Individualized Homeopathy: A Consideration of Its Relationship to Psychotherapy

Introduction

Homeopathy has endured as a worldwide system of medicine for over 200 years and spread globally from its origins in Europe. ¹ Because some of its tenets appear implausible, it has remained at the outer margins of mainstream medicine and many of its achievements have been ignored. ² Nonetheless, evidence suggests that homeopathy is more effective than placebo in humans and that it may be effective in animals, ³ animal models of pathology, and plant growth and bioassays. ⁴ Several reviews of human studies on the efficacy of homeopathy have been published. While detailed discussion is beyond the scope of this article, the issues arising from such reviews, both positive and negative, have been discussed elsewhere. ^{5 –7} A recent review suggests basis for cautious acceptance of the benefits of homeopathy in clinical medicine, ⁸ especially individualized homeopathy (IH), ⁹ which is one of several types of homeopathy. Besides its performance compared with placebo pills, large observational studies have documented long-term patient improvement from incorporation of homeopathy into practice. ¹⁰ So how might it work?

In the practice of IH, it is necessary to create a profile that most closely captures a person's individuality. Once those features have been identified, the remedy is selected. During the assessments, detailed questions are asked about how a patient feels and what affects those symptoms, with a special attention to unusual or unique patterns. The range of questions and expectations of response are wide: They include exploration of psychological symptoms, physical pathology, and even past illnesses. Later derivatives of IH exist but are not discussed here because they are less likely to use these unique psychological and social framings.

Any benefits from homeopathy are generally assumed to be the result of factors common to all treatments and so are attributed only to the placebo effect, with such effects assumed to be largely subjective and the result of suggestion and expectation. Such a conclusion is premature; homeopathy merits further study, particularly of its component parts (i.e., how it might work in the clinical setting or through what processes), an aspect that has been largely ignored as investigators have focused on the goal of whether it works beyond placebo pills. This article proposes that classical homeopathy or IH contains important elements of psychotherapy and also goes beyond those common factors, producing benefits that reflect specific processes arising from the way it is framed, organized, and delivered. An integral feature of homeopathic framing is that a physician's task is not merely to treat a defined disease but to treat the whole person (mind and body) with the disease and expect their health to be improved over long periods of time. As a result, treatment selection is based on a picture of the whole person, setting wider expectations for improvement in chronic disease than many other models in medicine, and then observing and tracking those improvements with the patient. It involves an assessment of disease symptoms, modalities (defined as factors that qualify a particular symptom, such as pain that is worse with motion but better with heat), individual peculiarities (e.g., bowel habits, food preferences, tendency for symptoms to be worse on one side), constitutional or personality factors, and reaction to life stresses and relationship issues. It also includes assessment of physical signs of disease (e.g., warts, rashes, growths, infections, and functions) and allopathic diagnoses, bundling these with symptom and person patterns into a comprehensive framing.

While homeopaths believe they offer more than nonspecific therapy, the latter cannot be discounted because IH embeds nonspecific factors. “Nonspecific” refers to effects that are unrelated to the postulated mechanism of action by which treatment achieves change. These include a listening and empathic therapist, a rationale for treatment, therapeutic ritual, expectancy setting, social learning, conditioning, the generation of meaning, optimism, and hope. The placebo is one form of nonspecific treatment that encompasses primarily expectancy, ritual, and social learning and conditioning. ¹¹ The term “common factors” refers to a subset of nonspecific elements, such as the manner of treatment delivery (e.g., patient–therapist alliance, expectancy). ^{10 –12} Going beyond the nonspecific, recent research has begun to characterize specific elements of IH, as will be summarized. “Specific” refers to effects of treatment that are predicted by the theory of how the treatment produces change. ¹³

Quantitative Studies of Therapeutic Process in Homeopathy

In a placebo- and non-IH–controlled randomized dismantling trial of rheumatoid arthritis (RA), Brien et al. ¹⁴ found greater benefit for IH consultation than non-IH consultation for RA, with an effect size similar to that of psychotherapy (cognitive–behavior therapy) for RA, a reminder that psychotherapy can be of benefit in medical conditions and not only for mental disorders. The authors failed to show greater benefit for homeopathic remedy over placebo and concluded that the IH consultation, rather than the remedy, was the active principle.

