12. Research methodology for studies of prayer and distant healing
Elisabeth Targ* and Harald Walach
Chapter contents
Introduction236
Defining the intervention237
Target systems241
Establishing causality243
Interpreting results: qualitative and mixed-methods approaches248
Mechanism of effect249
Barriers to research250
Why do distant healing research?250
Summary251
Introduction
The topic of distant healing or healing intentionality brings some of the most controversial and central questions to the area of complementary medicine. Within the scientific community, the usual explanation for any beneficial effects of prayer, energy, spiritual or ‘psychic’ healing efforts is that hope, expectation or the relationship with the healer mobilizes a psychogenic improvement in the patient’s health. Such psychogenic effects have been well described in the psychophysiology and psychoimmunology literature and are now being researched under the heading ‘placebo effects’. They are discussed in Chapter 16. Here we consider research approaches for assessing whether the intentions of one person can benefit the health of another independently of or in addition to any psychological factors. The term ‘distant’ when applied to healing intentionality is used to emphasize the removal of ordinary channels of communication between healer and patient, but certainly the modality of healing intention could be present when a healer and patient are in proximity. More than 80% of Americans believe that their ‘thoughts can cause healing for another person at a distance’, and most of the complementary and alternative medicine (CAM) practices said to be used by Americans refer to prayer (Barnes et al. 2002). Anecdotal reports of healing in a wide variety of conditions have stimulated more than 150 controlled studies dealing with human and/or biological systems. Of these, two-thirds found a statistically significant effect (for review, see Benor, 1992, Benor, 2001, Dossey, 1993 and Targ, 1997). The US National Center for Complementary and Alternative Medicine (NCCAM) now even has a category entitled ‘energy medicine’ that comprises the concept of distant healing. This implies a type of consciousness-mediated causality that has never been accepted within the medical sciences.
Few fields of research routinely raise such heartfelt opposition as research in distant healing; as one National Institutes of Health (NIH) reviewer wrote to this author, ‘healing is intrinsically a matter of faith, and therefore cannot be studied by science’. Such remarks illustrate a popular belief among the scientific community. Some healers have voiced the concern that research cannot test or study the subtle effects of their treatments. Religionists have objected that research in distant healing may dissuade people from prayer for the purpose of strengthening faith and mistakenly focus them on a causal interaction between prayers and physical outcomes (Thomson 1996). Typical concerns are that testing healing is ‘testing God’ and therefore blasphemous, if not impossible (Dossey 1997).
These concerns, when removed from the debate, do reflect important issues in studying distant healing. Clearly we must consider the limits of our studies. As we interpret results, we must remember that:
• finding that a change occurs in a biological system in the context of a directed prayer or healing intention neither proves nor disproves the tenets of anyone’s religion
• the spiritual, cultural and psychological contexts in which healing efforts are embedded are complex and may have many benefits (or detriments) apart from their efficacy in affecting clinical change through intention alone
• use of the double-blind randomized clinical trial has multiple inherent constraints that preclude testing of distant healing exactly as it is practised in the community.
Researchers interested in pursuing studies in this area will take heart from a list of basic research tenets published by the NIH Panel Report on CAM Research Methodology. This report states the underlying assumptions that:
• research is always feasible – and essential, regardless of the therapy under consideration
• research rarely provides unequivocal answers
• good research aims to minimize the effects of bias, chance variation and confounding
• our priority is research that investigates whether treatments do more good than harm (Vickers et al. 1997).
The methodological questions in research in distant healing necessarily rest on defining a specific intervention and evaluating its impact on a target system. This will be the main focus of this chapter. Questions of mechanisms depend on the successful negotiation of these first tasks, on theoretical and paradigmatic assumptions, and will be discussed more briefly at the end.
Defining the intervention
There are no established protocols or practice standards for distant healing practitioners as a group. Healer inclusion criteria in published studies have ranged from novice volunteers in many studies (Braud, 1989 and O’Laoire, 1997) to ‘people who believe in God’ (Harris et al. 1999), to healers of international renown (Grad, 1965, Rauscher and Rubik, 1983 and Rubik, 1995) or with many years of professional experience (Snel and Hol, 1983, Sicher et al., 1998, Astin et al., 2006 and Walach et al., 2008). Each experimenter must carefully choose and document the approach and experience level of healers in a study. The choice may have a theoretical basis, e.g. an attempt to compare one approach to another or to manipulate healing parameters. Or it may be based on a practical issue, e.g. an experimenter may wish to evaluate a method being used in a particular clinic. Documentation of healer approach or experience does not require that healers be identical on all descriptors. For example, one approach might be to require 5 years of experience or a certain score on a test of concentration but not to discriminate on the basis of philosophical approach.
