Pergamon Sot'. Sci. Med. Vol. 45, No. 7, pp. 1129 1133, 1997 i 1997 Elsevier Science Ltd. All rights reserved

P l h S0277-9536(97)00010-5 Printed in Great Britain 0277-9536/97 $17.00 + 0.00

SHORT REPORT

CONTINGENT LEGITIMACY: U.K. ALTERNATIVE PRACTITIONERS AND INTER-SECTORAL ACCEPTANCE

PHILIP TOVEY

Centre for Research in Primary Care, University of Leeds. Leeds, England, U.K.

Abstract--Although alternative medicine has achieved an increasingly high profile in recent years, sur- prisingly little social research has been conducted in the area. This is noticeably the case when consider- ing inter-sectoral contact and collaboration. This paper fills that gap by drawing on evidence from a large-scale study of non-orthodox practitioners in the U.K. By examining the lived experience of inter- action the study aimed to discover the level of professional legitimacy which alternative practitioners routinely enjoy or are denied by mainstream practitioners. Results show that the last decade has been characterised by an increasing liberalisation of attitude toward inter-sectoral collaboration throughout the mainstream. However, the evidence also shows that this cannot be equated with the existence of a generalised acceptance of alternative practitioners' professional legitimacy. There is a schism within orthodoxy on this issue and that schism is occupationally based: at the extremes, consultants remain characteristically dismissive of alternative practitioners, nurses overwhelmingly enthusiastic. The nature of the non-orthodox practice being considered was of little significance. It is argued that the identifi- cation of differentiation within orthodoxy on this issue marks a significant point in developing an understanding of relations between the "sectors" and its component parts. There is a clear potential for conflicting developmental paths of action between orthodox groups, and for differing conceptions of who and what constitute a legitimate part of the medical totality. Cross-sectoral alignments, which chal- lenge the state sanctioned dichotomy of mainstream/alternative, are viewed in quite different ways throughout orthodoxy. Knowledge of this intra-sectoral differentiation is essential to an understanding of emerging patterns of inter-sectoral relations. :~5 1997 Elsevier Science Ltd

Key words- alternative medicine, differentiation, inter-sectoral acceptance, legitimacy

INTRODUCTION

It is becoming something of a truism to state that alternative medicine is currently in the midst of a period of substantial change. Yet in many ways our knowledge of the character of this change is limited. Alternative medicine in general, and inter-sectoral contact in particular, remain under-researched (Cant and Sharma, 1994). Where published work has to date made direct or indirect reference to col- laboration or differentiation between the sectors it has tended to draw on evidence from small numbers of practitioners (Cant and Calnan, 1991; Sharma, 1992) use or thodox practitioners as respondents, (Reilley, 1983; Wharton and Lewith, 1986; Anderson and Anderson, 1987), focus on planned localised contacts (Christie, 1991), or has been con- cerned with the political differentiation of the sec- tors (Saks, 1992).

This paper provides an examination of contem- porary patterns of inter-sectoral acceptance. It is concerned with the level of professional legitimacy ascribed by mainstream practitioners to their "al ternat ive" counterparts. Professional legitimacy (the acceptance or denial of the occupational val- idity of practitioners or practitioner groups by another) is conceptually distinct from state sanc-

tioned (Jormal) legitimacy (a matter of political in- clusion and exclusion). They may, or may not, mirror each other.

Evidence relating to three themes is discussed. The first theme addresses whether it is possible to identify overall patterns in the ascription of pro- fessional legitimacy across the sectors.

The second theme is an assessment of differen- tiation within such patterns. This analysis is informed by an awareness of both the oft cited het- erogeneity of the alternative sector (Saks, 1992) which, it can be deduced, provides the potential for varying appraisals from the mainstream; and the much less widely discussed (in this context) diversity within or thodoxy-- the differences of status, auth- ority and financial rewards; gender compositions; and forms of practice which have been reflected in the emergence of programmes of concern specific to particular groups (e.g. nurses) throughout modern medical history (Witz, 1992).

The third theme, considers what the evidence in- dicates about shifting (inter-sectoral) professional alliances, the practical implications for bio-medical orthodoxy, and for those most closely allied to it; and the explanatory utility of the alternative/ortho- dox dichotomy.

1129

1130 Philip Tovey

METHOD RESULTS

A postal survey of 1000 practising U.K. non- orthodox practitioners was conducted between late 1993 and early 1994. It had been piloted on 6 alternative practitioners (2 chiropractors, 1 osteo- path, 1 homeopath, 2 multi-therapy) in Yorkshire, England prior to distribution.

