Repositioning Individualized Homeopathy as a Psychotherapeutic Technique With Resolvable Ethical Dilemmas

Abstract

The author puts forth the argument that the complementary and alternative medicine community should endorse specific aspects of the entire individualized homeopathic process, including its unique holistic consultation process, having dedicated lengths of time to enumerate the complete illness context, and the prescribing of homeopathic remedies, to reposition this modality as a psychotherapeutic technique. Moreover, placebo effects derived from homeopathic remedies could be used to further exploit favorable therapeutic effects that have accrued from the entirety of the homeopathic consultation process. The overall aim of this bold shift is to sustain the clinical practice of homeopathy from an ethical and clinically responsible (and plausible) framework that is properly evidence-informed.

Homeopathy, as defined by the College of Homeopaths of Ontario, is

a system of medicine used around the world and based on the principle of “let likes be cured by likes.” Patients who exhibit symptoms of disease are treated with administration of minute doses of substances to stimulate the individual’s natural healing process in order to restore and maintain health. ^1(p21)

Embedded within this definition is the concealment of what “minute doses of substances” precisely means. Scientifically speaking, homeopathic doses are much too low to possess pharmacologic or mechanistic effects beyond placebo. In his dismissal of the purported mechanistic effects of homeopathic remedies, Smith noted the following:

Simple arithmetic shows that to receive just one molecule of the diluted agent from a fairly standard homeopathic dilution of 1 × 10³⁰, the patient would have to consume over 30,000 litres of the homeopathic solution. And many homeopathic medicines are diluted to even greater extremes, ranging from up to 1 × 10⁴⁰⁰, meaning that to receive just one molecule of agent the patient would have to consume more matter than is present within the entire universe. Thus, for homeopathic dilutions to have mechanistic effects, it would appear necessary to reject virtually all that science has painstakingly elucidated over the last 200 years concerning the composition of matter itself. ^2(p510)

Thus, the clinical conundrum, that is, whether or not homeopathic remedies possess effects beyond placebo, should be a nonissue, and yet debate about homeopathy and the merits of homeopathic remedies continue to polarize clinicians within the complementary and alternative medicine community. Some notable publications have addressed the clinical practice of homeopathy and are worthy of inclusion here. Smith ^2,3 authored 2 articles against homeopathy, and Levy and colleagues ⁴ authored an article gently defending homeopathy. If you agree with Smith’s utilitarian perspective, then any possible benefit attributed to homeopathy is undone because it is unscientific. Moreover, if you side with Smith then homeopathy should not even be available as a health care option because it causes harm, delays care, and misallocates finite resources. If you side with Levy et al, the mere fact that homeopathy lacks proof does not in and of itself invalidate its therapeutic properties nor make it unethical because many potentially helpful biomedical treatments lack sufficient proof of efficacy. Also, if you side with Levy et al, then you believe that much larger numbers of people will be unharmed because of homeopathy compared with the very few that are, which should ensure its availability to any person wanting to receive it.

The problem emanating from both perspectives is that they demand or force the clinician to take a firm position as being either “against” or “for” homeopathy. Neither position helps create a reconciled practical perspective that is ethical and evidence-informed. An alternative position to adopt concerning the clinical practice of homeopathy, particularly individualized homeopathy, is that it is a psychotherapeutic technique and nothing more. Individualized homeopathy “is one of several types of homeopathy,” which aims to “capture a person’s individuality,” and then a homeopathic remedy is chosen based on symptoms, especially those with “unusual or unique patterns.” ^5(p594) The complementary and alternative medicine community should make use of those particular aspects of the entire individualized homeopathy process, which includes its unique consultation approach and the prescribing of homeopathic remedies, to find an ethical and appropriate way in which to clinically use this modality in the provision of health care.

