The Roots of Inequity in CAM

When I think of the potential that CAM (complementary and alternative medicine) has in a truly integrative model of medicine, where CAM can be used not only to treat subjective complaints that have no real biomedical basis, but also to help those with medical trauma or who are reluctant to engage with a conventional care provider, I find myself simultaneously believing in the possibility whole-heartedly, and stumbling when I think of the reality. CAM is not a medicine built on equity, from the barriers to access built into our insurance system, right on down to how providers are educated. To truly extend our scope to all patient populations, we in CAM have much to reckon with.

The first thing I stumble on is healthism, originally defined by Robert Crawford as a “preoccupation with personal health as a primary — often the primary — focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of lifestyles.” Though healthism occurs in conventional medicine, it is endemic in CAM. In practice, this manifests with CAM providers often making a slew of lifestyle recommendations without considering whether or not our patient is ready or willing to make that change. We gloss over the very real sociological barriers that these recommendations present to many people. Even a basic dietary recommendation of eating primarily based whole foods can be tremendously difficult for many due to access, time and education. There is also the prescription of supplements, none of which are covered by insurance, and the time and money it takes to maintain regular acupuncture appointments or yoga classes. Crawford put it this way: “To the extent that healthism shapes popular beliefs, we will continue to have a non-political, and therefore, ultimately ineffective conception and strategy of health promotion. Further, by elevating health to a super value, a metaphor for all that is good in life, healthism reinforces the privatization of the struggle for generalized well-being.”

I’ve made this mistake myself repeatedly in my acupuncture practice. It’s part of our education as providers. We’re taught that if the patient really wants to get better, that they should comply with the very practical suggestions we give them. It’s all too easy to gloss over what’s behind these benign seeming recommendations, which is not simply confined to the above. They also contain within them the seeds of paternalism and perfectionism, as if we CAM providers are somehow a step above others in our evolution as human beings, and creating the opportunity to confuse our role as healthcare ally with that of lifestyle guru.

Indeed, the pressure we put on ourselves as CAM providers here in the US is subtle but myriad. Holism becomes a coded perfectionism. We’re supposed to have a deep spiritual practice, meditate, mindfully exercise and keep fit, eat a diet so pure that even our perfectly formed shit is organic, abstain from anything more than moderate drinking or drug usage, avoid prescription drug dependency, and know what herbal tonics and supplements keep us from ever being ill for more than a day or two. Our lifestyles should keep us glowing with natural vitality. It’s taken me years to be at peace with the fact that my life doesn’t look like this, and that beyond that, that this is an expectation that reinforces inequity on a fundamental level. It’s as if we’re saying that those who can afford to keep such a lifestyle are somehow more worthy of good health than those who cannot, which is exactly what Robert Crawford was getting at.

How I see CAM as being able to bust out of this paradigm is by releasing any such expectations of our patients and ourselves. We have a unique placement in the healthcare system that has languished too long. Our very status of outsiders in mainstream healthcare give us the opportunity to work with people who fall through the cracks due to their reluctance to engage with conventional medical or behavioral health providers. Our training in looking at the individual as a whole is incredibly valuable, as is our ability to work with and treat conditions that may or may not have a biomedical diagnosis.

To do this, however, our education needs to change. For those with medical trauma or who distrust conventional care providers, having a CAM provider to talk to while undergoing treatment for a major medical condition can be enormously therapeutic. This involves a rethinking of CAM as an entire field. We’re taught that our primary therapeutic purpose is to give an alternative treatment, but the reality may be that the alternative treatment is the relationship itself with someone who is sympathetic and trained to look at the whole person. With this as a potential goal, we need to educate CAM providers to work with all people, not just the middle and upper classes. Students must learn to work with and value difficult patients as much as compliant patients, and we need better education regarding mental and behavioral health. Additionally, we need to know how to navigate and work with conventional healthcare systems and providers. Supplements, food therapy, and lifestyle recommendations should either take a backseat to training or be seen as equal in value to interpersonal skills such as reflective listening, motivational interviewing, anti-bias training, harm reduction, suicide prevention, and trauma-informed communication methods. If we emphasize the latter, we’ll be able to do the former with more skill and discernment than if the “Alternative” part of CAM is prioritized.

Going to step down from my soapbox now…FYI, this post has not been thoroughly edited, and may contain typos. Apologies.

How do we work with behavioral health issues as EAMPs?

I believe that one of the biggest untapped potential of the field of East Asian Medicine is how we can work with mental health. The stigma of mental health is present on every level of our society. Fear of being put on medications, of receiving a disturbing diagnosis, of having to face our psychological and emotional pain…the list goes on. For some, it can be so much easier to approach a holistic care provider of some sort, one who won’t necessarily label you, who can see the connectedness of body, mind, and spirit.

Or so it seems. The reality is that many if not most CAM providers are not trained to deal with people who are in crisis. We’re taught some theory about it in school, but when it comes to learning hands on approaches to working with people whose behavior is bizarre, disruptive, or disturbing, we conveniently default to this being outside of our scope of practice. This may be true, but this person may also not approach a professional for whom it is because of the reasons listed above. If that is the case, we have a unique opportunity to provide care that would otherwise be rebuffed. Why not take that opportunity?

First, we have to deal with our own prejudice against people whose behavior is outside the norm. I’ve dealt with a number of people over the years who other acupuncturists have not liked treating. Rather than seeing this as a failure of the other acupuncturist, I would attribute it to the fact that our education here in the US is geared toward people who are otherwise stable and resourced. The bulk of our clinical training is focused on acupuncture techniques and theory, and not how to work with a wide range of patient populations on a regular basis. While I was given externships at places where there were marginalized and underserved populations, the understanding was always that I wouldn’t make a career out of it because such positions don’t often exist outside of an academic setting in the field and aren’t profitable.

We as a profession need a better strategy on how we work with and view people with behavioral and mental health issues that avoids stigmatization. We have the opportunity to do better than labeling such people as having a “shen disturbance”; working with them through our own unique lens that can empower patients through speaking back what’s going on with them not as a static diagnosis, but as a fluid pattern of interacting elements. We just need to start extending ourselves to this patient base, and begin resourcing ourselves to deal with them better.