HEALING AND THERAPY IN THE AGE OF MASS AFFLUENCE
This paper first appeared in volume 5 of the 'Skeptical Intelligencer', 2002.
Part I: The Political, Social and Economic Context of Healing and Therapy
This paper is an updated version of an article that I wrote for the UK periodical The Skeptic ('Surely there is something in it: The social psychology of healing', The Skeptic, 9(4). The latter began as follows:
'This paper concerns the social psychology of healing and therapy. I am using these words more or less interchangeably and in a very broad sense. They refer to all aspects of the situation in which healing or therapy is intended to take place, regardless of whether it does so in reality. I am thus referring to the circumstances in which a person has some problem of mind or body and another person, the healer or therapist, attempts to alleviate that problem by means of some special knowledge or expertise.
'Defined as such, healing is a universal phenomenon, a significant activity in all societies at all ages of history. Indeed, if you survey healing throughout history and across contemporary cultures, and even within our own culture, you will encounter an extraordinary and fascinating range of human behaviour and beliefs, bounded only by the healer's own imagination and the compliance of those seeking to be healed, and therefore unbounded. I think this is more so than in any context other than religion. I am, moreover, challenged to understand why in our own society we have so many people involved in healing and therapy. I once visited an exhibition of alternative medicine and counted no less than thirty-five distinct remedies being offered for someone complaining of headaches. Perhaps the more treatments there are for a problem the less likely any of them has a direct therapeutic effect. But my puzzlement in this regard is not confined to unorthodox medicine. In a recent critique of contemporary medical practices (Skrabanek & McCormick, 1989) I was astonished to read the following:
"Sir Douglas Black, a past president of the Royal College of Physicians, estimated that only about 10% of diseases are significantly influenced by modern treatment. This echoes the opinion of Sir George Pickering who guessed that in some 90% of patients seen by a general practitioner the effects of treatment are unknown or there is no specific remedy which influences the course of the disease. Yet prescribing in general practice is the rule rather than the exception." (pp 10-11)
'In fact, I insist that if you put together mainstream public and private medicine, alternative or complementary medicine, commercially available, across-the-counter remedies, and so on, then you have a healing industry the collective scale of which vastly outstrips whatever it is really capable of achieving. In short, there seems to me to be far too much of it about. And yet the constant message that I am hearing is that we need more of it. Is it possible that there is another perverse law, namely that greater affluence brings less disease and better health but paradoxically the call for more healers? Indeed, I find little to restrain me if I speak of the "Healing Classes" since healing involves the exercise of power over a disadvantaged population.'
I wrote these words over 12 years ago and since then have given further thought to the questions that were puzzling me. Puzzling me also was, and still is, the phenomenon of alternative medicine. The impetus for the previous paper and the present expanded version has arisen from my own dissatisfaction with narrow, health-focused explanations of alternative medicine and its growth in popularity as manifested by the increasing number of practices that are gathering under its umbrella; its promotion by celebrity figures and institutions including the House of Lords and the Royal Family; and growing demands for recognition, regulation, wider availability within our National Health Service, more research into its efficacy, more rigorous training of its practitioners, and so on. Explanations of these developments are usually based on assumptions about the needs of the consumer â€" the 'fight against illness' and the promotion of good health - as well as public demands for treatments that have a different philosophical basis to orthodox medicine, namely those that are 'natural', and 'treat the whole person'. It is also frequently stated that the growing popularity of alternative medicine arises from dissatisfaction with what orthodox medicine can offer, including time spent with a doctor or specialist.
These considerations fail to take into account certain glaring anomalies, namely that all of the developments listed above are taking place in the almost complete absence of any scientific evidence to support the foundations of alternative therapies and to demonstrate their clinical effectiveness over and above natural symptom remission and placebo responding. It is all the more surprising that these developments are occurring while research into orthodox medicine, unlike alternative medicine, continues to advance our knowledge of illness and its causes, amelioration, cure, and prevention, and promises much more in the future. Moreover, we have the growing awareness of the financial limitations of health service budgets and the insistence on the use of empirically validated methods of treatment ('evidence-based practice').
I, and I dare say many sceptics, contend that the growth of the alterative medicine industry has little, if anything, to do with the health needs of the public or the remediation of illness. Moreover, factors such as the philosophical appeal of alternative medicine, whilst they are not to be ignored, are probably of comparatively minor status in understanding the totality of the phenomenon.
How then are we to further our understanding of these developments? It appears to me that to arrive at satisfactory answers it is necessary to understand the political, economic and social context in which the healing industry is located.
The Growth of Mass Affluence
It is undeniable that human beings are unique in the animal kingdom in possessing an extraordinary range of abilities and talents that are developed to a level well beyond that required simply for the survival of the individual and the species. How this has come about is not relevant to the present discussion. What is more important is that it is only relatively recently that the majority of people, at least in the Western world, have had the opportunity, in any significant measure, to reap the benefits of their inherent potentials as human beings instead of merely struggling to survive. That this has been possible is due to the increasing affluence of the population and the economic and political freedoms that they enjoy.
Associated with this are the relentless advance of knowledge and technology and the ever-widening range of choices available to each individual in virtually every aspect of his or her daily life. The skills and talents and the ability to enjoy their products are not only represented by the rich array of material goods on offer, but also in the following: housing; transport and travel; the acquisition of knowledge for knowledge's sake; the arts; the sciences; cuisine; hobbies, sports and leisure activities; entertainment; and physical accomplishments and feats of endurance. In all of these areas and others, more and more is on offer to and attainable by, men and women in our modern society.
It is not of course simply the case that a life rich in opportunity and fulfilment has only been realisable in the modern era. What is unique is not just the sheer scale of what is available to any individual in his or her daily existence (notwithstanding great disparities in wealth and opportunity amongst the population); of major significance is the fact that the range of benefits is available in varying degrees to all and not, as has been the case until recently, to just an elite minority.
