Shadow Medicine: The Placebo in Conventional and Alternative Therapies

Efforts to ascribe a conceptual coherence to postmodernism appear to violate its very premise that terms such as boundaries, core human values, and scientific positivism lack an objective reality. Instead, postmodernism’s argument—both epistemological and ideological—is grounded on subjectivity, viewing objectivity as an illusion, the outcome of what Friedrich Nietzsche (1844–1900) once described as “a sum of human relations, which have been enhanced, transposed, and embellished poetically and rhetorically, and which after long use seem firm, canonical, and obligatory to a people.”² From the writings of Nietzsche to those of Jacques Derrida (1930–2004), Michel Foucault (1926–1984), Jean Baudrillard (1929–2007), Clifford Geertz (1926–2006), and contemporary scholars such as John Lukacs (b. 1924), the attainment of a truly objective scientific method has been judged impossible, fragmented by social contexts and multiple levels of reasoning and meaning. Knowledge is a set of images or metanarratives that over time partnered with social, cultural, and political power to pass as authoritative, stable, and timeless concepts. All knowledge is historically and culturally based—that is, a discourse mediated by time-bound narratives existing within a culture. The postmodernist sees truth as a consensus of ideas agreed upon within a society at a particular period of time.³

Applied to medicine, postmodernism infers that the “truth” of an illness is no longer in the physician’s objectivist and biomedical account, but in the patient’s narrative, which is not only distinctive, but often confusing, if not self-contradictory.⁴ The implication for EBM is that because society’s current value system can and will alter with our changing understanding of nature, EBM should not be viewed as the only (or even preferred) basis for judgment. That said, biomedicine and its RCT felt the full brunt of the uncertainties that accompanied postmodernism and its multiple versions of fractured truths. The objective, verifiable, and replicative nature of EBM, supported by the RCT and expanded with the meta-analysis, was dismissed as a construct of myths that had wrongly been touted as unchangeable and universally applicable.⁵ As Paul Hodgkin explained in the British Medical Journal, “To the postmodern eye truth is not ‘out there’ waiting to be revealed but is something which is constructed by people, always provisional and contingent on context and power.”⁶ David P. Frost of University College London reinforced this view as well: “All meaning is constructed by a hermeneutic process and…all theories are metaphors which evolve as sociohistorical movements, selected by their rhetoric[al] strength rather than [by] any concept of proof.”⁷

While biomedicine touted an objectivist account of disease, its high-tech changes had come with the loss of the human touch, evidenced by what many understood to be shorter physician–patient encounters and the greater use of intermediary health professionals interacting with patients through lab tests, magnetic resonance imaging, computerized tomography scans, and other innovative technologies. The truism that physician–patient encounters were growing shorter in the postmodernist era—a belief reinforced by Ian Morrison and Richard Smith in 2000, who observed that patients were not experiencing sufficient quality time with their doctors—was refuted, however, by David Mechanic, Donna D. McAlpine, and Marsha Rosenthal, who showed that quality time with patients had actually increased in both the United States and the United Kingdom due to a continuity of care that included email communications with patients following their time with the physician.⁸

Notwithstanding these two contending positions, advances in treating infectious disease using vaccines, antibiotics, surgical management of trauma, and chemical manipulation of body functions came at the cost of increased health-care fees, expensive technology, questionable drug side effects, and depersonalization. Thus, although biomedicine showed impressive gains, especially in acute disease, it was noticeably deficient in areas of chronic or complex etiologies. Given the evidence of greater patient autonomy and interest in a more integrated approach, postmodernist medicine offered a new representation of illness involving social, psychological, and cultural components; innovative new discourses on pain, suffering, and empathy; and perceived limitations of the dominant biomedical model. Despite the continuing authority of reductionist science, patient interest in nontraditional therapies grew exponentially. The so-called art of medicine—namely, those aspects of the clinical encounter marginalized by the overlay of laboratory science and technology—found a supportive environment among CAM practitioners, who arguably have little to offer patients other than empathy and interventions that carry only minor validity beyond a range of anecdotal support.⁹

The challenge for conventional medicine, explained Michael A. Kottow of Olga Children’s Hospital in Stuttgart in the early 1990s, was patient objectification that focused on statistical generalities rather than on the sick individual. Being inductive and based on probabilities, science seldom offered room for individualized medicine. Biomedicine was scientific in both its diagnostic and therapeutic approach, whereas alternative medicine gave little regard to standardized diagnostics, replacing diagnostic evaluation with a subjective process focused on symptoms. Biomedicine centered its energies on “disease-eradicating therapy,” whereas alternative therapies looked instead at attacking symptoms and addressing patient well-being. As Kottow explained, “Alternative medicine does not cure but rather peripherally changes patients’ attitudes towards the natural event of their disease.”¹⁰

In the fabric of postmodernism’s conception of the universe, the lines of distinction between real science and pseudo- or deviant science remain blurred. At what point, the postmodernist asks, can deviant or pseudoscience be given an “alternative” or “complementary” status to normative science? What is to say that deviant or pseudoscience won’t at some time become normative science? Then again, is there sufficient reason to examine more closely the claims of deviant science? Is there enough disagreement with the orthodox viewpoint to question the consensus against which deviant science is judged? Does the fact that conventional medicine is showing greater favoritism to complementary and integrative approaches provide evidence of either disagreement or rival factions within orthodoxy? Is this evidence of what Thomas Kuhn called a “crisis” in normative science?¹¹

In the wake of what appeared to be a crisis in the reductionist world of science, a host of CAM therapies emerged, many of which were fashioned from debunked systems hoping for a second chance. Taking advantage of the changing health-care environment, advances in pharmacology (in particular psychotropic medications), increased signs of outpatient treatment of depressive disorders, and the rise of third-party payers, those who espoused these therapies set out to capture what they considered to be their fair share of the marketplace.