A tightly defined research population--current U.K. practitioners of chiropractic, "lay" homeop- athy (i.e. as distinct from homeopathy practised by those qualified in orthodox medicine), medical her- balism, and reflexology who are members of at least one national representative body--was employed. Clear parameters were set because the identification of the complete population of U.K. alternative practitioners is not viable. This is because individ- uals can and do operate independently of organis- ations and registers; moreover, which therapies can be classified as alternative is open to debate.

Systematic sampling (every nth practitioner) was used to select 250 respondents per therapy from alphabetically ordered membership lists of relevant representative bodies. Within each therapy prac- titioners had an equi-probability of selection. The response rate was 57% (546 respondents--a small number of the original sample had retired or ceased practicing for other reasons). This rate varied amongst the 4 therapies thus: homeopathy (62%), chiropractic (58%), medical herbalism (44%), reflexology (54%). The geographical origins and gender composition of respondents and non-respon- dents were compared; no significant differences were revealed.

Results were analysed both as a whole and by therapy. Data was subjected to weighted statistical analysis (to take account of the varying response rates); Chi square and Cramer's V tests were employed.

This section details results relating to two quite distinct issues. The first is whether alternative prac- titioners have experienced a change--positive or negative--in the attitudes of mainstream prac- titioners toward their practice in recent years. This is purely concerned with the direction of change and not the extent of it. Thus, evidence of a positive trend should not in itself be seen to represent enthu- siasm or approval, and similarly, a negative trend should not be assumed to equal rejection.

These matters of contemporary experience of enthusiasm or dismissiveness are dealt with by the second set of results. This data set provides insight into the extent of professional legitimacy experi- enced after the recent period of increased debate about alternative medicine.

Professional legitimacy and experience: recent trends

Respondents identified trends in their interactions with practitioners from six mainstream occupational groups over the last decade (see Table 1). The six incorporated occupations with markedly different roles, financial rewards, status and authority.

It is immediately apparent from Table 1 that far larger numbers of orthodox practitioners have moved toward a belief in increased inter-sectoral co- operation than moved away from that position. However, an examination of the raw data relating to specific orthodox groups shows that this was not a uniform phenomenon. For example, of those respondents who reported substantial contacts with consultants 169 had experienced a positive change; 29 the reverse: a ratio of more than 5:1. Whilst cer- tainly demonstating a liberalisation of attitude, the corresponding ratio for nurses was 231:1 (463 respondents noting a positive shift and--despite the vastly larger number of inter-sectoral contacts--a mere 2 respondents reporting a negative shift).

Table 1. Development of attitude amongst selected mainstream practitioner groups experienced by non-orthodox practitioners over the last 10 years (%)

A B C (n = 526) (n = 535) (n = 515)

More interested in working with alternative practitioners Less interested in working with alternative practitioners Have had little contact with this mainstream group No change Don't know

More interested in working with alternative practitioners Less interested in working with alternative practitioners Have had little contact with this mainstream group No change Don't know

31.0 78.7 24.5 5.5 2,1 6.0

43.9 10.3 49.9 11.8 5.6 9,5 7.8 3.4 10.1

D E F 01 = 538) (n = 534) (n = 523)

86. I 39.6 35.4 0.4 2.5 2.9 9.3 43.0 42.3 1.9 1.7 6.9 2.4 13.2 12.6

A: consultants B: general practitioners C: hospital doctors D: nurses E: occupational therapists F: pharmacists

Contingent legitimacy 1131

The evidence relating to change revealed a large degree of consistency across the four respondent groups. Where differences did emerge they tended to focus on one response group--chiropract ic--and its experience with specific orthodox groups: most notably, consultants.

59% of chiropractors reported a positive trend amongst consultants. (medical herbalism, 21.6%; homoeopathy, 16.4%; reflexotogy 21.6%). This pro- duced a statistically significant difference in each case (Z 2 = .00000) with high associated readings for Cramer's V (medical herbalism .47; homoeopathy .45; reflexology .62). The substantially greater con- tact between consultants and chiropractors is par- tially involved here (only 15.3% reported minimal contact: over 50% so reported in each of the other groups). But it is important to remember that such contact levels only provide the context. While reports of a positive attitude change amongst con- sultants increased with greater contact, a propor- tionate increase in negative attitude change was not found.

