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More Dialogs

There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. JAMA

Just just because there are flaws in aircraft design that doesn’t mean flying carpets exist. Ben Goldacre

Wiser heads than I have commented on “Invitation to a Dialogue: Alternative Therapies” in The New York Times. So why add my two cents? Partly because The New York Times wanted brief responses and I don’t do brief. Partly because I write for me; nothing focuses the mind like putting electrons to LCD, except, perhaps, a hanging. Partly we do need a dialog, just not of the kind suggested by the writer. And partly, life has been so busy of late I needed a topic that required no research.

The letter starts:

…the Affordable Care Act will likely reinforce current practice, which dictates surgical and pharmacological interventions that can be expensive, inappropriate, burdened by side effects and, often, ineffective.

Yep. Medicine has issues. And the solution? Using therapies based on fantasy and magic? Most alternative therapies cost money, have no good indications, have known side effects and are always ineffective beyond the wishful thinking of its practitioners. Those are the defining characteristics of alternative medicine. But what are alternative therapies? Even the NCCAM, given millions to study it, has no idea. One of the many ways the NCCAM inspires confidence.

But that gets to terminology. I am used to thinking of using a specific intervention for specific problem. Cephalexin for cellulitis. Proponents of alternative medicine rarely specify a specific treatment for a specific disease, since so many of their interventions are recommended for everything. Except, as I have noted before, birth control. To suggest we should have a dialog about the use of alternative medicine without being specific is to like suggesting we should discuss antibiotics not only for the treatment of infections but all of medicine. They remain vague, an ill-defined target.

Forty years ago, as a researcher at the National Institute of Mental Health, I began to study inexpensive self-care strategies — then called “alternative therapies” — that might address the underlying biological and psychological imbalances that contribute to chronic conditions. These included nutrition, exercise and “mind-body” techniques like meditation, guided mental imagery and biofeedback.

So it is hard to discuss the utility of SCAMs when the terms are so loose. I tend to think of SCAMs as coming in four varieties:

Type 1: Total nonsense with zero prior plausibility. These are SCAMs based on ideas divorced from reality as I understand it, cannot have efficacy and do not have efficacy. It includes, but is not limited to, homeopathy, acupuncture, chiropractic, ayurveda, reiki and other energy therapies, iridology, applied kinesiology, craniosacral therapy, water therapy, and on and on and on.

People who inflict these modalities on others may be well intentioned, but as we all know “the road to Hell is paved with frozen alternative care providers. On weekends, many of the younger demons go ice skating down it.”

All type 1 SCAMs are useless, non-reality-based magic. I would think anyone who proposes this type of SCAM for diagnosis and treatment should be kept as far from providing medical care as is feasible.

Type 2: Those SCAMs that may or may not have efficacy. These are mostly various herbs, whose reasons for use are often historical or related to aggressive marketing.

The prior plausibility that a given herb will actually have efficacy for a given disease is small, but not zero, and occasionally an herb or supplement, like red yeast rice, is discovered to have actual active ingredients and effect.

Type 3: Those SCAMs where a little efficacy in the test tube or in a small, poorly-done study that is blown out of all proportion to its real effect. The effects are perhaps real, often small, and usually not clinically relevant. Green coffee beans are a recent example, thank you very much Dr. Oz.

Type 4: SCAMs that are not SCAMs at all. For example, diet and exercise. Diet and exercise are often part of the marketing of SCAM, and there is nothing alternative about diet and exercise.

Often interventions that are not SCAMs are labeled as such in inflate popularity or used as a Trojan rabbit for more fantasy-based therapies.

This is what the author is suggesting as ‘alternative’: diet, exercise and relaxation techniques. I practice in teaching hospitals and to suggest diet and exercise are ‘alternative’ is laughable. Diet and exercise are major parts of the interventions used by and taught to our residents. Getting them implemented, especially in a clinic serving the underprivileged, is a challenge. I have a shtick that there are 4 things in medicine that are 100% sensitive and specific. I think I will add a fifth. Anyone who thinks diet and exercise are alternative is a shill for Big Alternative and is using advertising, not information.

The author does limit his definition of alternative to that which isn’t alternative, but I suspect a physician who writes:

homeopathic remedies are effective for common conditions such as asthma, arthritis and allergies

and recommends a book on homeopathy for his patients probably lives in a different reality than I do and has wider hopes for the application of pseudomedicines than just diet and exercise.

We spend about twice as much as many other industrialized nations on health care, often with inferior outcomes. Three-quarters of that spending is on chronic conditions, including heart disease, diabetes, cancer, arthritis, depression and chronic pain — exactly the ones for which self-care is best suited. Comprehensive programs that offer self-care in a supportive group are even more promising, for both treatment and prevention. This approach is also proving effective for psychological trauma.

Absolutely. A “comprehensive programs that offer self-care in a supportive group.” A fabulous idea. The problem is not a lack of alternative therapies in health care, but a lack of organization and coherence in the application of reality-based medicine to patients. In my system we call them Medical Homes. It is difficult to apply the concept in a country where medical insurance and organization is fractured and FUBAR, but it can be done.

So Dr. Gordon has it half right when he finishes:

If we are going to reduce our ruinous costs and improve our declining national health, we must make self-care and group support central to all care.

But with reality-based medicine, not the fantasy-based interventions that define so much of alternative medicine

We do not need a dialog on the need for SCAMs in healthcare. That would be ignoring more fundamental issues in US healthcare.

There are two dialogs we need: one is on the structure of health care in the US. Ain’t gonna happen in my lifetime as best I can tell.

The other dialog in medicine is what standards we are going to use in deciding care for patients – what constitutes valid research and how it will be applied to patient care.

Reality-based practice has important issues with inadequate or biased data, as “How evidence-based medicine is failing due to biased trials and selective publication” nicely reviews. Those problems are increased many fold in the world of alternative medicine research.

Is the standard going to be reality-based interventions with high quality studies free of financial and other bias? I suspect not. For alternative medicine, the standard is badly designed, badly controlled and ineptly reviewed clinical trials with negative or equivocal results to justify the use of interventions with no basis in known reality. The alternative medicine studies are haunted by poor methodology and a bias far more insidious and difficult to recognize than the bias from money.

Conflicts of interest are very common in biomedical research , and typically they are inadequately and sparsely reported. Prejudice may not necessarily have financial roots. Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings. Many otherwise seemingly independent, university-based studies may be conducted for no other reason than to give physicians and researchers qualifications for promotion or tenure. Such non financial conflicts may also lead to distorted reported results and interpretations.

Although it matters not a whit if quality studies show that highly implausible therapies such as homeopathy, reiki or acupuncture do nothing beyond placebo. There has never, ever, been an alternative therapy that has changed or been abandoned as a result of quality biomedical trials. Instead those discredited interventions become part of the core curriculum at naturopathic, chiropractic, acupuncture and other schools of pseudo-medicine. And has there ever been a published study of alternative medical practice whose goal is to improve practice and patent safety? Not that I can find. One would think acupuncture, with its puncturing of the skin, would be a low-hanging fruit for quality improvement. Guess not as no one has seen fit to improve:

The current situation is that acupuncturists have understanding insufficiency in hospital infection management, lack the sterile concepts and consciousness of disinfection and isolation. Aseptic technic principles aren’t strictly followed; disinfection and isolation systems are unsound; sanitary condition of hand of medical staff is unsatisfied; and there is shortness in traditional long filiform needle manipulation.

or the situation of naturopaths:

Concerning the hygiene control visits, a concept for hygiene was lacking in 79% of 109 practices, while in 49% a concept for cleaning and disinfection was also missing. In 60% of the practices, a dispenser for hand disinfection was lacking.

Somehow substituting or including the eternal and unchanging ‘truths’ of alternative medicine with no ability or interest in quality improvement, change or efficacy does not seem to me to be in the patients’ best interest. What has made medicine more effective and safer in my career is the ability for self-evaluation and subsequent change, a feature completely lacking in alternative medicine. There is no All Trials equivalent in the world of alternative medicine, much less a push for basic quality improvements like proper hand hygiene.

