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Why do ineffective treatments seem helpful?

Updated: Jan 7


Quotes taken from a fantastic review piece by Hartman, S. 2009.


After undergoing any form of therapy, treatment or intervention if symptoms improve we are likely to credit it to the treatment.


This is common, but ultimately flawed thinking.


Often treatments that lack any meaningful effect can also seem to illicit real world, measurable changes in signs and symptoms.


"Discomfort engendered by opinions at odds with one's own can derail one's best intentions of reaching the truth. "


"For thousands of years, practitioners administered therapies, monitored symptoms, and then proclaimed their efforts beneficial. Patients considered their post-treatment perceptions, and agreed. Now we know, both practitioners and patients often were wrong."


"Use of some irrational practices has diminished, and rest harmlessly in the dust-bin of medical history (e.g., the cure all of bloodletting). However, well-meaning practitioners still engage scientifically in undetectable body energies of traditional Chinese medicine and therapeutic touch. Why does faith in personal clinical experience persist, given its clear and protracted reputation for unreliability?"



3 RELATED COMPONENTS TO DEDUCTIVE MALFUNCT IONING:

  1. due to natural history of disease, regression to the mean, and the placebo effect, real signs and symptoms often improve--with or without treatment;

  2. patients and practitioners often convince themselves that treatment was effective-- when it was not (due to confirmation bias and other human cognitive imperfections).

  3. personal evaluation of efficacy is quick and convincing, but properly controlled, scientific determinations can be slow, complex, and costly.




"Occasionally, purposeful clinical treatment leads directly to symptom improvement. More often, patients and practitioners award credit to a particular therapy when healing is unrelated (or even imaginary). Independent of any specific treatment, measurable signs and symptoms often improve, due to the self-correcting course of many diseases; regression to the mean; placebo effects; and other factors coincident with (but directly unrelated to) treatment."



"Any one of these confounding factors, by itself, renders uncontrolled judgments of direct clinical efficacy unreliable. Only after formally controlled observations (limiting such biases) can practitioners be confident that clinical value of a treatment may have been accurately and reliably measured. Independent of direct, effective, therapeutic support, patients often come to feel better. This is not trivial, but ethics of all healing professions demand that such effects not be falsely credited to specific treatments."

Natural History


Humans are adaptable organisms with complex immune and repair systems .

Often something that is disrupting order within the body will be returned to baseline with time and symptoms will diminish naturally , with or without intervention. Sometimes this can happen over and over for an i s sue that comes and goes leading to a reinforcement in fault y think ing that trips to the acupuncturist/ osteopath/ chiropractor/ massage therapist etc. are the reason for improvement.

Regression to the mean


We are stubborn creatures and often only seek help with an issue when symptoms are at their peak and we no longer feel able to manage them. Symptoms when measured overtime present around a mean, like on a scatter graph with a few outlying plots but the majority scattered around the line of best fit. Often the more intense symptoms experienced at peak will dampen again or ‘ regress back to the mean ’ , with or without treatment.

The Placebo Effect


Where the psychosocial context of a treatment or intervention results in a physiological health improvement. Placebo effects are very real, and can be useful if used ethically , but often can be confused with seeing meaningful effects from a treatment.


Examples of psychosocial contextual factor s that may induce a placebo effect are:

  • Seeing a doctor wearing a white coat

  • The enthusiasm and confidence the practitioner has in a treatment

  • A display of certifications on the wall

  • The act of taking a pill

  • Receiving a physical examination

  • How expensive the treatment was

  • Seeing a needle go into a site of pain

  • The scent in the dentist’ s office


Post Hoc, Ergo Propter Hoc Fallacy


A common fallacy in thinking for cause/effect relationships.


A occurred before B occurred Therefore A caused B In latin: "after this , therefore because of this ”.


The cause can precede an effect, however this does not mean that we should confidently assume that one singular input was the cause of the outcome we sought when there are numerous inputs we may be overlooking. People often commit this fallacy when try ing to use anecdotal evidence in scientific debates.


Examples


  • Yesterday it was really cold out. My knee hurt more than usual on the evening. Therefore, the cold must make my knee pain worse.

  • I ate at a new restaurant last night. This morning I didn’t feel so good. Therefore, the restaurant food must have made me sick.


The second example here could be accurate, and the restaurant food did cause the person to feel unwell , however the argument is still logically invalid unless additional information is presented to support it. Remember, an argument can arrive at the correct conclusion and still be a rubbish argument.


Confirmation bias


"People sometimes see ... patterns for which they are looking, regardless of whether the patterns are really there. " (2)


Humans are remarkably bad at accurately discerning patterns.


We are AL L prone to confirmation bias . We want to be right and so will seek out information that is in support of our argument/ treatment/ method etc. rather than face an overwhelming body of evidence against it.


We will even surround ourselves with others that support our ideas , rather than people who challenge them to further reinforce our initial position. This is the echo chamber of ignorance.




Cognitive Dissonance


When a situation involves conflicting attitudes , beliefs or behaviours it creates a feeling of mental discomfort leading to an alteration in one of the attitudes , belief s or behaviours to reduce this.


E.g. A per son knows that smoking causes lung cancer, yet they continue to smoke.


This put s them in an uncomfortable position. How can they lessen this discomfort?


The person then says they ’d rather “live for today ” than quit or claims that “ research isn ’t conclusive about smoking and lung cancer anyway ”.


Thus , taking steps to reduce the extent of their dissonance.


Our likelihood to have confirmation biases is also influenced by our desire to avoid cognitive dissonance.


Some may seek out information to support the ideas that reduce their feelings of dissonance, or hang out with others that support these ideas too, further strengthening the beliefs.


Notice that the same author s alway s crop up together on papers that we already know support their biases? Or quacks cite other quacks in nutrition books?



Why are we like this?


Symptoms, illness , pain etc. are unpleasant.


Our desire for them to go away to reduce the psychological burden they lay upon us is great, so we may report and believe that we feel better. A successful treatment is ‘money well spent’ , we ’d rather not accept that a treatment has failed as this suggests we made a foolish investment with our time or money.


Someone’s personal experience or knowledge of a treatment can mean success is expected resulting in reports of effectiveness.


Trust in the practitioner can further bolster this or the social expectation that the practitioner is a ‘healer ’ and so this is the outcome they expect after work ing with them. Positive clinical findings such as clear imaging can also sway us to report symptom relief and act optimistically . Because the treatment preceded this it’ s another nod to the pos t hoc fallacy, assigning more credit to the treatment.



Practitioners also fall prey to cognitive biases and fallacies in thinking.


Professional and personal integrity and self esteem are on the line here. Questioning the efficacy of a treatment can open the door for dissonance to creep in, potentially threatening what they thought they stood for and forcing re-evaluation of practice. Practitioners want positive outcomes too, maybe even more so than their patients.


References

(1) Hartman, S. (2009). Why do ineffective treatment s seem helpful? A brief review. Chiropractic & Osteopathy , 1 7 (1).


(2) Nicker son, R. (1998). Confirmation Bias : A Ubiquitous Phenomenon in Many Guises . Review of General Psychology , 2(2), pp.1 75-220.


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