A qualitative analysis of adolescents' experiences of active and sham Japanese-style acupuncture protocols administered in a clinical trial

Participants experiences regarding the use of acupuncture as a treatment modality: A qualitative systematic review

BACKGROUND

Acupuncture is a promising modality in clinical practice, where the participants' experiences are crucial to acupuncture's use and effects. However, a comprehensive review synthesising participant experiences throughout treatment sessions is lacking. This study aims to explore the qualitative literature regarding participants' experiences of acupuncture as a potential treatment modality.

METHODS

A qualitative systematic review of existing literature was conducted through AMED, MEDLINE, Scopus, Embase, and Web of Science. The Joanna Briggs Institute (JBI) critical appraisal checklist was employed to evaluate research quality. Subsequently, the data were extracted and synthesised utilising the JBI Qualitative Assessment and Review Instrument (QARI) tool and data synthesis was carried out through meta-aggregation.

RESULTS

A total of twenty-eight articles were incorporated into the analysis. Four synthesised findings were identified: (1) Before acupuncture: last trust and hope; (2) During acupuncture: relaxing and calming; (3) After acupuncture: mind-body effects; and (4) Practitioner-participant relationship.

CONCLUSION

The findings highlight the changes participants experienced before and after acupuncture sessions. Implementing additional promotional initiatives for acupuncture can increase public awareness and encourage individuals to consider it an early symptom management option.

REVIEW REGISTRATION

This review was registered in PROSPERO (No. CRD42023475373).

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial

OBJECTIVES

To analyse participants' concepts about the open-label placebo (OLP) effect; to explore their views about the discussion points that are applied in conventional OLP trials and to examine their experiences of taking part in an OLP trial.

DESIGN

A qualitative study using thematic analysis of semistructured interviews that were nested within a randomised controlled trial investigating experimental OLP analgesia (registered at ClinicalTrials.gov: NCT02578420).

PARTICIPANTS

30 healthy adults who took part in the randomised controlled trial.

RESULTS

Participants mostly conceptualised placebo as something that is inert and requires deception in order to be effective. Interviewees used a broad definition of placebos, going beyond a conventional notion of sugar pills. In contrast to the conventional OLP rationale, participants seldom emphasised classical conditioning as a mechanism of placebo effects, stressing a variety of other well-established components through which placebos might be therapeutic, whereas the conventional OLP disclosures state that 'a positive attitude helps but is not necessary', participants in our study applied other attitudes, such as 'it's worth a try'. When asked about their experiences during the trial, the majority emphasised that the concept of OLP was completely novel to them. Participants were rather sceptical about the efficacy of the intervention.

CONCLUSION

Integrating lay perspectives into the scientific rationale of OLP treatments might enhance the plausibility and credibility of the rationale in ethical treatments.

TRIAL REGISTRATION NUMBER

NCT02578420.

Non-specific effects of acupuncture and sham acupuncture in clinical trials from the patient's perspective: a systematic review of qualitative evidence

BACKGROUND

Previous clinical trials have demonstrated that both acupuncture and sham acupuncture exert significant, non-specific effects on treatment outcomes when compared to no-treatment controls. A recently developed framework (mechanisms in orthodox and complementary and alternative medicine-MOCAM) suggests that the non-specific effects of acupuncture originate from multiple domains (e.g. patient characteristics, acupuncturist skill/technique, the patient-acupuncturist relationship, and the acupuncture environment). However, it remains to be determined precisely how these domains influence the non-specific effects of treatment among patients receiving acupuncture and sham acupuncture in clinical trials. Therefore, we conducted a systematic review to synthesize existing qualitative evidence on how trial participants randomized to acupuncture and sham acupuncture groups experience non-specific effects, regardless of the types of medical condition investigated.

METHODS

This systematic review included primary qualitative studies embedded in randomized controlled trials designed to investigate acupuncture or sham acupuncture interventions. Eligible studies published in English were derived from a search of five international databases. The methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme (CASP) tool. Using a framework synthesis approach, the identified MOCAM framework was adapted based on the synthesis of the available qualitative evidence.

