The ‘little extras’ that make ineffective treatments appear to be effective

I had come across them so often that I had almost stopped noticing them: the ‘little extras‘ that make ineffective so-called alternative medicines (SCAMs) seem effective. Then, recently, during an interview about detox diets, the interviewer responded to my explanation of the ineffectiveness of these treatments by saying: “but these diets include stopping the consumption of alcohol, cigarettes, and other harmful stuff; therefore they must be good.” This seemingly convincing argument reminded me of a phenomenon – I call it here the ‘little extra‘ – that applies to so many (if not most) SCAMs.

Let me schematically summarise it as follows:

1. A practitioner applies an ineffective SCAM to a patient.
2. Because it is ineffective, it has little effect other than a small placebo response.
3. The ineffective SCAM comes with a ‘little extra‘ which is unrelated to the SCAM.
4. The ‘little extra‘ is effective.
5. The end result is that the ineffective SCAM appears to be effective.

The above example makes it quite clear: the detox diet is utter nonsense but, as it goes hand in hand with effective lifestyle changes, it appears to be effective. A classic case. But SCAM offers no end of similar examples:

• Acupuncture is useless but it involves touch, time, attention, and empathy all of which are effective in making a patient feel better.
• Chiropractic is useless but it involves touch, time, attention, and empathy all of which are effective in making a patient feel better.
• Homeopathy is useless but it involves a long, empathic consultation and attention which are effective in making a patient feel better.
• Osteopathy is useless but it involves touch, time, attention, and empathy all of which are effective in making a patient feel better.
• Reflexology is useless but it involves touch, time, attention, and empathy all of which are effective in making a patient feel better.

Do I need to continue?

Probably not!

The ‘little extras‘ are often forgotten or subsumed under the heading ‘placebo’. Yet, they are not part of the placebo effect. Strictly speaking, they are concomitant treatments comparable to a pain patient using SCAM and also taking a few paracetamols. In the end, she forgets about the painkillers and thinks that her SCAM worked wonders.

Even ardent SCAM proponents have long realized this phenomenon. Here, for example, is a paper entitled ‘Acupuncture as a complex intervention: a holistic model’ by ex-colleagues of mine at Exeter looking at it but coming up with a very different perspective:

Objectives: Our understanding of acupuncture and Chinese medicine is limited by a lack of inquiry into the dynamics of the process. We used a longitudinal research design to investigate how the experience, and the effects, of a course of acupuncture evolved over time.

Design and outcome measures: This was a longitudinal qualitative study, using a constant comparative method, informed by grounded theory. Each person was interviewed three times over 6 months. Semistructured interviews explored people’s experiences of illness and treatment. Across-case and within-case analysis resulted in themes and individual vignettes.

Subjects and settings: Eight (8) professional acupuncturists in seven different settings informed their patients about the study. We interviewed a consecutive sample of 23 people with chronic illness, who were having acupuncture for the first time.

Results: People described their experience of acupuncture in terms of the acupuncturist’s diagnostic and needling skills; the therapeutic relationship; and a new understanding of the body and self as a whole being. All three of these components were imbued with holistic ideology. Treatment effects were perceived as changes in symptoms, changes in energy, and changes in personal and social identity. The vignettes showed the complexity and the individuality of the experience of acupuncture treatment. The process and outcome components were distinct but not divisible, because they were linked by complex connections. The paper depicts these results as a diagrammatic model that illustrates the components and their interconnections and the cyclical reinforcement, both positive and negative, that can occur over time.

Conclusions: The holistic model of acupuncture treatment, in which “the whole being greater than the sum of the parts,” has implications for service provision and for research trial design. Research trials that evaluate the needling technique, isolated from other aspects of process, will interfere with treatment outcomes. The model requires testing in different service and research settings.

I think the perspective of viewing SCAMs as complex interventions is needlessly confusing and deeply unhelpful. The truth is that there is no treatment that is not complex. Take a surgical treatment, for instance, it involves dozens of ‘little extras‘ that are known to be effective. Should we, therefore, try to use this fact for justifying useless surgical interventions? Or take a simple prescription of medication from a doctor. It involves time, empathy, attention, explanations, etc. all of which will affect the patient’s symptoms. Should we thus use this to justify a useless drug? Certainly not!

And for the same reason, it is nonsense to use the ‘little extras‘ that come with all the numerous ineffective SCAMs as a smokescreen that makes them look effective.