Judging from the continued expansion of magic into medical care, I suspect an interest in standards is lacking. The vast majority of docs don’t care, as mentioned by yet another shruggie:

If you get benefit from complementary therapies, who are we to argue? Those therapies might be able to meet your emotional and spiritual needs in a way that a blister-pack of Ibuprofen and ten minutes of weary scepticism just can’t manage.

Integrative Medicine Programs will continue to grow, with:

Services available in Flemington by appointment include acupuncture, massage therapy, nutrition counseling, herbal medicine consultations, and Reiki

in academic centers and the community hospitals. Those with the cash will get their alternative therapies, whether it is effective or even ethical to provide. It is a good thing I learned a long time ago that it is the journey, not the destination, that can be important.

Every day I see huge gaps and barriers to providing effective and quality care due to a deeply flawed health care system. People paying with their lives, health and financial wellbeing, due to lack of access to affordable science-based medicine, not a lack of access to alternative medicine, however it may be defined. That is the dialog that is lacking.

Posted in: Basic Science, Clinical Trials, Critical Thinking, Science and Medicine

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100 thoughts on “More Dialogs

  1. goodnightirene says:

    People paying with the[ir] lives, health and financial well being, due [to] lack of access of [sic] affordable science-based medicine, not a lack of access to alternative medicine, however it may be defined. That is the dialog that is lacking.

    Best summary ever.

    We all need to submit more formal letters to the NYT.

  2. FredJ says:

    “So why add my two cents worth? Partly the New York Times wanted brief responses and I don’t do brief.”

    I’m a little puzzled as to why you cannot “do brief” even for this one time. Try harder. This is a MAJOR opportunity to get a wider audience than SBM normally gets. The Times did not merely publish this rubbish as an article or even an Op-Ed, to which you can add comments that few people read. They are asking for official comments which they will publish right under the article. They are asking for a dialog.

    In my opinion, SBM cannot pass up an opportunity like this, and then complain that the mainstream media never hears the SBM “side of the story”. Get together and publish an official response. PLEASE!

    1. FredJ says:

      And make your response bearing in mind that they will let the author have the last word.

    2. Mark Crislip says:

      My biggest problem is time. I finally found the time to write this yesterday, so brief or long, I never had time to get to the NYT by their deadlines. We all do SBM in our spare time, of which there is very little.

  3. Jann Bellamy says:

    “the Affordable Care Act will likely reinforce current practice, which dictates surgical and pharmacological interventions that can be expensive, inappropriate, burdened by side effects and, often, ineffective.”

    Actually, the ACA “reinforces” just the sort of fantasy-based medicine Dr. Gordon advocates, via Section 2607 (heavily lobbied by CAM practitioners), which prohibits “discrimination” against state-licensed fantasy-based practitioners.

    1. mho says:

      I think the numbers are transposed and the act is 2706

      I posted more information on SfSBm under legislation –please comment on the guidelines.

      http://sfsbm.org/index.php?option=com_community&view=groups&task=viewdiscussion&groupid=12&topicid=14&Itemid=596

    2. Tazia Stagg says:

      Yes.

      Along with the composition of the national Prevention Advisory Group!

      I was fact-checking a rumor this afternoon and happened upon this in the text of the PPACA. Here’s the part that pertains to the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health… which group name gets truncated to “Prevention Advisory Group” for casual use (implying that “integrative” is somehow compatible with and belongs in the same category as prevention, health promotion, public health, under the umbrella of Prevention). Ugh.

      (f) ADVISORY GROUP.—
      (1) IN GENERAL.—The President shall establish an Advisory Group to the Council to be known as the ‘‘Advisory Group on Prevention, Health Promotion, and Integrative and Public Health’’ (hereafter referred to in this section as the ‘‘Advisory Group’’). The Advisory Group shall be within the Department of Health and Human Services and report to the Surgeon General.
      (2) COMPOSITION.—
      (A) IN GENERAL.—The Advisory Group shall be composed of not more than 25 non-Federal members to be appointed by the President.
      (B) REPRESENTATION.—In appointing members under subparagraph (A), the President shall ensure that the Advisory Group includes a diverse group of licensed health professionals, including integrative health practitioners who have expertise in—
      (i) worksite health promotion;
      (ii) community services, including community health centers;
      (iii) preventive medicine;
      (iv) health coaching;
      (v) public health education;
      (vi) geriatrics; and
      (vii) rehabilitation medicine.
      (3) PURPOSES AND DUTIES.—The Advisory Group shall develop policy and program recommendations and advise the Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion.

      Notice, in 2B, there is no comma after the phrase “integrative health practitioners” … so, technically, the only people who are actually mandated to be included are those!

      With respect to preventive medicine, there are currently two members who are board certified by the American Board of Preventive Medicine. One is board-certified in public health, and the other in occupational medicine. So, technically, no one on the national Prevention Advisory Group quite represents General Preventive Medicine.

      (Dr. Gorski actually mentioned this group, this past November; “it’s disturbing that President Obama would have appointed Ornish to such a committee”… but even worse, that appointment was only perfectly consistent with the new law.)

      I called in to the group’s most recent meeting. Deepak Chopra was mentioned, and that wasn’t the worst part. I’ve actually placed a FOIA request, so hopefully I’ll be able to provide exact quotations soon.

      1. weing says:

        Holy Crap.

        1. Tazia Stagg says:

          It only matters if the group has any power.

      2. David Gorski says:

        I’ve actually placed a FOIA request, so hopefully I’ll be able to provide exact quotations soon.

        Please do let us know.

        1. Tazia K. Stagg says:

          Thanks for your interest. The request is still “Pending program search.” I’m about ready for a FOIA lawyer.

  4. Ed Whitney says:

    Dr. Crislip is an infectious disease specialist and in that specialty, in which a specific remedy is needed against a specific disease, a placebo has no effect on the organisms which are making the patient sick; it is, in that setting, a worthless intervention. The specific disease is a product of nature, not of a committee. The same is not true of all specialties. In psychiatry, for example, a placebo may be as effective as the “real” medicine for a large proportion of patients. Specific remedies for specific diseases are not really called for when the specific disease is the product of a lengthy negotiation which leads to a list of agreed-upon criteria.

    Due to the constraints of today’s health care systems, psychiatrists have only enough time with patients to do pharmacologic abatement of symptoms. Other interventions, such as visualization, meditation, shamanic consciousness, talking to symptoms to discover their messages to us, transpersonal imagery, and the like, become “alternative” approaches. They may be as effective as anything that psychiatry has to offer. The soul may be a scientifically invalid concept, but practitioners who act as if it were real can often make a remarkable difference to troubled souls who are ill-served by the medications which conventional medicine has to offer.

    1. Harriet Hall says:

      “Other interventions, such as visualization, meditation, shamanic consciousness, talking to symptoms to discover their messages to us, transpersonal imagery, and the like, become “alternative” approaches. They may be as effective as anything that psychiatry has to offer. ”

      They may be, but they may not be; the evidence is lacking.

      Can fantasy, such as “acting as if the soul were real,” “often” make a remarkable difference to patients? Can it “ever”? I doubt it. It might temporarily be enjoyable to indulge in fantasy, but does it change the objective outcome of illness? And surely you are not suggesting that doctors who don’t believe in the soul or “shamanic consciousness” (!?) should pretend they do; lying is unethical. I think confronting reality is always preferable to fantasy. If you have any evidence that shows otherwise, I’d like to see it.

    2. Windriven says:

      “The specific disease is a product of nature, not of a committee.”

      I can think of several diseases that are products of committees less than one that is a medical disease. What medical diseases that are products of committees did you have in mind?

      ” In psychiatry, for example, a placebo may be as effective as the “real” medicine for a large proportion of patients. ”

      Echoing Dr. Hall: citations?

      “They may be as effective as anything that psychiatry has to offer.”

      Citations?

      “[P]ractitioners who act as if it were real can often make a remarkable difference to troubled souls who are ill-served by the medications which conventional medicine has to offer.”

