Social Science & Medicine 72 (2011) 1826e1837

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Social Science & Medicine

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Caught in the crosshairs: Identity and cultural authority within chiropractic

Yvonne Villanueva-Russell*
Texas A&M University e Commerce, Sociology & Criminal Justice, Dept. of Sociology, PO Box 3011, TX 75429-3011, USA

a r t i c l e i n f o a b s t r a c t

Article history: In this paper the discourse over identity and cultural authority within the profession of chiropractic in
Available online 13 April 2011 the United States has been analyzed using critical discourse analysis. As the profession struggles to
construct one singular image, versions of self must be internally debated and also shaped in consider-
Keywords: ation of larger, external forces. The dilemma of remaining tied to a marginal professional status must be
USA balanced against considerations of integration. Written texts from chiropractic journals and newspapers
Chiropractic
are analyzed in a multidimensional approach that considers the rhetorical devices and thematic issues of
Identity
identity construction; the representation of various voices within the discourse (both heard and
Professionalization
Cultural authority
unheard); and the extent to which external pressures affect the projection of cultural authority for the
Critical discourse analysis profession. A heterogeneous discourse characterized by conflict was found, with discrepancies between
Review everyday chiropractors in actual practice versus academic chiropractors and leaders particularly over the
idea, practice and significance of science for the profession.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction are constructed to enable professions to co-exist and compete with

one another in a larger system where they may be accepted or
Professional identity and cultural authority are two concepts rejected. This research will examine statements made by US
that have appeared in the chiropractic literature with increasing chiropractors found in printed sources (i.e., journals, newspapers)
frequency in the past decade. In 2002, Meeker and Haldeman to reveal how internal identity claims are formulated as well as how
published “Chiropractic: A Profession at the Crossroads of Main- an outward projection of cultural authority (the ability to be
stream and Alternative Medicine” which evoked a clarion cry for unquestioningly believed (Starr, 1984, p. 13)) is presented in
intraprofessional introspection. Commenting on the success of a changing health care environment.
having achieved professional status in the United States, Meeker In health care, orthodox medicine has “professional dominance”
and Haldeman argued that chiropractic was still “trapped” with an and possesses the largest jurisdiction (c.f., Freidson, 1970;
unsatisfactory marginal positionda part of mainstream medicine Pescosolido, 2006; Willis, 2006), although much discussion of the
but not fully accepted or participating in it. decline of this hegemonic power has also occurred in the literature
(c.f., Haug & Lavin, 1983; Wolinsky, 1993). Complementary and
Chiropractic still maintains some vestiges of an alternative
Alternative Medicine (CAM) has established itself as a “marginal
health care profession in image, attitude and practice. The
profession” in relation to this framework. Wardwell (1994) defined
profession has not resolved questions of professional and social
marginal as an occupation that operated with autonomy from
identity and it has not come to a consensus on the implications
medicine and rejected the medical definitions of illness and treat-
of integration into mainstream health care delivery systems and
ment held by the mainstream (p. 1063). In their original formula-
processes. In today’s dynamic health care milieu, chiropractic
tions, chiropractic, acupuncture, and homeopathy all existed as
stands at the crossroads of mainstream and alternative medicine
paradigms and theories of disease that stood outside of orthodox
(p. 223).
medicine and were largely incommensurate to the medical model.
Professions have been well studied for several decades in the In the US, chiropractic is unique from other CAM specialties
sociological literature. Andrew Abbott’s (1988) contribution has because it has fully achieved all aspects of professional status (it is
been to focus on the cognitive knowledge claims of expertise that recognized by state licensure, has standardized and accredited
education, and serves as a primary contact doctor) but has only
restricted access to the institutional aspects of medicine (lacks
* Tel.: þ1 903 468 6091; fax: þ1 903 886 5330.
university affiliation and therefore lacks major research funding,
E-mail address: [email protected]. has only limited access to hospitals, and receives limited insurance

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.03.038
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837 1827

reimbursement). Wardwell advocated for chiropractic to become This may initiate a movement toward integration with the main-
a “limited profession” whereby the scope of practice would be stream, orthodox medical system (e.g., obtaining hospital privi-
restrained to a more narrow range while remaining autonomous leges). The literature documents that when CAM professions
and free from the need for referral or supervision from orthodox attempt to co-exist in an integrative setting with orthodox medi-
medicine (1994, pp. 1062e1063). In recent years there has been cine, that “paradigm assimilation” (Hollenberg & Muzzin, 2010, p.
a heightened push within chiropractic to do just what Wardwell 34) often takes place. One exception to this is the work of Frank
(1996) had urged a decade before: transform from marginal to (2002) who found that German homeopaths did not disband
limited profession. This has triggered heated debate amongst their traditional, alternative beliefs in order to gain acceptance and
chiropractors. This debate forms a discourse: its content, power legitimacy in the larger health care system. More often, the
struggles and functions are the focus of this research. underlying vitalistic and holistic epistemology of CAM professions
is undermined, devalued, and largely omitted. Yoshida (2002)
Review of literature asserts that the “technical” value of CAM disciplines is privileged
over “theoretical” value.
Professional identity Dengele’s (2005) work focuses on the adaptation of homeop-
athy to the larger environment where the dominance of medicine
Professions must profess something. This is a reflection of the still figures prominently. Acceptance by the mainstream medicine
work they do, but also their inner-identity which defines who they has led to a fractioning within the discipline of homeopathy
are. In the case of CAM, this often means emulating the structural creating a tiered system of medically versus non-medically trained
characteristics established by orthodox medicine: obtaining licen- homeopaths (Cant & Sharma, 1996). Similarly, Hollenberg and
sure, educational accreditation, etc. Welsh, Kelner, Wellman, and Muzzin (2010) document that new regulation now separates TCM
Boon (2004) note that many CAM professions “run the risk of from acupuncture in Ontario, Canada (p. 48).
mistaking the allopathic medical model for the paradigm of The first part of this research will examine the micropolitics
professionalization” (p. 237). involved in generating professional identity through a textual
US chiropractors have achieved all professional attributes, yet analysis of written articles and news stories on the topic. The
the professional self continues to evolve and adapt. Rather than rhetorical devices used by various segments to assert their views in
assume professions are homogenous and cohesive, Bucher and the discourse will be presented. By focusing on segmental view-
Strauss (1961) note that various “segments” often occur within points represented in text, I hope to demonstrate the existence of
a profession, leading to internal conflicts and power struggles. The multiple, heterogeneous and even contradictory voices engaged in
micropolitics of segments may lead to “boundary work,” (Gieryn, a larger conversation of whom chiropractors profess to be. Addi-
1983) a process where groups may try to achieve demarcation tionally, the main thematic issues of contestation around identity
between themselves and rivals. Welsh et al. (2004) studied three construction will be explored.
different CAM groups in Canada to investigate the strategies
employed to gain state regulation, a key attribute of professional- Extraprofessional considerations and cultural authority
ization. In the case of Traditional Chinese Medicine (TCM)/
acupuncturists, one segment that regarded themselves as tradi- Professions must not only wrestle internally with themselves
tional and pure faced conflict with the more scientific Western, but then must amend these claims to be acceptable at the macro
allopathically-trained practitioners that viewed Chinese Medicine system level. In this way, professions may try to attain cultural
as an adjunct to their (largely biomedical) armamentarium. To authority and command the legitimacy and recognized expertise
demarcate the latter segment from the former, science was used as recognized by others. The literature suggests that in the US, public
a rhetorical tool to elevate their techniques and educational rigor as support and managed care are two key institutional actors that
superior. The use of rhetoric is a common way to formulate must be taken into account for professional survival.
professional identity, particularly during times of crisis, internal Public support and consumer demand have been integral to the
skirmishes or even interprofessional conflicts with competitors. growing utilization and acceptance of CAM professions (Pelletier &
Science is only one grounds of professional struggle, however. Astin, 2002). Yet, Pescosolido, Tuch, and Martin (2001) note that
Warnock (2005) found an agonistic or war-like use of rhetoric to public support for professions have been cantilevered with other
conjure up loyalty and cohesion when optometrists sought to structural characteristics of the system.
expand for greater autonomy against their interprofessional rival,
When the profession’s attempts at monopoly combine with the
the ophthalmologists. Allen (2000) found that nurses utilized
financial means to convert political legitimation into institu-
a rhetoric of “holism” to insist that the duplicated work they shared
tional support (e.g. insurance coverage) and visibility (e.g., large
with doctors was performed in a superior and more caring fashion
and impressive medical centers), the public is persuaded in
than the more dominant actors.
a subtle but nonetheless direct way. The building of institutions
To this point, I have presented the literature of internal identity
crystallizes and reinforces power differences, placing limits on
in the face of struggle. What happens to identity if a profession
individuals’ attitudes and behaviors and setting a context for
(peacefully) expands, merges or joins with another? Halpern
individuals’ socialization into a science-based society (p. 13;
(1992) investigated medical specialties working to increase their
emphasis in original).
autonomy by encroaching on the jurisdiction of another field. Those
that were successful in breaking into a previously-controlled area In this way, public support for professions is part of a more
depended upon 1) cognitive legitimacy (couching expertise in complex institutionalization of professional power in which the
a common language) and 2) demonstrating that the interests of the dominance of medicine is interwoven with science, and even third
interloper were compatible with the larger group. Halpern’s soci- party insurance/managed care.
ology in medicine orientation is not entirely helpful in analyzing In spite of initial ideological resistance to Health Maintenance
the interprofessional relations between CAM and orthodox medi- Organizations (HMOs) and managed care in the 1980s, orthodox
cine, however. medical physicians in the US not only expect but may demand to
The professional dominance of biomedicine leaves a deficit of work with these third party payment payers as preferred providers
resources and ecological space from which CAM has to maneuver. (Hafferty & Light, 1995). Chiropractic’s inclusion under managed
1828 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837

