Social Science & Medicine 72 (2011) 1826e1837

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

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

Professional identity and cultural authority are two concepts
that have appeared in the chiropractic literature with increasing
frequency in the past decade. In 2002, Meeker and Haldeman
published “Chiropractic: A Profession at the Crossroads of Main-
stream and Alternative Medicine” which evoked a clarion cry for
intraprofessional introspection. Commenting on the success of
having achieved professional status in the United States, Meeker
and Haldeman argued that chiropractic was still “trapped” with an
unsatisfactory marginal positionda part of mainstream medicine
but not fully accepted or participating in it.
Chiropractic still maintains some vestiges of an alternative
health care profession in image, attitude and practice. The
profession has not resolved questions of professional and social
identity and it has not come to a consensus on the implications
of integration into mainstream health care delivery systems and
processes. In today’s dynamic health care milieu, chiropractic
stands at the crossroads of mainstream and alternative medicine
(p. 223).
Professions have been well studied for several decades in the
sociological literature. Andrew Abbott’s (1988) contribution has
been to focus on the cognitive knowledge claims of expertise that
* Tel.: þ1 903 468 6091; fax: þ1 903 886 5330.
E-mail address: Yvonne_VRussell@tamu-commerce.edu.
one another in a larger system where they may be accepted or
rejected. This research will examine statements made by US
chiropractors found in printed sources (i.e., journals, newspapers)
to reveal how internal identity claims are formulated as well as how
an outward projection of cultural authority (the ability to be
unquestioningly believed (Starr, 1984, p. 13)) is presented in
a changing health care environment.
In health care, orthodox medicine has “professional dominance”
and possesses the largest jurisdiction (c.f., Freidson, 1970;
Pescosolido, 2006; Willis, 2006), although much discussion of the
decline of this hegemonic power has also occurred in the literature
(c.f., Haug & Lavin, 1983; Wolinsky, 1993). Complementary and
Alternative Medicine (CAM) has established itself as a “marginal
profession” in relation to this framework. Wardwell (1994) defined
marginal as an occupation that operated with autonomy from
medicine and rejected the medical definitions of illness and treat-
ment held by the mainstream (p. 1063). In their original formula-
tions, chiropractic, acupuncture, and homeopathy all existed as
paradigms and theories of disease that stood outside of orthodox
medicine and were largely incommensurate to the medical model.
In the US, chiropractic is unique from other CAM specialties
because it has fully achieved all aspects of professional status (it is
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
university affiliation and therefore lacks major research funding,
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
reimbursement). Wardwell advocated for chiropractic to become
a “limited profession” whereby the scope of practice would be
restrained to a more narrow range while remaining autonomous
and free from the need for referral or supervision from orthodox
medicine (1994, pp. 1062e1063). In recent years there has been
a heightened push within chiropractic to do just what Wardwell
(1996) had urged a decade before: transform from marginal to
limited profession. This has triggered heated debate amongst
chiropractors. This debate forms a discourse: its content, power
struggles and functions are the focus of this research.
Review of literature
Professional identity
Professions must profess something. This is a reflection of the
work they do, but also their inner-identity which defines who they
are. In the case of CAM, this often means emulating the structural
characteristics established by orthodox medicine: obtaining licen-
sure, educational accreditation, etc. Welsh, Kelner, Wellman, and
Boon (2004) note that many CAM professions “run the risk of
mistaking the allopathic medical model for the paradigm of
professionalization” (p. 237).
US chiropractors have achieved all professional attributes, yet
the professional self continues to evolve and adapt. Rather than
assume professions are homogenous and cohesive, Bucher and
Strauss (1961) note that various “segments” often occur within
a profession, leading to internal conflicts and power struggles. The
micropolitics of segments may lead to “boundary work,” (Gieryn,
1983) a process where groups may try to achieve demarcation
between themselves and rivals. Welsh et al. (2004) studied three
different CAM groups in Canada to investigate the strategies
employed to gain state regulation, a key attribute of professional-
ization. In the case of Traditional Chinese Medicine (TCM)/
acupuncturists, one segment that regarded themselves as tradi-
tional and pure faced conflict with the more scientific Western,
allopathically-trained practitioners that viewed Chinese Medicine
as an adjunct to their (largely biomedical) armamentarium. To
demarcate the latter segment from the former, science was used as
a rhetorical tool to elevate their techniques and educational rigor as
superior. The use of rhetoric is a common way to formulate
professional identity, particularly during times of crisis, internal
skirmishes or even interprofessional conflicts with competitors.
