Social and Judgmental Biases That Make Inert Treatments Seem to Work

[Серебряков Сергей]

Social and Judgmental Biases That Make Inert Treatments Seem to Work
Barry L. Beyerstein

Barry Beyerstein, PhD, is in the Brain Behaviour Laboratory, Department of
Psychology, Simon Fraser University, Burnaby, British Columbia.

[Scientific Review of Alt Med 3(2):20-33, 1999. ż 1999 Prometheus Books,
Inc.]

Introduction
If only ignorant and gullible people accepted far-fetched ideas, little else
would be needed to explain the abundance of folly in modern society. But, as
James Alcock discusses in this issue of SRAM, many people who are neither
foolish nor ill-educated still cling fervently to beliefs that fly in the
face of well-established research. Trust in the further reaches of
complementary and alternative medicine (CAM) is a case in point.
Paradoxically, surveys find that users of unscientific treatments tend to
have slightly more, rather than less, formal education, compared to
nonusers.[1] How are we to account for the fact that college graduates, and
even some physicians, can accept therapeutic touch, iridology, ear candling,
and homeopathy? Experts in the psychology of human error have long been
aware that even highly trained experts are easily misled when they rely on
personal experience and informal decision rules to infer the causes of
complex events.[2,3,4,5] This is especially true if these conclusions
concern beliefs to which they have an emotional, doctrinal, or monetary
attachment. Indeed, it was the realization that shortcomings of perception,
reasoning, and memory will often lead us to comforting, rather than true,
conclusions that led the pioneers of modern science to substitute
controlled, interpersonal observations and formal logic for the anecdotes
and surmise that can so easily lead us astray. This lesson seems to have
been largely lost on proponents of CAM. Some, such as Andrew Weil, reject it
explicitly, advocating instead what he calls "stoned thinking," a melange of
mystical intuition and emotional satisfaction, for deciding which therapies
are valid.[6]
CAM remains, for the most part, "alternative" because its practitioners
depend on subjective reckoning and user testimonials rather than scientific
research to support what they do. They remain outside the scientific fold
because most of their hypothesized mechanisms contradict well-established
principles of biology, chemistry, or physics. If CAM proponents could
produce acceptable evidence to back up their methods, they would no longer
be alternative -- they would be absorbed by mainstream medicine. It is my
purpose in this article to draw attention to a number of social,
psychological, and cognitive factors that can convince honest, intelligent,
and well-educated people that scientifically discredited treatments have
merit.
Those who sell therapies of any kind have an obligation to prove, first,
that their products 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 practices in CAM, or the frankly magical panaceas
of faith healers.
To distinguish treatment-induced changes in some underlying pathology from
various kinds of symptomatic relief that might follow any sort of
intervention, there has evolved a set of objective procedures for testing
the effectiveness of putative remedies. It is reliance on these procedures
that distinguishes so-called evidence-based medicine from all the rest.
Unless a ritual, technique, drug, or surgical procedure can be shown to have
met these logical and evidential requirements, it is ethically questionable
to offer it to the public, except on an admittedly experimental basis --
especially if money is to change hands. Since most "alternative,"
"complementary," or "integrative" therapies lack this kind of support, one
must ask why so many otherwise savvy consumers -- many of whom would not
purchase a toaster without turning to Consumer Reports for unbiased ratings
from financially disinterested experts -- trustingly shell out considerable
sums for unproven, possibly dangerous health products. We must also wonder
why claims of alternative practitioners should remain so refractory to
contrary data that are so readily available.
So, if an unorthodox therapy:
a. 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);
b. lacks a scientifically acceptable rationale of its own;
c. has insufficient supporting evidence derived from adequately controlled
outcome research;
d. 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
e. should seem improbable, even to the lay person, on "common sense"
grounds;
why would so many well-educated people continue to sell and purchase such a
treatment?
Users of unscientific treatments fall broadly into one of two camps. Once a
user of either stripe decides to try an unconventional treatment, and
believes that his or her personal experience alone is adequate to decide if
it has worked or not, the judgmental biases and errors discussed below have
a strong tendency to make even the most worthless interventions seem valid.
As Alcock points out in his article in this issue, users of the first type
try unconventional therapies because they assume, erroneously, that someone
else has put them to the test; i.e., they place misplaced trust in the usual
authorities on whom they rely. They see an uncritical news item, receive a
testimonial from a friend, or see a dubious product displayed alongside the
proven ones in their local pharmacy. They may also overgeneralize from the
occasional news report of an "alternative" treatment that has actually
passed scientific scrutiny and been adopted by orthodox medicine.
The other sort of user chooses his or her alternative treatments out of a
broader philosophical commitment. For users who choose CAM on ideological
grounds, their fondness for these practices is rooted in a much larger
network of social and metaphysical assumptions. Needless to say, their
cosmological outlook differs substantially from the rationalist-empiricist
worldview that underlies scientific biomedicine. Because these adversaries
enter the fray with so few shared axioms and rules of evidence, it is not
surprising that a consensus is rarely reached. Proponents of CAM disagree
with their detractors, not only about the basic constituents of the universe
and the nature of the forces that govern them, but also at the
epistemological level -- i.e., they cannot even agree about what are valid
methods for settling such disputes.[7] Health being such a basic human
concern, it is to be expected that differing opinions about the causes and
remedies for disease would form a integral part of these two incommensurate
worldviews -- one objective, materialistic, and mechanistic, the other
subjective, animistic, and morally driven. Because our views on health and
disease are so enmeshed with our beliefs about the nature and meaning of
life itself, not to mention the underpinnings of our moral precepts and our
fundamental conceptions of reality, to attack someone's belief in unorthodox
healing is to threaten this entire mutually supportive system of bedrock
beliefs. Not surprisingly, such attacks will be resisted with strong
emotion.
