Yoga as Entrée to Complementary and Alternative Medicine and Medically Pluralistic Practices

Article excerpt

Yoga is increasingly ubiquitous in the United States and globally. The growth of yoga's popularity alongside Indian healing philosophies, including Ayurvedic medicine, makes yoga an important influence on conceptualization of health in holistic terms. Because of these philosophies, the growing use of yoga has implications for how healthcare is sought and utilized. Yoga practitioners are likely to engage in pluralistic health care-seeking practices, yet, the underlying perspectives that drive yoga practitioners to engage in particular health practices are poorly understood in anthropological and public health literature. This study examined perspectives on health care-seeking among long-term yoga practitioners in a yoga community in Florida. Based on semi-structured interviews conducted in 2010 with 26 adults in a Florida yoga center who have practiced yoga at least once per week for at least one year, the study found that long-term yoga practitioners utilized yoga and other systems of complementary and alternative medicine (CAM) to address health needs that were not met by biomedicine. Moreover, once individuals embarked on long-term yoga practice, they expanded their health care-seeking practices to other CAMs. This study contributes to understanding of the pluralization of health care-seeking practices, highlights concerns with the biomedical health system, and contributes to current debates on health care reform.

Key words: yoga, complementary and alternative medicine, health care-seeking behavior, medical pluralism

Introduction

Yoga is becoming increasingly ubiquitous in the United States - yoga classes are offered at fitness and private centers around the country, yoga-related clothing has established a significant market niche, and the media even track celebrities' yoga routines. Yet this modern-day phenomenon, which has been described by scholars as both "energy medicine" and "mind-body medicine," has a long history of practice in India, possibly dating back 5,000 years (Chaoul and Cohen 2010; NCCAM 2010). Nevertheless, yoga as it is practiced today actually only dates back to the early 20th century, and many practitioners are unaware of this history (Singleton 2010). The growth of yoga's popularity alongside Indian spiritual and healing philosophies, including Ayurvedic medicine, make yoga inseparable from influences that conceptualize health and well-being in spiritual terms. Simultaneously, yoga as a health-related practice comes up against other health care systems in the United States, in particular biomedicine and CAM, and, therefore, has been the subject of a number of studies.

CAM is a broad and diverse field of medical systems and health care practice that are distinguishable by the fact that they generally lie outside the field of western biomedical practice. Yoga, as used by some, is just one form of CAM. CAM can be defined as "mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine" (Chaoul and Cohen 20 1 0: 1 67). It is also not uncommon for CAMs to include spiritual components. Each CAM practice may include all or parts of the aforementioned aspects. Since CAM is not a single healing philosophy, as the name would suggest, each modality can be comprised of multiple facets of what we have come to understand as CAM. As such, yoga as a CAM is also multidimensional, including philosophies about which foods one should or should not eat (due to particular health consequences), what are the appropriate breathing exercises to improve health and spiritual awareness, etc. Therefore, when describing a specific aspect of yoga as CAM, this article uses the appropriate terminology for that aspect given that simply saying "yoga" would not suffice to explain the importance of a particular argument.

The pursuit of health (in addition to spiritual goals) has been identified as the main reason for dedicated yoga practice (Hoyez 2007). A wealth of social science scholarship shows that consistent yoga practice is used by practitioners as a form of medical system and a self-care strategy, in addition to being perceived by practitioners as a "contemporary transnational [spiritual] community" (Strauss 2002b:237). Public health and medical perspectives on yoga show a variety of health benefits related to major chronic conditions, including cardiovascular disease, problems with blood glucose, blood pressure, weight, or sexual function, as well as maternal comfort during labor (Bijlani et al. 2005; Chaoul and Cohen 20 1 0; Dhikav et al. 20 1 0; Harinath 2004; Kaur et al. 200 1 ; Narahari et al. 2008; Robertshawe 2009; Ross and Thomas 20 1 0; Yang 2007). Positive psychological effects have also been identified (Birdee et al. 2008; Kissen and Kissen-Kohn 2009). For instance, yoga has been termed as a way of strengthening self-soothing, which can be important to recovery from illnesses (Calajoe 1 986; Kissen and Kissen-Kohn 2009). There have also been claims that yoga practitioners have the ability to voluntarily self-regulate blood pressure and modulate body temperature (Levin 2001). The social science research approach adds an important dimension to the understanding of CAM and yoga by focusing on the perspectives of the patients in how they understand CAM, its effectiveness, and how subjective experiences with illness and with biomedical providers and the health care system at large shape the perceptions and behavior of CAM practitioners.

