Integrative Medicine: A Bridge between Biomedicine and Alternative Medicine Fitting the Spirit of the Age

doi:10.4236/sm.2012.24057

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Sociology Mind

2012. Vol.2, No.4, 441-446

Published Online October 2012 in SciRes (http://www.SciRP.org/journal/sm) DOI:10.4236/sm.2012.24057

Integrative Medicine: A Bridge between Biomedicine and

Alternative Medicine Fitting the Spirit of the Age

H. J. Rogier Hoenders1, Martin T. Appelo2,3, Joop T. V. M. de Jong4,5,6

1Center for Integrative Psychiatry, Groningen, The Netherlands

2Center for Psycho-Oncology , Het Behouden Huys, Haren, The Netherlands

3Department of Clinical Ps ychology, University of Groningen, Groningen, The Netherlands

4Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands

5Boston School of Medicine, Boston, USA

6Rhodes University, Grahamstown, South Africa

Email: [email protected]

Received May 31st, 2012; revised July 6th, 2012 ; accepted July 24th, 2012

Complementary and alternative medicine (CAM) are increasingly used by people in first world countries,

almost always in combination with biomedicine. The combination of CAM and biomedicine is now

commonly referred to as “integrative medicine” (IM). In Groningen, The Netherlands, we founded a

center for integrative psychiatry, offering conventional and complementary mental health care. Like other

centers for integrative (mental) health we have mostly received positive reactions although there have

been negative and even hostile reactions as well, using phrases like “quackery” and “betrayal”. We will

try to illustrate that these polarising qualifications, in which “the good” is being positioned against “the

bad” in an over-simplified manner, are unnecessary and not useful. Moreover, it is unlikely that this

polarisation will stall the growth of IM. It seems that integration is not only a current tendency in

medicine, but also a trend fitting the contemporary spirit of the age in which integration seems to be the

most common focus. It can be observed in religion, philosophy, spirituality and psychotherapy as well.

This article will discuss the difference between differentiation and integration and will show that the focus

on differentiation or integration varies with time, mostly rising as a reaction to each other. The transition

from one period to the next is often met with resistance and criticism. If the integrative movement is to

survive, it cannot do without differentiation and must find a middle way in which appropriate attention is

being paid to keeping the integrated parts sufficiently differentiated and allowing them to keep their own

identity.

Keywords: Integrative Medicine; Complementary Alternative Medicine; Polarisation; Integration

Introduction

The Latin word “integralis” means: “forming a greater en-

tity”. Integration stands for “fusing or making collaborate dif-

ferent parts into a larger whole” or “including into a whole”.

The opposite of integration is differentiation; the process

whereby a homogeneous entity is being divided in parts with

different qualities. Integration and differentiation are not mutu-

ally exclusive. They should rather be understood as movements

of the same wave, or phenomena taking turns. When there is

too much integration, the different parts lose their identity or

experience a lack of autonomy. This provokes differentiation,

leading them to profile themselves independently from each

other. When there is too much differentiation, they lose sight of

each other and each other’s interests, which increases the risk

of polarisation and conflict. This will invariably lead to a need

for more integration.

This process can also be observed in medicine. At the end of

the 19th and the beginning of the 20th century, the need for dif-

ferentiation led to a change in medical laws and regulations in

various countries (for instance the Flexner report in 1910 in the

United States and the Health Care Implementation Act in 1865

in the Netherlands). These changes created a strict separation

between recognised treatments on the one hand (which later

became known as biomedicine or conventional medicine) and

other forms of medicine (which later became known as alterna-

tive medicine). Besides the distinction between biomedicine

and alternative medicine, a debate also arose between profess-

sionals who favoured a reductionistic and biomedical approach

of medicine and colleagues who preferred a more holistic or

integrative approach. In the seventies and eighties of the 20th

century George Engel was an influential physician from the last

group. In response to the dominant reductionistic view of medi-

cine, he formulated a biopsychosocial model. His criticism

(Engel, 1992) of the biomedical model encompassed among

other things: that illness perception can be insufficiently ex-

plained by biochemical changes (for instance, illness perception

varies with culturally shared cognitions about diseases, ill-

ness-related behaviours and social support); that clinicians pay

too little attention to personal factors and communication skills

(for instance with regards to stimulating therapy adherence);

and that behavioural and social variables can and do influence

the course of an illness.

