Essentials of Complementary and Alternative Medicine (June 1999)

I
NTRODUCTION:
 C
OMMON
 A
SPECTS OF
 T
RADITIONAL
 H
EALING
 S
YSTEMS
 A
CROSS
 C
ULTURES
 
Stanley Krippner
Introduction
 
A Shared World View
 
The Practitioner's Personal Qualities
 
Positive Client Expectation
 
A Sense of Mastery
The Cultural Context of Healing Systems
Models of Treatment
 
Example 1: The Pima Indian Healing Model
 
Example 2: The Curanderismo Healing Model
 
Example 3: The Kallawaya Healing Model
 
Example 4: The Chinese Healing Model
 
Example 5: The Allopathic Biomedical Model
Treatment Models in Cross-Cultural Perspective
Postmodern Perspectives
Chapter References
INTRODUCTION
Second only to the diversity of approaches to health, healing, and sickness around the world are their resemblances. Despite diverse languages, cultures, and 
concepts about the nature of reality, spirituality, humanity, and the human body, there are some remarkable similarities in how both traditional ethnomedical practices 
and allopathic biomedical practices approach wellness and illness. Attempts to relieve suffering and distress can be labeled  treatments; they typically involve a 
relationship between a practitioner and a client. Frank and Frank (
1
) have identified three historical traditions of these treatments: the religio-magical (e.g., 
shamanism, faith healing); the rhetorical (e.g., affirmations, psychodrama); and the empirical (e.g., allopathic biomedicine, behavior therapy).
According to the United Nations' World Health Organization (WHO), more than 70% of the world's population relies on non-allopathic systems of healing. Determined 
to ensure that medical care would be available to all the people of the earth by the end of the twentieth century, WHO staff members realized that this goal was 
beyond the scope of personnel trained in Western biomedicine. As a result, WHO initiated a program to prepare native practitioners to serve as health care 
auxiliaries. A former director-general of WHO pointed out that the great number of traditional (i.e., indigenous to a particular region or environment) practitioners 
should not be overlooked. He noted that traditional healers and local midwives could, at a very moderate expense, be trained to the level at which they could provide 
adequate and acceptable health care and treatment under suitable supervision (
2
).
At the same time, physicians in the industrialized countries are encountering clients whose ethnic backgrounds and/or belief systems challenge the physicians' limited 
contact with other world views and categories of illness as well as presumed causal agents thereof. At the same time, biomedicine has attained such a degree of 
primacy throughout the world that the adjective Western is superfluous. As a result, biomedicine is often poorly prepared to meet the challenge posed by its encounter 
with different cultures and their systems of health and healing.
The term ethnomedicine refers to the comparative study of indigenous (or native) medical systems. Typical ethnomedical topics include causes of sickness, medical 
practitioners and their roles, and specific treatments used. The abundance of ethnomedical literature has been stimulated by an increased awareness of the 
consequences of the forced displacement and/or acculturation of indigenous peoples, the recognition of indigenous health concepts as means of maintaining ethnic 
identities, and the search for new medical treatments and technologies. In addition, Kleinman (
3
) finds ethnographic studies an “appropriate means of representing 
pluralism ... and of drawing upon those aspects of health and suffering to resist the positivism, the reductionism, and the naturalism that biomedicine and, regrettably, 
the wider society privilege.” In other words, biomedicine gives priority to a world view that extols rationality to the near-exclusion of intuition, that focuses on “parts” 
rather than “wholes,” and that constructs a mechanistic model of humanity that frequently ignores potential spiritual and metaphysical components.
In his exhaustive study of cross-cultural practices, Torrey (
4
) concluded that effective treatment inevitably contains one or more of four fundamental principles:
1. A shared world view that makes the diagnosis or naming process possible.
2. Certain personal qualities of the practitioner that appear to facilitate the client's recovery.
3. Positive client expectations that assist recovery.
4. A sense of mastery that empowers the client.
Because Kleinman (
5
) has referred to Torrey's comparisons as  superficial, this list will be used as a structure to provide examples rather than an attempt to distill 
universal essences of cross-cultural healing.
The necessity to individualize treatment can be seen cross-culturally. The nature of the ailment determines what treatment options are available. The nature of the 
client's condition determines whether the ailment should be cured or healed. The nature of the environment establishes how much of a cultural and familial support 
system is available to assist the client's recovery, growth, or integration. These factors, singly or in combination, will ascertain how many of the four fundamental 
healing principles described by Torrey can be brought to bear.
A Shared World View
Reaching an agreement on the name of a client's condition demonstrates that someone understands, that the client is not the only person who has ever had the 
condition, and that there is a way to get well. Identifying the offending factor may activate a series of associated ideas in the client's belief system that produce 
contemplation, relief, and general catharsis. A physician can prescribe an antibiotic for a client who has a certain kind of infection, and that client will probably 
recover. The use of antibiotics does not depend upon a common language or shared world view for its effectiveness. However, the world views of some cultural 
groups posit etiological factors that biomedicine and psychotherapy, with their reliance on biological explanations of sickness, do not accept. For example, various 
cultures postulate an imbalance between  dark and light forces of energy, a punishment for the violation of taboos, or various types of  soul loss and spirit possession 
as the underlying causes of illness. Levi-Strauss (
6
) has observed that many shamans, physicians, and therapists attempt to bring to a conscious level the conflicts 
and resistances that have remained in the client's unconscious. The naming process involves the use of words as symbols for what is wrong; the process is effective 
not only because of the knowledge that the words convey, but also because this knowledge permits a specific experience to take place, in the course of which the 
client may begin to recover.
Depending on the culture, illness is thought to be caused by one or more of three factors: biological events, experiential events, and metaphysical events. The third 
factor, which is ridiculed by biomedicine, is the  very foundation of many other traditions. Thus, not only must the ailment be named, but the diagnosis must reflect the 
shared world view of the practitioner and client to be maximally effective. For example, there is no North American equivalent for  wagamama, which is an emotional 
disorder reported in some parts of Japan that is characterized by childish behavior, emotional outbursts, apathy, and negativity. Nor is there a counterpart to  susto, 
which is a loss of soul in certain parts of Latin America thought to be caused by a shock or fright, often connected with breaking a spiritual rule, sorcery, or a physical 
accident. Even within a specific culture, there can be different world views that interfere with treatment: for example, differences between upper-class practitioners and 
lower-class clients, or between practitioners whose gender or ethnic backgrounds differ from their clients.
Frank and Frank (
1
) explain how shamans supply their clients with a conceptual framework for making sense out of feelings and experiences that are often chaotic 
and mysterious, suggesting a plan of action that helps the clients gain a sense of direction and competence. Shamans have represented and transmitted their 
community's unified, all-encompassing world view—a role not possible in today's pluralistic societies. Nevertheless, health care practitioners still collaborate with the 
client to construct a treatment program, and this construct involves a  hermeneutic circle (i.e., the interpretation of the latent meanings and understandings embodied in 
treatment). This circle involves both practitioner and client as they attempt to understand why the client's health status is unsatisfactory, and endeavor to construct a 

