Alternative medicine has been defined as those medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals (1).

Despite the increasing use of alternative treatments by the American public, many health practitioners remain mystified by and skeptical of these approaches. The language, practices and underlying philosophies of alternative medicine may seem unfamiliar and at times even incomprehensible, and trying to step into the shoes of an alternative practitioner may be a bit like taking a journey to a foreign land. The purpose of this article is to provide you with a brief encounter with the world of alternative medicine by exploring utilization patterns, underlying beliefs and the scientific evidence for the efficacy of several therapies in treating physical and mental illnesses.

As we begin this journey to the realm of alternative medicine, we might initially observe the large number of people who are already there. Until recently, it was widely held that only a limited number of patients utilized alternative therapies. A 1993 telephone survey of 1539 adult Americans, however, found that 34 percent of respondents had used an alternative therapy in the past year. This would extrapolate, if we used 1990 census figures, to a total of 425 million visits, with expenditures of $13.7 billion.(1). We might wonder what is it that attracts so many people to this place. The majority of people seeking alternative therapies are those with chronic illnesses who believe that conventional medicine has few effective treatments for their conditions. In addition, many of these people endorse a "holistic" philosophy -- that body, mind and spirit are important in health -- and classify themselves as belonging in a cultural group identifiable by an interest in personal growth psychology, self-actualization and self-expression (2).

These observations might suggest to us that these patients are seeking certain qualities of the patient-practitioner relationship that are more readily available in alternative than in conventional health care settings. When we search for the reasons for these preferences, we are struck by what seems to be differences between the language and philosophies of the alternative traditions and our own.

In most conventional medical specialties, we focus on the physical aspects of the patient's suffering, dispensing "cures" to a relatively passive recipient of care, with the ultimate goal of eliminating physical symptoms. Indeed, our understanding of what produces disease and what makes us better is reduced to the cellular and ultimately, chemical level. Healing primarily involves providing chemical or mechanical (e.g., surgical) cures which come from outside the patient.

The underlying beliefs and practices in many alternative therapies are quite distinct from the conventional approach described above, but bear a closer relation to psycho dynamic psychiatry. Many psychotherapeutic models and many alternative systems hold that trauma and unresolved conflicts can result in the development of symptoms, both emotional and physical. Healing involves the expression and release of the emotional "energy" stemming from these conflicts. For this process to occur, the patient must be an active participant in treatment, since healing is not a cure dispensed from without, but is rooted in the patient's own internal corrective mechanisms. The practitioner then plays the role not of an expert dispensing cures, but of a guide to the transformational process. We are of course speaking here of psychotherapy and not psychopharmacology, which more closely fits a conventional model of care. Moreover, symptoms have meaning for the patient -- although the ultimate goal may be to reduce the distress caused by symptoms, they are at the same time guides for where growth and transformation need to occur.

As with any journey, we may go initially out of curiosity, but will stay only if the benefits seem to outweigh the risks. So it must be with alternative medicine; anecdotal reports may pique our interest, but are by themselves insufficient to justify long-term use. Even though underlying concepts and approaches differ, alternative medical interventions must be subject to the same rigorous scientific assessment as any medical treatment. To that end, we should examine soon of the research on the efficacy of several alternative interventions.

Psychological interventions such as relaxation, meditation, support groups, and hypnosis have long been utilized for the treatment of emotional distress, but their application to the treatment of physical illness is less widely accepted by the conventional medical community. This view is shifting, however, as research demonstrates the effectiveness of many of these approaches for a variety of somatic problems. For example, Spiegel studied the effect of a one year intervention of professionally-led support groups on health outcomes among women with metastatic breast cancer. He found, at the 10 year follow-up, a mean survival time of 36.6 months in the support group compared with 18.9 months in the control group (3). A study of malignant melanoma patients participating in a 6-week professionally-led support group showed a longer time to recurrence of cancer in the experimental group at the six year follow-up (4). In a study of chronic pain patients, mindfulness meditation has been found to produce statistically significant reductions in present-moment pain and increases in levels of activity previously inhibited by the pain (5). Similarly, a variety of studies have demonstrated the ability of hypnosis to reduce chronic headache pain (6-9).

Although only limited data is currently available, several research studies suggest that acupuncture may hold promise as an alternative treatment for depression. In an eight week study of 38 women aged 18 to 45 diagnosed with major depression and not being treated with an antidepressant, 64% of the subjects receiving acupuncture at acupuncture points specific for depression (as opposed to the no-treatment group and the group receiving acupuncture treatment at points not specific for depression) showed a reduction in depressive symptoms (10). Similarly, in a study of 41 patients diagnosed with a variety of depressive disorders, those receiving acupuncture for six weeks showed as much symptom improvement on the Hamilton Depression Scale as those subjects receiving Amitriptyline (11).

Although herbal medicines have been claimed to be effective treatments for a wide variety of mental conditions, research data is limited. St. John's Wort (Hypericum perforatum) is widely used in Europe, as evidenced by the 66 million daily doses prescribed in 1994 by German physicians (12). In a meta-analysis by Linde et al, polled data from 23 randomized trials comparing hypericum with either placebo or standard antidepressants (imipramine, amitriptyline and maprotiline) showed it to be effective in 55.1% of patients (compared to 22.3% in the placebo group). In the comparisons with standard antidepressants, hypericum was found to be as effective (13). Adverse reactions are generally mild and include dry mouth, dizziness, constipation, confusion and photosensitivity (14).

Kava kava (Piper methysticum) is reputed to produce a sense of tranquility, sleepiness and increased sociability (15), and could be useful as an anxiolytic. Only one clinical study supports this contention, however. In a 1996 randomized, placebo-controlled double-blind study, patients were treated with either kava or placebo three times daily for four weeks, resulting in a reduction in reported anxiety and tension (16).