A Consideration of the Perspectives of Healing Practitioners on Research Into Energy Healing

Abstract

Energy healing is a complex intervention with the purpose of enhancing wholeness within the client. Approaches to complex interventions require thoughtful utilization of a wide range of research methods. In order to advance the research in this field, we sought to understand the healing practitioners' point of view by reviewing qualitative literature, research reviews, and commentary written by and about practitioners. Further, we conducted a brief survey among healers, asking their opinions on types and topics of research in this field. Emerging from this inquiry is an overview of the healers' state required for successful healing, the importance of the clients' contribution, the heterogeneity of the process of healing, and the importance of choosing appropriate outcomes to reflect the goal of wholeness. Beyond attending to measurement of these nuanced aspects, we propose utilization of research designs appropriate for complex interventions, more use of qualitative research techniques, consideration of large data registries, and adoption of the perspectives of realist research. An important gap identified was the overall lack of understanding of the clients' experience and contribution to the healing encounter.

INTRODUCTION

Healing research and biofield science have contributed to advances in understanding energy healing practices. However, energy healing is a complex intervention with the purpose of enhancing wholeness within the client. Approaches to complex interventions require thoughtful utilization of a wide range of research methods.^1,2 In order to facilitate additional progress, we propose specifically taking into consideration practitioners' views on research into biofield science and healing. One approach is to ask what we know about practitioners' experiences in the healing encounter and consider how we could design research, paying attention to that information. Another approach is to ask practitioners what they think needs to be researched and how. Since our goal is to inform future research, we believe that both pathways will yield interesting fruit, and we discuss both approaches in this article, along with reflection on some potential research approaches.

REVIEW OF HEALERS' VIEWS

We begin with a look at qualitative research,^3–12 reviews,^13–15 and commentary^16–19 to construct a picture of the healing process and issues as experienced by those most knowledgeable, the healing practitioners themselves. A few caveats are in order. We employed a nonsystematic search of the literature on healing practitioners, adding articles in a snowball fashion from references and additional searches. Much of this research literature, whether qualitative or quantitative, has focused around specific types of healing such as therapeutic touch (TT), healing touch, or Reiki, with very few authors purposefully attempting to bridge across disciplines.^3,11,13,14 In pursuing this work, we were struck by the fact that much of the relevant research on healers' perspectives is situated in the nursing literature. In this discussion, we will attempt to synthesize across disciplines while acknowledging that the fit may not be perfect for the tenets and practices of every healer.

Definitions of Healing

Healing comes from the Old English word haelan meaning “whole” and thus signifies the process of becoming more whole or assisting another in that endeavor, even during failing health or death.^{5–7,13,15,19} Egnew further clarifies wholeness as becoming whole in the physical, emotional, intellectual, social, and spiritual aspects of the self.²⁰ Additional nuances of the meaning of healing are increased order, coherence, temporality, and balance.^6,13 Another prominent description of healing encompasses a journey of transformation in which there is transcendence of suffering and new meanings are found.^5,13,14 It is quite clear that healing is not synonymous with curing, which focuses on elimination of the signs and symptoms of disease. Understanding this definition is critical as we contemplate the measurement of appropriate outcomes for healing interventions.

Definitions of Healers

In keeping with the above definitions of healing, Zahourek defines healers as catalysts to a process that results in an integrated, balanced whole person. She further specifies that healers employ the intentional influence of one person on another without known physical means of intervention.¹⁵ Archetypally, the healer has a desire to serve others; a focus on repair of mind, body, and spirit; and an ability to channel energy to this end.¹³ Cooperstein defines healers as those who beneficially affect the physiology of living organisms by laying on of hands, prayer, energy transfer, and shamanic or other mystical practices.³ This latter definition is useful in enumerating the methods employed but it misses out on other important aspects of the person that ideally should be affected: emotional, intellectual, social, and spiritual wellbeing that can lead to increased wholeness.

Definition of Energy Healing

Common terms used in the field of energy healing include energy healing, energy medicine, energy therapies, laying on of hands, and spiritual healing.¹⁷ While there is a great deal of cross pollination within and across traditions, a useful categorization of the spectrum of energy healing includes

• East Asian traditions, which include systems such as Reiki and qigong;

• Western professional traditions, such as TT and healing touch, often practiced by nurses;

• bioenergy traditions, a family of healing theories and methods originating primarily in Eastern Europe; and

• contemporary metaphysical traditions that include spiritual healers and are exemplified by well-known North American healers such as Barbara Brennan, PhD, DTh; Rosalyn Bruyere, DD; and Donna Eden, who all have eclectic backgrounds in other established traditions.¹⁴

This diversity of practice challenges the traditional medical research process in which we are accustomed to specifying a well-defined and uniform intervention.