Science is only one grounds of professional struggle, however.
Warnock (2005) found an agonistic or war-like use of rhetoric to
conjure up loyalty and cohesion when optometrists sought to
expand for greater autonomy against their interprofessional rival,
the ophthalmologists. Allen (2000) found that nurses utilized
a rhetoric of “holism” to insist that the duplicated work they shared
with doctors was performed in a superior and more caring fashion
than the more dominant actors.
To this point, I have presented the literature of internal identity
in the face of struggle. What happens to identity if a profession
(peacefully) expands, merges or joins with another? Halpern
(1992) investigated medical specialties working to increase their
autonomy by encroaching on the jurisdiction of another field. Those
that were successful in breaking into a previously-controlled area
depended upon 1) cognitive legitimacy (couching expertise in
a common language) and 2) demonstrating that the interests of the
interloper were compatible with the larger group. Halpern’s soci-
ology in medicine orientation is not entirely helpful in analyzing
the interprofessional relations between CAM and orthodox medi-
cine, however.
The professional dominance of biomedicine leaves a deficit of
resources and ecological space from which CAM has to maneuver.
1827
This may initiate a movement toward integration with the main-
stream, orthodox medical system (e.g., obtaining hospital privi-
leges). The literature documents that when CAM professions
attempt to co-exist in an integrative setting with orthodox medi-
cine, that “paradigm assimilation” (Hollenberg & Muzzin, 2010, p.
34) often takes place. One exception to this is the work of Frank
(2002) who found that German homeopaths did not disband
their traditional, alternative beliefs in order to gain acceptance and
legitimacy in the larger health care system. More often, the
underlying vitalistic and holistic epistemology of CAM professions
is undermined, devalued, and largely omitted. Yoshida (2002)
asserts that the “technical” value of CAM disciplines is privileged
over “theoretical” value.
Dengele’s (2005) work focuses on the adaptation of homeop-
athy to the larger environment where the dominance of medicine
still figures prominently. Acceptance by the mainstream medicine
has led to a fractioning within the discipline of homeopathy
creating a tiered system of medically versus non-medically trained
homeopaths (Cant & Sharma, 1996). Similarly, Hollenberg and
Muzzin (2010) document that new regulation now separates TCM
from acupuncture in Ontario, Canada (p. 48).
The first part of this research will examine the micropolitics
involved in generating professional identity through a textual
analysis of written articles and news stories on the topic. The
rhetorical devices used by various segments to assert their views in
the discourse will be presented. By focusing on segmental view-
points represented in text, I hope to demonstrate the existence of
multiple, heterogeneous and even contradictory voices engaged in
a larger conversation of whom chiropractors profess to be. Addi-
tionally, the main thematic issues of contestation around identity
construction will be explored.
Extraprofessional considerations and cultural authority
Professions must not only wrestle internally with themselves
but then must amend these claims to be acceptable at the macro
system level. In this way, professions may try to attain cultural
authority and command the legitimacy and recognized expertise
recognized by others. The literature suggests that in the US, public
support and managed care are two key institutional actors that
must be taken into account for professional survival.
Public support and consumer demand have been integral to the
growing utilization and acceptance of CAM professions (Pelletier &
Astin, 2002). Yet, Pescosolido, Tuch, and Martin (2001) note that
public support for professions have been cantilevered with other
structural characteristics of the system.
When the profession’s attempts at monopoly combine with the
financial means to convert political legitimation into institu-
tional support (e.g. insurance coverage) and visibility (e.g., large
and impressive medical centers), the public is persuaded in
a subtle but nonetheless direct way. The building of institutions
crystallizes and reinforces power differences, placing limits on
individuals’ attitudes and behaviors and setting a context for
individuals’ socialization into a science-based society (p. 13;
emphasis in original).