The benefits of some forms of CAM are starting to be recognized in the provision of limited health insurance coverage for chiropractic or acupuncture, for example. Yet, significant philosophical differences in the ways in which health and disease are understood in biomedicine versus yoga and other CAMs often stand in the way of the integration of pluralistic therapies in the larger health care system in the United States, dominated by the biomedical paradigm. Despite this systemic fragmentation, individuals often integrate different forms of medicine based on subjective, first-hand experience, what medical anthropologist Linda Barnes (2005:258-259) explains as "different interpretations of clinical reality.. .occupying distinctive social structural niches and drawing on different culturally constructed explanatory frameworks" which result in a "kaleidoscopic appraisal of whether something worked and, if it did, in what ways." Dedicated yoga practitioners might be particularly inclined to integrate different therapeutic approaches based on yoga's philosophy that aims to transcend essentializing dichotomies such as mind/ body or culture/nature (Strauss 2004). Anthropologist Sarah Strauss (2002a:248-249) further describes yoga as an avenue to pluralistic health practices:

[Y]oga can be understood as part of a methodology for living a good life. Because of its basis in bodily practice, the yoga tradition is easily linked with physical health maintenance at the level of the person. The physical development of the person was seen by many as the first, necessary step to be taken in the service of improving a larger community, whether local, national, or global. Yoga re-oriented is new theory with old practice. Experientially based, it offers the individual hope that through the practice of yoga they might be freed from the constraints of "taking sides," because yoga suggests the possibility of transcending such essentializing dichotomies as East/ West, religion/science, mind/body or nation/world. By going between the horns of the dilemma, being free to choose which elements from each side make the most sense to them as individuals, these middle-class yoga practitioners seek a globally relevant model for living a good life.

This understanding of yoga identifies a "self-possessed" identity of yoga practitioners and the agentic nature of yoga with respect to body and health. In the context of this holistic philosophy, biomedicine's primary focus on the proximal, physiological basis of disease could be complemented by non-biomedical methods that consider the distal cultural, social, and contextual causes inherent in the health approaches seen in yoga and other CAMs. Moreover, the infusion of neo-Hindu beliefs into yoga practice may strengthen the bond between yoga practice and practice of alternative medicine in general, thus, it could be theorized that yoga may serve as an entrée to other CAMs. While specific health outcomes and the perceptions of benefits from yogic practice have been examined in some detail, the effects yoga may have on the acceptance of other CAM therapies by consistent, long-term practitioners has not been investigated. Therefore, this study set out to explore the relationship between long-term yogic practice and the perspectives on CAM and biomedicine. Since yoga and CAM have a common foundation that emphasizes prevention and holism, and due to the historical association of yoga with Indian spiritual and health beliefs, the question of the extent to which yoga practitioners may become more accepting of CAM therapies in general is noteworthy in the context of biomedical system's dominance in the United States. Specifically, given that yoga is irrevocably linked to Asian health practices (like Ayurveda) and has documented physical and psychological benefits, to what extent and how does it affect the use of biomedicine and CAMs by practitioners? By what means are medical pluralistic practices induced, maintained, and/or intensified? In response to these questions, this article examines the way that consistent, longterm yoga practitioners experienced changes in their beliefs, perception, and/or acceptance of CAMs and biomedicine and how this affected health care-seeking behavior among a group of long-term yoga practitioners in Florida. Understanding health care-seeking behavior in the United States has important applications in the realm of health policy as people navigate a context where biomedicine holds a dominant status, yet neoliberalization of healthcare is gradually stratifying access to biomedical health services.

In the following sections, we present the study methods and then organize the study's findings around three interrelated but also distinct explanatory themes that underlie the process of pluralistic health care-seeking among long-term yoga practitioners: (1) disenchantment and mistrust of biomedicine, (2) patient-provider relations, and (3) self-care and being your own doctor.

Methodology

This article draws on research conducted between September and October 2010 using semi-structured indepth interviews and participant observation at a Yoga Center in South Florida. The sample consisted of 26 consistent (at least once a week), long-term (at least one year) yoga practitioners, aged from their 20s to 90s (age was recorded in ranges), who were recruited using purposive sampling (see Table 1 for sample characteristics). Interviews lasted up to 90 minutes and were conducted by Jacqueline Sivén, MA (PI), were audiorecorded when permitted, and fieldnotes were taken by hand. Participants were encouraged to offer full narratives about their motivations for yoga practice, experiences regarding CAM and biomedicine, and their approach to health-related decisions. Interview narratives were transcribed and coded, and the narratives were then analyzed by the PI and the co-author in terms of major themes and subthemes that appeared within and across narratives. The PI also conducted participant-observation at the Center, which included attending yoga classes and the Sunday night satsang, which involved meditation, spiritual ceremonies, and a potluck. No remuneration was offered. Participants' names have been replaced by pseudonyms.