The ability to defend one's basic worldview is abetted by a number of
cognitive biases that filter and distort contrary information. I shall
return to these psychological processes that incline supporters to
misconstrue their experiences to support their belief in CAM. But first let
us examine the cultural milieu that has fostered a widespread desire to
espouse such practices.

Social and Cultural Reasons for the Popularity of Unproven Therapies
As the twenty-first century approaches, several social trends have coalesced
that enhance the popularity of CAM, in spite of (and to some degree, because
of) its rejection by mainstream science. Today's resurgence of folk medicine
can be traced, in part, to nostalgic holdovers from the neoromantic search
for simplicity and spirituality that permeated the "counterculture" that
attracted so many youthful converts during the 1960s and 1970s.[8] The aging
flower children of the '60s and '70s now form the backbone of the "New Age"
movement wherein unorthodox healing forms a central thrust.[9] Many of the
"baby boomers" who spearheaded the earlier movement now find that CAM
satisfies the mystical longings, desire for simpler times, and naive trust
in the beneficence of "Nature" they absorbed during those tumultuous times.
CAM also resonates with that era's mix of iconoclasm, reliance on feeling
over reason, mistrust of science, and promotion of consumer advocacy. Let us
examine how some of these features have promoted belief in nonscientific
medicine among its clientele.
The Low Level of Scientific Literacy among the Public at Large
Surveys consistently report that, despite our overwhelming dependence on
technology for our safety, nutrition, health, shelter, transportation,
entertainment, and economic well-being, the average citizen of the
industrialized world is shockingly ignorant when it comes to even the
rudiments of science.[10,11] In a recent survey, only 52 percent of
Canadians who were polled could say how long it takes the earth to orbit the
sun! These days, it is quite possible to make it through college and even
graduate school with virtually no exposure to science courses at all.
Consequently, most people lack the basic knowledge and critical thinking
skills to make an informed choice when they must decide whether a highly
touted health care product is a sensible buy or not. When consumers haven't
the foggiest idea how bacteria, viruses, prions, oncogenes, carcinogens, and
environmental toxins wreak havoc on bodily tissues, shark cartilage, healing
crystals, and pulverized tiger penis seem no more magical than the latest
breakthrough from the biochemistry lab.
An Increase in Anti-intellectualism and Antiscientific Attitudes Riding on
the Coattails of New Age Mysticism
As a major plank in the New Age platform, CAM is permeated with the
movement's magical and subjective view of the universe, epitomized in its
catchphrase, "You create your own reality."[12] In advocating emotional over
empirical and logical criteria for deciding what to believe, New Age medical
gurus such as Andrew Weil and Deepak Chopra have fostered the attitude that
"anything goes."[13] Even in elite academic institutions, there are strong
proponents of the notion that objectivity is an illusion and how you feel
about something determines its truth value.[14,15] To the extent that this
has led many people to devalue the need for empirical verification in
general, it has enlarged the potential following for those who sell magical
and pseudoscientific health products.16,17,18, 19,20
Mind-body dualism permeates New Age thought, not least of all in its
alternative medicine wing. Ironically, it is the New Age supporters of CAM
who accuse their scientific critics of being dualists.[21,22] However, it is
the CAM afficionados who are the real dualists, as evidenced by their
constant appeal to undetectable spiritual interveners in matters of health.
They need this obfuscation in order to support the oft-heard canard that
scientific medicine undervalues the effects of mental processes on
health.[23] The confusion this has spread in the public mind has paved the
way for a resurgence of many variants of "the mind cure" so popular in past
centuries; i.e., the belief that the real causes and cures for almost all
disease lie in the mind, conceived by New Agers as coextensive with the
immaterial soul.[24] It is easy to understand the appeal of such beliefs
among those who have elevated wishful thinking to a virtue. Wouldn't it be
nice if laughter and thinking optimistic thoughts would keep us healthy,
prayer could rid us of diseases, or imagining little Samurais in the
bloodstream attacking malignant cells would purge the body of cancer?
Admittedly, there is evidence for psychological effects on one's health, but
the size of these effects has been blown out of all proportion by CAM
promoters such as Herbert Benson.[25] Several good critiques of the errors,
experimental confounds, and artifacts that permeate the literature on
spiritual beliefs and health have appeared recently.[26,27,28]
A related and troubling supposition common to New Age health propaganda is
that one's moral standing can alter how forces in the natural world will
affect us. In accepting this anthropocentric and animistic worldview,
alternative healers are reverting to the prescientific notion that health
and disease are tied to one's personal worthiness, rather than to
naturalistic causes. This has fostered the return of an endless variety of
long since discredited practices that purport to make patients "deserve
wellness," rather than attacking the cellular bases of their diseases.
