GUE S T E D I TOR I A L

Culture and complementary

therapies
Joan Engebretson
Complementary therapies are becoming increasingly popular in cultures dominated by
biomedicine. Modalities are often extracted from various healing systems and cultural
contexts and integrated into health care, expanding the focus from treatment of disease to
the promotion of health.The cultural aspects of biomedicine are presented and compared
and contrasted with other healing systems.Three healing systems; traditional
Chinese medicine,Yoga, with roots in Ayurvedic medicine and Shamanic healing
illustrate these fundamental differences in approaches to healing. A reverse example of
isolating one healing intervention from biomedicine and interpreting it through other
cultural lenses is presented. Implications are drawn for practice and research. # 2002
Elsevier Science Ltd. All rights reserved.

Dr Joan Engebretson
PH, HNC RN,
University of Texas Health
Science Center at
Houston, School of
Nursing,1100 Holcombe
5:534E, Houston,
TX 77030, USA.Tel.:
+1-1713-500 -2045; Fax:
+1-713-500 -2073; E-mail:
Joan.C.Engebretson
@uth.tmc.edu

CULTURE AND COMPLEMENTARY

THERAPIES

CURRENT PRACTICE OF
COMPLEMENTARY THERAPIES

Health care systems and medicine are social

institutions. Culture and social institutions are
interdependent and reinforcing (Thompson et al.
1990). Social institutions generate and reect
those values relevant to the culture in which they
are situated, both in a specic time and place.
Thus, health care inuences and is inuenced by
the general culture. Complementary and Alternative Medicine (CAM) in Europe and North
America have gained enormous popularity in the
past decade. Many of these complementary
modalities have their origins in traditional
healing systems from historically or geographically dierent cultures. This increasing popularity raises a number of issues related to the
changes both in health care and in the general
culture. The following issues will be discussed:
(1) The culture of biomedicine as interdependent
with the general culture of Europe and North
America in the late 20th century. (2) The tensions
and dierences that arise between biomedicine
and healing practices from other cultural orientations. (3) The interpretation of healing modalities as they are transported from one cultural
healing systems to another cultural context. (4)
The concerns related to evaluating a therapy
practiced in one cultural context through the
cultural lens of another.

Complementary therapies have been dened as

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 (Ernst 2002;
Eisenberg et al. 2001). This denition has been
adopted by the Cochrane Collaboration. The
Center for Complementary and Alternative
Medicine (NCCAM) at the National Institutes
of Health in the US dened CAM as a broad
range of healing philosophies (schools of
thought), approaches, and therapies that mainstream Western (conventional) medicine does
not commonly use, accept, study, understand, or
make available (NCAAM 2002).
The increased popularity of these therapies
among the well-educated middle class of
Europe and North America has been well
documented. Community surveys have been
documenting use over the past decade, with
prevalence in the USA of 42% and lifetime
prevalence in excess of 60%, in Europe the
prevalence is 2065% (Ernst 2002). However,
representative trend data examining lifetime
prevalence indicates that the large numbers
using CAM therapies are representative of a
secular trend that began at least 50 years ago

ComplementaryTherapies in Nursing & Midwifery (2002) 8, 177^184 # 2002 Elsevier Science Ltd. All rights reserved.
doi:10.1054/ctnm.2002.0638