After more than a century of separation and conflicts be-

tween regular, biomedical medicine and alternative, holistic

medicine, from 2000 on there is a tendency towards integration

under the denominator of “integrative medicine” (Hollenberg,

2006; Hsiao et al., 2006; Jobst, 1998). Integrative medicine can

be defined as “the practice of medicine that reaffirms the im-

H. J. R. HOENDERS ET AL.

portance of the relationship between practitioner and patient,

focuses on the whole person, is informed by evidence, and

makes use of all appropriate therapeutic approaches, health

care professionals and disciplines to achieve optimal health

and healing” (Consortium, 2009). The most controversial part

is the use of “all appropriate therapeutic approaches” as it in-

cludes the use of complementary and alternative medicine

(CAM) within conventional hospitals/(care) delivery systems

(Hoffer & Hoenders, 2010).

“Complementary’ stands for forms of diagnostics, treatments

and prevention strategies that are based on theories accepted

in biomedicine. These are usually substantiated by scientific ar-

gumentation, but for different reasons do not form part of bio-

medicine. Examples are massage therapy and the use of herbs

and food supplements. Alternative treatments, such as healing

and homeopathy, make use of other than the basic concepts of

biomedicine. There is little proof for the efficacy of these treat-

ments or there is considerable controversy about the scientific

validation (Lake, 2007).

In integrative medicine the principles of evidence-based

medicine are applied to regular, complementary and alternative

treatments. This implies that in choosing an intervention, one

should take into account the highest level of available scientific

evidence about the different treatment options; the values, pref-

erences and frame of reference of the patient; and the profess-

sionalism and experience of the therapist (Sackett, Straus, Scott

Richardson, Rosenberg, & Haynes, 2000). The number of op-

tions in integrated medicine is larger than in regular health care

(Hoenders, Appelo, Van den Brink, Hartogs, & De Jong, 2011;

Lake, 2007; Lake & Spiegel, 2006), since CAM treatments are

not excluded beforehand.

The European Parliament (1997) and the World Health Or-

ganization (2003) plead in favour of promoting integrative

medicine (Chung, Hillier, Lau, Wong, Yeoh, & Griffiths, 2011).

However, this call is meeting a lot of resistance. There is an

enormous heterogeneity in views and behaviour concerning

CAM (Hirschkorn & Bourgeault, 2005).

The movement is even sometimes labelled as “quackery” and

the people who practice or promote CAM are sometimes dis-

qualified as betrayers. This can be observed when reading the

“rapid responses” to the editorial introducing this concept in

biomedicine (Rees & Weil, 2001) and more recently in a letter

by Ernst (2012). Our center for integrative psychiatry also met

these kind of criticisms (Kuipers & Gijsman, 2006). In this

essay we will try to illustrate that these polarising qualifications,

in which “the good” is being positioned against “the bad” in an

over-simplified manner, are unnecessary and not useful. The

fact is that integration is not only a current tendency in medi-

cine, but also a phenomenon that has manifested itself in the

history of mankind in all types of fields and all sorts of ways.

Not as an enemy of differentiation, but as a natural reaction to

it.

Manifestations of a Society Aimed at Integration

“Integration” and “differentiation” both play a central role in

the dynamics of life. Cells merge and split; people marry and

separate; companies are fused and subdivided; and power

blocks are formed and fall apart. The process of merging and

separation is taking place on each level of life. It forms a re-

turning theme in the history of humanity, and takes different

forms in different fields, over and over again. In this article, we

provide several typical examples from different spheres of life,

restricting ourselves to the themes related to our own field:

world view (philosophy, religion and spirituality), health care

(treatment demand, pathways to care and psychotherapy), and

scientific research.

Philosophy

The contemporary philosophy that evolved roughly after the

Second World War is called “postmodernism”(Anderson, 1999;

Bertens, 1994; Scruton, 2006). The core of this trend is the idea

that objectivity and the absolute truth do not exist. There are

many theories, ideologies, religions, convictions and principles,

but history teaches us that none of these has profiled itself in

such a way that it can be rightfully called “leading”, “all-en-

compassing” or “universal”.