The characteristics of the sample, summarized in Table 1, included 26 participants with the majority in the over 50-years-old category and possessing some higher education. The sample was predominantly female, and only two participants were of non-White ethnic origin. Nine of 26 participants practiced yoga between 3 and 10 years, and a large proportion of the sample (12) practiced longer than 10 years. The ethnic and educational characteristics of this sample are similar to other research samples among United States yoga populations (Birdee et al. 2008).

This study has some limitations. Although the yoga practitioners in this study pursue Sivananda yoga, which is one of the most comprehensive and globalized yoga styles, they do not constitute a random national sample due to the purposive recruitment, and, therefore, the generalizability of the findings is limited. Non-response was not as relevant in this study, given that the recruitment took place via class and newsletter announcements and posted flyers to which potential participants responded by approaching the PI. No volunteer declined to participate in the study after me consenting process, and no one asked to discontinue the interview.

Findings

This study found that the majority - 16 of 26 participants - began to pursue yoga practice as a form of health care-seeking in order to address physical and/or mental healdi needs, including difficult to heal injuries, chronic health conditions, and depression that were not adequately addressed by the biomedical system of care. Moreover, participants tended to expand the use of other CAMs in their health care regimens the longer they pursued yoga. Only four individuals had tried at least one CAM prior to beginning yoga practice, five had tried at least two, and two had tried more than two (Figure 1). However, there was a great increase in the use of CAM after individuals began practicing yoga, which is most evident in the "More than 2" category of CAMs used in Figure 1 , with 1 1 individuals having tried more than two CAMs post yoga practice, as compared to two individuals pre-yoga. CAMs practiced included acupuncture, Ayurveda, homeopathy, Reiki, chiropractic, massage therapy, hypnosis, hydrotherapy, sound therapy, naturopathy, tai chi, and qi gong.

The analysis of the narratives revealed three explanatory themes that were offered by the study participants to explicate their turn to yoga and pluralistic approaches to healthcare.

Theme 1: Disenchantment/Mistrust of Biomedicine

One of the major driving forces in the medically pluralistic practices of the yoga practitioners in this study were previous health care experiences that generated disenchantment and mistrust of biomedicine as well as biomedical providers. The majority of those interviewed expressed some form of dissatisfaction or distrust of the western biomedical system; for many, this was poignantly exhibited as the perceived inability of biomedicine to cure their chronic illnesses. Consequently, many interviewees decided to restrict the majority of their health care needs to CAM as a way to address more distal or final causes of ill health through prevention and holistic care. A general wariness about the rate at which prescription drugs are being dispensed in the United States, as a way to deal with complex health problems that might call for otherwise challenging lifestyle changes, was also evident throughout the narratives. Though all participants straddled both the biomedical and CAM realms by utilizing a range of health services, the degree to which this occurred varied significantly. Nevertheless, even those taking the middle path between western biomedicine and CAM expressed some dissatisfaction with the western biomedical system.

Emblematic of these sentiments is Beth's narrative. Beth, in her 20s, has been practicing yoga for over six years but began a more consistent practice around four years ago and eventually became a yoga instructor. During her interview, Beth detailed her experience of an illness with chronic physical symptoms. She explained that because medical physicians treated her symptoms but were unable to solve the problem, she decided after four years of ineffective treatment to pursue an alternative medicine practitioner. Within three months, Beth felt remarkably better and argued that the underlying problem had been solved. This experience turned her off western medicine, and since then, she began to pursue CAM with greater frequency.

Other participants' distrust stemmed from the perceived influence of money and the pharmaceutical industry on biomedicine. Frank, (age range 50 to 64), who has been practicing yoga for over 30 years in addition to Tai Chi and Kabbalah (Jewish mystical activities), shared Beth's feelings concerning biomedicine but for different reasons. Frank's dissatisfaction with western medicine concerns the power and influence of pharmaceutical companies on the medical system. He argued with some irritation that: "the pharmaceutical industry is absolutely ruthless; it comes from hell. . .. It owns our medical system. It doesn't affect it, it owns it. There's a difference. I think the AMA [American Medical Association] dances to their tune." Frank also asserted that as long as western medicine is focused on money, it cannot change. His sentiment regarding the role of pharmaceuticals was echoed by Aileen, a nurse (age range 50 to 64) who works in the medical setting and generally has faith in physicians. However, she believes integrating biomedicine and CAM may be beneficial for the patient - an approach that Aileen herself used to successfully treat her back problem. But, drawing on her experiences, she still believes many physicians are not ready to integrate CAM into their practice.

