takeaway: Many controversies among integrative health professions are outdated and a result of poor communication and negative habits. Examining evidence through interprofessional collaboration will benefit practitioners and patients alike.

In the March/April 2022 issue of Massage & Bodywork (“What Exactly Is Evidence?,” page 72), I explored the ongoing debate over evidence-based versus evidence-informed practice, questioning how far these definitions are correctly understood and applied in conversations surrounding bodywork practices, and looking at the implications of their misuse in practice.
One striking example of how terminology becomes misunderstood and misused in these fields, leading to complex problems, is the question of the body-mind connection in relation to healing and wellness. Nowadays, the establishment of the biopsychosocial model of health care leaves little doubt as to the significance or validity of that connection. So why is it that in discussions of bodywork and other integrative therapies, mentioning the “body-mind connection” all too often leads to accusations of pseudoscience and “peddling woo,” usually resulting in shutting down conversations or firing off one-liners rather than reasoned arguments?

The Backstory

The body-mind connection has often been seen as the defining perspective at the heart of holistic health care, representing the idea that “all the properties of a given system cannot be determined nor explained by the sum of its component parts alone. Instead, the system as a whole determines how the parts behave.”1 While “holistic health care” became a popular descriptor of what we now call integrative health care in the mid-1980s, it was applied to biology as early as the 19th century as a way to move away from the “fuzzy nonsense” of vitalism as it was understood in scientific debates of the time.2
Back in the 19th century, powerful debates raged between mechanists, who focused solely on the analysis of the components of a given system and saw all natural functions as equivalent to machines, and vitalists, who insisted that physical and chemical analysis were not sufficient to understand how organisms function as a whole and that certain unmeasurable forces were also at play. To resolve this, a school of thought known as holistic materialism emerged: an acknowledgment that living organisms, unlike machines, could reproduce, produce organized and intentional responses to stimuli, self-regulate in complex ways, and demonstrate efficient energy transduction. Over the next few decades, researchers developed various methods to investigate organisms as whole systems, rather than as a sum of mechanical parts, though their focus remained rooted in material (physical) elements alone.
The tensions remained between mechanistic and holistic thinkers, but by the mid-20th century, in biology and physics at least, the old mechanistic perspectives were seen as unsophisticated and reductionist, while holism had evolved away from the problematic “mystical” ideas that originally attracted accusations of pseudoscience. The need for a strong philosophical understanding of complexity and holistic thinking are now openly advocated in fields from genomics to physiology and developmental biology.3
Over the 20th century, these perspectives developed, and so did the supporting research. By the 1970s, research and training in what was then called psychosomatic medicine was just developing, but direct discussion of the impact of emotions and mental health on physical health was still met with skepticism and suspicion.4 Yet, throughout the 1980s and 1990s, research continued, and findings ranging from the impact of group therapy on the symptom control and overall prognosis of breast cancer patients to cognitive behavioral therapy on viral load in HIV-positive men emerged,5 alongside extensive research on the prevention and even improvement of heart disease progression and prostate cancer through lifestyle changes and stress management.6
Research institutes at Harvard, Stanford, Columbia, and UCLA, among many other major universities, have all contributed to the growth of robust literature to the degree that there is no longer any question as to whether there is a clear connection between physical health and mental well-being. Though many questions remain open regarding mechanisms of action and other factors (such as outcome predictors or the relative effectiveness of these therapies), there is now a strong evidence base for the efficacy of combined multimodal body-mind therapies for multiple conditions ranging from cancer to chronic pain. And of course, rich research into pain science and the potential of pain education is an additional significant area demonstrating these connections.

So Where’s the Problem?

