Scipsy

How Homeopathy Works

Today I was reading in the news from the blogs I follow in my feed reader, and there was this post talking about an italian blogger, B-Log (0), who wrote two articles about homeopathy, and then received a threat of lawsuit from a big corporation that claims that those articles were defamatory.

This really makes me angry. 

I thought I should write something about it. 

I know there are a lot of people who believe homeopathy works. Obviously there’s a lot of people who believe crop circles are messages from aliens. 

http://xkcd.com/765/

I know that there are very few possibilities that I can make them change their idea. 

So, I’m not going to write an article on why homeopathy doesn’t work. You can find good information and articles better than what I could ever write.

But this post is not on why homeopathy doesn’t work, chemists, physicians, and pharmacologists can do a better work in explaining that. 

This post is about how, and why, homeopathy works.

This could sound silly.

It is strange, indeed, to talk about this when I want to discourage people to use homeopathy products, but I try to study psychology, and I think there are other reasons rather than opportunism, marketing and ignorance explaining why people believe in homeopathy.

One of this reasons is that homeopathy seems to work.

To understand this topic we should say something first: medicine isn’t perfect. (for medicine I mean “western medicine”, I’m not talking about CAM, complementary and alternative medicine)

Health care systems are far from perfect, we all know that.

Despite from what we see on TV shows, physicians are women and men, like everyone else. They are not demi-gods, they are often tired, bored and unmotivated, they can be cold and unsympathetic. They have a lot of work to do, so the time they can spend with a patient is very limited. 

There are these and many other problems. 

The patient-doctor relationship is often considered as secondary to the “real” treatment. What matters is the drug, isn’t it? 

Micheal Balint, used to say that the doctor is the drug. He was a doctor and a psychotherapist who explored the importance of doctor–patient relationship in his book ‘The Doctor, His Patient And The Illness’. 

Nowadays scientific research demonstrated that doctor-patient relationship is a central aspect of the cure. When I first started to think about a project for my thesis, I thought it would be interesting a research on how the doctor-patient relationship influences the perception of illness. I found out that in the scientific literature there are thousands of research about how doctor-patient relationship has an effect on health.

Why all this premise? 

Let’s start talking about Shang et al (2005) meta-analysis:

We compared the effects of homoeopathy and conventional medicine that are seen in placebo-controlled trials, examined the presence of bias resulting from inadequate methods and selective publication, and estimated results in trials least affected by these biases. We assumed that the effects observed in placebo-controlled trials of homoeopathy could be explained by a combination of methodological deficiencies and biased reporting. Conversely, we postulated that the same biases could not explain the effects observed in comparable placebo-controlled trials of conventional medicine. Our results confirm these hypotheses: when analyses were restricted to large trials of higher quality there was no convincing evidence that homoeopathy was superior to placebo, whereas for conventional medicine an important effect remained. Our results thus provide support for the hypothesis that the clinical effects of homoeopathy, but not those of conventional medicine, are unspecific placebo or context effects.

The clinical effects of homeopathy are unspecific placebo or context effects. What does it mean?

Context effects can influence the effects of interventions, and the relationship between patient and carer might be an important pathway mediating such effects. Practitioners of homoeopathy can form powerful alliances with their patients, because patients and carers commonly share strong beliefs about the treatment’s effectiveness, and other cultural beliefs, which might be both empowering and restorative.

Thompson and Weiss (2006) ”explored literature on the placebo effect, universal anthropological models, psychotherapeutic practices and psychological models such as disclosure theory" and studied 18 patient at the Bristol Homeopathic Hospital. These patients attended "a ‘package of care’, consisting of an initial consultation and four follow-up appointments over an eight month period, with one of three allocated homeopathic physicians.

Thompson and Weiss were interested not in proving the efficacy (or inefficacy) of the treatment, they wanted to understand what are the active ingredients of the homeopathic process.

They identify various active ingredients, here I quote only the first ones.

- The role of patient expectations:

Classical placebo theory predicts that patients’ responses to an intervention are based on their expectation of likely benefit – their “belief” in the treatment. For instance branded aspirin is more effective than pharmaceutically identical generic aspirin […]

All the patients recruited were optimistic, they believed the treatment would be benefit to them and expectation of benefit was also generated during consultations. 

- Openness to the mind-body connection:

According to the authors, "not only are there alternative therapies but also alternative patients who bring with them a predisposition to respond to CM" (Complementary Medicine).

The homeopathic worldview favors an integration of mind and body and one might predict that patients who come to homeopathy open to this dynamic will fare better than those expecting a conventional pharmaceutical approach.

In the findings of Thompson and Weiss there’s something that, at first, seems very curious:

[…] data suggest that empathy is necessary for good outcome but there was no correlation between empathy levels and outcome. Indeed, peculiarly, the opposite was true. Those that did well clinically rated their doctors as less empathic within this small sample. These findings do not enforce the widely held view that it is the empathic nature of the consultations that governs their success.