An underpowered 2 × 2-design study in gastroesophageal reflux disease by Dossett et al. ¹⁶ showed greater benefit for the homeopathic consultation over standard consultation but no benefit for a fixed (i.e., nonindividualized) homeopathic remedy over placebo.

Qualitative Studies of Therapeutic Process

Brien et al. ¹⁷ identified insight gained into illness or self and received advice as among the active elements, but they found that improvement was not predicted by the common factor of an empathic relationship. Dossett et al. ¹⁶ showed that consultation length and perceived empathy were not associated with treatment outcome.

A placebo-controlled trial in attention-deficit/hyperactivity disorder by Jacobs et al. ¹⁸ found no difference for IH, but the authors noted clinical improvement in general, which they ascribed to the therapeutic relationship. Without a control group for the consultation process, however, it is impossible to know whether improvement was due to the relationship, other nonspecifics, or regression to the mean. Had this design incorporated a no-consultation arm, as was the case in Brien and colleagues' study, it would have been possible to assess the impact of IH.

Bikker et al. ¹⁹ demonstrated that therapist empathy and patient empowerment at baseline predicted outcome in a sample of 187 general medical outpatients, findings that are in agreement with those of Barber, ²⁰ who noted that patient-related factors may be important determinants of outcome. To this point, it has been shown elsewhere that patient readiness to change can determine whether an otherwise effective drug in panic disorder is better than placebo: in precontemplators (i.e., those who were unready to consider change), the drug was no better than placebo, whereas in those who were more ready for change, a difference was found in favor of adinazolam. ²¹ It is possible that the effect of not only a psychotherapy procedure but also a medication (or homeopathic remedy) could be affected by patient-related factors, such as readiness to change, and this could be a fruitful line of study in IH.

Thompson and Weiss ²² examined the active ingredients of homeopathy and singled out the homeopath's attention to perhaps seemingly insignificant idiographic material and the detailed and nuanced elicitation of bodily sensations as being distinctive to this form of medical practice. Thompson and Weiss also stated that remedy matching and accurate understanding of the person may play a part. They considered that healing is brought about through finding a “transactional symbol” acceptable to both patient and physician. Such an interpretation is similar to the notion that healing comes about from infusion of meaning, referred to as a “meaning response” by Moerman and Jonas. ²³ This is believed to be a core component of the placebo effect, infusing all types of therapies. In the case of IH, this meaning generation embraces the whole person, incorporating both physical and psychological pathologies, which are then held in the social expectation of improvement through the “transactional symbol” of the remedy.

Koithan et al. ²⁴ examined the “lived experience” and found that recovery was accompanied by an intensive process of self-discovery. They found that insight was achieved in the best responders, to produce an experience of transformation or “unstuckness.” The authors also observed that self-transformation led to clearer awareness (“the ability to see”) of body sensations, thoughts, and behaviors, which led to the ability to make wiser choices and find greater purpose. The authors noted that homeopathy is a package of care, like many other forms of treatment, in which the medicinal and consultative parts are interrelated and inseparable. If that is so, then a dismantling study design would be a logical next step to ascertain which, if any, component of IH is responsible for improvement. Such dismantling studies are well established for other psychotherapies, and two examples will be given.

In a study of suicidal patients with borderline personality disorder, ²⁵ standard dialectical behavioral therapy (DBT-ST), a package that includes social skills training (S) and individual therapy plus activities (I), was compared with DBT-S and DBT-I. DBT-ST was most effective, followed by S and I. The authors concluded that a DBT package with social skills training was more effective than one without.