Evidence of this new construct was the direction taken by psychosomatic medicine in the postmodernist age. The term psychosomatic, which derives from the Greek words psyche, meaning “to breathe,” and soma, meaning “body,” represents the interface between the behavioral side and biomedical side of medicine. The power of suggestion in the doctor–patient relationship had once been integral to the ancient Greeks’ humoral theories in their regard for maintaining a proper balance of the body’s fluids (i.e., “passions”). The Greeks accepted the notion of the influence of emotions on physical health and illness, and this belief grew progressively over the centuries. It was also apparent to the English scholar Robert Burton (1577–1640), who in his best-known classic The Anatomy of Melancholy (1621) observed that “the mind most effectually works upon the body, producing by his passions and perturbations miraculous alterations, as melancholy, despair, cruel diseases, and sometimes death itself.”¹²

Nevertheless, this interface lost much of its gravitas in the post-Enlightenment era when Cartesian dualism gave the mind (spirit) an entirely separate existence from the body. Despite the later work of French neurologist Jean-Martin Charcot (1825–1893), who used hypnosis to demonstrate the role of psychological factors in modifying the course of physical symptoms, the mind–body dichotomy remained prevalent in mainstream medicine and was given added empowerment with the advent of cellular pathology in the late nineteenth century. The advances made in bacteriology, biochemistry, and disease specificity had a disproportionate influence on medical practice, thereby prolonging the yet unresolved mind–body dichotomy.¹³ Austin Flint’s Principles and Practice of Medicine (1881) left room for doctors to find a connection between the emotions and the disease, but, symbolic of medicine’s reductionist emphasis, William Osler’s Principles and Practice of Medicine (1892) gave unrelenting attention to biomedical science, with little left over for the functional disorders of the nervous system.¹⁴

This emphasis on the physiological factors in human behavior emerged as a movement in the late nineteenth century when German physician, psychologist, and physiologist Wilhelm Wundt (1832–1920) chose to abandon introspection as the principal means of understanding mental processes and turned instead to the study of physically observable behaviors. Wundt’s Principles of Physiological Psychology (1874), which explored the feelings, emotions, and volitions of consciousness, marked a significant departure from the more mystical, religious, philosophical, and mechanistic approaches that had dominated in previous centuries. In that earlier era, both chronic and functional disorders were treated with specific therapies, and elements of “obscure pain” and addictions were most often classified as “moral deficits” of the soul and “shamefully disregarded.” In essence, physicians were “locked in by the limitations of the prevalent physiochemical views” of their discipline, and rare was the individual who attempted to transcend those limitations. Wundt’s American disciples included psychologist James McKeen Cattell (1860–1944), who contributed to the development of intelligence theory and testing; G. Stanley Hall (1844–1924), known for his prodigious scholarship in adolescence behavior; Hugo Münsterberg (1863–1916), famous for his contributions in applied psychology; psychologist and educational reformer Charles Hub-bard Judd (1873–1946); Lightner Witmer (1867–1956), known for his work in clinical psychology; and Edward Bradford Titchener (1867–1927), who contributed to the development of intelligence theory.¹⁵

Those changes that emerged to emphasize the unconscious aspects of doctor–patient interaction went unexplored until the psychological studies of Sigmund Freud (1856–1939), Carl Jung (1875–1961), and Pierre Janet (1859–1947) in Europe and those of William James (1842–1910), James Mark Baldwin (1861–1934), Charles Hamilton Hughes (1839–1916), and Ernst Meyer (1904–2005) in America. Each in his own way reported that the range of humankind’s knowledge of the mind was like a small island whose visible portion was just the top of a great coral mountain chain hidden by the ocean. Their collective exploration gave new meaning to the subconscious and, in turn, to the full range of the mind in its relation to disease and healing. Yet even into the 1930s few medical students were exposed to more than a smattering of these ideas, which lacked a disciplinary basis in the medical student’s curriculum. This meant that the subconscious, when discussed, was usually treated as an aside and couched in skeptical or even derisive terms.¹⁶

Men such as Austrian psychotherapist Alfred Adler (1870–1937), best known as the founder of individual psychology; Paul M. Schilder (1886–1940), author of popular The Image and Appearance of the Human Body: Studies in the Constructive Energies of the Psyche (1935); Roy R. Grinker (1900–1993), one of Freud’s last patients and founder of the Institute for Psychosomatic and Psychiatric Research and Training at Michael Reese Hospital; and Yale anthropologist–linguist Edward Sapir (1884–1939) eventually provided substantial new underpinnings along with interdisciplinary connections to the field of clinical psychiatry. Then, too, the work of physiologist Walter Bradford Cannon (1871–1945), professor and chair of the Department of Physiology at Harvard Medical School; neurologist Stanley Cobb (1887–1968), director of the Department of Psychiatry at the Massachusetts General Hospital in Boston; and pioneering endocrinologist Hans Selye (1907–1982) at the Université de Montréal laid the groundwork for the acceptance of behavioral components such as emotions, appetites, and stress as contributing factors in disease. Cannon’s The Wisdom of the Body (1932), Cobb’s Borderlands of Psychiatry (1943) and Foundations of Neuropsychiatry (1952), and Selye’s The Stress of Life (1956) questioned long-held distinctions between mental and physical symptoms, between psychic and somatic causes, and between psychology and physiology.¹⁷

The outbreak of World War II gave new impetus to psychosomatic medicine due to the traumas experienced by wartime casualties. Roy R. Grinker and John P. Spiegel’s War Neuroses in North Africa (1943) and Men Under Stress (1945) provided important new information on war trauma and treatment using an integrated biopsychosocial approach to human behavior. By the end of the war, a paradigm shift was under way to recognize psychological and socioenvironmental determinants in understanding human illness.¹⁸

The late 1940s and early 1950s witnessed a general engagement of the behavioral sciences in medicine. In 1949, for example, the Russell Sage Foundation as well as the Josiah Macy Foundation instituted symposia to help formulate an interdisciplinary exchange among behaviorists and the hard sciences. Other encouragement came from the Center for Advanced Study in the Behavioral Sciences at Palo Alto, California, and from the Ford Foundation, which supported studies on anxiety, depression, and other mental dispositions that became catalysts for dramatic growth in psychosomatic medicine. One byproduct of this interdisciplinary discussion was the question of whether these therapies had superior outcomes to that of the placebo, a query that led inevitably to furthering the evolution of placebo theory and the role of the physician’s personality or behavior in the clinical encounter. Tried first in mental hospitals, the placebo soon migrated into general hospitals with the creation of psychiatric units. This latter phenomenon was short-lived, however, as hospitals moved toward a more technical laboratory-based and compartmentalized pattern of services.¹⁹

Psychosomatic medicine entered into the 1950s on its way to becoming an integral part of every medical specialty when, as medical historian Theodore M. Brown explains, it suddenly fell from grace. The reason for this eclipse, he suggests, was internal medicine’s shift into numerous subdisciplines as well as into a more biochemical and reductionist mode—directions that disconnected internal medicine from psychoanalytic and behaviorist therapies.²⁰ According to E. D. Wittkower in his 1960 presidential address to the American Psychosomatic Society, “There is a growing cleavage noticeable in psychosomatic publications between those with more and more psychiatry and less and less physiology, and those with more and more physiology and less and less psychiatry.”²¹

