Native Healers. Anita Ralph
overlap in powerful and important ways.
—Daniel Moermann27
In our Western culture, the practice of medicine is very firmly rooted in a specific ‘cause and effect’ paradigm. We also operate in what may be described as a reductionist way of thinking.
Definition—Reductionist: The practice of analysing and describing a complex phenomenon in terms of its simple or fundamental constituents, especially when this is said to provide a sufficient explanation.
—Oxford English Dictionary
Breaking things down into their simplest parts so that we can understand them is at the root of Western medicine (think about the study of things like anatomy, microbiology, endocrinology etc). This has brought a fantastic understanding of human physiology on many levels, but is not very good at seeing the big picture, the phenomenon. Also, what about the things we cannot see?
Moerman lists three ways in which the human body responds to injury:
•Autonomous responses: Known biological mechanisms mobilized by the body for healing to take place (i.e. clot formation, white blood cell recruitment etc.).
•Specific responses: Interactions with medications (i.e. anti-inflammatories etc.)
•Meaning responses: Interactions within the context in which the healing takes place (i.e., blue pills are calming; the use of medical instruments and machines is viewed as very powerful). We ascribe certain meanings to the world around us and respond accordingly. Our world is full of meaning to us, some of it we are consciously aware of, and some of it is so ingrained that we are not aware of it.
Meaning responses are not just confined to medicines. Many other factors play significant roles in our response to healing. Consider the patient/therapist consultation. In consultation a) the doctor/therapist is very enthusiastic about the medicine she is prescribing. She has lis-tened carefully to all of the patients’ concerns, offered explanations and advice where necessary and is very confident that the medicine she is prescribing will be helpful.
In consultation b) the doctor/therapist is apathetic in attitude, spends half her time typing on a computer, does not give any information about the medicine itself or how it will benefit the patient and does not appear to be actively listening to the patient. Both doctors/therapists prescribe the same medicine at the same dosage. Which one do you think will be more successful? Why? The patients’ faith in the practitioner and the practitioners’ faith in their remedies can be crucial to outcomes. Meaning responses are not confined to inert medicines: active medicines are also affected by them.
The act of diagnosing a condition is an intervention of a kind and can be filled with meaning. When a diagnosis (and prognosis) is good, it is most likely that things will improve. How does this compare with the psychological significances of a charm? If the diagnosis (and prognosis) is bad, things are more likely to deteriorate. How does this compare with the psychological significances of a curse? Where does ‘self-fulfilling prophecy’ come into all this? There are hard facts and there are also meaning responses. Untangling them may be harder than we think.
One thing that we can take from all this is that things that please us psychologically have a knock-on effect on our physiological responses. Conversely, things that worry or displease us can do the opposite. This is an excellent example of the mind-body connection.
It is important for us to acknowledge that there is no form of treatment (up to and including surgery) that is not affected by a meaning response. Therefore to claim that the placebo effect is the only reason that some interventions work is to show a lack of understanding of how ubiquitous meaning responses are. The advent of the clinical drug trial has put a negative spin on what is a positive and very powerful influence on therapeutic outcomes. Meaning responses are a natural corollary of being human and interacting with the world around us according to the facts as we see them.
Biology and culture interact. To turn ones eye away from such powerful human interactions is not only short sighted and foolish, but utterly unethical.
—Daniel Moermann27
The nocebo effect
Although it was popularly accepted that approximately 30% of all patients treated would get better even with a ‘dummy’ treatment (intervention), it has now been shown that placebo benefits can occur in any proportion of a treatment group from almost none, to almost all, depending on the condition and circumstances.
It is not surprising therefore that such potency can also generate the opposite of a placebo—the adverse reaction, (even when a dummy pill has been given)—known as the nocebo phenomenon.
Most extraordinary of all is that adverse-placebo (nocebo) has been demonstrated in measurable physiological signs (altered blood test results) from the patients, not just reported symptoms!
In 1999 the liver enzyme alanine transaminase (ALT) was measured in a study monitoring 93 healthy volunteers all of whom were given a placebo (dummy) medicine over 14 days. During this time approximately 20% of them developed elevated ALT levels.
ALT is commonly used as a marker for liver damage, so this would have raised considerable concern if a real drug or herb was being tested.28
The power of adverse suggestibility occurs when the patient expects adverse events, or when patients learn from previous experiences to expect adverse events. Anxiety, among other conditions, increases the likelihood of nocebo response. So under certain conditions patients are more likely to report, and sometimes more likely to actually experience, adverse reactions.
In our own practices, patients have self-selected themselves and probably thought long and hard about whether to invest their time, trust and money in seeing a medical herbalist instead of their doctor. In that scenario, we have found that people are prepared to ‘put up’ with some transient discomfort to achieve their aims. They may not have instant results and may have to spend more money with us ‘in faith’ that given time, improvements will be seen. They also may notice discomforts ranging from the nasty taste of the ‘unfamiliar’ medicine, mild indigestion sensations on using it, or even the occasional transient ‘healing crisis’ where symptoms may appear that show that the body is responding to treatment and mobilising the immune response. For example a cough may become more productive before clearing altogether.
But patients who have self-selected themselves for complementary medicine have probably already committed themselves and have a more positive and benevolent attitude to this unconventional treatment. This is a regular criticism we receive from doctors when we give presentations on herbal medicine—self-selection is thought to induce a more powerful placebo response. Conversely however anxiety about the possible dangers of stepping outside of the doctor's advice may elicit a nocebo response.
A mini case history
A patient seen for a first follow-up consultation was delighted at the significant improvements to their mood (they had presented with depression), improvements to energy levels, headaches and digestive symptoms but also wanted to report that they had experienced an adverse event. They reported that they had been repeatedly woken from their sleep at around 3am since using the herbal prescription, but they were prepared to continue the herbs because so many other symptoms had been relieved.
However, recorded in the notes from their first visit, one of their original symptoms was waking at 3am on a regular basis. The patient was amazed, and admitted they had forgotten that this symptom had been present before starting treatment. They also admitted that they could not conceive of a drug (even a herbal one) having no side effects—if it works, there must be adverse events—by definition.
Quick checklist for clinicians advising patients about the use of herbal medicine
These groups of people should seek the advice of a qualified medical herbalist rather than buy over-the-counter herbal medicines.
•Patients who are at higher risk of herb–drug interaction or idiosyncratic drug reactions.
•Patients