2012. Vol.2, No.4, 441-446
Published Online October 2012 in SciRes (http://www.SciRP.org/journal/sm) DOI:10.4236/sm.2012.24057
Integrative Medicine: A Bridge between Biomedicine and
Alternative Medicine Fitting the Spirit of the Age
H. J. Rogier Hoenders1, Martin T. Appelo2,3, Joop T. V. M. de Jong4,5,6
1Center for Integrative Psychiatry, Groningen, The Netherlands
2Center for Psycho-Oncology , Het Behouden Huys, Haren, The Netherlands
3Department of Clinical Ps ychology, University of Groningen, Groningen, The Netherlands
4Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
5Boston School of Medicine, Boston, USA
6Rhodes University, Grahamstown, South Africa
Received May 31st, 2012; revised July 6th, 2012 ; accepted July 24th, 2012
Complementary and alternative medicine (CAM) are increasingly used by people in first world countries,
almost always in combination with biomedicine. The combination of CAM and biomedicine is now
commonly referred to as “integrative medicine” (IM). In Groningen, The Netherlands, we founded a
center for integrative psychiatry, offering conventional and complementary mental health care. Like other
centers for integrative (mental) health we have mostly received positive reactions although there have
been negative and even hostile reactions as well, using phrases like “quackery” and “betrayal”. We will
try to illustrate that these polarising qualifications, in which “the good” is being positioned against “the
bad” in an over-simplified manner, are unnecessary and not useful. Moreover, it is unlikely that this
polarisation will stall the growth of IM. It seems that integration is not only a current tendency in
medicine, but also a trend fitting the contemporary spirit of the age in which integration seems to be the
most common focus. It can be observed in religion, philosophy, spirituality and psychotherapy as well.
This article will discuss the difference between differentiation and integration and will show that the focus
on differentiation or integration varies with time, mostly rising as a reaction to each other. The transition
from one period to the next is often met with resistance and criticism. If the integrative movement is to
survive, it cannot do without differentiation and must find a middle way in which appropriate attention is
being paid to keeping the integrated parts sufficiently differentiated and allowing them to keep their own
Keywords: Integrative Medicine; Complementary Alternative Medicine; Polarisation; Integration
The Latin word “integralis” means: “forming a greater en-
tity”. Integration stands for “fusing or making collaborate dif-
ferent parts into a larger whole” or “including into a whole”.
The opposite of integration is differentiation; the process
whereby a homogeneous entity is being divided in parts with
different qualities. Integration and differentiation are not mutu-
ally exclusive. They should rather be understood as movements
of the same wave, or phenomena taking turns. When there is
too much integration, the different parts lose their identity or
experience a lack of autonomy. This provokes differentiation,
leading them to profile themselves independently from each
other. When there is too much differentiation, they lose sight of
each other and each other’s interests, which increases the risk
of polarisation and conflict. This will invariably lead to a need
for more integration.
This process can also be observed in medicine. At the end of
the 19th and the beginning of the 20th century, the need for dif-
ferentiation led to a change in medical laws and regulations in
various countries (for instance the Flexner report in 1910 in the
United States and the Health Care Implementation Act in 1865
in the Netherlands). These changes created a strict separation
between recognised treatments on the one hand (which later
became known as biomedicine or conventional medicine) and
other forms of medicine (which later became known as alterna-
tive medicine). Besides the distinction between biomedicine
and alternative medicine, a debate also arose between profess-
sionals who favoured a reductionistic and biomedical approach
of medicine and colleagues who preferred a more holistic or
integrative approach. In the seventies and eighties of the 20th
century George Engel was an influential physician from the last
group. In response to the dominant reductionistic view of medi-
cine, he formulated a biopsychosocial model. His criticism
(Engel, 1992) of the biomedical model encompassed among
other things: that illness perception can be insufficiently ex-
plained by biochemical changes (for instance, illness perception
varies with culturally shared cognitions about diseases, ill-
ness-related behaviours and social support); that clinicians pay
too little attention to personal factors and communication skills
(for instance with regards to stimulating therapy adherence);
and that behavioural and social variables can and do influence
the course of an illness.