Nevertheless, both Aileen and Frank perceive the negative role of pharmaceuticals and pharmaceutical companies in biomedicine as a barrier to expanding treatment discussions. Likewise, she believes that excessive prescription of pharmaceuticals is a serious issue in biomedicine, as she has observed:

I also see a good many of my patients, especially the older ones, that are on 25, 30 different pills, that I'm wondering, do you really need all of those...? Especially since I know that this one was probably added to counteract the side effects ofthat one. There's a lot of them like that, and the older you get it seems that the more patients have them.

Aileen also believes pharmaceutical salesmen, treatment of iatrogenic symptoms, and what she terms as "cover your ass medicine" are the underlying causes for this trend. She adds: "there's a lot ofthat. There's a lot of x-rays and medicines that that's where it comes from.... Because they're afraid of what will happen if a patient says 'Oh, well you didn't give me this, and so I got an ulcer. You caused an ulcer 'cause I got acid from taking that antibiotic.'" Observations such as Aileen's or Frank's lead to dissatisfaction and motivate them to seek other means of healthcare, especially those treatment approaches that philosophically rely on a minimal use of pharmaceuticals.

Despite Frank's dissatisfaction with the western biomedical health care system, he surrenders to the possibility of utilizing it as a last resort; but he typically seeks alternative medical methods before considering a biomedical doctor. When individuals in this study referred to the "last resort" situations, they often spoke about modern surgical techniques. However, each person had a unique perception of when these techniques were appropriate to pursue, and many emphasized that they would exhaust their CAM options prior to considering surgery. This distrust of western biomedicine had a significant effect on the way that study participants conceptualized health seeking: dissatisfaction was identified with the larger system rather than an individual physician or clinic and drove a desire to look for care outside ofthat system.

For example, another yoga practitioner, Carla, took charge of her treatment in the face of dissatisfaction with her treatment options for a severe spinal injury. Carla, aged 50 to 64 and practicing yoga for about six years, explained that her current yoga practice began as a way to treat a back injury sustained in a severe car accident which left her with seven herniated discs and immobile for six months. Although her insurance agent sent her to a chiropractor in addition to a biomedical doctor, neither helped much. Concerned with the lack of improvement, her daughter-in-law brought her to the Yoga Center where Carla found relief, as she related: "Then I started to do yoga, and I started to feel better and better." Carla went to a biomedical doctor initially because her insurance coverage forced her to pursue care that was covered under the policy, but when the doctor recommended surgery, she decided she had other plans: "So, the doctor said 'you have to go to surgery.' So I said 'okay, give me three months.' And then three more months." The doctor then asked why she wanted to wait; she responded that she wanted to try to recover naturally:

Then when I went back six months later, he said 'You know what, the hernia is shrinking.' I said 'Okay, that means it's been working, give me three more months. ' And then I was eating all raw foods, and juices, a lot of juices, and going for Reiki. And finally, when I went there he said to me, 'You know, I don't know what you are doing, but whatever it is, keep on doing [it] because it's working. There's no more hernia of the disc'

As Carla continued to practice yoga and took charge of her diet, she included Ayurveda and Reiki in her self-treatment. She believed that yoga was a major contributor to her back recovery not only in the physical sense, but she also benefited emotionally. Before yoga, her daily problems would cause nervousness and irritation and lead to insomnia, but due to yoga, she argued, she now worries less and lives "for today." Carla navigates between systems of healing based on her own judgment and sense of self-care.

Theme 2: Patient Relations

Perception that genuine care for patients was all too rare also played a significant role in how individuals perceived biomedicine and CAM, and subsequently navigated both realms. For the most dissatisfied, previous unsatisfactory experiences with biomedicine were critical in driving individuals to other healing systems.

Beth, who pursued alternative practitioners when it became clear that the treatment she was receiving from her biomedical doctors was ineffective, described the doctor-patient relationship as integral to her healing experience. She equated her experience of a hurried and often impersonal approach by her physicians as a reflection of the lack of desire to truly understand the patient - a problem she associated with the larger system:

I despise western medicine. ... I've had enough experience with western doctors who would rather prescribe you a prescription to treat the symptoms than to treat the illness. And it's just not something I agree with. I believe the body needs to be treated as a whole. ... I think the doctor needs to take the time to get to know you.

