mandag 8. desember 2014

Habitual reactions

- impressions from discussions on the Alexander Technique and medical research (written with the Alexander Technique teacher in mind)

Alternative therapies have come under scrutiny in recent years, following books like Trick or Treatment by Ernst & Singh. In Norway we have had similar books, and a very popular TV series on the same subject. Since the Alexander Technique is commonly categorised as an alternative therapy I have followed the debate on alternative treatments closely. I have to say that in my opinion practitioners of CAM (complementary and alternative medicine) have difficulties in dealing constructively with criticism.

Some time ago Edzard Ernst, an expert on CAM research, posted an article on his blog where he said that health claims from Alexander Technique teachers mostly were 'wishful thinking'. It was with some apprehension I posted a link to the article on social media. How would Alexander Technique teachers respond?

There was a great variation in responses and interesting discussions followed, but there were also signs of the typical habitual reaction of the average CAM practitioner.

It is not uncommon for CAM practitioners to want to ignore results from scientific research when they don't like them. Several in the Alexander Technique community said we should ignore Ernst's article. This is an ignorant thing to do. Ernst points out the fact that most of the health claims made by Alexander Technique teachers are not backed up by scientific evidence. Ignoring him does not make this fact go away.

Others claimed that Ernst was the ignorant, saying that as he had no experience of the Alexander Technique, he would ''not know what he was talking about''. I hope we Alexander Technique teachers aren't that bad at explaining the technique in words. You don't need first hand experience of the technique to assess research papers. The only caveat I would put down is that you have to understand that the Alexander Technqiue is something you learn. This understanding you can get from reading about the technique.

Someone commenting on Ernst's blog asked him if he had taken lessons, and if so, what his experiences were. Clearly, the person asking is ignorant about how science works. Ernst's experiences, or lack of experiences, changes absolutely nothing about the state of research on health benefits from the Alexander Technique. Even if Ernst had had lessons in the technique, and found them valuable, he could still have had the opinion that Alexander Technique teachers exaggerates their claims.

Some even answered Ernst's critique with the 'argument from ignorance', an example of fallacious argumentation. They said that lack of proof of effect didn't prove that the Alexander Technique doesn't have health effects. They also said that Ernst, if he disagreed, was free to disprove it. Yet another fallacious argument. The burden of proof is on the claimant. The only thing achieved by using this sort of argumentation is proving your own ignorance.

And someone was even in complete denial, arguing that since we don't regard the Alexander Technique as a therapy, we are not making health claims either.

Ad hominem
Ad hominem arguments is a speciality among CAM practitioners. Fortunately there were few of them from Alexander Technique teachers. One said that Ernst didn't seem to ever have had "an internal experience of positive change that made him wonder".

Another commentator said Ernst's blog was an example of hubris, presenting a façade of credibility with a list of degrees and "impressive databases" acquired through google. Quite a few others were eager to discuss Ernst's possible (hidden) agendas, seeing it necessary to find "enough information to make an evaluation of Ernst".

Even if there were few ad hominem arguments, there were sadly also very few comments that directly addressed what Ernst had written on his blog. Of hundreds of comments, only two or three criticised Ernst constructively.
There were comments which were emotional in character, Alexander Technique people finding Ernst ''dismissive'' or ''unfair'', his reporting ''irresponsible'' and ''insulting to the AT''. How can the Alexander Technique be insulted? The technique is not a person.

One commentator said Ernst's article was ''unscientific''. Labelling something as ''unscientific'' is, ironically, a very popular strategy among CAM practitioners. Ernst's article was further described as ''quack science'' with ''no scientific method'', ''no rigour of analysis, erroneous conclusions, and obvious bias presented as facts''.

Other commentators said Ernst had an ''opinion based attitude'', that there was''bias in his approach'', that he could be ''more objective'' and that he was ''not such a rational person as he likes people to think''.

This critique falls flat on its face because this was a blog article, not a scientific paper. It is perfectly all right to express ones opinion in a blog. The critics also fail to present arguments that supports their view. They are themselves only expressing an opinion, which as a matter of fact only ends up being empty words.