Individualized Homeopathy as a Psychotherapeutic Technique

When a patient seeks out care from any homeopathic clinician, the most essential element of the consultation process is the actual case taking. Sankaran ^6(p208) has outlined the essential elements of case taking, which include (1) recording “faithfully the picture of suffering of each individual patient in such a way that the indications for the similimum emerge out of it” and (2) documenting the “chief complaint, present symptomatology, previous history, personal history and family history, along with the abnormal findings on physical examination, and a summary of the previous treatments taken and their results.” He further stresses how important it is for the clinician to be alert, keenly attentive, allow the patient to “express his disorders without any interruption,” ^6(p209) and to refrain from asking leading questions. The intake should not be an interrogation with questions and answers, but rather should become a discussion and conversation so the patient does not feel compelled to answer any particular way. Moreover, the intake should ideally “draw a picture of the suffering of a living individual and to try and understand the whole circumstance that has given rise to these symptoms.” ^6(p212) Once the homeopathic remedy is given, there are multiple follow-up consultations that happen to sort out the patient’s response, determining potencies, whether a more appropriate remedy should be given, as well as many other particulars.

Since most individualized homeopathy encounters encapsulate much of what has been articulated thus far, it becomes apparent why therapeutic value could evolve from the homeopathic consultation process. Patients proceed through this process by first telling their health story without much interruption or interference, all the while the homeopathic clinician actively listens and attempts to get a sense of what it must be like to embody the patient’s life and current circumstances. Then, after having put in the requisite time and work, patients are offered a homeopathic remedy designed to uniquely lessen their suffering. Patients then return to get reassessed after some predetermined period of time, perhaps with potency alterations, or to be offered a different and more appropriate remedy, or with other specific matters to be formally assessed and addressed.

So much of this, except for the offering of the homeopathic remedy, reminds me of the late Carl Rogers, ^7(p241) who articulated the core conditions within the clinician-patient dyad that support positive change, which include congruence, unconditional positive regard, and having an “empathic understanding of the client’s internal frame of reference.” The main point here is that homeopathic clinicians, especially those that practice individualized homeopathy, are likely to function in ways that align with these core conditions, helping secure an effective clinician-patient relationship, and providing the conditions necessary for some therapeutic change to happen. This perspective, while not exclusively restricted to homeopathic clinicians, likely accounts for some of the therapeutic improvements that patients can experience when receiving individualized homeopathy.

Therapeutic changes have in fact been attributed to the homeopathic consultation process. For example, in a study pertaining to rheumatoid arthritis, none of the primary outcomes changed because of the homeopathic intervention, but among patients that received a homeopathic consultation, there were statistically (and clinically) significant improvements in secondary outcomes that involved disease activity, the number of swollen joints, and current pain. ⁸ The observed effect sizes resulting from the homeopathic consultation process for these secondary outcomes ranged from 0.30 to 0.90, and were greater than those associated with other nonpharmacological interventions, such as cognitive behavioral therapy. ⁹

Other published research has shown clinical benefits to arise from the homeopathic consultation process. ^{10 –12} In a cross-sectional study on outpatients attending the Glasgow Homeopathic Hospital, 3 independent variables—empathy, patient enablement, and duration of attendance—were shown to be associated with health outcome 12 months after the homeopathic “contact” consultation, as per a multiregression analysis. ¹⁰ The only significant predictive factor, however, in health outcome—as per both univariate and multivariate analyses—over the 12-month study, was that of patient enablement. Patient enablement encompasses how a patient copes and understands his or her illness, and is in large part mediated by perceptions of clinician empathy. It seems rather probable that the homeopathic consultation process helps patients better understand their illness, especially when working with empathic clinicians.

In another article that focused on the homeopathic consultation process, the following specific elements were examined, and are listed here in no particular order of relevance: the length of consultation, clinician empathy, hopefulness and enablement, narrative competence, and collaboration. ¹² This particular article espoused the homeopathic consultation process as being “a remarkable example of teaching and practicing important elements that have also been developed in the biopsychosocial model.” ^{12(pp175-176)} The concept of holism was also mentioned as being of vital importance to the homeopathic model, which aims to understand the “totality of a person” while respecting “patient individuality and autonomy.” ^12(p176)

In an exploratory study that attempted to determine the “active” ingredients in homeopathy, 18 patients were given comprehensive homeopathic care and their cases and responses were evaluated over a lengthy period of treatment. ¹¹ The results showed that 7 patients experienced a major improvement in health status, whereas 6 patients experienced some improvement, and the remaining 5 patients had no change in health status. This was a complex study because so many sources of data were used to determine whether or not each patient experienced clinical improvement over the duration of treatment. The specific features of comprehensive homeopathic care that seemed to have the greatest impact on clinical outcomes included openness to the mind-body connection, the narratology of homeopathic care, and disclosure.

