J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 792–797 ~ FULL TEXT
Jon Adams, PhD, Daniel Hollenberg, PhD,
Chi-Wai Lui, PhD, Alex Broom, PhD
School of Population Health,
University of Queensland,
This article argues for the importance of examining the phenomenon of integrative health care in broader social and historical contexts. The authors examine mainstream approaches to identify patterns of integrative medicine and criticize them for their neglect of clashes among different philosophical paradigms and the wider social contexts that govern health care in practice.
The authors outline a framework and highlight the values of a critical social science perspective in deepening our understanding of recent transformations in health care practice and issues surrounding biomedicine and complementary/alternative medicine (including chiropractic, naturopathy, massage, acupuncture/oriental medicine, etc) and traditional medicine. A critical social science perspective pays special attention to complex power relations, inclusionary/exclusionary strategies, and interprofessional dynamics in medicine.
Drawing upon recent research findings, the authors illustrate how such a perspective reveals the intricacies and tensions that surround the integration of different paradigms of health care practice. The authors summarize the importance of situating integrative health care in structural contexts and affirm their commitment to a critical social science approach.
Key Indexing Terms: Integrative Medicine, Complementary Medicine, Alternative Medicine, Health Care, Social Characteristics, Power, Professional, Delivery of Health Care, Integrated
The Full-Text Article:
Integrative health care (IHC) or integrative medicine are terms used to describe a fast-growing and developing field of health care in many countries, characterized by the combination of biomedicine and complementary/alternative medicine (CAM) and/or traditional medicine. [1, 2] Within this movement toward a greater incorporation of modalities outside the “mainstream,” there has been a reexamination of the language surrounding health practices (alternative vs orthodox) and the creation of new terms to articulate a more balanced or rounded form of health care practice. [3-5] The idea of IHC has not been unproblematic in terms of either its definition or actualization. Numerous conceptual models have been developed within and around the notion of IHC, and there are debates over what integrative care is and on the nature of the service transformation that is occurring. 
In this article, we argue that the mainstream work and commentary around IHC have lacked a critical social science perspective. In this context, “critical social science perspective” reflects a broad approach informed by the tradition of critical theory of the Frankfurt School [7, 8] and recent developments in the sociological study of science and professions. [9-11] A critical social science perspective maintains that the development of health services is shaped by social structural processes that often reflect power imbalances, marginalization, and often domination by one professional group or knowledge form over another. A critical social science perspective incorporates a belief that things could be otherwise and, through unpacking and problematizing what is usually “the taken-for-granted,” provides the potential for an alternative organization of health provision. In addition to providing a scoping review on existing modes and limitations of IHC, a critical social science agenda also helps illuminate a reflective sociology of health care that subjects the current assumptions and arrangements of the sociologist to critical reflection. [12, 13]
This article first briefly outlines the popular models of IHC as well as an examination of the limitations of these “noncritical” attempts to define IHC. Specifically, we argue that integrative care, as devised and defined in these conceptual models, is impractical for these models have paid little attention to the wider structural and cultural contexts governing IHC in practice. We then introduce the framework of a critical social science perspective and explain how this perspective could be applied to the study of IHC. In conclusion, we highlight the importance of allowing voice to the complex power relations between dominant and marginalized groups in contexts of potential or attempted integration. We argue that without extensive consideration of such interprofessional dynamics including dominance, marginalization, and negotiation, the very nature and evolution of IHC cannot be properly understood.
Prevailing Approaches/Models on IHC and Their Limitations
Over the last decade, many health service researchers and theorists have constructed models often to identify core values that may allow integrative care to be accomplished. [14-17] Such commentators have suggested that the construction of conceptual models may help in identifying possible patterns or forms of collaboration of conventional medicine and CAM in different health settings. For instance, Boon et al [16, 18] devised a conceptual framework based on a comprehensive review of the IHC literature and an international workshop. The framework comprises 7 different IHC models (parallel, consultative, collaborative, coordinated, multidisciplinary, interdisciplinary, and integrative) specifying the different ways conventional medicine and CAM integration may be undertaken. 
