HOMEOPATHY IN PERSPECTIVE

CHAPTER 12: WHERE DOES HOMEOPATHY STAND TODAY?

Just a placebo?

So where do we stand? The whole question of alternative medicine in general and homeopathy in particular is bedevilled by prejudice, but if we put this aside as much as possible the conclusions that present themselves are rather unwelcome for enthusiasts and critics alike.

Critics would like to be able to dismiss the whole thing as a mare's nest, but it is rather hard to do this in the face of the available evidence. Fisher is right: there is quite good research to show that at least some homeopathic medicines have a real effect.

On the other hand, the enthusiasts should be cautious about crowing too loudly. Yes, there does seem to be an effect, but it's small, and it cannot be related convincingly to any particular method of prescribing. Pathological prescribing, "classical" (i.e. Kentian) homeopathy, and complex homeopathy (the use of mixtures) all seem to be about equally effective. And some recent trials have been based on homeopathic medicines given by intra-articular injection or by external application to the skin, both of which seem to stretch the definition of homeopathy to the limit, if not beyond. The boundary between homeopathy and herbalism (phytotherapy) was always indistinct but seems now to be threatening to disappear altogether.

My own impression, after many years' experience of homeopathy, is that the 15% effectiveness rate is about right. Let me make it clear that I don't mean by this that only 15% of patients get better: the perceived effectiveness is certainly higher, but 15% is about the proportion of cases in which there seems to be an effect from the medicines that would be likely to show up in a randomized controlled trial.

I'm agnostic about whether this is a 'real' effect, due to the medicines themselves rather than to extraneous factors. One thing that concerns me is that it is very difficult to point to any groups of disorders that respond consistently well to homeopathy. This is not the case, for example, with modern acupuncture, whose effects are reasonably predictable. Such unpredictability tends to favour the idea that the effects are mainly due to effects unrelated to the medicines.

If we consider the "standard" homeopathic consultation, by which I mean the Kentian version, it is undoubtedly well suited to maximize the placebo effect, for a number of reasons.

First, it takes a long time; most homeopaths like to allow at least 45 minutes for a first consultation and many prefer an hour or more.

Second, patients feel that they are being treated "as an individual". They are asked a lot of questions about their lives and their likes and dislikes in food, weather, and so on, much of which has no obvious connection with the problem that has led to the consultation. Then the homeopath will quite probably refer to an impressively large and imposing source of information to help with choosing the right "remedy". In the past this would almost certainly have been Kent's Repertory, a large thick book like a dictionary. Today it may well be a computer, for programs now exist which allow the homeopath to refer not only to Kent's material but also to several other compilations of homeopathic lore. Unkind critics have seen a resemblance here to consulting the I Ching or casting an astrological horoscope.

Whatever adds to the ritual serves to enhance its efficacy. At one time I used to practise homeopathy privately in the rooms of a colleague who had a lot of remedies that were about fifty years old. They had been prepared long ago by a homeopathic doctor who had made them by hand, and they had been preserved by a process known as grafting. The medicines consisted of lactose powders, contained in bottles with handwritten labels and neatly stacked in rows on the shelves of cabinets.

The "grafting" consisted essentially in adding fresh lactose to the almost empty bottle, perhaps with a little alcohol-water mixture, and shaking it for a short time. This procedure was supposed to transmit the energy of the medicine to the added lactose - to potentise it, in fact.

This was quite a common procedure in earlier times but would generally be frowned on today; modern homeopathic medicines are made with strict "quality control" to ensure their effectiveness. The starting "mother tincture" is assessed for purity and the process of alternate dilution and succussion is carried out according to strict rules. The whole manufacturing sequence is carefully regulated to ensure that the medicines are made in the correct way.

Theoretically, medicines prepared in the modern way ought to be better. Our experience was, however, that patients nearly always seemed to respond better to the grafted medicines which we prepared ourselves, rather than to those which we had sent from the homeopathic pharmacies.

We would carefully tip out some of the granules from the bottle onto a little square of clean white paper, which we would fold into a packet. Typically there would be several of these packets, perhaps five or seven, which were numbered to be taken in sequence on a daily basis. Patients would watch us making these preparations and then carry the medicines away reverently to take later at home.

We were ourselves surprised at the consistently better results we obtained with our old medicines, but we weren't alone in this experience; other homeopathic doctors who used the same procedures, though with different stocks of medicines, also found that method to be better. Was this because the hand-made medicines of yesteryear really had some magic ingredient that their modern machine-succussed counterparts lack? Possibly. In retrospect, however, I think it more probable that the ritual of preparation witnessed by the patient was in itself impressively therapeutic and that the superior efficacy of the home-made medicines was due to this.

