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research-article2015

QHRXXX10.1177/1049732315582009Qualitative Health ResearchRamadurai et al.

Article

Roads Less Traveled: Finding a Path to Using Complementary and Alternative Medicine

Qualitative Health Research 1­–13 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315582009 qhr.sagepub.com

Vandhana Ramadurai1, Barbara F. Sharf1, and Srividya Ramasubramanian1

Abstract An increasing number of health seekers in the United States are looking outside conventional medicine to address their health needs. It is estimated that in the United States, 38% of adults use complementary and alternative medicine (CAM). Extant research characterizes CAM users as a unified homogeneous group, with little understanding of the differences among them in terms of attitudes toward body, wellness, disease, and pivotal aspects of their personal histories. In this article, we seek to better understand the nuances of who uses CAM and why, using the following questions: How do people communicate their life stories that explain their decision to use CAM? How do the life stories enable us to understand the similarities and differences among CAM users? Based on analysis of the narratives of 18 individuals, three clusters or types of CAM users emerged: natives, immigrants, and tourists. In an effort to push our analysis further, we theorized three dimensions that help to explain CAM users’ objectives, motives, and resultant sense of empowerment. Together, these dimensions comprise The Pathfinder Model of CAM Usage. The Pathfinder Model can be useful to clarify self-understanding among CAM users themselves, as well as for conventional and alternative practitioners, as they establish a working relationship and communicate with their patients during medical encounters. Understanding the path of the health seeker can help influence the quality of the relationship and the communicative strategies providers use to educate and influence. Keywords complementary and alternative medicine; health seeking; decision making; qualitative; interviews; narrative analysis; Southwestern United States Two roads diverged in a wood, and I— I took the one less traveled by And that has made all the difference. —Robert Frost, The Road Not Taken (1920)

An increasing number of health seekers in the United States are looking outside conventional medicine1 to address their health needs. It is estimated that in the United States, 38% of adults and 12% of children (0−17 years) use complementary and alternative medicine (CAM; National Center for Complementary and Alternative Medicine [NCCAM], 2012). This trend has led health services researchers to seek understanding of the profile of typical CAM users and their motivations for choosing such therapies. Through several national surveys, investigators have documented the trends in CAM use, reasons for using CAM, and demographic characteristics of CAM users. However, this body of literature characterizes CAM users as a unified homogeneous group, with little understanding of the differences among

them in terms of attitudes toward body, wellness, disease, and pivotal aspects of their personal histories. In this article, we seek to better understand the nuances of who uses CAM and why, using the following questions: Research Question 1: How do people communicate their life stories that explain their decision to use CAM? Research Question 2: How do the life stories enable us to understand the similarities and differences among CAM users? Through the stories of our participants, we show that life events affect health care choices and motivations for 1

Texas A&M University, College Station, Texas, USA

Corresponding Author: Vandhana Ramadurai, 20667 Forge Way, Unit 231, Cupertino, CA 95014, USA. Email: [email protected]

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integrating various healing modalities. Understanding the impact of these life stories on how people integrate differing healing modalities can be important for CAM and conventional practitioners. This self-understanding will better enable practitioners to communicate with health seekers and in turn affect their patients’ healing experiences. We begin our literature review by clarifying the definition of CAM and related terminology. We then discuss the literature on why health seekers use CAM.

because it is an alternative therapy that is amenable to being used along with conventional treatments. Alternative and complementary, however, are terms that are often used within the literature interchangeably and incorrectly. Furthermore, what at one point was regarded as strictly alternative, such as acupuncture, may eventually become accepted as complementary. As we review the literature, we use the term CAM to be consistent with other authors cited in the section.

What Is CAM?

Engagement in CAM

Complementary, alternative, integrative, holistic, unconventional, nontraditional, and unorthodox medicine are terms used to describe treatments that are not typically provided by conventional health professionals (Dokken & Sydnor-Greenberg, 2000). The many definitions of these terms have been debated (Lorenc, Ilan-Clarke, Robinson, & Blair, 2009) for reasons such as usefulness, accuracy, and inclusivity. In addition, terms like unconventional and unorthodox tend to connote judgments on the acceptance and popularity of the treatment instead of effectively describing it (Geist-Martin, Sharf, & Jeha, 2008). In this work, we use the most prominent terms, complementary and alternative, to provide conceptual clarity. The NCCAM (2012) within the U.S. National Institutes for Health defines CAM as a “group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Although this definition is cited often, it is problematic because differentiating between a CAM modality and a conventional treatment is not always straightforward and may change over time. In addition, the definition does not distinguish between alternative and complementary medicine. Alternative medicine refers to health systems comprised of philosophies that depart significantly from conventional medicine (Sharf, Geist-Martin, CosgriffHernández, & Moore, 2012). It is often used in lieu of conventional therapies for prevention or for the treatment of a particular health problem (NCCAM, 2012). For example, Ayurveda, an ancient medical system from India, conceptualizes the human body as consisting of doshas or energies. According to Ayurveda, a healthy human body is one that encompasses balanced doshas/ energies whereas unbalanced doshas are the root of health problems. Although Ayurveda can be used alongside conventional medicine, it is difficult to integrate the principles of two systems when addressing health problems. Complementary medicine refers to unconventional approaches used in conjunction with a conventional treatment. Chiropractic care is a good example of complementary medicine (NCCAM, 2012),

