This article originally appeared in The Skeptic, Volume 22, Issue 4, from 2011
It seems that every time I write or speak to an audience outside of the United States I am saddened to announce another quackery that originates from or has a major emphasis in that country. Today I am again ready to tell you about one more example of the gullibility to be found in the USA. Today’s example also claims to have research to support it. So let us begin.
The comfort of the patient and the alleviation of suffering have always been top priorities of the noble profession of nursing. In recent decades many nurses have felt that with the increasing use of technology, advances in scientific medicine, and the cost-cutting emphasis of health insurance groups and the introduction of ‘practical nursing’ (whose practitioners usually have less education, less experience, and who accept lower pay), nursing is becoming marginalised and trivialised.
It is understandable that frustration with this perceived situation would serve as an incentive to embrace new concepts and techniques that would be unique to nursing and be consistent with the priority of better patient care. Nurses have always felt that they were closer to the patients and more sensitive, more empathic and more aware of the needs of patients. They also have more time to truly ‘care’ for the patient than do overworked physicians.
In the early 1970s, Dolores Krieger, a professor of nursing at New York University, introduced the technique of Therapeutic Touch (TT). She also collaborated with Dora Kunz to develop a philosophical background to provide an understanding of the processes which underlie TT. Initially it was suggested that TT had close associations with Eastern mysticism and metaphysics. References were made to an undefined human energy field which could quite possibly be related to Chi, Prana, and chakra energy centres in the body and in addition the idea was that somehow this energy field could become disturbed and TT was one way to ‘unblock’ the energy field and restore health. However, some of these terms and associations have been minimised in recent years, perhaps in an attempt to reduce resistance from science – and evidence-based medicine. It is quite understandable that questionable New- Age associations would make it easy to dismiss TT as yet another quackery which would claim to be exempt from ‘Western’ scientific scrutiny.
The techniques of TT could easily be taught to nurses and soon claims were being made that patient comfort, satisfaction and recovery from various ailments were all markedly improved by the administration of TT. At the same time, critics were concerned by what they perceived to be New Age mystical nonsense. While the beneficial effects of actual physical contact/touch to the development of infants, the enhancement of interpersonal relations and general physical and mental health have long been recognised, this new TT is actually the application of ‘non-touch’ where a practitioner holds her or his hand(s) several inches (7-12 cm) above the patient’s skin. In demonstrations of TT the practitioner is seen to wave their hands over the patient and end by shaking their hands away from the patient, as if shaking off droplets of water, but here it is considered to be shaking off the ‘negative energies.’ If one ever observed the followers of Mesmer (animal magnetism), or the traditional psychic healers, the same hand-waving behaviours are seen.
Kreiger and her followers do deserve some credit for recognising that modern evidence-based medicine demands research to support new and controversial health care techniques. Adherents of TT point to more than 20 years of accumulated research that, they say, provides adequate support for the efficacy of TT. The latest available information suggests that more than 85,000 health care workers (mostly nurses) practice TT, that it is taught in 76 countries including the UK and over 100 schools of nursing. However, until recently critics easily dismissed such research because double-blind procedures were not used, the critical measure was actually irrelevant to the condition being studied, too few subjects were tested and results could not be replicated.
However, the field of TT seems to have a seriously split personality. On the one hand there has been some attention to research, but on the other hand there are probably many more instances of an outright hostility or antipathy to the requirements of a science-based healthcare practice. It is interesting that even some proponents of TT have written reviews of the research and concluded that not only is there inconclusive support for the proposed effects of TT, but also most previous research is seriously flawed (Meehan, 1998; Mulloney & Wells-Federman, 1996). Bullough and Bullough (1998) have given an excellent in-depth examination of the occult/mystical/spiritualism roots and continued associations of TT.
Recent research has attempted to examine TT effects on human cell growth and DNA synthesis. This is a marked departure from previous human subject research. It has been dissected by Rosa. As an interesting tidbit of history, one of the earliest critiques of TT was an article in the Journal of the American Medical Association by Emily Rosa (age 11) in April 1998.