Thus, at this point, on the basis of the evidence on trends, it might well seem appropriate to acknowledge the emergence of a generalised and significant positive trend. However, as will now be shown by the data on contemporary interactions, the situation is somewhat more complicated than that.

Professional legitimacy and experience." contempor- a O' interactions

Table 2 summarises respondent interpretations of orthodox practitioner attitudes as experienced in the 1990s. Evidence of differentiation is found in dramatic form when looking at the extent to which dismissiveness most frequently characterises inter- actions. Twenty-seven point five percent of respon-

dents felt encounters with consultants could be so characterised. Conversely, the corresponding figure for interactions with nurses was a mere 0.2% (remaining 0.2% after adjustments--just 1 respon- dent).

This differentiation within orthodoxy is brought into particularly sharp focus when an examination of the results relating to the two negatively orien- tated responses--dismissiveness and little interest-- are considered together, in direct comparison with the two positive responses. The findings (see Fig. 1) show that points of resistance to alternative medi- cine remain firmly in place, notably amongst con- sultants (including, perhaps surprisingly in view of the evidence on trends, attitudes to chiropractic this is discussed below) and hospital doctors.

Experience with other mainstream occupations was, though, reported very differently. In inter- actions with nurses ascriptions of legitimacy domi- nate to the extent that they are absent in the earlier examples (see Fig. 2). Nearly 87% of respondents identified either a genuine enthusiasm or a signifi- cant level of interest as the most characteristic fea- ture of professional contact with nurses; the figures of 17.6% and 13% for consultants and hospital doctors respectively stand in dramatic comparison.

Differences in experience across the four prac- titioner groups were difficult to find. Contact levels with consultants were, once again, higher for chiro- practic but this time increased interaction did not equate with substantially higher levels of positive judgements. Seventy-one point two percent of chiro- practors reported either dismissiveness or little interest as the characteristic consultant attitude similar to the mean figure (82.4%) for the whole sample. What this means, then, is that while the majority of chiropractors were able to highlight a trend amongst consultants which was characterised

Table 2. Nature of most frequently encountered experience with mainstream practitioners (%)

A B C (n = 534) (n = 537) (n = 525)

Dismissive of potential of alternative medicine A small level of interest A significant level of interest Genuine enthusiasm Have little contact with this mainstream group Don't know

Dismissive of potential of alternative medicine A small level of interest A significant level of interest Genuine enthusiasm Have little contact with this mainstream group Don't know

27.5 6.5 16.0 28.7 41.5 33.9

9.2 38.0 6.5 2.8 5.6 1.0

27.3 5.2 34.5 4.5 3.2 8.2

D E F (n = 530) (n = 523) (n = 527)

0.2 2.1 4.9 11.8 11.7 21.4 44.2 18.7 18.4 34.1 9.9 4.4

7.5 43.6 38.0 2.2 14.0 12.9

A: consultants B: general practitioners C: hospital doctors D: nurses E: occupational therapists F: pharmacists

1132 Philip Tovey

100

90

80

70

60

% 50

40

30

20

10

0

87 - - 0 - - Dismissive/little interest 82.~.....~m • X - - • - - Dismissiveonly

\ 53.6 •.__----•

40.4 52.4 0... 32.4

.~ 27.9 " ~ 2 "~ ~ 15.7 3.2

0--~ 10

I --I '5~.~°2 I

E ,~ ,.- Z

I I I

Orthodox practitioner group

Fig. 1. Dismissiveness/dismissiveness or little interest as most frequently encountered experience of alternative

practitioners in interactions with orthodox practitioners.

by an increased rather than a decreased level of interest (see Table 1) the extent of the attitude shift was actually very small: too small to cause a change to the pre-dominance of "dismissiveness/little inter- est" .

DISCUSSION

Three themes were identified earlier as pivotal to an understanding of professional legitimacy and contemporary medicine. Each will now be discussed in turn.

1. A trend toward attitude liberalisation through- out orthodoxy is observable. However, this should not be confused with a generalised con- temporary acceptance of the professional legiti- macy of alternative practitioners. Whilst the direction of change might well be towards greater

100 90

80 70 60

% 50 40

30

20

l0

0

86.8 /,// 3 / .47 .6 .4/46.4

_- ,76/ *~ , / ]3 I I I I I I

©

Orthodox practitioners group

Fig. 2. Significant level of interest/genuine enthusiasm as most frequently encountered experience of alternative

practitioners in interactions with orthodox practitioners.

inter-sectoral acceptance, in certain cases the extent of change has been marginal--fundamen- tally oppositional views remain.

