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Patient Expectations and Belief - Placebo or a Treatment Bonus

by Bernadette Ward(more info)

listed in complementary medicine, originally published in issue 188 - November 2011


The Therapeutic Relationship
Much has been written about the doctor / patient and Complementary and Alternative Medical (CAM) practitioner / patient relationships. A claim regularly put forward by detractors of complementary medicine is that one of the reasons that patients benefit from complementary healthcare treatments is the time the practitioner spends with the patient, and the empathy and listening skills the practitioner uses in discussing and treating the patient's condition and the relaxing environment of the CAM practitioner's clinic.

Pulse Taking

This has often been given as the sole reason that patients 'feel better' after treatment. Many articles have been written on the 'Placebo Effect'- the belief of the patient and the expectation that they will feel better following a CAM treatment. This is the theory that the expectation and belief of positive effect will in itself produce a positive result, without any clinical treatment or intervention. Practitioners have found that their acupuncture and CAM treatment results have been dismissed by detractors as being solely due to the patient's expectation, and in fact any positive clinical effect has been a placebo rather a good clinical intervention. The well worn cliché supports this theory and is used often by CAM detractors 'it's all in the mind', and much newsprint has been used to deliver this opinion.

While the patient expectation, hope and belief cannot be dismissed as without relevance to the treatment outcome, the theory that good clinical effect is just in the mind, does not stand up to examination.

The Voice of the Patient
A recent two centre qualitative study was conducted at Middlesex University[1] in which patients in both London and Dublin took part in in-depth interviews about their experiences as acupuncture patients. This research allowed the patients a voice on different aspects of seeking and receiving acupuncture treatments.

When patients were asked if they had considered whether positive results from treatments might be due to their expectations to feel better, or whether the one to one practitioner care, the treatment room and ambiance. and if those elements could have had an influence on the positive effect. These were some of the responses.

Patient 4 L UK said:
"Could be, but I felt physically better, it was astonishing really because in between periods on that day of the first treatment I was bleeding badly, but after the treatment it just stopped"

Patient 4 N Ireland said:
"I felt physically better, the fact that the treatment room was relaxing and the practitioner was good may have helped, but I went after I had 7 courses of antibiotics and one course of steroids for my respiratory condition. The treatments stopped all that, I have not had a cold in ages and I haven't had to use my inhaler half as much as before the treatments, so it couldn't have been just the relaxing atmosphere."

This shows that while the ambiance of the treatment room, the one to one care, and the prior perception or expectation that the treatment would work, creates a feeling of wellbeing and is an important aspect of the whole therapeutic picture; all patients reported additional substantial physical benefits which these factors alone could not account for and which previous medication strategies could not achieve.

This study presents a strong case for the hypothesis that a good CAM clinical effect is not "all in the mind".

Patient Expectation - A Factor in Treatment
The hypothesis of patient expectation was addressed in the Lewith, White & Pierte study at the University of Southampton in 2005. The study, entitled "Acupuncture: beyond the placebo effect" conducted in the University's Complementary Medicine Research Unit was a review and an analysis of available literature on acupuncture clinical trials and patient scanning. [2] The study succeeded in distinguishing between the placebo effects produced by a patient's expectation and the real effects of treatment in a group of patients with painful osteoarthritis. Specific responses were monitored in the brain during treatment, by measuring the difference in brain activity between sham needle intervention and actual acupuncture needling with using sophisticated Positron Emission Tomography (PET) scans.

The study affirmed responses to 'real' acupuncture in comparison to 'sham' acupuncture points with the brain activity in the group of patients receiving 'real' acupuncture demonstrating that real acupuncture elicits a significant physiological effect over and above a simple skin prick.
 
In addition, the response of the second group of patients who received the sham acupuncture treatments indicates that the expectation and belief in the treatment also has a physiological effect on the brain. The expectation appears to affirm a potentially powerful although non-specific clinical response to acupuncture.
    
Patient expectation and belief has been found to be a powerful factor in healing. Advocates of PMA (Positive Mental Attitude) suggest that the injection of hope and belief into the patients mind is a positive element in any treatment outcome, not only for the patient but for the practitioner or physician.