Despite increasing frequency, the use of CAM therapies to treat, improve, and maintain health still represents a significant deviation from the norm. This fact has motivated researchers to understand why people choose to depart from conventional medicine (Jain & Astin, 2001). Initial research suggested that engagement in CAM falls into two main categories: (a) patients are “pushed” toward CAM because of negative experiences with conventional medicine, and (b) patients are “pulled” toward CAM because of their belief in the philosophy of alternative therapies (Furnham & Smith, 1988). While the push and pull explanations remain useful, they account for only a partial understanding of why people opt for CAM therapies and how they incorporate them. In a study of CAM use among breast cancer survivors, the authors concluded that push and pull factors are valid and not exclusionary. These push and pull factors can coexist as people make decisions about their health (Boon, Brown, Gavin, Kennard, & Stewart, 1999). Research on the use of CAM for chronic conditions has also confirmed that patients consider CAM as part of their self-care management and not as a rejection of conventional medicine for an unrealistic search for cure (Thorne, Paterson, Russell, & Schultz, 2002). In general, research in the United States has shown that individuals who choose CAM are trying to improve their everyday well-being or trying to relieve symptoms (Astin, Pelletier, Marie, & Haskell, 2000). Others have noted that the side effects of conventional treatments are a cause for concern leading them to choose CAM (Humpel & Jones, 2006). In addition, wanting greater control over one’s own health has also been a reason for engaging in CAM (Barnes, Bloom, & Nahin, 2008). Health seekers are motivated to use CAM for a number of reasons and researchers have begun to systematically categorize these motivations.

Andersen Behavioral Model (ABM) In 1968, Andersen conceptualized the ABM to understand how and why families in the United States use conventional health services. The model has since been

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Ramadurai et al. expanded (Andersen, 1995) and argues that people’s use of health care services is a function of the following factors: predisposing factors, enabling factors, need factors, and health care experiences. Predisposing factors pertain to demographics (age, gender, education, race, and marital status). Enabling factors are those resources (income, insurance, etc.,) that allow or impede the use of health services. Need factors pertain to the perceived and evaluated medical needs for specific health care services. Health care experiences relate to patient satisfaction and are often influenced by factors such as convenience, quality, availability, and so on. Since the 1960s, ABM has been used in a variety of contexts to understand how patients use conventional medicine and how to better improve their experiences. In the recent past, health services scholars have used ABM to understand why health seekers in the United States use CAM (Lorenc et al., 2009; Upchurch & Rainisch, 2014) In a study investigating why individuals choose CAM, Lorenc et al. (2009) grouped the reasons into ABM’s four categories, with a good deal of emphasis on demographics as enabling. Research has indicated that women are somewhat more likely than men to use CAM, just as women are more likely than men to seek help from conventional health care professionals (Bishop & Lewith, 2010). In addition, older adults compared with younger adults are more likely to use CAM (Lorenc et al., 2009). Race and ethnicities do not predict the use of CAM (Astin, 1998). Individual beliefs and values (spirituality, openness, health effort, holistic, self-reliance, and internal locus of control) have also been identified as predisposing factors (Lorenc et al., 2009). Users believe that CAM might promote a number of things for the individual: self-actualization, empowerment or active roles, and a more rounded holistic approach to treatment (Broom & Tovey, 2008; Burstein, 2000; Davidson, Geoghegan, McLaughlin, & Woodward, 2005; McClean, 2005). In addition, through a metaethnographic analysis of 30 research studies, it was identified that individuals who use CAM strongly believed in a holistic approach. In addition to the biomedical factors, these individuals also believed in a wide range of social, cultural, and spiritual factors that affected health (Franzel, Schwiegershausen, Heusser, & Berger, 2013). Enabling factors have also been investigated for its influence on CAM use: resources (income and health insurance) and access to and availability of CAM practitioners. Lorenc et al. (2009) noted that there is little support for the idea that enabling factors influence CAM use. However, other studies have suggested that there is a relationship between higher income and CAM usage among some health seekers (Ashikaga, Bosompra, O’Brien, & Nelson, 2002; Bishop & Lewith, 2010; Chen et al., 2008;

Wanchai, Armer, & Stewart, 2010). Need factors such as evaluated need (chronic health problems, former smokers, current drinkers, pain, higher vitality, and depression) and perceived need (self-rated health, perception of illness as serious and intruding on daily life, and parental rating of child’s health as good/very good) influence CAM use (Lorenc et al., 2009). For example, CAM use increases as individuals suffer from more chronic health conditions (Bishop & Lewith, 2010). Health care experience (e.g., parental use of CAM preceding child use of CAM, dissatisfaction with medical doctors) is central to the use of CAM (Lorenc et al., 2009). As the preceding review shows, existing research identifies specific factors that influence CAM use. However, it does not conceptualize how these factors combine to create unique patterns that both epitomize and make distinctions among CAM users, how life histories are essential to formulating these patterns, and in what ways these patterns create corresponding forms of integrative health care usage.