The Three Components of Activity
As a rule, people will strive, individually and collectively, to avail themselves of as much of the benefits of modern life as possible, and to hold on to what they have. It is possible to conceive of at least three major components of social activity which, in combination, provide the means whereby these goals are achieved.
Component One is the procurement of the wealth whereby life's rich offerings may be purchased. The main source of most adult people's wealth is the income that they earn through their employment (and, in the case of retired people, at least nominally from the returns on the investment of a proportion of their earned income). There is also income through other investments and through welfare. Importantly, for many people, in addition to monetary reward, their work itself represents a life-enriching experience and a fulfilling deployment of their knowledge and skills, however basic.
Component Two is the acquisition of knowledge and skills by people:
- to secure for them the means to obtain wealth, as above, usually by employment, and
- to enable them to engage in, and enjoy, the ever-increasing range of activities, amenities and assets available, as listed earlier.
Acquisition of the relevant knowledge and skills is mainly by formal education, training, and mass communication and, like employment, can be a rewarding end in itself.
Component Three is the prevention, removal, or minimisation of:
- impediments to directly accessing the opportunities on offer, and
- impediments to indirectly accessing these by wealth acquisition (employment) and education and training.
Here we are mainly concerned with misfortunes or adversities that occur in people's lives and cause suffering, not only directly, but also by preventing them from fully accessing what would otherwise be available. These misfortunes or adversities originate from a limited range of sources (often in combination) such as bacteria, viruses, etc; poisons; genetic irregularities; bodily malfunctions; ageing; human malevolence, negligence, incompetence and retribution; animals (i.e. attacks by); and natural phenomena (the weather, earthquakes, etc). In human society, systems and agencies exist to prevent, remove or ameliorate these. Major examples are the medical services and, in the case of misfortunes due to human malevolence and negligence, the criminal and civil justice systems respectively. We may also include here insurance and welfare services.
Principles of the Three Components of Activity
Within each of the above three components of activity are systems, subsystems and agencies subserving the function of each, as well the general function of maximising human choice and potential. In the evolution of these, several important processes and trends may be discerned. It is important to stress that whilst these may not be successfully realised in every case, they are all driven by forces that are difficult to resist.
The principle of survival
Firstly, systems, sub-systems, agencies, and elements within them (e.g. occupations) that are associated with the above three components, once established tend to be difficult to disestablish. That is, forces exist that tend to maintain their survival, for their own sake if nothing else. At the most general level, societies and the people in them want to hold on to what they have, and this is evident in the tendency for systems, institutions, and so on to promote their own survival.
The principle of expansion
Not only do they tend to survive: forces exist that promote their expansion. At the most general level, we see the never-ending growth of mass affluence and the range of products and amenities on offer and available to an ever-widening section of the population. This growth is paralleled in manufacturing and service industries, educational, health and welfare services, the criminal and civil justice systems, and so on. Again this expansion serves the needs of these industries as well as those whom they supply and serve.
The principle of increasing diversity and specialisation
Within the systems, at every level we can usually detect an irresistible drive towards not just more of the same, but towards increasing technical and technological complexity, diversity and specialisation. Again this is evident generally when we consider the amenities, activities and assets that are available, but it is also evident in the evolution of activity at each of the three components summarised above.
Firstly, within Component One we see increasingly complex and specialised forms of legitimate employment and other forms of wealth acquisition. We also, incidentally, witness a parallel process in the illegal acquisition of wealth.
Secondly, and related to this, we note that the increasing complexity and diversity of (a) products and amenities and (b) employment make greater demands on the knowledge, abilities, and aptitudes of the population. Hence more complex and diverse must be the education and training that are delivered by the services concerned (Component Two).
Thirdly, this ever-increasing complexity is clearly evident in Component Three, notably in the health services, but also in the civil and criminal justice systems and in welfare and insurance services. Thus we witness the relentless advance of medical science in identifying and understanding illness, disease and injury, preventing their occurrence (as in the development of more vaccines) and treating them when they do occur. In association with this we have the ever-increasing diversification and specialisation of medical practice.
Here it is important to note how much more complex now are the consequences of illness and injury. In our early history, the main consequence of a non-fatal illness or accident was the loss of survival skills such as hunting, farming and defensive action. Now in our society, people who suffer disability do not die because they cannot fend for themselves; they very often do not even become totally dependent on others, and they can lead a very full life. However, the consequences of illness and disability are much more specialised and often more significant than in previous eras. They may be temporary, say when a holiday has to be cancelled, or activity in a favourite sport is suspended for a period, likewise the opportunity to socialise. Permanent consequences are, for example, the inability to undertake any sporting activity at all, likewise to engage in many games and leisure activities, to drive a vehicle, to enjoy music or the visual arts, and so on.
Very important are the consequences of illness and disability for activities related to Components One and Two. Again, these may be temporary â€" commonly a period off work or an interruption in education or training. However, an individual, because of a permanent disability, may be forever excluded from pursuing his or her career aspirations, including the relevant education and training. There is a multitude of obvious illustrations of this, but here it is worth observing how some disorders and disabilities owe their prominence, and almost their recognition, to their consequences for the individual in modern society. A very good example of this is dyslexia. Being dyslexic may compromise the ability of an individual to participate in certain pleasures of life and to qualify in and undertake his or her desired trade or profession. However, not too long ago, being unable to read or write satisfactorily would have been of no consequence, and most people would never have had the opportunity to acquire such skills anyway. A similar story may be told about Attention Deficit-Hyperactive Disorder; one of the impetuses in diagnosing this disorder may well be the increasing requirement on children, from an early age to at least their mid-teens, to sit still and concentrate for long periods of time if they are to make their way in the world.
