Alternative medicine Complementary and alternative medicine ESEARCH and royals patients

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					      Alternative medicine

         Complementary and
         alternative medicine
                  ESEARCH and royals, patients

         R        and politicians, counsellors and
                  clinicians – all have recently taken
         a considerable interest in complementary
         and alternative medicine (CAM). Fringe,                                             ADRIAN FURNHAM on the role of psychology in
         unconventional, unorthodox, natural and
         folk medicine have come in from the cold,                                           understanding the dramatic rise of alternative therapies.
         and CAM is now big business under this
         new label (Ernst & Furnham, 2000). CAM                   social causes to be specified in the             q   Therapy: Conventional medicine often
         seems to be favourably perceived by many                 aetiology of illness. The third model has            claims to destroy, demolish or suppress
         general practitioners (Easthope et al.,                  been labelled holistic and does not                  the forces that make people ill, while
         2000). Indeed the rise of CAM has led to                 distinguish between soma, psyche and                 alternative therapies often aim to
         a House of Lords inquiry into six aspects                social. It stresses total therapy and holds          strengthen the vitalising, health-
         of CAM: evidence, information, research,                 up the idea of a natural way of living.              promoting forces. CAM therapies
         training, regulation and risk, and NHS                       The wide scope of CAM makes it                   seem particularly hostile to chemical
         provision (Ernst, 2000).                                 difficult to pigeonhole within one of these          therapies and surgery.
             In recent years the increasing public                models, or to identify what unites CAM in        q   Patient: In much conventional medicine
         interest in CAM (see box opposite) has                   the face of the considerable diversity of            the patient is the passive recipient of
         been reflected in academic books (e.g.                   theories, philosophies and therapies. Yet            external solutions – in CAM the patient
         Abbot et al., 1996; Vincent & Furnham,                   there are common themes within the                   is an active participant in regaining
         1999) and journal articles (e.g. the ‘theme              philosophies of CAM. Aakster (1986)                  health.
         issue’ of the Journal of the American                    believes that they differ from orthodox
         Medical Association, 1998, 280, No.18).                  medicine in five ways:                           One way of classifying the many different
         So what answers has this research                        q Health: Whereas conventional medicine          CAM therapies is by ‘emphasis’ (structural,
         provided? Why is CAM so popular?                             sees health as an absence of disease,        biochemical, energetic and mind-spirit) and
         Does it actually work? And what role                         alternative medicine frequently              by their methods of care and treatment
         can psychology play in understanding                         mentions a balance of opposing forces        (Turner, 1998). Using factor analysis, I set
         the phenomenon?                                              (both external and internal).                out to see how 589 members of the public
                                                                  q Disease: The conventional medicinal            classified 39 different types of CAM,
         Unity and diversity in CAM                                   interpretation sees disease as a specific,   depending on whether they had heard of it,
         Aakster (1986) described three main                          locally defined deviation in organ or        knew how it works, whether they had tried
         models of medical thinking. The                              tissue structure. CAM practitioners          it, and whether they believed it works or
         pharmaceutical model is a demonstrable                       stress wide signs, such as body              not (Furnham, 2000). A pattern emerged
         deviation of function or structure that can                  language indicating disruptive forces        with art therapies (e.g. music, dance), talk
         be diagnosed by careful observation. The                     and restorative processes.                   therapies (i.e. counselling), and ‘foreign
         causes of disease are mainly germ-like, and              q Diagnosis: Regular medicine stresses           techniques’ (e.g. Reiki, Shiatsu) all
         the application of therapeutic technology is                 morphological classification based on        classified distinctly. The ‘big six’ therapies
         all-important. The integrational model                       location and aetiology, while alternative    – acupuncture, chiropractic, homoeopathy,
         resulted from technicians attempting to                      interpretations often consider problems      medical herbalism, naturopathy (a belief in
         ‘reintegrate’ the body. This approach is not                 of functionality (e.g. in dressing or        the healing power of nature) and
         afraid of allowing for psychological and                     feeding oneself) as diagnostically useful.   osteopathy – are often grouped together by
                                                                                                                   lay people, presumably because they see
                                                                                                                   them as most established and regulated –
                                                                                                                   despite the fact the they are based on very
       WEBLINKS                                                                                                    different methods and philosophies.
       Research Council for Complementary Medicine:                                                     In fact it is this diversity in the field of
       National Center for Complementary and Alternative Medicine:                               CAM that can lead to problems in
       Institute for Complementary Medicine:                                                  regulation. While there have been calls to
       Complementary Medical Association:                                                       find regulatory bodies to oversee all CAM
       House of Lords Science and Technology Report:                   practices, this has proved very difficult
                    pa/ld199900/ldselect/ldsctech/123/12301.htm                                                    because of the theoretical, historical and
                                                                                                                   political differences between the various


