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“Complex, multi-component therapy” can be studied well

This August was a tough month for SBM bloggers reading The New England Journal of Medicine (NEJM). Just one week after a review of acupuncture for back pain—in which the authors recommended referring patients to traditionally trained acupuncturists despite data showing that traditional needling does not outperform a blinded sham control (click here here here for the trifecta takedown)— NEJM featured an original article about a study of Tai Chi for fibromyalgia. As critiqued by Dr. Gorski, the control intervention for the Tai Chi study was arguably inappropriate: the test and control groups experienced different intensities of exercise, for different durations of time, led by different instructors with different levels of enthusiasm. The special pleading and the weak design were not of themselves surprising, only their presence in such an august journal.

A group of editorial authors in that same NEJM issue preemptively address the SBM critics by describing Tai Chi as a “complex, multi-component therapy” and thereby implying that an appropriate sham cannot easily be designed. I agree that studying Tai Chi must be trickier than matching drugs to sugar pills. But “complex, multi-component” interventions can indeed be studied in a way that leads to convincing conclusions, as illustrated in the August 25, 2010 issue of The Journal of the American Medical Association (JAMA). A team of Boston psychologists studied a complex, multi-component intervention for attention deficit-hyperactivity disorder (ADHD) and reported their findings in “Cognitive Behavioral Therapy vs Relaxation With Educational Support for Medication-Treated Adults With ADHD and Persistent Symptoms: A Randomized Controlled Trial.” The abstract:

Context Attention-deficit/hyperactivity disorder (ADHD) in adulthood is a prevalent, distressing, and impairing condition that is not fully treated by pharmacotherapy alone and lacks evidence-based psychosocial treatments.
Objective To test cognitive behavioral therapy for ADHD in adults treated with medication but who still have clinically significant symptoms.
Design, Setting, and Patients Randomized controlled trial assessing the efficacy of cognitive behavioral therapy for 86 symptomatic adults with ADHD who were already being treated with medication. The study was conducted at a US hospital between November 2004 and June 2008 (follow-up was conducted through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments.
Interventions Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (which is an attention-matched comparison).
Main Outcome Measures The primary measures were ADHD symptoms rated by an assessor (ADHD rating scale and Clinical Global Impression scale) at baseline, posttreatment, and at 6- and 12-month follow-up. The assessor was blinded to treatment condition assignment. The secondary outcome measure was self-report of ADHD symptoms.
Results Cognitive behavioral therapy achieved lower posttreatment scores on both the Clinical Global Impression scale (magnitude –0.0531; 95% confidence interval [CI], –1.01 to –0.05; P = .03) and the ADHD rating scale (magnitude –4.631; 95% CI, –8.30 to –0.963; P = .02) compared with relaxation with educational support. Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy (β = –0.41; 95% CI, –0.64 to –0.17; P <001), and there were more treatment responders in cognitive behavioral therapy for both the Clinical Global Impression scale (53% vs 23%; oddsratio [OR], 3.80; 95% CI, 1.50 to 9.59; P = .01) and the ADHD rating scale (67% vs 33%; OR, 4.29; 95% CI, 1.74 to 10.58;P = .002). Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months.
Conclusion Among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapycompared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months.

Cognitive behavioral therapy (CBT) is a psychotherapeutic intervention based on teaching patients to recognize, challenge, and consciously correct their maladaptive thoughts and behaviors. It has strongest evidenciary support in the treatment of mild to moderate depressive disorders, either alone or in combination with medical therapy. CBT is also sometimes used in the treatment of anxiety disorders, obsessive-compulsive disorder, personality disorders, and somatoform disorders. This focused therapy involves teaching patients to change easily identifiable thoughts and behaviors; it does not address or even presuppose any unconscious factors in the psychological disorder.

The details between the JAMA ADHD study and the NEJM fibromyalgia study are similar in several ways. Both studies address a condition of uncertain etiology, pervasive impact on a patient’s personal life, subjective measurability, and unsatisfactory response to medical treatment. (The latter is not always true for ADHD, but it was true by selection in this study.) Both studies examined a therapy that is non-medical, non-surgical and requires a trained therapist; in both cases the intervention had somatic and cognitive components, albeit in different mixtures, as well as a didactic component. Both studies refrained from overly restrictive inclusion criteria, allowing patients with different degrees of disease and medication history so long as no patient had experienced the therapy under study, thereby maximizing generalizability.