Because the efficacy of distant healing as a modality has not been established, there is no test by which to choose an effective healer. In addition, unlike a pharmacological agent or a technical device, distant healing depends specifically on the consciousness of a human being. This raises the important issue that, in addition to possible differing efficacy of various approaches, there may be differing skill levels of practitioners of a particular approach or even of an individual practitioner on a day-to-day basis. In a large study, one runs the risk that certain patients might be treated by an effective healer and others by healers of no ability. One novel approach used by us (Sicher et al., 1998 and Astin et al., 2006) has been to have healers that meet certain inclusion criteria work on different patients on a rotating schedule, so that if some of the healers were effective and others not, all patients would have contact with a range of practitioners, or have several healers working on the same patient in parallel (Walach et al. 2008). Because a healer might not always be performing at his or her maximum ability, it may also be appropriate to plan several intervention periods, rather than using a one-healer, one-session approach. Another way to think about this is that in studying intentionality as a healing modality, one has to ensure that the intentionality effort is really present and maximize the potential effects.
Many terms have been used to describe interventions which may fall into the category of distant healing. These include: intercessory prayer, non-directed prayer, energy healing, shamanic healing, non-contact therapeutic touch, spiritual healing. Each of these describes a particular theoretical, cultural and pragmatic approach to attempts to mediate a healing or biological change through mental intentions. The following are some operational definitions of modalities which include elements of distant healing.
• Intercessory prayer. Any form of requesting a transcendent reality or God to bring about a specific desired outcome (O’Laoire 1997).
• Non-directed prayer. Intercessory prayer in which the person praying wishes only that God’s will be done in the life of the subject (O’Laoire 1997). This prayer may typically be worded ‘Thy will be done’ (Dossey 1997).
• Energy healing. This large category describes attempts by a practitioner to send or direct atypical or ‘subtle energy’ flows either to or within the subject. Examples include attempts to interact with the Asian concept of chi, ki or prana (or life energy) through chi gong, jin shin jyutsu or reiki or chakra (human energy centres) energetic manipulations as taught in schools influenced by Ayurvedic teaching (Brennan 1987).
• Shamanic healing. This approach is typical of Native American and other indigenous cultures (Halifax 1979). These complex practices involve the healer entering a profound altered state of consciousness in which he or she experiences moving into different ‘realms’ and interacting with spirits whose aid may be enlisted in healing the patient.
• Therapeutic touch. A technique developed by nurse Dolores Krieger (1975) in which the healer uses meditative practice to induce a calm and focused state and moves his or her hands over the patient (without touching) while holding a mental intention for the patient’s healing.
• Spiritual healing. This very general term has been used to refer to a wide range of techniques including spiritist healing seances (Krippner & Villoldo 1979), as well as meditations focused on visualizing the patient connected with God, a universal force of love or the Absolute. Such healing efforts may be performed in a religious or a non-denominational context.
In a qualitative analysis of what he termed ‘transpersonal healers’, Cooperstein (1992) found that, whatever the cultural or religious orientation of the healer, most typically begin with a period of relaxation, followed by enhanced concentration, culminating in visualization. Types of healing can be distinguished according to whether they employ a rather technical metaphor (‘energy’) or more a spiritual one (‘divine light’) for the imagery, and according to the degree of altered states of consciousness induced.
Most healing efforts in the community occur within a cultural context either of interaction between the healer and the patient or expectation by the patient that healing is being performed on his or her behalf. This may or may not be the case in a study of distant healing.
What is the healer doing?
Healer strategy should be documented before any trial via interview of the healer and in extended studies healers should be asked to write daily logs describing their healing efforts. Healer selection might also involve questions as to level of experience and professional training or other issues of relevance to the study such as healer ability at concentration. Since it has not yet been established whether healer experience and training are significant for outcome, this will be an important variable to explore.
For how long is healing attempted?