care programs has been late-in-coming and then, only in a limited created and positioned), and 3) the social practice level (how
way. Most managed care insurance will cover only a limited discourses are influenced by ideology and the larger social envi-
number of visits per year, and will not reimburse for X-rays (needed ronment). As Luke notes, “CDA sets out to capture the dynamic
by many chiropractors for diagnosis and analysis) nor for services relationships between discourse and society, between the micro-
that are not quantifiable into an acceptable billing/reimbursement politics of everyday texts and the macropolitical landscape of
code (e.g. wellness care). These financing exigencies set finite ideological forces and power relations” (2002, p. 100). The “critical”
parameters within which chiropractic must constitute and present aspect of discourse analysis specifically goes beyond mere
claims of identity and cultural authority. description to include an interpretation that demonstrates how the
This research will extend prior research to discuss the way that discourse is shaped by power and ideology that is often not visible
identity and cultural authority constitute struggles in which to participants. Fairclough notes that one strategy to investigate
multiple, contradictory and heterogeneous claims are made in this is to capture discourse undergoing a “moment of crisis” to
a discourse within the profession. The ability to constitute an bring into relieve the multiple issues being discussed, as well as
identity is at once agential, but also constrained by structural making visible the practices that are often “naturalized” or taken as
boundaries and limited resources to define, survive and compete. common sense (1992, p. 230). By examining the discourse of
The following diagram outlines the multidimensional analysis of identity and cultural authority emergent around the literal moment
discourse utilized in this research (Diagram 1). of crisis announced by Meeker and Haldeman (2002) and the article
“Chiropractic at the Crossroads,” I have chosen to analyze the
Methodology debate occurring amongst chiropractors in the United States as they
struggle to create their own sense of identity and project that onto
This research utilizes critical discourse analysis (CDA) modeled a larger environment of health care providers.
after Fairclough’s (1992, 1995) work to analyze the heterogeneous
discourse surrounding identity and cultural authority within the Procedures
profession of chiropractic. Specifically, published articles are used
as sources of “texts:” utterances which make some form of truth The following keywords alone and in combination were used in
claim and which are ratified as knowledge (Mills, 2004, p. 55). a search of the Index to Chiropractic Literature (indexed by
Although there is no set of accepted methodological procedures members of the Chiropractic Library Collaboration) and the news-
to perform CDA, Fairclough (1992) suggests a discourse should be paper Dynamic Chiropractic: profession, culture, authority, identity,
analyzed in three-dimensions: 1) the textual level (a thematic scope, future. Articles published between January, 2002 (the year of
analysis of the content of the discourse), 2) the discourse practice Meeker and Haldeman’s “Chiropractic at the Crossroads” article) to
level (how discourse is produced, distributed and how subjects are December, 2010 were searched. From commonly referenced studies

Diagram 1. Multidimensional critical discourse analysis. Adapted from Fairclough, 1992, p. 73.
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837 1829