These models form a continuum of health care, as developed around 4 key components: philosophy, structure, process, and outcomes. Thus, a move from the parallel to the integrative pole implies an increase in diversity of health care philosophies, complexity of organizational infrastructure, degree of communication, and aspects of well-being upon which practitioners focus. 
In a similar vein, Mann et al  identified 7 IHC models that they suggest signify different degrees of conventional health care and CAM integration:
(1) the informed clinician;
(2) the informed, networking clinician;
(3) the informed, CAM-trained clinician;
(4) multidisciplinary integrative group practice;
(5) interdisciplinary integrative group practice;
(6) hospital-based integration; and
(7) integrative medicine in an academic medical center.
As these authors suggest,  (p157) the initial form and subsequent development of IHC practice in a specific health setting are dependent upon interests, motivations, and skills as well as the experience of the practitioners. In addition to constructing analytical models, other researchers have also identified a number of critical elements or factors dictating success and influencing the ability to create the perfect IHC clinic. These include adequate marketing, solid referrals, appropriate staff, effective record and communication, cross-professional education, provider compensation arrangement, as well as a supportive organizational structure. [5, 20-22]
Another leading approach of defining IHC often used by health researchers is the complex systems approach, which advocates treating the phenomenon of health or illness as an emergent property of a complex and dynamic system.  Drawing heavily on the sciences of biology and ecological philosophy, this approach emphasizes that the ideal IHC model is a particular service arrangement, which facilitates conventional and alternative practitioners working harmoniously and as mutually supporting partners for the improvement of patient health. The systems approach to integrative medicine attempts to go beyond the limitation of traditional thinking by shifting the focus of health integration from individual discipline/practitioner to the symbiotic exchange between and cooperation across different kinds of health professions and practices. 
Although these mainstream approaches to studying IHC provide a useful set of conceptual tools or categories for practitioners to describe integrative practices, they have limited value in accounting for the dynamics of IHC practice in a wide range of health care settings. Specifically, the mainstream approaches have 2 major drawbacks. First of all, the discussions on IHC models tend to downplay the tensions and contradictions inherent in different paradigms of medical or health care practice. By conceptualizing integrative care as a matter of degree or continuum determined largely by interests of the practitioners or organization, the mainstream discussions bypass the issue of incommensurability between knowledge paradigms  and assume the blending together of biomedicine and CAM modalities as unproblematic.
However, this does not appear to be the case in terms of practice reality. Different medical paradigms often embrace radically different ontologies or mechanisms of disease causation and treatment. [26, 27] It is not uncommon that explanation or prescription of one medical paradigm is incompatible with the other, and it can be extremely difficult (if not impossible) to bring them together in practice. Coulter and Willis  (p215) used the case of homeopathy to illustrate the difficulties involved in integrating different medical paradigms. According to the traditional allopathic medicine, the potency of a therapeutic substance is weakened when the substance is diluted. However, in the homeopathic tradition, the more dilutions a substance undergoes, the higher its potency will be. The controversy on the role of the placebo effect is another issue that highlights the tension or conflict in combining different medical paradigms.  While evidence-based medicine emphasizes the control of effects like subjectivity, therapeutic setting, and personality of the therapist from the etiology and experience of illness, many CAM practitioners consider these nonspecific “complex effects” a crucial part of the healing process,  (p4) which do not lend themselves to randomized or even “n of 1” controlled trials. In the case of systems theory,  which is now dominating IHC inquiry, it is clear that professions do not act like supportive components of an ecosystem, although the understanding of patient healing may follow more closely a systems approach.
The second drawback of the mainstream approach is that the IHC models or typologies proposed are ideal types that are necessarily static constructs and may diverge radically from how “integration” is actually implemented or carried out in everyday health care settings.  Although it is acknowledged that the purpose of an ideal type is to highlight aspects of the world that may be heuristically valuable, there do appear to be serious challenges to comparing and appropriating such ideal types to the empirical reality of integration as identified by research.