As academic psychotherapy migrated toward psychoendocrinology and neurochemistry, seeking to build a connection between immune and neuroendocrine systems and opening a new field called psychoneuroimmunology,²² the balance of psychotherapy fell into the hands of social workers, family doctors, celebrity physicians, healers, marriage counselors, psychiatrists, psychologists, self-help groups, and spiritualists, who turned the discipline into advice and self-help commentaries offered through workshops, books, TV shows, blogs, websites, and video packs, advocating new visions of health and happiness—a discourse that opened a wedge between biomedicine’s cure-centered focus and postmodernism’s definition of healing as a newfound wisdom regarding the quality of life.²³ As a cascade of changes impacted conventional medicine’s authority and legitimacy, psychotherapy with its competing brand names became a large part of the discussion in the 1960s, looking at illness from both a patient perspective and a cross-cultural and comparative view. This process included a review of the placebo effect, psychological experiments in persuasion or thought reform, a new perspective on religion and cultural contexts of persons and groups, and myriad psychiatric theories. Of principal interest were the beliefs, expectations, images, and perceptions that structured a person’s view of reality; the role of the healer or persuader in sanctioning or restructuring assumptive beliefs; and the role of the patient in internalizing and reevaluating those experiences.²⁴

In 1987, Americans spent $4.2 billion on 79.4 million outpatient psychotherapy visits.²⁵ In a Consumer Reports study by Martin E. P. Seligman in 1995, no specific modality did better than any other for any disorder. Psychotherapy was a self-correcting discipline; that is, if one technique showed signs of not working, its mental health specialists moved quickly to other techniques. Psychotherapy was and is a field concerned principally, if not primarily, with improvement in patients’ general functioning, and it is therefore hard to imagine it providing more than symptom relief to patients. For that reason, there remains the issue of empirically validating something that may be due to a specific problem as distinct from the patient’s “satisfaction” or “overall emotional state” and of distinguishing between psychotherapy alone and psychotherapy plus medication.²⁶

A number of individuals emerged as representatives of this holistic health/New Age movement, including psychic healers, lay practitioners, professionally trained heterodox practitioners, and even a few academically trained biomedical physicians. Among postmodernism’s celebrity healers were some of the first academically trained physicians to venture beyond reductionist medicine to learn from non-Western healing modalities. David M. Eisenberg of Harvard’s Osher Research Center was a medical exchange student to the People’s Republic of China in the 1980s, where he went to study acupuncture, massage, herbal medicine, meditation, Tai Chi, and food as medicine. Other contemporaries included author and physician Andrew T. Weil, who was drawn to the study of plants; Jon Kabat-Zinn of the University of Massachusetts Medical School, who studied the application of Buddhist meditation to medicine; Dean Ornish of the Preventive Medicine Research Institute in California, who examined the correlation between lifestyle and coronary artery disease; and Ted Kaptchuk, who studied traditional Chinese medicine. Outside the United States were others such as Brian Berman of Ireland and David Reilly of Scotland, who studied homeopathy; and Edzard Ernst of Austria and Dieter Melchart of Germany, who undertook various studies of complementary therapies. Altogether, their advocacy had the result of drawing a ragged boundary between metaphysics and the natural sciences, a testimonial perhaps to their willingness to entertain both a reductionist approach as well as an intuitive approach to health and healing.²⁷

Within this group, two biomedically trained individuals stand out: Andrew Weil and Deepak Chopra. Both are arguably the most visible spokespersons for holistic medicine, encouraging the fuller integration of alternative modalities. Trained in conventional medicine, they practice a more integrative form of healing that draws from a succession of alternative therapies as well as from the inner sanctum of biomedicine.²⁸

Andrew Weil (b. 1942) earned his medical degree from Harvard Medical School in 1968 before interning at Mt. Zion Hospital in San Francisco and then working briefly at the National Institute of Mental Health. He began experimenting with yoga and meditation and wrote The Natural Mind (1972), which reflected his growing disillusionment with conventional medicine. As director of the Center for Integrative Medicine at the University of Arizona and editor of the Journal of Alternative and Complementary Medicine, he has become a dispenser of New Age self-healing practices. His ten principles of health and illness include: (1) perfect health is not attainable; (2) it is alright to be sick; (3) the body has innate healing abilities; (4) agents of disease are not causes of disease; (5) all illness is psychosomatic; (6) subtle manifestations of illness precede gross ones; (7) everybody is different; (8) everybody has a weak point; (9) blood is a principal carrier of healing energy; and (10) proper breathing is a key to good health. At the basis of all good health, he argues, is attention to lifestyle.²⁹

Like Weil, Deepak Chopra (b. 1947) was biomedically trained, at the All India Institute of Medical Sciences in 1968 and in residencies at the Lahey Clinic in Massachusetts and the University of Virginia Hospital before earning board certification in internal medicine and endocrinology. He, too, became disenchanted with conventional medicine, turning to transcendental meditation and establishing the Maharishi Ayurveda Health Center for Stress Management in Massachusetts. In 1993, he moved to California to become director of the Sharp Institute for Human Potential and Mind/Body Medicine. In 1996, he opened the Chopra Center for Well Being in La Jolla, California, where he and David Simon led seminars on energy-based wholeness, Ayurveda, meditation, yoga, and other fulfillment exercises. As an advocate of a more metaphysical mind–body connection, Chopra insists that each body is an energy field and that aging is subject to each individual’s mental state. A proponent of “quantum healing,” he urges a form of positive or correct thinking as the motive force that governs each person’s energy field.³⁰

In the 1990s, Chopra took on the entrepreneurial mantra of the prosperity gospelers in Unconditional Life—Discovering the Power to Fulfill Your Dreams (1992) and Creating Affluence—Wealth Consciousness in the Field of All Possibilities (1993). His newfound interest represents a restatement of New Thought, whose writers, thinkers, and publicists adopt an idealistic view of the universe in which physical nature is a manifestation of the will of God and the world is as large and as immediate as consciousness can make it. This interest represents yet another effort to merge the spiritual insights of the East with the reductionist accomplishments of Western science.³¹