new direction.
The Practitioner's Personal Qualities
There is a consensus among healers, psychotherapists, and medical doctors that some practitioners have personality characteristics that are therapeutic, whereas 
others do not. Not only are the actual personal qualities of the practitioners important, but those projected onto them by the client are crucial. This process of 
projection often is termed transference by psychotherapists and can be a salient factor in a treatment's success.
Carl Rogers observed that, although a practitioner's intellectual training and acquiring of information have many valuable effects, it is not necessarily associated with 
the practitioner's success in producing positive outcomes. In his studies of psychotherapy, Rogers (
7
) found that a therapist's accurate empathy, nonpossessive 
warmth, and personal genuineness were the factors that most closely related to a client's behavior change. Personal qualities that foster recovery from sickness may 
differ from culture to culture. Levy (
8
), after observing the Yakut healers of Tahiti at work, reported that these healers feel an  inner force that does not offend clients 
yet is conscious of its power. The shamanic claim to communicate with spirits, which is valued in the individual tribes, would be considered deviant in most Western 
cultures. However, Boyer, Klopfer, Brawer, and Kawai (
9
) observed that Apache shamans received higher scores on tests of mental health than did the average 
members of their society who, in turn, scored more favorably than the individuals who claimed to be shamans but were not recognized as such by their community.
Positive Client Expectation
There is abundant evidence that demonstrates the importance of client expectation. What a person  expects to happen during treatment often  will occur if the 
anticipation is strong enough. Frank and Frank (
1
) describe the symbolic message of the placebo and its ability to evoke hope. At least 50% of people who receive a 
placebo will report significant relief (
1
). Such remedies as lizard blood and swine teeth have no known medicinal property, but they seem to have worked well for 
centuries, apparently because clients and their healers have expected them to work.
Torrey (
4
) has identified several factors that produce client expectations—hope, faith, trust, and emotional arousal. Frank and Frank (
1
) have noted that most 
psychotherapies use emotional arousal as part of the treatment, either at the beginning of therapy, followed by systematic reinforcement of newly developed skills and 
attitudes, or in the latter parts of therapy, when gains of the preceding therapeutic sessions can be crystallized.
A Sense of Mastery
A client's emerging sense of mastery equips him or her with knowledge about what to do in the future to cope with life's adversities. After recovery from a physical 
illness, a client may feel better and return to work. In addition, the client may have learned self-regulation procedures, dietary and exercise regimens, and other 
preventive techniques to forestall a recurrence of the ailment. If there are psychological problems, the client may have learned the proper prayers that counteract 
malevolent spirits, the healthy attitudes that counteract depression and anxiety, or the dream interpretation procedures that provide for personal empowerment. Each 
of these practices has the potential to bolster the client's sense of mastery and self-efficacy by providing a  myth or conceptual scheme that explains deleterious 
symptoms and supplies a ritual or procedure for overcoming them (
1
). These myths and rituals combat demoralization by strengthening the therapeutic relationship, 
arousing hope, inspiring expectations of assistance, and affording opportunities for rehearsal and practice in facing life's difficulties.
Learning and mastery are important components of treatment. In addition, they are important factors in both  curing (removing the symptoms of an ailment and 
restoring a client to health) and  healing (attaining wholeness of body, mind, emotions, and/or spirit). Some clients might be incapable of being  cured because their 
illness is terminal. Yet those same clients could be  healed mentally, emotionally, and/or spiritually as a result of being taught by the practitioner to review their lives in 
search of meaning, and thus become reconciled to death. Clients who have been  physically cured, however, may learn healing procedures that will prevent a relapse 
or recurrence of their symptoms.
Proper medicinal remedies can also empower a client, even one who distrusts the practitioner. For example, a patient may not trust the nurse or physician 
administering an antibiotic but will probably recover from the illness nevertheless.
THE CULTURAL CONTEXT OF HEALING SYSTEMS
Western perspectives of health emanated principally from the age of enlightenment and the philosophy of elementalism that divided the human being into body 
(soma), mind (psyche), and spirit (pneuma). Elementalism's assumption that sickness within one component could be treated without regard to the other component 
laid the groundwork for allopathic biomedicine, and the elevation of rationality in eighteenth century Western Europe made  spiritual concerns irrational and irrelevant. 