Often, this merely leads to blaming the victim, for, implicitly, the patient
must have done something despicable to "deserve" his or her affliction. And
if the treatment fails, as it so often does, sufferers feel worse yet, for
they must have been undeserving of a cure.
Vigorous Marketing of Extravagant Claims by the "Alternative" Medical
Community
Strong profit motives have led alternative healers to promote themselves
through aggressive marketing and intense legislative lobbying.[29]
Routinely, promises are made that no ethical scientifically trained
practitioner could or would make. In addition, new diseases of dubious
scientific status are invented -- and treated.[30,31] Unfortunately, facing
this slick promotional barrage is a citizenry poorly equipped, in general,
with the skills or information for evaluating this hyperbole.[32]
Inadequate Media Scrutiny and Attacking Critics
With some notable exceptions, the electronic and print media have tended to
give CAM a free ride. The enthusiastic claims of the "alternatives,"
typically supported by nothing but anecdotes and testimonials, make
uplifting stories that are all too rarely challenged by journalists who know
that audience satisfaction cashes out in the rush for ratings.
Another disturbing trend that has had a chilling effect on some who would
criticize unscientific treatments stems from the fact that many of these
procedures have been imported from non-European cultures and championed by
female practitioners. A rhetorical tactic that allows self-promoters to
sidestep the substance of fair criticisms is to hurl accusations of racism
and sexism at anyone who dares to express doubts; e.g., some practices, such
as "therapeutic touch," that have been rejected by scientific medicine are
being embraced by an increasing number of nursing schools. Because these are
still predominantly female institutions looking to enhance the autonomy,
scope, and earning power of their graduates by monopolizing new, sometimes
dubious, spheres of practice, critics of practices salvaged from the
trashbin of scientific medicine often find themselves accused of sexism.
Similarly, when a colleague and I published a critique of several
unsupported aspects of Traditional Chinese Medicine (TCM),[33] we were
accused of cultural insensitivity and racism.[34] We were chided for
presuming to criticize the effectiveness of TCM when we were not steeped in
the philosophy of the culture that spawned it. To accept this absurd
argument would be to agree that no one but a gourmet cook could tell when
she's been served a bad meal. My rejoinder is, of course, that the truly
racist and sexist attitude would be to hold empirically testable claims from
other cultures or female proponents to a lower standard of proof than any
others -- this would amount to an assertion that their defenders are
intellectually inferior. In the final analysis, appeals such as these to
"other ways of knowing" amount to nothing more than tacit admission that
these treatments cannot pass the standard procedures for vetting would-be
therapies. Fortunately, since good science is practiced in the same way by
all ethnic groups and both sexes, there are many strong opponents from
within these communities who find ancient, unproven practices just as
dubious as do white male critics.[35,36]
Increasing Social Malaise and Mistrust of Traditional Authority Figures --
the Antidoctor Backlash
Growing disillusionment with the conventional wisdom and apprehensiveness
about the future has fostered a certain crankiness in Western societies.
This has intensified the willingness of many people to believe that our
social, economic, and political shortcomings must be due to active
connivance on the part of powerful, secretive cabals, rather than the
cumulative mistakes of well-intentioned planners muddling through as best
they can. Consequently, there is a growing desire to espouse grand
conspiracy theories and to attack the institutions or interest groups that
are suspected of plotting against the common good.[37] In this climate of
suspicion, government is increasingly seen as a party to the plot and the
scientific and medical professions have also begun to bear the brunt of what
Richard Hofstadter identified decades ago as the "paranoid streak" in
American politics.
These conspiratorial musings have coincided with two other, not entirely
unjustified, undercurrents to promote an antidoctor backlash that CAM
proponents have been quick to exploit. One is a sense of disappointment
arising from the failure of certain overly optimistic predictions of medical
breakthroughs to materialize. The other is the realization that medicine, as
a self-regulating profession, has not always held the public good at the top
of its political agenda.[38] This has added fuel to the social envy many
people feel regarding the status, political clout, and earning power of the
medical profession. As Ambrose Bierce once wrote, a physician is "one upon
whom we set our hopes when ill and our dogs when well."
The inability of many people to separate in their minds certain self-serving
actions of medical associations in the economic/political arena from the
debate over whether scientific medicine's treatments are genuinely better
than those of CAM has been a boon to the latter. In this fractious climate,
the "alternatives" have also benefited by painting themselves as defenders
of the democratic ideal of "choice." This would be commendable if consumers
had the wherewithal to make an informed choice.
Dislike of the Delivery Methods of Scientific Biomedicine
There exists a widespread but exaggerated fear that modern medicine has
become excessively technocratic, bureaucratic, and impersonal. The narrowing
of medical specialties, the need to maximize the cost-efficient utilization
of expensive facilities, the advent of third-party payment and managed care,
and the staggering workloads of medical personnel have led some patients to
long nostalgically for the simpler days of the kindly country doctor with
ample time and a soothing bedside manner. They tend to forget, however, that
this was often all a doctor of that era had to offer. Nonetheless, medical
schools are coming to a renewed appreciation for the tangible benefits of
interpersonal relationships in healthcare delivery and have begun, in their
admission procedures, to look more closely at applicants' social skills in
addition to their academic and technical excellence. The "alternatives" can
rightly claim some credit for moving this up the agenda.