178 ComplementaryTherapies in Nursing & Midwifery

and suggests a continuing demand in the future

(Kessler et al. 2001).
The social institution of medicine has responded to these cultural inuences and in turn,
is inuencing the general culture. In 1998, the
Congress of the United States established the
Oce of Alternative and Complementary Medicine at the National Institutes of Health (NIH).
This was later upgraded to the National Center
for Complementary and Alternative Medicine
(NCCAM) with the purpose to stimulate, develop, and support research on CAM for the benet
of the public. The NCCAM advocates for
quality science, rigorous and relevant research,
and open and objective inquiry into which CAM
practices work, which do not, and why. Its
overriding mission is to give the American public
reliable information about the safety and eectiveness of CAM practices (NCCAM 2002).
More recently, in 2000, President Clinton commissioned a White House Commission on
Complementary and Alternative Medicine
Policy. This commission recommended continued research, education and dissemination of
information as well as regulatory concerns of
safety, ecacy and preparation of providers.
Additionally, it was recommended that an oce
to coordinate CAM activities and facilitate the
integration of safe and eective practices and
products be established (White House 2002). The
commission identied the need for some form of
credentialling of CAM providers that would
assure the public of standardized or professional
practice. The University of California, San
Francisco Center for Health Professions has
recently published a model for evaluating emerging health professionals and completed a case
study of Naturopathic Practice (Hough et al.
2002).
In Great Britain in 2000, the House of Lords
Select Committee on Science and Technology
made recommendations regarding complementary and alternative medicine in the UK (House
of Lords 2000). They proposed three categories
of therapies: (1) those being provided by the
most organized professions; (2) therapies that
most clearly complement conventional medicine
and (3) those for which no evidence base exists.
They recommended that CAM build up an
evidence base with the same rigor required of
conventional medicine. It was further recommended that CAM disciplines dene respective
areas of competence and willingness to refer
patients to conventional medical care when
appropriate. It was proposed that only those
CAM therapies that are statutorily regulated or
with robust mechanisms on self-regulation be
available through public funding.
Despite the widespread interest and process of
integration into mainstream health care, this
collection of therapies is a disparate and inclusive

category. CAM denitions often include all the

residual heath and healing practices that are not
taught in medical schools or listed on rosters for
insurance coverage. A number of classication
systems have been proposed. The NCCAM,
using the following categories, has identied
over 140 specic techniques. The categories
include: alternative medical systems, mindbody
interventions, biological-based interventions,
manipulative and body-based methods, and
energy therapies (NCCAM 2002).
Kaptchuk and Eisenberg (2001) have developed a taxonomy which separates these therapies
into two categories: (1) prominent and mainstream complementary and alternative medicine
(CAM), (2) a more culture-bound parochial
unconventional medicine. These categories were
further divided into the following components:
CAM-professional groups, layperson-initiated
popular health reform movements, New Age
healing, alternative psychological therapies and
non-normative scientic enterprises. The parochial groups include ethno-medicine, religious
healing and folk medicine. Engebretson (1997)
also dierentiated between alternative treatments, other traditional health care systems and
specic modalities. The specic modalities are
classied according to explanatory paradigms of
mechanistic, purication, balance and supranormal interventions. Each paradigm contained
activities of physical manipulation, ingested and
applied substances, energy, psychological or
mind therapies and spiritual therapies. A unique
feature of this taxonomy is that biomedical
modalities are entered into the classication of
modalities along with CAM modalities. All of
these classications dierentiate between indigenous, traditional or ethno-medicine healing
systems and the contemporary use of CAM
modalities in cultures dominated by biomedicine.
This is an important distinction, as many
contemporary popular modalities have been
derived from these traditional health practices.
In the course of being reinterpreted into another
culture, whether it be another ethnic culture or
treatments that were more commonly used
historically, they are now separated from the
original cultural contexts.
Many of these modalities with origins in other
cultures or historical periods have been popularized through New Age or Holistic Health movements. As these techniques have been taken out
of the cultural context of their historical and
geographical or ethnic setting, the techniques are
often used without a full understanding of
cultural or philosophical underpinnings, beliefs
and values. Every cultural healing system is
oriented around explanatory models of health
and illness. Kleinman (1980) describes cultural
explanatory models as cognitive orientations
that determine the way disease is named, dened,

Culture and complementary therapies

and understood. Treatments may emerge based

on the understandings of the pathology and
course of the disorder.

CULTURALORIENTATIONS OF
BIOMEDICINE COMPARED WITH
OTHER HEALING SYSTEMS
The hegemony of biomedicine has been well
established over the past century. Biomedicine
has been the dominant system in the United
States since the Flexner report of 1910 standardized a curriculum for medical schools. Licensing practices were enacted that excluded other
healers, thereby denying legitimacy to heterodox
practices. A resulting medical paradigm was
established that was mechanical, reductionistic
with an emphasis on standardization and ecacy
(Baer 2001). The strong association between
biomedicine, science and technology is mirrored
in the general cultures value of progress based
on science and technology. This has mitigated
against the perspective of viewing biomedicine as
a culturally constructed system. However biomedicine, as in all healing systems, is a construction of the respective culture.
Biomedicine reects many of the cultural
continuities and changes with other institutions
of society (Stein 1990). Biomedicine is grounded
in science and augmented by technology, reecting a highly industrialized society. The science
base privileges truth based on accumulated
knowledge from objective observations rather
than subjective perceptions. Technological advances have spurred the development of knowledge and the capabilities for treatment.
Anchored in capitalist industrial concerns of
eciency and cost containment, the biomedical
paradigm has been described as one that views
the body as a series of parts that can be repaired
or replaced (Baer 2001). This paradigm has a
number of features that distinguish it from other
healing systems as illustrated in Table 1.

