Alternative veterinary therapies – do they work?

 

Why do therapies seem to work – when they don’t?

by David W. Ramey, DVM

But you’ve got to be wrong – my horse was an absolute wreck until the (herbalist – manipulator – naturopath – horse dentist – faith healer… ) fixed him. Seeing is believing.”
Well actually no.

David Ramey is a general equine practitioner and has been in private practice since 1984 in Agoura Hills, California, and deals with show, pleasure and performance horses. He is the author of nine books on horse care, the most recent of which is Consumer’s Guide to Alternative Therapies in the Horse. In this article he explains, that sometimes what looks like a cure is nothing of the sort!

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Those of us who provide treatments and therapies for animals have a professional and ethical obligation to prove, first, that they are safe and, second, that they are effective. It’s usually not difficult to demonstrate that a therapy doesn’t do any harm to an animal. Proving that it’s effective can be quite another matter.

This is, at least in part, because there are many subtle ways that honest and intelligent people can be led to think that a treatment has been effective when, in fact, it has not (this holds true for both the giver and the receiver of the therapy) (1).

False claims and assumptions of effectiveness of treatments are a problem whether the treatment that is being assessed comes from scientific medicine, old folk remedies, fringe treatments described as ‘alternative’ or ‘complementary’ or the pure magic dispensed by faith healers.

Many dubious treatment methods remain on the market purely because satisfied customers offer testimonials to their worth. Essentially, these people say, “I tried it, my horse got better, so it works!”

Even when disease signs do improve following treatment, this, by itself, cannot prove that the therapy was responsible for the improvement. Without proper testing of a treatment’s true effectiveness, it is ethically questionable to offer that treatment to the public, especially if money is going to be exchanged.

Mistaking a correlation with a causation is a basic fallacy of logic known as post hoc, ergo propter hoc (‘it happened after so it was caused by’). People have a tendency to assume that when things occur together, they must be connected, although it should be obvious that this is not necessarily true.

For example, many people who drink diet soft drinks are overweight. Does this mean that the diet drinks cause obesity? When people count on their personal experience as the sole method of evaluating the success (or failure) of a therapy, there are many variables to consider and it is virtually impossible to determine cause and effect.

Without comparison to a similar group of patients, treated identically, except that the allegedly curative element isn’t given, individual givers or recipients of a therapy can never know if things would have gone just as well without that element.

The question then becomes, ‘Why might care givers and their clients who rely on anecdotal evidence and uncontrolled observations erroneously conclude that the therapies that they dispense and receive work when they may not?’

There are several good reasons.

The disease may have run its natural course. ‘Time heals all wounds.’ Many diseases take care of themselves. Provided that a condition is not chronic or fatal, the natural tendency of a living system is to heal itself.

Thus, before you can say that a therapy works, you have to show that the patients that are listed as improved exceed the proportion that would get better without any treatment at all (or that they get better faster than if they were just left alone).

Unless records of successes and failures over a sufficiently large number of patients with the same complaint can be evaluated, a treatment cannot be deemed to have been better than just leaving the condition alone.

Many diseases are cyclical. Conditions such as arthritis, allergies and gastrointestinal problems have ‘ups and downs.’ Most people look for treatment during the downturns, when things are the worst. Thus, treatments have an opportunity to coincide with upturns that might happen anyway.

Without valid controlled studies, it’s easy to misinterpret improvement due to a normal cyclical variation as a valid therapeutic effect.

The placebo effect. You may believe that the placebo effect does not exist in animals since they don’t know what treatment they are getting. However, their owners do. Recent research shows that up to 70 per cent of medical/surgical patients will report good results from techniques that we know today are ineffective (at the time of the treatment, both the patient and the physician were convinced that the treatment was effective) (2).

Furthermore, the pages of history are filled with examples of what, with the benefit of hindsight, seem like crackpot procedures that were once enthusiastically endorsed by physicians and patients alike (3). This sort of effect has apparently never been evaluated in the owners of animals but it is certainly reasonable to suspect that it exists, especially when evaluating such nebulous things as ‘better performance’, ‘improved disposition’ and ‘increased healing’.

To overcome the placebo effect, it is essential that tests be conducted in which patients are randomly assigned to groups and that the patients (or their owners) be ‘blind’ to whether the treatment being given is active or placebo.

Furthermore, the therapists who are doing the evaluating should also be ‘blind’ as to which patients are receiving treatment. Hence the term ‘double blind’, which is the gold standard of research that is based on results of treatment. When a clinical trial is completed, blinds can be broken into active, placebo and no treatment groups that can be statistically evaluated. Only if the improvements observed in the active group exceed those of the two control groups can the therapy be deemed effective.

Some allegedly cured problems are psychosomatic to begin with. One of the difficulties in trying to measure whether a treatment works is that some complaints can be alleviated by support and reassurance. An owner of an animal that is otherwise in good health may still be concerned that his or her animal’s perceived ‘poor performance’ may be due to some undefined physical problem. Supplying reassurance and support to the owner in such a case is obviously worthwhile but it is not necessarily medical or scientific.

The downside of catering to the desire for medical diagnoses for vague psychological complaints is that it promotes pseudoscientific thinking while providing virtually unlimited opportunities for medical quacks, who are often aided by the use of pseudoscientific devices and treatments to which treatment ‘success’ is then attributed.
Symptomatic relief vs. cure. Short of coming up with a cure, most owners want to make sure that their animals are not in pain or discomfort. Much research in people shows that the perception of pain is partly a sensation (like seeing) and partly an emotion. If the emotional component of pain can be controlled, benefits may be perceived even if the physiological basis of pain remains unaffected.

