Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, June 26, 2013

Book Review: "Do You Believe in Magic?", by Paul A. Offit


Paul Offit’s new book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine (HarperCollins, 2013) is a smoothly written, highly readable take on some important topics from the ever-changing complementary-and-alternative-medicine (CAM) territory. Offit’s primary theme is that treatments can harm as well as help—true of conventional medicine and its potential side effects, but even more true of unconventional treatments, with their untested effects. At several points in the book, Offit repeats the important dictum: there is really no such thing as “alternative” medicine, but only medicine that has been shown to work, effectively and safely,  and medicine that has not been shown to work or be safe. If it hasn’t been shown to be safe and effective, there’s no point in calling a treatment “medicine”.  

Offit begins the book with chapters considering two factors that help convince the public that an alternative treatment is a good idea: one is the belief that if a substance or procedure is part of an ancient tradition, it must be beneficial, and the other is the belief that whatever is “natural” is good for you.  (To these, I would add, by the way, the remnants of 19th century Orientalism that suggest that whatever is done in Asia is a good idea.)
Obviously, these beliefs are unsupported by evidence. We read with horror of the devastation of the Black Death, of scurvy on sailing ships, of death and deformity from smallpox and polio. Strolling through a New England graveyard, we count infant deaths and note how many wives each man got through in those pre-divorce days. As for the goodness of the natural, we all must be aware of poisonous snakes and insects, of ergotism from contaminated grain, and of death cap mushrooms, deadly nightshade, oleander bushes, and the whole panoply of attractive toxins Ma Nature has put on the table. Yet, you can fool many of the people much of the time, and some of the people all of the time, if you just mention that shamans used to use a method or that a potion comes straight from nature’s bounty. Most curiously, a number of the foolees are quite convinced that they are cleverly avoiding the manipulations of the medical profession when they go for the old, the natural, the non-evidence-based. “Nobody can  fool me,” they think, and of course nobody needs to as long as they fool themselves.  

Most of Offit’s subsequent chapters recount sad stories of adults and children unhelped or even harmed by the treatments celebrities and “healers” sell to them. In the course of this discussion, Offit shows that snake oil proponents are not necessarily recycled used-car salesmen or preachers of the Elmer Gantry ilk. Stanislaw Burzynski, for example, is a Polish-trained physician who has been assistant professor at Baylor Medical College. He had a research Grant from the National Cancer Institute  and later FDA approval to test a cancer treatment, “antineoplastons”, extracted from that most natural substance, urine. The celebrity-expert, Suzanne Somers, says Burzynski is right about his treatment; unfortunately the evidence shows that despite his academic and research background, Burzynski’s claims are wrong.

Offit’s final chapter, “The Remarkable, Highly Underrated Placebo Response”, addresses the fact that people sometimes do get better when given alternative treatments. He refers briefly to several explanations of the placebo effect, including cognitive dissonance and regression to the mean. But what I’d hoped for from this chapter does not materialize. I would have liked to see some discussion of the effect of spending time with a patient and of personal interactions that may go a long way to explain the occasional effectiveness of implausible treatments.

When alternative practitioners say that their acupuncture or energy field methods have helped  people’s back pain (for example), it‘s not uncommon to hear conventional physicians say, “If I could spend an hour with each patient, I’d have more successes too”.  What happens during that hour of contact? It seems to me that this question, if answered carefully, could focus thinking on an important placebo factor, social and emotional interactions with another person.  

When researchers compare psychological interventions (alternative or conventional), they ideally design their studies so the targeted treatment is compared to another well-known treatment, rather than to no treatment at all. Unless the research question has to do with evaluating a brief method of treating a problem, as many features of the treatments as possible are matched, including the length of the treatment. Psychotherapies are aimed at making a person feel better, so all factors that could achieve this need to be taken into account. Although psychotherapists may employ different techniques, there are factors common to all these treatments that contribute a good deal to “feeling better”: the practitioner’s warmth, empathy, acceptance, and encouragement of risk taking. Presumably, the length of contact with each of these factors has an influence on patient changes.

Do those common factors also play a role in medical effectiveness? At one level, medical treatments  are aimed at creating physical changes that can be objectively measured--  lowering a fever, shrinking a tumor, bringing about weight gain or loss. But many medical treatments also deal with the “feeling better” aspect. If a person reports that he is still in pain or still hears ringing in his ears and does not “feel better”, presumably the entire medical task has not been accomplished.