In this way, public support for professions is part of a more
complex institutionalization of professional power in which the
dominance of medicine is interwoven with science, and even third
party insurance/managed care.
In spite of initial ideological resistance to Health Maintenance
Organizations (HMOs) and managed care in the 1980s, orthodox
medical physicians in the US not only expect but may demand to
work with these third party payment payers as preferred providers
(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
way. Most managed care insurance will cover only a limited
number of visits per year, and will not reimburse for X-rays (needed
by many chiropractors for diagnosis and analysis) nor for services
that are not quantifiable into an acceptable billing/reimbursement
code (e.g. wellness care). These financing exigencies set finite
parameters within which chiropractic must constitute and present
claims of identity and cultural authority.
This research will extend prior research to discuss the way that
identity and cultural authority constitute struggles in which
multiple, contradictory and heterogeneous claims are made in
a discourse within the profession. The ability to constitute an
identity is at once agential, but also constrained by structural
boundaries and limited resources to define, survive and compete.
The following diagram outlines the multidimensional analysis of
discourse utilized in this research (Diagram 1).
Methodology
This research utilizes critical discourse analysis (CDA) modeled
after Fairclough’s (1992, 1995) work to analyze the heterogeneous
discourse surrounding identity and cultural authority within the
profession of chiropractic. Specifically, published articles are used
as sources of “texts:” utterances which make some form of truth
claim and which are ratified as knowledge (Mills, 2004, p. 55).
Although there is no set of accepted methodological procedures
to perform CDA, Fairclough (1992) suggests a discourse should be
analyzed in three-dimensions: 1) the textual level (a thematic
analysis of the content of the discourse), 2) the discourse practice
level (how discourse is produced, distributed and how subjects are
Diagram 1. Multidimensional critical discourse analysis. Adapted from Fairclough, 1992, p. 73.
created and positioned), and 3) the social practice level (how
discourses are influenced by ideology and the larger social envi-
ronment). As Luke notes, “CDA sets out to capture the dynamic
relationships between discourse and society, between the micro-
politics of everyday texts and the macropolitical landscape of
ideological forces and power relations” (2002, p. 100). The “critical”
aspect of discourse analysis specifically goes beyond mere
description to include an interpretation that demonstrates how the
discourse is shaped by power and ideology that is often not visible
to participants. Fairclough notes that one strategy to investigate
this is to capture discourse undergoing a “moment of crisis” to
bring into relieve the multiple issues being discussed, as well as
making visible the practices that are often “naturalized” or taken as
common sense (1992, p. 230). By examining the discourse of
identity and cultural authority emergent around the literal moment
of crisis announced by Meeker and Haldeman (2002) and the article
“Chiropractic at the Crossroads,” I have chosen to analyze the
debate occurring amongst chiropractors in the United States as they
struggle to create their own sense of identity and project that onto
a larger environment of health care providers.
Procedures
The following keywords alone and in combination were used in
a search of the Index to Chiropractic Literature (indexed by
members of the Chiropractic Library Collaboration) and the news-
paper Dynamic Chiropractic: profession, culture, authority, identity,
scope, future. Articles published between January, 2002 (the year of
Meeker and Haldeman’s “Chiropractic at the Crossroads” article) to
December, 2010 were searched. From commonly referenced studies
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
in these sources, three additional unpublished surveys were ob-
tained through weblinks provided. Articles were removed from the
initial pool (N ¼ 126) if they were duplicated entries, poster
presentations or abstracts at conference presentations without full
text to analyze, if the article dealt specifically with issues unique to
a country dissimilar to the US (a country where chiropractic was
not fully professionalized), or if the article did not deal explicitly
with issues of identity, authority or the future trajectory of the
profession. This created a database of 98 articles.
A close reading of all texts from the database was performed
with an eye to develop a three-tiered analysis. At the textual level,
the rhetorical strategies and techniques were categorized to create
an overall tone and tenor of debate. The question “who do chiro-
practors profess to be?” was asked and major themes were allowed
to emerge from the data. At the discourse practice level, the
question “who is speaking, who is not speaking and how is the
speaking being done?” was addressed. Here, the texts were viewed
as in interaction with each other, and part of a history of dialog e
what Fairclough (1995) would term “intertextuality” (pp. 188e189).