Method As is frequently the case with qualitative studies, our study design and methods were iterative, adaptive, and evolved during the course of the project. Our original intent was to investigate how and why parents decide to choose CAM options to treat illnesses and maintain good health with their children, an understudied aspect in the extant literature. In that respect, our initial approach was not theoretically informed; rather, we assumed a grounded theory perspective with the intention of developing an explanation of parental decision making with respect to CAM. Following the institutional review board (IRB) approval, study participants, defined as individuals who had chosen CAM treatments for themselves and/or their families and children, were recruited in several ways. Flyers soliciting participants to talk about their experiences were placed in various CAM practitioners’ offices and stores that sell natural and herbal products. E-mails detailing information about the study were sent to several local listservs with people we suspected may have reason to be CAM users, for example, an autism listserv. Snowball sampling also proved to be beneficial as respondents helped spread the word to other personally known CAM users. Interestingly, several CAM practitioners whom we asked to circulate the flyers indicated that they were also parents, who make health care decisions for their children and were interested in being included in the study themselves. We ended the data-gathering process after interviewing 18 individuals over 3 months and felt at the time that we had reached saturation in terms of recurring data. All interviews took place in individuals’

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homes or offices, for their convenience. All participants were from a southwestern metropolitan community of approximately 170,000 people. Interviewees included 16 women and 2 men. The gender imbalance is probably not surprising, given our recruiting emphasis on parental health decision making—mothers frequently take charge of decisions regarding children’s and family’s health care needs. The major racial/ethnic category represented was White American and two participants were of South Asian and South American origins, respectively. During the interviews, participants disclosed having access to conventional health insurance coverage and the financial ability to pay for CAM therapies. After explaining the goal of the study and obtaining informed consent, the first author conducted semistructured interviews, ranging in length from 45 minutes to 2 hours, based on a set of guiding questions designed by the authors to elicit participants’ responses in the form of detailed stories. Interviews were audio-recorded and then transcribed by a research assistant; transcripts were reviewed by the interviewer to ensure accuracy. All transcripts were read and annotated individually by each of the three authors. Then all three authors met multiple times over the course of several months to discuss initial impressions and consequent interpretations of the data. In the following sections, we use pseudonyms to protect the confidentiality of our participants. In addition, we have omitted other identifying information (e.g., specific biographical details) that could threaten the confidentiality of our participants.

Analysis: Pathfinder Sagas Our first pass at data analysis was a thematic analysis, using constant comparison, across cases, yielding a long, confusing list of codes that did not cluster easily and meaningfully into code families. Nonetheless, this initial struggle to understand the data did lead to a few, important realizations. First, we became aware that what our participants had shared with us had much more to do with their own personal histories with CAM use; decisions to choose CAM for their children may have been essential to the development of that history or may have been an outcome of prior defining circumstances. Second, we realized that in striving to use a grounded theory approach to identify common themes across all cases, we had not been sufficiently sensitive to the storied elements, such as plotlines, scenes, and chronologies (Yamasaki, Sharf, & Harter, 2014), that characterized each of the participant’s interviews. Thus, we returned to the data with increased attention to the nuances of individual stories, as well as to the common elements among clusters of similar stories, leading to a narrative analysis of story types. Concurrently,

we modified our research questions to be congruent with our redirected attention to the narration of life stories related to decisions about using CAM. Looking more specifically at the creation of narratives as described by sociologist Catherine Riessman (2008), individuals, including our participants, enact “everyday oral storytelling” that “connects events into a sequence that is consequential for later action . . .” (p. 3). Thematic narrative analysis, which we used in this study, focuses on the content of individuals’ stories (vs. story structure or performative aspects of storytelling, alternate forms of narrative analysis). Although specific details varied among participants’ stories, each with a compelling individual history, certain plotlines recurred, creating three major clusters or metanarratives (Sharf, Harter, Yamasaki, & Haidet, 2011). Importantly, Riessman asserted that interrogation of individual cases can be generalized in the sense of conceptual inferences or “theoretical propositions” (italics used by Riessman, p. 13). Accordingly, conceptual understanding based on analysis of our participants’ stories became our ultimate objective with this work. As the authors discussed the plotlines we discerned in the individual stories, it seemed evident that what we were hearing were renditions of life journeys in which critical health incidents, family and individual rituals, attitudes and values about mainstream medicine, and ideas about healing shape participants’ decisions about how and when complementary and alternative therapies were incorporated. For this reason, we refer to the story clusters as pathfinding metanarratives, described within a travel-related metaphor.

Pathfinder Clusters The first cluster of participants (n = 8) is identified as natives. For these participants, their choice of using alternative therapies is natural and organic within their life contexts. Exposure since childhood has made natives comfortable and familiar with alternative treatments and practitioners. Through their families and friends, natives have learned the philosophy of various alternative modalities. Natives continue to expand their knowledge about various alternative therapies and embody those corresponding values, beliefs, and practices as part of their everyday activities. Although CAM is central to their daily lifestyle and practices, experiences of natives are not without brief excursions to the world of conventional medicine. We dubbed the second cluster (n = 5) as immigrants. Within this category, CAM plays a central role, though typically it was not this way from the beginning. Immigrants come from households that have had a longstanding faith in conventional medicine. However, for

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Ramadurai et al. individuals in this category, their reliance on mainstream medicine has met with disappointment and discouragement because of poor health outcomes following treatment. For this reason, immigrants have reoriented themselves on a new path to healing, acculturating themselves to living with alternative modalities and lifestyles. Interviewees whose stories fit within the third narrative category (n = 5), we call tourists. Although conventional medicine is more central to their lives, these individuals have an open-minded predisposition that leads itself to exploring alternative options. Tourists use alternative medicine on an intermittent basis, as desired, and appreciate it for what it has to offer in selected circumstances. Hence, they bounce back and forth between the two approaches to healing, appreciating the best of both worlds. In the following section, we elaborate on each of these pathfinder narrative types through analysis of a representative individual account interwoven with stories from other participants to explicate each cluster. As we discuss the narratives, we use the term alternative therapy/medicine for many participants. In such instances, participants actively sought out these unconventional therapies and used them in place of mainstream treatments. We also use the term complementary and/or CAM when an alternative therapy was used in conjunction with conventional treatments