In fact, empirical studies on health care settings demonstrate that the actual practices of IHC are very complicated and seldom come near to the neat patterns prescribed by conceptual models. Patterns of service provision are fundamentally shaped by the power and available resources of different professional groups as well as the dominant ideology of health care policy. For instance, Hollenberg  found that each IHC setting is different, with a unique mix of biomedical and CAM therapies, varying from 1 CAM therapy to as many as 8 or more. Moreover, in many cases, the ideal of comprehensive access to health promotion, disease prevention, and community-based CAM and biomedical health care services  has been found to be absent from practice realities. Instead, biomedical options in IHC clinics have been shown to take precedence over CAM options, mainly because they are covered by national or other health care insurance plans and viewed as superior to CAM. In turn, patients must prematurely terminate the CAM part of their treatment plan because they cannot afford the private CAM treatments. As a result, CAM practitioners experience low patient flow, low salary, and ultimately marginalization in the IHC setting.  In IHC settings such as these, integration becomes tailored to the affluent and often provided by medical providers without full CAM practice and theoretical training.
A related problem of the conception of different integrative practices as a continuum is that the framework offers no explanation as to why a particular form of integrative practice would arise or prevail in a specific setting and, further, assumes that “complete” integration is in fact entirely possible as a final stage. In reality, ideal-type constructs that fail to take into consideration social and historical specificities of medical practice have limited value in accounting for the dynamics of IHC. This is why a critical social science perspective is crucial to providing a more rounded understanding of the development and future of IHC.
A Critical Social Science Perspective on Health Care
Strictly speaking, the critical social science perspective is not a unique school but an interpenetrating body of work informed by the tradition of critical theory of the Frankfurt School [7, 8] and recent developments in the sociological study of science and professions. [9-11] Critical theory recognizes that existing social arrangements may not exhaust all possibilities, and it advocates the need for a critical engagement with contemporary social structures and power relations. By systematically examining the historical, social, and political conditions upon which human behaviors depend, the critical theory approach is ideologically positioned toward encouraging critique of power, promoting individual emancipation and social justice. On a different but related path, recent sociological studies of science and professions examine scientific (and medical scientific) inquiry as social activity. By situating scientific practice within the wider social and structural contexts, these studies systematically examine the intersection, segmentation, and rivalries within the scientific community as well as the processes of professionalization and legitimation. 
Inspired by these predecessors, a critical social science perspective on health movements and practices has 3 main characteristics. First of all, this perspective emphasizes the importance of contextualizing health care activities and trends within macro structural and historical specificities. This attempt to link the transformation of these practices to the wider social and political parameters offers a better and deeper understanding of the phenomenon under study. Moreover, on examining health care activities and professions in context, the critical social science perspective calls for special attention to the intricacies and dynamics of power and strategy in establishing epistemic authority and/or resources. This is the second characteristic of the critical social science perspective. Finally, by analyzing the historical construction of specific practices as well as the conditions under which professional demarcation is established, a critical perspective helps create “windows on possible worlds”  (p289) for different health care actors.
In short, a critical social science perspective is concerned with a contextual analysis of power, knowledge, and critique. In sociology, power is conceived as a multidimensional concept.  Although power is often understood as the ability of an individual or a group to make a decision in a conflict situation, this is not the only way power is manifest in daily life. In reality, power can also be an ability of the individual/group to set the agenda so that potential conflicts are suppressed or excluded — an ability of “non–decision making”. However, as Lukes  points out, there is also a third dimension of power that refers to the ability to influence people's wishes or thoughts and make them act against their own interest. This third dimension of power is ideological in nature. This analysis of power provides an important conceptual tool to the study of health and illness and IHC. It directs researchers to various forms or strategies of domination that are embedded in health care settings and between different professional groups. The processes of medical professionalization as well as integration involve the use of closure or exclusive strategies aimed to limit or regulate the entering of competitors into the market. 
