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The future of psychiatry: emerging paradigms and integrative approaches in psychiatric diagnosis and treatment.

Contemporary mechanistic science was introduced by Francis Bacon at the end of the 16th century. This scientific method was formally derived to ensure a series of objective or value-neutral, scientific, approaches for analysis of the attributes of natural phenomena. However, as Medard Boss (1979) has observed in the introduction to his seminal work, Existential Foundations of Medicine and Psychology:
 Every science is ... necessarily and
 always based on prescientific
 premises. These constitute a
 fundamental structure that not
 merely sets forth in advance
 which inquiries are possible and
 which are not, but furthermore
 determines the very character of
 the science and the extent to
 which its results will be significant.
 It sets the goals for the
 science and establishes the procedures
 guaranteeing correct practical
 application of theory.

Contemporary Western scientific method continues to rely on the prescientific premise of Cartesian dualism, or the belief that human nature is reducible to a tangible physical part and an intangible, metaphysical or mental part. According to the dictum, each aspect of our nature is fundamentally different in quality or kind, and may not be reduced to or adequately represented or described according to properties inherent in the other quality.

In the United States and Europe novel therapies are entering into common use as complementary or alternative treatments for the range of psychiatric symptoms and disorders. Some of these rest on theories that are congruent with the prevailing empirical-reductionistic Western scientific framework. Other emerging therapies assume the validity of concepts or paradigms that are presently outside of or inconsistent with the tenants of contemporary allopathic medicine and scientific or philosophical premises from which these assumptions are derived. Increasing use of herbs or other natural substances as medicines in psychiatry is an example of an emerging systematic approach to complementary medicine in psychiatry that does not require changes in the basic theoretical or methodologic framework of Western science as it exists in the early 21st century. In contrast, the increasing use of techniques in the domain of Traditional Chinese Medicine (TCM), Ayurveda "Knowledge of Life," or other so-called "energetic" healing approaches, call for a reappraisal of fundamental assumptions underlying contemporary scientific understandings of principles inherent in basic concepts of "disease" and "healing."

Considerable vagueness and confusion surround popular usage of the terms "complementary" and "alternative" medicine. In the United States and much of the Western World, considerable debate is ongoing among conventionally trained physicians and non-conventionally trained practitioners in efforts to clarify meanings of these terms and to determine whether substantive differences actually exist between therapies that are labeled "complementary" and "alternative." At this time, a common understanding is that complementary treatments are based on concepts or practices that are contained within the dominant paradigm or formulaic system of medicine. In other words, complementary therapies are typically viewed as acceptable adjuncts to orthodox medical treatments. Conversely, alternative approaches are excluded for ideological, empirical or other reasons from the dominant contemporary paradigm that informs acceptable practices of medical diagnosis and treatment. An important distinction from the viewpoint of non-conventional medical practitioners is that alternative therapies are regarded as treatments that sufficiently address a symptom or illness, obviating orthodox medical interventions. In contrast, as the term implies, complementary therapies are intended as adjunctive treatments to conventional Western medical therapies, and are, therefore, not offered to patients as exclusive of such conventional therapies.

In the United States and much of the Western World, considerable debate is ongoing over the conceptual validity and value of most complementary or alternative treatments. The reasons for this are complex and include:

* Basic differences exist between paradigms (namely, between conventional medicine and non-allopathic healing approaches). These differences lead to apriori rejection of concepts outside the dominant scientific worldview as unverifiable by the sole accepted means of empirical validation.

* Conflicts have arisen because of perceived ideological or economic competition or "threats" by practitioners committed to different belief systems or paradigms. Both allopathic physicians and complementary/ alternative practitioners identify this problem.