Narrative Clusters Natives Maya and Vick are parents of two girls, Emma and Alli. Maya, a chiropractor by profession, is the main family health decision maker. Her interest in alternative medicine came from her father, a retired chiropractor and acupuncturist who used alternative therapies as the first resort for managing health problems in the family. Maya recalls, “I didn’t go to [a] medical doctor for anything until I was 12. I [was] allergic to peanuts and after I had a handful, I turned blue [and went to] the hospital.” Maya’s father also emphasized the importance of diet. She states, My dad [said] when I was a kid, [that] “they” are going to figure out that one of the biggest causes of the cancers is just what people put in their mouth. That’s why it makes more sense to me to [eat healthy].

In raising her children, Maya follows her own experiences. She proudly explains, “[My husband and I] feed [our kids] healthy, we are like food Nazis.” She uses conventional medicine only during infrequent emergencies, as when Alli suffered intense stomach pains. Maya describes a more typical approach to family health care as follows:

Emma was going to a psychologist who said that she was moderately depressed and that we might have to take her to a psychiatrist. We knew that if we went to the psychiatrist, we would have to take drugs so we are not going there. We [decided] to fly [a behavioral therapist] in for a couple of days, and he did training with us to manage her. [So] we definitely avoided doing the conventional thing.

However, Maya also is open to incorporating an integrative approach sometimes. For instance, she carefully selected a few important vaccines, while resisting most others. She adds, “[We carefully] picked our family doc. She was also willing to work on a vaccination schedule with us because no pediatrician in town will work with you unless you go with the AAP2 guidelines.” In our sample, the native classification was based in large part on these eight individuals’ exposure to alternative modalities since childhood. Through their upbringing, natives have learned to embody a holistic philosophy in their daily lives. Family culture of CAM use.  Being familiar and comfortable with alternative and complementary modalities, natives prefer it to conventional medicine, a choice only used as a last resort. Julie declared, “The only time [my daughter] saw [a pediatrician] was when she was born. You go in 10 days later and make sure everything is ok. After that there was no reason to see him.” Natives create a family culture that consistently inclines toward CAM routines. For example, Samantha’s family rituals involve regular sesame oil massages and daily gardening and cooking sessions with her husband and son. These practices are opportune times for Samantha to communicate with her family about holistic approaches to health management. Spouses of natives, who were unfamiliar with CAM, have become more invested in this orientation because of their spouses’ passion and commitment, while decisions not to use conventional medicine are recreated for children of natives. Embodying a holistic approach.  CAM, as compared with conventional medicine, leads natives to embody a holistic orientation to health. This approach involves paying close attention to physical, psychological, spiritual, and cultural aspects of health care and maintenance. In particular, natives emphasize the role of stress as a negative influence on well-being, including tensions related to school, family, physical environment, friends, and so on. Lisa details the importance of stress management: The hardest thing for us is reducing the stress in the household. Do [children] feel like they have the attention when they needed it? Do they feel like when they have something to say, do we sit down and listen to them?

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Participants in this group even relocated to different cities to expose their children to better environments. Another example of this holistic philosophy is the pattern of natives closely monitoring the regular diets of their children. Lisa says, “We don’t give him sugar at home, except for one thing. He gets ketchup sometimes and [that has] sugar.” When participants learned about their children’s health conditions, immediate efforts were made to alter their diets. For example, some removed gluten and dairy products to manage autism. Another informant who follows Ayurveda removed egg from her child’s diet to reduce hyperactivity. Active decision making.  Natives closely monitor their family’s health using various alternative guidelines that are significantly different from those in conventional medicine. For example, Samantha uses Ayurvedic principles to assess her son’s health by checking his potty daily. Although such surveillance might seem strange and invasive to others, it is integral to this native’s understanding of what health care entails, especially in terms of safeguarding her children. CAM beliefs and practices tend to increase overall involvement for natives as health seekers and managers. However, control of their family’s health care is sometimes threatened when they make occasional excursions to conventional medical practitioners with distinctly different philosophies and beliefs. Natives frequently consult conventional providers during times of emergency to obtain a diagnosis, which they later treat with alternative therapies. In some other cases, if natives aren’t seeing improvements with alternative therapies, conventional practitioners are consulted to address their concerns. The quote below highlights the power mainstream providers continue to have in the lives of natives. Lisa shared, When [my son] had an ear infection, I was trying to treat it with homeopathic stuff and it didn’t look like it was getting better. I then took him to [the pediatrician] and he got really worried. He said “You [have] to be careful [at] this age. They need to be able to hear to develop language skills and you could have a real problem if you don’t clear this up.”

All natives at one point experienced the dilemma of whether to rely on physicians or CAM practices. Nonetheless, natives believe that they have the ultimate power to make an informed decision regarding their family’s health. Of course, not all who choose to use CAM do so by way of having a native background. Many were raised with conventional health care, but became CAM users after they lost faith in conventional medicine.

Immigrants Hailey’s son Vincent was 15 months old when he experienced sudden intense coughing that led to choking.