RESULTS

A total of 20 studies of high methodological quality were included. Our proposed model indicated that the effects of acupuncture may be increased by maintaining a professional status, applying a holistic treatment approach, practicing empathy, and providing patients with an appropriate explanation of the theory behind acupuncture and sham acupuncture. From the patient's perspective, the efficacy of treatment can be increased by following the lifestyle modification advice provided by acupuncturists, maintaining a positive attitude toward treatment efficacy, actively engaging with acupuncturists during consultation, and making behavioral changes based on experience gained during the trial.

CONCLUSION

The results of this study may provide a basis for improving and standardizing key components of non-specific effects in acupuncture treatment, and for improving the isolation of specific effects in future clinical trials involving acupuncture and sham acupuncture.

Current usage of qualitative research in female pelvic pain: a systematic review

PURPOSE

Qualitative research has received growing attention in the multidisciplinary investigation of patients' perceptions about chronic diseases. The purpose of this systematic review was to characterize the usage of qualitative research in women with chronic pelvic pain (CPP).

METHODS

We performed a structured search in Web of Science, Pubmed, and EMBASE platforms until June 2019. The search combined the keywords: "pelvic pain", "endometriosis", "dyspareunia", "dysmenorrhea", "vaginismus", "focus groups", "qualitative research", "hermeneutics", "grounded theory", and "women". Qualitative studies on female CPP were included and the main findings combined using thematic synthesis.

RESULTS

We found 1211 citations, of which 52 were included in this review. The majority of included studies were based on phenomenological design. The main method for data collection was semi-structured interviews. Endometriosis was the theme of 23 studies, chronic pelvic pain of eight, dysmenorrhea of eight, dyspareunia of four, interstitial cystitis of two, vaginismus of two, vulvodynia of two, and pelvic inflammatory disease of one study. We found a wide variety of contributions. Among them, the impact of the disease on women's lives was the commonest.

CONCLUSION

Qualitative research has the potential to reveal and explain several aspects of CPP in women. The medical community may better accept knowledge gained from these studies if the methods are described more transparently in published articles.

Using psychological theory and qualitative methods to develop a new evidence-based website about acupuncture for back pain

INTRODUCTION

Potential acupuncture patients seek out information about acupuncture from various sources including websites, many of which are unreliable. We aimed to create an informative, scientifically accurate and engaging website to educate patients about acupuncture for back pain and modify their beliefs in a way that might enhance its clinical effects.

METHODS

We used psychological theory and techniques to design an evidence-based website, incorporating multimedia elements. We conducted qualitative "think aloud" audio-recorded interviews to elicit user views of the website. A convenience sample of ten participants (4 male; aged 21-64 years from the local community) looked at the website in the presence of a researcher and spoke their thoughts out loud. Comments were categorised by topic.

RESULTS

The website comprises 11 main pages and addresses key topics of interest to potential acupuncture patients, including beneficial and adverse effects, mechanisms of action, safety, practicalities, and patients' experiences of acupuncture. It provides information through text, evidence summaries and audio-clips of four patients' stories and two acupuncturists' descriptions of their practice, and three short films. Evidence from the think aloud study was used to identify opportunities to make the website more informative, engaging, and user-friendly.

CONCLUSIONS

Using a combination of psychological theory and qualitative interviews enabled us to produce a user-friendly, evidence-based website that is likely to change patients' beliefs about acupuncture for back pain. Before using the website in clinical settings it is necessary to test its effects on key outcomes including patients' beliefs and capacity for making informed choices about acupuncture.

Tai chi mind-body exercise in patients with COPD: study protocol for a randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic, progressively debilitating condition that is prevalent in the US and worldwide. Patients suffer from progressive dyspnea and exercise intolerance. Physical exercise is beneficial, but conventional pulmonary rehabilitation programs are underutilized. There remains a need for novel interventions that improve symptoms, quality-of-life, and functional capacity. Tai chi is an increasingly popular mind-body exercise that includes physical exercise, breathing training, mindful awareness, and stress management--components that are essential to the self-management of COPD. There are, however, limited data on the effectiveness of tai chi as a therapeutic intervention in this population.

