YAGO2

At present there is no accepted, standardized vocabulary for describing or clas- sifying medical treatments that lie outside of mainstream biomedicine (Kapt- chuk and Eisenberg 2001b). A single term can have very different connotations depending on whether it is used in the popular media or in peer-reviewed jour- nal articles (Eskinazi 1998; Gevitz 1995). This ambiguity often results in confu- sion and miscommunication when physicians and other health care professionals discuss nonconventional therapies with each other and patients.

The perceived legitimacy of any conventional or nonconventional diagnosis or treatment is heavily influenced by cultural beliefs. Therefore, any attempt to characterize nonconventional treatments must take into account the fact that fundamentally different understandings of the causes or meanings of illness are implicit in disparate cultural belief systems (Pachter 1994). Folk medicine has

always been an important part of Western as well as non-Western cultures, and folk medicine beliefs and traditions significantly influence patient perceptions of nonconventional medical practices (Hufford 1997). However, folk medicine and complementary and alternative medicine (CAM) are not equivalent do- mains of knowledge or clinical practice. In contrast to established alternative or complementary approaches, many folk medicine traditions are transmitted orally and have not been developed into systematic or formalized medical prac- tices. The situation is further complicated by the fact that most patients perceive CAM approaches as being more or less familiar or effective in the absence of a clear understanding of postulated mechanisms of action or the relative merits of the empirical evidence (Furnham 2000).

When examining the diverse perspectives of medicine, it is helpful to think in terms of a basic conceptual divide between conventional and nonconven- tional treatments. For purposes of this book, conventional treatments are contem- porary biomedical modalities in mainstream use in North America and western Europe. At present, conventional treatments in psychiatry encompass psycho- pharmacology, somatic treatments (e.g., electroconvulsive therapy, transcranial magnetic stimulation, vagal nerve stimulation), and many different forms of psy- chotherapy, including hypnosis. It should be noted that many approaches used in contemporary Western psychiatry have not been formally validated by the rigorous standards of biomedical research recently described as “evidence-based medicine” (Geddes et al. 1996). Indeed, although most conventional nonphar- macological treatments of psychiatric disorders can be evaluated using random- ized prospective clinical trial methodology, relatively few such trials have been conducted. Furthermore, it is much more difficult to propose and test a claimed mechanism of action. Nevertheless, psychotherapy, hypnosis, and other con- ventional nonpharmacological or somatic treatments remain in widespread use because of practice guidelines established through expert consensus.

The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health defines CAM practices as “those health care and medical practices that are not currently an integral part of con- ventional medicine” (“Major domains of complementary and alternative medi- cine,” available at http://nccam.nih.gov/health/whatiscam). In other words, CAM includes all modalities that are not currently accepted as conventional medical practices. This approach defines CAM in terms of what it is not and contrasts it with the domain of conventional Western medicine, but it does not clearly demarcate the scope of conventional or nonconventional medical prac- tices. It thus provides an ambiguous conceptual framework within which to un- derstand the concepts and treatments of nonconventional medicine.

In lay publications, professional medical journals, and textbooks, the terms alternative medicine and complementary medicine are often treated as equivalent cat- egories. They are not the same, however, and the gap between the treatments

denoted by these terms and their actual practice has led to considerable confu- sion. To avoid the linguistic and conceptual muddle that has arisen in the dia- logue on nonbiomedical approaches in medicine, it is important at the outset to introduce a few unambiguous terms.

A particular treatment is described as alternative or complementary with re- spect to approaches endorsed by the dominant system of medicine that defines the broad social and cultural context in which that nonconventional treatment is being used. In other words, the body of treatments that comprise mainstream medicine is constantly changing; by the same token, a particular treatment can be regarded as complementary or alternative depending on implicit or explicit assumptions that comprise the philosophical framework of the system of medi- cine within which they are regarded. Just as the whole domain of CAM modal- ities is defined by its exclusion from mainstream medicine, components are cat- egorized based on whether they are used instead of (alternative) or along with (complementary) standard medical care. In view of the above, it is reasonable to describe a particular alternative or complementary approach in the broader con- text of the conceptual framework underlying mainstream medical theory that defines conventional practices where that treatment is used. At present in North America and western Europe, biomedicine is the dominant system of medicine; thus in these regions it makes sense to regard nonconventional treatments as complementary, alternative, or integrative with respect to the core tenets or cur- rent practices of conventional biomedicine. The nonconventional treatments used in Western industrialized countries include modalities that rest on claimed mechanisms of action that are outside of current conceptual foundations of bio- medicine in the West (“Defining and describing complementary and alternative medicine” 1997). More than 100 complementary or alternative therapies are currently practiced in industrialized countries, and an unknown number of “tra- ditional” practices are used in developing world regions (Ernst 1997).

For example, acupuncture is classified as an alternative treatment because the conceptual framework in which acupuncture is accepted as a legitimate medical treatment involves a postulated “energy” (qi) that is outside of the worldview of contemporary biomedicine. Using the same criterion, Chinese medicine is thus an alternative system of medicine. In contrast, a complementary treatment rests on a mechanism of action that can be explained by mainstream biomedicine but, because of social, ideological, or other nonscientific reasons, is not endorsed by orthodox medical theory. An example of a complementary treatment in mental health care is the use of St. John’s wort (Hypericum perforatum) to treat depressed mood. Integrative approaches are combinations of alternative or complementary modalities with one or more conventional biomedical treatments.

As emerging research findings support some mainstream and nonconven- tional treatments while refuting others, the domain of legitimate biomedical practices will continue to change, and practices that are outside of conventional

medical practice will necessarily change to accommodate the shifting landscape of Western medicine. Emerging theories in physics, the life sciences, and con- sciousness studies and novel methods for evaluating treatment outcomes will eventually lead to the validation of some nonconventional medical practices that are currently at odds with the paradigm of contemporary Western science and not susceptible to present methods of measurement or verification (Ernst 1996; Margolin et al. 1998; Verhoef et al. 2000). A classic example is foxglove, which contains digitalis and was used for centuries as an herbal treatment for what was then called dropsy (congestive heart failure). As the methods of medicine con- tinue to evolve, certain approaches that are now regarded as alternative will be embraced as orthodox treatments, whereas other approaches that are now en- trenched in conventional biomedicine will be refuted or relegated to a future alternative medicine.

Changing Conceptual Foundations of Western Medicine