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PLACEBO THERAPY: HOW TO DEVELOP AN EFFECTIVE AND ETHICAL QUACK TREATMENT

This article appeared in the 'Skeptical Intelligencer', Vol. 8, 2005, pp 18-25. There are a couple of small additions to the text.

Introduction

If you are all of these things then you may well be able to help people who are suffering from a range of medical and psychological complaints by becoming a placebo therapist.

The following instructions provide a protocol for constructing a placebo treatment of your own devising. If you follow the instructions then you are guaranteed to have the means to be a successful quack. Your treatment will benefit many, though not all, of the patients you see and as long as your patient is also receiving the treatment indicated by mainstream medicine, it will have no adverse side effects. Many of your patients will express their gratitude to you and swear by the efficacy of your treatment.

Please note that in none of these instructions is the primary aim to deceive your patients or the public at large. The aim of every single recommendation is to enhance the benefits that your patients will receive from you ministrations; that is, it is entirely to maximise your patients' response to treatment that these instructions have been devised.

A blueprint for an effective placebo therapy

1. The healing environment

The first requirement is a suitable setting in which to conduct your practice. A conventional office is ideal and this should provide as relaxing an atmosphere as possible. You will need the usual office equipment; include a couch or reclining chair (or at least one comfortable chair). A bookcase or shelf filled with authoritative-looking books on medical matters is a bonus, and you can also have a few such books or learned journals (e.g. the British Medical Bulletin) lying around. Have one open on your desk to indicate that you are in the middle of reading a scientific paper, but remember to change this every week for obvious reasons. Posters depicting human anatomy are very appropriate. You might also consider placing one of those simple models of the brain on your desk. Some practitioners like to display their certificates on the wall - you can devise your own to show that you are qualified in your quack treatment (see later advice on training and qualifications). You also need headed notepaper, appointments slips, business cards, folders for your patients' notes, a filing cabinet that can be locked (patient confidentiality is of the utmost importance), and so on.

2. Appearance and demeanour

Your appearance and demeanour are important to inspire your patient's confidence. You are entitled (no pun intended) to call yourself a 'doctor' of your particular quack treatment and you can put after your name whatever letters you wish as long as these do not correspond to existing qualifications that you do not possess.

Dress formally but modestly. For men, a smart, sober suit and a plain shirt and tie are the ideal combination, but don't go over the top: for example, you may enhance the effect with a bowtie, a buttonhole or a breast pocket handkerchief, but all three together may appear rather affected. For women, smartness and sobriety are also de rigueur. However, instead of formal attire, you may consider wearing a white laboratory coat or jacket; this will convey the impression, however unfounded, that the technical skills involved in the execution of your therapy are such that your everyday attire (which will still be formal) requires some protection. But make sure that your coat is clean!

Advice concerning your general demeanour when interacting with your patients needs go little further than common sense. You should endeavour to communicate an air of authority along with the clear indication that the patient's welfare is your greatest care and concern - as, of course, it is. It pays also to cultivate a slightly apologetic manner. A bombastic, over-confident style may antagonise many patients but there are more subtle reasons for erring on the respectful side. Patients themselves tend to show deference to their doctor and part of this is because they are anxious to be accepted by him or her as 'a genuine case' ('I don't want to waste the doctor's time'). This can be so, even when they are paying the bill! A slightly deferential attitude on your part, the merest hint that you are prepared to do your humble best and are even ready to shoulder a little more than the usual burden of responsibility for their problems, will play on these anxieties just sufficiently to turn them to your advantage and theirs too - for one thing, the patient will be more committed to the treatment. And if the treatment does not yield the desired outcome, your patient will be all the more forgiving of you.

3. Assessing your patient

Whatever treatment procedures you invent and whatever you call your treatment (guidelines are outlined later) you must always devote the first appointment to taking a thorough history and a full description of the problem. You will require at least 90 minutes for this. Ask the patient to take you through his or her personal life story from birth to the present day. Enquire about early family life, education, employment, marriage, children, leisure activities, and so on. Ascertain how your patient feels or felt about each of these and whether any problems are or were experienced (e.g. family conflicts or bullying at school). Should your patient become tearful, show appropriate empathy and allow plenty of time for the venting of emotion. The sharing of difficult emotional experiences will strengthen the therapeutic bond between the two of you. Ask about his or her medical history (starting at birth) and any past or present psychiatric illnesses or psychological problems. Ask about health-related habits (exercise, diet, smoking, alcohol, drugs etc.). You must obtain an in-depth account of the presenting complaint, its history, how it affects the patient, whether it varies in severity over time and, if so, for what reasons, if any. Ask what medicines he or she is taking; sometimes patients will bring their medication to their appointment. Whether they tell you what it is or show you say, 'Ah! yes'and write it all down. Ask about any side effects they may be experiencing.