      The Psychologist             Vol 15 No 5                                                                                                             May 2002
                                                                                                                                   Alternative medicine

CAM specialities. Given this lack of an              THE RISE AND RISE OF CAM
official regulatory body, scientific research
into the effectiveness of CAM becomes                USA                                                    UK
even more crucial.                                   q In 1993, 34 per cent of the population visited       q Around 25 per cent of the British population
    Fortunately, the popular interest in                a CAM therapist, more than visited primary               have used some form of CAM.
CAM has indeed been matched by a                        care physicians. Expenditure was estimated at       q Around 80 per cent of the public who use it
relatively sudden and dramatic increase in              $13.7 billion a year (Eisenberg et al., 1993).           are satisfied with CAM therapies compared
research on the two central questions in             q By 1998, 47.3 per cent of all Americans were              with 60 per cent with ‘orthodox medicine’.
this area: do CAM therapies actually work,              estimated to visit a CAM practitioner. annual       q    Around 65 per cent of British hospital doctors
and why do people choose them?                          visits rose from 427 million in 1990 to 629              believe that CAM has a place in mainstream
                                                        million in 1997 (Eisenberg et al., 1998).                medicine.
Does it work?                                        France                                                 q    About 93 per cent of GPs have suggested
Is there good evidence from double-blind,            q Use of homoeopathy (the most popular CAM)                 a referral to CAM (Ernst & Kaptchuk, 1996).
placebo-controlled, randomised studies that             rose from 16 per cent of the population in          q    Nearly 67 per cent of local health authorities
a particular therapy ‘cures illness’ as it says         1982 to 29 per cent in 1987, and to 36 per               in the UK are purchasing at least one form of
it does? Properly designed and executed                 cent in 1992 (Fisher & Ward, 1994).                      CAM (White & Ernst, 2000).
studies are complex and very expensive,              The Netherlands                                        q    Individuals spend £1.6 million per annum on
and similar to the research effort to                q In 1981, 6.4 per cent visited a CAM therapist –           CAM therapies, the NHS about £40 million;
determine the efficacy of psychotherapy.                rising to 15.7 per cent in 1990 (Fisher & Ward,          and £500 million is spent on CAM products
Indeed, it is the extensive research into the           1994).                                                   (Ernst & Furnham, 2000).
placebo effect that makes psychological
input particularly valuable (Vincent &
Furnham, 1997).                                   efficiency, the central question must be                question is how the brand offers something
    The answer to the question is either          why patients choose (at their own expense)              quite different that no other product service
very little or no good evidence is available      to visit a CAM practitioner. What do they               offers. This raises the question – as yet to
for the therapeutic success of most CAM,          get from the treatment? Why do they                     be answered – of what makes an individual
possibly with the exception of herbalism          persist? This is where there have been                  brand loyal to a therapy, a therapist or
(Vincent & Furnham, 1999). This is                many psychological studies (Furnham &                   indeed a place of treatment.
because there has not been a concerted            Kirkcaldy, 1996; Vincent & Furnham,
scientific research effort to investigate the     1999) concerning the often mixed motives                People want a cure without side-
claims of many of the specialities of CAM         that patients have in shopping for health               effects or pain This may in fact
until recently. However, as more                  treatments. Results from various studies                distinguish different CAM therapies,
sophisticated meta-analyses are published it      (reported by Vincent & Furnham, 1997)                   offering a very strong, unique selling point
does seem to be the case that there is clear,     show several key factors.                               for homoeopathy over either herbalism or
incontrovertible evidence for small but                                                                   acupuncture, because of the scare stories
robust positive effects of specific CAM           People shop for health They want to                     about poisoning in the former and pain and
treatments (e.g. Ernst & Pittler, 1998).          use all possible (and affordable) options in            infection in the latter. It is for instance the
                                                  health care. People are not ‘brand loyal’ to            ‘gentleness’ of homoeopathy and its
Why choose it?                                    orthodox medicine or any particular                     dilutions that may be particularly attractive
If the evidence is limited and equivocal,         therapy. They experiment, and CAM is to                 to people.
and indeed often points to lack of                many just another product or service. The
                                                                                                          CAM is seen as a ‘last hope’ for
                                                                                                          chronic illnesses Many sufferers of
                                                                                                          chronic painful conditions or addictions
                                                                                                          have tried many other cures, and turn to
                                                                                                          CAM as a last hope. Some treatments
                                                                                                          have a powerful psychological component
                                                                                                          particularly those associated with touch
                                                                                                          (i.e. massage, reflexology). Equally the
                                                                                                          emphasis may need to move from cure
                                                                                                          to effective management of such chronic
                                                                                                          conditions, just as it does in clinical