Common Assumptions

One of us (SW) has proposed that

there is a coherent worldview expressed by energy healers that emanates from many cultural and disciplinary perspectives, and that describes the world in energetic terms [that go] beyond our common Western notions of the electromagnetic nature of all life forms, and [are] based on the extrasensory perceptions of healers and the philosophies they have been taught.¹¹

Key tenets of this worldview include^13,17,18

• the existence of a universal life force or vital energy flowing through and available to all beings;

• the existence of a subtle energy system or biofield that interpenetrates the physical anatomy of the human body and extends outward beyond it;

• the idea that in ill health, the human energetic field is out of balance or congested, free flow is blocked, which diminishes the normal self-healing capacity;

• the belief that the practitioner can detect abnormalities in the energy system, sometimes before physical manifestations, and restore the capacity for self-healing;

• the contention that the practitioner's conscious healing intent and compassion are essential to the effectiveness of therapy; and

• the assertion that the healing outcome is not dependent on the client's beliefs.

Despite the allure of finding common ground, Levin points out that each of these suggestions could be refuted in some way by some healers; for example, spiritual healers might well hesitate to speak of universal life energy and might exclusively attribute the source of healing to God.¹⁴ In the following sections, we will explore these and other constructs in order to build up our understanding of the process we would like to measure with greater veracity.

Sources of Healing Energy

In general, descriptions reveal that the healer must connect or come into resonance with a source of healing such as God, divine love, spirit, the universal life force, or the earth's energy.^11,13 The healer then channels this energy from outside the self or acts as facilitator or conduit of this energy to which the client may help themselves.^11,14 Others assert that healing comes more directly from an intervention of God, a mediation of spirits, or the assistance of other external agents. Some would situate the healing power with the healers who activate their hands and send a flow of energy.¹⁴

Nature of the Biofield

Two of us (RB, KW) participated in research supporting the existence of the biofield, both at University of California, Los Angeles, with Valerie Hunt, EdD (RB)²¹ and in the laboratory of Fritz Popp, PhD,²² in Kaiserslautern, Germany (RB, KW), using what he called a biophoton camera that measured the particles of the biofield. Much of Dr Popp's work was done with plants showing that when a leaf or branch was cut off, the entire plant exhibited a change in the biofield in reaction to the injury. This research suggests that the aura or human biofield is an electromagnetic field that surrounds and interpenetrates the body. Several other authors expound on the classical bio-electromagnetic nature of the field around living organisms,^23–25 but in building theories of the biofield, nonclassical fields described by the equations of quantum physics²⁴ or the physics of nonlinear, dynamical, nonequilibrium living systems²⁵ are also contributory. Work in theory and subtle energy detection may further illuminate mechanisms of action underpinning biofield energy healing.

Healers' Personal Journeys

The healer may initially have innate sensibilities or unusual experiences for which they have no cultural frame¹² or may experience an unaccountable summoning or calling to the work.⁸ This can lead to separation or isolation from family and community^9,13 and intense personal suffering.¹³ The individual enters their “healership” as they begin a process of education and development of knowledge about healing, often within a particular discipline.^6,9,12,14 This is accompanied by personal introspection, growth, and ultimately transformation that leads them to heal themselves.^9,12–14 They come to embody wholeness, practicing self-care physically, mentally, emotionally, and spiritually, and committing to self-management of the ego and motivations.¹² Their experiences bring them to a “radical empathy,” with an ability for deep connection to others and desire to alleviate their suffering.¹³ They have mastered skills required for healing others and are able to reintegrate within their communities in a new role.^8,9,13

Healers' Readiness to Heal in the Moment

There is general consensus across disciplines that 3 major states within the healer are paramount to effective healing: compassion, focus, and intention.¹⁴ Compassion involves unconditional love, a desire to help, a deep caring, and a shared humanity. The healer meets clients where they are and loves them for who they are in the moment.^12,14,15,19 Focus includes authentic presence¹⁹; concentration¹⁴; being centered, grounded, and relaxed; getting the self out of the way; reaching a mental stillness where the healer is aligned with the energy source, open and sensitive to altered perceptions.^12,15 The third essential state includes intention for the client's wholeness¹⁹ and/or intention for the client's specific needs assessed in the moment.¹⁵