Periods of time for healing interventions in the literature range from a few seconds in experiments attempting to arouse anaesthetized mice (Watkins & Watkins 1971) to 60 hours (Sicher et al. 1998). A majority of studies have required healers to perform their healing efforts serially on a daily or weekly basis for a series of treatments. Few, however, have indicated how much time the healer should spend on the healing efforts. For example, in three major intercessory prayer studies (Byrd, 1988, Walker et al., 1997 and Harris et al., 1999) no indication is given if prayers are prayed for a few seconds at bedtime or concentrated for minutes or hours. This problem can be addressed by requiring a set amount of time for the healing effort (Sicher et al. 1998) and providing healers with a log to document the extent of their compliance (Walach et al. 2008). In addition, it may be important to stay in communication with and actively encourage healers during extended studies, for the purpose of motivating their performance and ensuring that healing efforts will in fact be performed.
Individual versus group efforts
Most distant healing interventions have been organized such that one subject is treated by one healer. A variation of this approach described above involves sequential treatment of each subject by a series of different healers, or a simultaneous treatment of one patient by several healers operating independently. Another variation is seen in the Harris study: the name of each patient was given simultaneously to a ‘team of intercessors’ (Harris et al. 1999). Thus each patient was receiving pooled prayer efforts from a group of people working individually. In the study by Byrd (1988), prayer was performed as a group effort, by pre-existing Christian prayer groups. At this point there is no evidence to suggest that individual or group healing efforts are more successful. A logistical concern is the risk that, in a group setting, group members may distract one another from the task of focusing on the subject. In addition, studies using healing groups and pooled efforts have tended to use less experienced healers than those studying individual efforts. In order to comment meaningfully on the relative roles of experience versus number of interveners, it will be important that investigators considering one or another of these approaches document the experience and practice level of the healers.
Extraneous prayer
Dossey (1997) has pointed out that, in clinical healing studies, especially ones in which the patient is very ill, it is quite likely that patients may be receiving prayer or healing efforts from friends and family members or may be praying for him- or herself. In fact, on a daily basis, hundreds of thousands of people worldwide offer prayers ‘for all the sick’. Although one of the first studies of such a type of prayer by Galton (1872) did not reveal any benefit of such generic prayers, there is concern that such additional prayer might ‘interfere with’ or ‘dilute’ experimental effects of prayer. Although this might be true, it could be expected to be a typical random variable that is controlled for by random allocation (see below).
Defining the healing intention
The investigator has the responsibility to define parameters of the healing intervention engaged. This may or may not involve defining the specific mental techniques used by the healers. It does, however, require carefully defining the intentions of the treatment. Intentions may be very specifically prescribed, such as having healers hold intention for ‘lower blood pressure’, ‘reduced tumour size’, ‘decreased anxiety’ or even ‘increased emotional and physical well-being’ if the investigator plans to use a broad range of measurement tools. It is not appropriate for healers to pray for ‘religious conversion’ for patients and some studies have specifically directed healers not to do this.
It is also not useful for healers to focus their intentions for change in an area which the investigator cannot measure, e.g. ‘change in the etheric field’ or ‘balancing the heart chakra’. If within a healer’s theoretical orientation such an action is believed also to be associated with changes in the target system as defined by the experimenter, this type of focus may be acceptable as part of the healer’s working style but a measurable outcome intention should be defined and specified by the investigator.
Working with healers
Most healers have not worked in a laboratory or experimental setting and many are not comfortable with or sympathetic to the constraints put on their activity in the research setting. This represents a limitation of distant healing as it is performed in the community. It has been our experience that there is a great range of healing practitioners and some are eager to participate, very flexible and appreciative of research efforts. Others have been very angry about not being allowed to, for example, touch experimental Petri dishes or have felt investigators were discourteous because they were questioning the ability of the healers. As with all social and working situations, it is important that the healer–investigator team work toward mutual understanding, respect and consideration. Because of the history of scientists doubting healers, it is especially important to examine unconscious tendencies in the team to be dismissive toward healers. In addition, it is important to respect and understand cultural differences which may be present, such as whether it is important or insulting for a healer to be paid. Likewise, healers who participate in research studies should be fully appraised of the limitations they will experience and should be assessed for their motivation to participate in the study.
