Miracles do not happen in contradiction to nature, but only in contradiction to what is known to us of nature.
Latin, I shall please
First Known Use: 1785
1. An inert or innocuous substance used especially in controlled experiments testing the efficacy of another substance, such as a drug.
2. Something tending to soothe
3. Improvement in the condition of a patient that occurs in response to treatment but cannot be considered due to the specific treatment used
1.)The unwelcome guest at “Complimentary Medicine's” Gala.
2.)The bane of all our hopes and dreams of becoming legitimized doctors.
3.)No, its even worse than that. Its the secret fear prowling through the murky depths of your subconscious waiting for the opportune moment to strike, destroying all your sense of self-worth…”What if all this knowledge I have in my overstuffed cranium isn't as important as I like to think it is? What if there is something else, bigger and more important that determines the outcome? something I can't control”.
Meanwhile, back at the Gala event:
“Well…so….how do you know that it isn't just placebo?”, asks the slightly tipsy party goer while munching on some baby corn. You've faced this question many times before. Slayed many an opponent with your righteous blade, your 'Scientific Excalibur'. Fueled by the fury building in the bottom of your gut, your attack is practiced and perfected. Regurgitations of clinical trials and mountains of data, M-O-U-N-T-A-I-N-S of data supporting your claims for the efficacy of acupuncture in various conditions strike with the force of medical legitimacy like nothing before seen in these lands. Tossing back the last of your drink for emphasis, you walk away with sword sheathed muttering the words exclaimed when Excalibur was first drawn, that is of course, way back in the old land when Kind Arthur's sovereignty was first put to the test. “Thenne he drewe his swerd Excalibur, but it was so breyght in his enemyes eyen that it gaf light lyke thirty torchys.” The party goer meanders towards the foyer room looking for the punch bowl. Sensing your disguised uncertainty and wondering if maybe she shouldn't have asked what you do for a living.
That word. That dirty, dirty word.
I've been thinking a lot lately about the idea of placebo in treatment and how it affects the outcome of treatments. I first had to investigate a lot of my own ideas, fears, and judgements about the placebo effect to really dive in to it deeply. Why does that word hold so much power, and such negative connotations? Exploring this concept can be a scary thing really and a lot rides on wanting to discover the truth you want to discover. Not the least of which being $100,000 spent on a four year education can leave you wanting to be in possession of something that not just anyone can do. But even if acupuncture really is just placebo, wouldn't it be better to accept this premise as it is than to live in denial of it? To work with rather than against it? God I hope that I can say yes, and honestly mean it. However, this blog isn't about whether or not the placebo effect exists or proving that acupuncture really works. That blog would have been called, If the yellow Emperor has no clothes, than neither does Dr. Oz! There are plenty of interesting articles out there exploring that already. I think that it is pretty well understood now that the placebo is a part of any form of medicine regardless of where and how it's practiced or when it was invented. My favorite quote from one of those articles i found coming from Dr. Douglas Black, the president of Britain's College of Physicians. Dr. Black said, “New drugs create new hopes,” and he advised an audience of doctors that “one should treat as many patients as possible with a new drug while it still has the power to heal.” An ally in the struggle indeed. There even seems to be evidence that the placebo effect is getting stronger.
What I am interested in is that Acupuncture is already in large part a subjective medicine in itself. Can we can play with these same concepts in using placebo to help our patients? Its not a matter of “if” it works, its trying to better understand how it works and how to embrace it. If anything can act as a placebo, if chemotherapy and sugar pills function in very similar ways, then there is something beyond our ability to understand, something magical that happens when we put little sharp needles in to a person or when a pharmacist hands a patient a bottle of colorful pills. There is a great deal more importance on the patients part as to what the outcome of treatment will be than there is on ANY form of treatment intervention. So how can we assist or align ourselves with that process in the most beneficial manner?
What really spurred on this thought stream was a situation that happens from time to time that I'm sure most of you have experienced. I've only been licensed to practice acupuncture for about one year now, and despite the lack of years of experience under my belt, I have treated A LOT of patients. Thanks of course to the community acupuncture model which has given me the opportunity to get more experience in this short amount of time than many practitioners will get in years of practice. In this time I have had more than a few patients with any number of conditions that begin getting progressively better over their course of treatments. Thanks acupuncture. But where it becomes really interesting with these patients is that there comes this moment after a number of treatments where progress is continuing to go in the right direction, I have the right acupuncture point combination, proper needle technique, etc. etc. etc. but I just instinctively know at this point that this patient WILL get better regardless of what I am doing. I can completely change my protocol, balance the wrong meridians, treat a male patient with mid-back pain using gynecological points, and they will STILL get better. Something beyond me is happening here.