METHODS/DESIGN

The Primary Aims are to evaluate the efficacy, safety, and feasibility of a 12-week tai chi program for patients with COPD. We utilize a randomized controlled trial design, with participants assigned in a 2:1 ratio to either a group tai chi program (N = 63) or a time/attention-matched education control (N = 31). Our primary outcomes are COPD-specific quality-of-life and exercise capacity. Secondary outcomes include dyspnea, mood, functional status, self-efficacy, and lung function. Cardiopulmonary exercise testing is done in a subset of patients (N = 50). To explore optimal training duration, a subgroup of patients in tai chi are randomly assigned to complete an additional 12 weeks training (total 24 weeks) (Exploratory Aim 1). To explore the impact of a simplified seated intervention including only a subset of tai chi's training components, a third randomly assigned group (N = 31) receives a 12- week mind-body breathing program (N = 31) (Exploratory Aim 2).

DISCUSSION

Results of the BEAM study (Breathing, Education, Awareness, Movement) will provide preliminary evidence regarding the value of tai chi for improving quality of life and exercise capacity in patients with COPD, including information regarding optimal duration. They will also inform the feasibility and potential benefit of an alternative mind-body breathing intervention, and provide insight regarding how isolated mind-body exercise components contribute to the overall effects of tai chi. Should the results be positive, tai chi and related mind-body practices may offer a novel exercise option that is potentially accessible to a large proportion of patients with COPD.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, ID number NCT01551953. Date of Registration March 1 2012.

Individualised medicine from the perspectives of patients using complementary therapies: a meta-ethnography approach

BACKGROUND

Personalised (or individualised) medicine in the days of genetic research refers to molecular biologic specifications in individuals and not to a response to individual patient needs in the sense of person-centred medicine. Studies suggest that patients often wish for authentically person-centred care and personal physician-patient interactions, and that they therefore choose Complementary and Alternative medicine (CAM) as a possibility to complement standard care and ensure a patient-centred approach. Therefore, to build on the findings documented in these qualitative studies, we investigated the various concepts of individualised medicine inherent in patients' reasons for using CAM.

METHODS

We used the technique of meta-ethnography, following a three-stage approach: (1) A comprehensive systematic literature search of 67 electronic databases and appraisal of eligible qualitative studies related to patients' reasons for seeking CAM was carried out. Eligibility for inclusion was determined using defined criteria. (2) A meta-ethnographic study was conducted according to Noblit and Hare's method for translating key themes in patients' reasons for using CAM. (3) A line-of-argument approach was used to synthesize and interpret key concepts associated with patients' reasoning regarding individualized medicine.

RESULTS

(1) Of a total of 9,578 citations screened, 38 studies were appraised with a quality assessment checklist and a total of 30 publications were included in the study. (2) Reasons for CAM use evolved following a reciprocal translation. (3) The line-of-argument interpretations of patients' concepts of individualised medicine that emerged based on the findings of our multidisciplinary research team were "personal growth", "holism", "alliance", "integrative care", "self-activation" and "wellbeing".

CONCLUSIONS

The results of this meta-ethnographic study demonstrate that patients' notions of individualised medicine differ from the current idea of personalised genetic medicine. Our study shows that the "personal" patients' needs are not identified with a specific high-risk group or with a unique genetic profile in the sense of genome-based "personalised" or "individualised" medicine. Thus, the concept of individualised medicine should include the humanistic approach of individualisation as expressed in concepts such as "personal growth", "holistic" or "integrative care", doctor-patient "alliance", "self-activation" and "wellbeing" needs. This should also be considered in research projects and the allocation of healthcare resources.

Patients' preconceptions of acupuncture: a qualitative study exploring the decisions patients make when seeking acupuncture

Background

Like any other form of healthcare, acupuncture takes place in a particular context which can enhance or diminish treatment outcomes (i.e. can produce contextual effects). Patients’ expectations of acupuncture might be an important component of contextual effects, but we know relatively little about the origins and nature of patients’ expectations or wider preconceptions about acupuncture. Our aim was to identify the processes the underpin patients’ decisions to try acupuncture and thus begin to tease out the origins and nature of patients’ preconceptions.