Focus on disease rather than health

Biomedicine focuses on the identication of
disease, and treatment is aimed at restoration
to full or maximal function or to treat and cure

179

the source of the dysfunction (Caplan 1997).

Disease is the disruption that interferes with the
biological function of the organ or organism.
Diseases and treatments are viewed as independent of culture, time and place. Thus emotional,
social, spiritual or other factors are generally not
major considerations accorded to etiology or
treatment. Although there has been increasing
attention in the past years to address health, and
more recently social and spiritual issues, the
overall approach is the diagnosis and treatment
of specic biologic disease. In contrast, many
healing systems are focused on health and illness.
This broader view integrates health into the
complex fabric of life and incorporates the
cultural meaning of the experience. Disease is
seen as but one aspect of the health-illness
continuum. This expanded focus is captured in
the root word of health, meaning hale or whole.
Such an approach encompasses ones relationship to self, family, community, environment and
higher power. This is very close to the denition
of nursing which is to care for patients
experience or response to health and illness.

The philosophical underpinning is

reductionistic rather than holistic
The focus on disease is anchored in the
philosophical perspective of reductionism, which
looks to the smallest units to explain the whole;
for example organisms reduced to molecules
(Gordon 1988). This perspective has allowed for
scientic understanding of physiological processes and contributed to many therapeutic
treatments. In contrast, many other healing
systems apply holistic perspectives that integrate
external and internal forces in their approach to
health care and incorporate dimensions of
physical, psychological, social and spiritual.

The understanding of healing is

mechanistic rather than vitalistic
Mechanism of action on the physical and
biochemical level is the base for the development
and testing of biomedical theories. This understanding is evident in the metaphors commonly
used in biomedicine. The use of metaphor
condenses, organizes and consciously represents

Table 1 Comparison of biomedicine and other healing systems

Focus
Philosophical underpinnings
Understanding of healing
Nature of the human condition
Orientation to interventions
Approach to treatment

Biomedicine

Other healing systems

Disease and treatment

Reductionism
Mechanistic
Dualistic
Individualistic
Specif|c to disease and universally applied

Health and healing

Holisim
V|talistic
Unitary
Collective
Universal and systemic and
personalized for the individual

180 ComplementaryTherapies in Nursing & Midwifery

images that are widespread in a society. Medical

metaphors are dominantly materialistic (Lupton
1994), referring to the body as a machine with
moveable parts that function through a discernable mechanism. This metaphor also ts well
with the increasing use of technology used in
diagnosis and treatment. Stein (1990) identies
several other metaphors used in biomedicine
such as military, economic, sports, and technology and engineering. These all reect a strongly
material orientation to medicine. In contrast,
many other healing systems embrace a more
ethereal, non-material aspect to health and
healing, such as spiritual or vital energy or
subtle health-promoting inuences (Kaptchuk
2001). While vitalism is a concept that is
associated with medical therapies that were
popular in the 19th centuries in Europe and
North America, the concept of a non-material
healing force is reected in many healing
systems. A vital force that places the person in
harmonic relationship with the universe, presumed to be intrinsically healing, is central to
healing in most cross-cultural systems.

The nature of the human condition is

dualistic rather than unitary
Biomedicines has had a parallel ascendancy with
science. Scientic approaches to biomedicine
were accelerated by Cartesian dualism in the
17th century, which separated the non-material
mind from the physical body. This belief allowed
the advancement of scientic medicine because
the body could be understood and acted upon
without disturbing the mind or the soul
(Kirmayer 1988). This dichotomy, however, is
still apparent in the divisions between medicine
and psychiatry and the marginalization of the
spiritual realm from health care. Contemporary
discourses on mind/body medicine, while tracking the connection, attest to this inherent
separation. Conversely, many of the worlds
healing systems integrate mindbodyspirit and
often a spiritual leader acts as healer. Healing is
also a central theme in most of the worlds
religions (Kinsley 1996).