* Objective difficulties exist in formulating testable hypotheses or designing methodologically rigorous experiments, which in turn constrain the quality of information that will potentially lead to confirmation or refutation of a complementary or alternative therapy. For example, creating a falsifiable hypothesis regarding the efficacy of "energy medicine," or reaching consensus regarding observable or measurable events that correspond to presumed healing effects of complementary or alternative therapies is often problematic or paradoxical within the dominant framework. This is especially germane to uses of complementary or alternative therapies in psychiatry because of fundamental differences between concepts or descriptions of mind-body and presumed "normal" or "abnormal" emotional or mental states.

In areas of medicine where there is a greater tradition of openness to the investigation of unconventional therapies because of more established multidisciplinary perspectives, e.g., cancer research, substantial research barriers continue. A recent article in the British Medical Journal (319: 11 Sept 1999, pp693-696) identified several important obstacles to research in complementary and alternative medicine in the United Kingdom and in Western developed countries in general. These reasons are complex, and include, among others:

* Lack of funding: Only a fraction of National Institutes of Health (NIH) funding goes toward research into complementary or alternative therapies, and most pharmaceutical companies have little interest in this area.

* Lack of research skills: Most complementary or alternative practitioners have limited or no training in clinical research

* Lack of academic infrastructure: Most researchers in complementary or alternative medicine have limited access to academic support, university, or institutional research grants, computer or library facilities that are necessary for performance of methodologically rigorous research.

* Insufficient patient numbers: Most practitioners have no disease "specialty," and typically see small numbers of patients with vague complaints and no clear primary diagnosis

* Difficulty undertaking and interpreting systematic reviews: The poor quality of many studies makes interpretation or generalization of results difficult. Many publications in complementary or alternative medicine are not indexed on standard databases such as Medline.

* Methodological issues: As assessed by standard empirical means, responses to complementary or alternative treatments are often unpredictable and individual, and treatments are usually not standardized. Designing appropriate controls and blinding protocol for some kinds of complementary or alternative treatments is difficult. Factoring in the role of the therapeutic relationship central to many "patient-centered" therapies also leads to ambiguity in the interpretation of outcomes measures.

Governmental (NIH/National Center for Complementary and Alternative Medicine), institutional, and private efforts are beginning to address these pressing issues. Over 20 federally funded centers for research in complementary and alternative medicine are exploring basic questions pertaining to mechanisms of disease and healing posed by non-orthodox medicine. Postgraduate programs in integrative medicine have been founded in affiliation with several prominent universities. To date, however, there is no center dedicated to exploration of emerging uses of complementary and alternative medicine in psychiatry. The absence of a NIH-sponsored center for research in complementary and alternative medicine in psychiatry is likely related to complex issues surrounding efforts to examine emerging complementary and alternative therapies targeting psychiatric symptoms. Unlike emerging complementary and alternative therapies directed at correcting dysfunction at a physiological level, emerging concepts and therapies that are being explored as potential treatments for psychiatric symptoms typically rest on assumptions about consciousness, and poorly understood relationships between physical existence, various forms of "energy," and space-time. Concepts that are being explored differ fundamentally from classical Newtonian assumptions about space-time and reality that are embedded in the dominant Western paradigm of allopathic medicine. Some assumptions that inform emerging complementary or alternative approaches in psychiatry have become tenants of what is now termed "energy medicine." These include the requirement of a non-local effect of consciousness in healing, and the posited central role of directed intentionality in healing.

Efforts to develop a truly integrative medicine addressing symptoms and disorders that fall in the broad domain of psychiatric illness will eventually combine the most effective, evidence-based approaches to diagnosis and treatment in conventional Western medicine, with the most effective complementary or alternative approaches.

Integration of allopathic, complementary, and alternative diagnostic approaches will prove useful in cases where diagnosis based on conventional medical-psychiatric approaches, including brain scans, serologic studies and neuropsychological inventories, remains unclear.