in these sources, three additional unpublished surveys were ob- texts. I remained vigilant to differences and divergences and
tained through weblinks provided. Articles were removed from the embraced all as valid viewpoints. I do not claim to have achieved
initial pool (N ¼ 126) if they were duplicated entries, poster a value-free analysis, nor do I believe that I have presented the “one
presentations or abstracts at conference presentations without full correct reading” of the texts under examination. In fact, to do so
text to analyze, if the article dealt specifically with issues unique to would run contrary to the principles of CDA, as it should be
a country dissimilar to the US (a country where chiropractic was understood that texts are “socially constructed by and, in turn,
not fully professionalized), or if the article did not deal explicitly construct understandings of reality rather than describing a or the
with issues of identity, authority or the future trajectory of the reality” (Cheek, 2004, p. 1147; emphasis in original). I have
profession. This created a database of 98 articles. acknowledged my background so that the reader can understand
A close reading of all texts from the database was performed the possible influences on the interpretations in this research.
with an eye to develop a three-tiered analysis. At the textual level, Aside from the issues of reflexivity mentioned above, the
the rhetorical strategies and techniques were categorized to create methodology employed in this research is limited to written and
an overall tone and tenor of debate. The question “who do chiro- published texts. It is possible than an article from the initial pool
practors profess to be?” was asked and major themes were allowed was overlooked and omitted during the selection process, although
to emerge from the data. At the discourse practice level, the the author and a graduate assistant both performed the selection
question “who is speaking, who is not speaking and how is the process separately with identical results. Additionally, not all
speaking being done?” was addressed. Here, the texts were viewed viewpoints from chiropractors are represented equally. Opinions
as in interaction with each other, and part of a history of dialog e that were never recorded or printed, those outside or dissimilar to
what Fairclough (1995) would term “intertextuality” (pp. 188e189). the US context, and those written in a language other than English
How the genre of printed publications socially positioned certain were not included in the database.
voices to be heard while excluding other voices was the focus of this
level of analysis. Finally, at the level of social practice, texts were Findings
examined for connections with the larger socio-political context in
which the debates are situated. The following two questions: “how Textual level
is the profession projecting itself?” and “to whom are these images
being presented?” were posed. With consideration of existing At the textual level, analysis can either be intensively investi-
power relations in the health care environment, the external gated linguistically and semantically (as suggested by Fairclough,
organizations, professions and institutions most affected by issues 1992, 2003) or can be conducted at a more thematic level
of identity and cultural authority for the profession were also (Threadgold in Kamler, 1997, pp. 437e438). Similar to the approach
identified. of Threadgold as well as Smith (2007) this research will examine
the rhetorical techniques and larger thematic patterns that emerge
Reflexivity in the texts to elucidate the areas of debate, crisis and proposed
identity within the profession.
As Smith (2007) and Finlay (2002) note, it is important for
researchers utilizing CDA to be explicit about their relation to the Rhetorical devices
topic or participants through which the researcher has interpreted The texts reveal a tapestry of many heterogeneous voices.
the texts. I was initially sensitized to the discourse surrounding Although a multitude of perspectives emerge, there are some
cultural authority when I was invited to speak at the Association of repeated rhetorical strategies: 1) threat, 2) divisiveness, and 3) the
Chiropractic Colleges e Research Agenda Conference several years ideology of science. These devices are similar to what has been
ago. This conference is attended by chiropractic college faculty, noted in prior research (Warnock, 2005; Welsh et al., 2004).
administrators, researchers and policy-level decision makers. Feise
(2005) estimates that only a few dozen full time practitioners Threat
attend the conference (p. 20). Having just completed a dissertation There is a dire sense of emergency and an explicit call to action
that involved archival research as well as in-depth interviews with in many of the texts. Change is imperative inferring that death or
veteran “everyday” chiropractors, I was struck by the disjuncture in some disastrous consequence might ensue. One commentary
orientations between what I come to distinguish in this research as makes this clear: “Chiropractic, as a profession, is endangered. Its
two distinct characters: the everyday chiropractor versus the practitioners are soon to become clinically extinct. This is not
academic chiropractor. a drill” (Filippi, 2005, p. 1). Other words used in the texts to indicate
In the interest of full disclosure, my spouse is a chiropractor who a sense of threat include: assault, nihilistic, eaten alive, and crisis
over the course of my career has gone from being an everyday point.
chiropractor to a chiropractic college faculty member and now
a college administrator/academic chiropractor. Rather than seeing Divisiveness
my position as biased, I see it as akin to Collins’ (1986) “outsider- It is also clear there is considerable disagreement and debate
within” perspective. I am an outsider and not a chiropractor, but am concerning professional identity within chiropractic (see further
“within” because I am on the margins of both the everyday chiro- discussion, below). Rather than framing a persuasive yet dispas-
practor as well as the academic chiropractor, having been married sionate argument, the discourse features a great deal of emotional
to one, having interacted with dozens of chiropractors (both and rancorous name-calling in an effort to distance one segment
academic and everyday) and having researched the profession as from another and to denigrate colleagues as an undesirable “other.”
a whole for over a decade. Feise (2005) states he is “embarrassed” by his fellow chiro-
To ensure validity and trustworthiness, I have worked to practors for their lack of research experience and knowledge. He
examine as wide a range of voices as possible (albeit only those that further questions their intelligence: “most doctors of chiropractic
have been published and heard) asking consistent analytical are incapable of defending themselves.”(p. 21). Demarcation from
questions of each text, as suggested by Smith (2007). Following the undesirables extends to privileging chiropractic as superior to other
lead of Finlay (1998, 2002) I was conscious of instances where my CAM practitioners. Gleberzon, Cooperstein, and Perle (2005) assert
own feelings and experiences ran contrary to those reflected in the that the profession of chiropractic must reign in unethical
1830 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837

practitioners at the margins or else “perceptually if not legally be of chiropractors felt that serving as “back and neck pain specialists”
demoted to a ‘Group B’ status, lumped together with homeopaths, was the least desirable image of the profession to have (WFC, 2005,
acupuncturists and massage therapists” (p. 72). Survey of the Profession section, item 4e).
“Discourse” is somewhat of an overstatement when analyzing Contrarily, another segment in the profession seeks an
these texts. The corpus of publications as a whole involve numerous expanded scope of practice and aspires to capture a new area of
statements meant to provoke but not to converse; meant to hurt jurisdictional expertise: wellness. Hawk (2004) analyzed college
rather than to understand; meant to claim victory rather than mission statements and scope of practice definitions in all 50 states,
interact. There is much more talking at rather than actual dialog and found the common descriptors to be “primary-care providers
occurring. who emphasize health and help the body heal itself” (p. 46). An
international survey of practicing chiropractors found the most
Ideology of science desirable image of chiropractors (83%) to be “wellness doctors”
The most common rhetorical strategy is to wage that a segment (WFC, 2005, Survey of the Profession section, item 4e).
is not committed to science and the assumed rationality and But, even among those that advocate wellness there is
objectivity that come with such an orientation. As a result, disagreement over how broad this scope should be cast: as patient-
segments that do not embrace science in an appropriate way (by centered, part of public health, as doctors of natural medicine, or as
subscribing to a progressive lexicon and advocating evidence-based personal well-being? Gatterman (2006) suggests “a patient-
practice) are by default emotional, irrational and illogical. Murphy, centered paradigm that provides a model for health promotion
Schneider, Seaman, Perle, and Nelson (2008) equate a segment of and wellness in the patient’s interest” (p. 95) that is soundly
chiropractors (to be later identified as “subluxation-based chiro- restricted to only scientifically-verified techniques. A vocal segment
practors) as occupying the same metaphysical and pseudoscientific within the profession is pushing for chiropractic to become a part of
space as foot reflexology (Podiatrists and Foot Reflexologists the American Public Health Association (APHA) (Hyland & Baird,
section, para. 2), while Phillips (2004) castigates this segment as 2005; Johnson et al., 2008; Murphy et al., 2008). This would
akin to “creationists” and “fundamentalists” (p. 6). He goes on to enable chiropractic to ride on the coattails of the APHA’s sizable
privilege the position of progressive chiropractors (to be later membership, resources and lobbying efforts and could expand the
identified as back/neck/pain specialists) as having created “a soul range of insurance codes chiropractors could seek reimbursement
willing to search for truth, to challenge the status quo in hopes of under to include preventive medical care. To do this, chiropractic
making it better” (p. 10). would need to expand their daily routines to include screening for
Perhaps the irony is that most authors that elevate science on risk factors, health behavior counseling (e.g., weight reduction,
a pedestal as both the means and ends of professional change assert smoking cessation) and abandon a historically-held anti-vacci-
that their segment is much more proficient and knowledgeable of nationist stance. This becomes problematic when considering that
scientific practices than the other segments in chiropractic. McDonald’s survey of practicing chiropractors found that 50.1%
However, science is really much more of an ideology. Phillips believed the pro-immunization stance of medicine deserves to be
(2004) who speaks as part of the segment advocating limited questioned (2003, p. 60).
professional status, pleads for chiropractors to be scientifically Riggs (2007) proposes an even more aggressive scope to become
rational, yet presents personal communication from two chiro- comprehensive doctors of natural medicine and suggests that
practors as his “evidence” to do so. Good (2010a, 2010b) critically chiropractic merge with naturopaths and then focus on herbal,
notes that those who demand science as the arbiter of what should nutrition and functional aspects of health care, women’s health and
be practiced are the very ones that employ a selective interpreta- gerontology. Still others propose a nearly all-inclusive usage of the
tion of only some of the available evidence to support their agenda. wellness platform. This segment sees wellness as an opportunity to
For the back/neck/pain specialist segment who include many address any and every aspect of health, and a way to tie the vitalistic
chiropractic leaders, science is an ideology to be pronounced for roots of the profession by addressing “wellness, quality of life and
political expediency and as an expectation for others, but often not human potential” (Kent, 2009, p. 31). These chiropractors seem to
themselves, to meet. equate wellness with personal well-being and aim to address
concerns that go beyond physical symptomatology to include
Thematic textual analysis emotional, spiritual and psychological aspects of health.