As noted earlier, most studies, including meta-analyses, have found little or no difference in effectiveness between the professional psychotherapist and the minions of paraprofessional therapists and counselors.³² As late as 1997, the effectiveness of more than 90 percent of psychotherapy’s more than four hundred modalities had not proven superior to the placebo.³³ This speaks to the deep concerns raised earlier by Erich Fromm in The Crisis of Psychoanalysis (1970) when he noted the possibility of psychotherapy’s stagnation and potential death.³⁴ The question is thus raised whether, for example, there is a difference in effectiveness between the approaches taken in, say, Herbert Benson’s The Relaxation Response (1975) and Timeless Healing: The Power and Biology of Belief (1996), on the one hand, and those taken in Rhonda Byrne’s The Secret (2006) and The Power (2010), on the other.³⁵ Existing studies indicate little difference between professional and nonprofessional therapists or, for that matter, between psychotherapy administered by professionals and self-administered treatments resulting from self-help literature.³⁶ As Jerome Frank explains, “The placebo may be as effective as psychotherapy because the placebo condition contains the reasons, and possibly the sufficient, ingredient for much of beneficial effect of all forms of psychotherapy.”³⁷ This suggests that much of what has transpired under the umbrella of psychotherapy is little more than a variation of the phenomenon identified earlier as New Thought, mind-cure, Christian Science, healthy-mindedness, and positive thinking.³⁸

Today, psychosomatic medicine remains a gleam in the eye of its proponents as they look to the biopsychosocial model set forth by the American psychiatrist George Engel (1913–1999), who advocated the integration of the biological, psychological, and social factors in illness and healing. Former president of the American Psychosomatic Society and editor of its journal Psychosomatic Medicine, Engel never relinquished his vision of a medical education system that would promote the interrelationship of these factors in human health and disease. In an article titled “Realizing Engel’s Vision: Psychosomatic Medicine and the Education of Physician-Healers,” Dennis H. Novack, associate dean of medical education at Drexel University College of Medicine, enlisted Engel’s vision to project the ideal medical school curriculum, whose components would include both an understanding of disease pathogenesis involving nonbiological determinants as well as physical examination and technical procedures.³⁹

One particular marker of postmodernism was the positive relationship that emerged between spirituality and physical and mental well-being, a position that had already been well defined by William James in his 1902 book The Varieties of Religious Experience.⁴⁰ Spirituality may or may not connote a religious affiliation, tradition, or association; alternatively, it may merely suggest a more personal meaning, reflection, or wholeness irrespective of any external force or energy. In either case, however, there is the obvious possibility that it has the likely effect of a perception of healthy-mindedness. The mere expectation of relief for pain, for example, tends to relieve it. By contrast, administering a specific treatment with the attitude that it is either useless or might not work has the likely effect of a disappointing outcome. This more than suggests that a good communicative relationship between healer and patient fosters an effective outcome.⁴¹ In the mid-1990s, cardiologist Herbert Benson, founder of Harvard’s nonprofit Mind/Body Medical Institute at Beth Israel Deaconess Hospital in Boston, recommended improving health through “relaxation response”—a meditative process of word repetition that is remarkably similar to the late-nineteenth- and early-twentieth-century practices of New Thought mind-cure healers and self-help authors Charles F. Haanel (1866–1949), Frank Haddock (1853–1915), Emma Curtis Hopkins (1849–1925), Horatio W. Dresser (1866–1954), and Napoleon Hill (1883–1970). Today, Benson’s relaxation therapies are commonplace in medical schools and hospitals.⁴²

Those who advocate spirituality as a valid component of health care often criticize the biomedical model for viewing illness as a physical condition that can be logically analyzed and treated without incorporating the patient’s psychological and social experiences (and by implication, spirituality) into the encounter.⁴³ Spiritual beliefs, they insist, remain important factors in some patients’ perception, and clinical caregivers should take such things into account as they deal with disease or illness. Just as evident is the fact that professional ethics impose clear constraints on when and how this can or could be done. Religion has been historically connected with disease and illness from the earliest of times, but its intersection with medical science since the seventeenth century has been distant, each preferring to deal with the sick patient in an autonomous manner. Doctors and other health-care professionals, however, are increasingly including their patient’s religious or spiritual beliefs in order to make available a wider range of support systems in the course of treatment. There has even been a “growing recognition that patients present themselves as integrated beings whose physical, emotional, and spiritual welfare are intertwined.” However explained, spirituality’s effect on healing is to create a sense of oneness in the patient—an intersection of mind and body that strengthens physical and mental wellness.⁴⁴

Contemporary scholars are finding statistically meaningful evidence in a variety of clinical, community, cross-sectional, and longitudinal studies showing that spiritual involvement of various types or dimensions (i.e., prayer, meditation, religious services, study groups, etc.) can be beneficial to physical and mental health. Their studies have also attempted to factor in different health practices, social support, psychosocial resources, and belief structures. Mindful that communication is at the heart of the spiritual and religious component in health-promotion and prevention strategies, patient response might well be aligned to the communicative encounter itself irrespective of the particular subject matter. That said, research into health-related communication suggests a rethinking of the meaning, role, and importance of spirituality as distinct from provider–patient support or encouragement.⁴⁵

As a counterculture phenomenon in the United States, postmodernist medicine accommodates relationships with meditation, prayer, yoga, nutritional therapies, pop psychology, homeopathy, wellness, naturopathy, vegetarianism, and feminist theory. It represents health-care and healing modalities practiced outside and on the fringe of conventional medicine because of differences that may be cultural, economic, philosophical, scientific, medical, or educational in nature. In their accommodation to postmodernism, Americans learned about naturopathy, reeducated themselves about homeopathy, debated the relevance of orthodox medicine’s superiority, demanded the coverage of chiropractic under Medicare, and rediscovered the potential of traditional, Native, and Eastern forms of healing. Most importantly, the unquestioned authority of scientific medicine diminished despite its ability to offer sophisticated technological solutions for acute and long-standing problems. Modern medicine, its authority embedded within an increasingly technological and mechanistic framework, was viewed as having faltered in its ability to address the personal side of health and illness. The consequence of these changing views was the forging of a new social contract that included the reemergence of alternative modalities whose theoretical and methodological approaches competed alongside the dominant system of conventional medicine. First chiropractors and then acupuncturists won access rights in the states as interest in their therapies captured the public eye. Both were early beneficiaries of the growing role of consumer power. Conventional medical doctors continued to enjoy status and income but found themselves sharing the marketplace with a broad assortment of licensed and unlicensed healers and facing an increasingly hostile attitude to their once-sovereign position.⁴⁶