Integrative diagnostic planning in psychiatry will:

* be useful when the differential diagnosis is complicated or vague, requiring additional clarification;

* employ emerging approaches that are congruent with the orthodox paradigm, including neurobiofeedback or serologic studies of immunologic or endocrinologic factors that may correspond to certain kinds of psychiatric symptoms or be markers of predispositions to symptoms or disorders;

* use emerging diagnostic approaches that are currently outside the dominant paradigm, for example electro-acupuncture according to Voll (EAV) and numerous approaches to what is now termed "energy medicine;"

* employ rigorous efforts to identify evidence-based integrative diagnostic approaches and to develop systematic algorhithmic approaches to diagnosis. For example, the Integrative Medicine Data Collection Network (IMDCN) out of the Institute Of Integrative Medicine, Santa Fe, is working toward creating a standardized tool for determining safety and efficacy of integrative treatment approaches for the range of medical and psychiatric disorders based on rigorous statistical analysis of outcomes. The broad mission of the Institute of Integrative Medicine is "to conduct rigorous practice based outcomes research on effectiveness, safety, patient satisfaction, and costs when complementary and alternative therapies are integrated with conventional medicine." At this time, the institute is at the initial phase of collecting outcomes data from patients and health care providers on safety, efficacy, and cost of the range of complementary and alternative treatments. Such data will eventually be used to evaluate clinical outcomes following integrative treatments. Objective outcomes measures will include physiological and metabolic measurements, quality of life, mortality, and therapy-specific measurements. Patient outcomes measures will include symptoms, quality of life, functional status, and patient satisfaction. Economic outcomes measures will include direct and indirect measures of cost, cost-effectiveness, and burden-of-illness studies. An important long-range goal of the institute's work will be to develop evidence based treatment guidelines for the range of integrative treatment approaches in medicine and psychiatry. The reader can obtain additional information about the work and goals of the Integrative Medicine Institute at its website:; and

* clarify diagnoses in complex medical and psychiatric presentations presentations by combining diagnostic approaches from conventional medicine and complementary or alternative approaches to diminish diagnostic uncertainty.

Integrative diagnostic approaches in psychiatry will suggest the most productive and cost-effective approaches to integrative treatment planning combining the most efficacious allopathic, complementary, and alternative treatments targeting a specific psychiatric symptom or disorder.

Integrative treatment strategies in psychiatry:

* Will require an initial review of symptom history and treatment response history;

* Will incorporate on-going efforts (including IMDCN) to identify appropriate and safe complementary and alternative treatment options;

* Will require an evidence-based rationale for integrating specific conventional treatments with specific complementary or alternative treatments. The process of understanding how to construct algorithms for optimized integrative treatment planning is currently in a very early phase. At present, little unambiguous data exists in support of best-fit integrative treatment approaches for specific psychiatric symptoms or disorders;

* Will require a high level of cooperation and communication between practitioners of allopathic complementary and alternative medicine; and

* Will require frequent reviews of progress and appropriate, commensurate changes in integrative treatment approaches based on on-going analysis of results from outcomes studies.

Within the first decades of the new millennium, physicians will increasingly embrace diagnostic approaches and therapies that are now outside the domain of orthodox medicine. Based on evidence from traditional scientific inquiry and critical examination of emerging concepts or paradigms in medicine, including the role of "energy" and intentionality in healing, optimized approaches to integrative diagnosis and treatment will gradually emerge. The eventual result of this evolutionary process will be the establishment of truly integrative conceptual models of disease and healing and corresponding integrative approaches for diagnosis and treatment of the range of medical and psychiatric disorders. In this way, the continuing evolution of medicine toward a truly integrative paradigm will result in deeper, more accurate understandings of fundamental biological and "energetic" processes underlying disease and healing. The emergence of effective, integrative approaches for treatment of the range of psychiatric symptoms will prove to be an important benefit of on-going conceptual evolution in Western medicine.

James Lake MD

Complementary Medicine Clinic, Stanford University Hospital
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Title Annotation:News & Views
Author:Lake, James
Publication:Frontier Perspectives
Date:Mar 22, 2000
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