In a major critical review from 2003, the author highlighted the positive progress made in this field of research, while quoting the (then) director of the Osher Institute at Harvard Medical School, explaining that “medicine has not moved much beyond the biomedical model” because “practitioners are not exposed to the evidence supporting the biopsychosocial model.”7 This has certainly changed in the 20 years that have elapsed, since person-centered and the biopsychosocial model are prioritized in both the British and American primary-care settings, the same is true in many other European countries as well as Australia, and efforts to integrate social prescribing and behavioral modifications into geriatric care are also under way.8 It is worth highlighting that these practices have been central to naturopathic and osteopathic practice since their early beginnings, when lifestyle changes were at the very heart of natural health applications.
The same review noted that the growth of the evidence base might help body-mind medicine to “escape its negative association with alternative medicine.” Yet, although biomedical clinical practice has actively begun to adopt elements of holistic practice with solid evidence underpinning it, biomedical communities show little, if any, awareness of its long-standing use in the context of “alternative” disciplines. Similarly, in mainstream medical education the integration of holistic approaches into the curriculum is being presented as a new addition, without consideration of the principles, for example, of osteopathic education for which the holistic approach to health care is foundational. On the flip side, the (old) news of the integration of holistic thinking within biomedical practice does not seem to have reached many allied and integrative health practitioners or schools. As a result, holism and “alternative” practices are either defined in terms of their “negative associations” or upheld as a proud countercultural current holding out against the forces of allopathic approaches.
In both cases, the language and concepts are divisive. Since their inception, “nature cure,” “natural medicine,” osteopathy, chiropractic, and other holistic approaches to health care defined themselves in contrast to mainstream “allopathic” medicine. Historically, there were good reasons for this, not least because, particularly in the US, funding, political support, and public opinion played a strong part in the shaping of these approaches. It is worth noting that from the earliest days, holistic health care incorporated a strong emphasis on self-care and grassroots campaigning closely connected with political and social views; these contrasted strongly with the more top-down hierarchical power structures in the biomedical fields as they were developing at the time, so the countercultural dynamic is well-earned.9
Yet, in this age of taking such care over the connotations of language, this contrary negative definition (defining these therapies as not mainstream) has well and truly stuck. From outright accusations of quackery, to being considered “fringe” (1960s), “alternative” (1970s), “complementary” (1980s), then alternative again, then integrative, now, sometimes, “functional,” in all cases, these therapeutic approaches are “other,” a state often emphasized more by their practitioners than their historical “opponents” (who might well think of them as little more than part of the broad field of “allied” health professions, at least in some locales).
Thus, despite decades of work to professionalize and validate numerous aspects of integrative (complementary, alternative) therapies, the negative association remains; the mud has stuck. Even after accounting for the many very real flaws in research,10 it is now easy to point to good evidence for therapies that have become incorporated into interdisciplinary health-care programs at the highest levels of health care.
Even so, among many clinicians, and especially in the massage therapy community, debates about the relative validity, or indeed respectability, of many modalities continue, and perhaps most surprisingly, even when the weighty evidence base is pointed out, a certain denial seems to set in. For some, the acknowledgment of the body-mind connection often seems to extend only as far as the apparently “comforting” nature of massage, while denying outright the potential mechanisms of mechanotransduction—for others, the power of the connection is overstated and results overpromised. Acupuncture is frequently waved away as pseudoscience even though it is recommended as an effective method for many conditions—particularly chronic pain—by major health care centers and systems on the basis of the evidence.11 Laboratory and clinical findings on the role of therapeutic loading of fascia and the subsequent behavior of fibroblasts should leave no doubt as to the beneficial effects of skilled manual therapy on several levels,12 yet some insist that massage can only ever be skin deep and that to claim otherwise is pseudoscience. All these examples (and there are many more) illustrate a big gap between the actual evidence and the cherry-picking that seems to be the norm in current debates.

Bad Company or Bad Language?

There are many reasons why so-called “alternative therapies” continue to provoke debate, and, in some cases, (that I have written about previously)13 it is unfortunately because of own-goals. “Keeping bad company” is often touted as a key reason why the word “holistic” still meets with raised eyebrows; yet, these reasons are buried so deep in history that it is difficult to accept this is really the case—at least among trained professionals. However, the way we learn, think, teach, and speak about these ideas is in fact the root of the problem.
In the numerous cases in which evidence does demonstrate the safety, effectiveness, and measurable beneficial effects (with or without a full understanding of mechanisms of action) of certain modalities, it seems difficult to grasp why controversies persist. One key reason is down to what is called “discursive dissonance”—a fancy term for when an idea means different things to different people and results in them talking past each other. Sometimes this can be resolved with friendly dialogue, but all too often, and especially on social media, we don’t understand each other because we’re primed not to want to. The reason for this is that discursive dissonance can often result in cognitive dissonance—another fancy term that describes the mental stress we feel when confronted with two conflicting beliefs or attitudes and the emotional response that results from having a deeply held belief challenged. We are wired to see ourselves as rational and to justify our behaviors, so while scientific and professional matters are best handled without an emotional response, it is a very human reaction that can stem from four key sources:

