Prior to beginning work on this discussion, please read both Limitations to Evidence-Based Practice? and Rationale and Standards of Evidence-Based Practice,?and listen to the Case Studies i

UAGC | Case studies in non evidence based treatment Part one-1 UAGC

Hello, and welcome to this discussion. My name is Dr. Steven Brewer, and this is the first of two audio files that will introduce case studies in non evidence based treatment. But first, what is evidence based treatment? Evidence based treatments, or evidence based practices, are generally those that are supported by peer reviewed scientific literature.

This definition may lead you to assume that non evidence based practices are those that have been disproven by peer reviewed scientific literature, but that isn't the case. Non evidence based practices are simply those practices that have not been supported by peer reviewed literature yet. Joining me to talk more about non evidence based practices is Dr. Erick Cervantes, Assistant Professor and Chair of the Complementary and Alternative Health Program at Ashford University. He'll be sharing with us some fascinating cases where evidence based practices fail to completely help a patient's concerns.

Thank you Dr. Brewer. I appreciate this time. A little bit of background first, I have a relative by the name of Ivan S., and so Ivan is a Navajo descent individual born in the area of the Navajo reservation in Arizona. And in his early years, between the age of 20- years-old and 26-years-old, he was deployed to Iraq for a couple of tours in that war. In any event, the point is that the first time they returned from that war, Ivan came back with a lot of anger management issues at home and began to have a lot of squabbles with his wife and children, which was very different than what he was before.

He did another tour thereafter. Of course, there were other problems in the household prior to his next departure, but when he returned it was very apparent that he was very much affected by the war. He was taken to the Naval hospital here in Southern California. His mood became stoic, but his behavior continued to be very, very aggressive.

He began to beat his wife, began to beat his children, recurrent nightmares at night, night sweats, and many, many, many problems. And he continued on to go into the Naval hospital with no– here in Southern California with no apparent relief of his symptoms or his behavior. He began to drink, began to have issues with the law, and so to no– again, no rescue from conventional practice with the medications and the treatment. He began to also go to see a counselor, but that also didn't do very well.

OK so, a little bit of background on what we'll call patient M.D., so at a very– she grew up, basically, in a very poor town, a agricultural town of many, many migrants. Migrants of Mexican descent as well as Central American descent. Mother and father married at an early age. Probably, I think there was seven children in her family, if I remember correctly of this case, and she was one of the younger females of the family.

At that time and at this place, there were rival gangs that were part of her life, but as she began to go into her teenage years, she began to experience a lot of attention from a lot of her male peers. But one time, at one point, she began to have problems with these peers that were gang related, and then experienced gang rape from the age of 14 to 16. She belonged, actually, to one of the rival gangs, so therefore, it was very apparent that her collusion or her involvement with the rival gang brought her into more at risk for these things to happen.

Not that– not as a justification, but more of how these gangs relate to each other. She began to– then from that point, after 16, she began to use more heavily both marijuana, meth, heroin, alcohol, and she expressed that, more than anything, she was trying to drown out the anxiety, the fear, the panic attacks that she would experience on an everyday basis due to her belief that this would happen again at any time soon. She at the age of 18, she disbanded from these gangs and began to have her own life, trying to go to school, finish high school specifically.

She finished with the GED and was in and out of college between the ages of 19 and 24. And her family life, she dissociated completely from her mother and father because she felt that she felt abandoned by them, specifically when she was trying to address the trauma that she experiences so young. As a matter of fact, she even expressed to them that she was raped and that she wanted some people to go to jail for it, but the parents did not proceed to help her out with any legal ramifications that would come from that.

So she felt also disregarded, especially for what she wanted to do. Her parents actually blamed her for the rape, so she carries a lot of rancor and a lot of anger towards her parents and manifest that in many ways towards her parents. She's disrespectful. She reports that she's very disrespectful. She doesn't really visit them that often, she has a lot of fights with them for many, many little things.

She's been in and out of relationships, very short term relationships. Mostly been intimate relationships, rather than more of a whole relationships with peers, specifically male peers. She identifies as bisexual, but she prefers men, but still has a lot of issues with men and constantly fights with men, physically fights with men and especially her partners.

Socially, now her focus is she's an activist. She does a lot of work with migrant families trying to educate them, trying to empower them. She also goes to rallies too for migrant rights and also undocumented rights, so she is very much like a social worker, as well as an activist, and believes that she's doing this because she, you know, she's trying to give back for people that are also abused and disregarded in this society.