Include in your assessment some simple measurements such as weight and height. Have some weighing scales and a vertical ruler for measuring height. Give your readings in kilograms and meters, as they sound more advanced and scientific to most people. Have a height and weight chart on display. Check the patient's pulse and look at his or her tongue ('to see if it's a good colour') and fingernails ('to see how strong they are').

4. The construction of your treatment

Let us now turn to how you are to devise your placebo treatment. The following is a protocol on which to base this. Many existing placebo treatments are generated by the application of these principles and you do not have to use all them. We shall examine the naming of your treatment and how you describe to your patients the theory and the rationale behind it in due course.

Medicine

It is useful that your treatment entails the regular ingestion of some placebo substance. Your patient should be given to understand that this medication is specially selected and based upon your in-depth assessment of him or her and his or her particular problem, with reference to the theory behind your treatment. The medicine should be absolutely harmless and without the slightest adverse effects. It can be in tablet or liquid form, although you could also use an aromatic substance that the patient inhales ('aromatherapy'oils are readily available over the counter).

There has been some research on the influence of the size, shape and colour of tablets and capsules on their placebo value, but most practitioners are not in a position to capitalise on this. Vitamins in low doses (e.g. vitamin C) or a multivitamin pill are a possibility, as are over-the-counter homoeopathic or herbal remedies and pick-me-ups. Although very unlikely, check for any side effects and inform the patient of these. Tell the patient what is in the tablet and what he or she is to do in the following way. 'This medicine has been specially chosen to help you with your condition / problem / symptoms, etc. One of the main ingredients is X (vitamin C, a particular herb, etc.). Take one every morning on rising and one at bedtime (say) for the next 10 weeks (say)'. Have these instructions printed for the patients, with the heading 'VERY IMPORTANT'.

Liquid medicine can come in the form of tap water but it is a good idea to give it a little colour, say by the addition of some fruit juice. You can tell the patient, for example, that you have energised the water to resonate with vibrational frequencies attuned to natural healing (or words to this effect). Justify this claim by, for example, 'energising' the preparation beforehand by concentrating on the idea of healing and making hand passes over the container. Over-the-counter liquid preparations, elixirs and tonics may also be used as safe medicines. Prescribe the dosage in a manner similar to above.

Relaxation

A simple relaxation procedure can also be incorporated into your method, but link this to the rationale of your treatment. For example you could say, 'While you are doing this procedure you will literally feel those blockages of negative energy in your body and mind dissolving away'. Make the relaxation procedure short and simple, particularly as your advice will be that the patient use it every day. A good technique is calm, relaxed breathing: ask patients to focus on the rhythmical movements of their breathing, thinking of relaxing with each outward breath and imagining waves of relaxation flowing down their body. In addition you may ask them to imagine being in a safe, special place of their choice or you may suggest such a place. For example, you can suggest that they are in a special garden, one in which healing can take place. Suggest that they are feeling the healing warmth of the sun on their body, that the fragrance of the flowers has special healing properties, and so on.

Some placebo therapists use appropriate background music and mild incense or a scented candle when undertaking this kind of procedure.

Suggest to patients that they use this relaxation method every day when it is safe and convenient to do so.

Visualisation

You may also incorporate into the relaxation procedure some healing imagery that is specific to your patient's complaint. Tell your patient that both of you will now concentrate on his or her problem or condition. Ask the patient to construct a mental image of it (this may be a metaphorical image such as a dark cloud in the case of depression) and then to imagine healing taking place. You yourself will also make appropriate healing suggestions. Now and again ask the patient how he or she feels and encourage him or her to keep relaxing. Examples of healing imagery are: imagining pain dissolving away; imagining the skin becoming smooth and healthy (for a dermatological complaint); imagining the blood pressure coming down (hypertension); imagining any growth, tumour, etc., getting smaller and smaller (some practitioners use images of the immune system attacking the malignant cells); and generally imagining the affected organ becoming healthy and fully functioning again. These images may be used in the patient's daily self-relaxation routine.

