Investigate and incorporate the mechanisms of complementary medicine instead of rejecting it outright, says Jo Marchant.
“Insane”, “a joke”, and “exactly the sort of thing the NHS should not be doing!” are a few of the Twitter responses to last week’s news that Britain’s Princess Alexandra Hospital NHS Trust wants to hire a reiki therapist for a hospital in Epping. On a salary of up to £22,236 (US$34,000) a year, the appointed person “will provide Reiki/Spiritual healing to patients to enable them to cope with the emotional, physical and spiritual issues of dealing with their cancer journey”.
Critics of the advert — and there are many — advocate instead what they call “evidence-based” approaches to health care. These critics should look again at the evidence — because it shows that to dismiss the benefits of alternative therapies is simplistic and misguided.
Let’s be clear, I don’t buy into the pseudoscientific claims of reiki and spiritual healers. There is no evidence that they can tap into and manipulate human ‘energy fields’ to clear blockages and heal the body. Like many alternative therapies, these practices perform no better than placebos in clinical trials.
But that does not mean that such treatments have no distinct therapeutic value. To dismiss people’s complex psychological and physiological reactions to serious illness — and how it is treated — as mere placebo effects is not helpful.
Neuroscience studies show that placebo effects can trigger significant physiological responses that are often identical to those created by drugs, ranging from the release of dopamine in the brains of people with Parkinson’s disease to a rush of endorphins for those in pain.
The standard ‘evidence-based’ argument is that this is irrelevant. Even if alternative therapies induce a biological response, sceptics argue, patients are still better off receiving trial-proven conventional treatments, because then they benefit from both a placebo effect and the active effect of the drug.
This logic misunderstands the nature of placebo effects. Not all placebos are the same, and alternative therapies can sometimes trigger larger responses than conventional ones do. For example, in one trial, fake acupuncture relieved pain more effectively than a fake pill (T. J. Kaptchuk et al. Br. Med. J. 332, 391–397; 2006); in another, it relieved symptoms of irritable bowel syndrome with fewer side effects than available drugs (T. J. Kaptchuk et al. Br. Med. J. 336, 999–1007; 2008). It is true that if a therapy cannot beat a fake version of itself in trials, it is not working as the therapist claims. But if it triggers a big enough placebo effect, it might still be the best treatment available.
Conventional medicine often struggles to provide human aspects of care.
If drugs are effective and placebo responses small, this does not matter much. But people tend to turn to alternative medicine for subjective, stress-related conditions such as chronic pain, depression, nausea and fatigue (all problems that can affect cancer patients in treatment). Drugs for these conditions have significant downsides, such as unpleasant side effects and addiction, and placebo responses often account for most of the effect of the drug. So it becomes plausible that compared to popping a pill, a patient might get more relief — and fewer side effects — from an hour with a sympathetic therapist.
The benefits of therapies such as reiki and acupuncture go beyond what we normally think of as placebo effects, however. Alternative therapists do not get results just because they are particularly good at fooling people into thinking that they will get better. Many elements of the care they provide — from talking to touch — seem to have the power to relieve symptoms and even influence physical outcomes. These elements do not show up when therapies are compared against sham treatments, because they are present in both arms of a trial.
Such benefits can be indirect. For example, tackling patients’ anxiety during invasive procedures such as keyhole surgery can reduce the risk of dangerous fluctuations in heart rate. This results not only from the direct effects on physiology, but also probably from patients needing lower doses of sedatives and painkillers.
Conventional medicine, with its squeezed appointment times and overworked staff, often struggles to provide such human aspects of care. One answer is to hire alternative therapists.
This ensures that such therapies are regulated, and that patients also get the conventional treatment they need. Such ‘integrative medicine’ is now offered by dozens of major US academic medical institutes. The Stanford Center for Integrative Medicine in California offers acupuncture to help with chemotherapy side effects. If this helps patients to complete a conventional treatment by making those symptoms bearable, one therapist there told me, it might improve survival rates, too.
Critics say that this is dangerous quackery. Endorsing therapies that incorporate unscientific principles such as auras and energy fields encourages magical thinking, they argue, and undermines faith in conventional drugs and vaccines. That is a legitimate concern, but dismissing alternative approaches is not evidence-based either, and leaves patients in need.
Instead of rejecting such approaches wholesale, let’s learn from them. That means going beyond the simplistic practice of jettisoning anything that cannot beat placebo. We must tease out the real active ingredients of these therapies — things such as ritual, mental imagery, empathy, care and hope — so that we can learn how they work and find ways to incorporate them into patient care.
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Marchant, J. Consider all the evidence on alternative therapies. Nature 526, 295 (2015). https://doi.org/10.1038/526295a