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, . , 3 5 2001 .

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THERAPEUTIC TOUCH IS NEITHER

Jan Eisler, Center for Inquiry, Amherst, USA

Therapeutic touch (TT) is neither. It is not a backrub or something I regard as therapeutic. In fact therapeutic touch, as it is now practiced, does not involve touching at all. Although its roots lie in the traditional laying on of hands, which many religious groups still do, it is far removed from that. The concept of therapeutic touch in nursing was popularized by Dolores Krieger, and for her it was essentially a non-Christian therapy. Krieger believed that there were significant life energies in certain healers which can be directed to the patient in order to help in the healing process. It can be done with or without the patient's consent. Treating a patient without informed consent is an entire topic in its own right and beyond the scope of this paper. It is not regarded part of scientific medicine or nursing, but rather as an aspect of holistic practice, theoretically proven by Karilian photography, and with a history dating back to the ancient traditions of China, Egypt, India, and native Americans. (Krieger, 1975). Krieger reported that she became interested in it through the works of Dora Kunz, then the leader of the Theosophical Society in America , she also says she was influenced by Oskar Estebany, a former colonel in the Hungarian cavalry who had cured horses by his ability to communicate with them. When he retired to Canada he became affiliated with Kunz and it was in this setting that Krieger became acquainted with him, and the three began experimenting with therapeutic touch. In short, therapeutic touch is part of the religious teachings of the theosophists (Campbell, 1980), although somehow this is never mentioned.

Krieger does not believe that all persons can do therapeutic touch, since it requires the healer to take what J. B. Jung described as an archetypical journey, where we become aware of our interior experiences (Jung, 1963, 1969). That is once we learn not to fear the images stored in our collective unconscious, we can gain access to the ancient and common bond with others, and the potential we might have as healers. (That must have been my shortcoming; for when I took a continuing education course in Therapeutic Touch given in my hospital, I was not able to effect any degree of mastery. I aped the instructors and have the certificate of proficiency acclaiming a most excellent technique). How did this theosophical process of healing get into American nursing? The main reason for this was that Dolores Krieger was a nursing professor at New York University, which for a time was one of the earlier universities to grant a doctorate in nursing. New York University under its long time dean, Martha Rogers, was at the forefront of the movement for alternative therapies and mystical beliefs including Karilian photography and the existence of extra terrestrial forces (Rogers, 1970) Almost anyone who entered the NYU program, and there were hundreds of Ph. D. candidates, had to deal with this. Many became believers, and they went out to other developing universities, most of whom were only beginning to offer doctorates in the 70's and 80's.

Krieger first began publishing on the topic for the nursing audience in 1975 in an article (Krieger, 1975) in the American Journal of Nursing and amplified her views in a psychical energy journal (Krieger, 1976). Unfortunately this last article was not published in a nursing journal and as published demonstrates a lack of knowledge of physiological responses to some illnesses. It reported a significant increase in hemoglobin in a patient population treated with therapeutic touch but the illness from which the patient suffered was never identified, and in many illnesses, such as Chronic Obstructive Pulmonary Disease, this might well be a natural effect. It could also have resulted from simply resting. No control study was done, but it is a study often cited and apparently never really read since the journal is not particularly accessible. In fact almost every study done to demonstrate the value of the technique has been subject to serious flaws.

Still early studies demonstrated to its believers, that something did occur. It was found that a friendly touching of a patient led to the patient reporting feeling more relaxed and actual relaxation could be documented on an electroencephalogram (Krieger, Peper, Ancoli, 1979). This study, however, allowed for actual touching and did not really demonstrate the value of the concept of therapeutic touch as Krieger postulated it. To control for this, Heidt did a study of three groups of hospitalized cardiovascular patients, some of whom received therapeutic touch, while control groups receive casual touch, such as taking of temperature, and, still others received no touch. The greatest reduction in anxiety was reported as taking place among those receiving therapeutic touch. Unfortunately the study did not control for the implication that the nurse was spending time with the patient, and doing something out of the ordinary hospital routine. The same problems arose with another study on 100 patients, done by Keller and Bzedek (1986) which reported treatment for tension headache that involved first a period of quiet rest, then treatment of the experimental group by therapeutic touch therapists and of the control group by non therapist volunteers who focused on not the patient, but rather on subtracting 7's from 100. Unfortunately although these results appeared in reputable refe-reed journals, there were serious flaws in the controls exercised over the two groups, since it is doubtful whether those counting backwards by 7's were as relaxed in approaching the patient as those doing therapeutic touch, which encouraged greater relaxation of both the patient and the examiner.

By this time, devastating criticism began to appear in the nursing literature about therapeutic touch. One such study, published by Clark and Clark in 1984, examined therapeutic touch studies going back to the early 1960's and then concentrated on early nursing studies and found all of them methodologically flawed and badly designed Clark and Clark, 1984).