The principle of interdependence
It should be evident by now that the network of systems, subsystems and the elements comprising them (agencies and individuals) under the three components form an organic whole in which the structure and functioning of each, and their development according to the principles of survival, expansion and diversification, are intimately interwoven and dependent on every other. Once the conditions of political, social and economic freedom are in place, there is no simple line of dependency or causality amongst them, even between those subsystems and elements where a relationship of dependency or power is formally defined (e.g. hospital-patient, teacher-pupil, police-criminals). This will be discussed in more detail later; here let it be noted that the opportunity for any system or organisation to flourish and expand is greatly enhanced the more it enmeshes itself within this interdependent network across the three components.
The principle of inevitability
Once again, as long as the conditions of freedom and affluence are in place, the development of the systems associated with the three components, according to the principles of survival, expansion diversification, and interdependence, tends to occur in a relentless and irreversible fashion. This is directly parallel to increasing affluence, increasing range and diversity of available goods and opportunities, and the progress of human knowledge and science. Human nature dictates that this is very difficult to resist, for example, by religious and philosophical appeals to people to eschew the material trappings and comforts of modern civilisation or to adhere to strict rules and mores that demand honesty, fairness, unselfishness, tolerance, stoicism and so on. Likewise it would be very difficult to reverse the same trends in employment and wealth creation, medicine (in its widest sense), education, and the criminal and civil justice system. Even the growth in crime itself has proved difficult for governments to reverse. (There are other related social phenomena that also show great resistance to control, immigration and drug usage being two examples. Trade unionism, on the other hand, which in the UK peaked in the late 1970s, has declined in terms of activity and membership, but remains a significant presence).
This resistance to control of the systems and processes described here is probably in significant measure due to their close interdependence, as discussed earlier.
The principle of over-promotion
Another difficult-to-resist consequence is that personal service industries such as medicine (not just orthodox practice, but also allied professional services, alternative medicine and commercial medicine), education, the social services, and the criminal and civil justice systems tend to over-promote themselves in regard to what they achieve and how much they are needed by the population (cf. the manufacturing industries). For reasons that will soon be apparent, another way of stating this is to say that they exaggerate their authenticity. Let us study this now in further detail.
Each of the above enterprises has a set of aims that can be simply stated. For example, the purpose of the medical services is to promote good health and to prevent, cure or ameliorate illness; the purpose of education and training is to equip people with the knowledge and skills required to lead a fulfilling and productive life and to pursue a trade or profession; and so on. The extent to which these services, and the myriad of activities that take place within each, are acknowledged as offering the best available means of achieving these aims can be said to indicate their perceived authenticity. However, these public services also exist to meet the needs of their employees and stakeholders (e.g. in the case of the health services, the pharmaceutical industry). Like any industry, they need to survive, but also to expand, diversify and specialise, and, as we have seen earlier, to be part of the interdependent network that exists across the three components of activity specified earlier. One major requirement whereby these needs can be safeguarded is for the service to be, if not completely authentic (according to the above use of this term), then at least to be perceived as such by the public.
One strain on their authenticity is increasing public demands and expectations about what can be delivered (see below), but this is reciprocated by the needs of these services for expansion and increasing diversity and specialisation. Clearly then, there are strong forces on these services, as with any industry, to promote their authenticity and hence, very likely to over-promote it, namely to overstate what they can achieve, how much people need them, what promises they are able to fulfil in the future, and so on.
Indeed, the services in question have, in collusion with politicians and the public, been extremely successful in promoting their authenticity â€" that is their perceived ability, over any other possible system, to achieve their implicit and explicit goals. This is most clearly evident in the relentless expansion of public and private money allocated to these services and the almost universal and constant demand for more.
However, perceived authenticity is not the same as genuine authenticity. The realisation that the huge investment in and expansion of these public services brings disappointing returns in the most fundamental ways (e.g. more healthy, informed, skilled and law-abiding citizens, in contrast to 'sound-bite' statistics, such as classroom sizes and waiting times for surgery) either provokes calls for more of the same or questions about efficiency and the mechanics of funding (e.g. whether there should be more private sector involvement). The extent to which these megalithic institutions are embedded in the political and social structure of our nation precludes any effective challenge to their authenticity. This has become much more the case with the ever-growing tendency for governments to rely on the performance of public services as a measure of their own success (or in the terminology used here, their perceived authenticity) in the eyes of the electorate.
The principle of increasing demands and expectations
Yet another important aspect of mass affluence and the advance of science is the change in people's demands and expectations. People increasingly expect and demand more of the services that subserve the three components outlined earlier. (This principle is, incidentally, also subject to the principles of over-promotion - i.e. over-extension of expectation and demand - and inevitability.)
In the not-too-distant past, and sadly even now for a sizable proportion of humankind, most people could only expect a stunted life where illness, injury, deprivation and misfortune were always close at hand, to be accepted as fate or divine ordinance. For those who had faith, the real rewards would come in the life thereafter, provided they accepted their lot on earth with gratitude and humility. Now, as a result of economic and political freedom, mass affluence, and progress in human knowledge and its beneficial application, the common, and not too unreasonable, expectation for most people in our society is that life will be rich and varied, with an ever increasing range of opportunities and benefits to be sampled, and that obstructions to such (as listed earlier) have in many cases a reasonable chance of being prevented, minimised or removed. Inevitably then the attitude evolves that adversities and misfortunes should not occur and if they do there should be remedies for them. Hence when these expectations are not realised, a person's reaction is more likely to include a sense of injustice and unfairness and a demand for redress. Such attitudes are an inevitable consequence of the kinds of developments and progress in our society that I have discussed so far, which promote the expectation of a life that should not be free merely from disaster, but from even minor discomforts, annoyances and disappointments.