Hand contact and hand waving

It is strongly recommended that you incorporate some form of 'laying on of the hands' or hand waving ceremony in your treatment. First, however, some serious words of advice. You must explain to the patient the rationale for any physical contact or near contact and you must make sure that he or she feels comfortable about this. Broaching this with your patient will also convey the message that you are very sensitive to, and considerate of, his or her feelings, an ethical requirement, in any case, for all those who offer any sort of therapy to the public.

Such activity must be carried out with due propriety and with no opportunity for any misunderstanding. It is recommended that physical contact be limited to the head and shoulders if you are using massage as a supplementary procedure. (Some quacks also use foot massage: this constitutes the main treatment in the case of 'reflexology'.) One method is to stand behind the seated or reclining patient and support his or her head with your hands. Tell the patient to allow the whole weight of the head to rest in your hands. You may then use the relaxation procedures outlined above, including healing imagery.

In addition or instead of the above, you may choose to massage the patient's scalp. Use a gentle circular motion and explain that you are clearing blocked negative energy and this will help the patient feel more energetic, motivated, clear-headed, etc. Breathe deeply and audibly and go into a 'trance'(or pretend to - it doesn't matter which) and offer relaxation and healing suggestions and imagery. Now and then say to your patient, 'How does that feel?' You will be surprised by how much your patient appreciates this.

Another procedure is to make passes of the hand over the patient's body. Again explain that you are freeing blockages of negative energy that are detrimental to the patient's health. You may refer here to the 'aura', a non-existent sort of vital energy that supposedly radiates from the body. One technique is to make a series of sweeping downward movements of both hands several inches above the patient's body, concluding each movement by drawing the hands away from the body and shaking them in the same manner as dispelling droplets of water.

The placing of hands on the patient is a universal healing gesture with a long history; likewise healing by hand waving. One advantage of such manoeuvres is that permission is granted to the practitioner either to make physical contact with the patient in a way that is personal without being threatening, or at least to come into close proximity with him or her. That is, they legitimise a degree of intimacy that may enhance the efficacy of the treatment, particularly when the patient's problem has an emotional component.

Some quack practitioners also wave objects over the patient or actually place them on the patient. Common objects are crystals (you can probably buy these cheap from stores such as Woolworth's), magnets (ditto) and pebbles. You can explain their rationale with reference to vibrational energies and the like.

Scientific-looking hardware

The use of some scientific-looking contraption in your healing sessions can also be recommended. One such devise is a 'relaxometer'- a commercially available 'biofeedback' device that measures skin resistance (the first and middle fingers of one hand are the usual sites for placement of the electrodes). The reading is given on a dial or is converted into an audible tone - the lower the tone, the higher the electrical resistance and therefore the more relaxed the patient is. Even if the patient does not see or hear the reading, you can reassure him or her that the instrument is indicating a very good response to the relaxation procedure.

Advice on a healthy lifestyle

Another important component of your treatment consists of instructions for healthy living. These should be kept as simple as possible. In your most grave and professional manner say to your patient that to maximise the effect of the treatment it is important that he or she make some healthy adjustments to his or her lifestyle. Provide an explanation for this advice based on the rationale of your treatment that you have already presented to your patient (see later). For example, say that the negative energy and toxins (another very useful word) due to an unhealthy lifestyle will weaken the positive healing energy imparted by your treatment. One thing you can do is to type out some simple but important instructions for healthy living. Once you have established a trusting therapeutic bond with your patient it will astonish you how much he or she will accept everyday common-sense suggestions exemplified by the following.

  1. Stick to a healthy diet. (A few standard guidelines can be given such as eating more fruit and fresh vegetables, reducing salt and sugar levels, and cutting out junk food.)
  2. Take a little more exercise each day. (Encourage your patient to come up with some ideas; advise him or her to speak to his or her GP if there is any concern about the advisability of this.)
  3. If you smoke, try to commit yourself to being a non-smoker, but if you can't, cut down by, say, rationing yourself to a fixed number per day.
  4. Similar advice can be given concerning alcohol. (The recommended maximum weekly consumption of units of alcohol is 21 for men and 15 for women.)
  5. Cut down on your daily stress levels by putting yourself first -e.g. by saying 'No' when people make excessive demands on you. Have more time for yourself….etc.
  6. Take time out for relaxation each day.

Patients who follow these kinds of instructions will automatically benefit and will attribute this to your treatment. Patients who don't follow them may still benefit from your treatment, but if they don't benefit at all, then they may well ascribe absence of improvement to their failure to adhere to your instructions. In fact, they may volunteer this themselves by saying, 'I admit I haven't given the treatment a chance: I've not been very good about your advice'.