Beth currently relies on acupuncture for the majority of her healthcare. However, despite Beth's feelings that biomedical doctor patient relations are lacking, she believed that western medicine had important applications in emergency situations.

Alternately, Candace, in her 40s, who began practicing yoga with a friend at a gym over four years ago because of back problems, expressed a very positive relationship with her medical doctor (MD). She believed that her MD is fairly amenable to other treatments and has openly admitted that "we" do not know everything. This open, inclusive relationship, akin to the concept of patient centeredness in health related scholarship, is fundamental in forming patient respect and trust of health care providers and has been shown to shape the patient's perception of the treatment provided. Specifically, some public health studies demonstrate that patient centered care which incorporates patients' own perceptions of whether or not doctor patient relations were positive is closely linked to improved health outcomes (Campbell, Roland, and Buetow 2000; Stewart et al. 2000).

Ernest, a war veteran (age range 50 to 64), who has been practicing yoga since the 1960s, explained that positive relationships with past biomedical health care providers has affected his selective use of CAMs and biomedicine. When asked how he decides whether to see an MD or an alternative provider, Ernest asserted that a broken leg is clearly an issue for a biomedical provider, while soft tissue injuries are more appropriate for alternative types of providers. Ernest had no particular reluctance toward any system of healing, but chose providers selectively and pragmatically based on his own experiences and judgment of the efficacy and availability of treatment. His integrative use of biomedicine and CAMs was partially due to his experience with what he described as "small town medicine," an expression which refers to the socioculturel model of doctor patent relationships wherein a close relationship is sought between doctor, individual patient, and the community. For example, patients could visit the doctor for health care services at any time, possibly even at the doctor's home. It would also not be uncommon to see the doctor at community functions. Ernest lamented the loss of this approach in present-day medical systems. To explain, Ernest recounted an incident from 1967. While out late with a friend, he was injured and knocked on the local doctor's door in the middle of the night to get treated for the gash. He recounted that he was actually received stating, "And that was medicine to me, which is really alternative in these days.... I think it was easier for me to accept alternative healing techniques because of knowing my doctors that way. I mean, you know, it's so much less personal than the old family doctor." Ernest's comment that the type of western medicine he experienced in youth is now seen as alternative denotes a significant aspect of what drives some participants in this study to use CAM: a desire for a close personal connection to their health care providers and a holistic approach that is increasingly rare in the biomedical approach. Ernest is, thus, suggesting that this sort of interaction is part of what is now used to differentiate CAM from western medicine.

Likewise, other narratives in this study show that closer doctor patient relationships facilitate more effective care; when the provider listens to the patient, a more comprehensive understanding of the illness experience will result. Notably, the open relationships Candace and Ernest enjoyed with their biomedical providers were also characterized by a willingness of the doctors to facilitate medical pluralistic practices for their patients. In these cases, providers who were aware of their patients' use of CAMs supported holistic care. A lack of such a relationship was part of the reason why many interviewees had a negative perception of western medicine. They saw the focus as primarily on monetary gain rather than the needs of the individual seeking care. A number of other study participants interviewed related a similar concern. For example, Anne (in her 50s, practicing yoga for over seven years), who believes her allergies were cured through yoga practice, argued that western medicine is about "pushing pills" for monetary profit, while Gabrielle (in her 20s, a yoga practitioner for over two years) believes that biomedicine is a "money making scam," and Isabel (in her 40s, practicing yoga for over three years) relegated western medicine to "corporate money suckers." These perceptions of a larger profit driven nature of the United States health care system was used by the study participants to make sense of the poor doctor patient relations that many of them experienced.

Integration and Holism

Even some of the individuals who readily use biomedicine complained about the fragmentation of western medical care. Nancy, in her 60s, a master level Reiki practitioner who attributes her recovery from cancer to an integrated use of treatments derived from CAM and western medicine, faults the latter for being limited, as she argues that "it tends not to be holistic." Desires for holistic providers that facilitate pluralistic approaches to care was a common sentiment among those interviewed. On the individual level, this was understood as an integral aspect of positive doctor patient relations and an avenue to better health outcomes and satisfaction. For example, Gabrielle, a two-year yoga practitioner in her 20s who works in the mental health field, suggested that treatment for physical, mental, and emotional aspects of illness should be integrated. Even those participants who had not tried alternative medicine argued that the current system could benefit from integration, essentially voicing a desire for a more pluralistic approach within the United States health care system itself. Though a desire for different patient relations, more holism, and medical pluralism drove many individuals to CAMs, they were still discerning of CAM as divergence from biomedicine, often expressing some doubt or caution about the validity and effectiveness of CAM. For instance, although Gabrielle had used acupuncture, massage, and other holistic care, she admitted being wary of some CAM methods that appeared to her as "too over the top" or outside of the mainstream. Thus, it would be wrong to assume that those who are dissatisfied with biomedicine would accept any CAM or alternative provider. Instead, they use a variety of rationales that draw on their previous experiences, their state of health, and the perceived level of validity of particular healing methods offered outside of the dominant biomedical health system, as well as the quality of their relationships with providers.