She is very youth oriented, so she's– a lot of her focus is educating youth and also preventing youth violence, specifically sexual violence against youth and especially females. However though, on the other side of the spectrum, she's so ardently a zealot, actually, with these ways of being because she can't take no for an answer. She does things by force, so in essence she encompasses a very strong male, almost patriarchal attitude about things and she demands things to be done in a certain way, which hampers a lot of her relationships with people. She can't really form very good social bonds and really alienates a lot of people with her force or with the way that she is in forcefully pushing her agenda on folks and forcefully pushing a lot of her– yeah, mostly her agenda of helping youth, et cetera.

So I guess what I'm saying is that there definitely would be a better balance if she was a little more in tune with how she manifests to people. Right now, you know, she would probably have more allies if she wasn't so harsh in manifesting what her agenda is. Again, as previously said, I said she suffers a lot from anxiety, she suffers from insomnia, she currently takes medication for anxiety, and she continues to self-medicate with marijuana to also decrease the anxiety. She has some social phobia, but also very outgoing, interesting enough, so she has both of those polarities, and suffers from panic attacks on a constant basis.

Really even more interesting from a kind of holistic way of looking at this is that she was recently diagnosed with uterine cancer, and what that does from my perspective as a clinician and naturopathic doctor, what that tells me is that the energetic imprint of that trauma obviously is well imprinted in the uterus, and the manifestation of that trauma is still there. So if she goes on to do other work, specifically spiritual work or other forms of therapy, I think there's a possibility to lift that cancer growth. And not from a chemical perspective, you know, not from chemotherapy or radiation therapy, but more from a very intuitive, very mental, emotional, and spiritual practice, so other recommendations will be given from that. So that's the background on M.D.

Well, thank you Dr. Cervantes for that fascinating case study. Students your challenge as individuals looking at these cases is to provide a provisional diagnosis for these patients, and then propose the treatments as discussed in the discussion forum.

UAGC | Case studies in non evidence based treatment Part two UAGC Hello and welcome to this second audio file regarding non-evidence-based treatment. I hope you had fun with the discussion last week. My name is Dr. Stephen Brewer, and I'm again joined by Dr. Erick Cervantes.

And before we get into the non-evidence-based treatments with those cases that Dr. Cervantes presented on last week, I'd like to first talk about evidence-based practices a little bit, and the three general types of evidence-based practices out there.

So the first general type of evidence-based practice is the known efficacious, or well-established, treatment. Those are the ones that we hear about quite often, like cognitive behavioral therapy for anxiety, or interpersonal psychotherapy for depression. Those are all well-established treatments.

The second area is probably efficacious, and these are treatments that have some peer-reviewed scientific literature that support them, but not enough to where the field will point to the treatment and say, yes that's the definite go-to treatment for this condition.

And then three are the experimental treatments. These are the cutting-edge treatments that don't have almost any peer-reviewed literature but they're still being explored as treatments.

So I guess, Dr. Cervantes, my question is, is there something in complementary and alternative health or non-evidence-based practice that is similar to these three categories?

Well, I mean, not necessarily "similar to," per se, in these categories, because I think on some of these categories would basically have– they would have these rhythms that they follow. It's basically from top to bottom, the approach is that way.

From my perspective– from a naturopathic perspective, as well as, if anything, an alternative perspective– we consider empirical evidence the most important evidence, really. So if something works, we just follow that. We know that that specific thing works.

But we also do not limit ourselves and put ourselves in a box, and say like, well, if that works– if we've seen that, that that works, then we should just approach it that way. We think of something else like, well, that works for that person. That's one individual. What if we add that with another thing for the next individual?

Because again, from our perspective, this is individualistic medicine, or an individualistic approaches to any case– any case. So again, empiricism to adaptation, rather than a belief that everybody is the same and then approaching that sameness with the same approach. It's more of, let's actually look at the individual and what that individual needs.

So this isn't sort of like, as you would with a keyboard, a hunt and peck for the letters. This is more of an informed approach that will hopefully help the person. But it was informed by, what? It's informed by previous experience, by shared knowledge in the field?

Yeah, actually, it is. It's from many, many years of known knowledge in the field. It's passed down from practitioner to practitioner, or from specific disciplines to different disciplines within the alternative health realm.

So let's say, for example, someone comes in with a specific headache– specific headaches that also have vertigo and ringing in the ears. Some people would just approach it, well, that might be a neurological thing, of course. But let's provide him some medication so that they can actually tone down that.

But from our approach, it's like, well, what else is going on structurally? What else is going on mental emotionally? What else is going on, perhaps, spiritually? But it's interesting– not a lot of conventional doctors or maybe, perhaps, even other disciplines from the conventional side will look at it like, maybe structurally we could do something.

And maybe when you look at structure and maybe, perhaps, a vertebra is out of place, then boom– you put that vertebra back in place and all of a sudden you have this flow again of the nervous tissue as well as blood flow, et cetera. So you got to think outside the box rather than just simply thinking, oh, reductionistically all that must be just on the nervous system and stuff, so.