2. A process of sub-group specific differentiation is central to this heterogeneity; and the key vari- able of that differentiation is the occupational group of the orthodox practitioner. The therapy of the alternative respondent is, in comparison, substantially less important.

Bearing in mind the unequal distribution of autonomy, authority and financial reward within orthodoxy, there seems to be strong evidence to support the notion that what is being seen is, at least in part, a status related schism: a greater flexibility to the non-orthodox being expressed amongst those least effectively rewarded by the existing arrangements. As noted earlier, different occupational groups within orthodoxy have pur- sued their own particular concerns at particular times (Witz, 1992). The affinity between nurses and alternative medicine might well be seen as an example of this: as an historically ,specific pro- gramme of focus. The gender compatibility, the greater "human" dimension of nursing over say surgery (Morse, 1991)--including the more fre- quent opportunity to discuss experience of alternative practices with patients, as well as the status parallel between the excluded "outsiders" and the least well rewarded "insiders" can all reasonably be seen as conditions which might favour such an affinity.

As a consequence, any conception of orthodox medicine constituting a single block, either acting to reinforce its power and authority or, indeed, acting out any other unified strategy toward out- siders is clearly inappropriate. The situation is characterised by a contingent legitimacy: the pre- sence or denial of professional legitimacy is con- tingent upon which of a heterogeneous group of (orthodox) occupations is being focused on. The degree of the variation found demonstrates how alternative medicine is an issue which is produ- cing almost diametrically opposed actions and reactions in these groups. At the higher status levels there is an operational parallel between for- mal legitimacy and proJessional legitimacy; at the opposite end of the spectrum, the two are quite distinct.

3. The schism of opinion within orthodoxy has a direct bearing on the evolving character of U.K. medical provision as a whole. This is because (with individual exceptions) the two extremes of the continuum (nurses and consultants) are the embodiment of quite unrelated sets of beliefs about the role and utility of the formally excluded therapies. Evidence relatmg to the two groups reveals a fundamental tension about who can maintain a claim to be a (legitimate) health care provider: as a logical corollary who might come to represent the "'insiders" and "outsiders"

Contingent legitimacy l 133

of provision in the near future; and, as a conse- quence, how far the status quo, with its entrenched patterns of authority, remains viable.

Thus the potential is established for a marked divergence in both the direction of allegiances and in patterns of collaborations. Although the distinc- tion between orthodox and non-orthodox remains central to the allocation of state sanctioned legiti- macy, the extent to which it will hold explanatory power for understanding the full range of inter- actions between practitioners is open to question. Although the planning of professional collabor- ations remains locked into this dualism in certain orthodox groups, through their preparedness to engage in cross-sectoral referencing, nurses are already down playing (if not dismissing entirely) this distinction.

The process by which the relationships and boundaries between mainstream and alternative practice and practitioners are being re-defined is far from complete. The eventual outcomes of this pro- cess must, for the moment, remain at the level of conjecture. However, on the basis of the new evi- dence, what is now clear is that such outcomes will not be produced as the result of a simple interplay between the competing priorities of two unified sec-

tors. Conflicting intra-sectoral beliefs make the situ- ation rather more complicated than that.

REFERENCES

Anderson, E. and Anderson, P. (1987) General prac- titioners and alternative medicine. Journal of the Royal College of General Practitioners 37, 52-55.

Cant, S. and Calnan, M. (1991) On the margins of the medical marketplace? An exploratory study of alterna- tive practitioners' perceptions. Sociology of Health and Illness 13, 39-57.

Cant, S. and Sharma, U. (1994) Social aspects of comp- lementary medicine. Medical Sociology News 19, 23-24.

Christie, V. E. (1991) A dialogue between practitioners of alternative (traditional) medicine and modern (western) medicine in Norway. Social Science & Medicine 32, 549-552.

Morse, J. (1991) Negotiating commitment and involve- ment in the nurse/patient relationship. Journal of Advanced Nursing 16, 74 81.

Reilley, D. (1983) Young doctors' views on alternative medicine. British Medical Journal 287, 337 339.

Saks, M. (Ed.) (1992). Alternative Medicine in Britain. Clarendon Press, Oxford.

Sharma, U. (1992) Complementa O' Medicine Toda.v: Practitioners and Patients. Routledge, London.

Witz, A. (1992) Professions and Patriarch)'. Routledge, London.

Wharton, R. and Lewith, G. (1986) Complementary medi- cine and the general practitioner. British Medical Journal 292, 1498-1500.