Orientation to Intervention is
individualistic rather than collective
In practice, disease is considered a condition of
the individual and all care is oriented around
that person (Gordon 1988). The individual as the
dominant social unit is consistent with European/American orientations. In fact, ethical
codes often do not permit the disclosure of a
patients information to others. Patients are
generally seen alone and consent for treatment
is based on the individual patient. In contrast,
many societies may recognize the individual, but

the family, kinship group or communal group is

the primary social unit. In these cases healing
may involve a more collective eort. Healing or
treating the individual is perceived as a treatment
for the collective.

The approach to people is universal and

disease specif|c rather than a systemic
treatment that is personalized for the
individual
In biomedicine, a specic disease is understood
through its mechanisms of action and treatment
is developed specically for that disease. The
treatment may then be generalized for any
individual with that disease. Many cultures use
broad classications of treatments, many of
which have a systemic eect, but is then
personalized to the individual recipient to eect
healing that is unique to that individual. An
example of this practice might be a form of touch
or laying-on of hands. Biomedicine is universal
to people, but is specic to disease, thus all
people with a staphylococcus infection of a
wound would be treated with a staph-sensitive
antibiotic. Many healing systems universalize the
treatment that is individualized by the person.

EXAMPLES OF TRADITIONAL
HEALING SYSTEMS WHICH ARE
SOURCES OF POPULAR CAM
MODALITIES
Most healing systems originated in religion and
philosophy, espousing mystical union with God
or nature (Sheikh & Sheikh 1989). Historically,
healers in Eastern and Western traditions, as well
as around the world, were shamans or priests. As
modalities are taken from the worlds healing
traditions and imported into a culture oriented in
the assumptions of biomedicine, fragmented
elements of the healing practice have been
adapted. These fragments are taken out of the
context of their indigenous setting and interpreted through new cultural lenses. Therefore,
the practice of the modality is considerably
dierent than in its indigenous form. Three
examples will be briey discussed: Traditional
Chinese Medicine (TCM), Ayurvedic medicine
and the practice of yoga and Shamanism.

Traditional Chinese Medicine

The modalities of acupuncture and acupressure,
imported from TCM, have become increasingly
popular in the West. Chinese systems of medicine
are about 5000 years old and based on Eastern
philosophy, which is circular and predicated on
the assumption of oneness with the universe
(Sheikh & Sheikh 1990). Balance and harmony

Culture and complementary therapies

are continually sought and paradoxes are understood as part of a whole. Fundamental Chinese
philosophy is inclusive of opposites, such as yin
and yang. In fact these dual aspects are always
present simultaneously (Ergil 2001). Chinese
medicine was cumulative, and new theories
coexisted with old theories, rather that replacing
them, a practice common in biomedicine (Unschuld 1985).
The concepts of Tao, Chi and Yin/Yang
underlie TCM. Tao is the way the universe
unfolds, the way of nature, life and death; the
goal of life is to ow with the Tao. Chi is the
universal energy or life force; this force ows in
an orderly way and balance of this force is
equated with health. Meridians are pathways or
connections by which Chi is carried through the
body (Kaptchuk 1983). Yin/Yang represents the
fundamental dualities of the universe united in
the circle and the Tao. This philosophy contrasts
with Western philosophy, which is more linear
and dualistic. The ve phases of earth, metal,
water, wood and re refer to sets of dynamic
relationships in nature. For example these
elements can represent nourishment (earth),
strength (metal), change (water), growth (wood),
and love (re), all necessary for health and
reecting the laws of nature (Sheikh & Sheikh
1990). These elements are also associated with
organs in the body, senses, emotions, foods and
seasons. Ultimately, all disease is seen as a
disturbance of chi within the body and a
disharmony with the laws or ow of nature.
Healing is directed at balance and harmony
and includes curing the spirit, nourishing the
body, and restoring harmony with the environment (Veith 1972). Some of the activities of
healing include diet, use of herbs, moxibustion,
acupuncture, and working the chi through
movement, breathing and meditative practices.
Diagnosis made through a complex process that
includes pulse, temperature, appearance of the
tongue, appearance, tone and exibility of skin
and muscles and tenderness around acupuncture
points. Classications of disease are predicated
on an understanding of TCM. This approach to
understanding health and disease is very dierent
from biomedicine and therefore, trying to understand acupuncture through a material anatomical worldview denies one a full understanding of
how disease is categorized and understood. In
many cases, proponents of biomedical orientations, would look for anatomical or biochemical
connections between acupuncture/acupressure
sites and respondent organs or applying stimulation of these sites to a particular biomedical
disease category. Another example is the popularity of viewing acupuncture as a more legitimate form of therapy over other forms of
managing the chi, such as Chi Gong, Tai Chi,
etc. Acupuncture is one of the rst CAM