      Citations?

      You’ve made a lot of claims. Can you back them up or shall we just take your word for it?

      1. Sean Duggan says:

        I don’t see these methods stacking up against medication, but… psychiatry? My bias as an employed engineer is no doubt showing, but I would not be horribly surprised if SCAM worked just as well as therapy sessions for a receptive subject. After all, areas where it’s all in one’s head such as pain and nausea are where placebos show any effect at all. That said, I also have my doubts that therapy by itself does much good for most mental illnesses. A mild neurosis, that I could see yielding to talking, or to a “shamanic resonance session” or what-have-you, but depression is a chemical and/oir neural imbalance, as is schizophrenia, and those things you can’t just talk away.

        1. Windriven says:

          I have no expertise whatsoever in this area. A psychiatrist friend who worked at a state mental hospital once told me that he could teach me everything I’d need to know to do what he did in a week. That is not to say he could teach me psychiatry in a week, but the management of inpatients in a psychiatric facility. His point was bemoaning the sad state of rehabilitative efforts in that particular setting.

          He would disagree with you about talk therapy for even some fairly stark psychiatric conditions. But that may be nothing more than confirmation bias talking. His job at that time was almost entirely pharmaceutical with a little bit of group mixed in. I think he really missed close patient interaction. Whether or not it would have been productive, I couldn’t say.

        2. Andrey Pavlov says:

          @SD:

          You are nearly there, but I believe (I could be wrong, I’m trying to – honestly – read into your comment a bit) you are not quite approaching the idea correctly.

          You are correct that psychiatry might be an area one the whole more amenable to CAM for the reasons you cite. Ditto for the acknowledgement on limitations.

          The issue is that I believe the very fields themselves are conflated. Psychology and psychiatry are historically separate disciplines, but I believe the evidence shows us otherwise now. Psychology is the psychiatry that can be effected via talk therapy (of any kind; e.g. without drugs).

          The thing is that the way in which conditions manifest themselves is on a continuum and different etiologies can appear as the same clinical syndrome. We don’t have a direct way (yet) to determine whether it is a neurocytoarchitectural problem that could be amenable to minor changes in brain structure that come from talk therapy or whether it is a fundamental problem with receptor/ligand malfunction, or if it is the former but in a state bad enough that just talk therapy alone won’t be sufficient.

          Which is why we find what Lytrigian points out – that in mild depression drugs don’t work better than placebo, for moderate it is a mixed bag, and severe drugs work vastly better.

          So Lytrigian, you were right in your comment, but I would argue that it just means we haven’t actually segregated the etiologies presenting with “mild depression” adequately enough, rather than the drugs not working. It does not mean we should use placebo, nor does it mean we should ditch the drugs. What it means is that we should use more talk therapy when we can, use drugs when that isn’t yielding adequate results, and continue to refine our understanding of the underlying pathology to better segregate those populations.

          1. Lytrigian says:

            It’s true that I wasn’t terribly precise in my language, but my main interest was in addressing Ed’s interpretation. He took that study to mean that placebos were an effective treatment.

          2. Sean Duggan says:

            Ah, well said. I always get confused between psychiatry and psychology. I know it’s got something to do with which doctorate one got, whether it’s an academic one or an M.D., and whether one can prescribe drugs.

      2. Ed Whitney says:

        Well, I can offer an anecdote which is not likely to satisfy anyone at SBM, but submit anyway as “evidence” that it is legitimate to look to “alternatives” to biological psychiatry when its frame of reference is inadequate to the task at hand. Conventional psychiatry has become wedded to a model of psychosis in which the protoplasm of the brain is the single reasonable focus of inquiry, and has introduced into the wider culture a concept of mental aberration in which self-knowledge and moral agency are not only of no interest but are actively disavowed as illegitimate.

        There are three dimensions of the soul which I assert to be sound and sensible avenues of exploration. The starting point is the literal, factual level of cause and effect thinking. The second is that of metaphor and symbol, that of meaning and signification. The third relates to final cause, that of purpose, which considers what the process is trying to accomplish and where it is seeking to lead us. Only the first falls within the domain of psychiatry as it is done today. This is a flat and shallow world in which to limit our exploration; it operates to the detriment of many patients who come to the attention of the mental health system. I do get it that many doctors freak out at the mere mention of the soul and the spirit, but this is attributable to the socialization of physicians and should not be confused with reality itself.

        Speaking of pseudoscience, the “chemical imbalance” explanatory principles of conventional psychiatry achieved dominance and became fixtures of the culture with a very shaky grounding in science. The “serotonin deficit” and countless other models of melancholic experience were elevated to the status of established science in a manner which were out of proportion to their merits. As a marketing tool it was singularly successful, but as science is falls woefully short of the endotoxin/cytokine model of septic shock which the truly scientific discipline of Dr. Crislip concerns itself.

        Come to think of it, I have not seen many TV ads featuring little serotonin molecules bouncing around on the screen and binding to little cartoon receptors. Have all the SSRIs gone off patent or something?

        1. mouse says:

          Ed Whitney – Wait doesn’t that mean that Pluto’s orbit can be affected by visualization…because I think that’s what you just said.

          1. Ed Whitney says:

            “Wait doesn’t that mean that Pluto’s orbit can be affected by visualization…”

            Again with the literalism! Tsk, tsk. The literal, physical former planet, no. Its counterpart at the level of the soul, yes. Even though it is a dwarf, it has a mass about 1/500 that of earth; even the nuclear arsenals of all the world’s superpowers could not budge it. But as a metaphor for distance, coldness, and isolation, and the darkness of the underworld, it certainly can be affected by visualization. It is without mass, but it exerts an influence on human affairs beyond calculation.

            It is the same with Mars, whose counterpart at the level of the soul influences us profoundly, and can either endow us with the courage to face scary realities (like climate change), or can make us peevish and quarrelsome and readiness to see ourselves as under attack and needing to lash out at our attackers. We must defend ourselves against that Antichrist in the White House, whose tyrannical Affordable Care Act says that when we engage in commerce, we must be bound by laws governing commerce.

            That is why we need a psychiatry which is aware of different levels of interpretation, so that the pathologies which arise from their confusion can be averted. So no, I do not say that the orbit of any planet can be affected by visualization in the literal sense.

            I do say, however, that just because someone gets picked up by the police running around in his underwear in the middle of the night thinking he is Elijah the Prophet, is no reason to jumping to conclusions about his mental health. Some enquiry is needed into the context of the episode. More than one intellectual dimension is required for satisfactory dealing with the situation.

            1. Harriet Hall says:

              “just because someone gets picked up by the police running around in his underwear in the middle of the night thinking he is Elijah the Prophet, is no reason to jumping to conclusions about his mental health. Some enquiry is needed into the context of the episode. More than one intellectual dimension is required for satisfactory dealing with the situation.”

              I am intrigued! What might explain such behavior? What kind of “context” do you mean? What are the different “intellectual dimensions” and how can the situation be dealt with satisfactorily? I find this all very puzzling and would really like to understand what you mean.

              1. Windriven says:

                ” We must defend ourselves against that Antichrist in the White House, ”

                Wow! The Antichrist was born in Kenya and he’s a Muslim!!! That explains a lot.

                I wonder if his Elijah story is autobiographical?

