By Siegfried Othmer, PhD
“Do you believe in acupuncture?”
“Why yes. I’ve actually seen it done.”
The August issue of Scientific American not only featured a diatribe against facilitated communication, but also one against acupuncture. Really? Acupuncture? The article starts off by reminding us of how acupuncture first came to the attentions of the wider American public. Nixon’s visit to China in 1971 was the occasion. The use of acupuncture on columnist James Reston for post-operative pain was the signal event. The American medical establishment was resolutely uninterested, however, speculating that the Chinese might just be uniquely suggestible people. Americans would never fall for that kind of nonsense. But then they did.
The state of American medicine was actually very confused on the issue of pain back in that time. Doctors felt themselves duty-bound to divine whether their patient’s claim of pain was real or not. Difficult as it may be to believe, that was indeed the state of American pain medicine at the time. Perfectly competent doctors seriously undertook to differentiate between real and imagined pain in their patients.
Only decades later there was a kind of slow and passive capitulation, with the reluctant admission that “pain is what the patient says it is.” There was, after all, no objective measure. Pain is not like temperature, which you can measure with a thermometer. Pain is like hunger. You cannot measure it. Hunger is what the person says it is, and the same goes for pain.
Into this vacuum came acupuncture, and it has never ceased to trouble the mind rooted in the research traditions of Western medicine. “We have no evidence that [acupuncture] is anything more than theatrical placebo,” Harriet Hall, MD is quoted in the article.
Just what would such evidence consist of, since we cannot measure pain objectively? We have nothing but the patients’ own assessments of pain severity, and on that basis, acupuncture stacks up better in controlled studies than no acupuncture. Aren’t we done here? Apparently not. In the grand tradition of American medicine, one needs blinded controlled studies.
The problem lies at the conceptual level. The ‘placebo response’ is the label placed on what is just our natural self-regulatory response in connection with a particular procedure. As it happens, not being blind to what is happening is essential to the evocation of that self-regulatory response. For example, if a placebo pill is surreptitiously slipped into someone’s drink, then there is no reason to expect a placebo effect, and indeed there is none. The person has to see the pill being dropped into the drink.
All are agreed that in actual practice the acupuncture needle mobilizes the placebo response, so that the client may indeed assess his pain to be less severe. The question being posed is, does acupuncture do more than that? Well it certainly can do so, and here is how that might happen.
When we experience a surface wound, the body goes into a sympathetic response as a defense. When we experience a deeper wound, on the other hand, the body promotes a parasympathetic response to protect its core functional integrity. The penetration of an acupuncture needle may serve as an alert to the body to unleash that kind of self-preserving response.
There is even some evidence of such a response. I once witnessed someone getting acupuncture treatment while his EEG was being monitored. As soon as the needle penetrated the skin (“perimeter violation!”) the occipital alpha amplitude shot up dramatically and stayed high. The brain reacted immediately to this ‘assault’ on bodily integrity.
This increase in alpha amplitude is consistent with a parasympathetic shift in state, and is inconsistent with a sympathetic shift. A concurrent moderation in the appraisal of pain severity could well be part of such a shift. In any event, we have evidence here of an immediate physiological response of the body to the insult of the penetrating needle. Significantly, this response is not a consequence of wish fulfillment, and thus it cannot be written off as a placebo response.
Such shifts are also seen in animals, where a placebo response is not deemed to be operative. The earliest research along those lines was not published at the time because the researchers were unwilling to see their reputations trashed in consequence. But the experiment persuaded them of the merits of the procedure.
One of our dogs got acupuncture on one occasion. She was of paranoid disposition, and thus inclined to be suspicious of being penetrated by needles manipulated by perfect strangers. Instead she stood there motionless during the procedure, as blissed out as I have ever seen her.
So let us just see this contretemps for what it is: the struggle of the field of medicine to come to terms with our profound and multi-faceted capacity for a self-regulatory response, our capacity for self-healing. To call this a mere placebo is an insult to our exquisitely regulated physiology, and to our native capacity for functional recovery. The history of medicine is quite clear on the proposition that “Medicine is not interested in the brain that heals itself.”
The challenge to acupuncture is similar to the challenge thrust at neurofeedback: Is it more than a placebo? The real problem here is not one of experimental proof, but rather one of resolving a conceptual muddle within medicine itself. This muddle resembles the earlier one of trying to distinguish between real and imagined pain. That one was not resolved experimentally either.
One simply had to wait for the docs to come to their senses. After all, the pain patients were never in doubt that the pain that they were complaining of was real. Only the docs were in doubt, and we had no choice but to wait them out—because in those days they were sitting at the right hand of God.
The same thing will happen here. Neurofeedback has become a fact of the healthcare field just as acupuncture has, and the handwringing in the hallways of academia will not dislodge either of them.
There is yet another way to frame the issue, which is in terms of the role played by the mind. Back in 1980, an MD stated the fear succinctly at a conference: “If we start bringing the mind into the discussion, we’ll be setting back medicine fifty years.” In the clinical setting, the question was: “Are you really better, or do you just think you’re better?” This is the same question they were stuck on with pain: Is it real or imagined (i.e., only in the mind).
The question is inappropriate in such generality just as it was with regard to pain. The question cannot be resolved because it rests on the same conceptual muddle, namely the classical mind-body split that is unfortunately perpetuated within medicine. The question simply has to go away because it does not conform to how our biological systems are organized. Sending a patient off with the assertion that “the problem is all in your head” may be tactically useful, but it is bad neurobiology.
In the case of neurofeedback, we have the advantage of dealing with issues where progress is more tangible: the CP child who gains the use of his legs in ten sessions of training; the woman with ptosis who opens her eyelids within session and can then keep them open; the essential tremor that is stopped dead in its tracks; the smoking habit that is suddenly abandoned even in the absence of any intention of doing so; the autistic child who starts spouting sentences at session five; the years of bed-wetting that stopped at session three; the cluster headache that subsides within mere minutes of trying a new protocol after the standard ones failed; need we go on?
In the case of neurofeedback, then, it is easy to derail the placebo model. Neurofeedback training alters the entire regulatory system. The mind merely plays a role in mediating the response. It is not the sole responding entity. Acupuncture has the disadvantage of just targeting pain, where ancient understandings are slow to die. But the reality is the same. The mind may play a role in mediating the response, but the response is not just in the mind, but rather in the physiology. In both cases, we are looking at a system response.
P.S. The cluster headache case is particularly illustrative because the prior unsuccessful trainings with our conventional protocols can be seen as playing the role of a “placebo washout period” that is sometimes used in research. This is where a placebo is given to all potential study participants in order to screen out placebo-responders. If a placebo effect is going to occur, it is likely to occur in this early phase. The same assumption holds in this case.