181

modalities to receive support through NIH

consensus committee reports. Possibly this is
because needles are used and thus seems more
material. Despite taking this out of its contextual
understanding, acupuncture has proved eective
in treatment of pain and has ecacy for
substance abuse. One can only question the
potential ecacy when used more contextually.
This is not to say that a system of healing cannot
also be understood from our mechanistic framework. However, it would be ethnocentric to take
a healing strategy out of context and apply it to a
diagnostic problem from a dierent framework
and then draw legitimate conclusions about its
ecacy.

Yoga
The Western use of yoga is another example of
extracting a modality from one traditional
healing system and practicing it in another
cultural system. Similar to TCM, ancient Indian
systems of medicine viewed human beings as
minute representations of the universe; therefore
comprehending the world is crucial to comprehending the human (Zysk & Tetlow 2001). Yoga
comes from the Sanskrit word yui, meaning yoke
or bind. The practice of yoga means the yoking
of the powers of body, mind and soul to God or
uniting personal will with the will of God
(Sheikh & Sheikh 1989). Yoga is a path of
wisdom or a way to self-understanding, transcendence and union with the universe (Zysk &
Tetlow 2001).
Many yoga practices are related to one of the
orthodox philosophical systems of Indian philosophy or ancient vedic cultures. Veda means
science or knowledge. Vedas have religious
underpinnings and are concerned with spiritual
and moral values as well as physical and material
well-being of individuals and communities. One
of the vedas, ayurveda, is the knowledge or
science of life, vitality, and longevity. This is the
traditional Indian science of medicine and
health. The goal of this medical system is not
focused on treating specic diseases, but rather
promoting health, in all physical, social and
spiritual dimensions (Sheikh & Sheikh 1989).
Harmony with the environment, the persons age
and personal variation are all considerations in
this unied approach to health. The tridoshic
concept that identies three doshas or basic
constituents of every person is central. While all
people have the three doshas, vata, pitta and
kapha, each individual may have a preponderance of one or more which make up their
constitution.
Emphasis is placed on purication of the
physical body and mind through disciplines
practiced in daily life. Consciousness is the
practice of maintaining or restoring health.

182 ComplementaryTherapies in Nursing & Midwifery

Ayurvedic treatments aim at correcting imbalances through rejuvenating or healing elixirs or

