WHY WOULD ANYONE USE AN UNPROVEN THERAPY? Treasures in the Mist Another personal view by David Zigmond

Professor Edzard Ernst’s ‘Personal View’¹ is a short, robustly sensible piece. He leads us briskly along a much used path, pointing out how straying into surrounding, unscientific territory subjects us to the lures of fantasy, corruption and personal influence. The tarmacked path is smooth, firm, safe and even; the wilderness is unmapped, hazardous, disorienting. It is stalked by predatory creatures. Why would anyone choose to traverse this Wilder Ness?

I am reminded of many scientific-rationalist thinkers who pour easy scorn on religion: its tenets are absurdly unprovable, its conduct inconsistent, its basest expressions shockingly destructive. Why would anyone pursue irrational belief? But Ernst’s rhetorical question is less simple than apparent. It spawns many beyond. Some are explored in this longer reply.

While his critique is importantly true, it is crucially incomplete. In particular, myth and fantasy are often harbingers of our most positive aspiration and inspiration. Belief in the transcendent and the transpersonal can be powerfully transformative, but only for the believer. Far from whimsy, these complex phenomena have been shown to be essential components in studies linking religious faith and health resilience,² and multifarious research into placebos.³ Over several decades, repeated investigation identifies how the emotional state, the belief and faith of the sufferer, and the perceived quality of contact with the Healer, make critical differences in illness experience and outcome.⁴

Such interactional and transpersonal factors may be scientifically discerned generally, though with some difficulty. This cannot be said of the individual transmission and processing of such influences. Here we enter different and difficult territory: the ‘Art’ of Medicine and Healing. Here are personal perceptions of experience and meaning. These are transmitted mainly intersubjectively, thus generating subtly unique language, metaphors and rituals.^{5, 6}Such personal factors can become quite as important as the impersonal science of biomechanism. Dilemmas arise, for it is only the impersonal, the generic, that are readily accessible to the organising code of our quantitative science. With all else we must suffice with other kinds of understanding and evaluation. Biomechanical Medicine has had dramatic successes in the last century. It is also readily understandable, reproducible and testable in ways often impossible with other forms of healing.

But the reach and strength of science is gravitated to the externally measurable: the sharpness of its definition fades as it enters the dappled realms of inner experience and the complexly interpersonal. Absence of (scientific) proof is not proof of absence. We must be wary that this potent and precise, but limited, world of Biomechanical Medicine is not overused, assuming a kind of regal hegemony. Some areas are not its natural territory.

We should be imaginative, therefore, about complexity and thus paradox. It is true that interpersonal healing (in contrast to the Orderly Ness of generic biomechanical treatment) is a Wilder Ness; obscure to scientific mapping. Ineluctably, as Ernst reminds us, more vulnerable to contamination by human folly, deception, greed or grandiosity. But what of its opposite pole? By analogy, arcane and ancient religious texts have led to those most disturbing and cruel perversions of ‘righteousness’ and superstition. Yet those same texts, very differently selected, have led to millions of undramatic quieting comforts for the anguished, humble acts of inclusion and kindness and (irrational?) faith and hope in our troubled and evanescent lives.

We can think of a Genus of basic Existential Anxieties: primordially the chaotic meaninglessness of Life; our mortality, our cosmic insignificance, and our ultimate alone-ness. How well we make positive sense of, or adjustment to, or defences against, these anxieties will have a determining effect on the basic quality of our lives. This is enacted through our relationships, our state of health and our response to illness, when it comes.

Core biomedical practice does not address these inner workings. Religion and Healing have many approaches, both explicit and inexplicit. The inexplicit are conveyed by metaphor and ritual. Such become the common currencies of healing. Thus, for example, healing ‘procedures’ involving touch or gaze may symbolically communicate to the sufferer recognition, inclusion and significance; all important requisites to palliation and recovery.⁴The procedure is a kind of language, but it can only be ‘spoken’ if both participants have congruent belief systems about the affliction.^{6, 7,
8}

All this comprises something of the ‘Art’ of Healing and Medical Practice, and why it is so difficult to standardise, measure or mass-produce. Another important way of distinguishing and understanding these activities is to consider the source of resources: external and impersonal, or internal and (inter)personal. Prevailing biomechanical treatment exerts its influence via the former: by externally located agents – be they chemicals, manipulations, instruments, radiations, stents or sutures. Likewise, understanding and explanation are of an objective, generic and impersonal kind. Both are externally ‘conducted’.

By contrast the many kinds of healing address and facilitate the individual’s innate capacities of immunity, growth and repair: this is an ‘induction’ of internal resources. It is the product of interpersonal exchanges within a relationship field. Although induction may be individually powerful in-vivo, it is a protean, evaporative process, very dependent on individual attunement. In-vitro attempts to mass-produce or measure are left mostly with empty husks. Experience yields only external epiphenomena to measurement. Inductive healing can gestate only in the Wilder Ness: a conundrum for those Health Planners and Managers who understand.