Allopathic biomedicine adheres both to this rational approach and to empirical methodology, whereas many alternative medical systems are empirical without being 
rational in the Western sense, even though they work with world views that are internally consistent.
In 1925, a Nigerian  babalawo, or father of mysteries, was summoned to England to treat an eminent Nigerian who had experienced a psychotic breakdown. The 
babalawo successfully treated his client with rauwolfia root, which was better medicine than any English psychiatrist had available; it was not until 1950 that this herb 
was introduced into biomedicine as the tranquilizer reserpine. Further, many Native American treatment procedures have been remarkably effective, even when 
judged by current standards. Native American practitioners lanced boils, removed tumors, treated fractures and dislocations, and cleaned wounds in ways that were 
more hygienic that those of the European invaders. The Hurons used evergreen needles, which are rich in vitamin C, to treat scurvy; the Shoshone used stoneseed to 
produce spontaneous abortions; several tribes used the bark of willow or poplar trees, whose active ingredient, salicin, resembles today's aspirin for musculoskeletal 
aches. Of the herbs used by the Rappahannock tribe, 60% were later found to have had unquestioned medicinal value—a record somewhat higher than that for the 
medicines brought by the Europeans to America. The first United States pharmacopoeia, which was published in 1820, listed 296 substances, 130 of which were 
originally used by Native Americans. Pharmacological analyses of the herbs used in Chinese, Tibetan, and Ayurvedic medicine, and that of other traditions, reveal 
that a significant number have active medical properties (
10
).
MODELS OF TREATMENT
For several decades, social and behavioral scientists have been collecting data that reflect the wide variety of humankind's healing systems. Sicknesses and injuries 
are universal experiences, but each social group implicitly or explicitly classifies them as to cause and cure in its own way. Furthermore, each person has a belief 
system that provides an explanation of how he or she can maintain health and overcome sickness. For example, Chicano (Mexican-American)  curanderos (i.e., 
healers) often attribute a sickness to an  agent whose existence must be taken on faith because it cannot be detected with medical instruments. For example, the  mal 
ojo, or evil eye, has no status in allopathic biomedicine, but the  curanderos claim it is caused by a person staring intently at someone else, usually with envy or desire 
and can bring on various disorders. This condition is often treated by forming three crosses on the victim's body with an egg while the practitioner recites the Apostle's 
Creed. An Apache ailment, nitsch, is said to result from the neglect of natural entities. If an Apache does not properly salute an owl, he or she may suffer from heart 
palpitations, anxiety, sweating, and shaking. Shamanic prayers and songs are needed to treat this condition, which, it is believed, can lead to suicide.
Frank and Frank (
1
) have conjectured that the first healing model was built around the prehistoric belief that the etiology of sickness was either metaphysical (e.g., 
possession by a malevolent spirit) or magical (e.g., the result of a sorcerer's curse). Treatment consisted of appropriate rituals that supposedly undid or neutralized 
the cause. These rituals typically required the active participation not only of the sufferer but also family and community members. Spirits were believed to facilitate 
the healing process (
9
). Some perceived causes and cures were seen to operate from the world of nature through the use of herbs, exercises, and fasts.
There are both similarities and differences between allopathic biomedical medicine models and traditional medical models that have originated and developed in a 
specific place among members of a particular ethnic group (i.e., ethnomedicine). However, many anthropologists have proposed that the kind of logic developed by 
tribal people is as rigorous and complete as that of Western medicine; it is not the quality of the intellectual process that differs but the mode of its expression and 
application. For example, the cultural myths of pre–Columbian Mexican and Central American societies not only provided comprehensive guides to daily conduct but 
also explained the mysteries of the universe. Each mythic episode can be interpreted in several ways according to the context and the listener's understanding. The 
symbols used are manipulated with such economy that each serves a wide range of philosophical and religious ideas. For many Meso-Americans, Quetzalcoatl was 
the feathered serpent  (who symbolized the transformation of matter into spirit), as well as the god of the winds, the Lord of Dawn, the spirit of the sacred ocelot (a 
fierce jungle cat), the last king of the Toltecs, and (following the Spanish conquest) Jesus Christ.
The complexity of many traditional treatment systems can be demonstrated by evaluating them on the basis of a 12-faceted healing model proposed by Siegler and 