Safety and Side Effects
A quaint bit of romanticism that draws converts to New Age, "holistic"
healthcare is the assertion that "natural" remedies are necessarily safer,
gentler, and more efficacious than those of technological origin.[39] One
hears frequently, for instance, the ludicrous claim that herbal concoctions
have no side effects. If the ingredients in a natural product are potent
enough to affect one's physiology in an advantageous way, they are certainly
powerful enough to cause side effects as well. To say otherwise is to admit
that one is administering an inert substance. In fact, some popular herbal
concoctions are far from benign -- a growing number of reports show
allergic, toxic, even lethal, reactions among users of certain herbal
remedies.[40,41,42,43,44,45] Numerous examples of mislabeling and serious
contamination of popular herbal products have also been reported.[46,47] As
usage rates rise, interactions with prescribed medications are also becoming
more prevalent, since patients rarely know what is in the concoctions they
are self-prescribing or receiving from herbalists. This danger is compounded
by the fact that users are often reluctant to admit such indulgences to
their physicians. Public awareness of the possible adverse effects of herbal
concoctions has tended to be sparse because, unlike prescription drugs,
there is no requirement that ill effects of supplements and herbal
medications be reported to central registries. Unfortunately, under current
U.S. law, the reverse onus exists, requiring the government to show that a
supplement or herb is unsafe before manufacturers and vendors can be forced
to remove it from the market.[48]
Among purveyors and users of herbs and supplements, even when adverse
effects do occur, they are likely to be ignored or attributed to other
causes. That is because there is a touching belief in these quarters that
beneficent Nature would never pull such dirty tricks. In the same naive
fashion, health food devotees staunchly maintain that "natural" Vitamin C
from plants is more effective than the identical molecule manufactured in
the chemistry lab, an idea equivalent to saying that bricks recycled from a
cathedral will produce a better house than bricks salvaged from a brothel.
Boosters of "natural" products should also be reminded that tobacco,
bacteria, viruses, and prions are quite natural too, and that some of the
most deadly poisons known (e.g., belladonna, strychnine, cytisine,
aflatoxin, and mycotoxins) are are found in wholly natural plants. On the
other hand, over a third of all drugs routinely used in scientific
biomedicine were derived from herbal sources, including many of the most
widely used drugs in cancer chemotherapy.[49] The difference, of course, is
that the active ingredients in these products, though originally from
nature, are now known and have passed rigorous tests of safety and efficacy.
This allows their purity and dosages to be accurately controlled, something
than cannot be said of herbalists' products, whose active ingredients have
been shown in lab assays to vary, in different samples, by a factor of as
much as 10,000.[50]
Possible adverse consequences of other branches of alternative medicine have
also been slow in being compiled, for similar sociopolitical reasons.[51]
Fortunately, the Internet is beginning to provide some valuable sources of
such cautionary information, though such warnings are in danger of being
swamped by the torrent of hype and self-promotion on the Net. A number of
Web sites containing scientifically reliable data about herbal remedies and
supplements are listed in reference number 45, below. Similar listings
regarding other aspects of CAM can be found at www.quackwatch.com and
www.health watcher.net, the websites maintained, respectively, by Dr.
Stephen Barrett and Dr. Terry Polevoy. Dr. George Lundberg, the new editor
of the online medical journal, Medscape (www. medscape.com), has also
announced that this electronic journal will be expanding its coverage of the
possible harms of alternative treatments.

Psychological Reasons for the Popularity of Alternative Therapies
Psychologists have long been aware that people generally strive to make
their attitudes, beliefs, knowledge, and behaviors conform to a harmonious
whole. When disquieting information intrudes and cannot easily be ignored,
it is fascinating to observe the extent to which we can distort or sequester
it to reduce the inevitable friction. It is to these mental gyrations that
we now turn.
The Will to Believe
We all exhibit a willingness to endorse comforting beliefs and to accept,
uncritically, information that reinforces our core attitudes and
self-esteem.[52] Since it would be nice if many of the hopeful shibboleths
of alternative medicine were true, it is not surprising that they are often
seized upon with little demand for proof. Once adopted, such beliefs are
remarkably resistant to contrary arguments. As Zusne and Jones[53] have
emphasized, magical and pseudoscientific beliefs are typically parts of more
fundamental systems of belief, ones that define the holder's basic concept
of reality. Anything this central to one's cosmology and social outlook will
be defended strongly, by filtering or misconstruing contrary input if need
be.[54]
Logical Errors and Lack of a Control Group
One of the most prevalent pitfalls in everyday decision-making is to mistake
correlation for causation. Logicians refer to this error as the Post Hoc,
Ergo Propter Hoc fallacy ("After this, therefore because of this"). It is
the basis of most superstitious beliefs, including many of the underpinnings
of CAM. We all have a tendency to assume that things that occur together
must be causally connected although, obviously, they needn't be. E.g., 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, we necessarily do so in situations where we lack complete
information. The task of determining cause and effect is made even more
difficult in the case of healthcare by the fact that many relevant factors
are varying simultaneously -- something casual observation cannot accurately
track. This, plus the fact that the outcome of any single case could always
have been a fluke, makes it virtually impossible to isolate actual causes
when we base our decisions on personal experience in a single instance.