The uneasy relationship between CAM and conventional medicine has been due to the fact that although the origins of both disappear into the healing practices of ancient cultures, a distinction yet remains, with one having chosen to move forward on a materialistic path grounded in the natural sciences, and the other choosing a vitalistic path that connects cure to spiritual intuition and conjecture.⁴⁷ CAM’s popularity is representative of the more mystical propensities of the postmodern world, as evidenced in books and digital media that address the paranormal and the proposition that such propensities may be filling a void left by the decline of more formalized religion. The connection between spirituality and physical health, a long-standing tradition among unconventional therapies, offers important insights into CAM’s popularity.⁴⁸ As Brian M. Hughes at the National University of Ireland explains, given that patients tend to approach medicine on the basis of heuristic reasoning rather than logical rationalism, CAM is more often characterized “as a popular deconstruction of the hegemony of biomedical science, and a counter-cultural onslaught against modernist, technologically focused conceptions of progress.” CAM substitutes mystical expressions of physical and mental health for the faith-based beliefs and practices of organized religion. “The attention given to CAM,” Hughes suggests, “may be a displaced version of the attention previously devoted to orthodox religions.” In a statistical comparisons of CAM and religious observance in Ireland (not including Dublin), he found that CAM usage was greater in those regions where religious observance had declined. This, he feels, explains why the interest in the paranormal has not diminished in Western societies despite that interest’s more secular identity in the postmodern world.⁴⁹

The elements that now underlie postmodernist thinking are a complex mixture of religion, mysticism, cosmic energy, disbelief in Western reductionism, and an increased fascination with Eastern philosophies. In medicine, this combination has involved a new approach to treating disease and illness that stands in sharp contrast to the biomedical model. Whether referring to the serial dilutions of homeopathy, the subluxations of chiropractic, Barbara Brennan’s high-energy medicine, anthroposophy, therapeutic touch, or any number of other interventions, this discourse has encouraged a more metaphysical encounter with the world, one that questions the basic assumptions about the nature of reality. Rejecting the term sectarian as too pejorative, the vocabulary of postmodernism has welcomed the descriptions unconventional, complementary, holistic, and alternative into its lexicon—terms that are often politically or socially motivated, depending in large measure on the speaker and the audience. The term alternative suggests the exclusive use of nonorthodox therapies as substitutes for conventional ones, whereas complementary implies the use of nonorthodox therapies in conjunction with or supplementary to conventional medicine, suggesting in the process a more integrative approach to healing. Unfortunately, consumers have tended to use both terms simultaneously, a situation that suggests the more appropriate use of the term complementary and alternative medicine.⁵⁰

Not all accept the label CAM as appropriate, however. David Eisenberg, Thomas Delbanco, and Ronald Kessler consider it pejorative and insist on substituting integrative as a more accurate term.⁵¹ Integrative medicine is not intended as a synonym for complementary medicine but is indicative of treatments intended as adjuncts to conventional medical treatment that are not typically part of the medical school curriculum. Equally important is the fact that the term integrative focuses on health and healing rather than on disease and treatment. “It views patients as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment,” explain Lesley Rees and Andrew Weil. “It also involves patients and doctors working to maintain health by paying attention to life-style factors such as diet, exercise, quality of rest and sleep, and the nature of relationships.”⁵²

Still others prefer the term holistic medicine, which implies giving the individual patient an instrumental role—both conscious and unconscious—in building and maintaining his or her medical landscape (physical, social, and mental well-being) through health promotion, treatment, healing, and disease prevention. In contrast to the positivistic framework of conventional medicine, holism looks beyond the formalized canon of reductionist science to the interrelationship of mind, body, and spirit as contributing factors in human wellness. It assumes, therefore, that each individual represents a complexity of interdependent functions that are affected by physical, mental, spiritual, and environmental factors, any one of which might negatively or positively influence the whole body as well as the individual part. In this postmodernist scheme of things, there is the assumption that individuals should trust their intuitions, experiences, feelings, and personal insight as a source of ultimate knowledge of the external world.⁵³

Despite the lack of consensus on the proper terminology, the changes that accompanied this counterculture attitude led to the establishment of numerous lay and professional organizations operating on the periphery of academic medicine. Formed during the heyday of postmodernism, the National Center for Homeopathy (1974) and the American Holistic Medical Association (1978) served as catalysts to a consumer-driven movement to broaden the use of alternative therapies within the nation’s health-care system. Other representative organizations include the International Veterinary Acupuncture Society (1974), the American Holistic Veterinary Medical Association (1978), the International Foundation for Homeopathy (1980), the American Holistic Nurses’ Association (1981), the American Association of Naturopathic Physicians (1981), the American Veterinary Chiropractic Association (1987), and the Academy of Veterinary Homeopathy (1995).

Along with lay and professional associations came a plethora of journals. In the United States, some of the more popular include Acupuncture and Electro Therapeutic Research (1976), Complementary Therapies in Medicine (1986), Journal of Alternative and Complementary Medicine (1995), Alternative Medical Review (1996), Journal of Body Work and Movement Therapies (1996), Evidence-Based Complementary and Alternative Medicine (2004), and Research Journal of Medicinal Plant (2006). The higher-ranked journals from the United Kingdom include Acupuncture in Medicine (1983), Complementary Therapies in Clinical Practice (1995), Journal of Ethnobiology and Ethnomedicine (2005), Chinese Medicine (2006), BMC Complementary and Alternative Medicine (2009), and Chiropractic and Manual Therapies (2011). The popular journal Evidence-Based Complementary and Alternative Medicine, better known as eCAM, was founded by Edwin L. Cooper, who served as its editor in chief between 2004 and 2010. High in its impact-factor ratings released by Thomson Reuters in 2012 are publications on popular issues such as “acupuncture and herbal medicine for cancer patients,” “integrative oncology,” and “complementary and alternative therapies for liver diseases.” On its agenda for future special issues are topics such as “spirituality and health,” “scientific basis of mind–body interventions,” and “evidence-based medicinal plants for modern chronic diseases.”⁵⁴

After much discord, the tensions exhibited over the respective merits of the nation’s heterodox healing systems appear to have settled into détente. This uneasy coexistence is by no means the outcome of any mediation between the contending parties, but the consequence of increased patient empowerment, cost factors, medical consumerism, decision making in managed care, and changes in the nation’s health-care delivery system. The debate is no longer one of legitimacy, but of the degree to which heterodox therapies should be either sanctioned or included within the fortress of biomedicine. Increased interest in the relationship between doctor and patient and the emerging science of psychoneuroimmunology has opened innovative pathways involving behavior, attitude, and the placebo effect, encouraging a new look at the individual’s capacity for healing.⁵⁵