Length of treatment and outcome

There is no hard and fast rule about number of sessions and length of treatment but it is laudable not to allow the situation to arise where a patient comes indefinitely for treatment with no obvious continuing benefit. It is probably best to limit the number of sessions to a fixed number, say between four and ten. These can be weekly. Inform patients that healing will continue once the sessions have ended if they persist in following your treatment and advice. Tell them, however, that they may get back in touch with you if they feel that more treatment would be beneficial. Many quack therapists boast that 'very few patients feel the need to come back' (implying that the treatment is successful for those who don't). If a patient does come back then this must be because he or she has faith in your therapy. Either way you cannot lose.

Patients of course may be no better at the end of your treatment and unfortunately on occasions may be worse. There is evidence, however, (which is consistent with my experience of talking to people in such a position) that patients are more forgiving of quack therapists when they do not get better than of their conventional doctors. I believe that one reason for this is that often it is the patients themselves who have made the decision to consult a quack practitioner. If things don't work out, then blaming the practitioner implies that they were mistaken or even duped in deciding to seek his or her help in the first place. People do not like to feel this way and therefore may opt for a more benign resolution: 'It was worth a try', 'The doctor was a very nice man/ woman', 'He did his best', 'I'm sure he/she has helped lots of people', and so on. Compare this with what people often say when their more or less obligatory consultations with their doctor have proved unproductive: 'Those bloody pills the doctor's given me are useless'.

In addition, the healing industry, orthodox and otherwise, provides practitioners with the essential vocabulary for safeguarding their authenticity in the event of failure. Hence, rather than say, 'The treatment didn't work' say, 'The patient's condition proved intractable/ resistant/ unresponsive/ unduly stubborn/ too chronic/ too acute/ too severe/ too mild/ atypical, and so on. Or 'The expected improvement has yet to occur'. Or 'There has been no further deterioration'. If the patient did not adhere to your advice on lifestyle changes, then he or she is 'non-compliant'. You may insist that you may have been able to help had he or she come to you earlier or, especially in the case of psychological problems, that he or she is 'not yet ready' for treatment and should wait until a more propitious time.

5. Introducing your treatment to the patient

I have delayed discussion of this important issue, as there are a number of matters to consider that depend on the construction of your placebo treatment.

One of the guiding principle for constructing a rationale for your treatment is to stipulate that its origins are in the East but it is practised in combination with the latest in Western scientific knowledge. The origins must be 'traditional', that is 'thousands of years old'.

By 'East' I am referring to countries such as China, Japan, India and Nepal. 'A traditional Chinese/ Japanese/ Indian/ Nepalese healing method' has much more appeal than a Russian/ Belgian/ Ugandan/ Jordanian/ Jamaican one. A country in South America may also be a suitable origin if you prefer.

Now, you may feel that it is frankly dishonest to make out that your treatment originates in one of these countries when it doesn't. In actual fact, you may be surprised at how easy many ideas can be legitimately described as 'ancient' and 'Eastern'. So, you can say something like, 'This healing method is a combination of ideas and practices from traditional Eastern medicine and modern Western science'. Think carefully about a statement like this and you will find ways of interpreting it that apply to your treatment.

As well as 'traditional', the terms 'natural' and 'holistic' are essential descriptors. For the most part you may choose to refer to your treatment as 'healing' when communicating with your patients. The elastic properties of the term 'healing', as currently used by the quack medicine industry, lend themselves well to your purpose. 'Healing' may refer to 'curing', 'alleviating the symptoms', 'coping better with the symptoms', 'accepting the illness', 'feeling happier', 'coping better with life', 'being better prepared for death', and so on. Practise saying expressions such as 'natural, holistic healing' and 'I treat the whole person'. Impressive sounding, yet devoid of any real meaning, they are thus indispensable in the vocabulary of the quack practitioner. Say them in a calm, reassuring way with a gentle smile and a slight nod of the head. This is one of the hallmarks of the accomplished quack.

The notion of some kind of 'energy' is very popular in many quack treatments, likewise 'vibrations'. We have already seen how useful are the expressions 'healing energy', 'negative and positive (vibrational) energy', 'blocked energy', and so on. The idea that ill health is due to a blockage or interruption in the natural flow of some form of energy or fluid or life force (another useful expression, by the way) is universal in healing practices. In fact, this is also true of orthodox medicine: many illnesses are associated with a restriction in the flow of fluids or biochemical processes in the body (air, blood, urine, nerve impulses, the contents of the gastrointestinal or genito-urinary tract, etc.).