Personal endorsements supply the bulk of the support for unorthodox health
products, but they are an extremely weak currency because of what
Gilovich[55] 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, any individual recipient can never
know whether he or she would have recovered just as well without the vaunted
treatment. Probably the single biggest failing of the CAM movement is its
inability to see the need for the simple control group.
Judgmental Shortcomings
Those who cast doubt on fringe treatments are frequently dismissed with the
rejoinder, "I don't care what your research studies say; I know it worked
for me." It is well established, however, that this kind of intuitive
judgement often leads to seriously flawed conclusions.[56,57] Unfortunately,
the typical purveyor and purchaser of unproven therapies is insufficiently
aware of the many perceptual and cognitive biases that can lead to faulty
decisions when we depend on personal experience to decide what has caused a
disease or whether a therapy "has worked" or not. Redelmeier and Tversky[58]
showed how people are prone to perceive illusory correlations in random
sequences of events. They then demonstrated how these intuitive feelings of
association have led to the false but widespread belief that arthritis pain
is influenced by the weather. Proponents of CAM, who take many folk beliefs
like this at face value, seem oblivious to how easy it is to be misled by
uncontrolled observations and misrecollections such as these.
The pioneers of the scientific revolution were aware of the large potential
for error when informal reasoning joins forces with our penchant for jumping
to congenial conclusions. By systematizing observations, studying large
groups rather than a few isolated individuals, instituting control groups,
and trying to eliminate confounding variables, these innovative thinkers
hoped to reduce the impact of the frailties of reasoning that lead to false
beliefs about how the world works. None of these safeguards exists when we
base our decisions merely on a few satisfied customers' personal
anecdotes -- unfortunately, these stories are the "alternative"
practitioner's stock in trade. Psychologists interested in judgmental biases
have repeatedly demonstrated that human inference is especially vulnerable
in complex situations, such as that of evaluating therapeutic outcomes,
which contain a mix of interacting variables and a number of strong social
pressures. Add a pecuniary interest in a particular outcome, and the scope
for self-delusion is immense.
The job of distinguishing real from spurious causes in everyday situations
requires not only controlled observations, but also systematized
abstractions from large bodies of data. Dean and his colleagues[59] showed,
using examples from another popular pseudoscience, handwriting analysis,
that without large, sophisticated databases and statistical aids, human
cognitive abilities are simply not up to the task of sifting valid
relationships out of huge masses of interacting data. Similar difficulties
would have confronted the elders of prescientific medicine, and for that
reason, we cannot accept their, or their descendants', anecdotal reports as
sufficient support for their methods.
Noticing interesting correlations in one's surroundings is a reasonable
starting point for a systematic, controlled analysis that could actually
reveal the underlying causal structure that might be exploited. Observing
such a correlation, however, should never be the end point in a search for a
relationship that could eventually be put to therapeutic use.
In defending their enterprise, proponents of CAM generally ignore these
cautions and encourage instead another unfortunate human tendency, that of
placing more faith in personal experience and intuition than on controlled,
statistical studies. The "alternatives" encourage this in their followers by
calling it independence of thought, which, of course, can sometimes be a
good thing. They should know, however, that it can also lead the appraiser
astray in many situations in which personal experience is not a good guide
to the actual state of affairs.
Psychological Distortion of Reality
Distortion of perceived reality in the service of strong belief is a common
occurrence (see Alcock[60] and his article in this issue of SRAM). Even when
they derive no objective benefits, devotees who have a strong psychological
investment in alternative medicine can convince themselves that they have
been helped. According to cognitive dissonance theory,[61] when new
information contradicts existing attitudes, feelings, or knowledge, mental
distress is produced. We tend to alleviate this mental discord by
reinterpreting, i.e., distorting, the offending input. To have received no
relief after committing time, money, and "face" to an alternate course of
treatment (and most likely to the cosmology of which it is a part) would be
likely to create this kind of internal dissonance. Because it would be too
disconcerting, psychologically, to admit to one's self or to others that it
had all been a waste, there would be strong psychological pressure to find
some redeeming value in the treatment.
Self-serving Biases and Demand Characteristics
There are many self-serving biases that help maintain self-esteem and
promote harmonious social functioning.[62] None of us wishes to admit to
ourselves or others that we believe foolish things or that we are accepting
people's trust and money under false pretenses. Because these core beliefs
in our own virtue and intelligence tend to be vigorously defended -- by
warping perception and memory if need be -- fringe practitioners, as well as
their clients, are prone to misinterpret cues and remember things as they
wish they had happened, rather than as they really occurred. In this way,
therapists who don't keep good records and apply proper statistics (as is
generally the case in CAM) can be selective in what they recall, thereby
overestimating their apparent success rates while ignoring, downplaying, or
explaining away their failures.
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 a "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 clients necessarily realizing it, such obligations
(in the form of implicit social demands) are sufficient to inflate their
perception of how much benefit they have received. Thus controls for this
kind of compliance effect must also be built into properly conducted
clinical trials.[63] Again, proponents of CAM downplay the need for such
controls, possibly a form of self-delusion in itself.