As for the ''biased position'' as someone called it, it is clear that Ernst's attitude is that claim of health effects should be based on sound evidence. One can disagree with this position, but I don't think it is correct to call it ''biased''.

Cherry picking
When it comes to the much loved sport of 'cherry picking' I'm not sure if CAM practitioners are most zealous of practicing it themselves or of accusing others for practicing it. In the debate on Ernst's article on health claims made by Alexander Technique teachers, I'm happy to say that there was only a little hint about Ernst practicing 'cherry picking'. It was alluded that by 'not supported by evidence' he actually meant 'not supported by the studies he cited'.

To support a claim that Ernst was cherry picking, one would have to show that he had omitted relevant studies of sufficient quality. Since his article is based on systematic reviews there is very little material he could have omitted. I don't know about any further studies that could have shown a more positive effect for the Alexander Technique.

CAM practitioners very often blame it on cherry picking when trials with positive results are omitted. The reason for the omission is normally bad quality trials. Studies of bad quality is a big problem in CAM. When only studies of good quality is included, the positive results tend to disappear. Homoeopathy is the prime example.

There are a lot of other factors that can reduce the reliability of a study. Size is one such factor. A case relating to the Alexander Technique was mentioned in the discussion. A pilot study on musicians in Denmark indicated that the technique was effective against high blood pressure. For years this study has been cited by Alexander Technique teachers. Later it has come to light at this is an over interpretation of the results. We have no evidence after all.

Failed medicine
Attack is the best form of defence, as the saying goes, and CAM practitioners, when criticised, routinely point out the failure of doctors, the health service and the pharmaceutical industry.

Someone posted a rant on Ernts's blog about the problem with opoid drug addiction in the US. This is a real problem and it is easy to sympathise with the writer. But the comment is entirely misplaced. Both because Ernst is writing about CAM and has nothing to do with conventional drugs or the use/misuse of it, and because even if the Alexander Technique were to be found effective against more than just back pain, the technique will never be an alternative to analgesics.

It is easy to point out failures in the practice of medicine. In the discussion about Ernst's article, among the examples given were the failure of a doctor to see the connection between arrhythmia and digestive issues, or the link between voice problems and the locking of the knees.

It is easy to agree with this, especially as an Alexander Technique teacher. I see regularly how people for instance are aggravating their problem by the exercises given to them by physiotherapists. Some basic understanding is lacking.

But what do this mean for health claims made by Alexander Technique teachers? Sharing the understanding that 'use affects functioning' might have made Ernst think twice before he wrote ''wishful thinking''. But if by that he only meant 'not supported by evidence', it wouldn't change a thing.

If we Alexander Technique teachers present claims, the burden of proof is on us. The fact that doctors make mistakes does not change this.

Too subtle
A claim often made by practitioners of CAM is that their method is too subtle to the object of scientific research. Among the objections made towards Ernst's article were that the Alexander Technique : ''is more subtle than to be subject to this matter-of-fact testing'', and that ''the Technique is an exceptionally difficult thing to build a scientific test for''.

In relation to testing claims of health benefits, this is nonsense. You don't need to know or understand the working mechanism to test the health benefits of a method. Of course, you need to make sure that what you are putting to the test is a representative version of the method. In the case of the Alexander Technique this can be a challenge, but this is a problem on another level.

And if the method is too subtle to have a measurable effect, then the claims of effect definitely are wishful thinking.

Double standards
There seems to be a myth among CAM practitioners that, when it comes to the requirement of evidence base, there are double standards in their disfavour. In the discussion on Ernst's article it was said that the established health care system should ''go under same scrutiny as is used towards alternative approaches" and that they wished that ''the same degree of scrutiny were applied to drug treatments''.

It was also said that Ernst was criticising health professionals for using CAM, but that there was ''no looking into how evidence based is the normal practice''.

This gives the wrong impression. It is true that a considerable part of what is done in 'normal practice' is not evidence based. But that there is no scrutiny is positively wrong. The practice of medicine is constantly changing, and, thanks to an evidence based approach, mostly improving.