The CDA utilized in this research also involves a thematic Application and treatment
analysis of the major issues of contention in the discourse Abbott (1988) states the essential feature of a profession is the
surrounding identity within the profession. I present five different work that they do. For chiropractic, this involves debate over the
axes around which identity is actively debated within chiropractic treatment of patients and whether a conservative or liberal set of
today: 1) scope of practice, 2) application and treatment, 3) alter- work prerogatives are more appropriate.
native or mainstream positioning, 4) lexicon, and 5) service. Chiropractors are debating the proper application of care. On
one end of the spectrum are chiropractors who advocate hands-
Scope only adjustment of the vertebral spine. Winterstein, Phillips, and
I am using scope of practice here to refer to claims of the Kremer (2004) suggest calling this traditional and conservative
appropriate jurisdictional niche of the profession. Setting a narrow segment “subluxation-based chiropractors” and contrasts it with
scope as neuromusculoskeletal spine experts or back/neck pain the more liberal and progressive “physicians of chiropractic medi-
specialists has been advocated by several segments within the cine:” who “provid[e] differential diagnoses, manual medicine,
profession (Mootz, 2007; Murphy et al., 2008; Nelson et al., 2005; nutritional products, natural and physical medicine services” (p.
World Federation of Chiropractic (WFC), 2005). Others are vehe- 20). The segment advocating chiropractic medicine has been
mently opposed to this (Duenas, Carucci, Funk, & Gurney, 2003; working legislatively to amend educational accreditation standards
Kent, 2009; Riggs, 2007; Rosner, 2005; Sportelli, 2006). Smith to recognize this doctor title along with removing the phrase
and Carber (2009) report that 73% of surveyed chiropractors “without drugs and surgery” which would open the floodgates to
considered themselves as “back pain/musculoskeletal specialists” prescription drug-writing abilities. Abandoning the drugless stip-
(p. 23). Yet inconsistently, another international poll found that 47% ulation of alternative medicine has already been accomplished in
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837 1831

revisions to chiropractic scope of practice laws in New Mexico (c.f., domains of experience may be “reworded” as part of social and
Clum, 2010). political struggles. or how certain domains come to be more
There does appear to be consensus over allowing chiropractors intensively worded than others (p. 77).
a wide range of treatment options. In an investigation of self-
Chiropractic’s early history as “separate and distinct” proved an
reported actual practice by chiropractors in North America,
effective legal defense for chiropractors arrested for practicing
McDonald (2003) found a wide range of care (treatment) deemed
medicine without a license (Rehm, 1986). This rebel status
“acceptable” within the purview of chiropractic: prescribing vita-
extended to the use of a unique lexicon that included such concepts
mins/minerals: 96.7%; modalities [electric muscle stimulation,
as subluxation and Innate Intelligence. These terms that were once
ultrasound] 93.5%; massage 93.1%. Also, chiropractors in this survey
sources of pride are now seen by some segments as an embar-
reported a wide range of practice prerogatives (application) that
rassing stigma that needlessly ties the profession to antiquated
they actually performed beyond the adjustment/manipulation,
notions of self.
such as: exercise recommendation: 97.8%; and stress reduction
Of chief debate is the concept of subluxation, or verte-
recommendations: 86.4%. Similar results were obtained in
bralesubluxation complex (VSC). Viewed allopathically, a subluxa-
a national survey of UK chiropractors (General Chiropractic Council
tion is defined as a partial dislocation of a joint which should be
(GCC), 2004). Clearly, chiropractors in everyday practice are
removed or (biomedically) corrected (c.f. Kaptchuk & Eisenberg,
employing an expanded application and broad range of treatment
1998). The concept subluxation is inextricably tied to the under-
for their patients, but this does not extend as far as a desire to write
lying vitalistic and holistic epistemology of chiropractic. Viewed in
prescriptions. Only 11.4% of chiropractors surveyed by McDonald
this way, the subluxation is not only a blockage of nerve flow (a
(2003) felt chiropractors should be able to write prescriptions for
physical entity) but also a (as yet unmeasurable) interference of
all medicines (p. 52) an indication that the segment advocating
mental impulse and expression of Innate Intelligence (conceptu-
“chiropractic medicine” is not representative of the whole
alized as any form of life: physical, mental, spiritual, psychological).
profession.
It is undetectable and may be asymptomatic, signaling a state of
“dis-ease” in the body. A segment of chiropractors (often including
Alternative or mainstream positioning
the subluxation-based chiropractors, mentioned previously) wish
A third criteria central to intraprofessional identity concerns the
to remain tied to the original philosophy of the profession and do
degree of autonomy desired by the profession. That is, should the
not wish to make a diagnosis as that limits attention to a symptom
profession remain peripheral and part of CAM, or should it inte-
or condition rather than a holistic orientation of overall health and
grate and become part of the mainstream?
functioning. They believe the body can vitalistically restore the
One segment of chiropractors seeks integration (Lehman &
mental impulse but does so in ways that defies reductionist science
Suozzi, 2008; Morgan, 2005; Taylor, 2006). Proponents of this
and hypothesis testing. The result may be a desirable and
view envision increased respect and access to biomedical
measurable health outcome (e.g. lowered blood pressure, lower
institutions:
pain); however, it is just as possible for higher blood pressure,
The benefits of integration to the profession are too great to heightened pain or no physical manifestations to immediately
ignore. To be part of the system is to have access to all the result. The response is what the body needs, rather than what
resources of the systemdfunds for research, state supported science can accurately predict. As Chestnut asserts, chiropractic is
education setting, access to other educational institutions and more than just a mechanistic adjustment aimed at curing or
nearly universal inclusion in all reimbursement systems (Nelson treating a specific diagnosis.
et al., 2005; Integration section, para. 5.)
Manipulation may indeed by one of the best therapies in the
Branson (2009) presents some of the only direct reporting of world to decrease pain, but it will never be a feather in the cap of
actual integrative practice involving chiropractors working along- chiropractic. Reducing subluxations reduces pain and symptoms
side physical therapists in a hospital setting in Minnesota. Although but this is no more than a welcome, beneficial and lucrative
a pioneering achievement, the “integration” involved less than 10 side-effect to correcting VSC, improving function, and removing
chiropractors (whose numbers have been on the decline in more interference to the innate ability of the body to self-heal (2008,
recent years) isolated to an off campus facility which seems to Thinking Globally section, para. 4).
reinforce the findings of Hollenberg and Muzzin (2010) who found
The lack of scientific validation of the subluxation has attracted
that these arrangements were more co-opting and marginalizing
considerable ire in recent years. One segment within the chiro-
than integrative.
practic profession feels it important to transcend this lexicon and
Chiropractors in actual practice seem to reject both the alter-
its philosophical attachments (Good, 2004; Winterstein, 2002).
native and mainstream ends of the continuum. As Redwood, Hawk,
Most of the chiropractors who advocate removing subluxation
Cambron, Vinjamury, and Bedard (2008) note, 69% of their non-
from the lexicon have taken a more allopathic approach to chiro-
random sample rejected the label “CAM,” but also rejected the
practic, and also advocate becoming back/neck/spine specialists or
labels “integrative medicine” and “mainstream medicine” (p. 368).
limited professionals.
No other label achieved consensus in the sample, either. The
As Fournier (2001) and Warnock (2005) both note, rhetoric may
potential movement of chiropractic from a marginal to a limited
be used to initiate movement toward preferred ideals. By castigating
status brings with it “definitional vertigo,” (p. 366) at least for
subluxation-based chiropractors as dogmatic zealots, an “other” is
everyday chiropractors.
fashioned, against which a segment of the profession is attempting
to define themselves. The back/neck/pain specialist segment argues
Lexicon
that terms like subluxation, Innate Intelligence and vitalism are to be
Also relevant within discourse is the choice of lexicon used by
banished from the profession and considered only as “a personal
various authors laying ownership to certain vocabulary and
matter so long as these beliefs do not distort the discharge of
disparaging the use of other terms. Fairclough (1992) writes:
professional duties and obligations” (Nelson et al., 2005; What is the
One focus for analysis is upon alternative wordings and their Chiropractic Hypothesis? section, para. 5). Philosophy, they propose,
political and ideological significance, upon such issues as how should be referred to instead as a “refutable theory” or “hypothesis”
1832 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837

