Abstract
More dramatically, surpassing of expectations can take the form of substantial improvement in an area wholly absent from the practitioner's and patient's lists of therapeutic goals, as when headaches of long standing vanish following an intervention directed solely to the site of a symptom in a part of the body (the pelvis, for example) geographically distant from the location of the unanticipated improvement.
In addition, there are cases in which an ostensibly physical treatment (e.g., massage, manipulation, acupuncture, herbal medicine) brings improvements of a largely nonphysical nature (e.g., decreased reactivity to stress, or changes in attitude or worldview) or when a primarily nonphysical treatment (e.g., mindfulness based stress reduction, meditation, psychotherapy) clears or greatly reduces a physical pain pattern.
Extraordinary Cases
Like other veteran practitioners, I can recall many cases involving such pleasant surprises. Given that I am a chiropractor, most involved swift and substantial decreases in musculoskeletal pain when I had expected much more gradual progress. But some were more unusual—the man who suddenly experienced a drastic shift in food cravings (more vegetables, less sugar and fatty meats) following his first couple of chiropractic adjustments, the woman who sought care for neck pain and experienced unexpected relief from seasonal allergies, or the man who experienced a multicolored vision rich in personal and transpersonal meaning during manual therapy to the lower back.
Most awe-inspiring are those cases in which extraordinary change takes place simultaneously at both physical and psychospiritual levels. My most remarkable case in 25 years of practice came shortly after I earned certification in acupuncture. A female patient in her early 70s, who had seen me periodically for chiropractic treatment of back and neck pain, asked if acupuncture might help these conditions. I suggested that we give it a try.
When she returned for follow-up a week after her first treatment, she reported that, for the first time ever, she could hear the shower running when she was on the opposite side of the house, she could hear what her son was saying when he was sitting at the far end of their long family dinner table on Sunday, and most poignantly, she could hear her cat (who purrs softly) purring from several feet away. This woman had had a moderately severe hearing loss for several decades, since the age of 6. Moreover, she reported that, since her first acupuncture treatment, she had a “comfort feeling” in her chest, a steady sensation of relaxed and peaceful warmth. She stated that she had never previously realized that it was missing and that she hoped it would remain with her forever. At 10-year follow-up, each of these changes appeared permanent.
While it is essential that we not generalize too broadly from our most spectacular cases, it is equally essential that we not deny these experiences or push them under the rug for fear of harsh judgments from people whose preconceptions deny such possibilities. As the saying goes, it only takes one white crow to prove that not all crows are black.
Incorporating Unanticipated Effects into Standard Research Methodology
While all complementary and alternative medicine (CAM) practitioners have seen unanticipated positive effects in their practices and many of these practitioners have shared these stories with friends and colleagues, few practitioners have documented them with a researcher's rigor. Fewer still have incorporated a qualitative quest for such unanticipated effects into the design of research studies primarily focused on quantitative data gathering.
In the February 2010 issue of The Journal of Alternative and Complementary Medicine we witnessed precisely this type of far-sighted, whole-systems research. Clarissa Hsu, June BlueSpruce, Karen Sherman, and Dan Cherkin of the Group Health Research Institute in Seattle, Washington, dug deep and struck gold, setting a standard that should become a normal part of CAM (and conventional) clinical trials. 1 Alongside their gathering of quantitative data in five randomized controlled trials (RCTs) on the comparative effectiveness of CAM therapies for low-back pain (which generally showed CAM to be helpful), these investigators asked participants open-ended questions capable of eliciting information on effects beyond the pre-agreed outcome measures. Nearly all of these additional effects were positive, necessitating the use of terminology different from the usual, negatively tinged term, “side-effects.”
The unanticipated effects reported by Hsu et al. included both nonphysical and physical changes. 1 Less than half (37%) of their cohort reported such changes, which is consistent with my own experience and that of other CAM practitioners with whom I have discussed the issue. But, while unanticipated beneficial effects are not predictable and cannot be considered probable in any individual case, they do occur often enough to at least merit a check-box on practitioners' post-treatment evaluation forms. Evaluating these unanticipated effects should also become a normal part of research methodology.
Squaring the Circle
The long-running philosophical debate on reductionism versus holism generally reaches an impasse at the point where reductionists want researchers' outcome measures to be as specific and delimited as possible, while their whole-systems counterparts seek to expand the evaluative process to encompass a significantly broader terrain.
Hsu and colleagues point a way toward squaring this circle, having first published more conventional, quantitatively focused papers on each of their RCTs and now following that with a separate qualitative analysis pooling the information on unanticipated effects gleaned from their earlier studies. 1 This is an important step that, it is hoped, reflects a transitional stage rather than an endpoint.
CAM researchers cannot control the methodological norms of the broader research community but they have the power to lead by example, demonstrating ways to reflect the fullness of the healing encounter more comprehensively by incorporating both quantitative and qualitative methods.
Including a search for unanticipated physical and nonphysical effects as part of all clinical trials would be a welcome step in the right direction.