How the genre of printed publications socially positioned certain
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
examined for connections with the larger socio-political context in
which the debates are situated. The following two questions: “how
is the profession projecting itself?” and “to whom are these images
being presented?” were posed. With consideration of existing
power relations in the health care environment, the external
organizations, professions and institutions most affected by issues
of identity and cultural authority for the profession were also
identified.
Reflexivity
As Smith (2007) and Finlay (2002) note, it is important for
researchers utilizing CDA to be explicit about their relation to the
topic or participants through which the researcher has interpreted
the texts. I was initially sensitized to the discourse surrounding
cultural authority when I was invited to speak at the Association of
Chiropractic Colleges e Research Agenda Conference several years
ago. This conference is attended by chiropractic college faculty,
administrators, researchers and policy-level decision makers. Feise
(2005) estimates that only a few dozen full time practitioners
attend the conference (p. 20). Having just completed a dissertation
that involved archival research as well as in-depth interviews with
veteran “everyday” chiropractors, I was struck by the disjuncture in
orientations between what I come to distinguish in this research as
two distinct characters: the everyday chiropractor versus the
academic chiropractor.
In the interest of full disclosure, my spouse is a chiropractor who
over the course of my career has gone from being an everyday
chiropractor to a chiropractic college faculty member and now
a college administrator/academic chiropractor. Rather than seeing
my position as biased, I see it as akin to Collins’ (1986) “outsider-
within” perspective. I am an outsider and not a chiropractor, but am
“within” because I am on the margins of both the everyday chiro-
practor as well as the academic chiropractor, having been married
to one, having interacted with dozens of chiropractors (both
academic and everyday) and having researched the profession as
a whole for over a decade.
To ensure validity and trustworthiness, I have worked to
examine as wide a range of voices as possible (albeit only those that
have been published and heard) asking consistent analytical
questions of each text, as suggested by Smith (2007). Following the
lead of Finlay (1998, 2002) I was conscious of instances where my
own feelings and experiences ran contrary to those reflected in the
1829
texts. I remained vigilant to differences and divergences and
embraced all as valid viewpoints. I do not claim to have achieved
a value-free analysis, nor do I believe that I have presented the “one
correct reading” of the texts under examination. In fact, to do so
would run contrary to the principles of CDA, as it should be
understood that texts are “socially constructed by and, in turn,
construct understandings of reality rather than describing a or the
reality” (Cheek, 2004, p. 1147; emphasis in original). I have
acknowledged my background so that the reader can understand
the possible influences on the interpretations in this research.
Aside from the issues of reflexivity mentioned above, the
methodology employed in this research is limited to written and
published texts. It is possible than an article from the initial pool
was overlooked and omitted during the selection process, although
the author and a graduate assistant both performed the selection
process separately with identical results. Additionally, not all
viewpoints from chiropractors are represented equally. Opinions
that were never recorded or printed, those outside or dissimilar to
the US context, and those written in a language other than English
were not included in the database.
Findings
Textual level
At the textual level, analysis can either be intensively investi-
gated linguistically and semantically (as suggested by Fairclough,
1992, 2003) or can be conducted at a more thematic level
(Threadgold in Kamler, 1997, pp. 437e438). Similar to the approach
of Threadgold as well as Smith (2007) this research will examine
the rhetorical techniques and larger thematic patterns that emerge
in the texts to elucidate the areas of debate, crisis and proposed
identity within the profession.
Rhetorical devices
The texts reveal a tapestry of many heterogeneous voices.
Although a multitude of perspectives emerge, there are some
repeated rhetorical strategies: 1) threat, 2) divisiveness, and 3) the
ideology of science. These devices are similar to what has been
noted in prior research (Warnock, 2005; Welsh et al., 2004).
Threat
There is a dire sense of emergency and an explicit call to action
in many of the texts. Change is imperative inferring that death or
some disastrous consequence might ensue. One commentary
makes this clear: “Chiropractic, as a profession, is endangered. Its
practitioners are soon to become clinically extinct. This is not
a drill” (Filippi, 2005, p. 1). Other words used in the texts to indicate
a sense of threat include: assault, nihilistic, eaten alive, and crisis
point.