After more than a century of separation and conflicts be-
tween regular, biomedical medicine and alternative, holistic
medicine, from 2000 on there is a tendency towards integration
under the denominator of “integrative medicine” (Hollenberg,
2006; Hsiao et al., 2006; Jobst, 1998). Integrative medicine can
be defined as “the practice of medicine that reaffirms the im-
Copyright © 2012 SciRes. 441
H. J. R. HOENDERS ET AL.
portance of the relationship between practitioner and patient,
focuses on the whole person, is informed by evidence, and
makes use of all appropriate therapeutic approaches, health
care professionals and disciplines to achieve optimal health
and healing” (Consortium, 2009). The most controversial part
is the use of “all appropriate therapeutic approaches” as it in-
cludes the use of complementary and alternative medicine
(CAM) within conventional hospitals/(care) delivery systems
(Hoffer & Hoenders, 2010).
“Complementary’ stands for forms of diagnostics, treatments
and prevention strategies that are based on theories accepted
in biomedicine. These are usually substantiated by scientific ar-
gumentation, but for different reasons do not form part of bio-
medicine. Examples are massage therapy and the use of herbs
and food supplements. Alternative treatments, such as healing
and homeopathy, make use of other than the basic concepts of
biomedicine. There is little proof for the efficacy of these treat-
ments or there is considerable controversy about the scientific
validation (Lake, 2007).
In integrative medicine the principles of evidence-based
medicine are applied to regular, complementary and alternative
treatments. This implies that in choosing an intervention, one
should take into account the highest level of available scientific
evidence about the different treatment options; the values, pref-
erences and frame of reference of the patient; and the profess-
sionalism and experience of the therapist (Sackett, Straus, Scott
Richardson, Rosenberg, & Haynes, 2000). The number of op-
tions in integrated medicine is larger than in regular health care
(Hoenders, Appelo, Van den Brink, Hartogs, & De Jong, 2011;
Lake, 2007; Lake & Spiegel, 2006), since CAM treatments are
not excluded beforehand.
The European Parliament (1997) and the World Health Or-
ganization (2003) plead in favour of promoting integrative
medicine (Chung, Hillier, Lau, Wong, Yeoh, & Griffiths, 2011).
However, this call is meeting a lot of resistance. There is an
enormous heterogeneity in views and behaviour concerning
CAM (Hirschkorn & Bourgeault, 2005).
The movement is even sometimes labelled as “quackery” and
the people who practice or promote CAM are sometimes dis-
qualified as betrayers. This can be observed when reading the
“rapid responses” to the editorial introducing this concept in
biomedicine (Rees & Weil, 2001) and more recently in a letter
by Ernst (2012). Our center for integrative psychiatry also met
these kind of criticisms (Kuipers & Gijsman, 2006). In this
essay we will try to illustrate that these polarising qualifications,
in which “the good” is being positioned against “the bad” in an
over-simplified manner, are unnecessary and not useful. The
fact is that integration is not only a current tendency in medi-
cine, but also a phenomenon that has manifested itself in the
history of mankind in all types of fields and all sorts of ways.
Not as an enemy of differentiation, but as a natural reaction to
Manifestations of a Society Aimed at Integration
“Integration” and “differentiation” both play a central role in
the dynamics of life. Cells merge and split; people marry and
separate; companies are fused and subdivided; and power
blocks are formed and fall apart. The process of merging and
separation is taking place on each level of life. It forms a re-
turning theme in the history of humanity, and takes different
forms in different fields, over and over again. In this article, we
provide several typical examples from different spheres of life,
restricting ourselves to the themes related to our own field:
world view (philosophy, religion and spirituality), health care
(treatment demand, pathways to care and psychotherapy), and
The contemporary philosophy that evolved roughly after the
Second World War is called “postmodernism”(Anderson, 1999;
Bertens, 1994; Scruton, 2006). The core of this trend is the idea
that objectivity and the absolute truth do not exist. There are
many theories, ideologies, religions, convictions and principles,
but history teaches us that none of these has profiled itself in
such a way that it can be rightfully called “leading”, “all-en-
compassing” or “universal”.