                                                                                                          Disappointment with the traditional
                                                                                                          orthodox consultation GPs all too
                                                                                                          often have little time, may seem
                                                                                                          patronising, or may not fully examine the
                                                                                                          patient or touch them. Further, patients are
                                                                                                          often not asked the full set of questions
                                                                                                          they expect to answer for a ‘full’ diagnosis.
                                                                                                          In short, they are not treated like a modern


May 2002                                                                                                                The Psychologist              Vol 15 No 5
      Alternative medicine

          adult consumer. There is a strong departure                                                                                   associated with gait, balance, body odour,
          point for many CAM practitioners who                                                                                          and so on. The implication is that the
          have much longer consultations, and                                                                                           diagnostic interview may need to include
          appreciate patients’ need to talk or be                                                                                       questions about all aspects of the person’s
          examined. The question is how the                                                                                             life, not only their physical symptoms.
          traditional or average CAM consultation is
          different from both traditional orthodox                                                                                      Is there a CAM ‘type’?
          consultation and that of other (competitor)                                                                                   Comparisons of users and non-users of
          CAM therapies. It is possible to compare                                                                                      CAM have shown evidence of different
          and contrast across a number of variables                                                                                     beliefs about health and disease in general
          (history-taking approach, language used,                                                                                      (Vincent & Furnham, 1997). There is some
          patient role, decision-making process,                                                                                        evidence that frequent CAM users are more
          bedside manner) to show how different                                                                                         health conscious and believe more strongly
          they are, which may account for the                                                                                           that people can influence their own state of
          popularity of CAM.                                                                                                            health, both by lifestyle and through
                                                                                                                                        maintaining a psychological equilibrium.
          People want an emphasis on                                                                                                    Users of CAM appear to have less faith in
          ‘wellness’, not ‘illness’ Because many                                                                                        ‘provider control’ – the ability of medicine
          people want to learn more about self-care,                                                                                    (specifically orthodox doctors) to resolve
          fitness (wellness and preventive measures)                         balanced, natural and preventive, fitting                  problems of ill health. Some studies of
          orthodox medicine may be seen as a                                 in with the particular zeitgeist.                          cancer patients using CAM have found that
          narrow, restorative, disease- (complaint-)                                                                                    they were more likely than those not using
          oriented approach that aims to destroy,                            Many people believe in the ‘holistic’                      CAM to believe cancer was preventable
          demolish or suppress illness-inducing                              message It seems obvious to most that                      through diet, stress reduction and
          forces through such things as chemical                             lifestyle, personal relationships and work                 environmental changes and to believe that
          therapies and surgery. What many people                            operate all together and simultaneously                    patients should take an active role in their
          want is an emphasis on natural restorative                         have an impact on health. Equally they                     own health (Cassileth, 1988).
          processes. The emphasis is quite different                         believe that there are many and manifold                       Many CAM users seem to be
          – illness vs. wellness. Psychologists have                         signs of wellness and illness from                         sympathetic with green issues, ideas and
          long recognised this as a valid and useful                         digestion, sleep patterns and body                         understanding. These include
          approach. CAM is often seen as restorative,                        appearance to more subtle nonverbal signs                  environmentalism, anti-materialism and
                                                                                                                                        a belief in ‘one world’. Pro-CAM beliefs