My German Experience
Not so long ago this writer had the opportunity to visit with the founder of the Imre Kerner International School of Therapeutic Touch and Energy (formerly known as the Deutsches Institut für Therapeutic Touch) in Haltern, Germany. Dr Imre Kerner has an extensive website that includes references to his many training seminars, books and video tapes to buy, and coverage of recent research studies (all of which are reported as supporting TT) and an affiliation with a European group called International Therapeutic Touch Association (ITTA). One of Kerner’s goals is to standardise the training and certification of TT practitioners, including requiring a background in nursing or medicine, although his own degree is in chemistry. He has obtained his own background in TT through extensive travel to the United States including contacts with Dr Elmer Green (Topeka Kansas, biofeedback and ESP), Dr Janet Quinn (University of Colorado School of Nursing), and Howard Storm (California shaman, healer and writer). And prominently displayed on the wall of his office is a certificate from the Healing Light Center Church. This church is a spiritualist church in California founded and directed by self-proclaimed healer, clairvoyant and medicine woman, Rev. Rosalyn L Bruyere. Dr Kerner, like most adherents to alternative medicine (he prefers the term “cooperative medicine”), accepts completely and uncritically the ideas of energy medicine and a human energy field. Dr Kerner is convinced that the human aura is evidence of this energy field. Kerner’s (and the ITTAs) goals of standardised training are quite similar to those in the USA of the Nurse Healers Professional Associates International organised by Janet Ziegler. The problem for both groups is that neither one has the power to certify practitioners and neither is recognised outside of their own TT community.
Kerner’s web site lists thirteen “recent” TT “research” studies. The authors of one of these studies are bold enough to state that “control of confounding variables was not possible, and therefore not an object of concern.” This writer is alarmed that this almost seems to reflect an arrogance that scientific protocol is irrelevant as long as positive results are obtained. Five of the twelve studies report non-significance, two others misuse statistics, two are ‘pilot’ studies, one is a simple case report and the remainder lack adequate control groups and blinding of subjects. If early research has been either thoroughly discredited or (in a very few cases) not replicated, recent research has done little to increase one’s confidence in the case for TT. Turner’s (Turner et al., 1998) oft-cited burn study and an osteoarthritis study (Gordon et al., 1998) have been carefully examined and found to follow closely in the tradition of other poorly designed, poorly executed and poorly analysed studies (Wagner, 2000). Clearly, the well done research study still remains to be reported.
On the one hand Kerner is to be admired for his professed dedication to a more rigorously trained and respected profession of the TT practitioner. He also seems to avoid the emotional anti-science diatribes of many supporters of TT. On the other hand it is sad to see that he doesn’t seem to understand the subtlety of human interactions that are evident in any healing profession. And it is precisely this subtlety that needs to be critically examined and controlled in any scientific research study of TT. This writer wonders whether research training in the physical sciences (Kerner is a chemist) commonly ignores this problem because it is obviously seldom encountered there. (Of course one might counter that the historical examples of experimenter error found in the works of astronomers Nevil Maskelyne and David Kinnebrook in 1796 – reaction time – and the work of Rene P Blondot dealing with the elusive ‘N-rays’ in 1903 would suggest that such problems are indeed found in the physical sciences.)
Distant Healing?
Since TT does not involve actual physical contact, we may ask just how far away can the hands of the healer be from the subject? Can TT be compared to ‘distant healing?’ In fact Astin, Harkness, and Ernst (2000) attempted to review studies of distant healing. They included studies of prayer, mental healing, spiritual healing and eleven studies of TT. Their conclusion was that overall, approximately 57% of trials showed positive treatment effect. However, Courcey (2001) has shown clearly that these eleven studies do not give any support to the efficacy of TT.
Glazer (2001) reports that shortly after the September 11 World Trade Center disaster the NHPAI website suggested that long-distance non-touch therapy could be performed on people who died in the tragedy and quotes Dolores Krieger as she explains her (somewhat mystical) attempts to help the victims by long distance.