Situations where the patient does not “feel better” in spite of treatment are situations that open the door to alternative practitioners. If the patient subsequently “feels better”, the alternative practitioner counts this as a success for his or her method and may report this or publish it in a journal dedicated to alternative medicine. But, in most comparisons of alternative and conventional treatments, the influential common factors go unconsidered. However difficult we might find it to assess warmth, empathy, and so on, it’s reasonable to say that less contact means less exposure to the common factors. Thus, research on alternative treatments, to be valid, needs not only to involve comparisons with conventional methods (rather than with “no treatment”), but to make sure that treatment plans equalize the contact time of patients and practitioners in the two groups.  Comparisons that indicate greater success for an unconventional treatment should not be accepted (by anyone) unless these rules are followed.  Otherwise, we are risking “believing in magic”.

   

14 comments:

  1. This review promotes popular assumptions (like Offit's claims) unexamined. For instance, it states, "Offit’s primary theme is that treatments can harm as well as help—true of conventional medicine and its potential side effects, but even more true of unconventional treatments, with their untested effects." Fact is, documented with government data, that the tested products/services of conventional medicine cause many more times more harm than "untested" unconventional treatments. Offit's anti-vitamin accusations have been convincingly invalidated (see http://www.supplements-and-health.com/vitamin-benefits.html ). Something that is "smoothly written" isn't necessarily the same as stating the actual facts.

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    1. If they're untested, how does anyone know how much harm they caused?

      Nobody denies that conventional medicine has the potential for harmful side effects-- however, these are documented and their frequencies can be known to physicians and patients. If a possible side effect would be a problem for a particular patient-- e.g., he or she has high blood pressure, and a treatment for a different problem raises blood pressure-- that can be taken into account in ways that are not possible for products that have no systematic outcome data available.

      The writer at http://www.supplements-and-health.com cautions properly against an appeal to authority, but then cites Francis Bacon and other authorities to support his claim-- of course, what else can he do, when a real database is not available?

      In any case, the main thrust of my review had to do with explanations of factors in the placebo effect, common to both conventional and unconventional medicine, but perhaps more operative in unconventional medicine where "personalization" seems more likely.

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    2. "Untested" by whose definition? Yours, the medical orthodoxy's? Do you think an age-old healing system such as Chinese Medicine is "untested"? Careful observation, longterm clinical experience are reasonable measures of a test -i.e., they are "real databases".

      Also, if you scrutinize some of the references in the article at that link you will clearly see that the toxicity profile of the products of conventional medicine and supplements is as different as day and night.

      By the way, at a different page the writer at http://www.supplements-and-health.com does explains the reasons why he cites authorities (for example, authorities do at times divulge the facts, some more than others).

      But regarding your agreement to "caution against an appeal to authority", you seem to naively be convinced that with traditional medicine "harmful side effects are documented" but in the US there is no mandatory law for the medical profession to report on serious adverse events -but there is one for food supplements. You're missing the huge impact of politics in medicine...

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    3. Well-- as I see it, you only have a database if other people have access to the data, so actually clinical experience is not a "real database" in that sense. The fact that the conventional database is not perfect doesn't mean it isn't superior to the pretty much non-existent "traditional" medicine database.

      I would certainly favor mandatory reporting (by chiropractors too), but of course organized "traditionalists" don't want this any more than conventional commercial suppliers of pharmaceuticals and devices do. The political pressure isn't all on one side.

      Of course, yes, I think "age-old" systems are untested in any serious sense. They aren't all so old, either-- qigong was invented in the 1940s.

      Be this all as it may, my actual focus in the review was on why people "feel better" in circumstances, either "traditional" or "conventional", that seem to involve no specific active principle.

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  2. Anonymous user 2 here:

    It's hardly surprising that a psychologist looks to attribute the effect to factors like warmth and empathy, but this is the same fallacy as the broad stroke of ascribing all benefit to the placebo effect. Really, do we need yet ANOTHER author telling us this?

    Frankly this and statements such as "qigong was invented in the 1940s" just goes to show how such writing is intellectually lazy. Yes I understand the Chinese government made the effort to promote the class of practices, but it's hardly accurate to say they were "invented" at that time. That statement is like saying Alternative Medicine was invented at a specific time. Which one?

    And that's the problem with attempting to assess all alternative medicine, there are far too many factors to consider as they are also vastly different in nature, and of course it inevitably regresses into a psychological argument. Your statement that it is not possible to know how much harm supplements have caused also ignores this very basic fact, that many supplements are essential nutrients. Sure, taken in a large enough dose anything can be toxic, but that just goes to point out that framing it as how much harm "they" caused is to completely ignore proper an responsible use.