                                                                                                                                        may also include issues around inequality,
       References                                                                                                                       alienation, and social exclusion. CAM
       Aakster, C. (1986). Concepts in            Ernst, E. (2000).The British House of           Complementary Therapies in
                                                                                                                                        patients also seem to be interested in
           alternative medicine. Social Science        Lords enquiry into                         Medicine, 8, 82–87.                   general consumer affair issues and may
           and Medicine, 22, 265–273.                  complementary and alternative          Furnham,A. & Lovett, J. (2001).           even belong to bodies that attempt to lobby
       Abbot, N.,White,A. & Ernst, E. (1996).          medicine. Focus on Alternative and         Predicting the use of                 in favour of a certain position. They appear
           Complementary medicine.                     Complementary Medicine, 5, 3–5.            complementary medicine:A test
                                                                                                                                        to be sensitive to consumer rights, bad
           Nature, 381, 361.                      Ernst, E. & Furnham,A. (2000). BMWs             of the theory of reasoned action
       Bergin,A. & Garfield, S. (1994).                and complementary/alternative              and planned behaviour. Journal of     practice and poor treatment. CAM patients
           Handbook of psychotherapy and               medicine. Focus on Alternative and         Applied Social Psychology, 31,        appear to be particularly interested in the
           behaviour change. Chichester:               Complementary Therapies, 5,                2588–2620.                            ‘life of the mind’. They certainly believe
           Wiley.                                      253–254.                               Furnham,A. & Lovett, J. (in press).The    the maxim of ‘a healthy mind and a healthy
       Cassileth, B. (1988). Unorthodox           Ernst, E. & Kaptchuk,T. (1996).                 perceived efficacy and risks of
           cancer medicine. Cancer                     Complementary medicine – The               complementary and conventional
                                                                                                                                        body’. CAM patients are, because of their
           Investigation, 4, 591–598.                  case for dialogue. Journal of the          medicine: a vignette study. Journal   own medical condition, likely to be very
       Easthope, G.,Tranter, B. & Gill, G.             Royal College of London, 30,               of Applied Biobehavioural Research.   empathic to the plight of others, and hostile
           (2000). General practitioners’              410–412.                               Turner, R. (1998).A proposal for          to the ‘uncaring’ attitude of certain
           attitudes toward complementary         Ernst, E. & Pittler, M. (1998).The              classifying complementary
                                                                                                                                        specialists (e.g. surgeons). However,
           therapies. Social Science and               effectiveness of acupuncture in            therapies. Complementary
           Medicine, 51, 1555–1561.                    treating acute dental pain:A               Therapies in Medicine, 6, 141–143.    despite these suggested differences in
       Eisenberg, D., Kessler, R., Foster, C.,         systematic review. British Dental      Vincent, C. & Furnham,A. (1997).          beliefs and values, there is little to support
           Noriock, F., Calkins, D. &                  Journal, 184, 443–447.                     Complementary medicine: A             the widely held view that those who use
           Delbance,T. (1993).                    Fisher, P. & Ward,A. (1994).                    research perspective. Chichester:     CAM are especially gullible or naive, or
           Unconventional medicine in the              Complementary medicine in                  Wiley.
           United States: Prevalence, costs            Europe. British Medical Journal,       Vincent, C. & Furnham,A. (1999).
                                                                                                                                        have unusual (neurotic) personalities or
           and patterns of use. New England            309, 107–111.                              Complementary medicine: State         bizarre values or belief systems.
           Journal of Medicine, 328, 246–252.     Furnham,A. & Kirkcaldy, B. (1996).The           of the evidence. Journal of the           In terms of demography, those who use
       Eisenberg, D., Davis, R., Ettner, S.,           health beliefs and behaviours of           Royal Society of Medicine, 92,        CAM are more likely to be women, aged
           Appel,A.,Wilkey,A.,Van Rompay,              orthodox and complementary                 170–177.
                                                                                                                                        30–40, middle rather than working class,
           M. et al. (1998).Trends in                  medicine clients. British Journal of   White,A. & Ernst, E. (2000). Economic
           alternative medicine use in the             Clinical Psychology, 35, 49–61.            analysis of complementary             educated above average levels, and to live
           national survey. Journal of the        Furnham,A. (2000). How the public               medicine:A systematic review.         in urban rather than rural areas. Their
           American Medical Association, 11,           classify complementary medicine:           Complementary Therapies in            medical history is more likely to feature
           1569–1575.                                  A factor analytic study.                   Medicine, 8, 111–118.                 chronic problems than acute, often non-
                                                                                                                                        specific or with a heavy psychological (i.e.