In the second example, Bell and D'Zurilla ²⁶ reported that the entire combination of training in four problem-solving skills, along with positive problem orientation (versus problem skills only) is superior to single components in treatment of depression.

So is IH a particular form of therapy that incorporates and adds to psychotherapy? When studying the effects of particular components of psychotherapy, Borkovec and Sibrava ²⁷ have described four approaches, which they refer to as (1) dismantling, (2) additive, (3) parametric, and (4) catalytic designs. Dismantling studies identify the complete set of postulated specific techniques and compare the full package to one or more approaches that contain only a subset of the techniques. Brien and colleagues' study exemplifies, in part, a dismantling trial of IH in which the entire package of individual consultation and individually chosen remedy was compared with individual consultation with two non–individually chosen remedy options: placebo or a standard remedy formula. A nonconsultation arm was also included, thus making possible the determination of consultation effectiveness. The additive design could also be used to evaluate homeopathy, in which a second treatment is added to an already administered intervention. A (nonhomeopathic) example of innumerable such studies comes from post hoc analysis of a trial in post-traumatic stress disorder, which showed that in partial responders to sertraline, the addition of prolonged exposure, a form of cognitive–behavioral therapy, produced further improvement than sertraline alone, while in full responders it made no difference. ²⁸

Considering Common and Specific Processes in Relation to Homeopathic Therapy

Wampold has written at length about mechanisms that might explain outcome in psychotherapy. ^29,30 He considers how therapy produces recovery and proposes a model that integrates the common and specific, in which the first task is to establish trust and form a bond, followed by a three-arm process in which (1) the “real relationship” is elaborated, (2) expectations are developed, and (3) healthy actions are pursued via the “specific” components of the chosen treatment. For IH, study of the first two arms would not differ from similar study of other therapies. It would be in the third arm that the unique components of IH are applied, such as eliciting unique features (called “strange, rare, and peculiar” symptoms) in the patient's history, understanding the modalities, and selection of the remedy most likely to cover the whole person (called the “totality” of the symptoms). Therefore, dismantling studies could profitably evaluate this part of IH. However, interactive effects might also be found in which a certain aspect of the third arm could be facilitated or impeded by variables in arms 1 and 2.

Although dismantling studies are recommended, it should be acknowledged that the distinction between specific and common therapy factors is not always clear-cut in any therapy. ^30,31 The success of therapy may in part be determined by the manner in which the therapist blends specific and common elements within the chosen framework of therapy. ³² The perhaps understandable argument that homeopathy works solely through nonspecific factors (i.e., the “placebo response”) ³³ risks premature closure of the debate before the nature and contributions of common and specific factors, and their possible interactions, have been thoroughly examined. The components of the placebo response continue to be elucidated and expanded and currently include meaning generation, expectancy management, conditioning (including reinforcement of the expectancy), and social learning, ³⁴ all components embedded into the processes of IH.

IH as a Form of Humanistic Therapy

IH resembles certain aspects of humanistic or Rogerian psychotherapies and narrative therapy. Rogerian or humanistic treatment refers to a form of treatment that holds that failure to be true to oneself is at the root of psychopathology and that people have the capacity to self-heal. ³⁵ Narrative medicine may be defined as a medical practice in which the doctor develops and applies skills for recognizing, interpreting, and being moved by patients' stories and understanding their meaning. ³⁶ By these yardsticks, it is evident that IH shares many of the same characteristics, even though differing in some important ways, such as the role of the remedy and the range of assessment and application. Of the five general types of psychotherapy (psychodynamic, behavioral, cognitive, humanistic, and contemplative) and for reasons given below, a case can be made that IH contains important elements of humanistic or existential psychotherapies, while remaining mindful of its distinctive features as a remedy-based, whole person–focused treatment. Going further, because the psychotherapy and the remedy are considered to be inseparable, perhaps IH is a type of medical practice sui generis that merges the psychotherapeutic, placebo, person-centered, holistic, and postulated active medical remedy.