Right, the great point about thinking outside the box. More and more psychologists are starting to recognize the importance of thinking outside the box even though, for the past 50, 60 years or so, the zeitgeist has been evidence-based practice, and that being the practices that are supported by scientific literature. We're recognizing now that there are more and more practices out there that have been passed down through the generations that have maybe we don't know the why it works, but we know that it works.

There are more and more of those out there that we have to embrace and that we have to at least recognize, especially when we're working with people from different cultures. I hear more and more psychologists using their own personal definition of evidence-based approaches. And that being combining their experiences as a healer, the patient's values and preferences, and the scientific theories that many psychologists use. So it's sort of the middle ground between, I guess, what you're saying and what the field has been demanding for such a long time now.

Yeah, Dr. Brewer, if I may add– I think it's really– for me, from my standpoint– it's rather arrogant to state that one knows everything just based on what they're reading as evidence base. That's rather arrogant.

It's more because I have to really pound this belief or this philosophy that the alternative people believe is that no individual is the same. Everyone has lived in a different environment. So therefore, a different expression of being.

So you can't approach, from one perspective, every individual. You have to approach an individual with multiple perspectives and different approaches. And again, beating this horse here, thinking outside the box.

Well, it can't be a cookbook.

Yeah, exactly.

You can't just cookbook treatment approach for everybody, even though it may be easier to do that sort of thing on paper. In reality, when we get into the field, that is not the case.

Yeah. Cookbook's rather bland, then.

So this leads to another point regarding any practices that are not within the, quote unquote, "evidence base" being regarded as quackery. This has been the more extreme reaction, I would say, from the evidence-based camp in trying to discredit any practices that don't yet have any scientific support to them.

To me, it seems like it's throwing the baby out with the bathwater. There may be some practices out there that are harmful and that, over time, we can show through the peer-reviewed literature, the scientific literature, that they are indeed harmful. But we shouldn't throw out every practice out there just because we haven't gotten around to actually researching them yet. So I know that you have something to say about the quackery aspect of the field.

Sure, sure. That's a really good point. Without going to a lot, a lot of detail with the rest of the history of, basically, the territorial fight between conventional doctors and alternative practitioners, the split actually between conventionalists and alternative practitioners took place probably in the in the 1800s.

And actually, the 19th century when what began to happen was, I said a little bit before, René Descartes began to separate the human being into three components, basically. Which was, one was a mental emotional component, and the other one was a body component.

But interesting enough, what he didn't regard was the spiritual component, which came way before that. Because there is sufficient literature out there and historical literature that states that all cultures– specifically also Western cultures, speaking of European cultures– that they all treated individuals from the spiritual aspect first, and then treated the mental emotional, and then the body perspective.

We knew much more back in the day because we only knew about our environment, before we knew the micro level aspects of our life. I'm specifically speaking to chemistry and constituents of chemistry.

We as human beings, literally, were much more connected to the spiritual aspect, and then the mental emotional and then the body aspect, through rituals, ceremonial rites, and customs, as well as what we have around us, which were mostly were herbs and other things.

Again back to the 1900s, René Descartes really split us, in that his philosophy was that we were more like a machine rather than an actual, from our regard, a miracle of life. Often we don't think of ourselves as these entities that traverse shortly around the world– I mean, for a short time around the world, and then we move on.

So I know that's more of an esoteric kind of perspective. But so they call that a Descartesian Split. Alternative folks didn't have a split, but conventional doctors rode on that wave for a long time and began to really provide evidence that they were, at a very micro level, that there were these little machines or molecules working to express who we are.

So back to the issue of quackery, I think what it is– the difference between our approaches is that you have medical doctors that treat only physical disease. From one– I mean, if you're going to reduce it that way, they mostly treat trauma, as well– trauma as in mechanical trauma, like in accidents or in burns, et cetera. But they also treat chronic disease and some acute diseases. But again, for more from a body perspective.

Then you have the other split where you see counselors and psychologists and psychiatrists use only the mental emotional aspect. And then you have the other conventional side, which is spiritual people– meaning religious individuals, clerks, clerics, et cetera– they're treating the spiritual aspect.

So you have these three different entities trying to address the population. Where, from our side, is like, well, we don't think of them all separately. We are thinking them all as an entity. So every individual is compulsive– the spiritual aspect, the mental emotional aspect, as well as the mind and mental emotional.

So all of those together, that's the way we approach it. And we're called quacks for that. And it's interesting that that's the default when that is the whole human being. And every individual, again, is very unique in their way of living, their way of expression, the way they express themselves in their living environment.