surgery. Diet and herbs are prominent features in
Ayurvedic medicine as are other methods of
hygiene, cleansing and purication.
The practice or discipline of yoga can be
traced back to around 5000 BC. Some of the
yoga paths include Karma yoga, the yoga of
seless action or the path of dedicated work;
Jnana yoga, the yoga of knowledge or intuitive
understanding of the self and the unity with the
divine; Bhakti Yoga, the emotional path of
devotion and attaining self-realization through
love of God; and Raja yoga, the path of
meditation or controlling the kingdom of the
mind (Sheikh & Sheikh 1989).
The most common yoga practice in the west is
Hatha Yoga, which stresses physical discipline to
join mind and body. This practice uses techniques of postures (asanas), breathing (pranayama) and meditation (dhyana). The Tantric
school of yoga, which was based on fertility cults
in the fth century AD, has also gained some
popularity and in many Western practices is
combined with Hatha Yoga (Micozzi & Vlahos
2001). Tantra practice seeks to arouse the female
creative energy, the kundalini, through the
activation of the six chakras or vortices of
bioenergy situated along the vertebral column.
While the practice of yoga is not aligned to any
particular religion, god or leader, it is rooted in
the spiritual dimensions of life.
The popular practice of yoga in the West has
often been as a physical exercise. Yoga classes
are taught at many health clubs and yoga
videotapes and paraphernalia are readily available in stores and over the Internet. Research has
focused on the elements of exercise, relaxation,
breathing and meditation that have been extracted from yoga practice. Despite the reductive
approach of taking one element out of the
context of yoga practice, these have demonstrated positive health benets. Yoga has been
eective in lowering blood pressure, treating
asthma and stage 2 clinical trials in patients with
multiple sclerosis are currently in process
(NCCAM 2002). More recently, studies have
focused on the therapeutics of yoga in cardiovascular health, epilepsy, asthma, hypertension
and general well being. This raises the question
of what health benets might accrue with a more
culturally complete practice.

Ritual Healing and Shamanic Healing

Ritual healing has been a part of most religious
traditions, with practices of prayer, laying-on
of hands and other rituals related to healing.
Many of these healing rituals are historically
based in religious disciplines and are symbolic
re-enactments of sacred prototypes.

Shamanism refers to states of ecstasy or trance

which are voluntarily entered, during which the
Shaman journeys to another realm to acquire
knowledge and power to help people in their
community (Walsh 1990). These healing traditions generally reect a coherent integration of
health, medicine and religion. These practices are
universal behaviors across cultures that are
dependent on the interaction with the habitat
and the type of society (Goodman 1988). Goodman (1988) in tracing religious ritual and
shamanism across cultures of hunter gatherers,
nomads, horticulturists and agriculturists demonstrated the universal elements of ritual and
ritual healing with variations dependent on both
the type of society and the environmental
habitat. Many of these nature-oriented systems
are local, integrating the immediate environment
into their healing and ritual practices (Hultkrantz 1992). Many are polytheistic and situate
the healing in the context of harmony with the
environment through contact with spiritual
forces. The contacts with spiritual or supernatural forces and advice on healing is often
accomplished through a person who serves as
both healer and religious leader who intercedes
with the spirits for the benet of others. This
healer is often selected because of some striking
characteristic or experience. For example, the
healer may have survived a sickness and then
apprenticed with a master shaman. A period of
solitary withdrawal from society is common to
shamanic preparation. Shamans generally make
a life commitment to serve their people.
Healing practices are found around the world
and a number of activities are undertaken to
promote the altered state of consciousness or
trance necessary for shamanic work. These
practices are embedded in a complex pattern of
cosmology and meanings that both the healer
and the community share. Activities that evoke
altered states of consciousness are often appealing to contemporary seekers. However, many
times people expect instant mystical experiences
without the social-cultural context to prepare
them for the experience and from which to
interpret the experience. Walsh (1990) admits
that drugs, rhythmic sensations, and fasting can
induce mystical experiences; however, these
experiences are more likely to be evoked in
individuals who have been prepared through
lifetime immersion in the culture. Anthropologists have compared some of the popular New
Age shamanic activities with traditional shamanic practices. In contemporary New Age practices, the trance states are often approached with
an extreme form of individualism where the
healer is really seeking a personal mystical
experience rather than using these actions to
serve the community which is the pattern in the
traditional settings (Kehoe 2000).