And yet, compared to questionable sham of the NEJM study of Tai Chi (as described), the JAMA study of CBT had a very interesting control intervention. The test group had 12 one-on-one sessions of CBT, which included: education about the disease ADHD, organizational and planning strategies that compensate for ADHD symptoms, specific skills to increase concentration and reduce distractibility, and learning to think differently about the disease symptoms and triggers. The control group had an equal number of sessions of equal duration; they also were educated about ADHD, but in place of CBT they were taught progressive muscle relaxation (PMR) and practiced applying the techniques in response to ADHD symptoms. PMR is the process of sequentially tensing and relaxing specific muscle groups, and along with other techniques it can be an effective tool for reducing anxiety. Since anxiety is not thought to play a major role in ADHD, we can reasonably assume that PMR will not yield specific therapeutic effects for the study participants.

The problem with the Tai Chi control group is that it failed to control for the very types of nonspecific effects that the SBM critics suspect are most responsible for the perceived effectiveness of CAM: time spent with a caring professional focusing on your symptoms and performing an elaborate ritual. If you compare a “boring” sham with an “exotic” intervention, then you have not controlled for important placebo effects. Here are two examples of CAM shams that successfully control for these elements, and the resulting data are negative. The brilliance of the CBT study is that PMR controls for many of these nonspecific effects of the therapeutic interaction: a 50-minute session, one-on-one with the therapist, focused on noticing and responding differently to your symptoms. Furthermore, the CBT and PMR therapies were both conducted by the same individual psychologists (no confounding for a charismatic Eastern mystic!) who were trained before the study in both interventions and sporadically monitored for adherence. This CBT study should be held up as an example of how to properly evaluate a “complex, multi-component” therapeutic intervention.

Finally, there is good news from this study not just for SBM fans but also for our friends and patients who suffer from ADHD. The data from this study suggest that CBT can cause meaningful and durable improvement in symptoms of adult ADHD that is poorly controlled by medical therapy. Patients with ADHD who need an alternative or a complement to medical therapy need not look outside the realm of evidence-based treatment.

As a fourth-year medical student applying right now to psychiatry residency programs, I look forward to learning more about evidence-based psychotherapies like CBT.

Posted in: Clinical Trials

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27 thoughts on ““Complex, multi-component therapy” can be studied well

  1. windriven says:

    “[o]nly their presence in such an august journal.”

    Given the sloppy editorial oversight at NEJM, it might better be described as ‘that once august journal.’

  2. marilynmann says:

    I would be interested in hearing the SBM view on “dry needling.” This was recommended to me for back pain. The basic idea of it is that people who have pain often have “trigger points.” Dry needling uses acupuncture needles to needle the trigger points, which provokes first a muscle spasm and then muscle relaxation. Unfortunately, there doesn’t seem to be any good evidence that this actually works to reduce pain. There is anecdotal evidence, of course. I am unclear on how you could do a blinded study of this, or what you would use for a control. I guess you could use needling areas other than trigger points as the control.

  3. evilrobotxoxo says:

    I actually don’t think there was any serious problem with the way the tai chi study was controlled (with the exception of the single blinding, which would be difficult to get around), only the way the results were interpreted and reported. I think it’s reasonable to ask the question of whether Tai Chi is more effective than stretching/exercise alone. Now that there’s a positive result, someone can design a study to tease apart the mechanism for this difference using the methods Tim is describing. It could very well be the strength of the therapeutic alliance, it could be the meditative/relaxation aspects of it, or it could be a combination of these effects and something else I’m not thinking of.

    On an unrelated note, I’m glad Tim is going into psychiatry. The field needs more MD/PhDs!

  4. jmm says:

    I find it interesting the extent to which CBT is one of the most effective interventions available for many complex disorders. But you have to realise that the main principles of CBT are also the main principles of many “alternative” treatments, creating a very high a priori likelihood of their effectiveness. The question then arises as to which practitioners are most effective with these shared principles. I am not aware of any studies that have compared them head-to-head.