1. Forced compliance: Acting against one’s beliefs.
2. Loss of choice: Feeling upset at the loss of option B once we choose option A.
3. Contradicting beliefs: Being exposed to new information that forces us to reevaluate what we believed.
4. Effort: Making a great effort to achieve something (e.g., learn a technique), only to find that it was not as valuable as we thought, or coming to see it negatively.

In all four cases, there are two possible reactions: a change in behavior or seeking new information to either strengthen or weaken the concept that has challenged our original position.14 In the context of professional practice and the kinds of debates outlined above, if we have been taught throughout our professional lives to think a certain way, sometimes the mental challenge is such that it forces us to rethink our professional identity and public image. If the internal contradiction produces a sense of shame or exposure, it can provoke confusion at best, and possibly stronger emotions and conflicts with the ideas—or people—we see as being responsible for challenging us.
Yet, if we are supposed to manage patients’ expectations and practice ethically, then it is also critical that we are able to manage these responses in ourselves.15 Anthropological research suggests that because this kind of contradiction is social, we are likely to try to avoid it through some kind of shared communication strategy, rather than actually changing our beliefs. Though this strategy is best developed either through civilized dialogue or working groups and formal exchanges in scientific journals, all too often it descends into rude exchanges on social media that do nothing other than highlight the problem (while damaging the profile of one’s profession a whole lot more).

Toward Solutions

One powerful answer to these issues currently taking shape is the International Consortium on Manual Therapies (ICMT) and its conference that took place in May 2022. For the past two years, the ICMT has formed interprofessional working groups representing the main manual therapy professions, looking to establish a common vocabulary and frame of communication and to collect the theories and evidence that will allow the diverse manual therapy professions to understand and enrich each other while maintaining their unique features, while also raising their scientific and professional profiles. With open discussion sessions in the form of roundtables and an upcoming virtual conference, this is a highly significant step toward breaking down some of the critical problems between the manual therapy professions, paving the way for real dialogue.
This is a major achievement on the part of the organizers, but beyond the big events, this sort of dialogue needs to continue, both behind the scenes and on public fora, if the “bad company”—and worse behaviors—of the past are truly to be shaken off and fresh progress made.