Why Therapists and Their Clients Erroneously Conclude That Inert Therapies
Work
Although the terms "disease" and "illness" are often used interchangeably,
for present purposes, it is worth distinguishing between the two. In what
follows, I shall use "disease" to refer to a pathological state of the
organism arising from infection, tissue degeneration, trauma, toxic
exposure, carcinogenesis, and so on. By the term "illness" I will mean the
feelings of malaise, pain, disorientation, dysfunctionality, or other
subjective complaints that might accompany a disease state. Our subjective
reaction to the raw sensations we call symptoms is, like all other
perceptions, a complex cognitive construction. As such, it is molded by
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, monetary, and
psychological payoffs that accrue to those admitted to the "sick role" by
society's gatekeepers (i.e., health professionals). For certain individuals,
the privileges 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.[64,65] Awareness of these
dynamics can be quite minimal in the nondiseased patient who has learned,
through subtle psychological mechanisms, to feel ill. A conscious intent to
deceive is definitely not required.
Unless we can tease apart the many factors that contribute to the perception
of being ill, or being improved, personal testimonials offer no basis on
which to judge whether a putative therapy has, in fact, cured anyone's
disease. That is why blinded placebo-controlled clinical trials, with
objective physical measures if possible, are absolutely essential in
evaluating therapies of any kind. Bearing this in mind, then, why might
someone mistakenly believe that he had been helped by an inert treatment?
The Disease May Have Run Its Natural Course
Many diseases respond well to "the tincture of time." In other words, they
are self-limiting. Providing the condition is not chronic or fatal, the
body's own recuperative processes will restore the sufferer to health. Thus,
before the curative powers of a putative therapy can be acknowledged, its
proponents must show that the percentage of patients who improve following
treatment exceeds the proportion expected to recover without any
intervention 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, she cannot claim to have exceeded the norms for unaided
recovery. As noted above, without an adequate control group, any given
practitioner will never know how his clients would have fared without his
ministrations.
To be fair, the "alternatives" are correct that many effective treatments in
conventional medicine are also aimed at symptomatic relief or strengthening
the body's own recuperative mechanisms, rather than attacking the disease
process itself. It's just that proponents of CAM offer little convincing
evidence that their own unique efforts along these lines are particularly
effective. Nonetheless, the "alternatives" can take some satisfaction in the
fact that the debate they have provoked has spurred conventional biomedical
researchers to seek more effective ways of stimulating natural recovery
processes, such as enhancing certain immune reactions. Unfortunately, their
disinterest in research means that the "alternatives" will contribute little
to the understanding that will eventually lead to therapeutic improvements.
Many Diseases Are Cyclical
Arthritis, multiple sclerosis, allergies, and gastrointestinal complaints
are examples of diseases that normally "have their ups and downs." Not
surprisingly, 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
Any anecdotally reported cure could have been due to a rare but possible
"spontaneous remission." Even with certain cancers that are nearly always
lethal, tumors occasionally disappear without further treatment. One
experienced oncologist reports that he has seen 12 such events in about 6000
cases he has treated.[66] Alternative therapists can receive unearned
acclaim for such remissions because many desperate patients turn to them out
of a feeling 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 at present, 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. Some researchers think that
spontaneous remissions are less the result of immune surveillance than the
fact that certain biochemical reactions necessary for growth in malignant
masses can, on occasion, reach a self-limiting stage before the accumulated
tumor mass kills the patient. Whatever the mechanism, the documented
existence of spontaneous remissions in a variety of diseases, in people who
do not avail themselves of alternative treatments, means that an occasional
dramatic, unexpected turnaround cannot be used to validate the power of
prayer or a fringe therapy.
The Placebo Effect and the Need for Randomized, Double-blind Assessments
A major reason bogus remedies are credited with subjective, and occasionally
objective, improvements is the ubiquitous placebo effect.[67,68,69] The
history of medicine is strewn with examples of what, in hindsight, seem like
crackpot procedures that were once enthusiastically endorsed by physicians
and patients alike.[70,71,72] Misconceptions 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 attentional
diversion, patients given biologically useless treatments can often
experience measurable relief nonetheless. Some placebo responses produce
actual changes in physical symptoms; others are subjective changes that make
patients feel better in the absence of measurable changes in their
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 morphine-like
pain killers, the endorphins.[73] Because these learned responses can be
palliative, even when a treatment itself is irrelevant to the source of the
complaint, it is necessary that putative therapies be tested against a
placebo control group -- i.e., 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 treatment groups. Otherwise, sicker or more compliant
people could end up in one group or another, or people with harmful or
helpful lifestyles or certain habits, industrial exposures, and so on, could
be disproportionately allocated. These group differences could produce
effects that might be spuriously attributed to the experimental
manipulation -- something researchers call an "experimental confound." Good
examples of the mischief such confounds can wreak are discussed in a recent
critique of studies purporting to show that various religious practices
enhance health.[74] Indeed, practicing members of certain faiths do seem to
enjoy certain medical benefits. The question, however, is whether faith
itself is responsible -- i.e., a benevolent deity looks out for the pious --
or simply that observant believers also tend to smoke and drink less, engage
in fewer risky activities, live in less toxic environments, enjoy better
social support networks, come from certain ethnic backgrounds, and so on.
And, of course, given that stress can have adverse health consequences,
belief in a supernatural protector could be health-promoting via its ability
to alleviate anxiety, regardless of whether the belief is true or not. Once
again we see the perils of assuming that correlation implies causation.