There is one more descriptor that it is important to employ. Your treatment is 'complementary 'not 'alternative'! It is dangerous and unethical for you to state or imply that a patient should stop any treatment that has been prescribed by a doctor of orthodox medicine. In any case, as the quack medicine industry itself has come to realise, if you insist that your treatment is 'alternative' to orthodox medicine you are targeting a severely limited population and ultimately denying yourself access to the most lucrative market of all, namely the National Health Service. Now that the quack medicine industry is infiltrating the state sector, it is self-defeating to refer to itself as 'alternative': the term 'complementary' has the required properties noted above, impressive in its impact yet revealing absolutely nothing about the practice to which it refers, other than the likelihood that it comes with no rational explanation.

(Author's note: since I wrote this article I have noticed that quack practitioners have hit on an even more useful term that is now supplanting 'complementary' in some quarters: Integrative!)

Rather than adopt a posture in opposition to modern science, quack practitioners nowadays like to imply that their treatments have some grounding in science that has yet to be fully elucidated. 'Scientists don't know exactly how it works', or better still, 'don't yet know exactly how it works', 'are only beginning to understand how it works', etc., are good ways of describing your treatment (and are correct, since they are absolutely true of placebo medicine).

There are a number of scientific or scientific-sounding terms or discoveries that quacks have seized upon, as they convey very simple but effective mental pictures of what the treatment does to remedy any illness. We have seen how the concepts of energy (positive and negative) and energy blockages are very useful in this respect. 'It cleanses the system', 'removes toxins from the body 'or 'detoxifies the body', 'boosts the immune system', and 'balances the body's biodynamic resonance' (I have just made this one up - you can probably do better) are all very useful explanations. 'It causes the body to produce endorphins' has for some time been an essential selling point for some quack therapies, and now serotonin is putting in a similar appearance, word having got around that, like endorphins, it is A GOOD THING because some antidepressants are supposed to restore levels of serotonin in the brain. (You may conveniently ignore the fact that, in accordance with the general rule about the body's biochemistry, higher than average levels of serotonin are also detrimental, being associated, amongst other things, with hypomania.)

Now, here's a cracking piece of advice that all quacks worth their salt should incorporate into their practices. I first heard a reflexologist come out with this and have since heard other quacks do likewise. When you start your treatment say, 'You may find that your condition gets worse before it starts to get better'. Brilliant! You see, any change that occurs early on in treatment, or no change at all, can be construed as evidence that your treatment is having an effect. This is obviously so if the condition worsens or if it improves. And if there is no change, your patient can be thankful that the expected deterioration has not occurred, perhaps because the initial aggravation of the symptoms has been counteracted by the beneficial effects of the treatment. Whoever thought up this one deserves the Nobel Prize for Quackery!

6. The naming of your treatment

It is natural for you to select a name for your therapy that reflects the rationale that you have chosen. Try, for example, the three-term method: an adjective, a noun and the word 'therapy' or 'healing'. For the adjective, suitable words are 'positive', 'dynamic', 'biodynamic', 'magnetic' or 'biomagnetic' (if you are using magnets) 'natural', 'holistic', 'bioenergetic', 'morphic', 'morphogenic', 'isometric', and Greek letters such as alpha and omega. (Very recently, I noticed the word 'quantum' being used in this context.) For the noun, possibilities are 'energy', 'resonance', 'balance', 'equilibrium' and 'feedback'. You could instead make up a word for your treatment: how about biokinaesthetics, homoeology, reflexopathy or Chi-ching therapy?

Some quack treatments bear the name of their inventor, as in the case of Bach flower remedies. The best surnames are those that suggest a certain distinction, as in, for example, 'du Maurier's treatment', 'the Montgomery method' or 'the Jardine remedy'. In fact, most surnames will suffice, but a short, common surname such as Jones, Brown or Smith is unlikely to enhance the appeal of your treatment, and if your name is Higginbottom or Pratt you are at a considerable disadvantage.

What about calling your treatment 'placebo therapy'? I'll say more about this later. This label has a certain honesty about it and I have a feeling that if you market your therapy well you could get away with using the term. (You could translate the word 'placebo' into another language - Arabic, Urdu or Mandarin for example.)

Now, once you start offering your treatment to the public, people will come to consult you….yes? So what are you? You are….yes?......come on now…..don't be shy! Of course! You are not just, say, a Homoeologist. You are a CONSULTANT Homoeologist! And after you've been at it for a couple of years you might feel like advertising yourself as a SENIOR CONSULTANT. Brilliant!

