THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 7, Number 1, 2001, pp. 45–51 Mary Ann Liebert, Inc.

Chronically Ill Patients Treated by Spiritual Healing Improve in Quality of Life: Results of a Randomized Waiting-List Controlled Study
HARALD WIESENDANGER, Ph.D.,1 LUCIUS WERTHMÜLLER,2 KATJA REUTER, Dipl.Psych.,3 and HARALD WALACH Ph.D.3

ABSTRACT Objective: Little is known about the effects of distant healing in chronically ill patients, the population most likely to see a healer in practice. This study investigated whether distant healing as found in normal practice with patients representative of those seeking treatment from healers changes patients’ quality of life substantially. Method: Randomized, waiting-list controlled study of distant healing (anonymous, amulet, and allowing for personal contact) in chronically ill patients. Outcome measure: Patient-reported quality of life as expressed by the sum of all MOS SF-36 health survey items. Results: Sixty patients were treated by various methods of distant healing over 5 months; 59 patients were put on a waiting list (control). Quality of life improved significantly (p , 0.0005) in the treated group (10 points), while it remained stable in the control group. Positive expectation was significantly correlated with outcome. Conclusion: Chronically ill patients who want to be treated by distant healing and know that they are treated improve in quality of life.

INTRODUCTION

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piritual healing is a method of treating patients by positive mental intentions only. Practitioners frequently claim to “send healing energies,” “influence subtle material processes,” or simply pray for the well being of the recipient. Personal contact is no prerequisite, and in practice many healers treat over large distances. There is little epidemiologic knowledge about how many people seek the advice of paramedical healers. But a national survey
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in Iceland (Haraldsson, 1994) reported that 41% of the population had seen a healer, and according to our experience in Germany (Wiesendanger, 1994; Binder and Wolf-Braun, 1995) it is an increasingly used modality of unconventional treatment methods. Although spiritual healing is part and parcel of the medical system in almost all but the Western countries (Glik, 1988; Hahn, 1995; Al-Krenawi et al., 1996) as testified by the World Health Organization’s call for respecting traditional healing systems, little is known about its effects. Some studies

Schönbrunn, Germany. Switzerland. 3University Hospital Freiburg, Institute of Environmental Medicine and Hospital Epidemiology, Freiburg, Germany.
2 Basel,

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suggest positive effects of prayer and spiritual healing (Byrd, 1988; Brown, 1995; Dixon, 1998), others report either negative or inconclusive results (Beutler et al., 1987; Castronova and Oleson, 1991; Greyson, 1996; O’Laoire, 1997). A recent review of the Cochrane collaboration reported no effects for intercessory prayer over control (Roberts et al., 1998). Two recent reviews (Abbot, 2000; Astin et al., 2000) both concluded that there are enough interesting findings to warrant further study but not enough conclusive evidence. Because the situation is rather confusing, we decided to study distant healing, in which the patient is not in direct personal contact with his or her healer, in a setting akin to what can be found in practice. We studied healers who used various distant healing modalities on patients with chronic illnesses of various kinds, as they usually present to a healer. We sought to imitate the variety of healing practices that can be found and that patients seeking healing treatment are likely to encounter. We wanted to assess healing as close as possible to normal practice, as Brown (2000) recently called for. Therefore we deliberately did not define “healing” or “healing practice” in a specific way but used an operational definition: healing in the context of this study means the practice of distant healing that is used by different professional healers, who normally use distant healing, to benefit patients. The only prerequisite was that healers were prepared to practice mainly at a distance. Although healing frequently takes place in a personal encounter, we wanted to study mainly distant healing. Therefore, in the healing modalities used in this study, the main healing practice was distant healing, even though in some subgroups initial encounters were allowed for. Our question was: “Does distant healing as found in normal practice with patients representative of those seeking treatment from healers change patients’ quality of life substantially?” In this paper we describe the most important findings.