Patients' perception that the biomedical system or individual physicians do not understand them or care about them, and the all too often poor quality of relationships with providers, directly relates to anthropologist Arthur Kleinman's ( 1 995 :98) scholarship on the importance of provider attention to patients and their familial, social, and community context, that is, their "local moral world." He argues that health care providers tend to distort and delegitimize patient suffering when they transform the patients' symptoms into their own worldview which is often focused on the proximal causes of disease. Kleinman asserts (1995:95-96) that there is a need to see the illness through the lens of the patient as "a socially constructed reality," and to ignore this sociocultural context severely limits our understanding of the patients' actual experience of illness. This lack of understanding that participants in this study identified in their own experiences may be why so many had begun to turn to other methods of healing: they felt as though doctors did not understand them and sought to forge a more engaged relationship with other providers.

Theme 3: Patient Self-Care and Being Your Own Doctor

Long-term practice of yoga offers practitioners consistent exposure to the philosophy of self-care and the integration of body, mind, and spirit. This theoretical framework is particularly salient for individuals who experience health difficulties in the context of biomedical health care system. Disengaged patient relations and perceptions of ineffective medical treatment are prime motivators among yoga participants in this study to seek more control of their healthcare through self-care. The theme of self-care, so integral to the practice of yoga, constitutes a distinct mode of motivation and justification for the pursuit of CAM and is conceptualized less as a default strategy than an agentic form of actively taking control of one's health. This approach has been documented by anthropologist Jennifer Furin's (1997) work exploring the sociocultural factors involved in alternative medicine use among gay men living with AIDS in West Hollywood, California. Furin (1997:502) showed that the men who were dissatisfied with western biomedical treatments sought alternative medicine as a way to "become their own doctors" and take charge of their treatment strategy. The study found that about 73 percent of respondents turned to alternative medicine due to the need to become proactive in seeking care for AIDS-related secondary illnesses, often chronic, for which biomedical treatments were marginally effective (Furin 1997).

The need for taking control was also reflected among yoga practitioners in our study, as experiences of frustration with chronic illnesses drove many to seek CAM treatments to deal with the apparent helplessness of their biomedical providers, but also their own dependent position as patients. While the desire to take control of one's health prompted the pursuit of CAMs, yoga itself was also understood as a form of CAM and typically preceded the inclusion of other CAMs. Thus, yoga frequently acted as an entrée to CAMs, and, therefore, medically pluralistic practices in general. Nancy, a hospice worker and cancer survivor in her 60s, explained her approach as follows: "[Yoga] is a very good self-care tool.... It helps me to release and cleanse from the emotional detritus that gets to be overwhelming on people in my line of work." Nancy also uses different forms of yoga to treat her symptoms of chronic arthritis and chronic obstructive pulmonary disease. Abby, in her 30s and practicing yoga for over 1 3 years, who partially attributed her recovery from addiction to yoga practice and combined CAM with other types of care, expressed a similar sentiment: "Ya know, in some ways it's like being my own physician." Abby believes that, when facing an illness, she would first start with alternative medicine, but would use both biomedicine and CAM as she deemed needed and based on her own decisions.

Navigating within the dominant health care structure that leaves many patients feeling dependent or helpless and strategizing as western health care consumers, participants in this study revealed the desire to take control of their health needs and act as agents of their own well-being. Gabrielle 's example (discussed earlier) also shows the motivation to pursue healthcare that she perceives as most relevant to her own predicaments. These practices might be met with derision from their medical providers and, therefore, often require either a degree of resolve or a clandestine approach to pursue. But many individuals nevertheless feel compelled to take charge of their healthcare based on the available options of care, their knowledge of alternative approaches, and their own experiences of illness. The narratives show that individuals in this study gained knowledge and interest in CAM through long-term yoga practice, which promotes an integrative approach in understanding body and health. Through consistent yogic practice and exposure, individuals begin to experience, as Frank put it, "a natural gravitation towards health," wherein health is conceptualized as both the pursuit of a variety of healing practices as well as an agentic philosophy of well-being.