7. What conditions to treat

There are a number of conditions and problems that are amenable to a well-constructed course of placebo therapy. They include many that have a significant psychological component and are sometimes referred to as 'psychosomatic', although this term is less popular than it used to be and it is advisable that you avoid terms beginning with 'psycho' when you see your patient. The conditions can, for instance, be more troublesome when the patient is under stress: either the symptoms become worse or the patient finds it less easy to cope with them, worries more about them, and so on. For these and other reasons, the conditions run a variable course, waxing and waning over time. This is to your advantage. Often a patient will seek treatment when the symptoms or problems are particularly bad; thus there is a likelihood that once you start your treatment, they will be at the point in the cycle when they start to improve again. The patient will almost certainly attribute this improvement to your treatment.

In addition to this, many illnesses run a limited time course and the patient is going to get better anyway. This is obviously the case with common ailments such as coughs and colds, influenza, and other infections. Again this is clearly to your advantage.

Apart from these, conditions for which you stand a good chance of obtaining (or appearing to obtain) worthwhile results include the following: migraine and tension headaches, skin complaints such as eczema and psoriasis, asthma (but on no account discourage a patient from using his or her inhalants), irritable bowel syndrome, tinnitus, pain generally (e.g. due to arthritis), insomnia, stress, mild depression, chronic fatigue, high blood pressure, ulcers and infertility. You could also modify your treatment so that it is appropriate for patients wanting to lose weight or give up smoking.

In the case of the above problems, you can legitimately offer the patient the chance of a significant improvement in his or her condition and even the possibility of a complete cure. But it is certainly unethical to claim that, with your placebo therapy, you can treat conditions that are obviously not going to respond at all, such as baldness or poor eyesight. Lots of quacks offer to treat patients with major illness such as cancer, diabetes and heart disease. You may feel this is unethical. However, if you are tempted to offer your services to cancer patients, be reassured that the acceptable fashion seems to be that, so long as the patient is not dissuaded from abandoning conventional treatment (i.e. the treatment that has been shown to be effective), anything goes and 'everyone and his brother' is welcome to get in on the act whatever the pretext. Why this is so has nothing to do with the pathophysiology of cancer, but quack therapists need not trouble themselves with such matters: the sociology of cancer is such that it offers rich pickings to a vast diversity of industries, organisations and individuals for advancing their wealth and status.

8. More on ethics, precautions and safeguards

Although the treatment you are offering is placebo, this does not exempt you from adhering to the highest ethical standards in your clinical practice. This means that the welfare and dignity of all of your patients is your highest priority. Never, through your actions or any instructions or advice to your patients, put their wellbeing at risk in any way. Very importantly, never interfere with any orthodox treatment they may be concurrently receiving. Not only can this be dangerous: it is likely to compromise the apparent success of your own therapy. When you hear stories about how someone was apparently cured of an illness by an unorthodox treatment, seldom is it mentioned that the person was simultaneously receiving orthodox treatment.

I have already mentioned the requirement that at all times you maintain a professional manner that gives no suggestion of undue familiarity with your patient. You must also do all that is necessary to maintain strict confidentiality concerning your patients' disclosures to you and any documentation pertaining to this and your treatment. The importance of maintaining clear and comprehensive clinical records cannot be overstated.

Unless your patient objects to this, it is, at the very least, professional courtesy to write to your patient's general practitioner to inform him or her that you are treating his or her patient. Summarise the condition and the treatment and, when you have discharged the patient, summarise the outcome. As many quack practitioners know, this helps establish your reputation and the doctor may even mention you to other patients who have raised with him or her the possibility of consulting a private quack.

Throughout this protocol, suggestions have been given that may be construed as entailing some measure of dishonesty on the part of the practitioner. How like the real world of medicine - mainstream or otherwise! But compared to the slick advertiser who is paid a fortune for promoting the products of the pharmaceutical industry, the bright young lass who enthusiastically pummels her patients' feet in the sincere belief that she is 'working on' the various organs of the body, or the earnest fellow who prescribes water as a remedy for any illness, genuinely believing in its magical properties, are both on the side of the angels. And remember that the principle purpose of any white lie (and that is all that is ever suggested here) is not to bolster your self-image but to inspire your patients with the necessary confidence in the treatment you are offering. Doesn't an orthodox doctor prefer to tell her patient that he stands a good chance of getting better rather than to say that the last three patients she treated with this complaint deteriorated? Or that the specialist to whom she is referring him has a good reputation rather than an indifferent track record?