Lyotard (1979) called this “the end of the big stories”. There
is no winner and thus, there is no such thing as the ultimate
truth or essential knowledge. As a result, postmodernism is not
exclusively aimed at acquiring knowledge, but especially points
at its ignorant, emotional, narrative, theory-bound and thus
unstable foundation. If there is no absolute criterion, it is also
not determined which goals we should pursue. According to
one of the post-modern philosophies, existentialism, we are
therefore doomed to freedom (Sartre, 1965). According to an-
other philosophy, social constructivism, we are free to choose
what we make of our lives, because everything changes all the
time (Bertens, 1994). This implies fear and insecurity, but also
provides unrestricted space to numerous equal, parallel ways to
deal with things. Mainly because of this freedom, post-modern
philosophy is offering a visionary framework for integrative
thinking and act i ng.
Religion and Spirituality
Even though polarisation and hostilities between the major
world religions still exist, and even though inter-religious ten-
sion is a risk factor for war and armed conflict (De Jong, 2010),
there is a clear tendency of integration in the field of religion,
especially in the Western world. This is caused by the seculari-
sation of society, which has led to a decrease in popularity of
institutionalised forms of religion, such as the Church. This has
created a need for new forms of spirituality and interpretation,
in which Eastern and shamanistic traditions and philosophies
have played a considerable role in the last decennia. The way
this new form of spirituality is being created, is characterised
by diversity and the post-modern lack of claims on one exclu-
sive source of the truth. This is accompanied by the freedom to
choose how an individual would like to fulfil his spiritual
Research shows that spirituality has a strong positive asso-
ciation with health (Koenig, 2000; Koenig, 2001). It also con-
sistently shows that giving meaning to what happens to us, is
more important for the wellbeing of a person than any particu-
lar religion. The experience of finding purpose is more impor-
tant for the wellbeing of people than the capacity to clarify or to
give a logical explanation for things (Lewis, Maltby & Day,
2005; Scannell, Allen & Burton, 2002; Steger & Frazier, 2005).
Demands for Care
Also regarding to health needs and demands for care, a ten-
dency towards integration can be observed. The expression
Copyright © 2012 SciRes.
H. J. R. HOENDERS ET AL.
“supply creates demand” implies that when people are making
a choice, they take into account and use all available options. A
demand for care is therefore determined for the most part by the
available supply. Especially because of the internet, all health-
related knowledge has become accessible to everyone. This has
had a huge impact on the kind of health care demands people
make. Nowadays patients want to choose their own treatment
(Coulter & Willis, 2004) and are increasingly requesting an
integrated package of regular, complementary and alternative
treatment methods (Hök, Wachtler, Falkenberg, & Tishelman,
2007), not bothered by the differences in paradigms and work-
ing styles of CAM and biomedicine (Hoenders, Willgeroth, &
Appelo, 2008) and the ethical and scientific challenges result-
ing from it (Oguamanam, 2006).
Eisenberg et al. (1998) showed that CAM is being used on a
large scale in the United States, usually in combination with
regular treatments, and that there is an increase in use. In 1990,
34% of the Americans used CAM; by 1997 this percentage had
increased to 42%.
Even though patients do increasingly express demands for
integrative care, they seem to anticipate that caregivers still
restrict themselves to their own field of interest. About 60% -
75% of patients appear to conceal the use of CAM to their doc-
tor because of fear of disapproval or ridicule (VandeCreek,
Rogers & Lester, 1999). This is in sharp contrast with the fact
that patients would like to receive information about CAM
from their conventional providers. It would be advisable if
doctors would address this need respectfully, since an open
attitude towards nonregular treatment methods is essential (Hök
et al., 2007): It improves the therapeutic relationship (Stevinson,
2001) and increases the impact of medical interventions
(Koenig, 2000). It is also important to enquire about the use of
CAM for medical-ethical reasons. Uncontrolled use of CAM
can be dangerous, because of possible side-effects and interact-
tions with regular medicines (Ernst, 2002). In a study in Aus-
tralia less than 3% of the population was aware of this (Walter
& Rey, 1998). In this regard it is worrisome that one in five
patients combines herbs or foods supplements with medication
(Eisenberg et al., 1998). An open conversation about CAM can
take away misunderstandings and thereby prevent potentially
These considerations led to our own research (Hoenders,
Appelo, & Milders, 2006), which showed that 42% of almost
600 psychiatric outpatients in the Northern Netherlands had
used CAM. This figure is similar to older prevalence figures in
psychiatric patients (53%) (Knaudt, Connor, Weisler, Churchill,
& Davidson, 1999). We also studied the prevalence of CAM
use among patients of General Practitioners (GPs). A survey of
900 patients showed that they had used CAM in 62% of cases
(Borgemeester, Appelo, & Hoenders, 2008). Both groups of
patients report less than half of the cases of CAM use to their
conventional doctor. This is also in agreement with prevalence
rates offered by other researchers (VandeCreek et al., 1999;
Wetzel, 1998). Half of the psychiatric patients and 65% of the
GP patients would like to receive more information about CAM
and prefers that their conventional therapist would offer this. In
contrast, the psychiatrists and GPs who were surveyed in this
study heavily underestimated the use of CAM among their
patients, and only one third of them was in favour of offering
this information themselves. For one quarter of the psychiatrists
and one third of the GPs CAM had an outspoken negative con-
notation. So, it seems that despite most patients favour CAM
and integrative health care, a considerable number of conven-
tional doctors are not willing to work in this way, creating a
tension between health needs and supply.