nothing much more could be done by conventional treatment to alleviate their illness. The disease had to be a clearly diagnosed entity, to have been present for at least 1 year, and to be resistant to medical treatment up to now. Patients had to agree to the procedures, be willing to wait for 6 months for their treatment, and had given written informed consent. Exclusion criteria were psychiatric diagnoses and lifethreatening diseases. Patients sent in their medical histories and diagnostic documents from their general practitioners for eligibility screening and were subsequently randomly assigned to either the waiting-list control group or the treatment group. A list of all eligible patients was sequentially numbered, and randomization was done using a list of random numbers split at the median. Patients with sequential numbers below the median of the random number list were allotted to treatment; those above were allotted to waiting. Thus, all patients were completely randomized and allocation was concealed. Furthermore, randomization was stratified according to country (Germany and Switzerland). Patients who dropped out of the study after randomization were not just replaced by new patients, but every new patient taken into the study was again randomly assigned. Patients randomly assigned to the treatment group were distributed in a quasirandom fashion into one of three treatment modalities, which were meant to reflect different types of distant healing: Anonymous distant healing (n 5 30), in which patients did not know who was treating them and when and were treated simultaneously by three to four healers who did not have contact with the patients Amulet distant healing (n 5 10), in which patients were given an amulet “laden with healing energy,” which had to be worn at night, by one healer who specialized in this technique (patients knew the healer but did otherwise not have contact) Contact distant healing (n 5 20), in which patients knew who was treating them and were able to make telephone contact or see the healer if necessary, but personal contacts were restricted to an initial meeting and the main part of the healing took place at a distance.

METHOD Via a publicity campaign in print media we recruited patients suffering from chronic diseases who knew from their physicians that

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These three modalities are representative of important types of distant healing used in practice. Contact and noncontact distant healing practices were represented in equal proportion. Altogether, 50 healers from seven European countries—most from Germany and Switzerland, but also from Italy, Luxembourg, France, Spain, and the United Kingdom—volunteered to participate, answering campaigns in national healer newsletters. They were all in contact with some national healer communities and in this study practiced the type of healing they would normally use for distant healing. Distant healing sessions lasted 23 minutes on average, with a range of 5 minutes to 2 hours. Seventy percent of the participating healers thought that distant healing was equally effective as direct healing, 13% thought distant healing was even more effective, and 17% presumed distant healing to be less effective than direct healing. Patients in the contact group were treated by a single healer, as were those in the amulet group; patients in the anonymous group were treated by four to six healers simultaneously. For the anonymous and contact groups, treatment consisted of two weekly healing sessions over the course of 5 months; it was at the healers’ disposition to decide about the length and the techniques. In the contact group, the patients additionally knew their healer, and had, on average, four personal contacts, with one third of the patients not making use of this possibility. Patients in the amulet group were to wear the amulet on the body as much as possible and from time to time to focus their attention on the amulet. Those patients who were randomly assigned to the treatment group were seen at an initial information meeting and instructed as to the treatment modalities. They were either given the name of the healer to contact, given their amulet, or told that they would be treated anonymously. They were then seen by a physician who ascertained eligibility. Patients were asked to keep a weekly journal of their experiences and to come back for the concluding visit 5 months later, when they were again seen by a physician and filled out the final patient questionnaire. Patients allotted to the waiting-list group were told that their first interview would be in 5 months’ time and were sent the patient

questionnaire. Their healing treatment started after the treated group was finished. In a preformulated, dated, and signed protocol it was agreed that the main test should be between all patients in the treatment group, with subgroup analysis as exploratory, and that the main outcome criterion was generic health status or quality of life as measured by the MOS-SF36 health survey with a single sum score (Bullinger et al., 1995). Because patients in this study were expected to have heterogeneous diseases and because we wanted a practically relevant measure of therapeutic success, we opted for a sum score of all SF36 scales as the main and single outcome criterion, which is psychometrically sound, as an analysis of a large data set collected by us has shown (Walach and Güthlin, 2000). We agreed to use the difference between post-treatment and pretreatment scores of the SF36 sum of all items as the main outcome parameter and to test this difference score between the group with one single t test. SF36 data, together with items asking for expectations and health locus-of-control items, were filled in by the patients while waiting to see the physician (patients of the treatment group) or at home (waiting-list group). Patients were encouraged not to change any medications or conventional treatments given to them by their general practitioners during the study without consulting with their doctor. After the study all patients were sent a small questionnaire gathering information about other therapeutic actions during their trial. We set the number of patients to be included in the study at 60 per group. This study size was able to detect an improvement in quality of life in the treated group of half a standard deviation superior to the control group (d 5 0.50) at a power of beta equal to 0.86 (Cohen, 1987), which is clinically relevant and statistically reasonable.

RESULTS A detailed report in German is available from the first author (Wiesendanger, 1999). Of 281 patients who applied, 120 were randomly assigned, because resources within the study were limited. From among patients fulfilling

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TABLE 1. QUALITY
OF

WIESENDANGER ET AL.
LIFE, INITIAL VALUESa Treated Group sd 28.99 36.62 43.72 29.22 29.42 19.25 19.55 21.41 18.17 m 51.77 32.65 41.36 56.46 45.34 51.22 37.66 42.75 85.84 sd 34.24 41.24 42.24 26.79 26.49 18.03 18.82 20.86 17.87 m 57.91 34.61 47.75 53.36 49.10 51.21 36.94 42.33 87.23 All sd 32.22 38.90 43.28 28.08 28.12 18.56 19.12 21.05 18.00

