Clients asked me all the time, “What works?” Does chiropractic work? Does ultrasound work? Does craniosacral therapy work? And, of course, my clients especially wanted to know if massage therapy works — even as we were doing it! Good for them. (I had a lot of scientists and academics in my clientelle. Smart, critical thinkers.)
But no matter what you might say in favour of a kind of therapy, or against it, the more important consideration will always be the quality of the individual practitioner: his or her intellectual honesty, social skills, emotional maturity, academic diligence, and so on.
These personality traits are by far the most important variables that determine quality of care. Find a professional with those qualities, and it doesn’t really matter which letters they have behind their name, or what kind of therapy they are selling.1
Get stuck with a dishonest or socially incompetent professional, no matter what kind of professional they are, and all bets are off — you don’t want to pay them to do anything to you.
The effectiveness or ineffectiveness of therapists bears little relationship to either the type or duration of their training.
~ The efficacy of treatment, by Peter Watkins, 309–310
Defying professional stereotypes
Seems like hardly a day goes by lately without someone sizing up an entire health care profession with some sweeping generalization — “I don’t trust chiropractors” or “doctors are full of @#$!%.” But health care professionals defy stereotypes regularly. For example, a physician prescribed me some pure snake oil… and a week later a chiropractor I know laughed with me about how ridiculous it was. Role reversal!
It’s interesting that people put so little faith in the individual practitioner, and so much in the type of credentials they have — as if merely going to a certain kind of school either guarantees your competence, or seals your fate as a quack!
Let’s look a little more closely at a chiropractors and doctors — two professions that are particularly stereotyped …
If someone has a bad experience with a chiropractor, he tends not to think, “That sure was a bad chiropractor.” Instead, he will probably tell people for the rest of his life that “chiropractic is crap.” This is not fair. Chiropractors are people — they do not represent their entire profession.
I have often defended generalizations from the political correctness police, because they are useful mental shortcuts. It is a fact supported by evidence that the majority of chiropractors are “old school” and still base their practices on prescientific ideas2 That does say something about the odds of walking into a chiropractor’s office and getting useful treatment. Knowing those odds is useful information: it means that we actually can generalize meaningfully about the chiropractic profession.
And yet generalizing often goes too far. Many chiropractors are competent health care professionals, interested in science. Some of them are whistleblowers, honest men and women devoting much of their energy to encouraging us to seek out rational, evidence-based chiropractic treatment only.
For more about chiropractic controversies, see The Chiropractic Controversies
Doctors — friends or foes?
I tend to admire doctors, and I know some wonderful ones. My last two general practitioners have been competent and decent people. I have also been privileged to know several particularly talented physicians on a personal basis. But the range of quality of practitioners is dramatic. The best are truly great, and that’s to be expected when you combine the best of medical science and technology with a good heart and brain.
And, alas, the worst are as bad as the worst anywhere else. And with more power and influence.
A friend of mine suffered from a sudden onset of severe anemia (low iron) — something that is often a not-so-early warning sign of Very Bad News. Her general practitioner — a doctor she had been unhappy with for some time — showed an appalling lack of interest. She was rudely dismissive and apathetic. What accounts for such poor care from someone so well-trained? There are countless such stories.
“With doctors like these,” one patient quipped to me, “who needs enemies?”
You don’t have to look at the lives and jobs of doctors very hard to understand why many of them might become arrogant and jaded, but it’s pretty appalling to encounter it in the real world.
The quality of any healthcare professional really comes down to their strength of character and intellectual honesty. Credentials ultimately mean nothing.
Of course, the quality of the therapist is not the only consideration, just the most important. Unfortunately, many therapies truly are a waste of your time and money, and the absolute best that you can hope for is a placebo effect, no matter who is offering them. And while I’m the last person to turn my nose up at a good placebo, I’d much rather have mine on the side than served to me as the main course.