The Two Minds of TT
Many aspects of alternative medicine share with TT a deeply inconsistent nature. On the one hand they seem to be strongly committed to research. But when design flaws are found or the research is not supportive of the claims, the proponents of these alternative approaches quickly switch and say that science is irrelevant or is not necessary or that the mysterious physics of quantum mechanics surely has answers that confirm the legitimacy of TT. Not only is there evidence of inconsistent thought among TT practitioners, there is also a pronounced paranoia. One hears that physicians are conspiring to denigrate the noble profession of nursing and that health insurance organisations want to hire less-educated practical nurses to save money. Kreiger herself complains of the “strongly reactionary forces whose viewpoints are embedded in materialistic and reductionistic philosophies” and of “the frankly hostile lockstep reactions of the (skeptical) media.” (Krieger, 1999).
A critical editorial published in Research in Nursing and Health (Oberst, 1995) produced an avalanche of letters that clearly demonstrates the anti-scientific attitudes of many TT supporters. The writer of the editorial said there was neither empirical evidence for a human energy field (HEF) nor credible research supporting TT. She went on to suggest that TT actually wastes time and resources in patient treatment. Her main point was that too many doubters were unwilling to publicly say that “the emperor has no clothes.”
Also in Research in Nursing and Health, one letter-writer argued against the “blind acceptance of reductionist inquiry” (Wells-Federman, 1995). Another (Bright, 1995) managed to use at least three of the standard arguments of New Agers. She suggested that women have long suffered persecution because they threaten the “interests of conventional medical men.” Further, she argued that the perception of “the force of subtle energy” (the HEF) has been “dulled, even forbidden through years of Western mechanism and scientific positivism,” and that Krieger has re-discovered a sensitivity “long lost through the development of Western civilisation.” And Daniels and McCabe (1994) state that those male-dominated, authoritarian Western paradigms must be overthrown. Yet another writer (Malinski, 1995) suggested that an equally valid alternative worldview exists where “personal knowledge, feelings and values are primary sources of information,” and “this diversity needs to be celebrated in nursing.” Cynthia Hutchinson, a TT instructor in Boulder with a doctorate in nursing, told the Los Angeles Times that the Journal of the American Medical Association was itself suspect because “it is a political organisation and many physicians… feel threatened by human aura therapy because it means that their power and money are being taken away” (Satel & O’Mathuna, 2000).
It is clear that there is a pervasive anti-science, New Age viewpoint present among TT proponents. They bring up the false dichotomies of “Eastern” vs. “Western” science and of “Female Intuition” vs. “Male Science” when the actual dichotomy is between pseudoscience and science.
It seems that TT’s connection with New Age thinking is no mistake. Kreiger’s co-founder of TT is Dora Kunz. Kunz herself is a self-proclaimed psychic and has strong ties to the mystical Theosophical Society in America. The originator of Theosophy, Madame Helena Petrovna Blavatsky, has been called the matriarch of the New Age (Fish, 1996). Here one can only refer back to the certificate on Kerner’s wall from the spiritualist church, the Healing Light Center Church, and its founder the Rev. Rosalyn Bruyere to realise that even Kerner has such New Age associations.
New Age, TT and alternative medicine proponents are also well known for their consistent use of faulty logic. First, TT is claimed to be valid because “healing with energy has been in existence for at least 5,000 years.” (Davidhizar & Shearer, 1998). But longevity has never been an acceptable scientific criterion for validity, or else dowsing and astrology could now be labeled as science. Second, TT is claimed to be valid because there are more than 85,000 TT practitioners in the United States alone and many schools of nursing train students in TT. But again the citation of numbers or authorities or schools is also not acceptable. It has been said that if millions of people say a foolish thing, it still remains foolish. Third, one hears that many heroes of science were initially scorned. This is known as the Fulton non sequitur although the name of Galileo is often substituted. The argument says that “They laughed at Robert Fulton (of steamboat fame; or substitute the persecution of Galileo) and he was proven right. Now they laugh at (or persecute) us, therefore we will also be proven correct.” It should be clear that each of these three examples lack any validity, but they continue to appear as justification for pseudoscientific ideas. And finally several writers (Mackay, 1995; McCabe, 1994) attempt to tie Florence Nightingale to a “universal healing energy.” However, in fact she emphasised the quite natural healing powers of the body as was so nicely summarised by O. W. Holmes (1842):
90% of those patients seen by a physician in daily practice would recover, sooner or later, with more or less difficulty, providing nothing is done to interfere seriously with the efforts of nature.
