(Re)Discovering Ritual’s Role in Medicine

The term “healing ritual” often gets thrown around in ways that suggest it would be better if it were thrown out.

But let’s put New Age woo and dusty theology aside for a moment (although I enjoy dusty theology the way some people enjoy runny cheese) and ask the question on a more basic level: is there in fact a relationship between ritual and a successful recovery from injury or illness?

I promise there will be no crystals mentioned in this post.

The history of Western medicine has been the (very successful) attempt to strip “healing” down to its component parts and determine which have a demonstrable effect and which are mere ritual and cultural practice.   To the extent that we can’t get rid of ritual and cultural practice altogether, we’ve written them off as the “placebo effect.”

But an increasing body of research suggests that writing them is the wrong approach. The aspects of medicine that we’ve been trying to discard are in fact vitally useful – and there are even instances in which medicine without the placebo effect is ineffective medicine.

Or, to use the words of Harvard Medical School’s Program in Placebo Studies (PiPS):

“For many years, the placebo effect was considered to be no more than a nuisance variable that needed to be controlled in clinical trials. Only recently have researchers redefined it as the key to understanding the healing that arises from medical ritual, the context of treatment, the patient-provider relationship and the power of imagination, trust and hope.”

Double-blind clinical trials conducted through PiPS have had doctors go through the “ritual” aspects of patient care and then inform patients that they were going to be given a placebo – a sugar pill – instead of real medicine. Even knowing that they were not getting the medicine, the health of patients who went through the ritual of treatment still improved – sometimes more than the effect of using the actual drugs without the “medical ritual” component.

The placebo effect, then, is not “just the pill,” in the words of Harvard Professor of Medicine Ted Kaptchuk, who’s said in interviews that “The placebo effect is a surrogate marker for everything that surrounds a pill. And that includes rituals, symbols, doctor-patient encounters. … It’s basically the water that medicine swims in.“ And it matters.

Ritual can have a measurable impact on both subjective well-being and objective measures.

Not for everything, of course – let’s not get ahead of ourselves here. The research doesn’t suggest that ritual can shrink tumors or kill bacteria. The effect seems (thus far) limited to areas of the body which have a clear pathway to the brain. So it’s at its most effective when dealing with issues like pain, fatigue, nausea and malaise. But not only do these things matter – they’re what the reductive, “strip it to its component parts” approach to medicine is very bad at managing.

A July 2011 article published in the New England Journal of Medicine showed that “placebos can have effects similar to powerful medications as measured by a self-appraisal of subjective symptoms” for people suffering from asthma. Similar research, published in major peer reviewed journals, has shown such effects for chronic arm pain, acute migraine headaches, chronic lower pack pain, and osteoarthritis of the knee, among other maladies. There’s a host of research (not involved with PiPS) showing that visualization and relaxation techniques can create significant improvements in the lives of people who are suffering from the side-effects of chemotherapy.

“We’re showing,” Kaptchuk says, “that it makes major changes in people’s lives.”

Which raises the question: if ritual is actually a significant component of empirically based medicine, what creates this effect? What makes a “healing ritual” most effective?

The research is still ongoing, but to my mind the factors are best described by what a 2015 article in the New England Journal of Medicine calls the “therapeutic encounter.”

In a broad sense, placebo effects are improvements in patients’ symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions. These effects are distinct from those of discrete therapies and are precipitated by the contextual or environmental cues that surround medical interventions, both those that are fake and lacking in inherent therapeutic power and those with demonstrated efficacy. This diverse collection of signs and behaviors includes identifiable health care paraphernalia and settings, emotional and cognitive engagement with clinicians, empathic and intimate witnessing, and the laying on of hands.

A related idea was proposed by Psychology Professors Art Bohart and Karen Tallman in their 1999 book How Clients Make Therapy Work, in which they say that for most issues, the efficacy of mental health treatments come not from the particular approach that the therapist uses but whether or not the patient and therapist establish a meaningful connection. If they do, therapy is more likely to be effective across most measures – if they don’t, nothing done in therapy is likely to help much.

I suspect this same dynamic applies to the healing effects of rituals. The various specific elements that seem to make a difference – the use of meaningful symbols, the dress and behavior of the ritual leaders and participants, bodily engagement of various kinds – are all fundamentally in service to the basic issue: does the participant feel connected to someone or something? A person, a community, a higher power – something?

When that happens, I think, ritual power is real and good things follow. When it doesn’t, the ritual is empty formality with no impact except, maybe, boredom.

What we clearly know is that the ritual elements of cultural practices matter on a far more fundamental level than they’re often given credit for. Medicine without ritual is less effective; community without ritual is less connective; life without ritual of some kind is less meaningful, and even (some research suggests) spirals into neurosis and nihilism.

From a medical standpoint, the new placebo research is indeed bizarre and fascinating. From a humanistic standpoint, however, it’s very much in line with what we think we know about ourselves.

Cover painting “The Lady’s Death,” by William Hogarth, 1743