    I was diagnosed over 10 years ago with chronic fatigue syndrom. I went to a psychiatrist for CBT. I basically only succeeded in the “behavioral” and not the “cognitive” part, and this improved my symptoms substantially, but I could still only work part-time, and continued to suffer. Much later, I took up yoga and meditation. There, for the first time, I was really equipped by my teacher for what it takes to do the “cognitive” part. CBT, as found in the “conventional” sector, basically told me to “watch my thoughts” as though this were something easy! It is in fact incredibly difficult, and I believe meditation teachers are much better trained to teach someone to it. After I learned pranayama and meditation, my cfs cleared up to the extent that I am now in the 5% bracket that has returned to high-functioning. Most of this improvement was concentrated in windows within the 10-year period in the time just after CBT and just after learning yoga.

    Given that the alternative sector is cheaper and quite possibly better trained for CBT, doesn’t it seem worth while testing them directly? My impression is that “conventional” CBT could learn a lot from the community of meditation teachers.

  5. Shelley says:

    For JMM,

    I work as a PhD level cognitive behavioral therapist — which is a protocol driven therapy with specific tools and techniques that patients learn that help them control automatic negative or anxious thoughts associated with various problems.

    Unfortunately, due to the volume of evidence that supports CBT, it is in high demand, and almost all therapists claim to do this work, though they may have only a very basic understanding of what CBT is and does. In fact, most have done little more than take in a workshop on it. My training in CBT took four graduate-level courses and several months of direct supervision.

    We have no way of knowing what technique your therapist used or whether you’ve experienced “conventional” CBT. What I can say for certain, is that telling you to “watch your thoughts” is most certainly NOT a CBT technique.

  6. evilrobotxoxo says:

    @JMM:

    What you’re describing is basically the underlying motivation for DBT, or dialectical behavioral therapy, which is a form of CBT that incorporates meditation techniques. It was originally developed for use in borderline personality disorder and is the type of therapy with the strongest evidence base for borderline PD. As a result, DBT tends to be linked to that diagnosis, but people are finding that the approach is helpful for many other diagnoses as well. So to some extent, these “alternative” ideas like meditation are being incorporated into evidence-based therapies already with good results. And as you point out, there is of course nothing intrinsically “alternative” about exercise, meditation, etc.

    I actually suspect that the meditative aspect of tai chi is part of why it had superior efficacy to the exercise-only control, and I think it would be very interesting to see trials of exercise + DBT vs. exercise alone for conditions like fibromyalgia or CFS. Part of what’s interesting about that is that referring a patient for something like DBT forces them to confront the possibility that there’s a “psychiatric” or “psychological” aspect to their condition. However, tai chi or yoga, which involve some of the same meditation/relaxation techniques, are not viewed with this same stigma.

    As far as who is more effective at providing these services, I think there’s a difference you’re not taking into account. Even a mental health professional who only really engages in one type of therapy, for example, still has training to determine who is a good candidate for that therapy and who should be referred out for a different type of treatment or evaluation. Most Yoga instructors, however, teach yoga to everyone who comes through their door, which is fine as long as they’re not health care professionals. If tai chi were used as an effective treatment for fibromyalgia, for example, then tai chi instructors should have to either receive additional training in evaluating who’s a good candidate for tai chi, or only take referrals from professionals who have already evaluated them.

  7. ceekay says:

    The effect found in the NEJM Tai Chi study was very large — much larger than most behavioral fibromyalgia trials–certainly much larger than we see in most CBT trials (see for example Long-term efficacy of therapy in patients with fibromyalgia by Redondo 2004)

    … This effect size is of scientific interest even if it was caused by the enhanced placebo effect of a charismatic teacher….

    As scientists, we need to learn more about what that teacher did to get those Fibro patients up and moving, off of disability with improved mood and losing weight–what was the mechanism involved?

  8. Tim Kreider says:

    I agree that the Tai Chi study is valuable and that FM patients may benefit from knowing its results. From the perspective of a (future) physician-scientist, however, it is a frustrating study, because the choice of control leaves open so many possibilities for mechanism. Is it something specific about the types of movements, or rather the form of relaxation or mindfulness, or perhaps a genuine chi-manipulating skill of the master? Importantly, what role does expectation play, and if a large one, by what means does the master successfully promote high expectation?