I think placebo can be viewed as something along the same lines of faith when given a positive association and a redefining of its method. The better we understand how to help instill faith in our patients, in the needles, and in ourselves, it seems the better our outcome will be in the healing process. In large part, this faith in a treatment will come from an individual's beliefs and expectations of said treatment. It can be an acquired or conditioned belief from their life experience or can come from their particular set of cultural beliefs. An example would be a person raised in an average American household that values the therapeutic use of pills. This person takes an aspirin for a headache, it goes away and unconsciously they attribute the aspirin as the vehicle which took away their headache. If that pill had however actually been a sugar pill they would still expect that their headache will go away. This person believes that a pill will help them and it does. Whether its this culturally familiar scenario or one of a yogi in India using the ash from his fire pit to give to every patient regardless of their condition, the same force is at work here. That makes sense. However, Irving Kirsch, a prominent placebo theorist also noted that, “The effect of placebos depends on the strength of the person's expectancies, not on how they were formed.” What I find particularly interesting about that statement is that we as acupuncturists in this country are in an uphill battle on this one, but one that we can win. Acupuncture is still not regularly used by an extremely large number of its citizens, about 99% of those citizens actually. But if acupuncture spreads to the point of becoming a widely used means of care, the fact that it is born of a foreign cultural experience won't necessarily inhibit a placebo response. I see this changing for the better though with the continual rapid growth of community acupuncture clinics that are popping up everywhere, giving an ever multiplying number of people an accessible and affordable chance to experience how great acupuncture is. Community clinics are the driving force weaving acupuncture in to our culture as an everyday part of healthcare maintenance as well as normalizing the experience of coming in to a clinic to this time, place, and cultural needs. Making this a “normal” experience being an extremely important piece of that puzzle it seems from the above example. As a practitioner, I initially experienced this idea of finding faith in acupuncture when i attended my first Dr. Tan seminar in San Diego. During the famed dog and pony show, he steps to the front of the stage, throwing his arms up in to a wide 'V' shape and loudly declares in to his headset microphone that, “Balance Method ALWAYS works!”. While my first instinct is to laugh this off as pure showmanship, upon further insight I realize he actually is also imbibing faith not only in to his patients, but in to all of us practitioners who will then get better results when we return to our clinics. He is inviting the healing in, creating a relationship with it. And it comes. I know that was the first time I became truly confident that acupuncture could actually help with anything, and the first time I began seeing real results. Fast forward one year post-graduation, and now I have experienced this playing out as an increasing level of overall treatment results that comes simply through treating a large number of patients and varied conditions. Yes, of course a refining of technical skill is a part of that, but when you have seen and successfully treated something like Bell's Palsy or assisted in the turning of even one breech baby, that experience and confidence spills out of you and your patients will feel it. Raising their level of faith in your ability to help, in acupuncture itself, and in their own innate ability to heal. I think it is a similar idea that comes in to play when talking shop about certain points, herbs, and protocols. You develop a direct relationship, become allies with specific points and they work better for you where others might not work as well. It's why you can read of one practitioner's amazing results with using say, just LU7 for neck pain, but as many times as you try you just don't get anything with it. It's mutual relationship.
Speaking of relationship, there are other things we can do to better our treatment outcomes as well. And simply being present with that person is one of the best ways we can do it. Because at some level we are still taking part in common cultural roles of doctor and patient, we can choose to use this relationship that is being created to empower our patients or to disempower them. For a person to be able to reclaim the larger importance of their personal experience to that of an outside “authority” in determining how, what, or why something is going on with them as well as what the best way to address it allows the sense of faith and self-worth to flourish within them, inviting healing to take place. This will ultimately lead not only to better therapeutic results but a more authentic relationship. People gain many benefits from being actively engaged in treating their own problems. People seem to also get better results when surrounded by others in healing situations. In one particular study done in the 1980s, psychiatrist David Spiegel showed that breast cancer patients assigned to a support group lived an average of 18 months longer than those who received standard care, and despite the fact that their breast cancer had metastasized before the study began. By listening to each other, caring for each other, and helping each other to understand and deal with their symptoms, they invited in the healing response that works beyond ANY treatment intervention. This study also shows the importance of fostering an attitude of humility as practitioners. We realize that there is something bigger than us at work here. That we as individuals are only a piece of this puzzle and not the master of it.
Researchers have identified several pathways that link the physical health of a person to their mental states. This is an extremely important crux of acupuncture's ability to help a person heal with its ability to induce deep states of calmness, reduce the production of stress hormones, and trigger immune and pain killing responses in the body. This is also quite conveniently the place where we as practitioners can just get out of the way and let the needles do their work. What we can do is what these same researchers say will also bring measurable improvements in health. Practitioners who are optimistic, inspire trust, believe in their treatment, are clear in their explanations, and are sympathetic and involved will stimulate a stronger therapeutic response. By helping to reinforce positive attitudes such as pointing out when gains are made, we can help our patients to “rewire” their own attitudes towards their situation. A history of consistent pain doesn't have to mean that there will always be more pain. This can also take place in our first meeting with a new patient. If we enter each relationship with an attitude of optimism about the possibilities of healing that can take place, as well as convey this same message to our patients we can elicit stronger therapeutic response. Simply stated, the best results can be obtained when one of four messages is received and understood by the patient:
Someone is listening to me.
Other people care about me.
My symptoms are explainable.
My symptoms are controllable.
Its simple really. People need to feel cared for and to feel that whatever it is they have going on, there is hope. They are not alone and they are not helpless. We invite faith in, and it comes.