Anything that can allay a client’s anxiety, redirect their attention, foster a sense of control over the problem or lead to a reinterpretation of the signs of pain can help the patient cope with the problem.

Animal owners want to ‘make sure’ that their animal isn’t suffering. Pain clinics in human medicine put such symptomatic strategies to use every day (4). If clients perceive that their animals suffer less as a result of treatment, that is great, but it is important that such symptomatic treatments not be confused with actual cures.
Hedging your bets. Many animals receive more than one treatment at the same time. Often, that means that one treatment or another can receive a disproportionate share of the credit for improvement.

When ‘alternative’ or ‘complementary’ treatments are combined with scientific therapies, credit may be given where credit isn’t due.

Misdiagnosis. Many animals owners are afraid that their animals have conditions that they clearly do not have. Take well-publicized and relatively recent concern about Equine Protozoal Myelitis, for example. Many owners appear ready to ascribe any sort of vague sign of decreased performance or minor, intermittent gait problem (for example, stumbling) to a serious underlying cause. Combined with the apparent large incidence of exposure and the relative difficulty of obtaining an accurate diagnosis, many horses who are treated for EPM clearly don’t have it.

Of course, conventional diagnostic techniques are not infallible. A mistaken diagnosis followed by a trip to an ‘alternative’ therapist can lead to a glowing testimonial for curing a grave condition that never existed.
Furthermore, if conventional techniques fail to come up with an acceptable reason for the perceived problem, owners may gravitate towards alternative practitioners who can almost always find some sort of ‘imbalance’ to treat. If ‘recovery’ follows, another convert is born.

Psychological distortion of reality. Distorting reality in the face of a strong belief is common (5). Even when there are no improvements to be had, people who have a strong psychological investment in a therapy can convince themselves that the therapy has helped. According to a psychological theory known as cognitive dissonance (6), when experiences contradict existing attitudes, feelings or knowledge, mental distress is produced.

People tend to resolve this conflict by reinterpreting (distorting) the offending information. To have received no relief after committing time, energy and money to a treatment can create such a conflict. Rather than admit to themselves that the treatment has been a waste of time and money, many people will find some redeeming value in the treatment.

Many other self-serving biases can help to defend strong beliefs (7). Core beliefs in the effectiveness of a therapy are frequently vigorously defended by warping perception and memory. Practitioners and clients tend to remember things as they wish they had happened. They may be selective in what they remember, overestimating successes while ignoring, downplaying or explaining away failures. The scientific method of investigation evolved in no small part to help reduce the impact of this human tendency to jump to conclusions that agree with the proposed theory.

Finally, an illusory feeling that things have gotten better can also be due to demand characteristics that are found in any therapeutic setting. People normally feel obligated to reciprocate when somebody does them a good deed. Therapists, for the most part, sincerely believe that they are helping their patients and it is only natural that their patients would want to please them in return. Without realizing it, these obligations are enough to inflate the perception of how much benefit has been received from a treatment (8).

Individual testimonies of effectiveness should count for very little in evaluating the effectiveness of a particular treatment. Many false leads can convince intelligent, honest people that cures have been achieved when they have not. Thus, it is essential that any treatment be tested under conditions that control for placebo responses, compliance effects and judgmental errors before it can be deemed to be effective.
Any therapy that is supported only by testimonials, self-published books and pamphlets or items from the popular media must immediately be considered suspect. Even a single positive outcome from an experiment done in a carefully controlled fashion can always be a fluke.

If a practitioner of any therapy claims to be persecuted, is openly hostile to mainstream science, can’t supply a reason why the therapy might work that agrees with known principles or promises incredible results, there is good reason to be suspicious of that individual.

To people with an animal that is, or is perceived to be, unwell, any promise of a cure is intriguing. As a result, common sense can easily be replaced by false hopes. In this vulnerable state, the need for careful analysis and awareness is especially necessary. Unfortunately, it seems that instead, an eagerness to accept any alternative that offers some hope often takes over. Both givers and receivers of therapies should always be aware of the intellectual dangers of trusting personal experience and of the reasons why things sometimes seem to work (even when they don’t).

References
1 Beyerstein, B. ‘Why Bogus Therapies Seem to Work’, Skeptical Inquirer, 1997; 27(5): 29-34.
2 Roberts, A.H., et al. ‘The Power of Nonspecific Effects in Healing: Implications for psychological and biological treatments’.
Clin Psych Rev 1993; 13: 375-391.
3 Barret, S. and Jarvis, W. The Health Robbers: A Close Look at Quackery in America. Prometheus Books, Amherst, NY, 1993.
4 Smith, W., Merskey, H. and Gross, S. eds. Pain: Meaning and Management. SP Medical and Scientific Books, New York, NY, 1980.
5 Alcock, J. ‘The Belief Engine.’ Skeptical Inquirer, 1995: 19(3): 14-18.
6 Festinger, L. A. Theory of Cognitive Dissonance. Stanford University Press, Palo Alto, CA, 1957.
7 Beyerstein, G. and Hadaway, P. ‘On Avoiding Folly.’ Journal of Drug Issues 1991; 20
(4): 689-700.
8 Adair, J. The Human Subject. Little, Brown and Company, Boston, MA, 1973.

This article first appeared on the World Equine Veterinary Review Web Site and is reproduced with permission. Check out http://www.wehn.com/WEVR