Similar to Rogerian therapy, IH is loosely structured, person-centered, and nondirective; stresses congruence of therapist and client; values accurate empathy; and acknowledges an inner self-creativity that is directed at recovery or adaptation. Both approaches emphasize the therapeutic relationship more than the technique used. Rogerian therapy appears to be effective, ³⁷ and it has been asserted that the above, and hitherto presumed nonspecific, components in and of themselves are active and sufficient, ³⁸ a claim that invites further investigation for the therapeutic approaches that this report focuses on.

IH can also be compared to narrative medicine (NM). Both NM and IH regard the therapist as a “meaning-maker”: by constructing a life story in relation to the patient's disease, therapist and patient together bring understanding or meaning to that story. IH differs from NM and Rogerian therapy in the following ways, however: by (1) using a completely holistic view that integrates patient characteristics across the physical, psychological, and social components with no predetermined attributional assumptions; (2) eliciting that which is strange, rare, or peculiar (e.g., unique) to the patient; (3) holding that symptoms represent the body's attempt to heal itself, a normalizing belief that can be harnessed in therapy to diminish the negative cognitive impact of the symptom (and so prevent further “disease making” by repeating the chief complaint); (4) relating the “story” or meaning to a specific remedy; and (5) fusing this social framing into the concrete form of the “remedy,” which is physically given to and taken by the patient. The latter merges the treatment “agent” (the remedy) with the therapeutic “agency” of a more fully aware and empowered patient and physician. No other form of psychotherapy or placebo therapy simultaneously uses this unique combination.

IH adds to these several elements of placebo response recently characterized in studies of nonpsychiatric conditions, lending evidence to the ability to extend these mechanisms beyond the subjective or psychological. These elements include expectancy, conditioning, and social meaning. ¹¹ IH sets a common expectancy framework that includes psychological and physical signs and symptoms, generates a common perception of the meaning of these symptoms in patient and therapist, and reinforces this social framework by periodic administration of the remedy and by repeatedly reframing positive progress toward whole-person healing in follow-up visits. This framing is what makes it a medical and not just a psychotherapeutic method.

Conclusions

IH involves specific psychotherapeutic components, enhanced common components, and use of an active remedy, all of which allow it to affect the whole person. To the extent that IH incorporates important common elements, such as therapist factors, its study could generate findings applicable more broadly to other types of complementary and alternative medicine as well as provide enlightenment on mechanisms rarely explored in conventional medicine. ³⁵ To understand how IH works, the use of dismantling or additive studies could play a role. The list of possible study designs is endless, but a few examples are given. Dismantling studies can be designed in which some parts of the consultation are withheld, such as eliciting modalities or the search for strange, rare and peculiar features or in which physical or psychological framing are eliminated. For purposes of rigorous science, it could help to develop standardized procedures, as has been done with other therapies, both drug and psychological, which have been manualized. Thus, one could compare the complete package of IH with limited packages, lacking one or other of the above parts, or without the remedy being applied. Additive study designs could also be useful. Here one thinks of a situation in which a patient fails to respond sufficiently to the IH consultation, and then the remedy is added. Many other permutations of this design, such as providing a consultation without some element, could then be added for nonresponders.

While IH may be effective in both acute and chronic diseases, for the purpose of investigation, acute disease carries the risk of improvement regardless of what is done. Finally, the purpose of dismantling, additive, parametric, and catalytic study designs is to understand how (or what parts of) a treatment works rather than to simply explore whether it works. The need for the latter types of study remains as great as ever, and the considerations raised in this article apply more to the former question, one that has scarcely been studied in homeopathy.

Finally, exploring these mechanisms could benefit understanding far beyond homeopathy or complementary medicine, elucidating useful components of healing that apply across all systems. Thus, a more detailed study of IH may shed light on ways to enhance healing in general, thereby raising all therapeutic boats in healthcare.