Sometimes people enquiring about acupuncture ask whether you have to believe in it for it to work. What often lies behind this question is the belief that alternative medicine does not have any tangible, physical benefits and any success it may have must be due to the patient believing, or wanting to believe, that they are feeling better; alternative medicine is ‘airy fairy’. If you don’t have faith, perhaps even if you are not gullible enough, nothing will happen. This belief, like most of our beliefs perhaps, is not usually the result of clear thinking and sifting of the evidence; whilst it is true that some people have a more or less blind faith in alternative medicine, or in some branch of it, more common is this, a more or less blind faith that if something is classed as alternative medicine, it must be some kind of airy fairy mumbo-jumbo.
To begin with, the idea that you can lump together all manner of treatments and therapies under the banner of ‘alternative medicine’ and say something meaningful of them as a group, is highly questionable. What they have in common is that they are not generally considered part of mainstream medicine (although that is not entirely true of acupuncture). Whether they have anything else in common is open to question. Knowing something about Alexander technique does not mean you know anything about crystal healing. Knowing something about homeopathy does not tell you anything about acupuncture. Can some kind of vague new-age treatment dreamt up yesterday by someone in need of a quick buck really be classed alongside something like traditional Chinese medicine, an integral part of Chinese culture and civilisation with a history going back 2,000 years or more and providing effective treatments right now in hundreds of hospitals across China? Yet they might both be considered, at least in the west, ‘alternative medicine’.
So the idea that you can bunch all these various treatments together and say they depend on the patient’s faith or gullibility is a non-starter. It may very well be true that some of them do depend heavily on the patient having faith, but I at any rate am not in a position to say. All I can talk about is acupuncture.
As far as acupuncture goes, there are obvious physical measurable results from correctly inserting an acupuncture needle into an appropriate place on the body. To mention only a few, blood flow in the vicinity of the needle increases, certain kinds of nerve endings get stimulated, occasionally a muscle will twitch. It is true that, in the hands of a capable clinician, acupuncture treatment can be, when it needs to be, quite subtle; but it can also be a very vigorous kind of intervention indeed. In the latter case at least, there is nothing airy fairy about it; you don’t have to have faith that something is happening, because you can feel it happening. Of course that you can feel that something tangible is going on doesn’t in itself tell you anything about whether it is an effective treatment (although I think often patients can sense that an intervention is beneficial.) But at least we can be clear that it is, when it needs to be, working on a very physical level, and it is working on that level more or less independently of whether you believe it is going to work or not.
More or less. But in truth it does seem to be that patient expectations play an important part in many medical treatments – alternative, conventional or whatever. If you have a positive expectation that acupuncture will alleviate your symptoms, it is a bit more likely that they will. But it is also the case, for example, that if you have a positive expectation that having an operation(1) will alleviate your symptoms, it is more likely that it will. If you have a positive expectation that the drug diazepam(2) (used to treat anxiety, muscle spasms and seizures) will alleviate your symptoms, it is more likely that it will. And the same for anything from analgesic skin cream(3) to deep brain stimulation(2). (And indeed there is some evidence that if the person treating you has a positive expectation of the treatment, it is also more effective(4).)
This is the placebo effect. Conversely there is also the nocebo effect – if you have an expectation that any given treatment will be ineffective, or perhaps that it will involve some unwelcome side effects, these things become more likely to happen.
It is not that these things, placebo and nocebo, are ‘all in the mind’. If the problem you have is pain, the placebo effect encompasses a measurable increase in endogenous opioids, part of the body’s built in pain relief system(5). Something is happening in your body. Patients with the common cold who perceive their doctor is empathetic show reduced objective markers of inflammation in their blood stream as compared with ones who don’t get the impression their doctor is much bothered.(6) These patients aren’t just imaging they feel better; there are measurable improvement in their bodies.
There is though also the question of how we interpret our experience. A patient who insists that a form of treatment will be ineffective, but who is persuaded to try it anyway, is perhaps likely to undervalue any improvement in their symptoms, or perhaps to ascribe them to some other cause. It’s generally easier to say, if only to oneself, “I told you so” than it is to say “maybe I was mistaken”. Occasionally a patient will come into clinic for their second acupuncture appointment and say something like, “I have to admit my back feels a lot better”. As if in some ways they would rather it wasn’t better! No one likes to eat humble pie.
Another patient, say one who tends to favour alternative medicine, will have something invested in the treatment working, apart from the obvious desire to get better. They are likely to overvalue any improvement in their symptoms, although as we have already seen their positive expectation may make it a bit more likely they will be improving. But even if this improvement is slight, they will tend to make as much of it as they can.
A theme running through this question is that of the relation of mind and body. In the west we are inclined, for historical reasons usually laid at the door of the French philosopher Rene Descartes, to believe that mind and body are separate entities. But it is clear from the above that they are not. Someone with a positive expectation (in their mind, presumably) that their knee pain will improve with treatment may have a greater presence of those enogenous opiods in their body than someone who is more pessimistic. The mind and the body are deeply inter-related; what happens in the mind manifests in the body, what happens in the body triggers effects in the mind. Any slight change in what is going on in the body impacts on the mind; any passing mood or train of thought is associated with subtle changes in the body. And after all, what is mind? Does anyone really know?
So to sum up, the answer to the question is that you don’t have to believe in it for it to work, but on the other hand you are likely to get extra benefit from treatment if you have a positive expectation that it will work. And if you want to try to figure out how much of the benefit you have got from the treatment is ‘in your mind’, and how much of it is ‘in your body’….good luck!
Here is some of the latest news on acupuncture and related things, perhaps with a few of my thoughts thrown in for good measure.