Varieties of Healing. 2: A Taxonomy of Unconventional Healing Practices

Defining unconventional medicine by what it is does not work. Alternative medicine is an umbrella-like term that represents a heterogeneous population promoting disparate beliefs and practices that vary considerably from one movement or tradition to another and form no consistent body of knowledge (1). Alternative medicine is a large residual category of health care practices generally defined by their exclusion and alienation from the dominant medical profession (2). Besides an absence of shared principles, an accurate definition of alternative medicine is further confounded because the boundary demarcating conventional and irregular medicine has always been porous and flexible (3). Therapies move across that border; for example, nitroglycerin (4) and digitalis (5) began as alternative drugs, just as corn flakes and graham crackers began as unconventional health foods (6). Entire professions change sides. In 1903, when the American Medical Association needed both a larger referral base for specialists and new allies in its fight with osteopaths, chiropractors, and Christian Scientists, it boldly reversed its policy and declared homeopaths to be conventional MDs (7). Likewise, osteopathy ceased being a renegade profession after World War II (8-10). The first of two essays in this issue demonstrated that the United States has had a rich history of medical pluralism. This essay offers an overview of alternative medicine. Because of the inherent problems in defining a flexible residual category, we present a taxonomy of what is currently considered unconventional healing in the United States. The number of named alternative therapies available in the United States easily soars into the hundreds (11-16). Many classification systems have been proposed (17-24). In an effort to further discussion, we offer a new taxonomy that we believe configures the domains of unconventional medicine across a broader spectrum of health practices. We do not expect that our attempt will be definitive (nor do we necessarily believe a perfect schema is possible). Any classification system is limited because such human phenomena resist discreteness as well as being fixed in time. As we point out, overlap often occurs. Inevitably, subjectivity affects the categorization and perceptions of affinities. A summary of our schema is presented in the Figure. Figure. Unconventional healing practices: taxonomy with examples. Unconventional healing practices can be divided into two types: one that appeals to the general public and another that confines itself to specific ethnic or religious groups. The broadest category of unconventional medicine is easily recognized because its health care claims to be independent of any sectarian belief or faith and is said to depend on universal and even scientific laws (25). It is the best-known variety of unconventional medicine in the United States and recently, in a loose alliance, has become known as complementary and alternative medicine (CAM) (25). The second kind of unconventional practice is typically confined to narrow groups, such as members of particular religions (for example, Pentecostal Christians), ethnic groups (for example, Puerto-Rican spiritism), or regions (for example, southern Appalachian folk beliefs). These practices are culturally self-contained, function outside any broader coalition, often lack the markings of a health delivery system, and in this essay are referred to as parochial unconventional medicine. Complementary and Alternative Medicine The wide-ranging category of CAM can be divided into five main sectors, which are described below. Professionalized or Distinct Medical Systems Probably the most recognizable alternative healing practices are those that are organized into medical movements with distinct theories, practices, and institutions. Licensure as an independent profession is a goal if not always an actuality. Medical institutions, such as schools, professional associations, and offices with secretaries and billing procedures, are readily visible. An extensive corpus of technical literature helps guide therapy and practice and sharpens distinctness. Because they are easiest to describe and define, these systems are the most prominent in discussions of CAM. The six major components of this sector of CAM are chiropractic, acupuncture, homeopathy, naturopathy, massage, and dual-functioning MDs. Chiropractic, the largest alternative medical profession in the United States, accounts for almost a third of all visits to CAM providers (26). The body's biomechanical structure, especially the spine, is seen as basic to health, and chiropractic emphasizes spinal manipulation as treatment (27, 28). Licensed as primary health care providers in all 50 states, chiropractors especially treat musculoskeletal disorders (29, 30). Osteopathy was once a second manual therapy competing for the same patients as chiropractic. Since World War II, osteopathy