themselves, could help speed natural recovery.
Psychological spinoffs of this sort can also reduce stress, which
has been shown to have deleterious effects on the immune system
(Mestel 1994). Removing this added burden may speed healing, even if
it is not a specific effect of the therapy. As with purely symptomatic
relief, this is far from a bad thing, unless it diverts the patient
from more effective treatments, or the charges are exorbitant.
Psychological distortion of reality.
Distortion of reality in the service of strong belief is a common
occurrence (Alcock 1995). Even when they derive no objective
improvements, devotees who have a strong psychological investment in
alternative medicine can convince themselves they have been helped.
According to cognitive dissonance theory (Festinger 1957), when
experiences contradict existing attitudes, feelings, or knowledge,
mental distress is produced. We tend to alleviate this discord by
reinterpreting (distorting) the offending information. To have
received no relief after committing time, money, and “face” to an
alternate course of treatment (and perhaps to the worldview of which
it is a part) would create such a state of internal disharmony.
Because it would be too psychologically disconcerting to admit to
oneself or to others that it has all been a waste, there would be
strong psychological pressure to find some redeeming value in the
treatment.
Many other self-serving biases help maintain self-esteem and
smooth social functioning (Beyerstein and Hadaway 1991). Because core
beliefs tend to be vigorously defended by warping perception and
memory, fringe practitioners and their clients are prone to
misinterpret cues and remember things as they wish they had happened.
Similarly, they may be selective in what they recall, overestimating
their apparent successes while ignoring, downplaying, or explaining
away their failures. The scientific method evolved in large part to
reduce the impact of this human penchant for jumping to congenial
conclusions.
An illusory feeling that one’s symptoms have improved could also
be due to a number of so called demand characteristics found in any
therapeutic setting. In all societies, there exists the “norm of
reciprocity,” an implicit rule that obliges people to respond in kind
when someone does them a good turn. Therapists, for the most part,
sincerely believe they are helping their patients and it is only
natural that patients would want to please them in return. Without
patients necessarily realizing it, such obligations are sufficient to
inflate their perception of how much benefit they have received. Thus,
controls for compliance effects must also be built into proper
clinical trials (Adair 1973).
Finally, the job of distinguishing real from spurious causal
relationships requires not only controlled observations, but also
systematized abstractions from large bodies of data. Psychologists
interested in judgmental biases have identified many sources of error
that plague people who rely on informal reasoning processes to analyze
complex events (Gilovich 1991, 1997; Schick and Vaughn 1995). Dean and
colleagues (1992) showed, using examples from another popular
pseudoscience, handwriting analysis, that without sophisticated
statistical aids, human cognitive abilities are simply not up to the
task of sifting valid relationships out of masses of interacting data.
Similar difficulties would have confronted the pioneers of pre-
scientific medicine and their followers, and for that reason, we
cannot accept their anecdotal reports as support for their assertions.
Summary
For the reasons I have presented, individual testimonials count for
very little in evaluating therapies. Because so many false leads can
convince intelligent, honest people that cures have been achieved when
they have not, it is essential that any putative treatment be tested
under conditions that control for placebo responses, compliance
effects, and judgmental errors.
Before anyone agrees to undergo any kind of treatment, he or she
should be confident that it has been validated in properly controlled
clinical trials. To reduce the probability that supporting evidence
has been contaminated by the foregoing biases and errors, consumers
should insist that supporting evidence be published in peer-reviewed
scientific journals. Any practitioner who cannot supply this kind of
backing for his or her procedures is immediately suspect. Potential
clients should be wary if, instead, the “evidence” consists merely of
testimonials, self-published pamphlets or books, or items from the
popular media. Even if supporting articles appear to have come from
legitimate scientific periodicals, consumers should check to see that
the journals in question are published by reputable scientific
organizations. Papers extolling pseudoscience often appear in official-
looking periodicals that turn out to be owned by groups with
inadequate scientific credentials but with a financial stake in the
questionable products. Similarly, one should discount articles from
the “vanity press” — journals that accept virtually all submissions
and charge the authors for publication. And finally, because any
single positive outcome — even from a carefully done experiment
published in a reputable journal — could always be a fluke,
replication by independent research groups is the ultimate standard of
proof.