Target systems
Distant healing studies have historically shown significant effects in trials of influence not only on human medical problems but also human physiology in the laboratory, on animals (Grad, 1965, Snel and Van Der Sijde, 1995, Bengston and Krinsley, 2000, Chen et al., 2002, Bengston, 2004 and Bengston and Moga, 2007), bacteria (Rauscher & Rubik 1983) and cells in vitro (Baumann et al., 1986, Braud, 1989, Yount et al., 1997, Yount et al., 2004, Radin et al., 2004 and Taft et al., 2005). Animal and in vitro targets are often chosen for reasons including lower cost, less complexity in running a trial and ease of isolating a particular outcome measure. In addition, in animals and certainly in in vitro systems, it is much easier to eliminate psychological and placebo effects.
Population comparability
The same general rules for choosing target populations in any study apply to distant healing, with special emphasis on population homogeneity and the need for thorough baseline assessments of factors which may influence outcome, such as social support, levels of depression and anxiety, meditation practice and spiritual beliefs. In smaller samples it may be appropriate to stratify or use pair-matching to ensure balance between comparison groups on these and other relevant medical factors.
Healer attitude
Studies of distant healing, as with many psychosocial interventions, are studies of consciousness either directly or indirectly interacting with another living system. For this reason, it is important to consider issues pertaining to the relationship between the healer and the healing target. At the same time, we must consider the possibility of a target system contribution to the healing effect. Specifically, it may be important for the healing task to be motivating and relevant to the healer. For example, in developing studies in our own laboratory, we interview many healers who state that their preference would be to attempt to heal someone who was very ill, rather than to try and influence a minor problem. Despite staff concerns that healing someone very ill might be too hard, the healers insisted that this would bring forth their better efforts.
Another example of the importance of healer attitude toward the task and the target is a situation in which a chi gong master acting as a healer in our laboratory was asked to attempt to ‘kill cancer cells in vitro’. He vehemently objected that, as a healer, he was prohibited from killing anything. The situation was resolved when he agreed to ‘emit harmonizing chi energy’ toward the cells, holding an intention equivalent to ‘Thy will be done’ with regard to the cells. The cells died significantly faster than controls (Yount et al. 1997). Similarly, in studies at Lawrence Berkeley Laboratories, CA, USA, healer Olga Worrel was not willing to attempt to kill Salmonella bacteria in vitro but she was willing (and able) to protect the Salmonella from the harmful effects of antibiotics (Rauscher & Rubik 1983).
Subject beliefs
Questions have often been raised as to the relevance of subject beliefs about healing, religious orientation and desire for healing. Studies from the literature in parapsychology, for example, have repeatedly found that subjects who believe in clairvoyance or telepathy show higher scores on tests of psychic functioning than do non-believers (Schmeidler 1998). Very few studies have examined the contribution of belief specifically to healing. In our distant healing study EUHEALS patients blind to the intervention who believed that they had received healing had large and clinically relevant improvements, irrespective of the actual treatment (Walach et al. 2008).
Subject comfort with healing
In addition to differences in belief in distant healing, there may also be differences among patients in their comfort level with being the target of distant healing efforts. For example, in the Byrd study, which used 393 subjects, an additional 57 patients who were invited to participate refused. Byrd (1988) states that some of these refusals were based on religious convictions – a point of view reiterated by a commentator in the Wall Street Journal who stated that if any doctor tried to pray for him, ‘I would sue him’. We do not know if such opposition would modify the efficacy of distant healing efforts but it emphasizes the importance of documenting patients’ attitude as well as obtaining informed consent.
Subject desire for healing
A potential confounder in healing experiments became clear with the publication of a study by Walker et al. (1997), in which it was found that alcoholic patients did worse if they believed family or friends were praying for them. This emphasizes the complexity of prayer in a social context. Patients might have relied on prayer, instead of on their own decision to come clean. In designing a healing study, it would therefore be reasonable to ask subjects to indicate their own level of desire for recovery, as well as their comfort with the possibility of others praying for them.
Subject participation in healing
There has been debate among researchers doing studies in distant healing as to whether it is important for subjects to know they are receiving healing efforts. The primary objection to such trials is that telling subjects they are receiving healing eliminates the blinding and introduces possible placebo or expectation effects. This can be achieved by three- or four-armed trials in which some patients are informed about being prayed for and some are not (Benson et al., 2006
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