    In answer to the other commenter you said:

    "The fact that the conventional database is not perfect doesn't mean it isn't superior to the pretty much non-existent "traditional" medicine database."

    "Isn't perfect"? Really? That's not what was claimed, please don't misrepresent peoples arguments. It's a question of the toxicity of the substance, which you evidently completely ignored. Again, the substances are different in nature in their activity in the human body. Do you really need testing to understand the relative safety of a food supplement like fish oil compared to a pharmaceutical drug? I submit that common sense comes into play.

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  3. Okay, you two Anons. You're ready to ascribe my take on apparent effects of unconventional treatment to my professional prejudices. Before we proceed, please state for the reading audience your names, training and backgrounds, and financial interests in unconventional treatments. Then we'll all know where we are.

    As for common sense, Offit's book (like many other publications) goes into some detail about the problems of assuming that "common sense" conclusions are reliable.

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  4. I will respond in more detail later when there's time. You have a point about financial interst, but for the time being I'd like to point out that you are ignoring many points which can be discussed on their own merits.

    The fact that the nature of all these therapies are different should tell any reasonable person something about whether it is all a psychological effect. Why would you even try to reduce it to that factor alone across the board?

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  5. a) I didn't try to reduce it. I said that was a factor that needed further analysis.

    b)Does it take you a lot of time to explain who you are?

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  6. b) When pressed for time, as in having to get to the office for the day, do you prefer to answer a similar question about your bio without addressing the points under consideration, or would you rather make your points to address everything completely? You see some of us are not skimming what the other wrote and "responding" out of context by misrepresenting the others position.

    But in response to that request my name is Mark Chiang, I'm trained as a massage therapist and I have no financial interest in alternative medicine whatsoever, I own no stock in anything related.

    Thus far you seem to pick and choose what you wish to respond to so I'm not sure that a real dialogue can take place. You seemed to completely ignore the context in which I mentioned "common sense" and focused on semantics, whereas I never intended for that to be conclusive or the only factor necessary but simply to inform. It is simply *reasonable* to consider the nature of the substance when we're talking about toxicity, the most simple example being a food supplement vs. a drug. (herbals not typically found in our diet, for example would of course be of a different nature) Similarly I find your mention of "feeling better" is little more than a straw man argument in the way you characterized an alternative practitioner, as if nobody in the broad range of what can be called alternative practitioners understand anything beyond case studies.

    Actually, I'm a little surprised that you characterize psychotherapy itself as simply something that makes people feel better. This would basically imply no issues are ever resolved, as that would be more than what can be called "feeling better." It would seem to me while those factors are significant, there is a more significant aspect of understanding the psychological dynamics, specific personal issues and successfully working with that to enable the person to live a better life.

    To only address things in terms of feeling better in the psychological realm would be like the difference between a massage therapist that does a standard say Swedish style spa massage, and someone who has a good sense of palpatory anatomy and working knowledge of kinesiology to do corrective and rehabilitative work. Contact time would be one small variable in this picture that is not predictive of success, but any thinking person could understand that you will have vastly different results in terms of actually getting functional.

    If we simply THINK about it this is a question of the specific practitioners expertise rather than a generalized effect, as I'm sure is the case with psychotherapy. And again, if we consider the *nature* and complexity of the therapy, whether that is psychological or physical, there are no easy answers to make generalized, blanket judgments across the board. If you wait for one rather than consider the level of skill of the specific practitioner you will likely not avail yourself to the benefit of these types of work, or if you happen to do so it will be by blind chance.

    None of this is to say large scale studies are not useful and as one variable to control for it is not a good idea so please don't make another statement implying that is my position, but that's all it is.

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  7. Thank you for identifying yourself, Mark. So many people seem to think that they can comment anonymously and be quite belligerent about it, leaving me having to be polite because it's known who I am!

    Let me point out that you do have a financial interest if you make your living through massage therapy, just as I have a financial interest in that I'd like people to buy my books. In any case, because you (or someone, actually I'm not sure how many Anons are afoot) alluded to my professional prejudices, I wondered what yours were. We've all got 'em, and it's only fair to be transparent about them.

    As to comparing an artificial substance with fish oil (e.g.), it's certainly plausible that the more complex substance could have effects, both negative and positive, that the simpler one doesn't have, and that the more complex substance could have internal interactions such that one part of it either facilitated or countered the functioning of another part. These are things that to my mind need to be demonstrated for each substance. I'd reject the view that being "natural" makes a substance superior across the board to any synthetic substance.