If the practitioner claims persecution, is ignorant of or openly
hostile to mainstream science, cannot supply a reasonable scientific
rationale for his or her methods, and promises results that go well
beyond those claimed by orthodox biomedicine, there is strong reason
to suspect that one is dealing with a quack. Appeals to other ways of
knowing or mysterious sounding “planes,” “energies,” “forces,” or
“vibrations” are other telltale signs, as is any claim to treat the
whole person rather than localized pathology.
To people who are unwell, any promise of a cure is especially
beguiling. As a result, false hope easily supplants common sense. In
this vulnerable state, the need for hard-nosed appraisal is all the
more necessary, but so often we see instead an eagerness to abandon
any remaining vestiges of skepticism. Erstwhile savvy consumers,
felled by disease, often insist upon less evidence to support the
claims of alternative healers than they would previously have demanded
from someone hawking a used car. Caveat emptor!
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Keynes
wrote:
Nothing. He cuts paper dolls and posts them.
The reasons given are also how bogus
'official' medicine seems to work.
If only doctors would 'first do no harm'.
But there's no money in that. And patients
demand a pill for everything.
Placebos were standard medical practice before
penicillin, and they remain so today. Patients
come to the doctors, and the doctors give them
pills that the salesman swears will work. (The
real trials are 'flying blind into the public and
let's see what happens'.) A doctor will appear
to have complete confidence in his prescriptions
so that the patient will believe in them too.
A doctor will never say, "I don't know if this
will work for you, but let's just try it out
anyway." He would rather produce the
placebo effect on his patients.
Sometimes that's enough. But if not, there are
pills for the side effects, and more pills for the
other side effects, and so on. Drugs that kill
too many people are taken right off the market
in a few years. Lest the public realize that they
are being poisoned left and right because of
their fear of aging, sickness, and death, and their
misplaced confidence in pharma and the religious
sanctity of the white coated clergy.
Official medicine can do cures. Particularly
with surgery or with standard drugs with good
long term reputations. It also supports the legal
feel-good market of pain killers and mood elevators
that big pharma over produces for just that purpose.
If you suppose that all Rx drugs, and all therapies
are safe and effective, you'd better think again.
They never have been and they never will be.
Nobody in Particular
At any particular time in history, previous medical drugs were always
laughably and dangerously unsafe and ineffective, and current ones
were always safe and effective. "We've finally got it right". Well,
that shows how dumb those people were back then, they didn't get it
right after all. But NOW, we've finally got it right.
Right?
You betcha.
Charles E Hardwidge
news:ce8120cb-b836-4071...@21g2000yqj.googlegroups.com...
> <<If the practitioner claims persecution, is ignorant of or openly
> hostile to mainstream science, cannot supply a reasonable scientific
> rationale for his or her methods, and promises results that go well
> beyond those claimed by orthodox biomedicine, there is strong reason
> to suspect that one is dealing with a quack. Appeals to other ways of
> �vibrations� are other telltale signs, as is any claim to treat the
> whole person rather than localized pathology.>>
Sounds more like bad politics every day.
I did outlined a personality profile (which the media ran with in a more
expanded form a few days later) on David Cameron. So far it's stood the test
of time while George Osborne (another prime example of his type) is lying
like a carpet and describing Cameron as his exact opposite. George Osborne
claims that David Cameron's "compromises and lack of clarity" are driven by
a "positive one nation vision and coalition building". Uh, huh.
Such is the confusion in Tory ranks that they're reaching deep into the past
behind Thatcher and to even grander sounding people like Disraeli which
ironically betrays their own analysis and confirms mine. If it walks like a
duck, talks like a duck, and goes quack? David Cameron is a dumb and chummy
rigid minded bag carrier. Clueless flim-flam sold as a cure all like some
untested bogus alternative medicine.
--
Charles E Hardwidge