    One could argue that leaving further questions to be answered is in fact a hallmark of good science, and I would agree with one. What galled me in the NEJM was the implication (made in the editorial) that Tai Chi is somehow unique in being a complex intervention. It gets to the CAM double standard meme, which is even more frustrating when potentially good science is muddied, as Drs. Novella and Gorski described for the adenosine and acupuncture study.

    It seems to me that many practitioners of CAM modalities could teach many physicians a thing or two about managing patient morale and expectation. The potential for those valuable lessons is lost when we get bogged down in studying whether the magic “works” instead of focusing on (what I suspect is) the real value of the therapeutic interaction. A more tightly controlled study of Tai Chi might yield results that could be generalized to very different therapeutic interactions, therefore causing a greater impact on patient wellbeing than simply sending one group of patients to Tai Chi.

  9. jmm says:

    I’ll be a little clearer what I went through. There was indeed unmeetable demand for CBT in my area: I was told that the waiting list would be 12 months. A very nice and apologetic therapist, seeing the sort of person I was, squeezed me in immediately for just 3 visits instead, and gave me a self-help booklet that contained in-depth protocols, tailored to cfs. The materials were closely based on a successful clinical trial for CBT for cfs, which had occurred at the same location. These materials, plus the 3 meetings, were sufficient for me to self-administer at least the behavioral part, with substantial results in my case.

    The instructions did not explicitly say “watch your thoughts”. They did involve developing cognitive strategies to use every time I had a negative thought. I found this useless, since I did not notice when I had negative thoughts. I was not depressed, and was not particularly prone to negative thoughts: those that I had were pretty subtle. Without in-depth mindfulness training, I was not capable of observing my thoughts well enough to know when to use the countering strategies. The instructions simply seemed impossible. “Watch your thoughts” was not mentioned, but it seemed a prerequisite if I was to do as instructed.

    evilrobotxoxo, rather than divide people into the mentally healthy and those that are sane, yoga basically takes the position that we are all deluded. Some people’s delusions make their life more miserable than others, but we all mistake the temporary for the permanent, feel unhelpful attachments and aversions, and construct a narrative about the “self” that comes far from capturing the truth. We can all, independent of diagnoses, experience benefits from learning to see through our delusions. Interestingly, therapists are now not far behind: you don’t need to be mentally ill to see one.

  10. GinaPera says:

    Thank you for this article.

    Two comments on your points:

    1.

    “Since anxiety is not thought to play a major role in ADHD, we can reasonably assume that PMR will not yield specific therapeutic effects for the study participants.”

    Actually, anxiety is a common comorbidity with Adult ADHD (75% of adults with ADHD have a co-existing condition; much less in children with ADHD). It was useful that the researchers used relaxation exercises, because so many people mistakenly assume that people with ADHD simply need to relax.

    2.

    “The data from this study suggest that CBT can cause meaningful and durable improvement in symptoms of adult ADHD that is poorly controlled by medical therapy. Patients with ADHD who need an alternative or a complement to medical therapy need not look outside the realm of evidence-based treatment.”

    It is critical not to perpetuate the myth that this type of CBT is an alternative to medication for adults with ADHD. It is NOT. All of the studies to date on CBT for ADHD have been done in conjunction with medication for a reason: ADHD is not a “learning” problem. It is a neurogenetic condition.

    It is equally critical to emphasize that standard CBT is NOT recommended for ADHD. Any type of therapy that fails to take into account the neurobiological underpinnings of Adult ADHD is bound to fail, and can even make things worse.

    A prime component of CBT for ADHD is addressing the “emotional baggage” of living for decades not knowing you have ADHD and thus developing many misattributions for problematic behavior. Psychologist J. Russell Ramsay, who has researched this topic and co-directs the Adult ADHD program at UPenn, wrote a blog post on this topic here: http://tinyurl.com/2bs4kjz

    Gina Pera, author
    Is It You, Me, or Adult A.D.D.?

  11. GinaPera says:

    P.S. As for “poorly controlled by medical therapy,” I would add this: Most medical therapy for ADHD is poorly executed.

    Psychiatry really needs to step up its game in understanding the problems and doing better to help these patients.

  12. ceekay says:

    Tim,
    I agree with all of your comments but question your account of CBT trials

    First, I will wager you that the first CBT trials were actually much much less rigourous in their control methods than the NEJM Tai Chi trial….