      The Psychologist                   Vol 15 No 5                                                                                                                          May 2002
                                                                                                                  Alternative medicine

non physical) component. Many patients        including the explanations that they           psychotherapy – with all the associated
have a ‘thick file’ in the sense that their   provide, merits good research. Social          problems of unregulated practitioners of
interest in health issues has led them to     psychological expertise in questionnaire       very dubious practices.
seek out various remedies from many           design and analysis, as well as discourse         Psychological theories may also be
different sources.                            analysis, can be (and indeed has been)         applied to, and tested in, the CAM context.
    However, despite some differences in      very useful in trying to understand patient    Thus Furnham and Lovett (2001) showed
beliefs, it is dangerous and foolhardy to     motives and satisfactions. Research            the theories of reasoned action and the
talk about the ‘typical’ user. CAM rejoices   psychologists interested in experimental       theory of planned behaviour could be
in differences and individuality and the      design and meta-analysis may assist in         used successfully to investigate factors
uniqueness of people’s lives.                 evaluating the quality of the experimental     underlying intentions and actual use of
                                              evidence, as well as assist CAM                homoeopathy over a one-month period.
The role of psychology in CAM                 practitioners and less experienced research    Similarly, Furnham and Lovett (in press)
research                                      design studies so as to reduce artefacts and   demonstrated how attribution theory could
Psychological research can substantially      confounds. Recent studies on efficacy          understand patient perceptions of risk.
help medical and sociological research into   research into psychotherapy, perhaps even      There are many other psychological
CAM through both methodological and           harder to evaluate than CAM therapies, has     theories and models in the health and
theoretical contributions.                    helped psychologists address some of the       medical psychology literature (e.g. the
    Psychologists’ expertise in evaluative    issues concerned with evaluating the           health beliefs model) that may go a long
research and methodology, their               ingredients of therapeutic efficacy (Bergin    way to answering some of the fundamental
understanding of placebo effects and their    & Garfield, 1994).                             questions in this comparatively new,
emphasis on evidence-based methodology            From a theoretical perspective             multidisciplinary area of research.
means that they are ideally suited to join    psychology may be particularly useful in       Psychology and CAM may have a healthy
multidisciplinary research teams interested   helping understand patient pathways to         and fruitful relationship for many years to
in CAM. More sophisticated, longitudinal      CAM; the knowledge, attitudes and beliefs      come.
research is needed to explore differences     of patients as well as the dynamics of the
in orthodox medicine and CAM patients.        GP and CAM consultation. Indeed this           s Adrian Furnham is Professor of
Further, key elements in the CAM              knowledge may prevent the growth of CAP        Psychology at University College London.
consultation that make them popular,          – complementary and alternative                E-mail:


May 2002                                                                                                 The Psychologist         Vol 15 No 5