Lyotard (1979) called this “the end of the big stories”. There

is no winner and thus, there is no such thing as the ultimate

truth or essential knowledge. As a result, postmodernism is not

exclusively aimed at acquiring knowledge, but especially points

at its ignorant, emotional, narrative, theory-bound and thus

unstable foundation. If there is no absolute criterion, it is also

not determined which goals we should pursue. According to

one of the post-modern philosophies, existentialism, we are

therefore doomed to freedom (Sartre, 1965). According to an-

other philosophy, social constructivism, we are free to choose

what we make of our lives, because everything changes all the

time (Bertens, 1994). This implies fear and insecurity, but also

provides unrestricted space to numerous equal, parallel ways to

deal with things. Mainly because of this freedom, post-modern

philosophy is offering a visionary framework for integrative

thinking and act i ng.

Religion and Spirituality

Even though polarisation and hostilities between the major

world religions still exist, and even though inter-religious ten-

sion is a risk factor for war and armed conflict (De Jong, 2010),

there is a clear tendency of integration in the field of religion,

especially in the Western world. This is caused by the seculari-

sation of society, which has led to a decrease in popularity of

institutionalised forms of religion, such as the Church. This has

created a need for new forms of spirituality and interpretation,

in which Eastern and shamanistic traditions and philosophies

have played a considerable role in the last decennia. The way

this new form of spirituality is being created, is characterised

by diversity and the post-modern lack of claims on one exclu-

sive source of the truth. This is accompanied by the freedom to

choose how an individual would like to fulfil his spiritual

needs.

Research shows that spirituality has a strong positive asso-

ciation with health (Koenig, 2000; Koenig, 2001). It also con-

sistently shows that giving meaning to what happens to us, is

more important for the wellbeing of a person than any particu-

lar religion. The experience of finding purpose is more impor-

tant for the wellbeing of people than the capacity to clarify or to

give a logical explanation for things (Lewis, Maltby & Day,

2005; Scannell, Allen & Burton, 2002; Steger & Frazier, 2005).

Demands for Care

Also regarding to health needs and demands for care, a ten-

dency towards integration can be observed. The expression

442

H. J. R. HOENDERS ET AL.

“supply creates demand” implies that when people are making

a choice, they take into account and use all available options. A

demand for care is therefore determined for the most part by the

available supply. Especially because of the internet, all health-

related knowledge has become accessible to everyone. This has

had a huge impact on the kind of health care demands people

make. Nowadays patients want to choose their own treatment

(Coulter & Willis, 2004) and are increasingly requesting an

integrated package of regular, complementary and alternative

treatment methods (Hök, Wachtler, Falkenberg, & Tishelman,

2007), not bothered by the differences in paradigms and work-

ing styles of CAM and biomedicine (Hoenders, Willgeroth, &

Appelo, 2008) and the ethical and scientific challenges result-

ing from it (Oguamanam, 2006).

Eisenberg et al. (1998) showed that CAM is being used on a

large scale in the United States, usually in combination with

regular treatments, and that there is an increase in use. In 1990,

34% of the Americans used CAM; by 1997 this percentage had

increased to 42%.

Even though patients do increasingly express demands for

integrative care, they seem to anticipate that caregivers still

restrict themselves to their own field of interest. About 60% -

75% of patients appear to conceal the use of CAM to their doc-

tor because of fear of disapproval or ridicule (VandeCreek,

Rogers & Lester, 1999). This is in sharp contrast with the fact

that patients would like to receive information about CAM

from their conventional providers. It would be advisable if

doctors would address this need respectfully, since an open

attitude towards nonregular treatment methods is essential (Hök

et al., 2007): It improves the therapeutic relationship (Stevinson,

2001) and increases the impact of medical interventions

(Koenig, 2000). It is also important to enquire about the use of

CAM for medical-ethical reasons. Uncontrolled use of CAM

can be dangerous, because of possible side-effects and interact-

tions with regular medicines (Ernst, 2002). In a study in Aus-

tralia less than 3% of the population was aware of this (Walter

& Rey, 1998). In this regard it is worrisome that one in five

patients combines herbs or foods supplements with medication

(Eisenberg et al., 1998). An open conversation about CAM can

take away misunderstandings and thereby prevent potentially

dangerous situations.