Osmond (
11
) (
Table 1
). In the social and behavioral sciences,  models are explicit or implicit explanatory structures that underlie a set of organized group behaviors. 
The use of models in science attempts to improve understanding of the processes they represent. Certain models have been constructed to describe human conflict, 
competition, and cooperation, whereas other models have been proposed to explain communicable diseases, mental illnesses, personality dynamics, and family 
interactions. Greenfield (
12
) has proposed an information flow-based model to explain Brazilian spiritistic surgeries, whereas Russek and Schwartz (
13
) have 
propounded a systems model to examine interpersonal relationships across the domains of cardiology, heart-brain physiology, and social psychology. The Siegler 
and Osmond model is applicable to both  physical and mental disorders, although non-Western traditions usually do not differentiate between the two. Krippner (
14
) 
has modified this model, attempting to eliminate some terms that suggest a Western bias, and substituting terms that lend themselves to a more useful cross-cultural 
comparison (see 
Table 1
).
Table 1. Comparison of 12 Facets of Healing Models
It is beyond the scope of this introduction to describe how each system described in this book uses these fundamental aspects of healing. What follows is a 
description of how five different healing systems (including biomedicine) approach these aspects.
Example 1: The Pima Indian Healing Model
Pima Indian shamanism, still active in the Southwest United States, is often regarded as subtle and sophisticated as any Western medical theory and practice. The 
principles of Piman shamanism have been recorded in some detail as a result of a study in which an anthropologist, Donald Bahr, collaborated with a shaman, a Pima 
Indian translator, and a linguist (
15
). Some previous anthropological studies have been flawed because tribal respondents lied to the investigators, played jokes on 
them, or told them what they wanted to hear. Apparently, the anthropologists did not think that the natives they were studying had the intelligence to give information 
that was incorrect! In this case, the involvement of the shaman and translator provided for greater accuracy.
P
RACTITIONERS
It is the task of the shaman to make an accurate diagnosis and then to turn the client over to other practitioners for treatment. In doing this, shamans purportedly are 
assisted by benevolent spirits; it is believed that shamans are recruited, trained, and ordered into action by these spirits.
D
IAGNOSIS
Because of its elegance, the Piman theory of health and sickness lends itself to analysis in terms of the Siegler-Osmond model. Among the Pimas,  diagnosis is as 
crucial as treatment and is carried out by the shaman. A client's body is seen as the stratified repository of a lifetime's acquisitions of strengths and weaknesses.
C
AUSE
Etiology, or cause of the sickness, depends on the type of problem that is being treated. Some types of indispositions are untreatable because the body's self-healing 
capacities will deal with them (e.g., constipation, indigestion, venomous bites), or because treatment is futile (e.g., mental retardation, infant deformities). Other types 
of ailments are amenable to treatment: wandering sickness (problems caused by impurities that wander through the body) or staying sickness (problems caused by 
improper behavior toward such power objects as buzzard feathers, jimson weed, or roadrunners). For the Pimans, there was no separation between  physical and 
mental; therefore, problems could be mental/behavioral and/or physical in nature. When the Europeans arrived, the Pimas noted that their visitors did not fall victim to 
staying sicknesses. However, the Pimas did not lose faith in their model, merely concluding that the objects in question were not sacred to the Europeans; hence the 
newcomers could not be punished for treating these objects with disrespect.