The picture becomes even more complicated when the role of knowledge enters the discussion. Recent sociological studies on medical science have highlighted the conditions under which knowledge is incorporated into existing power relations and the constitutive role of knowledge in the production of new modes of domination. [37, 38] This focus on subtlety and intricacies of power, knowledge, and strategies offers a new angle to examine professionalization and integration.  Figure 1 illustrates the process of evolution of integrative medicine from a critical social science perspective. Drawing upon the various tenets of a critical social science perspective, we now turn our attention to applying such a perspective to the issue of IHC.
The development of integrative medicine in context.
Examining IHC From a Critical Social Science Perspective
In thinking about IHC critically, it is important to consider what is actually occurring interprofessionally between biomedicine and CAM within grassroots as well as wider sociohistorical contexts. Simplistic notions and models of integration suggest a coming together of practices and/or practitioners and a sense that there is more linearity to health care delivery across the modalities available. Yet, using a critical social science perspective and situating the development of IHC in wider sociopolitical parameters and in processes of struggles for professionalization and legitimation, we can see that the evolution of IHC and the relationship between conventional and alternative medicine are far from smooth and linear.
Historical studies on CAM movements since the 19th century reveal that the path of development of medical practice and the boundaries between different health paradigms are shaped by class, ethnic, and sex relations in the wider society [6, 40, 41] as well as by the strategies and resources marshaled by specific movement leaders.  While it has been argued that the increased role of CAM in health care could be seen as contributing to the deprofessionalization of biomedicine (resulting from reductions in the monopolization of medical knowledge, autonomy in work performance, and authority over clients [43-46]), this argument of the waning power or influence of the profession of medicine has been challenged by recent research and has been shown to be oversimplified, if not erroneous.
For instance, works of Mizrachi et al [47-49] on various clinical settings in Israel confirm the existence of a dual process of simultaneous acceptance and marginalization of alternative practitioners in health care settings. Although small numbers of alternative practitioners were allowed to practice and some of their techniques were absorbed by biomedical practitioners, they were seldom accepted as regular staff members; and their marginal status was marked by the use of structural, symbolic, and geographical cues in the clinical setting that helped redraw the borders between conventional medicine and CAM. In a similar vein, Theberge's  study on the integration of chiropractors into multidisciplinary health care teams in sport medicine is contingent on their acceptance of a reduced scope of practice.
Similarly, Hollenberg's [32, 33] study on IHC settings in Canada found that concepts like “widespread collaboration,” “synergism,” “trust,” “respect,” as well as “inter-/transdisciplinary practice,” which are commonly used in IHC discourse, were rarely actualized in health care settings. In addition, biomedical practitioners were found to enact strategies of exclusionary and demarcationary closure that restricted the role and activities of alternative health practitioners. These strategies range from the use of “esoteric knowledge”; dominating patient charting, referrals, and diagnostic tests; to regulating alternative practitioners to specific “spheres of competence.” Although the clinics under study offered some form of IHC practice with interactions between biomedical and alternative practitioners, these modes of practice or interaction did not represent what an IHC clinic should look like as described by the theory or ideal typical models.
Thus, from a critical social science perspective, the “integration” of CAM may in fact be resulting in a series of adjustments to the current social context rather than a breakdown in professional control. [44, 51-53] Broom and Tovey  examined and theorized ongoing attempts to integrate CAM with biomedicine in the United Kingdom, as a form of integrative medicine, suggesting that such efforts should not merely be viewed as either the “waxing or waning of the biomedical profession.”  (p555) Rather, in the context of their research, integration represents the complex process whereby multiple actors, health care settings, and institutions are reacting to and implementing the concepts of integration differently. As such, integration may in fact be more about strategic co-option of certain CAM procedures and technologies than the coming together of CAM and biomedicine.  The provision of CAM practices in biomedical settings may arguably result in a muting of metaphysical overtones (like notions of energy fields, qi, or chakras) in an attempt to increase their compatibility with the biomedical model.  In turn, this process has also been exacerbated by processes of professionalization and in particular the establishment of qualifications, licensing, and regulatory bodies.  As critically reflective sociologists, based on the above observations, we do not believe we are theoretically reifying the marginalization that is readily apparent in IHC. 