              2. Ed Whitney says:

                Harriet: I appreciate your genuine interest. The context I am referring to for Elijah the Prophet includes (1) feeling lost and out of place in clinical medicine, (2) a powerful desire to find a resolution to this dilemma, (3) longstanding interest in religion and its dysfunctions, (4) fascination with the Bible, manifested by immersion in its original tongues, Hebrew and Greek, (5) growing irritation with apocalyptic religion in the service of right-wing political causes, (6) irritation with Christian proselytizing of Jews and implicit dismissal of their messianic hopes, (7) recent close contact with the Hasidic rabbi/musician Shlomo Carlebach with his intense and poignant longing for the coming of Elijah the prophet, who will bring the messiah, (8) close reading of the confrontation between Elijah and the prophets of Baal on Mount Carmel, narrated in I Kings 1-40, (9) looking in the Chumash and noticing that the Haphtarah truncates the reading at verse 39, (10) noticing that verse 40 tells how Elijah takes the prophets of Baal to the brook Kishon and slaughters them there, (11) noticing that the word for “slaughter” refers to the kind of slaughter in which animals are prepared for sacrifice, (12) concluding that Elijah had not only killed the prophets but had prepared them for sacrifice, (13) fruitlessly searching various Haphtarah commentaries to see if this presented a problem for Elijah as the bringer of the messiah, (14) concluding that Elijah was tormented by guilt at what he had done, (15) concluding that the truncation of the Haphtarah reading just before the slaughter made Elijah feel that all Jews were ashamed of him, (16) concluding that this shame was like that of some families in which the infamous actions of a family member are never spoken of, (17) asking various Jewish friends and rabbis about this matter, (18) being told that this was an interesting and possibly original observation, (19) concluding that if I were so obsessed with this matter and all alone in this obsession, it must be some kind of personal issue, (20) concluding that the answer must be that I had been Elijah in a past life, explaining so many nominally irrational guilt feelings, (21) watching the Lubavitcher Hasidim saying on CNN that their beloved Rebbe, then on his deathbed in a New York hospital, was the messiah himself, (21) knowing that they would not bandy words about when it came to the messiah, (22) entertaining the possibility that they could be right, and (23) thinking that I was responsible for figuring this all out on my own, and (24) getting caught up emotionally in what could be the immanent redemption of the world and its deliverance from war. Add in a prolonged lack of sleep as this obsession became a round the clock affair, simultaneous weekly or twice weekly attendance at a Foursquare Gospel Church, a determination to work everything out without assistance, and you have the context for wandering out at night in T-shirt and underwear to seek the truth directly from listening to the ocean, which connected all parts of the earth throughout all of human history. Like a kid playing around with a chemistry set, I had thrown a bunch of different stuff into a beaker and had shaken it to see what would happen; what happened is that it blew up.

                Summary: what appears to an outside observer to be a chaotic hodgepodge may appear from the inside to be a seamless narrative. What appears pathological to an observer may look very different from another observer’s point of view. Context may depathologize the whole thing once the underlying structure is elicited. Some basic acquaintance with history, religion and culture may be required; depending on the specific content of the ideation involved.

                Windriven: you forgot the socialist Marxist Antichrist, under whose administration corporate profits have set new records, private sector employment has returned to its pre-recession levels, and the Dow has more than doubled in value. Major politicians in a certain political party actually believe this stuff, including a former governor of Arkansas who thinks that maybe they have more freedom in North Korea than we do here under the current president. And he is allowed to run around loose!

                Mouse: you are correct that CBT is a useful intervention which deserves to be applied to full-blown psychoses. Some intrepid soul (pardon the expression) ought to try it. And soon.

              3. Harriet Hall says:

                The fact that there is a seamless internal narrative doesn’t mean the whole thing is depathologized. It doesn’t explain why this person reacted this way while another person would not react the same way in a similar situation. This person’s reality testing is defective. He is not mentally healthy, is suffering, and is going to endure the consequences of society’s intolerance of such behavior. And you neglected to answer the most important question: how does understanding his internal narrative allow you to better help him? Medication has been shown to eliminate the internal narrative, the false beliefs, and the inappropriate behavior. Can you show that any other approach works better?

              4. Harriet Hall says:

                “CBT is a useful intervention which deserves to be applied to full-blown psychoses. Some intrepid soul (pardon the expression) ought to try it. And soon.”

                It has been tried. Check PubMed. It helps with psychosis as an adjunct to pharmaceutical treatment but has not been very useful when used alone. Patients like “Elijah” are unable to cooperate with CBT when in the throes of a full-blown episode like the one you described.

            2. mouse says:

              @EW – Yeah the CBT folks are way ahead of you. But they actually research their ideas and how their therapies work in comparison to other approaches, rather than waving their hands about, spouting off misty ideas about metaphors and the soul online.

        2. Andrey Pavlov says:

          Conventional psychiatry has become wedded to a model of psychosis in which the protoplasm of the brain is the single reasonable focus of inquiry, and has introduced into the wider culture a concept of mental aberration in which self-knowledge and moral agency are not only of no interest but are actively disavowed as illegitimate.

          Well, in essence, that is because that is what the science is telling us rather clearly.

          Everything you describe in the following paragraph is nothing more than a description of the various emergent phenomena of that protoplasm of the brain, as you say.

          I do get it that many doctors freak out at the mere mention of the soul and the spirit, but this is attributable to the socialization of physicians and should not be confused with reality itself.

          Actually, the sad part is that the majority don’t and themselves believe in something as silly as a ghost in the machine.

          Speaking of pseudoscience, the “chemical imbalance” explanatory principles of conventional psychiatry achieved dominance and became fixtures of the culture with a very shaky grounding in science. The “serotonin deficit” and countless other models of melancholic experience were elevated to the status of established science in a manner which were out of proportion to their merits.

          Actually, that is rather old hat. I can suggest reading Isaac Asimov’s The Relativity of Wrong. The theory as you describe it is in the “flat earth” stage as per that essay. We are now approaching (but not quite yet at) at the “spherical earth” stage. We understand that the chemical imbalance model is very incomplete, but not wrong. Serotonin deficit is undoubtedly a part of the picture. But the simplistic idea that it is literally like “happy gas” and your tank is running low is simply not entertained by serious experts in the field. But, with undoubtedly significant limitations, that model is producing effective results. We don’t yet have a much better model and until we do we are stuck with what we have and to modify it rationally as we can.

          We simply don’t have the technology or understanding yet to create that better model. We need the psychiatric equivalent of the Vanguard I satellite to inform that better model.

          But your analogy and explanation, while not intentionally so, is overly simple enough to be attacking a straw man.

          1. MadisonMD says:

            Thanks for linking the Relativity of Wrong, Andrey. It is a wonderful essay I had missed before.

            1. Andrey Pavlov says:

              @MadisonMD:

              Thanks for linking the Relativity of Wrong, Andrey. It is a wonderful essay I had missed before.

              My pleasure. It is a wonderful one that I had forgotten about for too long myself. I’ve since had a few discussions with people on my recent travels using it as a reference which led them to look at me and literally say “You’ve blown my mind.” My set up involves asking them how ridiculous an idea flat earth seems to them and then relating it to the levelness of a table. It seems to work well.

          2. Ed Whitney says:

            The “straw man” I willfully employ is one which is actually used on (or foisted upon) patients and families by the psychiatric profession. There are other, more sophisticated and nuanced avenues of research which you refer to; these discussions take place at the cutting edge of research and are pretty fascinating if you can understand them. But the kind of discussion that takes place in the pages of Trends in Neurosciences is far from doctrinaire in tone; the “chemical imbalance” model is all too dogmatic and it misleads millions to believe that their symptoms have nothing to do with things they have any choices about, and that model is far from being a straw man. It is, rather, a household word. It influences people’s attitudes far out of proportion to its merits.

            I am not hostile to anything that alleviates human suffering, including biological research; I participated in a study (not as one of the controls) of cerebral asymmetry in bipolar disorder, cheerfully putting up with the mild discomfort of median nerve stimulation for somatosensory evoked potentials in order to contribute to the advancement of any kind of knowledge that will lead to the development of any kind of tool that will help someone somewhere someday. My beef is with biological reductionism, which adds to human suffering.

            Speaking of straw men, the “ghost in the machine” is a fine example when it refers to the soul. The inner world of humanity is vast and has within it the resources which are needed if we are to be freed, even a little bit, from our desire-natures and our emotional reactions about ourselves. “Ghost in the machine” is a slogan which fits nicely on a bumper sticker, but is entirely insufficient for any purpose beyond that.

            1. Andrey Pavlov says:

              @Ed Whitney:

              My beef is with biological reductionism, which adds to human suffering.

