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Why Regulate? Why Research?

by John Wilks and Mij Ferrett(more info)

listed in evidence, originally published in issue 49 - February 2000

A flood of documents has appeared in the last nine months from various organisations including The Consumer Council, the NHS, the Department of Health, the Healthcare National Training Organisation (Healthwork UK), the Foundation for Integrated Medicine and various Government and House of Lords select committees. All say more or less the same thing, basing their recommendations on the Foundation for Integrated Medicine's report Integrated Healthcare – A Way Forward for the Next Five Years? Their message to complementary therapists is simple; regulate, research and integrate or bust – or more exactly, if you do not regulate yourself better and come up with some conclusive research, someone else will do it for you, and it may not be in a way that you like!


NHS Cartoon



SHS Cartoon

The integration of Complementary and Alternative Medicine (CAM) therapies into "mainstream" practice, useful research and regulation that protects the public from fraudsters are all useful objectives, but have the consequences really been thought through? It seems that in the move towards communication with allopathic approaches, holistic therapists have unwittingly adopted a set of beliefs that has led to a desire to measure, categorise and regulate with little serious discussion of where this need to measure comes from, where it will lead, and ultimately whether it will be of any real benefit to therapists and most importantly, clients.

Much of the push towards regulation and research has come from the government, probably as a result of pressure from the EU, but the reality is that CAM therapies are now a genuine alternative and there are also other pressures coming to bear. The main reasons given for this drive are our old friend "public demand" and public safety concerns. As a practitioner, I have what I hope is a healthy scepticism about this need. I am sure that I am not unusual in that 95% of clients come to me because their friends have been helped.

Not once have any of my clients voiced concern about the safety of my therapy. Usually, they do not even seem concerned as to how our therapies work. If one were inclined towards scepticism, one might think that the demand for regulation is coming more from the government itself rather than from the public at large. When in this sceptical mood, I cannot help feeling that a desire to control and tax is behind much of it.

When it comes to complementary therapies, many approaches to measuring treatment outcomes can be fairly mechanical and have the inherent danger of missing the subtler and the most important aspects of many complementary therapies – that rare and valuable commodity called well-being. It seems that many complementary practitioners have a sense of embarrassment at their inability to quantify changes and with that, a need to distance themselves from a past where complementary therapies were considered wishy-washy and vague. Most of us will admit however, that we do not fully understand the mechanics of our profession and doubt, at least in private, that it is ultimately useful or even possible to do so. Is the verbal description and analysis of a Turner painting or a Mahler symphony as useful as, or a substitute for, the work of art itself? Something of the wonder and magic of creation would be lost in analysis and measurement. Just touching and listening to that in a client can be immensely healing in itself. How can it possibly be measured?

Ken Wilber[1] writes of the impossibility of understanding existential questions from a logical approach – he points out that contemplative questions need to be investigated by contemplative means. If you want to get to grips with a Zen koan, then you have to sit down and meditate on it for a few years. The same is true for methods of investigation in holistic medicine. Experiments and research need to be developed from a foundation of understanding, which encompasses the basic premises of the interrelationship of mind and body. The presence of the observer and the observed affects the outcome of any experiment; healing is not just simply a question of alleviating symptoms; quality of life is enormously important too. It is also useful if symptoms are not seen as problems, or that disease and even death are not necessarily failures.

The "placebo effect" is frequently considered of little or no value in a scientific analysis of health benefits. Nevertheless, practitioners know from experience its usefulness in terms of reducing suffering and facilitating healing. From an "orthodox" perspective, the estimated value of the placebo (ie, any kind of change which is intended to be healing) has gone up as the years go by. Initially thought to be around ten per cent, some researchers now put it as high as fifty per cent.

Some time ago, a television documentary followed the work of a traditional Chinese doctor working in Soho. She sees dozens of people every week who have eczema and has a very high success rate. The work is all the more remarkable because all of her patients have already tried modern medicine without any benefit. Her fame spread to the people working with eczema in one of the larger London hospitals. After the initial contact was made, and an understanding that she uses many different herbs was reached, the researchers tried to isolate the active ingredients so they could produce a medication suitable for all eczema sufferers. While watching the programme I was jumping up and down and tearing my remaining hair out. "But can't you see!" I shouted impotently at the tube, "You're missing the point" – the whole reason for her success is because she tailors the approach to the individual.

Rollin Becker, one of the most competent and effective cranial osteopaths and teachers, frequently wrote the initials SH in his treatment notes after a successful session. "Something Happened" was enough for him. A client usually knows when something significant happens in a session and they know that they feel significantly better for it, although it is sometimes very difficult for them to quantify it. They might feel more "in the body" or more "in touch". However, under questioning from a researcher steeped in the tradition of double-blind trials, even a client who feels significantly better after a treatment might admit that they could not be 100% sure whether the treatment had anything to do with their feeling of well-being. That bane of holistic work, the expression "anecdotal evidence", is frequently rolled out by the orthodox medical establishment as an excuse for not wanting to even consider the obvious benefits of treatment.

