Summary: Have the complementary healthcare disciplines been strengthened, compromised or both in their maturation and inclusion processes? Might healthcare professions choose directions other than those which ape practice of an already broken system? These questions were of central interest when the International Association of Yoga Therapists (IAYT) sponsored the Integrator series on the Future of Yoga Therapy. This closing article in the series features a conversation with Pamela Snider, ND, who has worked closely with leaders of all of the complementary and alternative healthcare
disciplines. Snider spoke before 850 Yoga therapists on these critical themes in January. Her title: Accountability and Soul.
All the healthcare disciplines, complementary and conventional, face fundamental questions regarding their relationship with the mainstream business of medicine. Some in each discipline resist any engagement, fearing interfacing with the other prompts. Others push for as rapid of assimilation as possible by following conventionally-defined paths of least resistance.
When Veronica Zador, RYT 500 and John Kepner of the International Association of Yoga Therapists contacted the Integrator last spring for this series, they made it clear that they were interested in exploring a “third path” for Yoga Therapy. (See whole series here.) One person they asked that I interview was Pamela Snider, ND, the founding executive director for the Academic Consortium for Complementary and Alternative Health Care (ACCAHC). In this capacity, Snider worked amidst the stories and decisions of a half-dozen disciplines. (Her work with ACCAHC is featured in a separate article here.)
Snider’s experience includes nearly 30 years in leadership of her own profession. She now directs the Foundations of Naturopathic Medicine Project. She was a former associate dean and policy leader at Bastyr University, held an appointment to a Medicare advisory panel, and has held numerous leadership roles in policy related to multi-disciplinary, integrated health care. Snider was also part of an exploration of professional development issues in CAM through an Arkay Foundation study engaged through the University of California, San Francisco Center on Health Professions. Snider is an Integrator editorial advisor and has been my close colleague in numerous efforts, including ACCAHC, over the last half-decade. The Integrator spoke with Snider in a ranging conversation which touched on most of the disciplines
with which she has been working, including Yoga therapy.
Integrator: Let’s jump right in. There is a split in the Yoga therapy world between some who wish to pursue licensing and others deeply opposed – particularly because they are not pleased with what they have seen from the experiences of chiropractic and naturopathic medicine and other disciplines. Some of which I know has been confirmed for them in this series of articles. Is there a “third path” for Yoga therapy which may also cast some light on directions of other disciplines?
Snider: I think “yes,” but with caveats.
The unifying, public purpose behind licensing and certification and
accreditation of schools, for that matter, is accountability.
Accountability to the public. I can imagine a profession – Yoga therapy
– finding a new way forward, but there must be public oversight. There
must be a public recourse. So if a profession has decided it opposes
licensing, for instance, I can imagine a noble path which carves a new
relationship with the public. Because the other key concern for a
profession is to respect the fullness of its discipline. We know from
experience that some of the fullness of a discipline can be lost if the
discipline – whether chiropractic, naturopathic medicine, massage
therapy or acupuncture follows the conventionally established paths
toward accountability. So Yoga therapy can move forward, but to do so
it must find new ways to respect its diversity and still be accountable
to the public.
Integrator: What is an example of the way this tension plays out in another profession?
What Snider Means
Safety, Efficacy and
redress if something
– from a presentation
Snider: Some in massage therapy are seeking high education standards of 1000 hours or more. Others are trying to set the bar at 500 hours or less. The former tend to have a more medical or integrated care perspective, the others may be focused more on wellness or relaxation massage. Many in the spa industry don’t feel they need as much training in Western diseases or in how to collaborate with other practitioners. One camp says it is focusing on wellness and relaxation . It may judge the other for being too medical, for focusing too much on billable techniques, for instance. The American Massage Therapy Association is just now re-entering into a significant look at its body of knowledge. This is an exploration which will likely bring it face-to-face with these accountability and soul issues.
Integrator: But won’t the move into conventional directions and toward billable services always risk medicalization?
Snider: We often see something like “mistaken identity” in the choices people wish to make. Professionals in emerging disciplines who are engaging the new processes of accountability often think that this means emulating conventional medicine. Professionals in emerging disciplines who
are working in the trenches and mountaintops of
establishing their own processes of accountability can
confuse this with emulating the ways that conventional
medicine has chosen to do this. They mis-take that identity and those processes for their own. They take these as their measures of accomplishment and accountability. Maybe the focus should be on finding the metric out
there that works for us – whether it is the example of conventional
medicine or an example from another field. Maybe the field should set its own metrics.
Integrator: Okay, give us an example.
Snider: Here’s a juicy example in my own profession of naturopathic medicine. We joke that one of our principles in naturopathic medicine, along with find the cause, and doctor as teacher and doing no harm and others, is what we call “Principle 7”: Don’t tell me what to do.
We don’t want anyone limiting our ability to use
the range of
natural approaches and therapies that are available -applied based on the principles and theory of
naturopathic medicine-the progress of knowledge and as we are
trained. We love the process of rigorous inquiry and support standard setting, yet
we don’t want to limit ourselves. What results can be like the wild
West. Does it mean everyone can do whatever they want without
restraint? No, but we need as a profession to continue to establish metrics that
respect what we believe and to be accountable. We have to find a way to
give the clinician this freedom to individualize in order to meet the
individualized nature of a patient’s needs. We respect evidence, of
various sorts, and we need to not just allow clinicians to
individualize but we support that, because it is a value we believe
enhanced patient care. Yet we still have to provide lines of
“Professionals in emerging
in the trenches and on the
has chosen to do this.”