(and therefore, something that can be falsified and disbanded). One offer practice-building seminars and life coaching, coupled with
proponent states: “The fixed ‘single chiropractic concept’ [sublux- allegiance to subluxation-based chiropractic have existed for
ation] that some struggle to keep alive has for them unfortunately decades (Baer, 1996; Haneline, 2005; Keating et al., 2005). Kisinger
past (sic) on, as has bloodletting, wooden teeth and the Flat Earth (2009) voiced concern that these practice-management organiza-
Society” (Carter, 2005, p. 10). tions targeted the profession’s young, who are impressionable, or
The segment wishing to move to limited professional status those facing fiscal distress (Gleberzon et al., 2005).
seems impatient and no longer willing to discuss the matter The discourse surrounding intraprofessional identity is the most
because of the presumed size of their group and a history of contentious area for the chiropractic profession. No clear division of
unsuccessful communication with the other side: camps can be noted. Those segments that are conservative in the
area of treatment/application may be liberal in the area of scope
There can be no unity between the majority of non-surgical
and then once again conservative when it comes to autonomy. The
spine specialist chiropractic physicians and the minority of
same segment that opposes another on the issues of scope of
chiropractors who espouse metaphysical, pseudoreligious views
practice may very well be united on issues of service. Some
of spinal subluxations as ‘silent killers.’ The latter minority
segments are not well represented in the chiropractic literature at
group needs to be marginalized from the mainstream majority
all. They do not publish their views, but rather circulate them in
group and no longer should unrealistic efforts be made toward
seminars and conferences led by charismatic leaders. Each issue is
unification of these disparate factions within the profession
a separate line of fault leading to dissensus on identity.
(Murphy et al., 2008; Podiatrists and Foot Reflexologists section,
The issues scope of practice and lexicon are most contested, and
para. 3).
the profession as a whole cannot agree on whether to remain
Yet, polls of practicing chiropractors are strongly in favor of alternative or join the mainstream. Service is much less debated
retaining their distinctive lexicon. McDonald (2003) found: and there appears to be consensus on the issue of treatment but not
application. The discourse, itself, is characterized by the rhetoric of
For all practical purposes, there is no debate on the vertebral
threat, divisiveness and an appeal to the ideology of science. The
subluxation complex. Nearly 90% want to retain the VSC as
level of dissensus documents that there are multiple, contradictory
a term. Similarly, almost 90% do not want the adjustment
and heterogeneous voices within the discoursedparticularly a gulf
limited to musculoskeletal conditions. The profession as a whole
between chiropractic leaders and everyday chiropractors, as well as
presents a unified front regarding the subluxation and the
subluxation-based chiropractors and those who advocate
adjustment (p. 20).
becoming back/neck/pain specialists. This muddied notion of self
The views of everyday chiropractors as indicated in surveys are makes co-existing and competing at the macro level more difficult.
discrepant from the pronouncements by their chiropractic leaders.
Discourse practice level
Service
Parsons (1951) noted the key characteristic of a profession was Fairclough notes the discourse practice level involves the
its service orientation. True professionals operated with fiduciary “production, distribution and consumption of texts” (1992, p. 78).
obligation toward their clients, placing the client first (collectivity Specific genres of discourse (e.g., newspapers) contain conventions
orientation) regardless of the inconvenience or sacrifice this meant and rules that operate to “control linguistic variability for particular
for the professional (self orientation). One chiropractor, Kisinger areas” (Fairclough, 2003, p. 24). The goal in this section is to
(2009) stated “pursuit of affluence, entitlement and personal determine the dominant, contradictory and/or silent voices within
excess as the ultimate calling and reward.” has displaced the texts and what functions they serve. The sources analyzed in
a commitment to beneficence (p. 44). Many within the profession this research are 1) peer-reviewed chiropractic publications, and 2)
target practice-management groups where chiropractors are news stories from Dynamic Chiropractic, the major periodical of the
taught hard-sell techniques aimed at achieving short-term wealth profession.
for the individual. These techniques are unscrupulous because they Texts are shaped discursively, so there is a controlled way in
rely on intimidation and fear tactics and often dupe patients into which questions are asked, answers are presented and information
visits that are not needed or are excessively drawn-out so as to is expected to be conveyed. Imploring the chiropractic profession,
financially exploit them. One chiropractor offers these concerns: Hawk (2004, p. 45) notes: “if it is not published, it didn’t happen!”
which denotes the exclusionary character of publishing in the
For example, some practice consultants promote the policy of
academic press. What is unsaid here, is any author must have the
withholding administration of treatment on the first visit,
acumen to present, cite, research and organize ideas in a way that is
preferring to reschedule the patient for a report of findings on
parallel, rigorous and worthy of inclusion into the peer-reviewed
a subsequent visit.Others promote the use of X-rays on nearly
marketplace of printed research. Peer-review also operates as
every patient in order to determine biomechanical deviations
a filter where alternative voices and opinions may be rejected
from a theoretical “model” of a normal spine implying that this
because they lack alignment with the dominant discourse, lexicon
information is so essential to successful treatment that the
and method expected in a journal. In newspaper sources, column-
benefit outweighs the very real risk of radiation exposure. These
space, topicality and relevance are criteria held at the discretion of
and other business practices promoted across the profession are
editorial staff. Again, alternative voices (e.g., letters to the editor,
tolerated without challenge by the rank and file (Nelson et al.,
press releases) may or may not be published (Villanueva-Russell,
2005; The Search for Cultural Authority section, para. 5).
2009). The vast majority of texts in this research (78%) come from
Fournier (2001) found something similar in aromatherapy when peer-reviewed journals, so the bulk of analysis will be devoted to
the idea of the “quack” was evoked implying an inappropriate that particular media source. Within this discourse the conventions
commitment to profit using any means necessary. Welsh et al. of journal publications elevate the academic chiropractor segment
(2004), too, seem to touch upon a similar phenomenon noting that and those advocating a science-oriented, back/neck/pain specialist
charismatic leaders were divisive within homeopathy in Canada, position while structurally limiting the ability of everyday chiro-
pulling followers in divergent directions and toward alternate practors as well as subluxation-based segments from having their
visions and identities. In chiropractic, charismatic personalities that views voiced.