There are several aspects of modern life that are often the subject of sceptical commentary that can be understood from the present analysis as being an inevitable consequence of political, economic and social freedom and the advance of scientific knowledge and its application. One of these is the tendency to pathologies and medicalise problems and misfortunes that until recently were implicitly acknowledged as the responsibility of the individual to accept or cope with, with the support of his or her family, friends and spiritual advisors. That is, more and more of these problems are now regarded as the province of experts in medicine (conventional or otherwise) and related disciplines who are perceived as the best equipped (i.e. the most authentic) at understanding them and prescribing or delivering the remedies for them. This theme of the 'over-pathologising' or 'medicalising' of human problems (or 'the colonisation of discontent') is taken up later in this journal
Two more phenomena of interest that are predictable from the present analysis are 'NIMBYism' (the attitude of 'not in my back yard') and 'the compensation culture'. These topics are also discussed later in this journal.
Yet another topic of relevance here is the 'nanny state', i.e. what some perceive as an excessive tendency for our government to be involved in many major aspects of our lives. This is not a topic for the present discussion. It is sufficient to point out here that, despite their best efforts, governments are subject to the same difficult-to-reverse tendencies to survive, expand and diversify in their activities and functions and to overextend themselves in what they offer for the present and what they promise for the future in the most basic aspects of daily life. Inevitably, public expectations about what governments can actual achieve also become overextended, placing considerable strain on the government's perceived authenticity. Nor is it possible for the current opposition party to resist these trends. In the 2001 General Election, the huge scale of the Conservative Party's defeat was ascribed to their campaigning on the ideological issue of whether the UK should in the future exchange the pound for the Euro as its national currency. Now the obligatory political mantra for both the government and opposition is 'better public services'.
The Importance of Perceived Authenticity
The idea of authenticity of roles, agencies (and professional practices) is very important for the analysis of healing practices and will be studied in greater depth here. Firstly, however, since we are interested in healing in the modern age, it is useful to be aware of one important context in which the evolution of the healing industry has taken place in recent years, namely employment (or more broadly personal wealth creation or Component One activities).
Modern trends in employment
As was stated earlier, the prime means whereby people acquire wealth is by their employment. It is important here to make a note of recent demographic changes in employment statistics (Labour Market and Skill Trends, 2000). Firstly, although there have been fluctuations over the last 50 years, employment levels in the UK are currently at record levels. (It is also noteworthy that, at the time of writing, the government is suggesting that people should stay in work longer and therefore retire â€" say at 70 years. This is partly because the returns on their accumulated investments in their pension schemes may not be sufficient to support them in the long retirement period that people these days enjoy, owing to their greater longevity.) Secondly there is proportionately more part-time, temporary, contractual and home-based employment. Thirdly, and very significantly, the expansion and diversification of employment has occurred much more in the service sector, including personal and protective occupations, than in production industries (manufacturing, agriculture, fisheries, etc.). In 1978 the largest employment sector (30% of the market) was manufacturing industry; in 1998 it was public administration, education, health and other services (28%, with manufacturing down to 17%). Skill requirements have become more demanding, with a corresponding increase of young people in higher education and training. Finally, the move to a service-based economy is matched by the rise in the proportion of women in employment (47.1% of those of working age in 1960, compared with 69.4% in 2001, the corresponding rates for men being 96.1% and 79.6%).
The symbiotic nature of supply and demand
It would be incorrect to state that all of these changes only reflect the expanding and increasing diversification of the needs and demands of the consumer and the growing ability of human knowledge and expertise to meet these needs. Classical economics acknowledges that there is a reciprocal relationship between those who supply goods and services and those who demand them. That is, it is not the case that the activities of the former are simply motivated by the requirement of ensuring that the needs of the latter are completely satisfied. The prime motivation of suppliers is, in fact, the satisfaction of their own needs. This principle is summarised by the great Scottish economist Adam Smith who wrote:
It is not from the benevolence of the butcher, or the brewer, or the baker, that we expect our dinner, but from their regard to their own interests (The Wealth of Nations, 1776).
In other words it serves well the needs of, for example, the butcher (the need to earn a living, to have job satisfaction, to enjoy status in the community, and so on) to ensure that he is perceived by the consumer as occupying the role best placed to provide them with the meat that they desire. In this respect we can say that the butcher has a strong need to be perceived as authentic. Remember, however, that perceived authenticity is not the same as actual authenticity. For example, it may be better for people to obtain the meat they desire at the best possible price from some source other than a butcher. If such were the case, the butcher would not be authentic in this respect. (Note that the idea of 'authenticity' is best applied to the role that the person occupies, not the person himself or herself. So, Fred Jones, for example, may be 'authentic' as a butcher â€" qualified, well trained, honest, and dedicated - but this does not mean that the activities prescribed by the role defined as 'butcher' are themselves authentic.)
Putting it another way, a job itself is like a commodity or service; it addresses a range of needs on the part of the role-occupier. This fact in itself indicates that the distinction of supply and demand is not simply one way; those who supply may also be said to demand and those who demand may also be said to supply. In other words the relationship between the two can be said to be symbiotic, and underlying this is the need of the person or agency to be perceived as authentic in his, her or its designated role. (In fact, if we pursue the argument further according to role theory, we may assert that in many formal reciprocal role relationships, such as doctor-patient, pupil-teacher, complainant-lawyer, there is also a need for the other member (the 'client') to be perceived as authentic. We need not, however, concern ourselves with this here.)
I believe that this issue of the need for perceived authenticity is especially salient in service industries, in particular the agencies and professional roles associated with personal services such as those in education and training, health and illness, and welfare, safety and personal protection (in the main those coming under Components Two and Three as described earlier). Moreover, the need to expand the personal service sector, not merely to meet demand but also to meet employment needs, increases the strain on these services to demonstrate the authenticity of their activities and practices.