These considerations led to our own research (Hoenders,

Appelo, & Milders, 2006), which showed that 42% of almost

600 psychiatric outpatients in the Northern Netherlands had

used CAM. This figure is similar to older prevalence figures in

psychiatric patients (53%) (Knaudt, Connor, Weisler, Churchill,

& Davidson, 1999). We also studied the prevalence of CAM

use among patients of General Practitioners (GPs). A survey of

900 patients showed that they had used CAM in 62% of cases

(Borgemeester, Appelo, & Hoenders, 2008). Both groups of

patients report less than half of the cases of CAM use to their

conventional doctor. This is also in agreement with prevalence

rates offered by other researchers (VandeCreek et al., 1999;

Wetzel, 1998). Half of the psychiatric patients and 65% of the

GP patients would like to receive more information about CAM

and prefers that their conventional therapist would offer this. In

contrast, the psychiatrists and GPs who were surveyed in this

study heavily underestimated the use of CAM among their

patients, and only one third of them was in favour of offering

this information themselves. For one quarter of the psychiatrists

and one third of the GPs CAM had an outspoken negative con-

notation. So, it seems that despite most patients favour CAM

and integrative health care, a considerable number of conven-

tional doctors are not willing to work in this way, creating a

tension between health needs and supply.

Psychotherapy

Eventually, the struggle between different schools of thought

in Western psychotherapy had come to an end. It was replaced

by a so-called “Dodo bird verdict: Everybody has won, and all

must have prizes” (Luborsky et al., 2002). This was done be-

cause empirical evidence had shown that the “specific ingredi-

ent’ in any given therapy—that which theoretically makes it

work—adds little to the nonspecific elements of psychotherapy

(Asay & Lambert, 1999). Moreover, this research has shown

that clinical success is more a function of differences among

therapists than among therapies (Wampold, 2001), and the suc-

cess of therapists is primarily related to the quality of their alli-

ance with patients (Baldwin, Wampold & Imel, 2007; Luborsky

et al., 2002).

This revaluation of nonspecific therapy factors is also being

stimulated by an increasing collaboration between behaviour-

oriented sciences such as neurology, biology and experimental,

social and clinical psychology. The results of this interdiscipli-

nary research questions the existence of the free will: the neo-

cortex appears to be less dominant and therefore has less influ-

ence on our behaviour than it would like us to believe

(Dijksterhuis, 2008; Lamme, 2010). It seems that we are pre-

dominantly controlled by automatic neural networks. Someone

who would like to change his behaviour does not benefit much

from a wonderful all-encompassing theory, but needs the disci-

pline to replace all old automatisms with new ones that fit into

his own (small, but subjectively significant) story (Appelo,

2011; Brewin, 2006). The treatment method that facilitates this

type of learning, is no longer forcefully dictated by a particular

viewpoint or school of thought. In line with the principles of

evidence-based medicine, this integrative method results from

the interaction between the (preferences of the) patient, the

(expertise and experience of the) therapist and the number of

effective interventions that are available at that moment. This

gives the psychotherapeutic practice an integrated, eclectic

character (Korrelboom & Ten Broeke, 2004).

Another form of integration in psychotherapy is that of East

and West. Eastern philosophies are increasingly being inte-

grated into Western (psycho) therapies; examples are mindful-

ness and Acceptance and Commitment Therapy (ACT) (Ka-

bat-Zinn, 2003). So, it seems that also in psychotherapy there

are many developments with a tendency towards integration.

Scientific Research

Although there still are well-defined schools of thought in

the world of science with their own methodological preferences,

we also see, especially in health care, a growing space for the

equal coexistence of different research methods (Plochg, Jutt-

man, Klazinga, & Mackenbach, 2007; Walach, Falkenberg,

Fønnebø, Lewith, & Jonas, 2006). This is facilitated by the

criticism of the doctrine of the randomised controlled trial

(RCT) as a “sacred” scientific research method (Ottenbacher &

Hinderer, 2001). This criticism is predominantly based on the

difference between internal validity, or efficacy (does a method

or intervention work as such?) and external validity, or effect-

tiveness (is it beneficial in a certain context?). Proven efficacy

does not say much about effectiveness, as what works in a large

H. J. R. HOENDERS ET AL.

group on average does not per se apply to all individuals in

various contexts. On the other hand, effectiveness does not

simply imply efficacy, because what works for a person in a

particular situation, cannot always be generalised to a group.