You should look for a good therapist rather than a good therapy because a good therapist will tend to recommend therapies based on the best evidence available, therapies that have been shown in peer-reviewed scientific research to have more benefit than a placebo. A good therapist will do this because that’s what being a good therapist is all about. If you have a good therapist, you don’t really have to worry about doing your own homework so much. It’s never a bad idea, of course, but it’s nice knowing that you have an honest guide.
An extreme example: antidepressants
Here is a fairly extreme example of a situation where even a bad therapy can be used to good effect by a therapist: anti-depressants.
The popular SSRI anti-depressants (i.e. Paxil, Prozac, Zoloft) are seriously overprescribed and have been proven to be ineffective for most patients (patients who don’t have serious depression). I can’t think of a better example of a therapy that doesn’t work for most people, but which is also routinely delivered with more helpful assistance from a health care professional. The scientific rationale for anti-depressants is tissue-paper thin, they have proven dangerous side effects, a proven lack of therapeutic effect on non-severe depression, and the companies that make them have the largest snake oil profit motive in history, and have repeatedly attempted to obscure relevant science about their products. No, antidepressants do not work for most people (there are undoubtedly important exceptions, but I’m talking about the majority here). And yet …
Although they basically just interfere with brain neurology in very poorly understood ways, patients routinely report benefits. These benefits can be attributed to a combination of placebo, dumb luck avoiding the worst side effects, and the merciful relief of simply being “stoned” with medical approval and supervision. And that’s not such a bad thing. It might even be worth the risk … with the right psychiatrist.
What if your psychiatrist were not only impressively credentialled — I’m going to go out on a limb here a bit — but also wise and compassionate? What if she actually warned you about the dangers? What if she helped you go into it with your eyes wide open, deliberately leveraging the admittedly potent effects of the drug in your favour, and with expert guidance in evaluating the side effects and switching to other kinds if necessary? And what if she was there to help you process the consequences of being “stoned”?
In this context, antidepressants could definitely “work.” So what’s more important: the therapy, or the therapist?
Be a secret shopper
Most people feel uncomfortable telling a health care professional, “I’m just checking you out. If you don’t seem to practice evidence-based care, I won’t be back.” So do it in secret. Go shopping for therapists before you are in trouble, present some minor problem for their consideration, and take the opportunity test them discreetly.
- Do they ever refer to research or evidence?
- Do they explain their treatment choices?
- Do they promise too much?
- Do they seem curious about you?
- Do they admit to any shortcomings?
If not, run away.
I strongly recommend trying one therapist after another — of any kind, of many kinds — until you find one who seems knowledgeable, compassionate, and intellectually honest. That person will be a valuable resource for life.
The bottom line
It’s a truism that not everyone can graduate top of his or her class. Although the nature of the therapy offered is not unimportant — some things aren’t going to work, no matter what — the skill and good sense of the therapist is much more important. A few ethical, intelligent practitioners of any helping profession will always deliver better care than the less responsible members of any profession.
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
- Reviews of Pain Professions — An opinionated guide to most popular sources of professional help for injuries and chronic pain
- Battle of the Experts — A guide for patients caught between conflicting diagnoses and prescriptions
- The Not-So-Humble Healer — Cocky theories about the cause of pain are waaaay too common in massage, chiropractic, and physical therapy
- Does Massage Therapy Work? — A review of the science of massage therapy … such as it is
- The Chiropractic Controversies — An introduction to chiropractic controversies like aggressive billing, treating kids, and neck manipulation risks
- By my definition, intellectually honest professionals will never try to sell you any serious nonsense. Really dubious cures are eliminated from concern, because professionals of a certain quality just never get into offering bogus cures in the first place — or they get into it like wandering down a dark alley and then smarten up, Dr. Edzard Ernst being the classic example. Someone offering you a remedy on the margins of credibility is either (a) not actually intellectually honest, or (b) will present it to you in an honest way, fully informing you about its disadvantages and uncertainties as well as its possible benefits.
- Mirtz TA, Morgan L, Wyatt LH, Greene L. An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chiropractic & Osteopathy. 2009 Dec;17(1):13. PubMed #19954544 ❐ PainSci #55783 ❐ “Despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.”