Experienced healers (RB, KW) agree that healing is a consciously focused activity yet point out that a more useful term than intention might be volition. One uses will not to influence outcome but to initiate energy flow; then the process becomes kinesthetic as energy moves. Healers, because healing means the transfer of energy from one field to another as well as sometimes physically manipulating the client's body with energy, have found healing to be a physical—one might even say athletic—endeavor and not one of thought and feeling alone. From a research perspective, we need measures of all of these cardinal attitudes or states: compassion, focus, intention, and volition.

States of Consciousness Involved

The concept of focus encompasses a shifting state of consciousness from a concentration that is entered into purposefully with practice, meditation, prayer, or affirmations and keeping the healer's will out of the way¹⁴ to expanded, profound, or visionary states of consciousness. These latter states might include access to spiritual entities, intuition, multiple realities, or experiences of the world of spirit, ineffable sensations, altered perceptions, and transcendence.^6,8 In some electroencephalography (EEG) studies of healer-healee dyads, the healer's brain shifts to alpha waves and the healee's brain shifts to the same wave state.²⁶ In a systematic review, EEG changes were inconsistent across studies, but in some forms of healing, heart rate variability shifted to a more aroused state during healing activity.²⁷ This shift of consciousness and physiology within the healer appears to be linked to the healing.

The Role of Specific Techniques or Discipline

The study of modalities is a part of the development of the healer as identified above. It doesn't seem to matter what the system is as long as the healer is well trained in some discipline. Great healers exist in all traditions as do skilled but ineffective healers.¹⁴ According to one study, by investigating technique, “participants learned the process of giving up control, letting go of fear, developing courage, preparing self, engaging in self-reflection, and developing confidence.”⁶ Healers need a basic background in energy anatomy as well as physical anatomy and physiology. The trained healer learns to channel energy and turn that flow of energy on and off with accuracy (RB, KW). Quinn however acknowledges that “often the techniques are just a cover, a way of getting in.”¹⁹ The real requisites of healing are compassion, focus, and intention, regardless of technique.

Healer/Client Relationship

The call for compassion and intention highlights the importance of relationship within the healing encounter. The healers interviewed by one of us (SW) also spoke of compatibility and collaboration as critical to the process, as well as creating a sense of trust and adhering to ethical standards. Communication underpins the whole process, which includes setting the stage, sharing information during the treatment, and debriefing after the session.¹¹ Likewise, Enzman Hines emphasizes connection and co-created relationships. Additionally there is an “energetic intimacy” or “shared consciousness of the transpersonal fields.”^8,13 Each of these constructs would be important to observe or measure in a research setting.

Client/Healee Contribution and Perceptions

People who are ill undergo threats to wholeness that generate suffering, involving physical, psychological, social, and spiritual dimensions of the person.²⁰ Clients of energy healers come with a variety of needs and play an active role in the process that reflects an interplay of belief and “readiness to heal.”¹⁰ Important beliefs include the belief in the healer or practice and the belief in the body's ability to heal. Readiness to heal includes a relaxed openness to the healing energy and to change, an intention or desire to heal, and a willingness to engage with the process and release suffering.^10,13,14 Clients also have a kind of veto power in that they can “put up a wall” or block the healing. This negative response can change with experience.¹⁰

When asked about their experiences, clients, whether healthy or in a critical care unit, describe energy feelings predominantly as warmth and tingling along with quiescent feelings of being relaxed, sleepy, calm, or peaceful.^4,7 In one study, cardiac care unit patients were more stable, had less pain, and less anxiety; most requested the energy treatment again.¹⁸