Doctors concluded that a bronchoscopy3 would help with understanding the problem. Hailey and her husband quickly consented to this relatively simple procedure and were informed that Vincent would return to them in less than an hour. The wait for Vincent was considerably longer. Described Hailey, Three hours later [the doctors] told me he almost died on the operating table and that they are trying to stabilize him and that they do not think he is going to make it through the night. They had no idea how much brain injury [had] already occurred. His heart stopped [and] they gave him a shot of adrenaline. When we got home, our son now was a total invalid. He could not suck like a new born anymore. He could not turn his body. He could not say the words he [had been] saying. He could not walk. He could not see. The [doctors] pretty much told us “sorry” and that they have no answers. “So here, pretty much the damage is done, see ya!”

Soon after this surgery, Vincent started having seizures and was on medications to control them, but they did little to help. Hailey remarked, “I started looking elsewhere and started talking to people as doctors told me that they had nothing to offer.” She commented that rehabilitation was their only focus at that point, including physical, vision, speech, and occupational therapies. During these sessions, Hailey listened to other parents’ experiences and learned about alternative treatments. Soon she had enrolled her son for reflexology4, cranial sacral therapy5, and massage. With reflexology, there were immediate benefits such as Vincent’s having regular bowel movements, which led to the removal of one medication from the cocktail he was taking. With cranial sacral therapy, his seizures improved, resulting in removal of another medication. Hailey continued, [Vincent] is off all the drugs, takes no medication whatsoever. To me it is just phenomenal. You know drugs [were] treating symptoms, then [they] cause[d] other problems, [and] then you ha[d] to use other drugs. We knew that we did not want that for our child.

Alternative treatments, although effective at improving Vincent’s situation, were expensive and not covered by their insurance providers. The financial problem did not stop Hailey: My husband and I went to massage school so we could do massage on [Vincent] everyday. We took cranial sacral therapy classes and that’s [what] made us cranial sacral therapists. We started to do work on our son and . . . Next thing you know, other parents are like “How can I get that for my kid?”, and so we just opened our business.

Although Vincent still has significant disabilities, originally no doctor would have been able to predict such

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Ramadurai et al. functional progress. In addition to using alternative therapies on Vincent, Hailey and her husband use these to maintain their own health, providing hope for others in their community. Hailey proudly shared, “Not only have we seen that alternative treatments do great things for our son, but we are able to spill that over and help other people.” Immigration, a process of relocating to another place and culture, usually permanently, is an apt metaphor for this narrative cluster. Like Hailey, for our other four immigrant participants, their path to CAM is both permanent and prompted by necessity. Feeling abandoned by their conventional health providers, immigrants had sought alternative pathways to regain a sense of control over a personal health crisis. Alternative therapies provide hope, restore normalcy, and result in new ways to understand health and illness. Interestingly, in our study, all immigrants eventually became professional alternative practitioners. Sense of abandonment.  Hailey’s story is representative of immigrants who came to use alternative treatments, out of desperation, during a family health crisis. The crisis significantly changed the way immigrants understood and managed their health; it also permanently changed their relationship with conventional medicine, on which they had previously relied. The unfortunate crisis for each participant in this narrative cluster involved medical mistakes and unexpectedly severe side effects. What exacerbated the crisis was the lack of solutions from conventional medicine; even worse, doctors washed their hands off the problem for which they were partially responsible. These situations left immigrants feeling abandoned by physicians, leading to skepticism about conventional medicine. Hope of recovery.  As immigrants explored their treatment options using alternative therapies, a sense of hope was regained based on the discovery of many previously known modalities. Michael explained that when he discovered cranial sacral therapy, he became exposed to additional alternative therapies. Michael stated, This started us on a path of, “Wait a minute, if this stuff is available outside of the insurance system, what else is available?” And then we found that there is a whole world out there of wonderful stuff that you are not going to get [covered for].

were said to have damaged bodies beyond any hope of repair. Physicians or conventional treatments could not restore health and alleviate the crisis. This disappointment served as an impetus for these participants to challenge biomedical standards of what it means to be healthy and normal. Philosophies of alternative modalities, therefore, became tools to make sense of their bodies and reconceptualize their notions of health and illness. When their son John was born with Down’s syndrome, Michael and Alicia already had been using alternative treatments to address their personal health crisis. Michael explained, In Down syndrome, the body is compromised genetically at every cell. When you look at those [genes], a lot of them can be influenced from the outside. You can’t change the genetics but you can bring the body to a closer balance. So in thinking about Down’s syndrome with an alternative approach, our question was: How can we help his body come closer to balance? It did not bother us that this was genetic; it was irrelevant. So again, the thinking is what drives the use of different alternative therapies.

After sharing this philosophy with his physician, Michael lamented, “The [doctor] did not even understand the questions we were asking and what we wanted to accomplish. So, it was pretty quickly exhausted what was available in [conventional] medicine.” Empowerment through CAM. Although immigrants report reaching a new state of normalcy and stability, they continue to experience the consequences of their crises in their daily lives. As their life journeys continue, immigrants empower and heal themselves using various alternative modalities. For the participants in our study, not only did being an immigrant result in being survivors but also all immigrants eventually became alternative practitioners as a result of the crisis. Immigrants assume the role of activists as they raise awareness about the effectiveness of alternative therapies in their practice. In addition, they empower patients to manage their health by educating them about the philosophy of alternative medicine. Michael illustrated how he conceptualized his role as an alternative therapist:

However, it was not necessarily a smooth experience for immigrants as they invested significant money, time, and energy and waited patiently to see results.