Notes

1. Leon Chaitow, “Evolution from Quackery to Integration to Functional,” Chaitow’s Chat (January 26, 2008), www.leonchaitow.com/2008/01/26/evolution-from-quackery-to-integration-to-functional.
2. Garland E. Allen, “Mechanism, Vitalism, and Organicism in Late Nineteenth- and Twentieth-Century Biology: The Importance of Historical Context,” Studies in History and Biology and Biomedical Sciences 36, no. 2 (June 2005): 261–83, https://doi.org/10.1016/j.shpsc.2005.03.003.
3. S. F. Gilbert and S. Sarkar, “Embracing Complexity: Organicism for the 21st Century,” Developmental  Dynamics, 219, no. 1 (September 2000): 1–9, https://doi.org/ 10.1002/1097-0177(2000)9999:9999<::AID-DVDY1036>3.0.CO;2-A; Barry Commoner, “Unraveling the DNA myth,” Harper’s Magazine (February 2002): 39–47.
4. Vicki Brower, “Mind-Body Research Moves Towards the Mainstream,” EMBO Reports 7, no. 4 (March 2006): 358–61, https://doi.org/10.1038/sj.embor.7400671.
5. P. J. Goodwin et al., “The Effect of Group Psychosocial Support on Survival in Metastatic Breast Cancer,” New England Journal of Medicine 345, no. 24 (December 2001): 1719–26, https://doi.org/10.1056/nejmoa011871; David W. Kissane et al., “Effect of Cognitive-Existential Group Therapy on Survival in Early-Stage Breast Cancer,” Journal of Clinical Oncology 22, no. 21 (December 2004): 4255–60, https://doi.org/10.1200/JCO.2004.12.129; Michael H. Antoni et al., “Randomized Clinical Trial of Cognitive Behavioral Stress Management on Human Immunodeficiency Virus Viral Load in Gay Men Treated with Highly Active Antiretroviral Therapy,” Psychosomatic Medicine 68, no. 1 (January–February 2006): 143–51, https://doi.org/10.1097/01.psy.0000195749.60049.63; Sarah-Jeanne Salvy, “Psychological Interventions in Prostate Cancer: A Farewell to Mind–Body Dualism,” Prostate Cancer and Prostatic Diseases, 24, no. 3 (April 2021), 587–88, https://doi.org/10.1038/s41391-021-00350-3.
6. Dean Ornish et al., “Intensive Lifestyle Changes May Affect the Progression of Prostate Cancer,” Journal of Urology 174, no. 3 (September 2005): 1065–70, https://doi.org/10.1097/01.ju.0000169487.49018.73; Dean Ornish, “Avoiding Revascularization with Lifestyle Changes: The Multicenter Lifestyle Demonstration Project,” The American Journal of Cardiology 82, no. 10, suppl. 2 (November 1998): 72–76, https://doi.org/10.1016/S0002-9149(98)00744-9; Dean Ornish et al., “Effects of Stress Management Training and Dietary Changes in Treating Ischemic Heart Disease,” JAMA 249, no. 1 (January 1983): 54–59; C. B. Nemeroff, D. L. Musselman, and D. L., “Depression and Cardiac Disease,” Depression and Anxiety 8, suppl. 1 (1998): 71–79.
7. Vicki Brower, “Mind-Body Research Moves Towards the Mainstream.”
8. “Social Prescribing,” Journal of Holistic Healthcare 15, no. 3 (Autumn 2018); College of Medicine and Integrated Health, “Social Prescribing Network: Putting People at the Centre of Health Care,” https://collegeofmedicine.org.uk/social-prescribing; Therese Feiler, Kezia Gaitskell, Tim Maughan, and Joshua Hordern, “Personalised Medicine: The Promise, the Hype and the Pitfalls,” The New Bioethics 23, no. 1 (May 2017): 1–12, https://doi.org/10.1080/20502877.2017.1314895.
9. Susan E. Cayleff, Nature’s Path: A History of Naturopathic Healing in America (Baltimore, MD: Johns Hopkins University Press, 2016); Holly Folk, The Religion of Chiropractic: Populist Healing from the American Heartland (Chapel Hill: The University of North Carolina Press, 2017).
10. Cal Cates, “Flawed Research: Four Reasons Why it’s Difficult to Conduct a Proper Study,” Massage & Bodywork (March/April 2022); Sasha Chaitow, “What Exactly is Evidence and What Do We Do With It?” Massage & Bodywork (March/April 2022).
11. Johns Hopkins Medicine, “Types of Complementary and Alternative Medicine,” www.hopkinsmedicine.org/health/wellness-and-prevention/types-of-complementary-and-alternative-medicine; National Institute for Health and Care Excellence, Chronic Pain: Assessment and Management: Evidence Review for Acupuncture (August 2020), 209, www.nice.org.uk/guidance/ng193/documents/evidence-review-7.
12. Catherine Ryan, “Scar Tissue: Not Breakable, But Changeable,” Massage & Bodywork (July/August 2020).
13. Sasha Chaitow, “Science, Pseudoscience, and Communication Battles,” Massage & Bodywork (July/August 2020).
14. David G. Casagrande, “Power and the Rhetorical Manipulation of Cognitive Dissonance” (Presidential Session of the Annual Meeting of the American Anthropological Association, Atlanta, GA, December 15–19 2004), www.lehigh.edu/~dac511/pdfs/Casagrande_power&cogdiss_AAA2004.pdf.
15. Caroline J. Barron, Jennifer A. Klaber Moffett, and Margaret Potter, “Patient Expectations of Physiotherapy: Definitions, Concepts, and Theories, Physiotherapy Theory and Practice 23, no.1 (July 2009): 37–46, https://doi.org/10.1080/09593980601147843.