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Conventions of academic publishing This small group of researchers has worked with remarkable
Welsh et al. (2004) note an increasing impetus for CAM cohesion and productivity: generating a research agenda, white
professions to accommodate medical science and research. But, this papers and a strategic plan to mark their future priorities (Lawrence
endeavor has been difficult for chiropractic due to a lack of infra- & Meeker, 2006; Triano et al., 2010). Their ideological underpin-
structural support necessary to fund and sustain biomedical nings of integrative alignment with the medical model set the
research (Keating, Green, & Johnson, 1995). Not only does chiro- foundation for efforts to standardize lexicon and research practices,
practic lack the institutional basis to conduct its own studies, the reform licensing and scope of practice standards profession-wide.
outlets in which this is done are clearly structured toward In this sense, the discourse practice level is dialectically linked to
biomedical research that relies solely on a positivist methodology the textual level. Professional identity is constructed agentially by
in which randomized controlled trials are privileged. Research is chiropractors, but is also constituted and constrained by the
done without consideration of the epistemology of CAM. As Nelson activities at the discourse practice level, and specifically, the actions
(1997) notes “clinical studies of the effectiveness of spinal manip- of discourse technologists/academic chiropractors.
ulation are conducted and reported without reference to the Two examples of this are separate efforts to reach “consensus”
presence or absence or even the existence of subluxations” (p. 46). on key terminology for stages of care (Dehen, Whalen, Farabaugh, &
Young (1998) detailed that even after the Office of Alternative Hawk, 2010) and on a strategic research plan (Triano et al., 2010). In
Medicine (which eventually evolved into the National Center for both cases, a select group of chiropractors made policy-level deci-
Complementary and Alternative Medicine e NCCAM) was created, sions, then published and announced these in an attempt to stan-
the initial funding went to major research institutes that proposed dardize practice and “naturalize” activity (Fairclough, 1992) thus
allopathic research (such as evaluating cartilage products and rendering the discourse closed and ruled upon. But, by their own
antineoplastons for cancer prevention and treatment) (p. 293). The admission, the strategic planning consensus conference began with
NCCAM and some researchers (c.f. Tataryn, 2002) classify chiro- the “assumption that successful future [professional] growth
practic as a “manipulative and body-based therapy” rather than as requires cultural change” (Triano et al., 2010, p. 396). So, tradition
an “alternative medical system,” so a bias exists toward studies that and concerns of subluxation-based chiropractors were never rep-
mechanistically focus on the effects of treatment, only (Redwood resented, entertained or considered as valid viewpoints from which
et al., 2008, p. 362). This then adds ammunition for those to construct a future trajectory. In the case of a consensus confer-
desiring limited professional status as back/neck/pain specialists. ence to standardize terminology, the authors (Dehen et al., 2010)
Reductionist, positivistic research demanded by evidence-based admit that agreement on definitions to be used for terms such as
practice divorces the underlying philosophy (of which “wellness” and “acute” were determined by only 27 participants, of
subluxation-based chiropractors are advocates) to mere therapies which only three were non-chiropractors, two-thirds belonged to
or procedures. Tang aptly writes that a similar process in one single chiropractic association and nearly a quarter also served
acupuncture is a: “process not unlike completing a jigsaw puzzle as consultants to third party insurance payers (p. 460). Establishing
using scissors” (2006, p. 259). lexicon or a research trajectory by a specialized subset of academic
Everyday chiropractors and the subluxation-based segment are chiropractors in isolate from the larger practicing population of
not represented well in the discourse. Not only are they not practitioners ensures that nothing close to an “ideal speech situa-
engaged in research or authors of peer-reviewed publications, their tion” (Habermas, 1990) or true “consensus” will result.
views are only indicated by proxy through surveys and unpublished At the discourse practice level the conventions of peer-reviewed
polls. Further, each of these sources are methodologically flawed journals privilege the voice of chiropractors that wish to become
and suffer from small sample sizes (Smith & Carber, 2009), self- limited professionals while silencing those who prefer to remain
reports of activities (McDonald, 2003) and non-random samples marginal. The academic chiropractors assume a dominant voice in
(WFC, 2005) which mean that the views of this segment are partial the discourse not only because they use their degrees and positions
and incomplete, at best. to legitimate their voices, but also because they are in gatekeeping
positions that control access to journals, the content of these arti-
Discourse technologists cles, and the lexicon to be used within the profession. In this sense,
the discourse practice level is dialectically linked to the textual
Fairclough notes that the underlying power relations and ideol- level, as identity is both shaped yet constrained by the discourse.
ogy of society also underlies a discourse. His main emphasis is on the
effects of the “new capitalism” and how this has triggered the Social practice level
“technologization of discourse” (1995, p. 102). Perhaps the “scien-
tization” of CAM seems to underlie much of what is occurring at the Analysis at the social practice level situates the discourse in the
discourse practice level found in this research. Fairclough (1995) larger socio-political and historical context to see how ideology has
notes that the “discourse technologist” plays a crucial role in shaped the dialog. Discourse affects social relations and the iden-
disseminating this new orientation. “This is done through a process tities of those within them. The focus of this section is to examine
of redesigning existing discursive practice and training institutional the debates over identity as they are situated in a larger context of
personnel in these redesigned practices” (1995, p. 102). existing power relations. The structural features of the US health
Fournier (2001) notes in aromatherapy, those evoking a profes- care landscape shape the discourse and efforts to project the
sional trope projected an image of “disinterested gentlemanly cultural authority of the profession, as well.
scientist” (p. 124) who were objective, rational and solely in pursuit
of truth and knowledge. A similar stratification seems to be Public
developing within the chiropractic profession as a segment of Appealing to the public is important. Without clients and
academic chiropractors serve as discourse technologists who are at patients, doctors cannot financially survive. However, the public
the root of the majority of articles in which science-oriented change adjudication of claims cannot wholly be manipulated or predicted.
toward becoming back/neck/pain specialists is advocated They The public seems to have a long-term memory of professions, and
evoke authority through their degrees, leadership positions and these images are not easily molded or altered (Abbott, 1988).