Discussion

Despite the growing popularity of yoga as a health related practice and the growing body of scholarship on the utilization of CAM in the context of the dominance of biomedical paradigms in health care structure, comparatively little research has been conducted that examines the underlying perspectives that drive yoga practitioners to engage in particular health-seeking practices. As the narratives in this study demonstrated, the production of particular health-seeking practices emerged from an intersecting set of influences, including: exposure to yoga practice and its holistic and agentic body philosophy, the use of yoga as a form of CAM, favorable experience with other CAMs in terms of effectiveness and holism, experience with ineffective biomedical care, poor patient relations, and feelings of abandonment or lack of being cared for by the biomedical system. Moreover, once individuals embarked on long-term yoga practice, they expanded their health care-seeking practices to other CAMs; thus, yoga had a dual effect of offering an alternative treatment and self-care practice, as well as an entrée and motivation to pursue other CAMs.

This study also shows a significant variation in perspectives in the way study participants integrated various health systems. The narratives demonstrated a range of CAM acceptance from avid support to ambiguity and wariness toward utilizing nonbiomedical approaches alone. However, no long-term yoga practitioner in this research was closed to the concept of trying different CAMs or integrating CAM with the biomedical health system. Furthermore, those participants who were avid supporters of CAM were not always strongly critical of western medicine; in fact, most of the participants selectively utilized CAM and biomedicine based on their own sense of need and previous experiences with health and illness. Indeed, those who had fairly positive previous experiences with western medical doctors were more likely to take a more accepting and positive stance toward biomedicine. Those with rather negative experiences with physicians, in particular experiences in which biomedicine was unsuccessful in treating their illness or in treating the individual holistically, were more likely to express a severe dichotomy in their feelings between CAM and biomedicine. This ultimately affected the ways in which individuals desired to integrate these different approaches to healthcare.

While this study showed that negative views of biomedicine motivated many to use CAM, a study conducted in Canada demonstrated a different effect, where dissatisfaction with biomedicine was diminishing as a motive for CAM use and increasingly the incentive was the knowledge of, and overall positive viewpoint on, CAM (Sirois 2008). Such shift in perception may occur in the United States, as positive experiences with CAM might eventually override the initial doubt. In addition, the growing body of empirical research to determine the health outcomes of specific CAMs (Kaur et al. 2001 ; Riley 2009; Robertshawe 2009; Ross and Thomas 2010; Yang 2007) has the potential of bringing attention of a wider public to CAMs and perhaps the attention of health policymakers. These studies, however, are evaluating the validity of various healing methods and traditions from the western medical perspective that is based on a paradigm which requires narrowly defined biological and physiological evidence as the proof of the efficacy of particular treatments. However, as CAMs are each linked to a set of cultural practices and beliefs, including those of spirituality and particular conceptualizations of illness, it would be difficult to separate the physiological effect of a healing practice from the cultural worldview upon which it is set. As the narratives in this study suggest, a complete analysis of the health effects that a particular CAM might necessarily have include the physical, mental, and spiritual benefits along with the sense of empowerment that accompanies the pursuit of CAMs in the context of United States healthcare in which biomedicine remains the dominant model. As problematic as the approach to test for physiological validity of CAMs may be, research findings that show positive effects of nonbiomedical therapies may prove to be a form of legitimization that could encourage more patients in the United States to seek CAMs and may also facilitate better integration of other healing approaches into the current medical system.

Indeed, the integration of CAM and biomedicine by those interviewed reflected a complex medically pluralistic set of decisions based on previous experiences, current perspectives, and also the ability to access care. As anthropologists Margaret Lock and Vinh-Kim Nguyen (2010:63) contend, though biomedicine has a significant influence internationally, medical pluralism and the utilization of biomedicine is dependent on local concepts of disease and health, "geographical location, and [that] the reasons for the choices that people make can only be fully appreciated in light of local histories and current conditions." Certainly, the politico-economic context of United States health care system, characterized by growing concerns among the public about access to services, rising costs, and the role of pharmaceutical industry in healthcare and clinical decisions, play a significant role in shaping individuals' motivations for, and abilities to pursue, health services within and outside of the biomedical system. The narratives in this study demonstrate a common perception of systemic flaws in the current United States health care system, including a lack of holistic patient care, poor engagement with patients' needs, and the excessive prescription of what was perceived as unnecessary drugs. These views were often linked to the observation of the biomedical system as a "money making scam" focused primarily on profit margins, as well as the nature of the cozy relationship between pharmaceutical industries and many biomedical doctors and hospitals. This view of medicine as an impersonal, rigid, and oppressive system focused on sales rather than effective treatment of patients was juxtaposed in the narratives against health producing practices of yoga and other CAMs.