Culture and complementary therapies

REVERSE CASE: BIOMEDICAL

MODALITIES TAKENOUTOF
CULTURAL CONTEXT
The concerns of taking a healing practice out of
one context and evaluating through another can
be illustrated by a hypothetical case. In biomedicine the antibiotic amoxicillin is often used to
combat bacterial infectious agents sensitive to
this antibiotic, often in children with upper
respiratory and middle ear infections. This
practice is grounded in the germ theory. Amoxicillin is often delivered in a sweet-avored pink
liquid. An observer from another culture would
likely notice the use of pink liquid for children
who appear sick. A practice that is often found in
many developing countries is the lay marketing
of drugs, some of which are outdated or
discarded batches of antibiotics. It would be
logical and empirical to make the observation
that pink liquid is eective treatment for sick
children who are fussy and febrile. Examining
the ecacy of this treatment taken out of the
context of biomedicine would reveal several
problems based on taking a treatment out of
the context of biomedicine and using or evaluating it in the context of another culture. (1)
Dissonance of understanding the action. In some
cultures the color of the treatment is signicant
so using a pink liquid could lead to using any
pink liquid, such as Pepto BismoTM or other
products. (2) Dissonance of dosage. One might
give an entire bottle in 1 day or only give one
dose, therefore, inappropriate doses would be
used. (3) Dissonance of preparation. Even though
it was amoxicillin, the preparation and storage
may render it no longer viable. (4) Dissonance of
matching disease categories with the treatment.
Other cultures may have another classication
for the problem and give it for babies who are
febrile, fussy or other than the specic disease for
which the antibiotic is eective. (5) Harm in
inappropriate use. The inappropriate use of this
treatment diminishes its eectiveness overall by
promoting the development of antibiotic resistant microorganisms. (6) Dissonance in conclusions. One could conclude from observations that
this medicine works some of the time, but most
of the time it is not eective, and in some cases
people even got worse. A critical observer might
even note that after using this pink liquid for a
long time, some of the children got sicker and the
medicine was overall harmful.

CONCLUSIONS
The use of CAM is increasing and indicates a
cultural shift in both the general culture and in
the health care system. A move from a predominantly disease focused paradigm toward a

183

focus on health has been taking place over the

past 30 years. There is also a substantial movement toward enlarging health care toward a
more holistic perspective that incorporates psychological, social, cultural and spiritual dimensions. These are features of other health care
systems and reect the growing demand of
Western society. Modalities of healing are often
adapted from other traditional systems to
capture a more holistic approach. Additionally,
may people are personally exploring spiritual
traditions from their own cultural backgrounds,
as well as from other cultures and integrating
these into their current health practices. However, with the importation of modalities into
integrated systems and the movement to subject
all therapies to rigorous clinical trials, it is
important to recognize the pitfalls of taking
these modalities out of their cultural context.

Implications for clinical practice

and research
Health care providers are increasingly caring for
clients from diverse cultures. Cultural competence is an important goal of contemporary
health care. This competence requires a respect
for the healing traditions of all clients. Many of
these traditions are oriented to staying healthy
and are often related to spiritual disciplines. It is
important to understand these practices to
evaluate if they are harmful to the clients health
or facilitative to a higher level of wellness. It
would be ironic if health care interfered with or
was detrimental to staying healthy in any
dimension. It is impossible to know about every
culture and also impossible to understand how
people are mixing healing practices from dierent cultures. Therefore, a good assessment of
health and healing practices is essential for each
client.
Biomedicine focuses on disease and treatment.
Biomedical research is based on specic treatment for specic disease, with that treatment
being generalized across individuals. Blinded
randomized controlled trials (RCT), the gold
standard based established for pharmaceuticals,
are considered the most authoritative especially
if the mechanism of action is understood.
Mechanisms of action are grounded in laboratory science and provide excellent pathways for
biomedical advancement. This method of investigation is useful for CAM and many modalities
may be understood in a new light once the
mechanism of action is understood.
It is important to keep in mind, however, that
many of these modalities are based in very
dierent cultural frameworks. Treatments work
systemically for multiple problems, many focusing on maintaining health through balance and
harmony. Isolating one aspect of the modality

184 ComplementaryTherapies in Nursing & Midwifery

out of context alters the intervention. This would

be comparable to isolating the aspect pink liquid
in the amoxicillin example. Secondly, many
healing modalities are focused on health rather
than treatment of a specic disease. Identication of an appropriate outcome is a perplexing
problem of researchers studying health promotion. Disease or disruption of health takes
dierent forms in dierent people, so it is dicult
to determine states of health or prevention of
disease prospectively. Even in determining eective treatment, basing the treatment from one
culture for a disease that is understood from a
dierent paradigm is problematic. Again using
the amoxicillin analogy, amoxicillin would not
be eective for viruses or inuenza. Without an
understanding of germ theory from the context
of biomedicine, one could make an erroneous
conclusion that amoxicillin is not eective in
treating sick and febrile children. It is important
to keep in mind that absence of evidence is not
evidence of absence.