Part II: The Need for Authentication in Healing and Therapy
Authenticity and Power in Healing and Therapy
I shall now confine the discussion to healing services (i.e. orthodox medicine, alternative medicine, commercial medicine, counselling, etc.) although this analysis may be adapted to other personal services such as education and the law.
Healing usually involves a practitioner as an expert doing something to someone - treating or assessing him or her in some way and, most notably, interpreting on behalf of that person what is right or wrong with his or her body, mind or personal circumstances and what are the necessary remedies. Consequently they are about power and one thing that sustains such practices is the power relationship - the practitioner's need for power and the recipient's need for someone with that power. (I am not necessarily using the term 'power' in a pejorative sense; in fact it is an essential feature of everyday life.) Hence the crucial need is for the practitioner to be perceived as authentic in his or her role and anything that challenges the authenticity of his or her ideas and practices challenges the authenticity and power of the practitioner. (Recall that 'authenticity' is best applied to the role occupied by the practitioner; we are not so much concerned with whether the particular individual is, good or bad at being, say, a homeopath or has the proper qualifications and training; much more relevant is the authenticity of the activities prescribed by the role of 'homeopath' itself.)
The Purpose of Healing and Therapy
In our own society the role of healer or therapist has a certain permanency; that is, it is usually a profession or occupation from which the person derives his or her livelihood and to some degree social identity. In consequence the question of the authenticity or legitimacy of his or her power is all the more significant. In fact this combination of firstly the importance to the therapist of his or her perceived authenticity and secondly the power imbalance between therapist and patient seems to me to be of such significance that I am persuaded to make the following assertion. Normally we would define the purpose of healing or therapy as, say, 'to alleviate the sufferings of the patient'. I propose the following definition:
The purpose of therapy is to authenticate the therapist
...that is, to legitimise his or her power and his or her beliefs and practices. It is apposite to emphasise that we are always speaking of the therapist's perceived authenticity.
I am here referring to what determines the behaviours and beliefs of both the therapist and the patient. In most instances, the crucial issue to which therapist and patient or client apply themselves is the authenticity of the therapist (see Note 1). But because of the power imbalance the practitioner has greater control over defining the needs of the patient, the remedies to prescribe, the range of legitimate outcomes, and so on, and will tend to do so in ways which are self-authenticating.
The Means of Authentication
In what ways can a healer or therapist promote the perceived authenticity of his or her role? One obvious way is by adherence to the traditional healing ceremony, which fulfils the expectations of the person wishing to be healed. This includes taking a history, performing an examination, administering tests, providing a diagnosis(preferably based on a rationale acceptable to the patient), administration of a remedy, monitoring progress and outcome, and so on. But adherence to a ceremony is not in itself sufficient for a practitioner to be perceived as authentic.
Authentication by scientific validation
Clearly the most effective way of authenticating the healer's role is by the patient's getting better, or at least being perceived to do so. One way of increasing the likelihood of this is by accountability to scientific knowledge and enquiry. Firstly, diagnoses and treatments should be based upon scientifically established finding in the fields of human physiology, biochemistry, pathology, and so on. Thus we have therapies that are authenticated by being 'process-based' according to scientific knowledge. However, this is now recognised as insufficient. These treatments should also be scientifically demonstrated to have a specific remedial effect on the disease or condition to which they are applied. Thus the treatments are authenticated or otherwise by the 'evidence-based' (or 'outcome-based') approach.
Here we have the principle that the ideas and practices must have a clear derivation based upon careful and objective observation, experimentation, and logical and mathematical deductions made therefrom. They must also be accountable to the self-correcting process of scientific enquiry, as a result of which they may be left intact, modified, or abandoned altogether. Historical examples of the last category are trepanning and phrenology. More recent treatments that have been subjected to the evidence-based approach are provided by Sackett & Rosenberg (1995) who observe that certain drugs that suppress unstable cardiac rhythms in patients who have suffered myocardial infarction have now been found to increase rather than decrease the risk of death; likewise many process-based manoeuvres that have been used in obstetrics and childbirth have now been found to be of doubtful value or harmfull.
However, this alone is now considered insufficient to establish the authenticity of a treatment. The clinical benefits of the treatment should be demonstrated to be worth the time, effort and money spent, particularly when weighed against considerations such as the cost effectiveness of other treatments, the patient's quality of life, and adverse side effects. The UK government, which is responsible for the distribution of finite resources, recognises the importance of this, as demonstrated by the establishment of the National Institute for Clinical Excellence, whose brief it is to advise on the availability of treatments in the Health Service according to these criteria.
Even all of this, however, ought not to be regarded as sufficient for establishing the authenticity of any treatment. More radical challenges to the authenticity of any curative approach to illness may be made by asking whether resources should be diverted to, say, preventative measures. For example in recent years we have witnessed the dramatic rise in the incidence of asthma, notably in children, and it may be argued that the most authentic way of addressing this is by researching the causes of this epidemic and remedying these, rather than trying to find ever more effective treatments. Similarly we have seen an alarming increase in the proportion of overweight and obese people in the population, again particularly children, with enormous implications for their future health. Effective remedies may be available to treat obesity and the diseases that are thereby caused, but it may be that the most authentic specialists are those who are promoting appropriate lifestyle changes and to whom priority should be given in allocating resources. There may some justification for the claim that the current prejudice is to perceive the curative medical practitioners (and the pharmaceutical industry) as more authentic (because their practices are 'evidence-based') than those advocating preventative measures such as changes in lifestyle and government action on social and environmental issues (see Note 2).
Authentication by validation through scientific enquiry is only one way that a therapy promotes its perceived authenticity. In fact, when attempts have been made to authenticate unconventional therapies in this way, little scientific support has emerged for the processes on which they are presumed to be based, and despite sometimes extraordinary claims for their efficacy, clinical measures of outcome appear to be vanishingly small the more rigorous the procedures used to test them (e.g. NHS Centre for Reviews and Dissemination, 2001, 2002).