    Of course there are no easy answers, and the outcome research for any treatment is very finicking stuff. However, some treatments are repeatedly shown to be effective in large scale studies, even when done without the "allegiance effect" of researchers who are deeply committed True Believers. Also, in those large scale studies, infrequent but severe adverse effects may be revealed. If such evidence of effectiveness and safety are available for some treatments, and not for others, I don't see why I would choose the latter rather than the former for myself or my family. I especially don't see why I should think a practitioner can reliably tell me how good he or she is.

    As for the issue of psychotherapy, I think there are some well-supported treatments that help correct parent-child difficulties, and some that work well to reduce anxiety about remembered traumatic events. (In my opinion and that of quite a few others, if they aren't remembered, they probably are not the cause of anxiety.) Lots of people who seek psychotherapy feel better just because they make an appointment or get on a wait list, and as they probably don't make these moves until they're at their most miserable, the natural variation in mood would have started to improve how they feel already. For most therapies, the actual treatment may work primarily through the experience with a friendly,supportive person, who makes the client feel better, and this leads to a cascade of benign events as the "feeling better" person now acts nicer to other people and gets better responses from them, frames daily events more positively, etc. As for deep dynamic changes-- it seems to me unparsimonious to assume that those are possible or needed.

    So, here I've stated some positions of my own. I am assuming that they are the opposite of yours, but I expect you will tell me if that's not so.

    One more statement about my positions: I'm really most concerned about the information people use when choosing treatments for children or other dependent people. Those who have fiduciary responsibilities have an obligation to make very careful choices. Adults who choose for themselves and deal with the outcome of their choices are in a very different position.

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  8. Hello Jean, Mark here. In fact I no longer make my living through massage therapy, and while transparency is good in the end the argument either follows or it does not. I do not expect people to take my word on anything and aim to make arguments that are self evident for people without special knowledge on the subject.

    I do not disagree with everything you say, the fact that anything is natural automatically makes it safe is not in question. As I noted before, there is a difference between an herbal that is not normally found in the diet and a substance like fish oil that is. It is not a matter of both being found in nature, the distinction is whether it is natural for human beings to consume it. And we know it is natural because we *already* consume it if we eat fish, that is the significance of the difference. And again, more generally we can consider the nature of any therapy whether it be a substance or a form of work. It's a matter of a little critical thinking rather than a one dimensional view of referring to numbers.

    I do appreciate your position in choosing treatments for children as opposed to an adult doing so for themselves, but I do not think we should rule out things that are safe to try by their very nature (not just that it's found in nature) simply because the studies have not been done. With fish oil (even if there were no studies) there may be the concern of heavy metal contamination, but that does not mean *as a substance* it is unsafe to ingest, that is a quality control and manufacturing issue so it's a question of whether there are trustworthy products rather than whether fish oil itself can be safely used. In that case it's a matter of doing your homework.

    I can certainly understand that given the nature of psychotherapy, deep changes are not so easy to come by - but the point is there is a difference between simply feeling better and real therapeutic change. Of course I also recognize that with psychological matters it may also simply be very gradual, but certainly there is a difference between one with training and just another friendly supportive person.

    And it seems to me in practice, as a health care consumer we would do well not to only refer to the generalized large scale answers when it comes to something as intimate as psychotherapy, even though we should utilize that as well. It may be challenging to determine whether the specific therapist is as skillful as they seem, but this too has to do with being careful in making choices. We must not only avert possible danger but also seek the best treatment possible.

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    1. The thing is-- most arguments, especially if pecked out on a blog, don't include every possible bit of information-- so transparency about the prejudices and purposes of a writer can help readers interpret and weight what is said on each side.

      I'm not sure what you mean by real therapeutic change in psychotherapy. Perhaps if you gave an example I would have a better idea about the assumptions you are making about what can be done.

      I think that what you are saying about trusting fish oil because we already eat fish, is what I would describe as examining the plausibility of a proposed treatment. Is it congruent with other things we know, about human diets, about early development, about causes of mental or physical illness, etc? You can certainly rule out some options because they are not congruent with other things that are known. But even if they are congruent--- what if they just look that way because there are things we don't understand about those matters? That's why I want to see an evidence basis, and one that's from a large enough, non-homgeneous enough population that we could see how often and even for what kinds of people it's safe and effective.

      I think what we are "arguing" here is really about two contradictory belief systems, such that no conclusion is possible. However, discussion of specific treatments might be more productive.

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  9. http://larrytanner.blogspot.com/2012/06/magical-thinking-sometimes-you-just.html?showComment=1376634700217#c6671256882885426788

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    1. I'm not sure what this has to do with the topic, but people might like to read it.

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