So are we to conclude that homeopathy is simply a powerful placebo? Probably, yes, but a placebo in the sense that psychotherapy is a powerful placebo. A homeopathic consultation affords the patient an opportunity to talk at length about her or his problems to an attentive and sympathetic listener in a structured environment, and this in itself is therapeutic.

Psychotherapy is defined as "the talking cure", and judged on that basis, homeopathy is a form of psychotherapy. This is true whether or not the homeopath recognizes that she is using psychotherapy. Many homeopaths would agree that there is an element of psychotherapy in the consultation, but they would not accept that that is the main part of it. However, homeopaths generally pride themselves, often with justification, on being people with good powers of intuition and empathy; indeed, unless they have these abilities they will not succeed in their profession. This also means that they are good psychotherapists.

The psychiatrist Anthony Storr is sceptical about much psychoanalytic theory but nevertheless thinks that psychoanalysis can have beneficial effects on patients. I should say the same is true of homeopathy.

Much or all of homeopathic theory may be mistaken, and the remedies themselves may have little objective efficacy or even none at all, but patients often get better nevertheless. To say that this is due to the placebo effect is to beg the question, because we don't know what the placebo effect is anyway. For many patients, especially those whose symptoms really arise from their life situation, merely stating their problems verbally is sometimes enough to put them in a new light and to suggest the direction to look for a solution. In such cases the therapist is merely a sounding board; indeed, even a computer will do as a listener for some people. Many others do need a human individual to interact with, however.

So is the therapist no more than a sympathetic friend? No; this is where the theory comes in. It often doesn't matter much what a therapist's theoretical beliefs are (provided they are not actually dangerous, of course); their function in many cases is not to be "right" but to provide a framework to keep the discussion in focus.

The homeopath is not just chatting vaguely and asking questions at random, but is trying to use what the patient is saying as a guide to the right remedy. This gives the interview a frame of reference and prevents it from becoming totally shapeless. In this sense, homeopathy undoubtedly "works".

Most practising homeopaths, of course, would reject this analysis and would insist that the remedies they use have real effects and that the psychotherapeutic aspect of the consultation is secondary. Some, however, do give due importance to the placebo effect; one very experienced homeopathic doctor, with a strong research background, told me recently that he would continue to use homeopathy even if research were to show that the medicines had no objective effect.

The future of homeopathy

Much of the popularity of alternative medicine today, homeopathy included, is that it appears to be philosophically different from mainstream medicine. The fact that it is condemned as unscientific by some orthodox doctors is for many people a positive merit, not a criticism. For how long this will continue is impossible ÷to know; the question is bound up with the whole future of our civilization.

As we saw earlier, Richard Hughes in the nineteenth century tried to bring homeopathy and orthodox medicine together. He failed, but there may be a return to this way of thinking now. Modern doctors who study homeopathy tend to do so more empirically than used to be the case. Homeopathy today seems to be less firmly based on its alleged foundation in the provings, and we increasingly see research papers on treatments which are called homeopathic but which stretch the definition of homeopathy to the breaking point; the boundaries between homeopathy and herbalism (phytotherapy) are becoming ever harder to discern.

In spite of these changes, however, homeopathy is unlikely to become widely accepted by doctors unless and until a plausible explanation for its alleged effects appears. This applies with particular force to the potency phenomenon but it also applies to the medicines themselves. Vague statements claiming that homeopathy "stimulates the body to heal itself" are unacceptable scientifically. At present such explanations seem pretty remote. But, if they did emerge, what would be the effect on homeopathy?

I think the effect would be that homeopathy would lose much of its aura of mysticism and ultimately become just a branch of pharmacology, very much as Richard Hughes envisaged. That may or may not happen, but if it does, those people who are reacting against science (some doctors, most non-medical homeopaths) will lose interest in it and look elsewhere for what they need. Throughout the history of homeopathy there have been two divergent tendencies among its adherents. Some, such as Hughes and Dudgeon, have been scientifically minded and have sought to minimise the differences separating homeopathy from orthodox medicine, whereas others, such as Kent and his twentieth century British epigoni, have rejected orthodox medicine more or less completely and have sought to keep homeopathy "pure". The difference in outlook seems to be a temperamental one and will probably always exist.

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