    Even now, there are many people who question whether positive CBT trials are really the result of putative CBT mechanisms since these trials are filled with artifacts and poorly measured constructs (see for example Westen 2004 review, Empirical status of Empirically supported therapies) ….

    Second, it is important to point out that CBT trial you cite is the end product of 30 years and 100s of studies refining trial methods…..

    It is not reasonable to ask this first study of Tai Chi for fibro to present an equivalent level of refinement.

    I think we are in agreement that this NEJM Tai Chi trial offers proof that an effect is possible (in this specific Tai Chi class with a specific teacher) in Fibro. Now countless follow-up studies are needed to disaggregate mechanisms….

  13. qetzal says:

    @ceekay:

    It is not reasonable to ask this first study of Tai Chi for fibro to present an equivalent level of refinement.

    Perhaps not, but it is reasonable to ask for some rationale and consistency in the choice of the comparator group. My beef with the Tai Chi study is that there were so many unnecessary differences between the groups, especially: one instructor vs. many; and hour-long Tai Chi sessions vs. ‘control’ sessions split between 40 min. of lecture and 20 min. of stretching.

    Why attempt to compare such disparate interventions? As I said elsewhere, one could equally compare Tai Chi to drinking orange juice. You might well find that Tai Chi is significantly better, but so what?

    The ONLY justification I can imagine for that design is if the ‘control’ treatment actually represents an established intervention for fibromyalgia. In that case, it becomes a comparison of Tai Chi vs. current standard of care. That would be reasonable, IMO. And to be fair, a commenter in that other forum did claim that the control regimen was something they had been ‘prescribed’ as a fibromyalgia suffer. I haven’t seen any independent confirmation of that however. (Again, to be fair, I don’t have full text access to the published trial; perhaps the authors address this very issue?)

  14. evilrobotxoxo says:

    @jmm

    What you’re describing, that yoga’s position is that we’re all deluded, is exactly what I’m talking about. It is a near-prerequisite for premodern medical systems to believe that all disease has one cause and one treatment. The advent of diagnoses, i.e. the idea that there might be multiple causes requiring different treatments, is probably the single greatest insight in the history of medicine. Yoga is great for some people, but it’s not great for everybody. Most people would benefit from yoga in some way, but a lot of those people might benefit even more from something else. Some people are actually harmed by doing yoga. In particular, meditative practices can exacerbate psychotic symptoms in people who are predisposed. Even people in the yoga community acknowledge this. I have never personally treated a case of “kundalini psychosis,” but colleagues of mine have had patients become very psychotic in the context of meditation, some mutilating themselves very badly.

  15. ceekay says:

    Hi Tim,
    Someone in South Africa appears to have posted a full-text .pdf of the Tai Chi NEJM study, which is handy…. :)

    Here is the link.

    http://www.kimloong.org/images/pdf%20files/tai%20chi.pdf

    I think your point about a possible disparity between an intervention with many teachers who know they are part of a control intervention vs one enthusiastic teacher is fair

    The next study should address this and the other questions raised on SBM more directly (ie., is Tai Chi really different from low intensity exercise and stretches led by a competent, enthusiastic aerobics instructor? if so, how?)

  16. Tim Kreider – “Finally, there is good news from this study not just for SBM fans but also for our friends and patients who suffer from ADHD. The data from this study suggest that CBT can cause meaningful and durable improvement in symptoms of adult ADHD that is poorly controlled by medical therapy.”

    Shelley – “Unfortunately, due to the volume of evidence that supports CBT, it is in high demand, and almost all therapists claim to do this work, though they may have only a very basic understanding of what CBT is and does. In fact, most have done little more than take in a workshop on it.”

    One of my issues with therapy research is that is seems to provide the therapy in an unrealistically high and consistent quality and quantity. The problem with many therapies is the varying levels of skill and training of the practitioners in the ‘real world’. While research like this may suggest to the clinician that they can helpfully apply certain techniques to a patient with ADHD. It does not necessarily suggest to the patient that the available therapist who does CBT will be helpful or accomplish the same results.

    It’s sort of like testing a drug in perfect lab conditions and finding it works. Then turning the production over to a few thousand factories with only minor standards and few quality control measures.