What physician or practitioner tells their patient "there is no hope, we can do nothing"? It is well documented that the removal of hope from patients receiving a stark terminal diagnosis, results in that many just give up and in many cases die quickly. It is unfortunate that current western medical thinking reserves its consideration for the mind, body and spirit in any treatment plan to palliative care. Why leave it to the point when all medical strategies have failed to introduce consideration of the emotional and spiritual aspects of the person being treated ? This is illustrated in the following article

In a 2004 article in the US Journal of Alternative and Complementary Medicine, the author Gerffen discusses the need for a new attitude and recommends a new medical paradigm and the need for cancer care professionals to balance scientific knowledge with "rational thought with the need for wisdom, kindness, compassion, and love. Finding and maintaining this balance is one of the most important challenges inherent in creating optimal healing environments (OHEs) for cancer care. This new medical paradigm, which promotes awareness, healing, and transformation at the deepest levels of the body, mind, heart, and spirit for patients and their families, must make an equal commitment to developing the health, well-being, awareness, and communication skills of medical and other staff members".[3]

Shen and its Place in a Treatment Outcome
The acupuncturist has always considered the mind and emotional wellbeing in assessing the patient and delivering a holistic treatment. Shen is a term used in Chinese medicine theory to describe the mind or spirit, and discussed in one of the early Chinese medicine texts the Neijing. Shen is one of the three treasures of Chinese medicine and has always played a vital part of an acupuncture or Chinese medicine treatment plan. It represented the mind aspect of the holistic treatment plan in daily use by Acupuncturists and Chinese medicine practitioners.

It would be easier to count how many practitioners do not use emotional balancing and soothing acupuncture points in their treatments. Points such as Baihui, Taichong or Yintang will treat emotional stresses, anger, frustration and mild to moderate depression. The holistic concept of mind body and spirit is alive and well in the day to day acupuncture treatment, and not just reserved for the desperate or despairing. It is almost unusual for an acupuncture patient not to receive points for soothing the smooth flow of Qi or calming the Shen as part of their holistic treatment.

Acupuncture - Holism and Functional Medicine
The term 'functional medicine' is being used recently to describe the concept of 'alternative' medicine practitioners who work from a holistic perspective, and use a broad assessment of their patient to define a treatment plan. According to the author Cooperman, writing in the US Journal of Medical Acupuncture, practitioners who consider their patient's mind, body and spirit in defining their treatment, are in fact using a model of functional medicine.

The article entitled "Creating the Next Level of Healing: Western Medicine, Complementary and Alternative Medicine, and the Rapidly Changing Roles of Physician and Patient"[4] discusses the need for change of the physician's sole control and direction of a treatment and the growing empowerment of the patient with regard to their own treatment. He outlines a functional medicine eight-system matrix which should be considered when designing a treatment.

The Functional Medicine Vantage Points are:

  1. Diet and nutrition;
  2. Immune imbalance and inflammation;
  3. Digestion, absorption, and systemic gastrointestinal factors;
  4. Physical structural imbalances;
  5. Energy, mitochondrial function, and oxidative stress;
  6. Detoxification processes;
  7. Hormonal and endocrine factors;
  8. Stress and psychological health.

Although this is a new way of thinking for the western doctor, functional medicine has been the modus operandi of the Chinese medicine practitioner since the early texts became available. This article also discusses the re empowerment of the patient, and the collective shift in the experience of spirit, it is possible to see where medicine is going:
1. The physician is now called on to recognize the patient as a whole person, who is in charge of his or her own destiny."[4]

The CAM practitioner has always empowered the patient as discussion of their condition and treatment , lifestyle, nutrition, emotional wellbeing represents a significant aspect of the clinical exchange so it is good to see this being discussed within the wider healthcare community.

Chinese Medicine Patient Assessment and the Therapeutic Relationship
There is no doubt that Chinese medicine assessment is an active 'functional' exchange between practitioner and patient. The acupuncture patient has always been empowered by this exchange.  Maciocia [5] states that the nature of the Chinese Medicine assessment of the patient, from the initial case history taking, to observation of the patient, the assessment of the physical and emotional condition could lend itself to the building of the therapeutic relationship.

The practitioner aims to gather information to treat the condition, and in the acupuncturist's case to probe the underlying causative factors and any other relating conditions including emotional and mental which can be weaved into the treatment plan.[6] The primary goal of the professional practitioner is to inquire, listen, palpate, assess and probe in order to establish a holistic diagnosis and treatment plan. The reasons for the inquiry and probing are not unlike the initial biomedical testing a doctor will carry out with a patient presenting with a condition.

While some suggest such a holistic assessment creates in itself a 'placebo effect', evidence of patient reports would dispute this. Nevertheless it must be acknowledged that there is a patient benefit from a therapeutic relationship nurtured by CAM professionals in their treatments.

There is no doubt that the holistic practitioner, listening to the patient and delivering a focused one to one treatment in a pleasant environment does contribute to the overall treatment benefit; however this cannot account for dramatic physical improvements reported by several patients in this study, such as bleeding of several days which stopped after treatment being just one reported example.

Bio Physical Change - Reported Clinical Outcome
Some of the physical benefits reported by patients in the Middlesex University study were chronic pain relieved, digestive function improved, irregular menstrual cycle regulated, respiratory function improved. There are reported examples of positive clinical effects of acupuncture treatments..[1]

Patients are very willing to acknowledge the feel good factor of a one to one focused assessment and treatment. They recognize and judge it as is a welcome bonus of acupuncture treatment, but dismiss it as the reason for a good clinical result. They have no reason to promote CAM treatments over their medical treatment , in fact the opposite, as in the UK medical treatments are free, and they must pay for their acupuncture or other CAM treatment.