REFERENCES
Baer H 2001 Biomedicine and alternative healing systems
in America. University of Wisconsin Press, Madison
Caplan A 1997 The concepts of health, illness and disease.
In: Veatch R (ed) Medical ethics, 2nd edn. Jones &
Bartlett, Boston
Eisenberg D et al. 2001 Perceptions about complementary
therapies relative to conventional therapies among
adults who use both: results from a national survey
Annals of Internal Medicine 135(5): 344351
Engebreston J 1997 A multiparadigm approach to
nursing. Advances in Nursing Science 20(1): 2133
Ergil K 2001 Chinese medicine In: Micozzi M (ed)
Fundamentals of complementary and alternative
medicine, 2nd edn. Churchill Livingstone, New York
Ernst E 2002 Complementary and alternative medicine:
What is it all about? Occupational and Environmental
Medicine 59: 140144
Goodman F 1988 Ecstasy ritual, and alternate reality:
religion in a pluralistic world. Indiana University
Press, Bloomington
Gordon D 1988 Tenacious assumptions in western
medicine In: Lock M, Gorden (eds) Biomedicine
examined. Kluwer Academic Publishers, Dordrecht
Hough H, Dower C, ONeil E Prole of a profession:
naturopathic practice. Center for the Health
Professions, UCSF. http://futurehealth.ucsf.edu/cam
Accessed April 5, 2002

House of Lords 2000 Complementary and alternative

medicine CAM Select Committee on Science on
Technology sixth report http://www.uk-therapy.com.
Accessed March 28, 2002
Hultkrantz A 1992 Shamanic healing and ritual drama.
Crossroad, New York
Kaptchuk T 1983 The web that has no weaver. Cogdon &
Weed, New York
Kaptchuk T 2001 The double-blind, randomized, placebocontrolled trial: gold standard or golden calf? Journal
of Clinical Epidemiology 54: 541549
Kaptchuk T, Eisenberg D 2001 Varieties of healing, 2.
A taxonomy of unconventional healing practices.
Annals in Internal Medicine 135(3): 196204
Kehoe A 2000 Shamans and religion: an anthropological
exploration in critical thinking. Waveland Press,
Prospect Heights, IL
Kessler R, et al. 2001 Long-term trends in the use of
complementary and alternative medical therapies in
the United States. Annals of Internal Medicine
135(4): 262268
Kleinman A 1980 Patients and healers in the context of
culture. University of California, Berkeley.
Kinsley D 1996 Health, healing and religion: a crosscultural perspective. Prentice-Hall, Upper Saddle
River, NJ
Kirmayer L 1988 Mind and body as metaphors: hidden
values in biomedicine. In: Lock M, Gordon D (eds)
Biomedicine examined. Kluwer Academic, Dordrecht
Lupton D 1994 Medicine as culture. Sage, London
Micozzi M, Vlahos C 2001 Yoga: ancient art and modern
practice. In: Micozzi M (ed) Fundamentals of
complementary and alternative medicine, 2nd edn.
Churchill Livingstone, New York
NCCAM National Center for Complementary and
Alternative Medicine, http://nccam.hin.gov. Accessed
April 3, 2002
Sheikh A, Sheikh K 1989 Eastern and western approaches
to healing: ancient wisdom and modern knowledge.
Wiley, New York.
Stein H 1990 American medicine as culture. Westview
Press, Boulder
Thompson M, Ellis R, Wildavsky A 1990 Cultural theory.
Westview Press, Boulder
Unschuld P 1985 Medicine in China: a history of ideas.
University of California Press, Berkeley
Veith I 1972 The yellow emperors classic of internal
medicine. University of California Press, Berkeley
Walsh R 1990 The spirit of shamanism. Jeremy Tarcher,
Los Angeles
White House commission on complementary and
alternative medicine policy: Final report.
http://whccamp.hhs.gov/es.html. Accessed
April 8, 2002
Zysk K, Tetlow G 2001 Traditional Ayurveda. In: Micozzi
M (ed) Fundamentals of complementary and
alternative medicine, 2nd edn. Churchill Livingstone,
New York