institutional positions in education, journals and chiropractic Claims of cultural authority must be projected in spite of unfa-
associations. vorable stereotypes of chiropractors as “back crackers.” One
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professional segment has decided to turn the stereotype into little concern for the patient and not much more for our
a more positive image as “spinal care specialists” (Briggance, 2005; profession. We did this for immediate satisfaction, mixed with
Murphy et al., 2008; WFC, 2005). Briggance (2005) reasons that greed and low self-esteem, searching for something to create
chiropractic should simply align themselves with the public’s our identity (Sportelli, 2006, p. 77).
image because that is what chiropractors do, anyway. “One only has
The extent to which chiropractic seeks inclusion within third
to look at chiropractic office signs, advertising materials, websites
party payment schemes remains undetermined. If chiropractic
and so on, to see that practitioners already accept this fact and
seeks continued inclusion within managed care, this will surely
continuously reinforce it in their public interactions” (p. 14).
mean an increasingly narrow scope of practice and diminishing
The suggestions to model in the public’s preferred image are not
returns in terms of reimbursement into the future (Hyland & Baird,
unilaterally supported within the profession. One critic argues “It is
2005), unless perhaps it can gain authorization to utilize the
merely a daisy chain of mind games. It would truly be a comedy of
preventive medicine insurance reimbursement codes available to
errors e to say nothing of a tragic mistake e to cast the future image
public health.
of chiropractic’s potential exclusively on what one believes the
public wants to hear” (Rosner, 2005, pp. 43e44). Defensively
Science
catering to the public’s misinformed image of the profession seems
Science is an epistemic movement that is larger and external to
contrary to asserting expertise through claims of cultural authority.
the system of health care professions. This demand for empirical
proof has triggered an “audit culture” (Shore & Wright, 1999)
Market
obligating professions to demonstrate measurable health
Others within the chiropractic profession advocate shaping
outcomes. Evidence-based practice (EBP) is one indicator of this
authority around what the public demands, but justifies this in
movement within health care today.
terms of economic exigencies. Greenawalt (2004) believes that
Chiropractic has wedded itself to the ideal of EBP; however, this
hiring a public relations firm to create a marketing “brand” for
benchmark has been difficult for the profession to meet, partly
chiropractic is the most prudent strategy. Utilizing a metaphor of
because there is a lack of infrastructural support for research in
the nearly-bankrupt Winn Dixie chain of US supermarkets to
chiropractic educational institutions (see Section Discourse
suppose a similar fate for chiropractic, Sportelli states: “Our success
practice level for more on this). The protocols of EBP are more
(or lack of success) in establishing a credible, coherent, ethical
aligned with the segment of chiropractic that favors becoming
identity in the minds of the consumer is the only and final arbiter of
limited professionals (back/neck pain specialists) because EBP has
market share. Regardless of what we claim to be, unless our image
not been able to validate the philosophical orientation of
is congruent with public perceptionsdour customersdnothing
subluxation-based chiropractors, such as the existence of the
else matters” (2005, p. 26).
subluxation, Innate Intelligence, nor has there been enough valid
scientific study to provide support for such widespread practices as
Insurance
wellness care, pediatrics and animal chiropractic (Villanueva-
Another major actor within the US system of health care
Russell, 2005). This means that the majority of care actually
professions is third party insurance and managed care. Managed
provided and deemed acceptable by the majority of chiropractors
care is an external force that directly impacts acceptance of chiro-
reported in national surveys (GCC, 2004; McDonald, 2003) should
practic in the larger health care system. As managed care reim-
in theory, be deemed unacceptable and accompanied by the
bursement is clearly set up to reflect the structure, diagnostic
disclaimer “this procedure does not have strong backing from high
language and practices of biomedicine, many chiropractors argue
quality systematic reviews of all available relevant scientific
that altering identity, lexicon and practices toward allopathic, pain-
studies” before being performed on any patient (Nelson et al., 2005;
oriented conditions is necessary for survival in today’s world. To
The Acceptance of Evidence Based Healthcare section, para. 4).
maximize insurance reimbursement, lexicon cleansing is necessary.
The imperative for EBP from the larger health care environment
[F]or the theory [philosophy of chiropractic] to be embraced by translates to pressure and constraints that impact the practice of
the greater social system, it should offer implementation that everyday chiropractors. Those advocating EBP also advocate for
can fit within constraints of the existing system. A theory that chiropractic to evolve into a limited professiondone in which the
requires the elimination of the two entire industries of medicine scope, application, treatment and lexicon are self-circumscribed to
and insurance will probably not be embraced in Western be aligned with that which can be verified through science. This
cultures no matter how feasible and promising it might be process appears to be well underway internationally. Revisions by
(Mootz, 2001, p. 7). regulatory bodies in both Great Britain and Australia have amended
the Code of Conduct standards for chiropractors to eschew use of
Others argue that chiropractic has been sabotaged by the very the term subluxation or VSC because they lack clinical research
attributes of professional status it fought so hard to attain. evidence (Chiropractic Board of Australia, 2011; GCC, 2010). Addi-
Achieving reimbursement in third party insurance brought the tionally, the GCC’s revised code also calls for the allegiance to
opportunity to obtain profit through creative billing and over science to trickle down to the practice of advertising and reiterates
utilization (Gleberzon et al., 2005). The irony in becoming a service-oriented imperative for the profession: “when adver-
a profession was that status was attained at the cost of a service tising, claims for chiropractic care. ‘must be based on best
orientation, a self-limited scope of practice, and distortion of research of the highest standard’ only” (GCC, 2010, n.p.).
application to appease others. As one chiropractor reflects:
The evidence to support my contention is clear to the field Conclusion
practitioner who witnesses the erosion of economics, authority
and influence almost daily. Medicine and the insurance payers The notion of Meeker and Haldeman’s (2002) “crossroads” is
pointed us to a set of diagnoses that we currently claim to be still unresolved nearly a decade later. There is considerable
experts for. We willingly took the bait in expectation of money. disagreement on scope, autonomy and lexicon. External pressures
We systematically abandoned the claims that we treated those create a need to remain financially viable while accommodating
other diseases that they didn’t want us to treat. We did this with science. Efforts to construct professional identity are made difficult
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837 1835