The growth in CAM’s popularity coincided with a decided increase in the cost of health care, which grew exponentially over the decades. Between 1965 and 1975, expenditures tripled in the United States, rising from $41 billion to nearly $130 billion; between 2000 and 2010, they rose from $1.2 trillion to more than $2.6 trillion.⁵⁶ During this period of rising costs and unintended consequences stemming from complicated new technology, the ineffectiveness in managing certain chronic conditions (i.e., lower back pain and fibromyalgia), the add-on costs of risk management, and the tragic story of birth defects due to thalidomide and other drug side effects, conventional medicine found itself competing with an emerging holistic health-care movement. Unconventional therapies, many of which had been around for centuries, claimed safer and less-expensive treatments.⁵⁷

In studying citations in the five most influential US medical journals (Journal of the American Medical Association, New England Journal of Medicine, American Journal of Medicine, Annals of Internal Medicine, and Archives of Internal Medicine) over a thirty-five-year period from 1965 to 1999, Terri A. Winnick notes a “steady stream” of articles on unconventional medicine.⁵⁸ Many of the early citations concerned the issue of licensure and whether chiropractic should be included for payment in Medicare and Medicaid. Later, following the visit of President Richard Nixon to China in 1972, attention focused on Chinese medicine, opening a robust discussion of acupuncture and related modalities. Other popular topics covered Laetrile treatment for cancer and interest in herbal medicines. Not surprisingly, articles in the early years were arrogant, insulting, and “bitingly negative” toward unconventional medicine, especially regarding chiropractic, but they moderated over time to “measured discussion” and “objective disinterest.” In this latter phase, occurring after the establishment of the OAM within the NIH in 1992, authors showed an enhanced awareness of unconventional medicine’s appeal and a more realistic view of its place in a pluralistic, consumer-centered marketplace. There was even a decided increase in the use of terminology such as holistic, holism, natural, gentle, nontoxic, whole patient, self-actualization, and nonpathologic goals, all of which suggested a desire on the part of doctors and patients for a more inclusive, compassionate, and empathic approach to healing. Journal articles also focused increasingly on specific unconventional treatments and the results stemming from controlled trials. Choosing objectivity over ridicule, the journals mounted an effective educational campaign using the controlled clinical trial as its mechanism for establishing efficacy. “Evidence-based medicine” became the new watchword for validating unproven heterodox treatments. Here, the OAM and the NIH became useful vehicles to lead medical heterodoxy through the intricacies of scientific testing.⁵⁹

CAM therapies encompass not only highly complex traditional health systems such as those found in Chinese, East Indian, and Native American cultures, but distinct entities such as dietary, spiritual, and botanical modalities; practices such as hypnosis and chiropractic taught in degree-granting institutions; and less-structured entities such as therapeutic touch, Reiki, anthroposophy, and crystal healing, to name just a few. Some modalities involve manipulations or applications to the body; others utilize discrete active or inactive organic and inorganic substances, the adjustment of paranormal forces that supposedly surround or enter the body, or mind–body activity originating from inside or outside the patient.⁶⁰

Ethnographer Bonnie Blair O’Connor identifies seven categories of CAM in her 1995 book Healing Traditions: (1) alternative systems such as acupuncture, Ayurveda, and homeopathy; (2) bioelectromagnetic applications; (3) diet, nutrition, and lifestyle changes; (4) herbal medicine; (5) manual healing such as massage, osteopathy, and therapeutic touch; (6) mind–body control such as biofeedback and meditation; and (7) pharmacological and biological treatments.⁶¹ The Clinician’s Complete Reference to Complementary and Alternative Medicine (2000) adds two additional categories: community-based health-care practices and unclassified methods.⁶² In all, virtually hundreds of healing modalities are in use today and employ a wide range of diagnostic and therapeutic methods. Of this number, many have cycled in and out of popularity. To the extent that these therapies have elements common with conventional medicine, they are more easily subject to examination and evaluation for their safety and efficacy. Others, in particular those more doctrinaire in their embrace of paranormal forces or energies, prove difficult to assess using normative science.⁶³ Most significantly, CAM has become a symbol of postmodernism with its skepticism of science and technology, its preference for spirituality and the natural environment, and its emphasis on choice and responsibility.⁶⁴

Most states license some level of CAM. As of 2002, all states license chiropractic; a lesser number license acupuncture and massage therapy; eleven license naturopathy; and three (Connecticut, Arizona, and Nevada) license non-MD homeopathic practitioners. Ayurveda, however, is not licensed in any of the states even though it has existed as a healing system for more than a thousand years. Notwithstanding this situation, thousands of Ayurveda practitioners operate openly in the United States.⁶⁵

Not only has there been a proliferation of new healing modalities and health delivery services in postmodernist medicine, there is also evidence of a rising proportion of women as healers contributing to the construct of medical values, identities, and practices.⁶⁶ In conventional medical schools, the percentage of women doctors increased from 5.8 percent in 1960 to roughly half in 2011.⁶⁷ Today 53 percent of family-practice residents, 63 percent of pediatric residents, and nearly 80 percent of obstetrics and gynecology residents are female.⁶⁸ The overall number of women in complementary and alternative medicine is even higher (72.2 percent of yoga practitioners; 77 percent of naturopaths; 85 percent of massage therapists; 58 percent of acupuncturists; and nearly 90 percent of homeopaths). Drawing wisdom from both the secular sciences and America’s alternative spiritual traditions, women have become disproportionately central to maintaining the delicate balance between the healthy individual, the social environment, and the spiritual energies thought to course through the universe.⁶⁹

The definition of CAM produced by the OAM in 1997 and later adopted by the White House Commission on Complementary and Alternative Medicine Policy in 2002 represents the product of competing social and political forces:

Although heterogeneous, the major CAM systems have many common characteristics, including a focus on individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual. In addition, many CAM systems have characteristics commonly found in mainstream health care, such as a focus on good nutrition and preventive practices. Unlike mainstream medicine, CAM often lacks or has only limited experimental and clinical study; however, scientific investigation of CAM is beginning to address this knowledge gap. Thus, boundaries between CAM and mainstream medicine, as well as among different CAM systems, are often blurred and are constantly changing.⁷⁰

Nevertheless, consensus remains problematic because complementary and alternative medicine is more an “umbrella” term for multiple modalities that operate beyond the borders of conventional medicine as well as several that are now being taught in regular medical schools. Given this reality, Edzard Ernst and his colleagues have suggested a new definition: “CAM is diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine.”⁷¹