Authentication by authority
Power should always come with accountability, but this has not always been so in medicine. It is generally accepted that until relatively recently physicians and their treatments tended on balance to make their patients worse rather than better. Indeed, some treatments would, outside of the medical context, have involved the physician and patient in roles hardly different from that of torturer and victim: viz., trepanning, purging and bleeding, (which were used for hundreds and even thousands of years) and procedures used up to end of the 19th century on mentally ill people, such as beatings, cold-water treatment and 'spin therapy' (whereby the patient was spun round at great speed).
Despite all this, the perceived authenticity of medical doctors was upheld and the medical profession survived. And today the same is true of alternative therapists, whose treatments have not been authenticated in the ways described earlier, and whose adherents often reject this form of authentication. Are there other means of authentication at their disposal? Consider this claim: 'The fact that these practices have been used by people for hundreds of years proves that they work'. Or 'We don't need to test whether or not our procedures are effective - we know they are from our own experience' or 'our patients tell us so'. This is authentication by authority.
It sounds very reasonable; but we should bear in mind that many patients have problems and conditions that are variable over time and not infrequently have a tendency to change for the better regardless of their therapist's ministrations. Add to this the fact that when we judge the validity of our own valued beliefs, we attach greater weighting to confirming as opposed to disconfirming evidence and the consequences are obvious.
Consider also this cumbersome piece of advice: 'Maximise the range of conceivable positive outcomes'. For example, if your patient improves, obviously your therapy is working. If your patient gets worse, your treatment is starting to show some effect. (Some alternative therapists inform their patients that their condition may worsen at the start of treatment before it gets better.) Finally, if your patient is unchanged, any further deterioration has been halted. In this regard I was interested in the reactions of the staff at a well-known alternative cancer treatment clinic when they received some adverse publicity concerning their therapy regime and hence their authenticity. In interviews given by the personnel involved it seemed to become increasingly obscure what defining qualities would distinguish a satisfactory and an unsatisfactory response to their programme.
Authentication by mystique
As I have implied, in most of the kinds of practices under discussion the knowledge and ideas underlying them are fixed and unchallenged; we may describe them as 'dogma'. We therefore need some impressive answers to the question 'How were they derived?' 'Many thousands of years ago by Chinese physicians, philosophers or astronomers' may be one answer; or 'By Amazonian Indians long before the invasion of white men'. Similar reasons could also be used to support the practices of trepanning, purging and bleeding.
Authentication by magic and religion
The appeal of magic for those seeking power - albeit the power to do good - and those seeking relief from suffering and unhappiness should not be underestimated. I mean magic in a very broad everyday sense. We invest things and ideas with magical properties when we do not understand them, when they have an intangible and ethereal quality, and when in some way they appear to have the potential for some unusually powerful or supernormal properties. Some magical concepts are of course nonentities such as animal magnetism or ghosts. Of course the magic is in the mind of the beholder, not in the thing itself.
One of the most convincing ways of persuading anyone of the authenticity of some procedure or phenomenon (say a healing ritual or even a religious faith) is that it has magical or miraculous properties. In India, for example, many healers and gurus owe their power over their followers to their apparent ability to perform miracles such as materialising jewels and holy powder out of thin air. Some of them even attract the attention of politicians, either because it gives the latter credit to be seen consorting with them, or perhaps they need a miracle or two to keep them in public favour. Enter the Indian Science and Rationalist Association, a group dedicated to eliminating this kind of religious fraud and superstition. The rationalists show how they themselves can pluck precious stones from the air without recourse to divine powers.
But of greater interest are the extraordinary physical feats accomplished by devotees of the gurus. They are able, through 'trance states', prayer and devotion, to walk on red hot coals without being burnt, have spikes thrust through their cheeks and tongue; be spun around on ropes with metal hooks skewered in their flesh; and have their heads buried in the ground without suffocating. What is the answer of the rationalists to all this? They call for volunteers from the onlookers and, with a little persuasion, have them performing all of the above acts without any kind of religious indoctrination or even any indication of their entering into a 'trance state'. Are the gurus and healers happy to have this kind of attention and rational insight into their practices? Their reactions would suggest otherwise (Eagle, 1995).
Sometimes the magical phenomenon is a special gift the person has: 'I have an energy flowing from my hands' I once heard a healer say. Consider three interesting aspects of this assertion, which I have also heard from other religious healers.
'I have an energy flowing from my hands.' Note the attraction of the idea of an invisible force or energy that has fluid properties. This is a very common theme in the history of healing; recall the activities of Anton Mesmer in the eighteenth century and the extraordinary carryings-on at his Paris salon, which he ascribed to an invisible fluid force, animal magnetism. You may also be reminded of the theories and practices of Wilhelm Reich in the last century, and the ideas behind acupuncture.
When a concept or entity is invested with magical properties, it acquires the capacity to evoke an almost boundless range of behaviours and beliefs, but only amongst those people who accept those magical properties, which they tend to do in a dogmatic fashion. A concept in psychotherapy that elicits much magical thinking is the 'unconscious mind' (see Note 3). Another one, fashionable in alternative therapy, is the 'aura', the presumed field of energy that radiates from the bodies of living things, including humans.
Some years ago I attended a training course in therapeutic massage at a well-known centre in West London. One thing we had to practise was massaging the aura. This involved passing the hands up and down the client's reclining body without touching it, thus supposedly clearing congested areas of 'negative energy'. Various hand movements were employed; for example, now and again while 'massaging the aura', one was instructed to shake one's hands away from the person's body in the manner one does when dispelling droplets of water. When massaging around the head one used twirling movements as though gathering the energy up, and then one slowly drew it backwards away from the head in the manner of pulling on the reins of a horse. This was especially recommended if the patient needed to resolve a past trauma; the more distant in time the trauma, the further one pulled back the 'energy', so that in a small consulting room this might necessitate making a gradual backward exit out of the door. We were also urged to wash our hands on completion of the massage lest the client's 'negative energy' adhere to us and leave us with bad feelings.