It is about the hope and hav[ing] a companion on [the] journey. I coach people, that we are on this journey, but you need to be able to tell your body and yourself, and not have someone tell you, if you are [healthy or not]. If you can’t tell that, then how are you going to be empowered on this journey? You can be helped along the way, but you have to do it on your own. I think most people that are truly into the alternative philosophy are already empowered and are looking for the [therapies] to go in the right direction.

Reconceptualizing health. By the standards of conventional medicine, the individuals involved in the crisis

CAM users who neither have the upbringing of natives nor the urgency and commitment of immigrants

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constitute a third distinct cluster of individuals who are interested yet inconsistent in exploring alternatives to conventional medical care.

Tourists Amy is a divorced mother of three. When she was growing up, she had limited exposure to alternative therapies and learned more through her massage therapist who suggested Aston Patterning6 to manage her muscular pains. “I tried it and it worked for me.” Her open-mindedness about health matters and skepticism about conventional medicine kept her interested in alternative therapies. She commented, I also did [acupuncture]. It was either [acupuncture] or get a device in my mouth. My back tooth was becoming loose from grinding my teeth. [With acupuncture] I fixed it in six visits. In the long run, it was much less expensive.

When raising her children, Amy relied on conventional medicine for general health checkups and emergency care; she continues to value her relationships with the pediatrician. For this reason, she is hesitant to disclose her use of alternative therapies with her mainstream health providers. She shared, I generally don’t put it out there because I don’t really want it to be an issue. It’s a personal choice. Sometimes “they” say, “Talk to your doctor about what [therapies] you are [doing].” I just really don’t want to go into that with my doctor because I guess I don’t feel that going in a positive way with [some of my doctors].

Once her children got older, Amy felt more confident exploring alternative solutions to health problems: I talked to an alternative therapist about my daughter getting braces and they said cranial sacral therapy can help without her having to get braces, but it was a long, slow process. My daughter just wanted to move on with it. So we went ahead and got braces. What I do is we go right after [dental appointments and complement it with] cranial sacral therapy.

Amy however, remains hesitant to explore other alternative therapies. Amy remarked, CAM practitioners need to think more on a scientific basis. I am willing to take things in faith but I think cranial sacral does an excellent job of talking about the scientific basis. I don’t know that an herbalist can do that, just being able to talk more in terms of research and results.

Tourists are a group of individuals who rely on conventional medicine as their main mode of treatment. Typically, they began using alternative treatments because

someone they trusted recommended a visit to a CAM practitioner. Tourists conceptualize alternative treatments as remedies, serving the same purpose as conventional medicine, that is, treating problems and managing symptoms. There is little interest in the philosophy behind the modalities. In addition, alternative medicine is mainly understood as therapies supporting the work of mainstream medicine. Third, tourists experience enjoyment and relief when they use CAM therapies, but they are cautious in their use of these treatments. In our study, five individuals were designated in the tourist category. Trusted recommendation.  Tourists began their use of alternative therapies because of a recommendation from someone they trusted who introduced them to systems of healing, about which they had little knowledge. In Amy’s case, anti-inflammatory medicines did not ease her muscular pains. She enrolled for massages and through her therapist, she learned of other treatments. Rebecca described how she became a tourist: I went to a psychiatrist when Jamie [my daughter] had depression. We had been watching her, knowing that [me and my husband] have it. [While] we were waiting for her anti-depressant to kick in, she was miserable and was missing so much school. So I called [my psychiatrist] and he said [acupuncture] can help her.

This was the beginning of Rebecca and Jamie’s use of alternative therapies. Stories of tourists implicitly suggest that there was some need for a therapy, outside of what conventional medicine could offer. Recommendations from trusted sources provided them with information, that they likely would not have found themselves. Skepticism.  With the use of alternative therapies, tourists have felt satisfaction and relief; such outcomes have kept them interested in continuing. However, tourists also feel a sense of fear and concern, as they travel through the unchartered territories of CAM, which often lack research testing for efficacy and safety. Amy asserted that scientific research would help her branch out to other alternative therapies and increase her comfort in using them. She noted, “I would like CAM [practitioners] to learn from the medical practitioners about communicating the scientific basis [of their treatments]. Just being able to talk more in terms of research and results.” Maggie illustrates the tension she experienced when her son got cranial sacral therapy: I was like “Are you kidding?” This has got to be the most ridiculous [thing]. I am embarrassed to think we have been there. I told [my pediatrician] that we have been to what I affectionately call the voodoo doctor and she did some really weird things, but I tell you he has not had any [breathing]

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Figure 1.  The Pathfinder Model of CAM usage.

Note. CAM = complementary and alternative medicine.

problems! [The pediatrician] asked, “What kinds of things?” I was hesitant to tell him because it was so unusual. When people tell me about a problem and that they cannot find a doctor that helps them, [and they] have tried everything that’s logical . . . then maybe the next step is go to the illogical.

Maggie is a more extreme example of the anxiety tourist mothers experience when using alternative therapies. Although tourists recognize the deficiencies with conventional medicine, it still represents science, logic, and a sense of comfort. They return to conventional medicine on a regular basis and trust it to be their main source of health knowledge. However, their exposure to CAM therapies has reduced their reliance on conventional medicine. For some, CAM is a last resort to address health problems; for others, a good alternative experience leads to seeking other forms of CAM.