because of power struggles between intraprofessional segments. mere a by-product of intellectual fashioning of academic chiro-
Those advocating changes are differentially positioned and so have practors. Surveys provide a glimmer that everyday practitioners
a greater impact on the shape and content of the discourse. vary in their views, although no systematic studies exist to date to
Should chiropractic sequester itself to become an evidence-based, empirically document their voices. It could very well be that an
back and neck pain specialty that is integrated with medicine as analysis of the discourse of everyday chiropractors (through in-
professional leaders have proposed? Pressure from insurance, the depth interviews, CDA of conferences attended by these practi-
market and science all operate to produce momentum toward this tioners, etc.) would reveal an equally diverse, contradictory,
end state. What are the potential consequences of this limited rhetoric-filled conversation. Good (2010a, 2010b) presents his
professional status? Robbins notes that “political self-betrayal” personal views as a “centrist” who is part of the “silent middle
(1992, p. 3) may occur in which some are accused of selling out their majority” in chiropractic that wishes to take a more moderate
ideals and philosophy for status. Segmental differences may be stance on issues of lexicon (p. 33). He suggests that this mass of
heightened rather than diminished, as was the case internationally chiropractors could decide the future direction of the profession,
for acupuncture (Hollenberg & Muzzin, 2010) and homeopathy (Cant but at this point have not been mobilized to act as a collective unit.
& Sharma, 1996). If integration means limiting the scope, truncating “We must become vocal about directing our research ini-
the application and abiding by only those aspects that can be scien- tiatives.To sit by idly and hope that this is accomplished without
tifically demonstrated, then assimilation and co-optation are much the centrists will only allow those at the fringes to continue their
more likely outcomes than integration. destructive ways and continue to allow the profession to evolve
Contrarily, everyday chiropractors are content with the current into an entity that does not represent the majority” (p. 38).
status quo as marginal professionals, wishing to remain tied to the Whether these everyday chiropractors have something unique to
traditionalist lexicon and an expansionist range of application and say that would reinforce or challenge the academic chiropractors
treatment authority. Until the market position, self interest/profit, has yet to be determined.
or range of treatment prerogatives are affected, the identity crisis of However, to allow everyday chiropractors meaningful partici-
chiropractic will not become a true reality nor a cause for concern pation in the discourse over professional identity and cultural
for this segment of the profession. authority would certainly be beneficial for the profession, as
While a heterogeneous and often contradictory discourse on a whole. The science-based research and EBP created by academic
both identity and cultural authority is present, the ideological chiropractors could be complemented by what Gabbay and Le May
underpinning of each segment and the timing of this “moment of (2010) describe as “mindlines” or tacit knowledge gained from the
crisis” remains unpacked. It is worth asking why these debates are practical clinical experience of the everyday chiropractors. Rather
occurring at this time. There is no ensuing crisis and no external than strong-arming change that may be contradictory to the pref-
imperative to reshape or initiate discourse on this particular topic. erences of chiropractors, incorporating mindlines and insights from
Redwood et al., echo this point: actual practice could help to bring context, the complexities of the
real world and the challenges and exigencies of a clinical practice to
No governmental body is demanding it. There is certainly no
balance the more rational and purely scientific guidelines often
groundswell in the CAM community to eject chiropractors (who,
created by academics (that are just as swiftly ignored by practi-
after all, make up the largest cohort of CAM practitioners as
tioners). Allowing everyday chiropractors to contribute to policy
defined by NCCAM). Moreover, it would be a drastic over-
decisions will ensure a more representative professional dialog, as
statement to assert that MM [mainstream medicine] is rolling out
well as encourage buy-in. As Gabbay and Le May (2010) note,
a rainbow-colored welcome mat for chiropractors (2008, p. 368).
a consideration of mindlines possessed by everyday practitioners
Analysis of the discourse suggests that debate over identity and coupled with the more formal knowledge of academics could help
cultural authority seems largely a politically-motivated intra- bridge gaps between theory and practice and encourage actual
professional movement, focused more on paternalistic occupa- implementation of guidelines. “Mindlines [should] reflect not
tional control than over cohesion and unity. Hollenberg and collective folly, nor coercive scientism but communal wisdom”
Muzzin’s (2010) work on paradigm appropriation of acupuncture (Gabbay & Le May, 2010, p. 203).
in Britain does not wholly seem to apply to the case of chiropractors Analyzing this professional discourse within chiropractic
in the United States. Rather than seeing the dominance of enables us to see who is participating and who is not; what is
biomedicine engulf a subordinate marginal profession, the impetus being stated and what is left unstated. As Cheek (2004) notes,
to engage in paradigm assimilation (integrative medicine or the CDA is a useful methodology to use in recognizing “the con-
idea of becoming a back/neck/pain specialist) is being driven from straining effect of a particular discursive frame’s dominance
within the profession of chiropractic, itself. Rather, changes to which then creates the possibility of a space to be opened up for
identity are being initiated internally by academic chiropractors as other discourses or ways of thinking” (p. 1143). What emerges
a coup d’état using the commitment to science (seen operating at from the interpretation of available texts in the discourse
the textual, discourse practice and social practice levels through amongst chiropractors is that a rhetoric-filled, one-sided
EBP, lexicon cleansing and reformed scope of practice laws) to conversation that is heavily weighted toward science-oriented
achieve intraprofessional control. reform is not conducive to real interaction. It is the hope that
The growing divide between the everyday chiropractor whose by bringing these underlying ideological power struggles to light,
views are only available by proxy through methodologically flawed that a more participatory dialog can commence with more
surveys are being systematically silenced by the claims of academic representation by everyday chiropractors and subluxation-based
chiropractors, who utilize rhetoric, status, institutional position, chiropractors (who may not be one in the same group) whose
and their roles as gatekeepers to journals as a means to dominate livelihoods will be impacted by implementing the policy deci-
the discourse. As Harding (1998, p. 145) notes: “Truth claims are sions and institutional practices (e.g., scope of practice laws,
a way of closing down discussion, or ending critical dialog, or insurance reimbursement, requirements for licensure and its
invoking authoritarian standards.” Perhaps the idea of crossroads renewal, etc.) that are currently being decided by academic
should more appropriately be replaced with “crosshairs.” chiropractors and the back/neck/pain specialist segment (who
One could also ask whether the debate over professional iden- may not be one in the same group) who will not, themselves, be
tity and cultural authority has any actual basis at all, or whether it is held accountable to these same standards.
1836 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837

Acknowledgments General Chiropractic Counsel. (2010 August 18). Guidance on claims made for the
chiropractic vertebral subluxation complex. Retrieved from. http://www.gcc-uk.
org/files/link_file/Guidance_on_claims_made_for_the_chiropractic_VSC_
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