Methods

One-off semi-structured interviews were conducted with a purposive, varied sample of 35 adults who had tried acupuncture for various conditions. Interviews explored people’s experiences of acupuncture treatment and techniques from framework and inductive thematic analysis were used to relate the data to the research question.

Results

We identified four distinct processes within participants’ accounts of deciding to try acupuncture: establishing a need for treatment, establishing a need for a new treatment, deciding to try acupuncture, and finding an acupuncturist. Family, friends and health care professionals played a role in these processes, providing support, advice, and increasing people’s general familiarity with acupuncture. When they came to their first acupuncture appointment, participants had hopes, concerns, and occasionally concrete expectations as to the nature of acupuncture treatment and its likely effects.

Conclusions

Existing theories of how context influences health outcomes could be expanded to better reflect the psychological components identified here, such as hope, desire, optimism and open-mindedness. Future research on the context of acupuncture should consider these elements of the pre-treatment context in addition to more established components such as expectations. There appears to be a need for accessible (i.e. well-disseminated), credible, and individualised, patient-centred materials that can allay people’s concerns about the nature of acupuncture treatment and shape realistic hopes and expectations.

Acupuncturist perceptions of serving as a clinical trial practitioner

OBJECTIVE

This article describes the experience of four acupuncturists in terms of what it meant for them to be a practitioner in a recently completed sham-controlled acupuncture randomized control trial (RCT) with a standardized protocol.

DESIGN

At the completion of the RCT for women with ovarian dysfunction, study acupuncturists (2 male MD/acupuncturists and 2 female professional acupuncturists) were queried about their perceptions of participating in the RCT using both written responses to 5 open-ended questions and a focus group interview. Data was analyzed to categorize responses and identify themes.

SETTING

Virginia, USA.

RESULTS

The acupuncturists' experience of participating in a RCT was generally very positive, including: usual practitioner/participant relationships, collegial sharing, and increased patient volume and diversity. There was angst expressed about the unknown RCT results. While there were concerns about standardizing the acupuncture session ("dilutes the power of acupuncture therapeutics"), the acupuncturists' were supportive of the pre-established protocol. The acupuncturists overall did not have concerns with a sham intervention arm because the sham recipients did not know their treatment arm and felt as satisfied with study participation as the true acupuncture recipients.

CONCLUSIONS

Despite initial misgivings about both a standardized protocol and a sham arm, all practitioners discovered positive aspects of being a study acupuncturist. The analysis highlights the need for communication before, during and after a clinical trial between the study investigators and the intervention practitioners. As stake holders in the perception of CAM therapies with the public and with conventional medicine practitioners, it would benefit future research on CAM to similarly assess experiences of being a CAM study practitioner in order to enhance provider recruitment and reduce provider drop-out.

Qualitative research as the basis for a biopsychosocial approach to women with chronic pelvic pain

Chronic pelvic pain (CPP) is a highly prevalent clinical condition and is recognized as a public health problem. Although the number of qualitative studies related to the topic is increasing, it is essential that this knowledge be presented in a synthesized manner, grounded in the context of the care provided to patients with CPP, in order to increase the clinical and research applicability of the findings. Little attention is given to CPP in undergraduate courses and in meetings for the continuing education of health professionals, the approach to CPP typically being based on the biomedical model. We believe that qualitative research can provide insights into CPP and form the basis for a biopsychosocial approach to the condition, which can in turn lead to better results, including resolution of the pain and greater patient/health professional satisfaction. Therefore, we conducted a metasynthesis of seven qualitative studies of CPP, the principal themes of which were as follows: (a) coping with CPP versus secondary gain; (b) the great importance of determining the cause of the pain; (c) expectations regarding the doctor-patient relationship; and (d) gender issues. We hope that the present study can aid in restoring the humanistic aspects of CPP treatment.