The film ‘The Wizard of Oz’ illustrates this fertile but paradoxical subterraneum of healing with charming simplicity. Each major character represents a universal human developmental task; the failure to address these leads to disease or sickness. The Lion must find the courage to be himself (Identity); the Tin Man his heart for others (Love); the Scarecrow his own thoughts (Logos); and Dorothy a place of peace, acceptance and kinship: ‘finding my way home’ (Belonging). To re-own these they must achieve something that seems impossible to them as individuals: destroy the Wicked Witch of the West – the despair, nihilism and hatred that we can all harbour and inflict. They manage this communally, pursuing a shared belief in a myth: the all powerful Wizard of Oz. It is through faith in this mythical Other that they transcend their habitual (self-)limitation, subtly trance-formed, then transformed.

Dorothy, later, accidentally discovers that The Wizard is an unremarkable man operating a panoply of pyrotechnics to create such hypnotic charisma. Dorothy confronts him:

I am reminded of a recently retired Bishop telling me that he had lost his Faith, but had found verve in becoming a Born Again Atheist. With a further paradoxical garnish, he told me he still liked to attend church services.

After my amused bemusement had passed, I was left thinking how multilayered and meaningful his reply had been. Or was I imagining his encoded and askance wisdom? Was that a private myth, of mine? In any case, this contact induced in me a burgeoning constellation of new thoughts and connections: I was enlivened, enriched and energised. A small incident, but I reflected on how this offered a microcosmic example of the questions we face with both healing and prayer. How do we even begin to measure, manage or mass-produce such subtle Life-exchanges, such treasures in the mist? Do we need a Yellow Brick Road?

Part 2 of this reply to Professor Ernst’s Personal View will explore some of our frequently overlooked myths about the clarity and integrity of our ‘diagnoses’ and ‘evidence’: our supposedly firm bedrock, rooted securely in scientific method.

2. Frank J Persuasion and Healing. New York: Schocken, 1972

Frank J Psychotherapy and the Human Predicament. NewYork: Schocken, 1978

Frank, a Professor of Psychiatry at John Hopkins Medical School, was a prodigious academic researcher and writer for several decades. He demonstrated the pathogenic influence of alienation and despondency. As a corollary, and quite as important, he showed the therapeutic effect of: feeling re-engaged with peers, having an explanation congruent with native beliefs, a sense of positive personal agency and some evidence of its success. Pre-requisite to these were faith, trust and positive attachment to healers and their institutions. He showed, too, how these placebo effects could all be reversed by pessimism, mistrust and negatively-experienced attachments: the ‘Nocebo’ effect.

Frank’s work is equally impressive in its breadth, depth, meticulousness and clarity. The above two books offer the most accessible introduction.

3. Ibid.

Zigmond D. Mother, Magic or Medicine? The Psychology of the Placebo. British Journal of Holistic Medicine 1984; 1:113–9

The paper provides a brief survey of placebo research as well as providing some explanations from developmental and social psychology.

5. Balint M. The Doctor, his Patient and the Illness. London: Pitman, 1957

Balint’s informal, qualitative study was of encounters between General Practitioners and their patients. Amidst his clarifications was the importance of the inter-subjective in medical practice, which has become increasingly defined and confined by an objective view and language. He explored the different kinds of diagnostic and therapeutic opportunities that were possible from this interpersonal perspective, as well as the perils that followed its neglect.

Due the difficulty (?impossibility) of standardising, regulating or mass-producing this approach, it has been responded to with bewilderment, indifference or hostility by, first, contemporary health planners and economists and, then, managers and practitioners. In this author’s view, the consequent loss of ‘emotional literacy’ to the cultures of General Practice and Psychiatry, is grievous: therapeutically, economically and experientially.

6. Zigmond D. Three Types of Encounter in the Health Arts: Dialogue, Dialectic and Didactism. British Journal of Holistic Medicine 1987; 2:68-81

A short paper considering how practitioners and patients jointly process experience and language in different kinds of transactions. These confer power, agency and responsibility in very contrasting ways. The origins of these and the consequences of misappropriation and misalignment are illustrated and explained.

7. Balint M (1970). Treatment or Diagnosis. A Study of Repeat Prescriptions in General Practice. London, Tavistock

Another of Balint’s substantial, small scale, quantitative researches, over many years. Explores how many illness behaviours and their medical responses are best understood as ritualistic, encoded communications, which both doctors and patients often resist decoding. As with (6), above, now much neglected, with considerable loss of personal types of understanding.

8. This was well illustrated in an NHS project in the late 1980s. An Alternative/Complementary Medicine Clinic was set up for GPs and Hospital Practitioners to refer to. The results, in terms of therapeutic results, and even attendance, were poor. The Alternative Practitioners were equally dismayed and puzzled: they had abundant good evidence of much better results in their private practices.

In this author’s view, although the procedures might be the same in the two settings, transactionally they were very dissimilar. In Private Practice both patient and practitioner are likely to assume convergent values, expectations, maybe myths. There is a shared ‘language’. In the NHS, where a third party organises the dyad by referral, there is less likelihood of such a ‘match’, and thus no occult ‘common-language’. These exchanges are thus less receptive to the possibilities of ‘induction’.

The hypothesis here is that it is the encrypted ‘communication’ that is therapeutic, not the procedure per se.

[Experience from Author’s own practice.]

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We can be absolutely certain only about things we do not understand.

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com