Establishing, publicising and expanding your business

To make your business viable requires effective publicity. Money thus spent is like an investment, although there is no guarantee that your premium is recoverable. How you set about doing this is largely beyond the scope of this article (it is more to do with business acumen than effective placebo medicine) but you will no doubt be aware of obvious means of promoting your practice. The local press is a ready source of publicity. You may have noticed that local newspapers carry what are in effect advertisements for quack treatments (presumably paid for by the practitioner) that have the appearance of news announcements. In fact, newspapers and magazines seem very keen to report on quack treatments, presumably because of their newsworthiness: a feature about a 'complementary therapist' who treats insomnia by Indian head massage, Hopi candles, crystals, homoeopathy, herbs, reflexology, acupuncture or past-life regression provides a more interesting read than one about a general practitioner who prescribes Temazepam. 'Health' magazines, such as the free ones you find in supermarkets, are often little more than propaganda sources for the quack medicine industry and are another obvious place to publicise your business. Likewise 'Body And Mind' exhibitions.

Elicit testimonials from your patients (you will find that there is no need to invent them) and ask permission to use them in your publicity brochures.

It is also worth mentioning the following strategy. One effective way that quacks have discovered to secure a viable practice is to join forces and share rented premises, which are then advertised as centres or clinics for complementary, holistic, or natural medicine. (It does not matter one whit that you will all be offering completely different explanations and treatments for the same kinds of ailments.) Once you establish such a clinic you can afford to advertise it with your colleagues in the ways described above.

A final hint: dabble in other quackery. You can undertake short introductory courses (or just read books) on treatments like hypnosis, reflexology, homoeopathy, colour therapy, crystal healing and aromatherapy. Incorporate appropriate techniques and ploys into your treatment that you learn from these other systems.

Whatever you do, don't give up your daytime job unless or until you have achieved a thriving practice.

On to greater things

Having established your quack practice, it will sooner or later dawn on you that more lucrative than treating patients with your therapy is training others to do so. (Calculate the earnings from training ten people at a weekend workshop, charging 500 pounds each, and compare this with the likely earnings from clinical practice over the same time period, assuming that you can recruit a constant flow of patients.) In fact, training others will significantly enhance the profile of your treatment: for example, you will be able to establish a network of therapists trained in your methods (see below).

If you want to aim for these heights you will need a certain 'take-off velocity'. To achieve this you will probably need to persuade a number of people to join you, which means acquainting them with your therapy. You are also probably going to have to make quite a financial investment in publicising your therapy and training programme.

Training others proceeds in tandem with establishing an organisation for practitioners in your particular brand of placebo medicine. Titles for your organisation are suggested by the following examples (which I have just invented): the 'Association for Holistic Homoeology'; the 'Society of Biomorphic Healers', and the 'Institute of Curative Acutherapists'. More impressively, precede the title with 'National' or even 'International'.

For a long time now, the public has been reassured that professionals such as nurses and physiotherapists are 'registered' (e.g. 'state-registered'). So, in your publicity, emphasise that all your members are 'registered' (which they are, since they will be on your register). Thus, you can call yourself a 'registered practitioner'. (The word 'recognised', being both impressive and meaningless at the same time, is thus also a useful descriptive term.)

Having established an organisation of therapists you can then advertise your own 'recognised' training schemes that award 'recognised' qualifications. Notice I use the plural. The trick is to start with just one training scheme and one qualification to put after your name - e.g. 'Diploma in Curative Kinesics'or DICK (or perhaps not). Having trained enough people, don't stop there. The next qualification is an Advanced Diploma (Adv. DICK in the above instance). Later you can have specialised training workshops ('Applications of Kinesics in Children'; 'Kinesics in the Treatment of Pain', and so on).

The target trainees include existing quack therapists (so, for example, you could advertise your course in a 'health' magazine); people from the 'caring professions' such as nurses, care assistants, and occupational therapists - in fact anyone looking for a career change or simply seeking to supplement his or her income with work on the side - disgruntled teachers, failed business people, bored housewives, etc. It is also not unusual for people who have been 'successfully' treated by a particular quack medicine to seek a career in the same.

Try to cultivate and promote a small group of trainers who become celebrities in the practice of your treatment; as the founder you will of course be one of them. Your organisation may never expand to international dimensions but it is worth noting that special kudos is attached to a speaker or teacher who has had to travel across water - the Atlantic Ocean for instance ('A unique opportunity to train with one of the world's leading practitioners of Biomorphic Crystal Healing…..').