Integrator: No one ever said that pioneering would be easy. What is an application for Yoga therapy, as you know it?
Snider: I read the series of Integrator articles before this call. It was stimulating, very interesting. I read in the article about the program started by (Larry Payne,PhD) called Yoga Rx. It’s a very integrative, medical approach. Payne spoke of Yoga therapists using the language of CAM instead of Ayurveda. I thought, what a loss. What we want is not one or the other but both/and. When you lose the minority linguistic – Ayurveda – in coming into the dominant culture of Western medicine, you can lose the meaning and depth of a practice. The hospital, the mainstream institution and for certain the insurer are not going to care to figure out how to maintain that depth. This has to be the profession itself, setting its own metrics.
Integrator: So, setting one’s own metrics. This is easy to say …
Snider: It is very challenging, and probably our most important work. If I was in charge of all of the professions I would ask: What is it that your values require you to institutionalize, to make sure you keep as your own? Then I would ask them each to make a plan on how to invest resources in developing and applying these metrics. This is hard work, but richly rewarding and about as exciting as professional work can be, I think. These principles and our metrics to accompany them need the investment of professional organizations and educational institutions to make them real. It is
the day to day work of converting philosophy into policy and then applying it.
Integrator: What is a good example of a profession doing this successfully?
work of converting
Snider: Here’s one. Direct-entry, homebirth midwifery provides a perfect example. As these homebirth-oriented midwives were developing their accreditation standards through the Midwifery Education Accreditation Council (MEAC) and beginning the track toward federal recognition, the natural tendency – following the conventional metric – was to put all the training in a school context. But in doing so the midwives would have had to abandon the historic, apprenticeship model through which generations of exceptional midwives have been trained. So MEAC designed a formal strategy which did not throw out this historically-valued method of education. Instead, they set up competencies around it.
Integrator: This reminds me of a moment 25 years ago when your profession was first looking at regional accreditation standards as promulgated through the then Northwest Association of Schools and Colleges (NASC). A widely respected herbalist, Cascade Anderson Geller, taught botanical medicine at Bastyr. But because she had no advanced degree – the NASC metric – her position was given to a faculty member with a terminal degree. Students got an ND with significant book learning but little clinical experience instead of a having seasoned clinical herbalist, proudly connected to the earth. Choices.
Snider: In retrospect, another metric which respects both the naturopathic connection to Gaia and to science and standards would have been closer to the naturopathic soul.
Integrator: Maybe an accreditation requirement that at least part of the botanical medicine faculty needs to have dirt under its fingernails at least three times a week. There’s a protection against “green allopathy.” But let’s get very practical: Is it really
possible for a field in health care to become a respected player, likely to receive significant referrals without the
passing the barriers to entry such as developing national education standards, accrediting agencies and licensing?
Snider: Yoga has certainly advanced a long way into public use without licensing. Many hospitals offer outpatient yoga programs. So there is clearly a level of acceptance that can be gained by Yoga. But the more the move is from Yoga teaching to Yoga therapy, the more that one is located in medicine with all its attendant norms. And here the usual standards are likely to dominate unless Yoga therapists can come up with another means of guaranteeing accountability.
Integrator: What is the role of the national organization then?
Snider: Ask the questions. Frame the issues. Make the commitments of resources. In fact, as we look back, the development of councils of colleges and accrediting standards and of licensing is typically driven, first, by professional associations. The new organizations become independent as they grow. I would say that the kind of meeting that (IAYT) held in January, the first Symposium on Yoga Therapy and Research is a good example of the helpful work of an organization at this time. Bring together leadership to focus on practice, evidence and professional growth themes.
“I hope that Yoga
therapy, out of its
long tradition, will
teach us a new
way of relating.”
Integrator: Yes, and again, isn’t some kind
of standardized national certification something really required in order to
promote the IAYT’s mission to establish Yoga as a respected and recognized therapy in
both the Western and Eastern worlds? Doesn’t Yoga therapy need to define a scope of practice?
Snider: We come around to where we started. If I am a practitioner who wants to refer to another practitioner who is offering some kind of therapy, I am going to want to know something about that other practitioner and what he or she is trained to do. Our short-hand way of doing this is through checking one’s credentials. Does the practitioner meet certain accountability standards regarding education, tested competency, and some form of regulation or third party review. If I am a practitioner inside an institution, then I will have the rules and regulations of that institution shaping my choices. This is the default pattern. I hope that Yoga therapy, out of its long tradition, will teach us a new way of relating. One thing for sure: accountability must be part of it practice.
Integrator: Thank you for your time and perspectives, Pamela. To the IAYT, I would like to finish this series by saying that I’ve enjoyed the interviewing for the series nd meeting the people to whom I have been sent. I hope that these reflections on what moves all of our professions may have helped stimulate some useful thinking among some readers. Thank you, Veronica and John, an the IAYT board, for your invitation to develop this series. Here’s to the 3rd path!
for inclusion in a future Your Comments Forum.