Specifically, those patients in the aforementioned study that improved valued how deeply and comprehensively their physicians inquired about bodily symptoms. ¹¹ Some patients seemed to respond better when encouraged to reveal deep aspects of what was termed their “Lifeworld,” such as, for example, past traumas, existentially based crises, and relationship conflicts. Disclosure was another feature involved in experiencing major health improvements among some of the patients. Disclosure was explained as a process that facilitates a reengineering of a patient’s sense of identity, by taking fractured elements that result in patient incongruence, and assisting with insights that might in some manner repair self-perceptions and yield a more resilient self-concept.

Published research does suggest that a significant factor in experiencing clinical benefits from homeopathy indeed arises from its unique consultation process. First, the holistic nature of the homeopathic consultation process—by endeavoring to understand the emotional, spiritual, and physical aspects of a person’s health issues and life—honors the very essential aspects of what it means to be human. Second, because the homeopathic consultation process is lengthy and takes lots of time, this allows the patient to develop a better understanding of the illness or illnesses for which care was sought after, as well as additional time to develop better coping abilities, or to at least come to grips with the reality of having an illness or illnesses. Thus, having dedicated consultations to fully enumerate the complete illness context would not only afford increased illness knowledge but would also surely allow for and facilitate discussions that directly affect coping ability, and how best to navigate life when bounded by the need to manage illness or several medical illnesses at a given time.

The other essential aspect to the homeopathic consultation process is the collaborative work done between clinician and patient to find the correct homeopathic remedy that best matches the totality of the patient’s symptoms. This process happens despite the fact that there are no pharmacological (or mechanistic) effects from any purported ingredient or ingredients in any homeopathic preparation beyond placebo effects. ^2,3 Systematic scientific investigations into the effects of homeopathic remedies have yet to show clinical effects beyond those ascribed to placebo. ^13,14 Placebo effects, however, are very real, and ought to be celebrated as something that can invoke positive clinical outcomes with effect sizes similar to actual treatments. ¹⁵

Placebo effects derived from homeopathic remedies could be used to further exploit the favorable therapeutic effects accrued from the homeopathic consultation process. Papakostas and Daras ¹⁶ redefined the term “placebo response” in the context of the “healing situation,” which implies that beneficial effects connected to placebo must be intimately linked to effects attributable to, or that arise from, the treatment setting or treatment process. Of relevance, are the psychological and neurobiological placebo mechanisms that have value, particularly within the overall therapeutic context. ¹⁷ Psychological mechanisms such as expectancy and classical conditioning have been linked to placebo effects. Neurobiologically, placebo effects are mediated by endogenous opioids, and the release of various neurotransmitters and neuromodulators.

When revisiting the therapeutic potential of homeopathy as a psychotherapeutic technique, an honest and ethical approach would involve telling patients that they are receiving a placebo or “sugar pill” that is inert and contains no medication. Several clinical trials have shown that giving patients placebo without deception does result in favorable clinical outcomes. ^{18 –20} This could be framed positively by informing patients that taking a placebo daily could very well bolster any therapeutic effects that have accrued from the homeopathic consultation process itself.

Conclusion

The published data have heavily focused on the clinical merits of homeopathic remedies, while only recently have there been investigations into the merits of the homeopathic consultation process itself. The literature has repeatedly shown that homeopathic remedies lack clinical efficacy, ^{21 –25} which is precisely why the practice of individualized homeopathy and other similar types of homeopathic practice should rightfully be considered a psychotherapeutic technique. The overall aim of this commentary has been to sustain the clinical practice of homeopathy from this ethical and clinically responsible (and plausible) framework that is properly evidence-informed. Individualized homeopathy, including other similar types of homeopathic practice, should be open and deliberate about being a psychotherapeutic technique.