Outcomes That Matter

Given the definitions of healing, the explication of the process and roles of both the practitioner and the client, what are the most relevant outcomes to measure in trials and when do we employ them? We need measures of wholeness, suffering, transformation, and transcendence. If healing is a journey, we need to thoughtfully select the timing of measurements to correspond to our understanding of the timeframes involved which may not be immediate.^2,28 The Self-Assessment of Change Scale, a new measure developed for complementary and alternative therapies, may be particularly relevant in capturing the profile of suffering and the transformative changes that have been described as indicative of healing.^29,30 Other selected outcomes need to include but also go beyond physiology or disease symptoms and attend to emotional, intellectual, social, and spiritual issues.²⁰ For example, in oncology settings, energy healing trials have included measures of pain, fatigue, health function, safety, mood, and quality of life, as well as harmony and balance that are important elements of whole-person healing.¹⁶ These latter, more difficult-to-measure aspects of healing may require validation of additional outcome measures, as has been done for the Brief Serenity Scale.³¹

We have explored qualitative and review literature to discern the practitioners' point of view on the process of healing and have begun to consider how that view could inform the research endeavour. We now turn to healing practitioners themselves to investigate their views on research into energy healing in its many forms.

SURVEY OF HEALING PRACTITIONERS

Our searches of the literature (albeit not systematic) suggest that relatively little research has been undertaken with the specific aim of understanding practitioner perspectives of healing, and almost none that has asked them what research they think should be conducted. Therefore, we decided to undertake a small pilot project of our own.

Pilot Methods and Results

The most straightforward way of gaining data on practitioner perspectives is to ask them via a simple questionnaire. To help us with the framing of this article, we designed a brief questionnaire and circulated it to about 60 energy or spiritual healers in the United Kingdom (UK) via their membership in the UK Confederation of Healing Organizations (CHO).³² The survey was approved by the trustees of the CHO. After the 3-week deadline for responses, we had obtained 44 replies (a response rate of around 70%).

The first question we asked was “How important do you think it is to undertake research on energy healing?” We asked respondents to circle 1 of 5 options, ranging from “very important” to “not at all important,” with “indifferent” as the middle option. All 44 respondents circled 1 option: 29 said that research was very important, 13 that it was fairly important, and 2 respondents were indifferent about research. None of the respondents considered research to be unimportant.

Our second question asked healers “Which type of research do you think could be of most value?” We provided them with 6 options as well as a free text “other” category. Our options were clinical trials, collection of data about healing encounters, observing interactions between practitioners and clients, understanding the experience of practitioners, understanding the experience of clients, experiments on mechanisms of actions, and other—in that order. We asked healers to record their top 3 options. Forty-three people completed this question appropriately; the other one marked nearly all the boxes and had several options as their top priority. We have tabulated the number of participants who gave each option as one of their top 3 priorities in Table 1.

Table 1.

Number of Respondents Prioritizing Each Research Option

Type of Research	Number Ranking 1, 2, or 3 (ranked 1)
Understanding the experience of clients	32 (17)
Clinical trials	26 (15)
Collection of data about healing encounters	20
Experiments on mechanisms of action	18
Observing interactions between practitioners and clients	13
Understanding the experience of practitioners	9
Other (various different suggestions)	4

Our third question concerned who should carry out the research; we offered the options of energy healers, doctors, scientists, or others. Only 30 of the respondents provided us with options with more suggesting scientists than any other categories, and many who ticked the “other” box suggested clients (or ex-clients), collectives, or professional organizations should carry out the research. Several people noted that they thought the research should not be carried out by anyone with a vested interest in the outcomes.

Our final question asked “What research question would you most like asked about energy healing?” with a free text space for the response. Thirty-five of the 44 respondents completed this section of the questionnaire. We fitted the responses to the 6 categories used in the second question: 12 were about the experience of the client, 9 about mechanisms of action, 8 about trials or collection of data on healing encounters, 6 concerned data collection about interactions, and 4 about the experience of practitioner. In addition, under the “other” theme, 2 people suggested that we should study the effect of the physical and mental health of the healer on responses, one highlighted research on pain relief, and one thought that sorting out the core concepts around what healing is was the priority. Finally, 3 people highlighted the need for educational research about healing and energy. In Table 2, we provide some quotes from those responses themed as being about the clients' experience.

Table 2.

Healer-generated Questions for Future Research on Client Experiences

Participant Questions
In what way does healing affect the clients' feelings of wellbeing and health?
What do clients feel when exposed to different forms of healing or allopathic treatments for different conditions?
Does adding healing to traditional medical care improve symptoms and quality of life?
When and where is the most energy felt by the client?
What difference does energy healing make to the client's general wellbeing?
What changes does the client notice during the session, and how long did it last?
How and in what ways does energy change the client and move them towards health?
How does it improve the way the client feels?
What physical changes occur in clients as a result of energy healing?