Still therapeutic touch kept its adherents Why? I submit that one of the reasons was a continuing mystical view about the importance of bedside nursing. As the nature of medical care and nursing care continues to change, and in fact, become more impersonal, there has been an effort to assert the importance of the individual in the equation. Nurses historically have viewed themselves as supportive, loving, and helpful individuals, who, by their interventions, brought patients back to health. For the most part the practitioners of TT are innocents. They, as bedside nurses, are seeking methods of alleviating suffering in what small ways open to them. In the United States, nurses are close to the bottom of the hospital pecking order and often feel powerless to affect comfort measures on their own. Statements of that nature were common in the review of reasons as to why practitioners were seeking accreditation in therapeutic touch. The New Age movement has also added its layer of wishful thinking advocates. As our class opened we were asked to fill out comment cards as to what we hoped to achieve in learning the offered skill. Most answered that they were looking for a method whereby they could help the patient, some were frustrated that some small comforts could not be offered a written order from a doctor and more autonomy was desired. Again, to comfort the patient. Each and every reply, save one were along those lines. When the last comment card was read there was a hushed aside uttered by the instructing professors; that there must be a scientist in the audience I had asked for reports and results of double blind studies from differing sample sizes of nurse-patient teams. Needless to say, it was all I could do to keep from walking out of the full day class (nine hours of continuing education credits were offered).

The latest developments in the field, however, might well undermine the nursing belief in therapeutic touch. The Sausalito Consciousness Research Laboratory, in Marin County, CA., underwrote a study by Kate Mac Pherson, pairing 20 AIDS patients with 20 healers using therapeutic touch. Although the results have not been published, the interesting part of the experiment is that none of those using therapeutic touch met the patients. They had photographs of them and knew their first names but all of the therapy took place at a distance. In effect, with remote healing, much as performed by Christian Science practitioners, there is no need to involve a nurse at all. This is a logical conclusion of the theosophical assumption behind therapeutic touch. It will not be science, which weakened therapeutic touch in the nursing community, but the mystical advocates of therapeutic touch itself.

For a single article on the matter of TT please read the fall/winter issue of Scientific Review of Alternative Medicine, Prometheus Books, 1997: Theraputic Touch: Evaluating the Growing Body of Evidence Claim by Bela Scheiber. Just last year, 2000, Prometheus also published a book edited by Scheiber and Selby, titled Therapeutic Touch. Much of the information in this paper has come from discussions and comments by Vern Bullough, acclaimed as USA nurse of the year. As a significant secondary note: only in very recent months we have been apprised of the unmasking of the placebo effect.

Not long ago, an unconventional entrepreneur tried to sell placebos over the Internet. That in itself is not so unusual except that he actually labeled them Placebos. To the best of my knowledge the poor guy never sold more than a dozen bottles. After all, the trick to a placebo is in the trickery. It sells belief in a bottle, hope in a sugar pill.

Indeed it is the trick that supposedly accounts for the placebo effect, that much  accepted notion that many patients get better when they unknowingly take dummy medication or fake treatments.

Now it appears that the placebo effect may be nothing more than a medical myth. Placebo is the Latin word for I will please. But it seems that the most pleased were doctors, not patients.

Two Danish researchers peeled the layers of the medical onion until they came down to the original research: a single 1955 study that compared patients given dummy pills with those given real pills. The research said one-third improved with fake treatment.

The Danes took their skeptical look a step further. They analyzed 114 studies in which the patients got real, fake or no treatment at all, and guess what? They reported in the New England Journal of Medicine that the folks who got no treatment improved just as much as those who got sham treatments.

In short, the placebo didn't have an effect, except a small amount of pain relief. The improvement may have been from natural healing or from the roller-coaster path of the disease process itself. But the researchers conclude, placebos are unjustified for anything but controlled experiments in clinical trials. There is no justifiable placebo use outside of clinical trials.

This astonishing bit of myth-busting arrives in the middle of an uneasy ongoing medical discussion on the relationship between truth and hope, mind and body, medical science and medical art.

For much of history, after all, medicine had little more to offer than placebos, if we accept their definition in an 1811 dictionary as something given more to please than to benefit the patient.

Today, medicine has become much more of a science. And less of an art. It's become more about curing patients. And less about comforting them. At the same time  and perhaps in reaction to medicine's coolness  placebos have continued to flourish. Many doctors, who don't want to just stand there but do something, have gone on prescribing antibiotics to flu patients even they don't help. Others offer the treatments that, in essence, treat only the patients expectations of treatment.

The placebo effect gave this some legitimacy. It also gave support to the burgeoning movement to reconnect the mind with the body, the art with the science, and the patient with the practitioner. The placebo effect, after all, suggested that the illness was all in your head. Or less pejoratively, that we have some emotional control over health.

A director of a mind-body program at Harvard told a National Institutes of Health conference, We might be able to put sugar pill beside the morphine and antibiotics in the arsenal of medicine. Small wonder that so many nurses have been duped into the wishful thinking mode of therapeutic touch.

Hopefully, not any more. This great debunking doesn't shatter the idea of the mind's influence on the body or the power to heal. What it does shatter is any justification for, in essence, trying to deceive that mind. If there is no magic in the trick, its just a trick.

I am aware that doctors are pressed by patients and by time. They may deal with patients they can't cure, and don't want to abandon, by offering something. But the Danish study seems to prove that a sham something is not better than nothing.

All in all a doctor, a nurse, owes a patient the truth. But the truth does not preclude comfort any more than a bleak diagnosis precludes a squeeze of the hand. And the most important part of medical care is still in the caring. The placebo effect and therapeutic touch has come undone. It carries the harsh sound of a quack. It's a scam, and when properly labeled, nobody buys it.

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