              Then your beef is simply at odds with the reality of the universe. That emergent phenomena, like consciousness, can arise from the aggregate effects of simply brain components and functions does not mean there is something magically more than the essence of that biological reductionism. It merely means that we have yet to fully understand precisely how that happens, which in this case is primarily a limitation of technological capacity rather than missing something because of what you pejoratively call reductionism.

              and it misleads millions to believe that their symptoms have nothing to do with things they have any choices about

              Once again, you are indeed attacking a straw man. More accurately a non-existent man. The idea of libertarian free will – which is implied in your statement here – is simply not a tenable position. Even Dan Dennett has recently come to admit as much, even though he has always been in agreement with the relevant neuroscience. The simple reality is that choice as you imply does not exist. What people do and how they act is the direct product of the brain in their skulls. There are ways to modify that brain – both architecturally and neurochemically – but until that modification occurs, the outputs of it are simply the products of that physical process. The truly unique and wonderful thing about the brain is that it is, to a large but not limitless degree, able to self modify. All sensory inputs, including thoughts and ideas, modify both the neurochemical and cytoarchitectural state of the brain. The thing is that some pathologic states are simply too aberrant to be sufficiently modified in this manner. Hence pharmaceuticals.

              And once again, the simplistic serotonin depletion model is not wrong. Merely incomplete. We have evidence that depletion of serotonin in otherwise healthy individuals leads to depression (look up reserpine for more information). We have evidence that SSRI’s alleviate depression. We also know that in both cases those effects are not universal. Thus, while the serotonin model has some merit to it, it is obviously incomplete.

              It may be true that the overly simplistic version is common parlance and overused. That doesn’t mean that it should be regarded as a failed idea and completely discarded.

              The inner world of humanity is vast and has within it the resources which are needed if we are to be freed, even a little bit, from our desire-natures and our emotional reactions about ourselves.

              It is vast. And just like how the universe itself can – and is successfully – reduced to a number of (relatively) simple equations that can then produce multiverses, so can the inner vastness of humanity be reduced to a (relatively) simple understanding of neurochemical and neurocytoarchitectural interactions.

          3. AlisonM says:

            The “serotonin deficit” definitely doesn’t work in the soul. In fact, it’s been awfully hard to do scientific tests on the soul. Fortunately, the brain seems to be the driver, despite what dualists might think. Yay, neuroscience!

    3. Lytrigian says:

      In psychiatry, for example, a placebo may be as effective as the “real” medicine for a large proportion of patients.

      That’s an interesting take on this meta-analysis. Another way to put is that for mild depression, antidepressants have no effect above placebo. In such cases, the information we gain is that the drug doesn’t work, not that we ought to be using placebos instead.

    4. AlisonM says:

      Actually, there are some highly effective psychotherapeutic interventions that rely on teaching the patient reality-based thinking. Since they are behavioral modifications that can help the patient understand a problem rationally and think through solutions and put them into action in real life, they are far more effective than the games that focus on imaginary worlds.

      I would much rather work with a practitioner who will teach me how I can change my real-world thinking and behaving so I can have the ability to fix my own problems, than one who sends me off into some fictional other dimension in which I don’t have to change anything, just accept my problems as a side effect of being a special precious snowflake.

      1. Dave says:

        You’d enjoy the website despair.com, an “antimotivational” website that spoofs the trite ubiquitous motivational posters. One of their posters has a large photo of a snowflake with the caption “You are a totally unique individual.” Below it in small print are the words “So are the other 6 billion people on earth”.

  5. FredJ says:

    Dr. Crislip, I’ve seen enough posts by the SBM editors and contributors over the last few days to let me know that someone has the time to make a short, reasoned, reply to the Times article. I’m still hoping that one of you can do it. If not, it will be a big disappointment and a big teaching moment missed. I’m trying to figure out why someone doesn’t jump at this chance.

  6. Windriven says:

    I hope you will take the time in a future post to explore the medical homes concept at length. The glossies that Legacy links are compelling but incomplete. An exposition on the mechanics and financials would be really interesting. This could be a transformational model and a catalyst for the discussion of the structure of healthcare that you identify as needing to be had.

    “It is a good thing I learned a long time ago that it is the journey, not the destination, that can be is important.

    The only destinations that matter are way stations on the journey. Once the journey is complete the only destination left is a cold hole.

  7. Calli Arcale says:

    Ed, either you misunderstand the point of a placebo in a clinical trial, or you think it is acceptable to lie to patients, sometimes quite expensively, if their subjective experience is positive. That’s rather close to how most alt-med proponents defend their lack of evidence — why do I need evidence when my patients are satisfied? Isn’t that evidence enough? I knew a girl with bipolar mood disorder in college. When she was in the manic phase, she was absolutely on top of the world. Why take medicine? She’s *happy*! Of course, the fact that she felt so good wasn’t really good at all, and when the depressive phase hit, she was a total wreck, but far too crippled with angst to do anything about it.

    Honestly, I have a feeling that psychiatry is one field where you definitely do NOT want to content yourself with a placebo response, because we’re talking about disorders that color one’s perceptions of the world around them. These are people whom you cannot expect to have a true perception of how the medicine is working. Using placebos intentionally in lieu of actual medicine is just wallpapering over the fact that the person isn’t really getting any actual treatment.

    1. Ed Whitney says:

      Lytrigian above links to the JAMA meta-analysis which provided evidence that antidepressants are not more effective than placebo for mild and moderate depression. These findings are well known and have been for years. Is it ethical to prescribe them for people who do not meet criteria for severe depression? Is this not an act of deception? What if the patient reports feeling better on an antidepressant? Is the patient mistaken about his/her relief of symptoms?

      As for mania and its companion, depression, there are routes of inquiry which deserve a hearing. The mood swings are so dramatic that they grab everyone’s attention and give the appearance of great disorder. But what if mania has a structure? How would we explore it? What if we were to look for what is invariant (albeit not apparent) when the moods expand and collapse? What if we were to ask, “What is it that stays the same when mania gives way to depression?” What might we find if we asked if the two extremes of mood were variations on a common theme?

      For example, that theme could be something like, “To be OK, we must be special and even amazing.” In the depressed state, the theme plays as “I am not even close to being extraordinary; this means that I am not OK and I may as well not exist.” In the manic state, the theme plays as “I am extraordinary and amazing after all, this means that I am OK after all; isn’t that wonderful?” If you go after the common theme and avoid being distracted by the drama of the mood swings, you may find that there is a structure to the “disorder” after all.

      Proven? No. Plausible? Yes. And at the SBM plausibility should mean that the question is worth asking. It should be a green light that someone could profitably undertake an investigation into the possibility that there is another way of thinking about mania, which is notorious for “resisting” treatment; with a case fatality rate of approximately 15%, this condition warrants fresh thinking and a few new attitudes.

    2. AlisonM says:

      Thank you, Callie Arcale. I, for one, definitely appreciate the advances in psychiatric medicine. They may not be perfect, and they might not be the eventual answer, but they sure as heck beat the alternative. I’m one of those extreme cases with depression so deep that SSRIs are, quite literally, lifesavers. And I know more people than I’d care to who are in the same straits and have pursued the magical placebo-based treatments Ed is advocating. End result – I’m still alive and never had to stay in a psych ward, and am actually doing quite well, indeed. My woo-believing friends (the ones who are alive) have not fared so well.

  8. Mark says:

    Cam and mental health? Sure

    “massage therapy (MT) has an effect on trait anxiety and depression “that is similar in magnitude to what would be expected to result from psychotherapy suggests the possibility that these different treatments may be more similar than previously considered.””

    http://www.psychradio.org/sites/default/files/user1/pdf_files/Docs_pdf/MT%20meta-analysis%2C%20PB2004%281%29.pdf

    Perhaps not so oddly, this makes me question psychotherapy rather than increasing my faith in massage.

    1. Lytrigian says:

      My own take on psychotherapy, based on ongoing experience, is that it’s cheaper than a bartender.

      Bar tabs aren’t covered by my insurance, after all.

      1. Windriven says:

        If you find a carrier that covers bar tabs, let me know!