These data should obviously be treated with great caution. Our numbers are small, and the respondents were all energy healers from the UK with links to the CHO, so they are unlikely to be representative of the movement as a whole. Furthermore, those who responded are likely to be the people who have more interest in research than those who did not. The questionnaire had not been piloted (this small study is the pilot for a larger project that we hope to undertake in both the UK and the United States), and we were not able to talk to respondents about how they viewed the questionnaire. The time constraint also meant that circulation of the forms by members of the CHO's board was unsupervised and somewhat haphazard. Finally, the order in which the options were offered may have affected the answers, and it was clear that our question about who should be doing the research was not well understood by many respondents.

Nevertheless, it is quite clear that some healers think research is a high priority, and some think the most important area to be explored is the experience of their clients. Not only was client experience voted the highest priority in response to question 2, it also came up as the most important area in the response to the open question. Further, several respondents suggested that clients should be involved in carrying out the research.

Methodological Issues: How Can We Research the Experiences of Healers and Their Clients?

The methodological approach needed to answer a research question obviously depends upon the question. In this article, we are discussing the perspectives of healing practitioners, so the research questions revolve around the thoughts, feelings, and actions (cognition, emotion, and behavior) of practitioners of energy healing and related techniques. The heterogeneity of healing practices as well as the beliefs and behaviors that surround them can be major obstacle to many of our current research techniques, both qualitative and quantitative. However, our pilot questionnaire survey of the views of healing practitioners provides some guidance on issues and research methods they find compelling.

Qualitative Methods

Qualitative research methods offer an approach that can be applied to the experiences of both healers and clients. Healers have been interviewed by 2 of the authors of this article (PD, SW).¹¹ In addition to in-depth or semistructured interviews, focus groups can be undertaken, and sensory ethnographic techniques and other qualitative techniques can be used.³³ Anthropological or ethnographic approaches can also be used to observe behaviors of healers and their interactions with clients or to try to understand the healing movement better.³⁴ Qualitative research is useful to develop understanding of a practice and generate theories or models of processes. However, qualitative research also has its limitations, most obviously the limitations on generalizability due to the relatively small numbers of people who can be included in such work.

Development of Large Databases

The healers we surveyed suggested that we should collect more data about healing and healing interactions. We agree and would like to suggest the development of databases or registries of healing. Large databases or registries containing both survey-type data and other quantitative measurements are a recognized way of helping us to monitor health practices and interventions.^35,36

Large observational databases or registries have been used to explore a number of other complex medical issues. There are 2 types of registry: those concerned with specific diseases (such as cancer registries) and those concerned with a specific intervention (such as energy healing). Databases on interventions have been particularly valuable in surgical contexts.³⁷ Surgery, like healing, is a complex intervention with great heterogeneity in the contexts and ways in which it is practiced. Total joint replacement is an example. Randomized controlled trials of joint replacement (vs no replacement) have never been carried out and would be difficult to conduct, but surgeons and their clients “know” that this surgery works, just as many energy healers and their clients “know” that healing energy can work. Furthermore, in each case of healing or joint replacement, the treatment does not work for everyone, which raises issues about who responds and why. Using the National Joint Replacement Registry in the UK, we have been able to provide some answers to such questions, uncovering, for example, the importance of the size of prostheses used and likely causes of mortality.^38,39

A large database of healing events could be developed with the help of organizations like the UK CHO that helped us with this article. It would depend on the cooperation of individual healers (and perhaps their clients) as well as their societies and organizations so that data from as many healers as possible could be collected, thus reducing bias. Such a database could be developed by the regular submission of questionnaire data from healers in relation to client-healer interactions. The database could be used to explore simple questions, such as who seeks out healing and why, as well as to explore the heterogeneity of the practices used and the outcomes of healer-client interactions. If the initiative were international, we could explore cultural differences and new research questions would be bound to emerge from analysis of the data. We believe that a well-designed large database about energy healing would allow us to make important discoveries about the “what, when, and why” of healing responses.