In addition, adequately controlled research requires that all recipients
must be "blind" with respect to whether they are receiving the active versus
the placebo treatment. Because the power of what psychologists call
"expectancy and compliance effects" is so strong, the therapists must also
be blind as to the group membership of individual patients.[75] 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 events.[76,77] If one's
professional advancement or net worth depends on validation of a putative
treatment, there is all the more need for blind assessments. Ideally, the
end points being measured will be objective, and if the measurements can be
mechanized and automated to reduce the effects of observer subjectivity, so
much the better. It is odd that CAM supporters who would not think much of a
wine tasting that failed to obscure the labels on the bottles still downplay
the need for blinded assessments when it comes to their own stock-in-trade.
When the clinical trial is completed, the blinds can then be broken to allow
statistical comparison of active, placebo, and untreated groups. Only if the
improvements observed in the active treatment group exceed those in the
other two groups by a statistically significant amount can the therapy claim
legitimacy.
Defenders of CAM often complain that conventional medicine itself continues
to use many treatments that have not been adequately vetted in
placebo-controlled, double-blind trials. This may be so in some instances,
but the percentage of such holdovers is grossly exaggerated by the
"alternatives."[78] At any rate, this does nothing to enhance the
credibility of CAM, for merely arguing that "they're as bad as we are"
offers no positive evidence in favor of one's own pet belief. The crucial
difference between scientific biomedicine and alternative medicine is that
the former is institutionally committed to finding empirical support for its
treatments and eventually weeds out those that fail to pass muster. And,
unlike the "alternatives," biomedicine does not cling to procedures that
contradict well-established principles in the basic sciences.
Scientifically-based therapies change because new research accumulates;
alternative medicine is mired in the past and changes rarely, if ever. This
is because the latter has no serious commitment to testing its rationales
and procedures under controlled conditions. Alternative medicine clings to
the belief that its procedures must be valid because they have stood the
test of time. But the longevity of racism, sexism, and the belief in demonic
possession belies the assertion that ability to survive implies validity.
Some Allegedly Cured Symptoms Were Probably Psychosomatic to Begin With
The pioneering neurologist Joseph Babinski (1857- 1932) coined the term
"pithiatism" to refer to conditions he concluded were "caused by suggestion,
cured by persuasion." A constant difficulty in trying to measure therapeutic
effectiveness is that there are many such complaints that 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.[79,80] Although there are many "secondary gains" (i.e.,
psychological, social, and economic payoffs) 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.[81]
Alternative healers cater to these members of the "worried well" who are
mistakenly convinced that they have organic diseases or morbidly fearful
that they may lose their good health. Their complaints are instances of
somatization, the tendency to express psychological concerns in a language
of symptoms like those of organic diseases.[82,83,84] The "alternatives"
offer comfort to these individuals who need to believe their symptoms have
medical rather than psychological causes. Often with the aid of
pseudoscientific diagnostic devices, fringe practitioners reinforce the
somatizer's conviction that the cold-hearted, narrow-minded medical
establishment, who can find nothing physically amiss, is both incompetent
and unfair in refusing to acknowledge a very real organic condition. A large
proportion of those diagnosed with "chronic fatigue," "environmental
sensitivity syndrome," irritable bowel syndrome, fibromyalgia, and
posttraumatic stress disorders (not to mention many suing manufacturers
because of the allegedly harmful effects of silicone breast implants[85])
look very much like classic somatizers.[86,87] Similar dynamics seem to
underlie reports of a more recent variant of what Stewart[88] has called
this family of "fashionable diseases," i.e., "Gulf War Syndrome."[89]
If a patient's symptoms were psychologically caused to begin with, he or she
is likely to respond favorably to an acceptable blend of suggestion,
reassurance, psychological support, and reaffirmation. Often this is what
(probably unknowingly) these patients are really seeking though their
illness behavior. In rejecting this interpretation, CAM practitioners ask
why, if the malaise is really of psychological origin, wouldn't relief have
been achieved already from any of the typically long list of abandoned
conventional physicians? One answer is that the patient-doctor rapport
necessary for such reassurance to be effective is likely to become strained
as soon as the doctor says she cannot find any physical cause for the
illness. If a physician even hints at a psychosomatic diagnosis, the
relationship is likely to be poisoned irrevocably-for, sad to say, even in
this supposedly enlightened age, psychological diagnoses still carry a
social stigma for many. Thereafter, no amount of support and reassurance is
likely to bridge the gap that has been opened. Curiously, though, when the
alternative healer gives the sought-after physical diagnosis and then, in
the next breath, reverts to the New Age line that all diseases are caused by
mental/spiritual shortcomings, the same patient may well accept this
about-face with enthusiasm. To the extent that alternative healers are often
charismatic personalities who are willing to spend extensive amounts of time
reassuring their clients and catering to their existential concerns, this
heightens their ability to capitalize on patient suggestibility.[90] It also
stands to reason that suggestions arising from someone who buys into the
patient's metaphysical outlook might be more effective in countering
psychosomatic complaints than those following from a philosophically
skeptical point of view.