        1. William O. B'Livion says:

          Maybe under the ACA we can get that covered as “preventative treatments”?

        2. AlisonM says:

          You can have a prescription for vodka, or you can have a prescription for whiskey, but you can’t have prescriptions for both. . .

          1. Lytrigian says:

            But… but my prescription reads one bourbon, one Scotch, and one beer! Surely that’s on the formulary!

      2. AlisonM says:

        There are some pretty awful therapists out there. Some might never make it as bartenders, either. But when you find a good one, it is a really wonderful thing. It takes a lot of tries.

        1. Lytrigian says:

          Mine is very good. And I do occasionally get some alcohol out of him. He makes Spanish-style wine.

    2. Thor says:

      Mark, I hear what you are saying, but think massage therapy falls perfectly into Dr. Crislip’s Type 4 Variety of SCAM, namely that it isn’t really SCAM at all but has been co-opted into into the SCAM world. It all depends on the parameter, the claims made for massage.

      The manual manipulation of the body’s soft tissues (muscles, tendons, ligaments, fascia) to promote a senses of well-being, to provide pleasure and relaxation, and to aid in minor aches and pains is definitely NOT alternative. It is an accepted mainstream method for this. Massage has real effects on the human body. For this, no faith is needed. It is conceivable that a mentally ill patient would gain some benefit from massage.

      On the other hand—and this might be what you’re referring to—massage is absolutely SCAM when unfounded claims are made for it. Sadly, this is way to often the case, as it has been infected with SCAM ideology. Today, realistically, the field is fraught through and through with the wildest of claims about health and healing, with no evidence to back these up. Much of these claims concern some form of special, magical healing via the various energy modalities, “cleansing of toxins”, or manipulation of unsubstantiated entities like trigger points and “pressure” points.
      So for SCAM massage, yes indeed, you may need quite a bit of faith, just as with all the rest of the kooky stuff on offer.

  9. William O. B'Livion says:

    So where would you put Retro-Phrenology–changing people’s minds/attitudes by causing large bumps on their heads?

    1. AlisonM says:

      I would go back to school to study that.

  10. Sagely says:

    Could someone please do a post on soy and phytoestrogens? I can’t stand the pseudoscience about the “feminization” of boys and the hints at precocious puberty for girls. It is such fear-mongering, and the uppity parents that think they are “protecting” their children from a food source that has been consumed in large quantities by an entire continent is appalling.

  11. goodnightirene says:

    There is a lot of mixing up of terminology in the comments about psychiatry. People refer to meds and psychotherapy and placebos in a rather mashed up way. I spent some of the best years of my life dealing with a seriously ill child (no, I won’t say “mentally” ill because it’s a useless term) who saw quite a few doctors, many of whom were psychiatrists–none of whom did psychotherapy–this is done by psychologists and “counselors” who may or may not be psychologists. We did very little of that because there is little evidence of efficacy and few of the real doctors recommended it.

    Meds were a nightmare but did help once the right “cocktail” was established. No shamans, placebos, or soul savers required. He’s doing well at 27.

  12. Pete A says:

    sCAM relies entirely on (frequently inept) inductive arguments that have only rhetorical force: their inductive force varies from the totally absurd and wholly illogical to a minuscule level above zero.

    The very few areas of sCAM that were based on both deductive arguments and solid evidence have already been incorporated into science- or evidence-based medicine.

    The hallmark of quackery is its idiotic inductive rhetoric used to obfuscate its dire inability to construct any valid deductive argument.

    sCAM is indeed efficacious: this industry is annually milking at least tens of millions of £/$ from gullible members of the public.

    sCAM is not alternative medicine, it is an alternative means of acquiring personal incoming either directly or indirectly via fraud. It is, at best, a theatrical placebo that fully exploits the plethora of well documented human cognitive biases and both formal and logical fallacies. sCAM is a shining example of what can result from astutely combining good business models with the findings of modern social psychology and cognitive neuroscience.

    1. Dave says:

      Well said

  13. “Every day I see huge gaps and barriers to providing effective and quality care due to a deeply flawed health care system. People paying with their lives, health and financial wellbeing, due to lack of access to affordable science-based medicine, not a lack of access to alternative medicine, however it may be defined. That is the dialog that is lacking.”

    We have a loosey goosey SBM system and limited access to CAMs that work, both situation leads us nowhere! This impasse will not be broken with the same logic that got us here in the first place. I’ve being doing both and both sides are stuck in the a type of deception.

    Fortunate that I was disenchanted with SBM and really did not adapt full lethal dose of CAM modalities.

    I consider my ideas “immune” to the dogma of both. Arrogance? NO just a plain old gumshoe and fully independence of group loyalty. My mantra is patients first and why does a therapy work and why does it fail? I’ve seen failures in both and know for certain that modern medicine and some CAMs are flawed. The reason for both failure are about the same!

    1. Missmolly says:

      Wow, that was a non-specific and vague kind of response- I mean, are you aware that there’s seriously absolutely no content in what you just wrote…
      It did make me giggle to think about a “full lethal dose of CAM modalities”! Acupunctural liver laceration! Homeopathic waterboarding! Therapeutic touch Jackie Chan style!
      Made my day :)

    2. Dave says:

      What’s that old saying about the whole world being crazy except yourself?

  14. Young CC Prof says:

    The NY Times did not publish one single comment that opposed the use of alternative medicine! Outrageous! Is it because there weren’t any? Personally, I didn’t learn about it until after the deadline, but surely someone wrote to them!

    Or is it because the Times asked for a dialogue and then told only one side of the story?
    http://www.nytimes.com/2014/05/18/opinion/sunday/self-care-strategies.html?ref=opinion&_r=0

  15. FredJ says:

    Any one of the editors or contributors on this blog who could have made a very coherent response. They all knew about it well in advance. Either no one made an attempt, or else no one considered a response that would be seen on the editorial page of one of the world’s most-read newspapers to be worth making.

    Now, let’s go back to complaining about why the mainstream media won’t listen to the SBM-side of the argument.

    1. Sawyer says:

      Fred and Young CC,

      But someone DID get a word in against alternative therapies. Ed Erwin pointed out that gullible consumers will pay good money for treatments not proven effective. Beyond that I don’t know what an SBM writer could have offered.

      Obviously there is a lot more to say about alternative medicine, but how is it even possible to offer a substantial critique in 2 or 3 paragraphs? The entire conversation that takes place in a newspaper is biased from the very beginning because it takes several pages of text just to explain the basic philosophy behind science based medicine, let alone start tackling individual therapies. And with the decline in print media I don’t see this trend changing in our favor any time soon.

      Once again I have to hand it to the cynical leaders of the alternative medicine movement. For several decades they have framed the conversation about medicine in a way that fits conveniently in a newspaper column or five minute television segment. Heck, they even come out ahead on shows like Science Friday that should in principle not give them the time of day. Short attention spans and feel-good reporting are the best allies of CAM. The rest of us that write for an audience that reads journals and textbooks are in an impossible situation. How do we condense hundreds of years of science into a half page op-ed?

    2. weing says:

      “Either no one made an attempt, or else no one considered a response that would be seen on the editorial page of one of the world’s most-read newspapers to be worth making.”

      Or what we are seeing is what the editors and author agreed to publish and respond to.

      1. Tazia Stagg says:

        They can’t publish anything that doesn’t get submitted.

        1. weing says:

          “They can’t publish anything that doesn’t get submitted.”
          I should hope not.

    3. Tazia Stagg says:

      You’re right.
      Everyone’s busy. (That happens to be one of the reasons that people are “too” credulous to begin with!)
      Here’s my more specific personal excuse: I didn’t know about it until Friday.

  16. Irreducibly simplex says:

    Stephen S. Rodrigues.
    I understood all of the words you used but halfway through your post they started to spin in a counterclockwise direction faster and faster until soon they made no sense at all.

    1. Windriven says:

      Dr. Rodrigues’ “reasoning” skills are slightly less coherent than his attempts at expression. Many of us here have squandered countless hours trying to explain the fundamentals of science and logic to him. Steve can say the words but, like a TRS-80 struggling with a Turing challenge, they don’t mean anything.