If an intervention with only one mode of action is being

studied, as is the case with medication, and if a subject does not

prefer the experimental condition over the control condition

(because he cannot know the difference between the two), it is

indicated to establish the internal validity of the intervention

first. In this case, the RCT is the research method of choice. If

however the expectation of the result and the preference of

subjects play a role and these are not the same for the experi-

mental and the control condition (as is the case with almost all

psychological and non-placebo-controlled medication research

in health care), establishment of the external validity is indi-

cated first. Observational, quasi-experimental and mixed-

methods research is the method of choice in this case (Barry,

2006; Plochg et al., 2007). This offers possibilities for CAM

(Barry, 2006) as most CAM users have a strong preference and

therefore it is difficult to do RCTs for CAM therapies. Al-

though in biomedicine it is common to start with randomised

trials first, possibly later followed with effectiveness studies, in

CAM it seems acceptable to work the other way around. To

start assessing the effectiveness in a certain context and verify-

ing it later in a RCT. This also makes sense as in biomedicine

new pharmacological compounds are only allowed on the mar-

ket after assessing efficacy and safety in RCTs, but most CAM

are already being used, even though efficacy has not been es-

tablished yet. So, it seems that it depends entirely on the re-

search question, kind of treatment and circumstances, which

kind of research design is needed. No design (not even RCT)

can be considered best in all circumstances (Walach et al.,

2006). This calls for an integrated research approach.

Discussion

This essay suggests that the integrative movement in health

care does not stand on itself. It is a phenomenon that is mani-

festing itself worldwide and in different aspects of daily life. It

follows a period in which differentiation took central stage but

did not lead to absolute, unquestionable truths.

The conclusion that integrative health care fits into the spirit

of the time therefore seems justified. However, there is a

chance that, with continuing integration, this movement will

develop into another direction. The different parts in this case

might eventually lose their identity, develop a need for auton-

omy and try to promote more differentiation. The dynamics of

the processes of differentiation and integration show that both

poles are connected (similar to the perpetual dynamics and

balance between yin and yang in Eastern philosophy or the

theory of dialectics). If the integrative movement wants to sur-

vive, it will have to make sure that the balance is not lost.

In other words: a continuing integrative movement cannot do

without differentiation and must find a middle way in which

appropriate attention is being paid to keeping the integrated

parts sufficiently differentiated and allowing them to keep their

own identity. Then, integrative health care predominantly

means a good and equal collaboration between parts that are

well differentiated. In this regard it would be useful if everyone

who is involved in the process, critically contributes to the de-

bate and raises the alarm once the balance between differentia-

tion and integration is getting lost. In the last few years a dis-

torted balance due to a lack of criticism or supervision has be-

come visible in various spheres—e.g., the worldwide financial

crisis and fraud in scientific research.

Finally, it would be interesting to raise the question why in

the process of integration and differentiation people may feel

the need for polarisation and rowing against the flow, instead of

contributing to the debate. We think that the main reason why

people would protest against integration is that they do not

consider themselves sufficiently profiled and recognised in the

process of differentiation. After all, it looks like integration

works against one’s own identity. Especially when a person’s

identity has not been satisfactorily established during the proc-

ess of differentiation, he may fear that integration will destroy it.

This phenomenon is visible in the viewpoint of Kuipers and

Gijsman (2006), who present as an argument against the psy-

chiatric branch of the integrative movement, that it has taken

regular psychiatry already a lot of efforts to be seen as a normal

part of medicine. The resistance against integration is then re-

lated to the lack of a clear identity. Developing such an identity

is a good thing. But fighting against something else is, in our

opinion, not an appropriate method to reach this goal. It would

be better to invest in the profiling of your own message and

methods. Once we feel that we are being carried away, against

our will or not, in an integrative movement, we do not have to

be afraid that we will lose ourselves in it. We can get out of it

on our own, or take part in the larger whole and help create

something that is more than the sum of its parts, all the while

making sure that we can still recognise ourselves in what we

are doing. That will assist in finding and keeping the middle

road between preservation of one’s own identity and integration

into a larger whole.

Acknowledgements

The authors thank E. H. Bos and N. K. Vollbehr for their as-

sistance in preparing the manuscript.

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