Apart from these behaviours I found interesting the reactions of the teacher and group to the lone questioning voice. I shall not say whose this was and I shall leave it to the reader to imagine the nature of these reactions. My point is this: that were the aura a more visible or tangible entity and more rationally understood then one would see a more restricted range of beliefs and behaviours, and yet a greater tolerance of divergent opinion (since there is less demand on faith).
'I have an energy flowing from my hands'. The second point to note is that in any other context such an assertion would invite not mere disbelief, but some harsh questions about the claimant's motives and even mental stability. But place him or her in a context of healing - in this case a hospice for the terminally ill - legitimise this with religion, and merely to raise an eyebrow becomes an act of profanity. So we have authentication by religion.
Thirdly, note the lure of the cheap source of power. It is not only physicists who are looking for this - it appeals to us all. Why bother with the toils of six years' full-time study when the power to heal is literally there at your fingertips? Take a set of simple techniques, endow them with magical properties by some quasi-scientific, mystical or spiritual theory, make extravagant claims about their healing properties, and you have a common formula in the market place of unorthodox therapies.
Authentication by mystery
'Nobody knows how it works' is an oft-used paradoxical means of authenticating an unusual practice, the implication being that it does work but by some means that presently outstrips human knowledge. Consider the reply of a Kirlian photographer to my question 'What exactly is the `aura'?' 'It's a form of electromagnetic radiation, but it's not recognised by scientists.' Better variations on this authenticating theme are 'not yet recognised by scientists', 'scientists still don't understand how...', and so on.
Yet science itself carries its own aura of magic and mystery. Most of us do not understand science, and the achievements of science astonish us. People therefore inevitably attribute to science, and to modern medicine itself, magical properties in the manner described earlier. Not surprisingly, therefore, certain concepts elucidated by science have been appropriated by alternative therapists, invested with magic, and presented as authentic ideas and practices. So we have:
Authentication by pseudo-science
As we have seen, the above concepts include force, energy, magnetism, and electromagnetic waves. More recent ones are vitamins and minerals, hormones, toxins, allergy, biological rhythms, brain waves - particularly the alpha rhythm (which has given rise to the magical 'alpha state') - subliminal perception, and left-right brain differences, the right cerebral hemisphere having now become a magical entity.
The same fate has now befallen endorphins; these are neuropeptides that ameliorate our experience of pain and are related to certain pleasurable experiences. I have seen several unorthodox therapies authenticated by the assertion that they 'cause the brain to produce endorphins' for which magical claims are then made.
I earlier suggested that magical therapeutic properties are often conferred upon phenomena which, having an ethereal and intangible quality and, not being fully understood, somehow hold out the promise of an accessible source of unusual power. Acquisition of this power provides the main motivation for this process, but it is in fact difficult to predict with any exactitude which phenomena may be selected. Half seriously, I believe that one great attraction of the alpha rhythm is simply its name. When alpha biofeedback was a fad in the USA in the 1970s, group sessions of alpha training used to be held in special places called 'alpha temples'. Would any of this have happened had the phenomenon been labelled 'Higginbottom's rhythm'? I very much doubt it. However, I lately read an interesting account of the ways in which no less a mundane substance than water is marketed as a panacea (Gardner, 1993). Clearly my portrayal of magical remedies as 'ethereal and intangible' is in need of further elaboration.
Another relevant attribute for a phenomenon to be endowed with magical healing properties is that, at least in our own culture, it must be without harmful side effects. This would be an unusual characteristic for any treatment of scientifically proven efficacy, since most organically active interventions can't help but carry some risk of compromising healthy functions as well as ameliorating diseased ones. The key point is this: the administration of any substance or procedure that may have harmful effects is usually subject to legal restriction and it is thereby unavailable for recruitment as a magical nostrum. So something like X-ray radiation, which would appear to be eminently eligible for endowment with magical healing properties, is not promoted as a remedy in the marketplace of alternative therapies only because its cumulative harmful effects restrict its accessibility. But there was a time when these harmful effects were not recognised and X rays were advertised as a cure for all manner of medical and psychological complaints. No doubt they still would be had not their harmful effects been discovered.
Authentication by charisma
The ideas and discoveries were made by some extraordinary and inspired individual - viz. homeopathy, osteopathy, chiropractic, iridology and biorhythms.
As I have described them, unlike orthodox practices, these systems of ideas tend to form rather static structures; we do not hear, for example, of any discoveries or breakthroughs by alternative medical practitioners. My impression is that rather than gradual change, transformation or decay by the process of self-regulation, there is a kind of grafting of ideas often related to some impressive or charismatic figure who introduces his or her own version of the practice in question and creates a following - the Bach Flower Remedies, the Alexander Technique, the Feldenkrais Method, Rolfing, Ericksonian Hypnosis, and so on.
Authentication by celebrity
It is by no means uncommon for the popular media to feature stories of famous individuals who subscribe to some unusual and unorthodox treatment. More often than not these people are film or television stars, but in the UK, two of the most prominent are the Prince of Wales and the wife of the Prime Minister. It would be of no interest to readers of the newspapers to hear that now and again Mrs. Blair takes a Paracetamol for tension headaches that must be an inevitable consequence of the kind of life she leads. However, it is certainly newsworthy when her choice of treatment is, say, Indian head massage. Why there is such media interest in celebrities' choice of alternative medicine is, mercifully, beyond the scope of this paper.