      I suspect that he did his residency in a Syrian torture chamber or some such place. He speaks of countless failed surgeries and regiments of damaged patients, wracked with pain.

      He also seems to have some sort of messiah thing going on where he sees himself and his needle quackery as a great savior. But I compared his patient satisfaction ratings on one of the healthcare sites and he didn’t fare well compared to other internists in his immediate area. So it would appear that some. Portion of his patients were looking for something he couldn’t or wouldn’t deliver. One wonders if that might have been traditional medical care.

      I’m not sure why he comes here. He hasn’t said anything new in months, he is regularly corrected and increasingly ridiculed. But there he is uttering bursts of barely coherent inanities as if suffering from some bizarre variant of Turette’s.

      1. Windriven says:

        Tourette’s

    2. “Irreducibly simplex”
      If you read the references, practice, research, ask questions, use the 5 why concept, you may break the cycle of group thinking.

      How do you expect to expand your knowledge if you hang out with dogmatist.

      “windrive”
      Has knowledge but no common sense and has no idea of the plight of the clinical practitioner. You really do not have to respond to my post, I’m here to add balance, reason and insight into the CAMs that are vetted valid and beneficial.

      1. Windriven says:

        ” I’m here to add balance, reason and insight into the CAMs that are vetted valid and beneficial.”

        Hahahahahahahahahahahaha! You’re hysterical, Steve! You are here to muddy, to distort, to cloud, to add illogic, fantasy, and delusion. But most importantly, you’re here to provide comic relief.

        1. Ed Whitney says:

          Not to worry, Steve old chap. Windriven has insufficient information to diagnose Tourette’s without examining you.

          I do distinguish between strong disagreement with someone and making a medical diagnosis of the same person. I disagree vehemently with the Tea Party, with Neo-Confederates, with fundamentalists who interpret the Bible literally, with free market extremists, and with Constitutional originalists, but I do not think that they have anything organically the matter with their brains. I do not think they need to be medicated, only that they need to be opposed politically at every turn, and that they must be kept away from exercising unopposed governmental powers.

          Modern medicine can do nothing for them. Nor should it.

          1. Windriven says:

            Ignore Ed, Steve. His language skills are apparently as … unusual … as your own. The giveaway is the phrase ‘as if’ in the predicate clause:

            ” But there he is uttering bursts of barely coherent inanities as if suffering from some bizarre variant of Turette’s.(sic)”

            The ‘as if’ is your clue that what follows should be taken metaphorically rather than literally.

  17. Ed Whitney says:

    Website comment threads illustrate some of the perils of the digital age. Most of us have never met one another, and, in contrast to when people sit around a table and listen to one another talk, our dialogue is constrained by a lack of eye contact, inability to detect nonverbal cues (emoticons do not quite suffice), and considerable lapses of time between statements of opinion, challenging questions, and response to questions. In a verbal conversation, we can say, “Do you mean this?” and our interlocutor can say, “No, I mean that.” Blog threads do not work that way. We are all of us at the mercy of the ability of supposedly educated persons to read.

    Reading is difficult. I have been working at it for nearly six decades and am still trying to get the hang of it. Hardest thing is knowing the difference between reading what is printed on a page and reading into what is printed on a page. In reading their comments, I may form mental pictures of other parties to this long interchange, but can also have some awareness that these mental pictures are, formally speaking, hallucinations, divorced from reality and bearing no resemblance to the actual flesh and blood person. This can happen to anyone.

    Writing is not much easier than reading; crafting a paragraph whose clarity precludes misunderstanding is another skill easy to aspire to but fiendishly difficult to attain. Dr. Crislip began this thread by discussing what he does for a living, finding specific interventions for specific diseases. He also runs through a differential diagnosis when seeing a patient with fever and prostration, knowing very well that things are not always as they seem at first glance and that one condition may very well masquerade as another.

    I asserted that not everything which comes to the attention of a psychiatrist is a real disease, and “documented” this assertion with a link to a piece of autobiography which declares that when presented with an apparent case of manic psychosis but no history of drug intoxication, medical illness, or prior psychotic history, psychiatrists need to be able to consider more than one possible explanation for what they are seeing. They need to have a differential diagnosis, just in case what looks like one thing is really something else. Spiritual emergency was the possibility I suggested they consider. I further contended that this is not a real disease. It is more apt to consider it as a disarray of language, which (autobiographically) responded to intervention in the form of language whose vocabulary is adequate to re-connect its idiosyncratic preoccupations back into the grounded language of the social community in which its fellow human beings reside.

    This language includes references to higher orders of being, the nature of transcendence, the traps into which souls can become entangled, what it means to be made in the image of God, and other forms of discourse which, while incurring the disapprobation of many, elicits the empathic understanding of others. The dénouement of my particular episode was fairly prosaic; the whole thing served the purpose of learning that I could get the hell out of clinical medicine and switch to occupational epidemiology without somehow betraying the memory of my internist father. Nothing airy-fairy about that.

    A little flexibility goes a long way. Science is a powerful language, but not the only one. Some physicians, psychiatrists especially, need to speak more than one.

    1. Windriven says:

      “The dénouement of my particular episode was fairly prosaic…”

      To my eyes your proclamation of a dénouement appears premature.

      1. Ed Whitney says:

        Good point, Windriven! No sense in jumping to conclusions of stability based on twenty years of no recurrences and 18 years of steady work in the same place. Better wait for more data. Never pays to be hasty.

        Allow me to amend “dénouement” to “provisional dénouement.”

        1. Windriven says:

          Yeah, sorry Ed but your grip on reality seems a bit tenuous. I don’t think you can claim even provisional status until that firms up a little.

          1. Lytrigian says:

            I’m dealing with a bit of this at home right now, and believe me: From inside their own heads, they can’t see it.

  18. QTone says:

    Acupuncture- based on mysterious energy flows that nobody has yet identified. This from people who did not know that blood flows round the body.

    1. “QTone … Acupuncture- based on mysterious energy flows that nobody has yet identified. This from people who did not know that blood flows round the body.”

      Where did this come from???
      It is not based in reality!!!
      This is conclusion is short sighted!!

      1. these mysterious energy flows are all around us and we do know of many and will discover more in the future. ie magnetism, IR radiation etc
      2. we do know that birds and humans are influenced by these “invisible” energy flows. oh yes Wifi is one of those too
      3. I really think that eventually they figured out that blood flowed through vessels as anyone who slaughters animals for food. They we astute observers of nature.
      4. They were bound by a dogma isolated society that locked them out of many scientific concepts.

      This is not the best way to disparage a very effective therapy.

      1. WilliamLawrenceUtridge says:

        Where did this come from???
        It is not based in reality!!!
        This is conclusion is short sighted!!

        Acupuncture isn’t based on reality, that’s true.

        1. these mysterious energy flows are all around us and we do know of many and will discover more in the future. ie magnetism, IR radiation etc

        So you actually think acupuncture works by manipulating qi? We can detect a single photon landing on a detector from a star that died a billion years ago, but somehow qi, powerful enough to change the physiology of whole organ and organisms escape us? Really? You’re seriously basing your claim for the effectiveness of acupuncture on the existence of a hitherto-undetected form of energy that solely influences living tissues but can be influenced through the use of metal needles? If this energy flow is so important and vital, why do different schools of acupuncture identify different acupuncture points, different meridians, use different materials and on different parts of the body yet all achieve the same success? And if you rely on the manipulation of qi, why do you cite Travells and Simons, whose theories operate purely on the belief of a physical mechanism of trigger points caused by diseased muscle tissues? Which is it, qi or trigger points?

        2. we do know that birds and humans are influenced by these “invisible” energy flows. oh yes Wifi is one of those too

        We can measure the energy produced by Wifi, we can map it, and we can use it to connect electronic devices separated by thousands of kilometers. The energy might be undetectable with our raw senses, but we can easily detect it. Also, this energy does not affect humans.