Acupuncture for pain in endometriosis

BACKGROUND

Endometriosis is a prevalent gynaecological condition, significantly affecting women's lives. Clinical presentations may vary from absence of symptoms to complaints of chronic pelvic pain, most notably dysmenorrhoea. The management of pain in endometriosis is currently inadequate. Acupuncture has been studied in gynaecological disorders but its effectiveness for pain in endometriosis is uncertain.

OBJECTIVES

To determine the effectiveness and safety of acupuncture for pain in endometriosis. 

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group (MSDG) Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, CNKI and TCMDS (from inception to 2010) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised single or double-blind controlled trials enrolling women of reproductive age with a laparoscopically confirmed diagnosis of endometriosis and comparing acupuncture (body, scalp or auricular) to either placebo or sham, no treatment, conventional therapies or Chinese herbal medicine.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed risk of bias and extracted data; we contacted study authors for additional information. Meta-analyses were not performed as only one study was included. The primary outcome measure was decrease in pain from endometriosis. Secondary outcome measures included improvement in quality of life scores, pregnancy rate, adverse effects and rate of endometriosis recurrence.

MAIN RESULTS

Twenty-four studies were identified that involved acupuncture for endometriosis; however only one trial, enrolling 67 participants, met all the inclusion criteria. The single included trial defined pain scores and cure rates according to the Guideline for Clinical Research on New Chinese Medicine. Dysmenorrhoea scores were lower in the acupuncture group (mean difference -4.81 points, 95% confidence interval -6.25 to -3.37, P < 0.00001) using the 15-point Guideline for Clinical Research on New Chinese Medicine for Treatment of Pelvic Endometriosis scale. The total effective rate ('cured', 'significantly effective' or 'effective') for auricular acupuncture and Chinese herbal medicine was 91.9% and 60%, respectively (risk ratio 3.04, 95% confidence interval 1.65 to 5.62, P = 0.0004). The improvement rate did not differ significantly between auricular acupuncture and Chinese herbal medicine for cases of mild to moderate dysmenorrhoea, whereas auricular acupuncture did significantly reduce pain in cases of severe dysmenorrhoea. Data were not available for secondary outcomes measures.

AUTHORS' CONCLUSIONS

The evidence to support the effectiveness of acupuncture for pain in endometriosis is limited, based on the results of only a single study that was included in this review. This review highlights the necessity for developing future studies that are well-designed, double-blinded, randomised controlled trials that assess various types of acupuncture in comparison to conventional therapies.

"Maybe I made up the whole thing": placebos and patients' experiences in a randomized controlled trial

Patients in the placebo arms of randomized controlled trials (RCT) often experience positive changes from baseline. While multiple theories concerning such "placebo effects" exist, peculiarly, none has been informed by actual interviews of patients undergoing placebo treatment. Here, we report on a qualitative study (n = 27) embedded within a RCT (n = 262) in patients with irritable bowel syndrome. Besides identical placebo acupuncture treatment in the RCT, the qualitative study patients also received an additional set of interviews at the beginning, midpoint, and end of the trial. Interviews of the 12 qualitative subjects who underwent and completed placebo treatment were transcribed. We found that patients (1) were persistently concerned with whether they were receiving placebo or genuine treatment; (2) almost never endorsed "expectation" of improvement but spoke of "hope" instead and frequently reported despair; (3) almost all reported improvement ranging from dramatic psychosocial changes to unambiguous, progressive symptom improvement to tentative impressions of benefit; and (4) often worried whether their improvement was due to normal fluctuations or placebo effects. The placebo treatment was a problematic perturbation that provided an opportunity to reconstruct the experiences of the fluctuations of their illness and how it disrupted their everyday life. Immersion in this RCT was a co-mingling of enactment, embodiment and interpretation involving ritual performance and evocative symbols, shifts in bodily sensations, symptoms, mood, daily life behaviors, and social interactions, all accompanied by self-scrutiny and re-appraisal. The placebo effect involved a spectrum of factors and any single theory of placebo--e.g. expectancy, hope, conditioning, anxiety reduction, report bias, symbolic work, narrative and embodiment--provides an inadequate model to explain its salubrious benefits.