In essence, CAM conceptualizes the body, mind, and environment in an all-encompassing holistic relationship. In numerous surveys of CAM patients, statistics reveal that 80 percent or more of its users report leaving their treatments “emotionally stronger, less anxious, and more hopeful about the future.” Much of their satisfaction is attributed to their ability to choose a therapist; the amount of time spent in the physician–practitioner encounter; the manner in which the illness is explained; the practitioner’s focus on the patient’s emotional state rather than on the underlying disease; the “low-tech” approach involving more physical contact; the individualized nature of the intervention (the holistic approach versus the disease approach of conventional medicine); and the setting (i.e., private and noninstitutional) in which they are treated. In the absence of organic disease, where both doctors and patients struggle to understand and “cure” ill-defined symptoms, CAM provides a valued set of palliative therapies.⁷²

The first significant national survey of CAM usage by adults in the United States was carried out by David Eisenberg and his colleagues and published in the New England Journal of Medicine in 1993. Examining the usage of sixteen major CAM therapies, the researchers estimated that 34 percent of the adult population had used at least one complementary therapy in the previous year and that this segment of the population made an estimated 425 million visits to CAM practitioners. Surprisingly, the number of these visits roughly equaled visits to primary-care physicians. In spite of such robust figures, an estimated 90 percent of CAM patients were self-referred, which suggests a lack of knowledge or communication between patients and their primary-care physicians regarding the use of alternative treatment. No doubt, this phenomenon was reinforced by patients’ reluctance to face their conventional physicians’ hostility toward their choice of an unorthodox competitor.⁷³

In a follow-up survey of trends, Eisenberg and his colleagues surveyed 1,539 adults in 1991 and 2,055 in 1997 to measure prevalence, cost, and disclosure of CAM therapies to conventional medicine. The findings were no less remarkable.

In an effort to correct sampling errors, the National Center for Health Statistics conducted a survey in 1999, providing respondents with a list of eleven potential therapies (acupuncture, relaxation techniques, massage therapy, imagery, spiritual healing or prayer, lifestyle diet, herbal medicine, homeopathy treatment, energy healing, biofeedback, and hypnosis), with the option of adding a therapy not on the list. With a response rate of 70 percent from a total of 30,801 adults, the survey revealed that 28.9 percent of US adults had used at least one CAM therapy during the previous year, a percentage that was higher for women (33.4 percent) than for men (24 percent) and higher among persons with health insurance than among those without it. When organized by groups, the most popular modalities were those considered body–mind interventions, such as prayer, relaxation, imagery, hypnosis, and biofeedback (16.4 percent). Other popular forms of CAM were herbal therapy (9.6 percent) and chiropractic (7.6 percent). The survey also showed that CAM was more popular in the Midwest and West than in the Northeast or South and more highly used among those who rated their health either poor or fair.⁷⁵

In 2005, Hilary Tindle and her colleagues (including Eisenberg) returned to the original 1993 Eisenberg questionnaire to find comparability of information. In doing so, the researchers looked at eighteen CAM practices but excluded prayer. Their survey indicated that the most commonly used therapies were herbs (18.6 percent), followed by relaxation techniques (14.2 percent) and chiropractic (7.4 percent). The evidence suggested that the percentage of the population using at least one CAM modality in the previous year, 35.1 percent, indicated a stable environment for CAM between 1997 and 2002, except for yoga and herbal therapy usage, which showed disproportionate increases.⁷⁶ These and several other surveys reveal a number of characteristics that have appeared constant over the years.

Although surveys indicate that the majority of patients using CAM treatments do not inform their primary physician, there appears to be much less opposition among mainstream physicians to CAM therapies than in earlier decades. A 1992 survey of nearly six hundred family physicians queried by the Department of Family Medicine at the East Carolina School of Medicine in Greenville, North Carolina, indicated that 44 percent of the physicians reported being willing to work with CAM and that 23 percent believed that CAM could help where regular medicine had failed.⁸⁴ In Canada, a comparable survey of two hundred practitioners indicated that 54 percent had referred patients to CAM healers and 16 percent were actually practicing some type of CAM.⁸⁵ In other words, regular physicians were either referring patients to what they viewed as more or less respectable forms of CAM or adopting CAM in some manner in their own practices. Referral rates in 2000 ranged from 50 percent for chiropractic and 47 percent for acupuncture to 24 percent for massage, 10 percent for homeopathy, and 4 percent for herbal medicine.⁸⁶

A 1996–1997 American Medical Association survey indicated that 46 of the 125 US medical schools included CAM topics in their curriculum. A subsequent survey in 1998 indicated that 75 were offering CAM electives or including CAM topics in existing courses. Exactly how CAM had been presented—namely, whether instructors encouraged CAM or accompanied their comments with a bias—was not determined.⁸⁷ In a 1998 survey of 1,297 faculty at six health science center schools, the highest use of alternative therapies reported was by allied health faculty (76 percent), followed by nursing (74 percent), dentistry (65 percent), pharmacy (56 percent), veterinary medicine (55 percent), and medicine (52 percent). Clearly, however, the question of educating medical students about CAM therapies without marginalizing them remains an issue, particularly if the goal is to include or integrate CAM into the full range of therapeutic modalities taught in the medical curricula. As yet, there is no clear set of objectives or competencies with respect to CAM therapies that medical students are required to learn for the US Medical Licensing Exam.⁸⁸

Writing in 1998, Jay Udani, at the Health Services Research and Integrative Medicine program at Cedars-Sinai Medical Center in California, reported that equating alternative medicine to quackery was no longer accepted practice in US medical schools. He attributed this change to the increased use of the terms complementary and integrative and the fact that CAM modalities were most often performed as adjunct to conventional medicine. Udani noted that such therapies used in combination with conventional medicine had increased from 34 percent of the US population in 1990 to 69 percent in 1998 and that only 4 percent of the population chose to use such therapies exclusively.⁸⁹ The more popular of these nonconventional systems included chiropractic, acupuncture, vitamin and herbal treatments, homeopathy, biofeedback, massage, hypnotherapy, and yoga.⁹⁰ Even as the use of complementary medicine continued to grow in the 1990s, there remained a clear lack of standards or guidelines for how it could or should be integrated into conventional medicine. During the late 1990s, much of what was taught came in the form of continuing medical education.⁹¹

In response to a 2000–2001 questionnaire sent to all 125 conventional medical schools in the United States by the Liaison Committee on Medical Education, ninety-one schools reported including CAM in their required curriculum, sixty-four reported offering CAM as an elective, and thirty-two reported including CAM as part of an elective. It was still clear, however, that the content of these courses varied widely from one school to the next, with opinions ranging from neutrality to limited acceptance to outright scorn.⁹² Included among those schools offering substantive teaching of CAM were Harvard Medical School, Albert Einstein College of Medicine, Columbia University, Duke University, Mount Sinai School of Medicine, Stanford University, University of Arizona, Georgetown University, Jefferson Medical College, University of Minnesota, and several of the University of California medical schools.⁹³

Numerous suggestions for the inclusion of CAM in schools emerged from discussions among medical educators, including those listed here and published in the Annals of Internal Medicine in 2003.