Control Group Scale Physical functioning Role functioning, physical Role functioning, emotional Social functioning Bodily pain Mental health Vitality General health perception Sum score of all items (not transformed) m 64.15 36.59 54.23 50.21 52.92 51.20 36.21 41.90 88.65

a SF36 scales and sum score (main outcome parameter), mean (m) and standard deviations (sd) for the groups and the whole sample; 0 5 lowest possible score; 100 5 highest possible score (except sum score); multivariate difference between groups nonsignificant.

inclusion criteria, those patients were chosen whose illnesses were comparatively more severe and chronic. Among the randomized patients, nine withdrew their consent shortly before or after randomization; these patients were replaced by newly randomized ones. One patient in the waiting-list group dropped out rather late and never handed in any data. Therefore, the final study size was 119, with 60 patients in the treated group and 59 in the control group. Two patients in the treated group and three in the control group gave insufficient data. These patients were evaluated according to intention-to-treat. Missing data at the first measurement were interpolated by grandmean estimations; missing data at the second measurement were interpolated with data from the first measurement. Patients had a mean age of 44.6 years, 68% were female, 22% had higher education (A-level with or without a university degree), 51% were married, 60% were living together with a partner, 83% were religious, and 60% were regularly or at least sometimes practicing their religion. Patients were very open toward spiritual healing (mean of 4.33 on a 5point Likert scale), were confident (4.45), and were faithful (4.35). They rated the chance of being substantially helped at 63%. Patients suffered from a variety of diseases such as complicated migraines and headaches (35 patients), inflammatory bowel diseases (3), pain syndromes (29), psoriasis (8), and congenital anomalies (4), to name only the larger categories. The mean duration of illness was 11 years, with a range of 1 to 37 years.

Randomization resulted in roughly comparable groups. Although there was a slight difference between groups in some scales (Table 1), this difference was not significant in a multivariate analysis of variance (Wilks’ Lambda1/110 5 0.882; p 5 0.077). Quality-oflife data are presented in Tables 1 and 2. Positive difference scores indicated improvement. The treated group experienced improvement on all scales. In some the improvement was substantial (emotional role-functioning, pain, mental health) whereas the control group reported either only slight improvements or aggravations. The main outcome criterion, which was defined as such a priori in a protocol, the pretreatment-posttreatment difference of the sum of all SF36 items, showed an improvement of 10.18 in the treated group, while the control group stayed virtually the same. This difference was highly significant (t 5 2 3.61; df 117; p 5 0.00045). There was no statistically significant difference among the treatment modalities (anonymous, amulet, and contact distant healing), although patients of the contact group showed the greatest improvement (12 points difference), patients in the amulet group medium improvement (10 points), and the anonymous group the least improvement (8 points). The effect size of the difference between treated and untreated groups was d 5 0.66 standard deviations. We tried to explain some of the variance by regressing theoretically interesting expectancy and attribution variables on the outcome criterion. In order to avoid capitalization of chance,

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TABLE 2. QUALITY
OF

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LIFE, DIFFERENCE A FTER 5 MONTHS Control Group (C)
OF

TREATMENT a Treated Group (T) Difference (T-C) m 11.18 12.57 22.49 2.88 14.78 8.14 7.48 7.67 10.19*

Scale Physical functioning Role functioning, physical Role functioning, emotional Social functioning Bodily pain Mental health Vitality General health perception Sum score of all items (not transformed)
a

m 22.20 23.97 2.82 2.12 24.50 1.75 2.03 20.29 20.01

sd 20.92 29.30 30.51 23.35 25.23 14.98 15.26 17.93 14.47

m 8.98 8.60 25.31 5.00 10.28 9.89 9.51 7.38 10.18

sd 18.47 40.82 46.70 31.49 25.74 20.90 20.96 17.11 16.22

Post-treatment minus pretreatment score for control (C) and treated (T) groups; mean value (m) and standard deviations (sd); negative values indicate aggravation, positive values indicate improvement; SF 36 single scales and sum of items (main outcome parameter); *, p 5 0.00045 by t test.

we first inspected first-order correlations of descriptive variables with the outcome criterion and used only theoretically interesting ones. For the treated group, this yielded a significant multiple regression coefficient of an adjusted R2 5 0.22 (F 5 6.08; p , 0.002) with two variables: “expectation of improvement” (beta 5 0.32) and “others have an influence on my illness” (beta 5 20.27). That is to say, the higher the expectation of improvement and the less others were believed to influence the disease, the more improvement could be seen. Regression coefficients and the regression equation were significant, with 22% variance explained. Other therapeutic activities during the trial (e.g., changing the general practitioner, starting psychotherapy, spa treatment) were not different between the groups.