So maybe, perhaps, that's part of your question, or one I'm answering, but maybe perhaps you can lead me on a little bit further than to other things.

I think that's– you come to a great explanation and understanding of why you're being called quacks as a field. Which I think is unfortunate because, again, if you're able to take all three of these components, combine them, and understand the whole of the human being, therein is the holistic healing. You hear about holistic healing quite a bit. We don't really understand what that means, but what you just described– that is holistic healing.

And it could be that people in your field are ahead of your time. It could be 100, 200 years from now– we finally have all the literature to back up what the treatments that you have and the approaches that your field is proposing. But for now, because we have such a medicalized model and the medicalized model is so attached to the evidence base, it's almost like there's a willful ignorance of anything that's outside of that evidence base, unfortunately.

But if we could just take all the research from each of these three areas currently, combine them– which hasn't been done yet, to my knowledge– then we will have more support for your area and, perhaps, that'll lead fewer people to calling you quacks. Maybe they're afraid of that. That could be the case.

When you were adding this, I was thinking that, from a medical standpoint, it's almost– it's hard to understand that you would approach someone only from a body perspective and you're only approach someone only from a mental emotional perspective, and then spiritual. It's hard to believe that.

Because what that happens is that, from an economic perspective, you're approaching everybody– I mean, you're pushing someone monetarily. You're not approaching someone from, again, what you said is holistically. You're not– that is, in essence, our medicine is one of sustainability rather than something that would be splitting them up to– just always money. We know that there's a pharmaceutical industrial complex, in some regard. And then we know that there's a lot of money going into our medical system, unfortunately, where we're having a lot of issues and the–

What we have is sickness management system right now, rather than a health enhancement system.

Right, rather than a preventive, as well. Yeah, to add into that. So anyway, that's a really interesting point you make.

Fascinating discussion on both these topics. And now, Dr. Cervantes, we'll be talking briefly about what actually happened with those case studies that we learned about last week.

Ivan, though, is a traditional Diné, Navajo. And instead of continuing on with the conventional practice or follow-through treatment, he decided to seek out a medicine man in the Navajo Indian reservation. So he and his wife and children went to seek out help from these elders and they sought out a medicine man there.

Basically, he partook of a ceremony that took place for three days. He entered at sundown on the first day and did not come out of, what they call a hogan, until 3 days later, also after sunset.

During that time, the Diné performed, what they call, the Calling the Spirit Back, or Calling the Warrior Back, ceremony of that Indian reservation. And Ivan returned from that trip from that medicine man, from that ritual and, little by little, regained his old self.

So I think the point of this is that there are elements from different disciplines, and specifically natural medicine, where one really needs to approach a case not solely from a chemical perspective, also in a trauma perspective, or mental emotional perspective, but also seek out one that treats the spirit.

So from that medicine man, what he did was call the spirits back into his life and, therefore, Ivan returned to becoming a more sustained individual. He came off of the medications on his own. He no longer sought out the intervention of counseling, and began to practice other traditional Navajo ceremonies, which include the sweat lodges, Sundance, and tipi ceremonies.

So that's the case– the first case where Ivan and where he's now a better person– doesn't have any behavioral issues, and PTSD symptoms that he described previously are no longer with him.

The second case is of a 29-year-old female who sought out counseling due to being gang raped when she was 14 through 16 years old. There were– she had a lot of issues with, obviously, with her parents due to the projection that, obviously, they didn't protect her at a youthful age. She began using drugs after that– drugs and alcohol, specifically methamphetamine and heroin.

And– which is interesting, though, she also began to seek out Native American ceremonies to also help her. During that process, though, one of her elders, as she states, began to tell her that she acquired a specific spirit at a very young age.

And what that elder was saying is basically that she began to manifest the spirit that was put onto her from a male, from males, because she was a very aggressive individual, always fought with everybody. So her demeanor was very– I guess you would just describe it from a Chinese perspective as a young energy, rather than more of a female essence of a yin.

So in any event, the reason I'm mentioning this case is because the 29-year-old finally decided to take a further step in and do, what they call also in Native American ways, a spirit ceremony as our previous case was. So, spirit retrieval ceremony.

And that took place, and again, when she had no resolved issues with Western medicine or Western approaches– which would be counseling and other medication– she began to experience, after the ceremony, a lot of alleviation of her symptoms. Specifically the anxiety that– actually, yeah, the anxiety.

A lot of issues with her sleep patterns– she wouldn't be able to sleep very much. She would have constant nightmares. She was often– she had panic attacks.

But little by little, after the ceremony, she began to find relief from that. She's currently seeking, also, further assistance from a naturopathic doctor who provides herbs and other types of counseling that are different than approaches from the conventional approaches of counseling. And that's it for that case.