Eventually, the struggle between different schools of thought
in Western psychotherapy had come to an end. It was replaced
by a so-called “Dodo bird verdict: Everybody has won, and all
must have prizes” (Luborsky et al., 2002). This was done be-
cause empirical evidence had shown that the “specific ingredi-
ent’ in any given therapy—that which theoretically makes it
work—adds little to the nonspecific elements of psychotherapy
(Asay & Lambert, 1999). Moreover, this research has shown
that clinical success is more a function of differences among
therapists than among therapies (Wampold, 2001), and the suc-
cess of therapists is primarily related to the quality of their alli-
ance with patients (Baldwin, Wampold & Imel, 2007; Luborsky
et al., 2002).
This revaluation of nonspecific therapy factors is also being
stimulated by an increasing collaboration between behaviour-
oriented sciences such as neurology, biology and experimental,
social and clinical psychology. The results of this interdiscipli-
nary research questions the existence of the free will: the neo-
cortex appears to be less dominant and therefore has less influ-
ence on our behaviour than it would like us to believe
(Dijksterhuis, 2008; Lamme, 2010). It seems that we are pre-
dominantly controlled by automatic neural networks. Someone
who would like to change his behaviour does not benefit much
from a wonderful all-encompassing theory, but needs the disci-
pline to replace all old automatisms with new ones that fit into
his own (small, but subjectively significant) story (Appelo,
2011; Brewin, 2006). The treatment method that facilitates this
type of learning, is no longer forcefully dictated by a particular
viewpoint or school of thought. In line with the principles of
evidence-based medicine, this integrative method results from
the interaction between the (preferences of the) patient, the
(expertise and experience of the) therapist and the number of
effective interventions that are available at that moment. This
gives the psychotherapeutic practice an integrated, eclectic
character (Korrelboom & Ten Broeke, 2004).
Another form of integration in psychotherapy is that of East
and West. Eastern philosophies are increasingly being inte-
grated into Western (psycho) therapies; examples are mindful-
ness and Acceptance and Commitment Therapy (ACT) (Ka-
bat-Zinn, 2003). So, it seems that also in psychotherapy there
are many developments with a tendency towards integration.
Although there still are well-defined schools of thought in
the world of science with their own methodological preferences,
we also see, especially in health care, a growing space for the
equal coexistence of different research methods (Plochg, Jutt-
man, Klazinga, & Mackenbach, 2007; Walach, Falkenberg,
Fønnebø, Lewith, & Jonas, 2006). This is facilitated by the
criticism of the doctrine of the randomised controlled trial
(RCT) as a “sacred” scientific research method (Ottenbacher &
Hinderer, 2001). This criticism is predominantly based on the
difference between internal validity, or efficacy (does a method
or intervention work as such?) and external validity, or effect-
tiveness (is it beneficial in a certain context?). Proven efficacy
does not say much about effectiveness, as what works in a large
Copyright © 2012 SciRes. 443
H. J. R. HOENDERS ET AL.
group on average does not per se apply to all individuals in
various contexts. On the other hand, effectiveness does not
simply imply efficacy, because what works for a person in a
particular situation, cannot always be generalised to a group.