When, through the role-governed rituals of "delivering treatment," fringe
therapists supply the reassurance, sense of belonging, and existential
support that their clients are seeking, 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 pseudoscience and magical
thinking while unduly inflating the success rates of medical quacks. Saddest
of all, it perpetuates the prejudicial anachronism 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.[91,92] Researchers have found repeatedly that
anything that successfully reduces the emotional component of pain leaves
the purely 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 multidisciplinary
pain clinics put these strategies to good use every day.[93] 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 for
the underlying condition 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" or "integrative," 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.[94] 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 suffer from 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 always find some kind of "energy imbalance," nutritional deficit, or
dubious "sensitivity" to treat. If "recovery" should follow, another convert
is born.
Scientifically trained physicians do not claim infallibility, and a mistaken
diagnosis, followed by a trip to a shrine, alternative healer, or herb
counter, can lead to a glowing testimonial for having cured a grave
condition that never existed. Other times, the diagnosis may have been
correct but the time course, which is inherently hard to predict, might have
proved 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, the discrepancy was merely due to an unduly pessimistic
prognosis. I.e., survival was longer than the expected norm, but within the
range of normal statistical variation for the disease in question.
Derivative Benefits
Alternative healers often have forceful, charismatic
personalities.[95,96,97] To the extent that patients are swept up by the
messianic aspects of CAM, a psychological uplift may ensue that can have
both short and longer term spinoffs. If an enthusiastic, upbeat healer
manages to elevate the patient's mood and bolster his expectations, this
enhanced 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 improve their eating and
sleeping habits and to exercise and socialize more. These changes, by
themselves, could help speed natural recovery, or at the very least, make
the recuperative interval easier to tolerate.
Psychological spinoffs of this kind can also reduce stress, which has been
shown to have deleterious effects on the immune system.[98,99] 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.

Conclusion
Before anyone agrees to accept an unconventional treatment, he or she should
ask whether it has been subjected to the sort of controlled clinical trials
described above. As should be obvious by now, personal endorsements are
essentially worthless in deciding the value of any therapy. Instead,
supporters of unorthodox therapies should be able to supply empirical
evidence, based on large groups of patients and published in refereed
scientific journals. Only by this process of peer review can we be assured
that the supporting research has been checked for the sources of error and
bias described above. For example, reviewers look to see that the sample
sizes were sufficiently large, the experimental design and statistical
analyses were appropriate, and that obvious confounding variables were
controlled for. The peer review process will determine that the participants
were randomly assigned to treatment groups and that they were treated and
assessed under double-blind conditions. It will also ensure that the
condition of each patient was accurately assessed and documented before and
after the intervention and, ideally, that the participants were followed up
for a reasonable interval thereafter to gauge the duration of any beneficial
changes. And, of course, because any single positive outcome could always
have been a statistical fluke, replication by independent researchers with
converging methodologies is the ultimate assurance. A single experimental
result practically never settles an important scientific issue. It is the
long-term track record that counts. And even with published papers that pass
on the foregoing criteria, one should always look to see how large the
reported treatment effects are. Beware of the "true but trivial effect."
There are many statistically significant outcomes in research articles that
are real but too small to be of any clinical use.
Any practitioner who cannot supply this kind of backing for his or her
procedures is immediately suspect. One should be even more wary if, instead
of peer-reviewed research, the "evidence" comes solely in the form of
anecdotes, testimonials, or self-published pamphlets or books. To be
credible, supporting research articles should come from impartial journals
in the appropriate scientific fields, rather than from journals owned by
associations promoting the questionable practice, or from the "vanity
press," which accepts virtually all submissions and charges the authors for
publication of their work.
If the practitioner is ignorant of, or openly hostile to, mainstream science
and cannot supply a reasonable scientific rationale for his methods, the
would-be buyer should proceed with caution. If the "doctor's" promotional
patter is laced with allusions to spiritual forces or vital energies or to
vague planes, vibrations, imbalances, and sensitivities, suspicions should
also be aroused. Likewise, if the treatment provider claims secret
ingredients or processes (especially if they are named after him- or
herself), extols ancient wisdom and "other ways of knowing," or claims to
"treat the whole person, not diseases," there is also good reason to
question his or her legitimacy. If the therapist claims to be persecuted by
the medical establishment, encourages political action on his or her behalf,
and is prone to attack or even sue critics rather than answering their
criticisms with valid research, alarm bells should begin to ring.
Practitioners who sell their own supplements and other proprietary
concoctions in their offices and stress the need for frequent return visits
by healthy people, "in order to stay healthy," are also a cause for concern.
The presence of any pseudoscientific or conspiracy-laden literature in the
waiting room ought to set a clear thinker looking for the nearest exit. And
above all, if the promised results go well beyond those offered by
conventional therapists, the probability is that one is dealing with a
quack. In short, if it sounds too good to be true, it probably is.
When people become sick, any promise of a cure is especially beguiling. As a
result, common sense and the willingness to demand evidence are easily
supplanted by false hope. In this vulnerable state, the need for critical
appraisal of treatment options is all the more necessary, rather than less.
Potential clients of alternative therapists would do well to heed the
admonition of St. Paul: "Test all things; hold fast to what is good" (I Th.
5:12). Those who still think they can afford to take a chance on the hawkers
of untested remedies should bear in mind Goethe's wise advice: "Nothing is
more dangerous than active ignorance."