Viewed in this way, although there are a recent push for and attempts to implement a more diverse model of health care delivery in certain contexts, there are also evolutionarily processes occurring that may work against integration and produce new forms of appropriation and marginalization. [6, 32, 58, 59] Although, at a broad level, diversity in educational programs and training is an important factor to facilitate communication and collaboration, there is little evidence that this factor has been taken seriously by stakeholders. A recent study on curriculum of medical schools in America found that more than half of the schools offer no education and training in integrative medicine or CAM.  Moreover, it is clear that, at least in the United States, there are 2 IHC movements currently attempting to work through tensions related to who will define and dominate IHC pedagogy and practice:
(1) the group of biomedical academic health centers involved with IHC (the Consortium of Academic Health Centers for Integrative Medicine)  and
(2) the group of CAM professions, including naturopathy, massage, and chiropractic, involved with IHC (the Academic Consortium for Complementary and Alternative Health Care). [62, 63]
Perhaps most significantly, attempts at integration are not flattening power dynamics between professional groups (ie, CAM and biomedicine). Rather, biomedical practitioners are adapting strategically to the “challenge” of integration, reconfiguring their status as medical elites within the plurality of providers available. It is through a critical social science perspective that such processes of marginalization, negotiation, and co-option can be identified, unpacked, and potentially addressed in future discussion of IHC.
This article argues for the importance of examining the phenomenon of IHC in broader social and historical contexts. Through critiquing the mainstream approach to defining IHC, we highlight the value of a critical social science perspective in deepening our understanding of recent transformations in health care practice.  With its concern to investigate power and knowledge, the perspective highlights the intricacies and tensions that surround the integration of different paradigms of health care practice.
Integrative health care often involves combining different paradigms that are based on ontologies and knowledge systems that are essentially incompatible.  Most importantly, the processes of interaction, conflict, or negotiation between these ontologies are not operationalized within social or cultural vacuums. In fact, the manner of evolution and encounter between different medical and health paradigms is partly shaped by wider social processes, power relations, as well as what Hirschkorn and Bourgeault  identify as “professional-level” and “work/organizational structures.” Viewed from a critical social science perspective, specific forms of IHC are social and historical constructs; and any account of possible patterns of integration between conventional medicine and CAM that does not pay due attention to the social, historical, and institutional specificities is at best potentially misleading.
The priority for IHC research can thus be stated as follows: a sound conceptualization of integrative care needs to be conducted across all possible settings, based on empirical research that highlights the dynamics between health care practices and sociopolitical relations more generally. In this regard, the IHC field would benefit if researchers could maintain and advance a critical social science perspective to examine a number of specific areas relating to IHC — exploring the interface, power relations, and dynamics between key IHC providers in a range of different settings. For example, a currently unexplored area is the use of qualitative methods (ethnography, interviews, focus groups, and diary methods) and mixed-method designs to explore the dynamics of integration in numerous IHC settings consisting only of collaborative CAM practitioners.
Only through empirical investigation of a range of settings can we appreciate whether CAM practitioner-based IHC or other types of IHC initiatives, free from medical dominance, could produce a different form of integrative medicine. As CAM practitioners often comment, “we are already doing integrative medicine.” Regardless of substantive focus, it is essential that the wider insights identified from a critical social science perspective are used for further empirical investigation of IHC.
This article criticizes mainstream approaches to integrative medicine for neglecting the wider structural contexts that govern health care in practice.
The authors call for a critical social science approach that situates integration within complex power relations and interprofessional dynamics.
Funding Sources and Potential Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
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