Here's another masterly ploy. Instead of hotels or commercial conference centres, hold your training courses at hospitals, medical schools or colleges. Most universities, for example, have long ceased to take seriously their tradition as centres of scholastic excellence; income generation is a key priority and they are now more than ready to offer their rooms and facilities to anyone willing to pay the rental fees. Organising training at a hospital or university gives added weight to its perceived authenticity. You may consider it unethical to put on the certificates of your successful trainees the name of the hospital or college but some quack organisations consider this acceptable, as do members of such who claim they have, for example, 'trained at St. Ann's Hospital' or 'Kings College London'.

Instead of all this you could, as some quack organisations do, offer to train people by 'distance learning'(i.e. a correspondence course - i.e. sending the trainees a set of handouts and written tests).

Incidentally, training activities are sometimes undertaken by a separate wing of the organisation in question, and this is given a title such as 'School', 'College' or 'Institute' (the 'International College of Applied Morphobionics', the 'Institute of Chi Qi Medicine', etc.) These labels conjure up images of lecture theatres, libraries, and even laboratories, but for all practical purposes, your 'College'or 'Institute' may simply consist of a rented office, a terraced house, or even a post box. Have no fear: such humble realities have not impeded the success of many quack enterprises and, who knows, one day you, your association and your college may attain the giddy heights achieved by the more successful of these: the homoeopathy industry has even managed to set up its own hospitals.

Your organisation should have a newsletter and, depending on the success of enterprise, you may consider having some kind of journal in which members may, amongst other things, contribute accounts of their clinical work. Other activities and projects include arranging professional indemnity for members, the setting up of local branches, and an annual conference (incidentally, you can't get much better than the facilities offered by the Royal Society of Medicine in London, provided you can cover the exorbitant expenses.)

These developments only apply should your enterprise hit the big time. They are the trappings of legitimacy and authenticity that are important for your business to expand and maintain its viability. Once your business guarantees the livelihood, or at least part of the livelihood, of a sufficient number of individuals, then you are in a strong position. 'But surely', you say, 'this is not possible if all that is on offer to the consumer is nothing more effective than a placebo?' Believe me, it certainly is.

There is one other suggestion I would like to make. A bold and strikingly honest step would be simply to call your treatment 'Placebo Therapy' and your organisation something like the 'Association of Placebo Therapists'(APT). As I said earlier, I feel that this would work but am less optimistic about the designation 'Quack Therapy'.

The world is your oyster!

Thanks to relentless economic growth and affluence, tens of billions of pounds are spent annually in the UK on something called 'health', the remit of which is no longer restricted to the curing or alleviation of illness but to the removal of every impediment, real or imaginary, to a carefree existence. The health industry thrives on this promise and politicians are obliged to offer the same. In the state, private and commercial sectors combined, a colossal and expanding workforce is benefiting from this ever-increasing demand. Fortunately for them, in relation to the scale of this industry, the benefits that the public derives are disproportionately small; if it were otherwise, then demand would fall as people's health improved and the requirement for remedial interventions would diminish. This was the naive expectation of those who set up our National Health Service in post-war Britain.

As a consequence, we are now in The Golden Age of Quackery. The quack medicine industry is strong, well organised, and expanding. Never were its prospects so gloriously bright. Paradoxically, this is partly due to the success of orthodox medicine; the more that the latter is able to accomplish, the more people expect of it and the greater their disappointment.

Step forward the quacks! You are in demand as never before! You now have the opportunity to bilk the taxpayer of some of the massive funds that our Government makes available to the National Health Service. And look who is lobbying for this on your behalf! None other than our future sovereign, the Prince of Wales himself! Yes, the very same person who is able, by the flick of his fingers (or those of whichever of his menials is assigned that duty) to summon the finest practitioners of orthodox medicine in the land immediately to attend to whatever ails him!

'I am sometimes surprised by the attitude of my orthodox colleagues'. This statement was made with reference to practitioners of conventional medicine by a 'consultant' in Feng Shui. Yes, of course, that's it! Since you are a practitioner of COMPLEMENTARY medicine, all those doctors and professors of medicine and its specialities, who have undertaken six years of intensive study and many more years of post-qualification training, are not your rivals but your colleagues! You are all part of one great and glorious enterprise, that of healing the sick.

And so, having now become a quack therapist, you can take your place amidst the ever-swelling ranks of other quack therapists, in the main sincere, dedicated people who truly do bring comfort, hope, and sometimes even cure, to people who are suffering mentally and physically or who simply want to feel better. Rejoice and be proud!