The Pathfinder Model of CAM Usage The Pathfinder Model of CAM Usage consists of three dimensions pertaining to aspects of usage, each expressed as a specific continuum (see Figure 1). The two ends of each continuum depicting a specific dimension related to CAM usage are not necessarily intended to imply extremes or causality, but instead depict the breadth and variation of meanings about health and healing related to CAM usage over time. In addition, the model is dynamic in that the location of the clusters within each continuum can vary and the arrows in the model represent the movement of each cluster within a continuum. Movement within the continua can be influenced by situational factors such as the severity of a health condition or even change in financial status for a health seeker belonging to any of the clusters.

Therapeutic Objective

Summary On the basis of common elements within and across personal narratives describing how various individuals found their respective ways to incorporating complementary and/ or alternative forms of healing in their lives, we have distinguished three clusters of users who had positive experiences with CAM. In an effort to deepen our analysis and further understand the underpinnings and implications of CAM usage, we have theorized the identified groups along three dimensions denoting their objectives, motives, and resultant sense of empowerment. These dimensions have been represented as continua to allow comparisons of variability among the three narrative clusters.

The first dimension of usage, therapeutic objective, is concerned with the expected outcomes as a result of choosing CAM. At one end, treatment solutions is the use of alternative therapies to address specified health problems and manage symptoms. In this sense, the use of alternative therapies serves a similar purpose as conventional medicine. All three narrative clusters use CAM as treatment solutions, especially when health problems constrain their everyday lives. Treatment solutions and harmonious balance is the other end of the continuum, additionally encompassing the commitment to a holistic philosophy of health as embodied by alternative modalities. Hence, not only do alternative therapies serve as a

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treatment but they are also a set of health-related tools, practices, and beliefs to find, maintain, and restore individual balance. To this end, natives and immigrants are more likely to use CAM as a way of life to maintain harmony and balance in their everyday lives.

Reliance on Conventional Medicine This second dimension represents the range of attitudes that influence how and when individuals use CAM medicine. On one hand, reliance on conventional medicine reflects an approach in which health seekers consider conventional medicine to be their trusted source of knowledge for treatment and health maintenance. On the other hand, best solutions for health is defined as an individual’s willingness, desire, and efforts to incorporate alternative and conventional forms of medicine whenever necessary to address health problems. As has been noted, all three clusters have a working relationship with their mainstream health providers, albeit to varying extents. What began as a sole reliance on conventional medicine for immigrants’ health needs, quickly turned to dissatisfaction and distrust during crisis situations in which conventional medicine did not help, and may even have caused harm. Even as immigrants moved away from crisis management to holistic health practices, the antipathy toward the philosophy of conventional medicine has continued. Natives are relatively similar to immigrants in that they rely mainly on alternative modalities. However, when necessary, natives are more willing to collaborate with conventional practitioners to address health concerns. Tourists are more likely to rely primarily on conventional providers and occasionally on CAM practitioners to manage their needs.

Empowerment Empowerment refers to how the use of CAM affects individuals’ sense of self and participation in health-related settings. Agency is conceptualized as the characteristic of an individual to learn about choices outside the realm of conventional medicine and make decisions about when and how to incorporate alternative therapies in their lives. Dutta (2008) asserted that agency is the capability of individuals to make independent choices and negotiate structures. Activism encompasses agency but it also reflects a deep sense of commitment such that individuals are engaged in promoting and raising awareness about alternative therapies, empowering other health seekers, and the establishment of alternative practices and structures to formalize such efforts. We believe that all of our participants who ventured beyond the realm of conventional medicine enacted their agency. Tourists enact their agency when they selectively choose and resist conventional

treatments and alternative therapies recommended by their providers. In addition to enacting agency, some participants raise awareness about CAM among community residents by sharing their experiences in their practice. We argue that natives who were raised using alternative therapies enact agency when they make active choices to continue the use of alternative therapies. For natives, alternative therapies are such a significant part of their lives that it also shapes their careers. By the same token, immigrants are highly committed to the philosophy of alternative modalities. As their path evolves, immigrants empower and heal themselves using various alternative modalities. Their path however, does not end with their being survivors; all immigrant participants eventually became alternative practitioners as a result of the crisis. Immigrants enact the role of activists as they raise awareness about the effectiveness and philosophy of alternative therapies by sharing their experiences.

Conclusion Broadly speaking, the literature on CAM categorizes health seekers into CAM users and non-users. This is one way to conceptualize individuals who choose to use CAM and those who rely solely on conventional medicine. Among those who use CAM, the existing literature identifies the factors that influence health seekers to use CAM. These influencing factors can be neatly categorized into the four categories in the ABM: predisposing factors, enabling factors, need factors, and health care experiences. However, there is little insight into how these factors interact with one another to capture the variety of ways in which people incorporate CAM into their lives. In this work, we have attempted to augment the current literature by addressing how people explain their decisions to use CAM through the communication of life stories, and how these life stories enable understanding the similarities and differences among CAM users? From the narratives of 18 individuals in our study, three clusters or types of CAM users and three dimensions of usage emerged to comprise a theoretical model, The Pathfinder Model of CAM Usage. Together, the clusters and model significantly alter how CAM users are conceptualized in the literature. Using the Pathfinder Model, we illustrate several ideas. First, why and how individuals decide to complement and supplement conventional treatments with alternative therapies is better understood in terms of life experiences and not just in terms of demographic characteristics, such as gender, income, or education. Second, the form of pathfinding has a reciprocal impact on the identity of the health seeker. For example, the embodiment of values and practices associated with CAM influenced the careers many

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Ramadurai et al. natives and immigrants chose for themselves. Finally, the model challenges and complexifies monolithic ideas about how people choose to integrate alternative and conventional modes of illness prevention and health care.