A major restructuring is now occurring in the way that CAM services are organized and delivered in an environment of managed care. In a 2001 survey, nearly 16 percent of the nation’s community-based hospitals offered some level of CAM service. In addition, several major medical centers, including cancer centers, have integrated CAM therapies into their patient care: M. D. Anderson in Houston; Memorial Sloan-Kettering Cancer Center; Columbia–Presbyterian Medical Center in New York City; Duke University; and the Integrative Medicine Program managed by David Rakel at the University of Wisconsin.⁹⁵ At the Integrative Medicine Service unit at Memorial Sloan-Kettering in New York, practitioners utilize massage, music therapy, and acupuncture in their wards and offer outpatient referrals for relaxation, yoga, and Tai Chi classes.⁹⁶ What remains at issue is how the modern hospital, the bastion of biomedicine’s specialty care, accommodates an umbrella health-care system with multiple providers offering competing modalities, some of which have radically different epistemologies and without clear scientific evidence of benefit. Should these modalities require the acceptance by conventional medicine and third-party providers before being made available? Should hospitals be required to address problems of health, illness, and healing in ways that challenge the reductionist view of the world? To date, hospitals appear not to encourage this type of discussion.

That said, much remains to be learned about what is being done in CAM practices, the conditions for which it is being done, by whom, and what education and training prepare practitioners to do it.⁹⁷ Both integrative and collaborative CAM programs are in their infancy. Their challenges over the next decades involve improved communication; training and certification; reimbursement; appropriate research models; comprehensive information for both the public and conventional practitioners; and appropriate education in all stages of conventional and CAM health-care training. Given the restrictions on licensing qualifications to all but a few CAM modalities, the training of alternative healers varies from bona fide medical degrees to self-identification of expertise among healers who operate on the fringes of the health-care industry.⁹⁸ Equally important with all of these factors is the daunting challenge for CAM to provide a “proof of efficacy”—beyond its exaggerated promotional literature—for its healing treatments given the fact that both the Kefauver–Harris Amendment of 1962, sometimes called the “Drug Efficacy Amendment,” and the Dietary Supplement Health and Education Act of 1994 excluded herbal preparations, phytomedicinals, dietary, and food supplements from quality-control measures instituted by the US Food and Drug Administration (FDA). CAM manufacturers do not have to establish efficacy before they market their products. As a result, many CAM products are mislabeled, misidentified, and adulterated with different plants of unknown origin. Without enforced standardization, it is impossible to determine the active ingredients, much less their stability. The fact that so many patients combine their prescription drugs with herbals of unknown origin or efficacy creates serious risks-to-benefits ratios associated with patient outcome, a situation that raises the question of whether CAM treatments do more harm than good given the risks of misdiagnoses, contraindications, and the competence of nonmedically qualified practitioners.⁹⁹

Beginning in the 1960s and 1970s, postmodernist healers emerged to challenge the muscular strength of conventional medicine’s reductionist bias. Beset with a host of issues, including rising costs, inadequate insurance coverage, excessive use of antibiotics, exposés involving patient rights, and the decline of physician autonomy and authority, conventional medicine entered a period of self-doubt and introspection as it tried to reconcile its scientific achievements with a declining doctor–patient relationship. Postmodernism challenged conventional medicine’s disease protocols, the RCT, and even the meta-analysis. The outcomes of the clinic and the laboratory also came into question as attitudes and expectations regarding the EBM underwent closer examination, transforming it into a “soft” science based on knowledge socially constructed to fit the needs of the culture. In this new setting, even the Cochrane Collaboration was made an object of derision, a storefront for housing “evidence” (i.e., different narratives) in the health sciences. To the extent that the collaboration “worked,” it was said to function as a service to the culture’s immediate needs. To the extent that postmodernism became the mindset of the age, it opened the door to an assault on the scientific method, offering entreé to CAM and open-mindedness to CAM’s proposition that the RCT was little more than a cultural artifact.

By the early 1990s and the beginnings of managed care and efforts at cost containment, conventional medicine faced an even greater threat to its professional sovereignty and to the doctor–patient relationship as insurance providers chose to extend patient coverage to less costly alternatives. Along with these changes came the US Department of Education’s decision to accredit numerous complementary and alternative healing programs, thus breaking conventional medicine’s virtual monopoly on the practice of healing.¹⁰⁰ This change eventually led medical schools to include discussion of unconventional medical practices as part of their regular curriculum.¹⁰¹ In more recent years, biomedical doctors have added elements of complementary and alternative treatments to their individual and corporate practices. Although not necessarily trend setting, these changes have suggested a willingness on the part of conventional medicine to accommodate epistemologically different healing systems.¹⁰²

Even with the openness among many mainstream practitioners, conventional medicine has not found assimilation easy due to CAM’s epistemological, ideological, and methodological differences. Postmodernism goes far to explain the popularity of unconventional therapies in that an increasing number of patients have come to reject the assumptive practices, quantitative methods, and overarching and objective certainties of reductionist medicine for their own intuitive and nonlinear truths. Nevertheless, CAM’s modalities diverge so sharply from biomedical reductionism (i.e., in the nature of their evidence and the subjective manner of their production) that they defy explanation using the framework of scientific medicine. Methodological pluralism may open the gates to a new global medicine, but its usefulness in the creation of commonly shared evidence-based medical knowledge remains problematic.

Instead of fading away as an anachronism in the postmodernist world, CAM has experienced significant growth in both the United States and abroad. Nearly half of all Americans now use some form of CAM, including a considerable percentage of the well-educated middle class, who find themselves troubled by environmental issues, aware of the importance of individual choice, and anxious over the negative impacts of science and technology. In this regard, CAM’s popularity has become as much a social movement as a reflection of individual choice. Nevertheless, issues remain regarding its safety, efficacy, and potential side effects. Consumers need to be better educated on their choices, and conventional physicians need to have a stronger relationship with their patients to better understand how patient choices may or may not benefit from a combination of CAM and more conventional therapies. Neither the unconventional healer nor the scientific community can view CAM therapies as simply a “fringe” interest among consumers. That said, CAM has yet to explain how its therapies work and for the reasons its proponents believe. As will be seen in chapter 3, the rapidly growing recognition of the placebo effect and the conditions under which it operates not only challenged normative science but also undermined CAM’s reputation, if not its actual legitimacy.