Implications for Trial Design

Clinical trials were advocated by many energy healers, but to conduct research that remains true to the healers' experience, we need to include the awareness of the “energetic” state of both the client and the practitioner. Zahourek asserts that research and hard data “can be nearly meaningless if the experience of the healer and healee, and the total process, is not fully understood.”¹⁵ Thoughtful creation of standardized scales that capture relevant characteristics of healers, clients, and their relationships may make an important contribution to our ability to more accurately test the effectiveness of biofield energy therapies.¹¹ An additional level of complexity stems from the understanding that relevant outcomes are holistic and are expected to cross many domains of a person's wellbeing. The UK Medical Research Council has made numerous recommendations on the design of research into complex interventions, and these might thoughtfully guide the conduct of future trials, including embedding evaluation of the process of the intervention within the trial.¹

With regard to healers, we could consider documenting sociodemographics, elements of their journeys and training, their level of experience,¹⁶ their reaction to the environment and research protocol, their physical and emotional status at the time of healing,¹⁵ and their ability to come to compassion, focus, and intentionality. The Subjective Experience of Therapeutic Touch Scale (SETTS) developed by Krieger and Winstead-Fry⁴⁰ reliably differentiates experienced TT healers (in numbers of treatments) from both inexperienced and untrained individuals. Further, better scores on SETTS correspond to better patient ratings of effect but not necessarily to years of experience.⁴¹ This might be a good starting place for development of a scale that would measure the requisite aspects of healing—compassion, focus, intention, and energy direction—and be applicable across a variety of healing disciplines.

For clients, we could measure sociodemographics, beliefs as discussed above, and readiness to heal and document their experiences during the healing encounter as well as their perception of effectiveness. A useful tool might be the Effectiveness of Therapeutic Touch Scale employed by Ferguson.⁴¹ Again, adaptation may be appropriate to broaden the applicability.

When trials are used, it is important to employ therapies as they are normally practiced, including all usual treatment procedures: adequate session time, number of sessions and intervals between them, and individualized rather than standardized therapy protocols. Elements such as touch or noncontact healing need to be considered. Appropriate trial designs need to be used, and innovative approaches, such as step-wedge designs, cluster randomized trials, and prerandomization, can be considered.¹ Appropriate comparison groups must be selected depending on the design, including usual care, waitlist controls, or sham controls (placebos).^1,16,42 Two of us (RB, KB) who are experienced practitioners suggest that a particularly good research design would work with preverbal children or infants for whom one would not attribute success to the placebo effect.

Clearly, study designs should be carefully selected to match the study questions. As we have seen, reviews can help us find commonalities across disciplines and important divergence as well. Qualitative studies can explain phenomena and generate models, theories, and appropriate research questions. Mixed method studies (qualitative and quantitative) have the potential of establishing effect while illuminating elements of patients' beliefs, expectations, and perceptions of the process and the meaning they give to the experience. These data can add to our understanding as to why and how the intervention works, for whom, and in which contexts.⁴³ Further, there is potential utility in employing the methods of epidemiology and health services research, such as databases or registries.¹⁶

The Search for Mechanisms of Action

The healers surveyed encouraged experiments on mechanism of action and pose many questions about what the client experiences. We would like to suggest the use of a realist research approach that offers an alternate stance from which to undertake research into complex, context-dependent practices such as energy healing.^44,45 Realist research, which comes from social science and is increasingly used in the fields of public health and policy development, focuses on refining theories by describing how, for whom, and under which circumstances complex interventions work.⁴⁶ Realist research and synthesis provide tools that allow us to infer which mechanisms might be responsible for a specific type of outcome and could thus provide new insights into the process of healing and the design of future studies.^47,48

CONCLUSIONS

Energy healing is a complex intervention encompassing significant heterogeneity of healing practice, with dependence on the state of the healer, the healee, and their relationship. We recommend that these factors be taken into account by employing designs that are suited to complex interventions, emphasizing understanding of the process, and measuring variables related to the health, beliefs, and behaviors of individual healers and their clients. Healing is to make whole, so measured outcomes must go beyond physiology and attempt to document transformation in cognitive, emotional, social, and spiritual domains as well. After reviewing the literature and asking the healers themselves about uncharted areas, it is clear that the experience of the client and the client's contribution to the healing encounter deserve much greater recognition in our inquiries into energy healing. Finally, given the complexity of energy healing and the human participants, it is important to embrace other research methods in addition to clinical trials including the use of qualitative techniques, large data registries, and innovative realist research that seeks to understand what works for whom in which contexts.