Limitations When this project began, our initial goal was to uncover the in-depth experiences of parents who used CAM themselves and their family. When we had completed our 18th interview, we believed we reached saturation based on the recurring themes across the interviews. For example, there were commonalities in how parents defined alternative medicine, motivations to use it for their children, and concerns with conventional medicine. However, once we started to dive deeper into our analysis, we were able to group our participants and identify similar themes within these groups and differences among them based on the life narratives they described. Hence, we were able to discern three clusters of CAM users who shared commonalities in their life stories, in how they came to use CAM, and their goals and intentions when using CAM. The saturation we thought we had achieved initially did not apply to this secondary analysis. This limitation requires acknowledgment. In addition, there is a possibility that the themes of our findings and dimensions of the model could change with more representation from men and individuals from other ethnic groups. In general, research has identified that women are more engaged health seekers and are also more likely to choose alternative therapies than men. Hence, including more men and their life stories of how and why they came to use CAM, as well as a broader range of cultures and ethnicities, could well alter and expand the narrative typologies, as well as the variabilities and comparisons available through the Pathfinder Model.

Practical Implications We anticipate that our model has practical implications for three groups of people: CAM users, CAM practitioners, and conventional practitioners. CAM users may benefit from seeing themselves in relation to others in the context of health pathfinding. In addition to enhancing their self-understanding, this knowledge can help them better articulate their priorities, rationales, and misgivings to their practitioners. The Pathfinder Model can also be useful for both conventional and alternative practitioners as they establish a therapeutic relationship and communicate with their patients during medical encounters. Understanding the path of the health seeker can clarify how past influences are affecting current behaviors and health-related choices, as well as help influence the

quality of rapport and the communicative strategies providers use to educate and influence their health seekers. For CAM practitioners, we believe the model will help them to be more conscious of the differences among their patients. Instead of assuming their patients are similarly motivated, CAM practitioners can pay closer attention to how their patients’ beliefs, attitudes, and practices influence their CAM usage. The model can also empower CAM practitioners to tailor their communication for different clusters to foster collaborative decision making. Finally, the Pathfinder Model can also benefit conventional practitioners who take the time to understand the life stories of their patients who integrate different healing modalities. Tourists continue to rely on conventional medicine as their primary healing modality and natives rely on conventional medicine in specific instances without concern or anxiety. However, immigrants are very reluctant in their limited relationships with conventional medicine. Understanding the life stories and experiences of immigrants could be the first step to repairing a soured relationship one that could have significant impact on their health-related choices.

Possibilities for Future Research Our expectation is that as other scholars use this model to further understand the goals and choices of CAM users with other populations, additional clusters may emerge. Scholars could explore how the Pathfinder Model is potentially changed or expanded by purposefully including the narratives of people who were less satisfied with their CAM experiences. For example, we suspect the model will expand as the experiences of CAM users who have been disappointed while using alternative therapies are documented, perhaps (to continue the pathfinding metaphor) forming a cluster of repatriates, that is, people who have left conventional medicine to try CAM, but then decide to return to using conventional medicine only. As noted above, we are curious to discover how the Pathfinder Model would be changed or expanded by enlarging the sample of participants to include greater diversity in terms of gender, socioeconomic status, and ethnic and cultural background. Finally, we also question whether the Pathfinder Model will need to be altered based on research with health seekers who use specific CAM modalities. Are those committed to a regular yoga and meditation practice for life-long well-being different in significant ways than those who choose to use chiropractic or acupuncture to address specific instrumental needs, and, if so, how do such distinctions map onto the Pathfinder Model? These questions are potential research opportunities for CAM scholars to build upon the theoretical foundation described in this work.

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Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Notes 1. A system in which medical doctors and other health care professionals (such as nurses, pharmacists, and therapists) treat symptoms and diseases using drugs, radiation, or surgery. Also called allopathic medicine, biomedicine, orthodox medicine, and Western medicine (National Cancer Institute, n.d.). 2. American Academy of Pediatrics. 3. A diagnostic and therapeutic medical procedure that helps with visualizing of the airways through the insertion of a tube with a camera down an individual’s throat and airway, while they are sedated. 4. “Reflexology is a non-invasive complementary practice involving the use of alternating pressure applied to reflexes within reflex maps of the body located on the feet, hands, and outer ears” (Reflexology Association of America [RAA], 2012). 5. Cranial sacral therapy is a non-invasive procedure in which the practitioner subtly and gently encourages the conditions that allow for the reemergence of the body’s primary respiratory motion (Kern, 2012). 6. Aston patterning is an approach that includes a combination of bodywork, movement coaching, ergonomics, and fitness training. Aston work is helpful for individuals seeking assistance with acute or chronic pain and for those who wish to improve their posture and increase the efficiency and effectiveness of their movement patterns (as explained by Michael & Alicia).

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Author Biographies Vandhana Ramadurai received her PhD in Communication from Texas A&M University. She is an independent scholar and most recently her research has focused on digital health communication and user experiences of technology. Barbara F. Sharf is an independent scholar and Professor Emerita of Communication at Texas A&M University. Her research has focused on qualitative approaches, particularly the application of narrative inquiry, to investigating a variety of issues in health communication. Most recently her work has centered on communication occurring in complementary, alternative, and integrative approaches to healing and health care. Srividya Ramasubramanian is an Associate Dean of Liberal Arts and Associate Professor of Communication at Texas A&M University. Her research focuses on cultural diversity, media stereotyping, global media and social change, and holistic health.

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