If there really are double standards, they work the other way round. Practitioners of CAM can for the most part do whatever they like, someone in the health care system can't. CAM practitioners can do what they have done 'for thousands of years', someone in the health care system may have to change their practice due to increased knowledge. CAM practitioners can sell sugar pills and claim it is 'medicine', the pharmaceutical industry are not allowed to. (Not that they are not trying). CAM practitioners should be very pleased with having double standards.

Big medicine and Big business
If CAM practitioners feel they are not getting the aknowledgment they believe they deserve from scientific research, they tend to blame someone else for it. Big pharma, Big medicine and Big business are the usual culprits. This is also so according to voices in the Alexander Technique community.

It was said that large corporates have no interest in doing research on the Alexander Technique. This is true. And why should they? The Alexander Technique is tiny, probably only a few thousand teachers world wide. Why spend money on the Alexander Technique when there is so much else to study? The technique is tiny even when compared to CAM, which is a global billion dollar industry.

Someone criticised Ernst for not pointing out this fact. I'm afraid that sounds more like an attempt at excusing making claims of health benefits.

CAM practitioners often point to ulterior motives. It was claimed in the discussions that the Alexander Technique would be a threat to the '' thousands of scientists and billions of dollars'' in medical research. Amusing thought.

What is not so amusing is when some CAM practitioners come up with conspiracy theories to explain why their claims are not accepted. There were some glimpses of conspiracy theories in one of the discussions I followed. The problem with conspiracy theories is that they imply that a lot of people are evil. Such a position is ethically questionable. Most CAM practitioners come across as very nice people. All they want is to help others. But there is a dark side to CAM. Conspiracy theories is a sign of this. We shouldn't go there.

Failed science
When scientific medical research does not support the claims of health effect of an alternative method, CAM practitioners sometimes come to the conclusion that then it must be science that is wrong.

One of the discussions on Ernst's article I was following, hardly touched upon the question of validity of health claims by Alexander Technique teachers before heading into debating the limits of science. It was interesting stuff in the view of science philosophy, but in the context of questionable health claims it looked more like an attempt at avoiding the problem.

It was said that the 'scientific method' does not exist as such,, which is true at some level. But randomised controlled trials, which are normally used to test an hypothesis of treatment effect, is very close to being an example of what is commonly known as 'the scientific method'. Arguably randomised controlled trials exists.

It was argued that no matter how many randomised control trials that are being performed, they will always be within the context of the framework for the research, which is true of course, but beside the point. Alexander Technique teachers putting forward health claims have already put themselves within the scope of medical research, and within the very narrow frame of the question: does it work?

It was also argued that there is no common agreement of what constitutes a good quality trial. This is not quite true when it comes to assessing the quality of randomised controlled trials in medical research. Anyway, pointing to the fact that scientists disagree is usually an indication that the person has not got the hang of how science works.

Celebrity based medicine
Edzard Ernst wrote a paper together with another scientist, tongue in cheek, about ''celebrity based medicine". This could be seen as a comment on the fact that CAM practitioners love to use famous people as case stories to prove the trustworthiness of their method. Alexander Technique teachers are not much different. When it was revealed that Victoria Beckham had lessons, the story was all over the place.

Someone put a comment on Ernst's article saying that a Dr so an so, M.B, B. Ch, BAO, FRCS, D.L.O., Senior Surgeon, president of this and that, was of the opinion that the Alexander Technique should be part of medical trening of doctors. I don't think Ernst was much impressed.

This is called appeal to authority and is a fallacious argument. It does not say anything about the veracity of the health claims made by Alexander Technique teachers. I also find it embarassing. This is not the way we should put our arguments forward.

What now?
What I have written here does not show the whole scope of the discussions that have taken place in response to Ernst's article on the Alexander Technique and claims of health effect. I have only quoted fragments, rephrasing comments with my own words, and according to my own impression of the meaning. It is totally subjective and not based on science.

My aim has been to try to show examples of what we as Alexander Technique teachers should not do in a discussion about the technique and medical research. More discussions will take place in the future. My hope is that we will do better next time.

But should we bother about medical research at all? The Alexander Technique is an educational method, not a therapy. This is a question I'll discuss in my next article.

Please feel free to comment below!

Related blog posts:
Research on health benefits

Related blog posts in Norwegian:

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