If an intervention with only one mode of action is being
studied, as is the case with medication, and if a subject does not
prefer the experimental condition over the control condition
(because he cannot know the difference between the two), it is
indicated to establish the internal validity of the intervention
first. In this case, the RCT is the research method of choice. If
however the expectation of the result and the preference of
subjects play a role and these are not the same for the experi-
mental and the control condition (as is the case with almost all
psychological and non-placebo-controlled medication research
in health care), establishment of the external validity is indi-
cated first. Observational, quasi-experimental and mixed-
methods research is the method of choice in this case (Barry,
2006; Plochg et al., 2007). This offers possibilities for CAM
(Barry, 2006) as most CAM users have a strong preference and
therefore it is difficult to do RCTs for CAM therapies. Al-
though in biomedicine it is common to start with randomised
trials first, possibly later followed with effectiveness studies, in
CAM it seems acceptable to work the other way around. To
start assessing the effectiveness in a certain context and verify-
ing it later in a RCT. This also makes sense as in biomedicine
new pharmacological compounds are only allowed on the mar-
ket after assessing efficacy and safety in RCTs, but most CAM
are already being used, even though efficacy has not been es-
tablished yet. So, it seems that it depends entirely on the re-
search question, kind of treatment and circumstances, which
kind of research design is needed. No design (not even RCT)
can be considered best in all circumstances (Walach et al.,
2006). This calls for an integrated research approach.
This essay suggests that the integrative movement in health
care does not stand on itself. It is a phenomenon that is mani-
festing itself worldwide and in different aspects of daily life. It
follows a period in which differentiation took central stage but
did not lead to absolute, unquestionable truths.
The conclusion that integrative health care fits into the spirit
of the time therefore seems justified. However, there is a
chance that, with continuing integration, this movement will
develop into another direction. The different parts in this case
might eventually lose their identity, develop a need for auton-
omy and try to promote more differentiation. The dynamics of
the processes of differentiation and integration show that both
poles are connected (similar to the perpetual dynamics and
balance between yin and yang in Eastern philosophy or the
theory of dialectics). If the integrative movement wants to sur-
vive, it will have to make sure that the balance is not lost.
In other words: a continuing integrative movement cannot do
without differentiation and must find a middle way in which
appropriate attention is being paid to keeping the integrated
parts sufficiently differentiated and allowing them to keep their
own identity. Then, integrative health care predominantly
means a good and equal collaboration between parts that are
well differentiated. In this regard it would be useful if everyone
who is involved in the process, critically contributes to the de-
bate and raises the alarm once the balance between differentia-
tion and integration is getting lost. In the last few years a dis-
torted balance due to a lack of criticism or supervision has be-
come visible in various spheres—e.g., the worldwide financial
crisis and fraud in scientific research.
Finally, it would be interesting to raise the question why in
the process of integration and differentiation people may feel
the need for polarisation and rowing against the flow, instead of
contributing to the debate. We think that the main reason why
people would protest against integration is that they do not
consider themselves sufficiently profiled and recognised in the
process of differentiation. After all, it looks like integration
works against one’s own identity. Especially when a person’s
identity has not been satisfactorily established during the proc-
ess of differentiation, he may fear that integration will destroy it.
This phenomenon is visible in the viewpoint of Kuipers and
Gijsman (2006), who present as an argument against the psy-
chiatric branch of the integrative movement, that it has taken
regular psychiatry already a lot of efforts to be seen as a normal
part of medicine. The resistance against integration is then re-
lated to the lack of a clear identity. Developing such an identity
is a good thing. But fighting against something else is, in our
opinion, not an appropriate method to reach this goal. It would
be better to invest in the profiling of your own message and
methods. Once we feel that we are being carried away, against
our will or not, in an integrative movement, we do not have to
be afraid that we will lose ourselves in it. We can get out of it
on our own, or take part in the larger whole and help create
something that is more than the sum of its parts, all the while
making sure that we can still recognise ourselves in what we
are doing. That will assist in finding and keeping the middle
road between preservation of one’s own identity and integration
into a larger whole.
The authors thank E. H. Bos and N. K. Vollbehr for their as-
sistance in preparing the manuscript.
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