If we leave aside the "widely held view", we can suggest at least one, simple explanation for this finding: even patient in homeopathic treatment are more comfortable when the doctor match their expectation on how a medical consultation should be. In normal medical consultation, empathy has a minimum role so that patients are led to expect that real doctors do not show empathy.

The authors suggest that at least some of these active ingredients are not specific of the homeopathy. They suggest also that

[…] traditional healing and western psychotherapy have roughly the same structure. In each the suffering patient attends the healer/therapist who listens to their lament and persuades them it can be understood in terms of a shared cultural myth. The healer/therapist then attaches the patient’s emotions to “transactional symbols” particularized from the general myth and manipulates the symbols to allow the patient to “transact” these emotions. In the case of homeopathy the transactional symbol would be the remedy, which is manipulated through the expectations applied to it and the intricacies of the prescribing regimen. The further the homeopath goes into the state of the patient, the more apposite the symbol will be and the more powerful will be the healing response.

The psychotherapist as shaman is a common metaphor although it’s wrong. 

There is a major difference: whatever way the practice of psychotherapy is conceptualized, a psychotherapist knows what he’s doing, he knows that he’s working with the emotions, motivations, expectations, representations, etc, of the patients. He doesn’t think he’s doing something else, and by accident, he helps the patient with something he is not aware of.

Instead, homeopathic practitioners (and patients) think (or they say they think) that it’s the remedy that heals.

Now, this is a thing I think I know a little bit. I’m writing a thesis on the negative effect of psychotherapy, so I’m aware of what are the risks of establishing a therapeutic relationship without the necessary awareness of its mechanisms.

If we examine just the simplest aspect: this type of relationship encourages the patient to expect a beneficial effect from something that has no effect. This belief reduces the ability of the patients to make informed decisions about their health.

Sehon and Stanley (2010) suggest this example:

Suppose, for example, that a particular patient, call her Jane, takes a homeopathic remedy and recovers quite quickly from condition X; but suppose that we also know that approximately 10% of patients with X also exhibit a similar recovery, and that nobody knows why. So there are two questions, a particular question and a general one:

    Why did Jane recover from condition X?

    Why do 10% of patients recover in this fashion from X?

The homeopathic theory can answer the particular question about Jane, for the homeopath claims that the homeopathic remedy explains Jane’s recovery. But conventional medicine will also have something to say in answer to the particular question: ‘Jane recovered for the same reason as the approximately 10% of patients with X recover; Jane’s case is not unique.’ So both homeopathy and allopathy answer the particular question, but neither currently has an answer to the second and more general question. So, in terms of the number of unanswered questions, the homeopath and the conventional doctor are on a par. Thus, individual cases of dramatic recovery will not create new unanswered questions for conventional medicine, at least when it is known that similar recoveries occur with some frequency even in the absence of homeopathic remedies.

Of course, practitioners of homeopathy have seen more than the occasional isolated case, for they have seen hundreds or thousands of patients, and have presumably heard from many patients that their conditions improved after homeopathic treatment. In accord with the simplicity principle, such results surely count as some evidence unless there is an alternate explanation for these results. But the problem with such unsystematically gathered evidence is that various alternate explanations seem, at least at a general level, to be available:

    • patients tend, on average, to improve regardless of treatment;

    • memory is unconsciously biased in favor of positive results, particularly when one considers that the entire livelihood of practitioners is on the line;

    • selective reporting (e.g. patients who don’t improve might be expected to forego further visits to the homeopath, and thus their negative reports will not be heard), and

    • the placebo effect.

The placebo effect might be especially strong in the case of visits to homeopathic practitioners for a couple of reasons. First, judging from information gathered from websites of practitioners and other sources, initial visits to homeopathic practitioners tend to be long, detailed interviews, and second, they are costly […]. The high cost could be relevant in a surprising way: Waber et al. found that the analgesic response to placebo pills was greater when subjects were told that the pills were more expensive.

Thus, from the standpoint of the simplicity principle, case series evidence and other observational studies do not provide incredibly strong evidence, for the observations made (viz., patients whose conditions improved after taking homeopathic medications) are not significant unexplained mysteries for the alternative theory.

What is the simplicity principle?

Given two theories, it is unreasonable to believe the one that leaves significantly more unexplained mysteries.

Given that the homeopathic theory hasn’t said anything so far that comes close to providing valid answers for the mysteries behind the presumed functioning of the homeopathic remedies, we must reject the homeopathic theory as an explanation for phenomena like the Jane’s case. Psychological explanation seems to be far more convincing, given for example the growing amount of data regarding placebo effect, doctor-patient relationship. In fact if we accept the homeopathic theory ”answering those mysteries would appear to require massive revision of standard chemistry and physiology.

But let’s face it: we would need a massive revision of standard chemistry and physiology only to confirm the homeopathic theory, refusing the overwhelming evidence that the reality is another.