Authentication by labelling
One of the simplest ways that we endow any activity with legitimacy and authenticity is to give that activity a label. 'What is this?' we bemusedly ask a woman who is vigorously massaging the soles of the feet of another woman. 'I'm a reflexologist; I'm doing reflexology on a patient with myalgic encephalomyopathy is the answer.
In fact a most impressive array of interventions present themselves to the above patient. She may be administered various potions (synthetic, herbal or whatever); she may have her head massaged, her feet pummelled, her whole body rubbed with exotic-smelling oils; electric appliances may be attached to her, pendulums swung around her, prayers said for her, needles stuck into her, crystals passed over her and so on. However extraordinary the practice, the therapist's assigning a label to it (and to himself or herself as a practitioner of that therapy) is a first start to authenticating his or her claim to power. The same can be said for his or her labelling of the patient's problem; however anyone seeking treatment also needs authentication in his or her role as a patient (cf. 'I'm not making this up, there is definitely something wrong with me'), hence the dual role of the diagnostic label.
I once received through my door a leaflet advertising a 'hypnotherapist'. Hypnotherapists have some problems authenticating themselves, as the expectations of the hypnotic subject are very often not confirmed by the experience (cf. 'I could hear everything you said'). The hypnotherapist in question got round this by labelling his therapy as a type of hypnosis called 'conscious hypnosis'.
Finally on this theme is the subtle switch in the UK in the re-labelling of unorthodox medicine from 'alternative' to 'complementary'. 'My treatment is complementary not alternative' was the insistent headline of a local newspaper article concerning a fringe therapist. There may be a number of reasons for this change but the most important one in my opinion is the more flexible arrangements within the National Health Service that allow unorthodox practitioners greater access to this lucrative market. Co-operation rather than conflict with the health care establishment is thus indicated. And so, 'alternative', at one time assertive and uncompromising, the proud boast of unorthodox medicine, now lies abandoned and forlorn, while 'complementary', at least when it manages to get itself spelt properly, joins its comrades-in-arms, 'natural' and 'holistic', on that ever increasing pile of convenience vocabulary - meaning anything, everything and nothing at all.
Authentication by splitting
I have borrowed this term from Melanie Klein's theories. 'There are authentic practitioners and there are inauthentic practitioners; the former are properly trained and do a good job; any challenges to authenticity apply to the latter group (the 'cowboys'), the ones who aren't properly trained.
Authentication by qualification, professionalisation and legislation
'What we need are regulations and laws limiting practice to properly qualified individuals ...... in order to protect the public'. Here I should emphasise that I am not challenging the validity or desirability of this assertion. I am saying that to understand the behaviour and attitudes of those who make them we would do better to interpret their intention as to authenticate themselves and not simply to benefit the public in general. As was argued earlier in this article, once a system of activities becomes institutionalised within the interdependent network of employment, education and, in this case, medicine, there it tends to remain and flourish.
In a modern free and prosperous society the intimate collusive nature of the processes of supply and demand in seeking to fulfil the needs of each party ensures that both what is offered and what is demanded of them will expand and become increasingly diverse and specialised. Consequently, by mutual consent, more and more areas of human distress, disappointment and discontent become colonised by assumed experts, especially those in the healing industry. Likewise, what is promised and what is expected become more detached from what is achievable. Yet, the major underlining requirement on both sides is that the roles of those who supply these services are authentic.
Conventional practitioners in the healing industry have become progressively more accountable to scientific knowledge and enquiry as a means of authentication, both for the hypothesised basis of the diagnoses and remedies they offer and for the efficacy of their remedies. Yet we can still challenge their authenticity by asking questions about the broader costs and benefits (not just financial but also physical, emotional, spiritual, and so on), other possible approaches such as prevention and a focus on ecological and lifestyle factors, and personal freedom and responsibility.
Practitioners of alternative medicine are not authenticated by science. Instead, authentication is sought by appeals to authority, mystery, magic and pseudo-science. There is no doubt that belief in the power and magic of a treatment may promote some form of healing. Also, unlike the typical general medical practitioner, many alternative therapists have the advantage that they are able to devote sufficient time to the entire healing ceremony, notably a thorough examination and the nurturing of a close healer-patient relationship. Furthermore, whereas a brief visit to one's general practitioner is often seen as an obligation when one is ill, likewise taking the pills that the doctor prescribes, consulting, say, a homeopath or reflexologist is more the personal choice of the individual, who can therefore claim some ownership of the solution to his or her problem. This and the payment of a fee may encourage greater personal commitment to and belief in the therapy - no mean consideration.
It comes, then, as no surprise that surveys have revealed very high levels of consumer satisfaction (i.e. perceived authenticity) with alternative practitioners. Why, therefore, try to fix something that isn't broken? I suggest that there is considerable merit in having a clear and rational distinction between orthodox and alternative practitioners and preserving public access to the latter. I therefore make the following suggestions.
- It is unproductive and wasteful to teach medical students and trainee and qualified doctors about alternative medicine.
- No Health Service funds should be allocated to therapeutic practices whose foundations are contradicted by existing scientific knowledge.
- Research into such practices is a waste of resources and will bring no significant returns for public health or the amelioration of illness.
- Practitioners of alternative medicine should be allowed to work with the minimum of government regulation.
I doubt whether any but a small minority would endorse this package in its entirety, and the reasons for this are, I hope, not too difficult to understand from this paper.
- Perhaps we can define 'placebo' here as 'the readiness of the patient to authenticate the therapist'; in psychotherapy at least, the opposite could define 'resistance'.
- Some years ago the then Health Secretary Frank Dobson was featured on local television opening a general medical practice in an inner city 'sink' estate. To universal acclaim, he announced that this would be a great help in improving the health of the people on the estate. Nobody was heard to ask whether, in this instance, priority was being given to the most authentic means of achieving this aim.
- The sovereign means for believing what one likes in psychology and of turning what might become a science into a tumbling ground for whimsies. William James (1890, p 163)
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