    If I saw the same results for the same patients who sought out CBT through the typical channels (insurance referral, doctor referral, etc) I would feel much more comfortable with a conclusion that CBT is helpful to people with ADHD.

  17. Also, I can not speak to yoga, having only done the more mainstream exercise versions, but I have found that reading Buddhist philosophy can be a nice complement to some CBT exercises that require you to let go of expectations and control.*

    *My words not a particular therapist.

  18. qetzal says:

    ceekay,

    Thanks very much for the full-text link to the NEJM tai chi paper.

    Unfortunately, the authors don’t really give a justification for their mismatched control group design. Paragraph 2 of the intro specifically discusses the potential benefit of exercise for fibromyalgia, yet the authors intentionally compared 60 min. sessions of Tai Chi to a control that included only 20 min. of stretching. It’s a bit like comparing a new formulaton of aspirin to a control formulation with one-third the dose.

    Of couse, participants were also supposed to practice daily at home, and the study claims they were to document their practice with daily logs, but there is no summary of those data. That seems like a pretty significant omission to me.

    So I respectfully disagree that the next study should test whether Tai Chi is really different from low intensity exercise and stretches led by a competent, enthusiastic aerobics instructor. I think THIS study should have done so.

  19. “If tai chi were used as an effective treatment for fibromyalgia, for example, then tai chi instructors should have to either receive additional training in evaluating who’s a good candidate for tai chi, or only take referrals from professionals who have already evaluated them.”

    “Most Yoga instructors, however, teach yoga to everyone who comes through their door, which is fine as long as they’re not health care professionals.”

    Not sure about the thought process there, because tai chi and yoga are only very incidentally medical therapies.

    “If hot baths were used as an effective treatment for sore muscles, for example, then bathtub marketers should have to receive additional training in evaluating who’s a good candidate for bathing, or only sell bathtubs on prescription from professionals.”

    “Most bathtub retailers, however, sell bathtubs to everyone who comes through their door, which is fine as long as they’re not health care professionals.”

    “If fresh fruit and vegetables were used as an effective treatment for constipation, for example, then greengrocers should have to receive additional training in evaluating who’s a good candidate for fibre, or only sell fruit and vegetables by prescription from professionals.”

    “Most greengrocers, however, sell fruit and vegetables to everyone who comes through their door, which is fine as long as they’re not health care professionals.”

    There are risks to yoga and tai chi; there are also risks to bathing and high-fibre diets, especially in susceptible individuals. I’m not sure why you would want to medicalize something that is primarily recreational just because it might happen to also be of benefit to someone with a medical condition.

  20. Swimming is routinely recommended in popular magazines as beneficial exercise for people with arthritis. Do you think that swimming pools should only be accessible by prescription?

  21. jmm says:

    @Alison Cummins: nicely said.

    @evilrobotxoxo: In the US at least, a culture has developed where seeing a therapist is viewed as appropriate for everybody, irrespective of diagnoses. Therapy can also be dangerous and make problems worse. How is this different?

    A good yoga teacher does not treat all their students the same way, and takes into account any diagnoses. Breathing (pranayama) practices are incredibly powerful for many things, but should not be taught to someone with OCD. You really don’t want someone to direct their obsession onto their breath. The dangers of aggressive kundalini practices are widely acknowledged within the yoga community, and should certainly not be taught to anyone with a tendency towards psychosis, but they seem to be great for depression. A little common sense is all it takes to choose which techniques to try, including corrective action if meditation does start to go wrong, and plenty of available techniques are no more dangerous than Alison’s examples. The way I was taught yoga, it is definitely not one treatment for all.

    As for us all being deluded, well we are. We all routinely assume there is this unitary thing called the “self” that makes decisions, a position not supported by neuroscience either. We are generally in denial at some level about the fact that we will die. These statements are not at all the same as saying that all disease has one cause.

  22. evilrobotxoxo says:

    @Alison: I didn’t mean to imply that we should medicalize tai chi as an activity. I’m saying that if it were going to be used as a specific treatment for a specific medical condition, it should be connected to the medical system somehow to minimize misuse.