Problems with Subject ‘Blinding’
As this article was being prepared I questioned whether space should be devoted to this particular subject. But in all research which involves humans there is the potential for subtle biases to influence the results whether it be medical research or behavioral studies. ‘Blinding’ is essential to attempt to control this bias. It still seems that researchers of TT are unaware of how to adequately conduct a ‘blind’ study where the subject is truly unaware of being treated differently. The sham techniques used in some studies (while commendable in their aim) have been previously criticised, but continue to be used.
In many of these sham techniques assistants are trained to mimic TT hand movements and they practice until “uninformed observers could not tell whether TT or sham was being performed in a staged demonstration.” In an actual TT session the practitioner assumes some kind of meditative state and claims to manipulate some invisible energy field and channels new energy into the ill person’s body. The practitioner must consciously intend to heal and he or she must consciously will that the individual be healed. During the sham treatment the assistants counted backward from 100 by serial sevens to avoid treatment/intent/attention. Several questions need to be answered. First, during the staged demonstration, did they also count backward? Second, could the observers see their facial features during this concentrated backward counting or did they merely attend to the hand gestures? Third, and most critically, why were sham-treated subjects never questioned about whether they knew they were receiving sham treatment? Surely the facial expressions of the calm, relaxed TT practitioners were markedly different from the assistants who were anxiously preoccupied with a mathematical problem. Therefore, we are really not given convincing evidence that this blind technique is at all effective.
First of all, subjects are often able to respond honestly to inquiries. One has to ask why, if nursing professionals are concerned with patient wellbeing, that to date no one has bothered to ask the patients whether they are aware of the differences between sham and actual TT treatment that they are receiving. By asking the patients it might be discovered that ‘blindness’ was not achieved at all. We do know that experimental subjects respond to eye contact, to implied suggestion and to someone with a caring personality although they may not always be aware of these cues. This unawareness is the basic reason for ensuring that the subjects are ‘blind’ to the experimental treatments. There is ample evidence in decades of psychological research of subjects being unaware that they are responding to very subtle cues. One has only to remember the Hawthorne Effect, the Greenspoon Effect (subtle verbal cues, 1950) and the Carpenter Effect (ideomotor action, Vogt & Hyman, 1959). The subtle cues supplied by the practitioners of the sham or mock TT treatments may easily explain any group differences that are found. A lack of awareness on the part of TT researchers of the psychological literature on these subtleties leads one to wonder whether the TT researchers have gone out of their way to deny these subtle influences (other than the wondrous subtlety of TT itself) so that they can ultimately conclude that TT intervention is a ‘proven’ success.
Conclusions
Here we have looked at the origins of Therapeutic Touch (TT). We have examined briefly some of the comments by proponents of TT which have ranged from a bizarre anti-science bias to a New Age orientation and in addition we have examined their use of faulty logic. We have also seen an encounter with a German proponent of TT. Finally, we have looked at the necessity of the subject being ‘blind’ and how the adherents have failed to accomplish this due in large extent to an ignorance of how to properly conduct research with humans.
We are still waiting for a well-designed, well-conducted truly blind (preferably double-blind) study of TT. The research sophistication of some TT researchers continues to grow. However, research of substandard quality must not be accepted as evidence that practices such as TT are efficacious. If the nursing profession itself is to continue to enhance its prestige in the health care community it must distance itself from New Age mysticism and anti-scientific philosophies.
References
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All web sites in this article were accessed on March 11, 2011.