Conversely, a client might report going through a "healing crisis" immediately after a treatment and curse us as a result! A few years ago, a woman came to me with a slight elbow injury. The day after I treated her (no manipulation of any kind I might add), she was in agony. Her words were that it "felt like something was moving inside her spine trying to straighten it out". What she had failed to tell me was that she had been hiking in the mountains and had fallen and landed on her head a few weeks previously. After a while her symptoms settled down and she was fine. Now the question is, what would have happened if she had not had treatment? Would she have been OK, or would she have gone down with osteo-arthritis or some other complaint after a few years? How can we possibly measure that sort of outcome in a way that would be of any use to us at all? A "scientific" study of this event might well have concluded that the therapy was highly dangerous and should not have been used with this sort of complaint.

The difficulty of analysing data in a way that is useful came home to me recently when reading a letter in a physiotherapy journal alleging harmful effects of a particularly gentle form of treatment used on a patient with ME. It appears that a particular treatment protocol had been followed without a clear understanding of the way the therapy worked. This was a case of the dangers of a complementary therapy being adopted by the orthodox medical profession without a full understanding of its function. One must not forget that any technique that is capable of tremendous benefits has considerable risk if used inappropriately. With a medical establishment that is not as yet capable of measuring subtle but profound changes in a patient's system, research that concentrates on narrow criteria could be extremely misleading. A recent research programme that used only one homoeopathic remedy on a number of asthma sufferers without taking into account constitutional factors is testimony to that.

Along with the desire to understand complementary therapies from a reductionist viewpoint, there inevitably comes a "dumbing down" of our therapies – an inability of regulatory agencies to understand the intrinsically holistic nature of complementary therapies. Attempting to take from individual therapies protocols that seem to be effective in given clinical situations is also at risk of losing available benefits of treatment. We have already seen this happen in medical acupuncture, reflexology ("reflex" therapy being taught to nurses and physiotherapists) and aromatherapy (the teaching of practitioner courses using only a very limited number of oils) to name a few. The fundamental flaw behind this approach is that it overlooks the fact that each therapy has developed organically from a holistic philosophy. Break it down into parts, procedures and protocols and one is left with nothing better than a set of techniques. Holism has gone out of the window and in its place is a hotchpotch of approaches without a holistic philosophy as the foundation.

The often highly mechanical approach to research has now got to the point where from any rational viewpoint much of it is highly unscientific. The original definition of "scientific" – knowledge gained by experiment and observation – has been narrowed down to such a limited style of investigation as to completely eliminate many forms of enquiry. Science has reached a position where, paradoxically, it has developed an occult significance while simultaneously decrying previous methods of investigation as mystic.

Scientists have become what they feared and sought to destroy – an entrenched priesthood with all the trappings of superstition: mysterious equipment and rituals and the unquestioning belief of their followers. Whilst the holy grail of "scientific proof" is still unfailingly worshipped in the media, science is still unable and unwilling to look at the areas of public health that are difficult to measure, but are of vital importance; for example, the more subtle effects on our immune system of mass vaccination and genetic engineering. As Craniosacral practitioners, we can often feel the effects of vaccination on a tiny baby's body as its immature immune system goes into overdrive to deal with the sudden toxic invasion, but trying to explain how one feels it and what it means to a medical practitioner is impossible. The language is just not there, nor is the holistic understanding that makes communication possible.

One of the main problems for researchers in complementary medicine (apart from the tiny amount of money available for funding compared to that spent by the pharmaceutical companies) is that research findings are very rarely conclusive enough to be useful.

How often does one hear on the radio that a new approach to health will definitely help a particular condition? The National Federation of Spiritual Healers revealed recently that one of the large medical journals in the UK refused to publish conclusive research on healing because it rocked the scientific boat too much, and only relented after considerable pressure.

It is interesting to note that when I was a medical student we were told that, by the profession's own methods of statistical analysis, modern medicine has only been clinically effective since 1911, ie, before then you were equally likely to improve or worsen irrespective of whether or not you consulted a doctor. It seems a bit presumptuous that an approach that has only been effective for eighty-eight years is so sure of its ground that it is determined to dictate that its own analytical methods are applied to other approaches, many of which have been effective for much longer. The problem is that the classic approach starts with such an entrenched set of beliefs regarding cause and effect, philosophy etc that it is impossible to genuinely analyse methods which have different foundations of understanding.