        Bird navigation does not rely on magical energy, it relies on landmarks, the sun, the stars, memory, the Earth’s magnetic field and scent maps.

        3. I really think that eventually they figured out that blood flowed through vessels as anyone who slaughters animals for food. They we astute observers of nature.

        Do you know who William Harvey was? Until Harvey, nobody, including in the Chinese, knew vein flow was unidirectional. And that’s despite animals being slaughtered and humans dying in accidents and battles the world over. I’m not saying this to assert the West was magically wiser than the Chinese – the use of empirical research to test claims just happened to reach a self-perpetuating critical mass there first, at which point it inevitably became permanent.

        4. They were bound by a dogma isolated society that locked them out of many scientific concepts.

        What the hell are you even talking about? Chinese dogma meant bodies could not be dissected, which means they relied solely on dogma for their ideas. China’s failure was relying on dogma, your failure is perpetuating this error.

        Truly you are the punchline of the joke “what do they call the worst graduate of medical school?”

        This is not the best way to disparage a very effective therapy.

        Acupuncture doesn’t work.

        1. All circular logic and personal attacks on the people. Of course you statements have some correct info but in your argument they do nothing to bolster your position.

          Do some leg work talking to real people. It is much different that looking at words every day.

          ?? did you say you see and treated patients ??? I have to find that story.

          1. WilliamLawrenceUtridge says:

            All circular logic and personal attacks on the people. Of course you statements have some correct info but in your argument they do nothing to bolster your position.

            I’ve asked you for references to support your beliefs, but you just dump irrelevant lists of citations that do not support your assertions. After asking for citations many, many, times, and after getting nothing but vague platitudes, claims that I should trust you because you’re a doctor (more on that below) and accusations of being a paid shill for some illusory entity, I’ve come to the conclusion that calling you a liar, a hypocrite, and plain stupid are all closer to simple facts than insults.

            Look, it’s easy – you claim that acupuncture is a miraculous healing thing. I’ll be more likely believe you if you can provide me with some references to substantiate this point. And real references, not irrelevant lists.

            Do some leg work talking to real people. It is much different that looking at words every day.

            ?? did you say you see and treated patients ??? I have to find that story.

            Both doctors and patients swore that bloodletting was an effective treatment for every disease under the sun. Priests of Thoth and their worshipers in Ancient Egypt swore that prayer to Thoth was an effective treatment for every disease under the sun. Orthopedic surgeons and their patients swore that knee cartilage debridement was an effective treatment for knee pain.

            Talking to real people and doctors is not nearly so helpful as well-controlled scientific trials. People can believe incorrect things, such as the earth being flat and orbiting the sun – beliefs without proof and careful testing are more likely to be wrong than right.

            So – where are the sources that you use to justify charging patients money to stick needles in them?

  19. QTone says:

    Re Stephen Rodrigues comments: Which of my statements is not true? First, what is the evidential basis of the Qi hypothesis? My understandings that it is ascribed to some form of energy flow, but on what evidence? If it is a form of energy it has eluded detection for millennia, so I have difficulty in understanding how one can claim it is a form of energy without evidence.
    Second, I would be grateful to hear of any evidence that the ancients who invented acupuncture actually knew that blood flows around the body as opposed to merely seeing that blood comes out when you cut into a body. It seems strange to hypothesise an undetected energy flow while not understanding the flow of blood.

    1. WilliamLawrenceUtridge says:

      Have a look at this paper, which I also link to above:

      http://www.nzasia.org.nz/downloads/NZJAS-Dec01/Jingbao.pdf

      Of course, Steve, being incapable of actually reading something (but perfectly capable of copy-pasting irrelevant lists), will pretend he never saw this comment.

      1. Windriven says:

        That link provided fascinating breakfast reading, William. Thanks.

        1. WilliamLawrenceUtridge says:

          Random google result- traditional chinese medicine blood history beliefs was the search string if I recall correctly.

      2. That article is correct but does not negate the effectiveness of all aspects of “Acupuncture.”

        You have to look a lot deeper and more expansive into the data.

        1. WilliamLawrenceUtridge says:

          That article is correct but does not negate the effectiveness of all aspects of “Acupuncture.”

          You have to look a lot deeper and more expansive into the data.

          What data? You have yet to provide any relevant sources that justify acupuncture as a form of medical treatment? But at least we have agreement that the Chinese had no rational basis for their use of acupuncture, that their acupuncture points are irrelevant and that the meridians or conduits don’t exist. I’ll assume you think qi doesn’t exist either.

          But I will ask again – what data justifies charging patients for acupuncture?

    2. Windriven says:

      In the unlikely event that Steve replies to your questions, his answers will predictably be non sequiturs and will be summed with unsupported assertions that acupuncture works for his patients; sad unfortunates who have been damaged by amputations (yes, he actually argues that joint replacements are amputations) or otherwise suffered from mistreatment by a medical system interested only in its own profits. He might also ask who is paying you.

      This is a pattern from which he rarely deviates. Consider yourself lucky if he simply ignores your questions.

      1. “(yes, he actually argues that joint replacements are amputations)”

        To some Mandela was a radical to others he was a freedom fighter.

        When you remove a part of the human body it can be called amputation:
        http://www.vascularweb.org/vascularhealth/pages/amputation.aspx

        Another name I give to the removal of a joint without a complete informed consent is “theft of property.”

        @Qtone, what is your intent? The truth or consensus?

        1. WilliamLawrenceUtridge says:

          To some Mandela was a radical to others he was a freedom fighter.

          Yes, but that is a political question. “Does acupuncture work” is a medical question that needs to be answered by references in the scientific literature. Where are the scientific sources that justify charging patients money for acupuncture?

          When you remove a part of the human body it can be called amputation

          And when you replace a broken lever with a titanium duplicate that isn’t in danger of fracturing, the titanium replacement works well.

          Or do you consider surgery to remove a bullet “grievous bodily harm”?

          Another name I give to the removal of a joint without a complete informed consent is “theft of property.”

          What do you call it when a doctor offers services for which there is no evidence base? I call it medical malpractice.

          @Qtone, what is your intent? The truth or consensus?

          Rather than attacking the person, why not address the issues he raises?

  20. QTone says:

    Thank you for the links. Fascinating stuff. And the other insight is the belief that food goes from the stomach to the lungs. Another piece of the knowledge base supporting acupuncture.

  21. Yall are mixing science, evidence and personal beliefs, which in the SBM world or even medicine should be done with clarifications.

    Acupuncture is a vast world of disciplines, concepts and ideologies, some are rooted in ancient traditional beliefs and some in pure science. The most effective are in a class of myofascial release therapy with needles so called Myofascial Needling.

    Pure science and the truth can not be negated, sorry! The trues of both SBM and CAMs will compensate for their deficiencies which will improve clinical outcomes. So that means CAMs are a part of this pure science and is forever. CAMs must be converged back into traditional medicine for modern medicine to survive into the future.

    What you have thought through are your personal concepts. Without all the data your thoughts are flawed, incomplete and dangerous to unsuspecting people. Please let people know these are only your opinions.

    1. WilliamLawrenceUtridge says:

      See my reply here, since this is an exact duplicate of another post you made.

  22. Hmmm it’s been 6 hours from the time I pressed send for my post??

    Is someone sleeping or are you guys excluding me from the most fun I’ve had in a while?

    1. Windriven says:

      “Is someone sleeping or are you guys excluding me from the most fun I’ve had in a while?”

      Neither, Steve. We’re bored. You say the same stuff over and over and over. It gets tiresome. After a while it just isn’t worth bothering to respond. And those last two paragraphs are so incoherent and delusional that no one is likely to touch them.

      Do you know Neitsche’s observation?

      “Beware that, when fighting monsters, you yourself do not become a monster… for when you gaze long into the abyss. The abyss gazes also into you.”

      It applies to crazy every bit as much as it applies to evil.

  23. QTone says:

    I asked two specific questions as to the validity of the two points. Neither point has been rebutted. Some of the other stuff is going too far. I am reminded of Hanlon’s Razor: Never attribute to malice that which is adequately explained by stupidity.

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