has reconfigured itself and has become conventional; the status of an osteopathic physician is equivalent to that of an MD. A minority of patients (<17%) visiting DOs receives the kind of manipulative therapy that would still be considered unconventional by orthodox MDs (31, 32). Acupuncture relies on the insertion of fine needles at well-defined specific sites to regulate and balance humoral forces and energy (qi) and to promote health (33). As a component of East Asian medicine, acupuncture is often complemented with herbal treatment. Since the 1970s, acupuncture has spread throughout the United States and is independently licensed as a health care profession in 37 states (34). Homeopathy uses the principle of like cures like: A substance that produces a set of symptoms in a healthy person is used to treat an identical symptom complex in a sick person (35, 36). The substance, however, is extremely diluted, often to the extent that none of the original substance is likely to remain. Currently, homeopaths can be independently licensed in only three states, but other licensed practitioners also prescribe these remedies. Naturopathy uses a wide assortment of therapies that its practitioners call natural. Herbs, nutritional supplements, dietary and lifestyle advice, homeopathy, manipulation, and counseling can all be components of the repertoire (37). The term naturopathy was adopted in 1902 to replace the old word hydropathy, which denoted water-cure therapy. Currently, naturopaths can be licensed as primary care providers in 11 states; naturopathy is most common in the Pacific Northwest (38). Massage therapists can be professionally licensed in more than 25 states (39). Although massage therapists (also called body-workers or hands-on therapists) clearly perform unorthodox interventions (40-42), they overlap with recognized biomedical professions, such as physical therapy, or simple attempts at relaxation. Complementary alternative medicine techniques that address body alignment and awareness (such as the Feldenkrais method [43] and the Alexander technique [44]) are often classified as massage therapy because they involve body-work. Medical doctors who have opted to deliver, supervise, or advocate CAM are a significant force in alternative medicine (45, 46). These dual-trained practitioners lend enormous prestige and legitimacy to alternative medicine and can be prominent spokespersons (47-50). Providing what is sometimes called integrative medicine, these physicians can deliver a broad range of CAM services or can focus on a single therapy. Popular Health Reform (Alternative Dietary and Lifestyle Practices) The health food movement, also known as alternative dietary and lifestyle practices, is an important component of CAM. Depending on how one calculates, it may in fact dwarf the professional sector (51). In the scholarly literature, this type of healing is labeled popular health reform because these practices are often advocated by untrained laypersons who often claim knowledge superior to that of expert scientists (6). Popular health reform is delivered by a melange of resources, such as health food stores, popular books and journals, charismatic leaders, alternative provider recommendations, mass media attention, and a considerable amount of neighborly advice. This popular movement usually espouses a vegetarian or near-vegetarian diet, or avoidance of chemically treated and, more recently, radiated or genetically altered food. Details of particular programs tend to have enormous heterogeneity. Recommendations might range from eating only cooked food (for example, macrobiotics [52]) to eating only raw food (for example, fruitarianism) (53), or from heavy reliance on nutritional and botanical supplements or aromatherapy to their absolute prohibition. Recent shifts in biomedicine's understanding of nutrition and its role in pathophysiology have also encouraged a general social movement toward behaviors that were once thought to belong to health food nuts (54). This, in turn, has caused a blurring of the distinction between orthodox and unorthodox lifestyles and has helped increase the awareness of CAM in society (51). New Age Healing The New Age is the source of many extremely disparate beliefs and practices that can describe overlapping religious and healing movements (55, 56). Furthermore, confounding discussion, the term New Age may not be adopted by a given individual (indeed, may be rejected), even though to outsiders the practice appears to fall into this category (57). As a religious movement, the New Age is about a new dispensation: less about law and limitation and more about unrestricted self-expression and unlimited abundance. Instead of any fixed religious doctrine, the movement emphases a fluid spirituality. It is not uncommon to see an iconography that is a grab bag of Hindu, Christian, Buddhist, Rosicrucian, and pagan motifs (18). The New Age is also a health care category because spiritual equanimity and physical health are