2.5 The therapeutic relationship as a placebo
Mitchell and Cormack propose that the relationship aspect of a therapeutic encounter can be as important as the technical dimensions of healing (Mitchell and Cormack, 1998). CAM practitioners argue that the therapeutic relationship itself may be an important tool in healing. Critics of CAM turn this argument on its head, suggesting that CAM is, in fact, no more than a powerful form of placebo. What they generally mean is that it is not the specific treatments used that evoke a healing response; rather, it is the combination of non-specific effects of the CAM therapeutic relationship which create a belief in the user that they are being healed. In other words, it is not the acupuncturist's needles, or the homoeopath's remedies, or the osteopath's manipulations that benefit the user, but the ritual, supportive relationship and powerful belief in the effectiveness of the therapy that makes users feel better. Obviously, CAM practitioners regard this assertion as contentious, and a denigration of their technical skills, which often have been learned over many years. Peters (2001, p. xi) notes that practitioners might find it demeaning having to accept that recovery might depend on responses they trigger. For many practitioners, calling CAM ‘mere placebo’ is a way of dismissing it as trickery or an elaborate sort of con. To call CAM a placebo is to infer that, if it heals users at all, the healing is all in the user's mind, and not a result of the treatment.
Placebo generally means an inert substance, given in place of an active drug or treatment. Over the centuries, physicians realised that some people felt better for taking a placebo, even if it was nothing more than water or sugar. The placebo effect refers to the phenomenon that, in certain conditions, including pain and depression, approximately 30 per cent of people will get better, even when they have been given a dummy pill or procedure. The placebo effect is not the same as spontaneous remission or the natural waxing and waning of symptoms over the course of a disease.
To understand why this is such a contentious debate, remember that orthodox medicine (not to mention pharmaceutical companies) has much invested in the idea of ‘magic bullets’, or specific interventions to cure specific diseases. Much clinical research is dedicated to proving that drug X works for condition Y. Drug trials are carefully designed to prove whether the drug (or procedure, or device) can demonstrate a desired specific effect beyond any possible placebo effect. In order to prove this, potential biases and variables are taken out of the equation as far as possible, so that the only aspect being tested is the intervention with the specific effect. This form of scientific method led to the development of the double-blind, randomised controlled trial (or RCT).
RCTs represent the scientific gold standard for assessing the effectiveness of any new treatment. They eliminate the very factors that exert a powerful effect in the CAM therapeutic relationship: the practitioner's time and interest in the user; the formation of a close, empathetic relationship; the giving of hope; and the practitioner's enthusiasm for the therapy. This represents a clash of systems and values. Some scientific scholars argue that the only definitive way to prove that a CAM therapy works is to subject it to the same scientific processes as conventional medicine (that is, the RCT), whereas other scholars (and many CAM therapists) argue that it is pointless to consider the specific effects of their therapy in isolation, since it is a combination of the specific and non-specific effects, acting together, that creates the power of the healing effect. They also argue that it is unfair and unrealistic to be expected to test their therapies in a way that fails to capture the holistic nature of the interaction.
This argument is not simply about research methodology. As with so many other dimensions of CAM, it has political overtones. The future integration of CAM requires more evidence of its efficacy and cost-effectiveness. Sustained consumer enthusiasm for CAM similarly depends increasingly on evidence to support its claims. Many practitioners appreciate that developing a stronger evidence base is essential to maintaining their increasing credibility and professionalisation, and they accept that research must be done. Compromises will have to be sought, which may include innovative research design for testing specific and non-specific effects (for example, the use of pragmatic RCTs, which test the intervention as a whole, as it is delivered in practice) and sufficient research funding in CAM, so that any placebo effect can be rigorously and scientifically tested (for example, by comparing an active CAM treatment with a placebo and no treatment whatsoever).
Regarding the claim that orthodox medicine is becoming more patient-centred, doctors may also want to explore how the non-specific effects of treatment might make patients feel better. Whether or not specific effects are caused by evoking a placebo response, or through chemical processes in the body (as PNI might suggest), anything that improves a patient's subjective experience of suffering is worth investigating.
Placebo might work through psychoneuroimmunology (Armstrong, 1993); that is, the complex interrelationship between the mind or psychology, the brain, the immune system and general health. A psychoneuroimmunological approach tries to take all these facets of a person into account in understanding a symptom, an illness or a disease. Thinking about and treating the whole person could evoke a stronger placebo effect. As Evans (2003) notes, rather than dismissing CAM practitioners as frauds or quacks, if their healing abilities are ‘just’ about placebo then orthodoxy could learn a great deal from them.
Without further research, the question of whether CAM is a placebo will continue to generate controversy and polarise CAM practitioners and scientists.