The Patient - An Informed Consumer
The inferred assumption of the CAM treatment room placebo effect theory is that the patient is a naive participant of their acupuncture or CAM treatment, living in a fantasy of hope and unable to make a judgement as to their treatment, is at best ill informed and narrow minded and is not a little insulting to the patients themselves.

It is also far from the reported patient reality, as the Middlesex study found patients to be informed consumers, who research their practitioners as best they can before seeking a treatment and who judge their continuing participation in treatments by their treatment results. Patients have shown themselves to be 'informed consumers' of acupuncture and CAM treatments.

Analysis of data from patient interviews shows that patients try to find someone who has had a previous experience with an acupuncturist or TCM practitioner as some sort of recommendation. .

Patient 3 N (Ireland) commented "I had worked in a hospital and one of the nurses had been to ........and recommended her, and I would trust her judgement."
Patients also reported evaluating their continuation of treatment on the treatment effect.

Patient 1 A UK reported
"I approached it (the treatment) on a week to week basis; I thought I would try it and see if something was happening, and as I got some improvement I came back."

Data was similar from patient interviews in Ireland.

Patient 3 N Ireland
"I was suffering with inflammation of the joints and I was very low at times, so I decided to give it (acupuncture treatment) a go and I found it helped."

Patient 1 H UK, when asked if she found the Acupuncture treatments effective responded "Yes of course, otherwise I would not keep coming".

Conclusion
Patient expectation and belief in a positive treatment outcome, aids the treatment outcome and is of benefit to both the patient and to the practitioner. Belief and expectation provide a positive mental attitude but belief alone cannot account for biophysical change and positive clinical outcomes.

Until the concept of 'healing' is introduced into healthcare rather than the treatment of a single organism or condition, the patient will continue to choose and benefit from the CAM treatment for their conditions. Holism goes hand in hand with the concept of healing, and has long been a strong element in acupuncture and the broader CAM treatments.

Patients are in today's world informed consumers with unprecedented access to healthcare information and the confidence to make their own judgements and choices. To make the assumption that all patients who report a positive clinical outcome are creating their own fantasy and it's all in their mind, is not a viable theory which is not substantiated by any of the reported evidence.

References
1. Ward B. "The Absence of Regulation for Acupuncturists and Chinese Medicine Practitioners Impacts on the Clinical Relationship" Middlesex University, Health and Social Sciences. London. 2009.
2. Lewith, White and Pariente. "Investigating Acupuncture Using Brain Imaging Techniques: The Current State of Play" Primary Medical Care, School of Medicine, University of Southampton, School of Health Professions (UK). 2005.
3. Geffen J. "Creating Optimal Healing Environments for Patients with Cancer and Their Families: Insights, Challenges, and Lessons Learned from a Decade of Experience" The Journal of Alternative and Complementary Medicine. 2004, 10 (supplement 1): S-93-S-102. doi:10.1089/acm.2004.10.S-93. 2004.
4. Cooperman O. "Creating the Next Level of Healing: Western Medicine ,Complementary and Alternative Medicine, and the Rapidly Changing Roles of Physician and Patient" MEDICAL ACUPUNCTURE Volume 21, Number 2, 2009 # Mary Ann Liebert, Inc. DOI: 10.1089=acu.2009.0680. 2009.
5. Maciocia G. The Foundations of Traditional Chinese Medicine. pg 143. Churchill Livingstone, London UK. 1998.
6. Maciocia G. The Foundations of Traditional Chinese Medicine. pg 311 - 327. Churchill Livingstone, London UK. 1998.

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About Bernadette Ward

Bernadette Ward PhD MSc (Traditional Chinese Medicine) is Director of the Acupuncture Foundation Ireland. She is an Acupuncturist and Herbalist having studied with The Acupuncture Foundation Ireland  and The Nanjing University of Traditional Chinese Medicine, China. She regularly visits and studies at the Nanjing University and monitors her students on clinical placement in hospitals around the city of Nanjing. She has been active in TCM education and clinical work in Ireland for many years. She completed an Master of Science in Traditional Chinese Medicine at Middlesex University London and has been a long term active campaigner for government registration of Acupuncturists and Chinese medicine in Ireland for many years. She is a Vice President of the WFCMS (World Federation of Chinese Medicine Societies International Instruction Committee and chair of the PEFOTS (Pan European Federation of TCM Societies) Education Committee. She recently completed her doctorate and had her book published -  CAM An Irish Solution to a Global Question - an analysis of the CAM sector.  Her research topic was skills based education and training as it applied to complementary therapies. She may be contacted via bwardafi@hotmail.com

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