Attitudes to research are often ambivalent, even in people with a viewpoint which is supposedly holistic. Unfortunately, holistic is a term which is becoming increasingly corrupted and is now often used to mean simply something other than classic allopathic medicine. Simply to replace the treatment of, say, menopausal hot flushes from HRT to Chinese Dong Quai herb is not holistic in the slightest. It is merely a continuation of a symptomatic approach – holism implies an individual appreciation of each person – what is happening for them and then responding appropriately. Even Proof magazine, which claims to be a consumer watchdog of alternative medicine, can completely miss the point. In Proof – Summer 1997, Vol 1, No 4, p 20 – a reference is made to say that "the well-respected programme 60 Minutes followed 27 patients in Cuba and the results, again unpublished, were even more vague: cessation of pain, improvement in appetite, attitude and quality of life. Nowhere does it say how many died and how long after the treatment" (my italics). This quote refers to shark cartilage as a proposed cure for cancer.

Call me naïve, but I would have thought that cessation of pain, improvement in appetite, attitude and quality of life are changes which are likely to be highly regarded by anyone – and especially people with cancer – irrespective of whether their life was prolonged or not. This obsession with statistics whilst trivialising life quality is a tendency of old-style scientific attitudes which has little or no relevance to genuine health-care.

Any serious research student will tell you that it is impossible to construct a truly objective research project, although most research projects and their findings are repeatedly presented to the general public as such. An experiment with nematode worms where a group of students were given two samples of the unicellular organisms and told to test them demonstrates the point. Nematodes tend to behave predictably in terms of their movements in heat gradients, saline gradients and light/dark gradients. One group of nematodes had been in a control medium and the other in a medium mixed with an experimental medication. Sure enough the worms in the trial drug medium behaved atypically and crawled all over the place. However, unbeknown to the research students, there was no trial medication – both groups of worms were the same. The only difference was the students' belief in the difference of the two groups.

In this case, we are only talking about a simple experiment with single-celled organisms – when you start to try and extrapolate this kind of effect to organisms as complicated as humans, then the mind boggles. Even if it were considered ethical and practical to test say, acupuncture, by having practitioners needle people in their normal way and then insert needles at random, the practitioners would still know. Similarly, with Craniosacral therapy, once you know how to make the kind of therapeutic contact that is so effective it is impossible not to. You cannot just rest your hands on someone and not start working; it is like trying not to think of pink elephants for ten minutes.

The kind of research is the important question, and how we are to measure things. The answers are of vital importance if research is to be of any use to us in the subtle world of complementary therapies. What we are trying to do at the moment is to please the orthodoxy by presenting them with predictable and repeatable results in nice neat research packages. This may have its place and usefulness, but it is only ever going to represent a small percentage of what our real work is about.

Although as practitioners we need to keep abreast of Government legislation and ensure that our standards of practice and training are of the highest, we should not be fooled into thinking that the current trend towards legislation will necessarily do us any favours or benefit the public in the long run. If we take a look at what has happened with the osteopaths as a result of the Osteopaths Act, which comes into force in May this year (the Chiropractors will follow suit next year), it is interesting to see that many of them are angry and dismayed at the extent of the bureaucracy that has been introduced.

Most ironic is that many of the procedures that are causing the complaints were all introduced by the osteopaths' own regulatory bodies. Although there has been real progress in terms of safeguards against fraudulent claims of competency by practitioners or teaching schools, how much real benefit has been gained by the osteopaths or the general public? We should bear in mind that there is no evidence that research would make our practices any safer. In a recent book, Medical Mafia, Dr Guylaine Lanctot points out that "adverse reactions to prescribed researched medicines cause or contribute to one third of all deaths in the USA every year". A few years ago, a London-based GP estimated that NSAIDs (non-steroidal anti-inflammatory drugs) caused over twelve thousand deaths a year from their side-effects.

There is a real danger that by adopting criteria that are not suited to our way of working we shall lose the most vital element of our work… its art… the immeasurable… and throw the baby out with the bathwater. The need to justify and explain our work in terms that are essentially alien to us and in ways that have largely been adopted wholesale from the orthodox medical establishment is counter-productive. Often, a desire to understand betrays a need to control, and control is seldom desirable in the therapeutic relationship. There is much work that needs to be done, but if we get the ground-rules sorted out, there is at least a chance that something useful might come out of this desire to measure and control our therapies.

* This article is a modified, extended and updated version of an article published in JACM, September 1999.

References

1 Wilber K. The Eye of Spirit. Shambhala. 1997.

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About John Wilks and Mij Ferrett

John Wilks is chairman of both the Craniosacral Therapy Association of the UK and the Bowen Association UK. He has clinics in Somerset and Dorset and teaches the Bowen Technique in the UK and Ireland for the Bowen Therapy Academy of Australia. He can be reached on 01963 220615, email: JohnWilks@cwcom.net Mij Ferrett is editor of The Fulcrum, the journal of the Craniosacral Therapy Association of the UK. He practises in France and Italy and teaches Craniosacral Therapy for the Karuna Institute and the Craniosacral Therapy Educational Trust and Lifeshapes™. He can be reached on 0033 46831 4984, email: mij@craniosacral.co.uk For simplicity the first person applies to either or both authors.

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