Furthermore, yoga's ancient legitimacy is noteworthy in practitioners' view of yoga as an effective healing modality; the participants in this research never indicated any perceived difference between modern yoga and the ancient Indian practice. While participants in this research initially sought yoga as an alternative to a broken health system, those who become dedicated practitioners, embracing both physical and spiritual aspects of yoga, were also drawn to what Max Weber (1946) refers to as the "traditional" form of legitimacy as they perceived yoga as an ancient form of wisdom and practice. For some practitioners, yoga as the embodiment of an ancient wisdom and spiritual philosophy, may offer the answer to the social alienation and anxieties of late capitalist modernity characterized by consumptive priorities and a decline in physical and psychological wellness (Alter 2011). These alternatives may also give individuals a greater sense of control over their health as individuals make their own decisions on the validity and effectiveness of each method of treatment and providers, as well as draw on their own conceptualization of health and the nature of illness.

As a result of these clear observations of systemic flaws, those interviewed devised individualized strategies by incorporating western medicine and CAM in complex ways that blended previous experiences, the quality of relationships with their providers, the relative effectiveness of various healing approaches, and the need to take charge of one's health in situations of perceived helplessness and deteriorating health. These individualized strategies were devised as participants saw themselves as agents, able to act apart from "the system." But this effort can also be interpreted as precluding an organized critique of the current health care system, which is failing in a number of ways as insurance premiums and out-of-pocket expenses grow, rationing of care prevails, and millions go without health care coverage. The United States health care system has suffered due to the globally dominant neoliberal economic approach marked by deregulated health insurance and pharmaceutical industries and a pressure to reduce the role of the state in social welfare. This approach aims to shift the responsibility for health needs from the state onto individuals who "ought to" take greater responsibility for their own health. In contrast, the take-charge style health practices of this study's participants are confined to the narrow spaces of individual strategies and experiences. They are also privatized in the sense that most of the CAMs they seek to deal with persistent health problems are not covered (or covered nominally) by various United States health insurance schemes currently in place. The predominantly socioeconomic middle-class status of this study's participants enables them to access non-covered health services; however, lower income populations lack these options. Therefore, greater public attention to the flaws of the current health care system are urgently needed, including the need for comprehensive health services, including preventive care and the incorporation of certain CAMs into the health system, not only financially in terms of insurance coverage but also philosophically into the patient-centered care.

This project's participants' dissatisfaction with the health care system is irrevocably linked with the causes for dissatisfaction among those of lower socioeconomic backgrounds. For example, participants' complaints resonate with the issue of health affordability in that they believe that in the current United States system, insurance companies make profit more important than treating patients, and the system leaves many with unmet medical needs - observations made by advocates of universal health coverage (Bybee 2009; Hwang et al. 2010). The privatization of health insurance makes for a profit focused, not patient focused, health system. As a result, the position of these research participants and those of low socioeconomic backgrounds in the current health system makes it important for them to assert their agency in the face of an inadequate provision of care. The complaints of both populations stem from the same systemic flaws; however, this study's participants' reaction to the problem - the middle-class reaction - is an individualized strategy, which contributes to the continued stratification of healthcare, as patients who can afford to do so seek care outside of the current system.

Thus, findings from this project make a contribution to the understanding of the process of the pluralizaron of health care-seeking practices wherein disenchantment with the biomedical approach to care drives individuals to devise pragmatic individualized strategies as they go outside of "the system" to pursue other forms of healing. Illuminating health and wellness producing practices is increasingly important as epidemiological rates of chronic illnesses in the United States, often considered "lifestyle" problems, call for greater attention and concern from a public health perspective. Qualitative findings that capture individuals' experiences and perspectives underlying health-seeking behaviors are, thus, significant in helping make sense of larger population trends. In addition, understanding motivations that underlie particular forms of utilization of health services is useful from the perspective of health promotion within the larger health care system and can also contribute to the current discussions about health care reform.

[Reference]

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[Author Affiliation]

Jacqueline Sivén has a Master 's degree in Anthropology from the University of Central Florida. Joanna Mishtal is an Assistant Professor of Anthropology at the University of Central Florida. The authors express gratitude to the director of the Yoga Center for facilitating this research and to the yoga practitioners who generously agreed to participate in this study. We also thank Matthew Mclntyre and Rosalyn Howard for valuable comments and suggestions. The authors alone are responsible for the content and the writing of the paper. The authors report no conflicts of interest.