DISCUSSION This nonblinded, randomized, waiting-list controlled study of distant healing showed that patients suffering from various types of chronic diseases can experience a statistically significant and clinically relevant improvement in quality of life as measured by the SF36 questionnaire after a 5-month treatment period with distant healing. A few words of comment are appropriate. First, we tried to assess distant healing as it is practiced normally. Therefore, we did not incorporate blinding procedures, because treat-

ment in practice is done openly. Patients knew when they were treated or not treated. This is exactly what happens in practice: People who are willing to be treated by healing and who think or know that they have not much to expect from the medical system any more seek out this form of treatment. We have not tested any theoretical components of distant healing (such as the effectiveness of “healing energies,” let alone any supernatural powers), but rather the complex of expectancy, knowledge of being treated, and treatment. Our results suggest that this combination is a powerful treatment modality when seen against the background of relatively severe and stable chronic diseases. It is more powerful than spontaneous remissions or the change of time, as controlled for by the waiting group. The effect-size of d 5 0.66 standard deviations is comparable to the efficacy of psychotherapy (which ranges from d 5 0.5 to d 5 1.2) (Smith et al., 1980; Matt, Wittmann, 1985; Barker et al., 1998; Crits-Cristoph, 1992) and can be considered clinically relevant. Second, we do not and cannot make any judgments about the specific or nonspecific nature of these effects. We do not know whether the effects were due solely to the expectations of patients or also to some healing specifically induced by the healers. There are two indications in our data that point to the first explanation as the more likely one. The expectation of being cured correlated positively with improvement—that is, the more people expect healing to improve them, the more they im-

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prove. Furthermore, there was a quasi doseresponse relationship between contact and improvement, albeit not a significant one: Patients, who had the possibility of contacting the healer, and who knew the healer, experienced more improvement than those receiving either an amulet or anonymous distant healing, although the differences were smaller than anticipated. Therefore, it is likely that part of the improvement was a result of expectancy effects, which probably make up a substantial part of what is normally called placebo effects (Kirsch, 1997). This hypothesis needs to be submitted to a further test in another trial with appropriate controls. This could be achieved without dummy interventions by conducting a four-armed trial with two waiting and two treated groups, one of each knowing about the assignment, and one of each masked. Therefore, without any other control or sham procedure, just by having patients treated or waiting but knowing or not knowing about the assignment, specific effects could be disentangled from nonspecific ones. This would be the next step, which we are currently planning to do. Third, we only assessed subjective reports from patients as outcome criteria. This is standard procedure in many clinical trials (Staquet et al., 1998). It would have been impractical for this study to gather disease-specific information because it had to be based on the volunteer collaboration of medical doctors in their free time. The information that was gleaned by general practitioners at the final interview substantiated the findings from patient data. Therefore we think it is valid information. Four, only patients of the treated group were seen by doctors. We did this to ascertain that no patient in the treated group would suffer from a life-threatening illness and to gain some more information apart from patients’ selfreports. One might argue that this in itself could have been a treatment that explains the difference between the groups. Theoretically this is possible, but it is highly implausible, because patients were seen by a panel of completely different persons and furthermore had a lot of experience with doctors checking and diagnosing them. There is no reason to expect that this check-up would have brought about

the changes that were missing after other occasions. Finally, the optimal trial of healing, in our view, would test the effects of healing in both a blind and an open setting, ideally in one single randomized trial. This would enable researchers to disentangle the nonspecific effects brought about by expectancies and any specific effects of healing. Measures of expectancy should be introduced, because this is an important moderator. We conclude from our data that chronically ill patients whose medical condition is stable and who have not much to expect from further conventional treatment can experience a clinically significant improvement in their quality of life if they decide to have a healing treatment. If patients are open to healing and have a positive expectation, the addition of distant healing to conventional treatment can be a good way of improving patients’ quality of life. We do not know at present whether this effect is specific or nonspecific. ACKNOWLEDGMENT Harald Wiesendanger and Lucius Werthmüller received limited financial funds for administrative expenses from “Messe Basel.” Harlad Walach is funded by the Institut für Grenzgebiete der Psychologie, Freiburg, Germany. There was no other private, commercial or public funding involved. We are grateful to all healers and doctors involved in the study, who gave their time for free, and to the patients who collaborated.

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Address reprint requests to: Harald Walach, Ph.D. University Hospital Freiburg Institute of Environmental Medicine and Hospital Epidemiology Hugstetterstraße 55 D79106, Freiburg Germany E-mail: walach@ukl.uni-freiberg.de

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