    @jmm: I think I’m just not getting my point across. Any medical professional has special training to recognize when NOT to do the thing they’re trained to do. Surgeons learn when not to do surgery. Psychotherapists learn when not to do therapy. When do yoga instructors not teach yoga? Who gets referred out because they would benefit more from something else? I’m not implying that yoga instructors should do this because yoga doesn’t claim to be a medical treatment, and they don’t have the responsibility to do this. However, I’m saying that if yoga were to be used as a medical treatment, as you were discussing above, that is something about its current implementation that would have to change, and it’s an important difference to take into account.

  23. jmm says:

    Why would its current implementation have to change, if that current implementation were shown to be beneficial to certain conditions with minimal risk? What would need to change? What sort of “connection” to the medical system do you mean, other than that doctors should recommend it if it is proven effective? And can you give an example of what do you mean by “misuse”?

    Yoga teachers are already trained at quite some length to look for contraindications, as well as for unexpected problems arising that suggest the practice should be discontinued.

  24. “I didn’t mean to imply that we should medicalize tai chi as an activity. I’m saying that if it were going to be used as a specific treatment for a specific medical condition, it should be connected to the medical system somehow to minimize misuse.”

    I’m not sure what the difference here is from:

    “I didn’t mean to imply that we should medicalize bathing as an activity. I’m saying that if it was going to be used as a specific treatment for a specific medical condition, bathtubs should be connected to the medical system somehow to minimize misuse.”

    “I didn’t mean to imply that we should medicalize fruit and vegetables as food. I’m saying that if they were going to be used as a specific treatment for a specific medical condition, their sale should be connected to the medical system somehow to minimize misuse.”

    Maybe you’re just talking about marketing claims? For instance, that activities shouldn’t be marketed as specific therapies, in the same way that “dietary supplements” can’t be marketed as autism cures, chiropractic can’t be marketed as an earache cure, prayer can’t be marketed as a diabetes cure and psychoanalysis can’t be marketed as a schizophrenia cure? What’s the current legal status of non-pill therapies?

    “Psychotherapists learn when not to do therapy.”
    Not in my experience they don’t. When all you’ve got is a hammer, every problem is a nail. In my experience, they are utterly unable to distinguish between their patient/ client getting better (your subjective distress means you are getting to the root of the problem! keep going!) and getting worse (the psychologist messing with my head is making me crazy). I have seen PhD clinical psychologists working out of hospitals who took the initiative to tell me to stop taking medication or who actively took steps to block my access to psychiatrists.

    In my experience, psychotherapy (which you don’t need a doctor to get) is waaay more dangerous than tai chi.

  25. evilrobotxoxo,

    Perhaps you mean that now that it seems that tai chi can be of benefit to people with fibromyalgia, tai chi instructors must henceforth refuse anyone who has fibromyalgia (who until now have had as free access to it as anyone else) until they can come up with a doctor’s prescription? This would seem a little odd.

    I’m just trying to get you to be more precise about what you mean, because what I’m interpreting from what you’re saying isn’t making sense to me.

  26. evilrobotxoxo says:

    jmm: “Why would its current implementation have to change, if that current implementation were shown to be beneficial to certain conditions with minimal risk? What would need to change? What sort of “connection” to the medical system do you mean, other than that doctors should recommend it if it is proven effective?”

    What you’re describing, a referral from a doctor, might be enough. That is a connection to the medical system. Maybe a clearer way to describe this is to say that there is diagnosis and treatment of disease, and both are important. Modern health professionals receive training to diagnose patients to realize when their treatments are not going to be effective. Of course, there are exceptions to that, I guess, like radiation oncologists, who only treat patients by referral from an oncologist who made the diagnosis, but that is their connection to the system. If yoga, tai chi, or whatever are to be used as treatments, there still has to be some way that accurate diagnoses are made. My original point was that psychotherapists do both diagnosis and treatment, and they are connected to the system to refer people for diagnoses outside their scope of expertise. Yoga instructors offer something that could be a treatment for certain conditions, but that’s it. That is why I said that your idea for a direct comparison between the two is problematic.

    @Alison: sorry to hear about your bad experiences with psychologists. I agree with you that the way things actually happen does not always match the way things are supposed to happen, and this is a daily source of frustration to me as well.

  27. evilrobotxoxo, if I understand correctly, you are saying that Tai Chi instructors should not be empowered to diagnose fibromyalgia?

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