Divisiveness
It is also clear there is considerable disagreement and debate
concerning professional identity within chiropractic (see further
discussion, below). Rather than framing a persuasive yet dispas-
sionate argument, the discourse features a great deal of emotional
and rancorous name-calling in an effort to distance one segment
from another and to denigrate colleagues as an undesirable “other.”
Feise (2005) states he is “embarrassed” by his fellow chiro-
practors for their lack of research experience and knowledge. He
further questions their intelligence: “most doctors of chiropractic
are incapable of defending themselves.”(p. 21). Demarcation from
undesirables extends to privileging chiropractic as superior to other
CAM practitioners. Gleberzon, Cooperstein, and Perle (2005) assert
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
demoted to a ‘Group B’ status, lumped together with homeopaths,
acupuncturists and massage therapists” (p. 72).
“Discourse” is somewhat of an overstatement when analyzing
these texts. The corpus of publications as a whole involve numerous
statements meant to provoke but not to converse; meant to hurt
rather than to understand; meant to claim victory rather than
interact. There is much more talking at rather than actual dialog
occurring.
Ideology of science
The most common rhetorical strategy is to wage that a segment
is not committed to science and the assumed rationality and
objectivity that come with such an orientation. As a result,
segments that do not embrace science in an appropriate way (by
subscribing to a progressive lexicon and advocating evidence-based
practice) are by default emotional, irrational and illogical. Murphy,
Schneider, Seaman, Perle, and Nelson (2008) equate a segment of
chiropractors (to be later identified as “subluxation-based chiro-
practors) as occupying the same metaphysical and pseudoscientific
space as foot reflexology (Podiatrists and Foot Reflexologists
section, para. 2), while Phillips (2004) castigates this segment as
akin to “creationists” and “fundamentalists” (p. 6). He goes on to
privilege the position of progressive chiropractors (to be later
identified as back/neck/pain specialists) as having created “a soul
willing to search for truth, to challenge the status quo in hopes of
making it better” (p. 10).
Perhaps the irony is that most authors that elevate science on
a pedestal as both the means and ends of professional change assert
that their segment is much more proficient and knowledgeable of
scientific practices than the other segments in chiropractic.
However, science is really much more of an ideology. Phillips
(2004) who speaks as part of the segment advocating limited
professional status, pleads for chiropractors to be scientifically
rational, yet presents personal communication from two chiro-
practors as his “evidence” to do so. Good (2010a, 2010b) critically
notes that those who demand science as the arbiter of what should
be practiced are the very ones that employ a selective interpreta-
tion of only some of the available evidence to support their agenda.
For the back/neck/pain specialist segment who include many
chiropractic leaders, science is an ideology to be pronounced for
political expediency and as an expectation for others, but often not
themselves, to meet.
Thematic textual analysis
The CDA utilized in this research also involves a thematic
analysis of the major issues of contention in the discourse
surrounding identity within the profession. I present five different
axes around which identity is actively debated within chiropractic
today: 1) scope of practice, 2) application and treatment, 3) alter-
native or mainstream positioning, 4) lexicon, and 5) service.
Scope
I am using scope of practice here to refer to claims of the
appropriate jurisdictional niche of the profession. Setting a narrow
scope as neuromusculoskeletal spine experts or back/neck pain
specialists has been advocated by several segments within the
profession (Mootz, 2007; Murphy et al., 2008; Nelson et al., 2005;
World Federation of Chiropractic (WFC), 2005). Others are vehe-
mently opposed to this (Duenas, Carucci, Funk, & Gurney, 2003;
Kent, 2009; Riggs, 2007; Rosner, 2005; Sportelli, 2006). Smith
and Carber (2009) report that 73% of surveyed chiropractors
considered themselves as “back pain/musculoskeletal specialists”
(p. 23). Yet inconsistently, another international poll found that 47%
of chiropractors felt that serving as “back and neck pain specialists”
was the least desirable image of the profession to have (WFC, 2005,
Survey of the Profession section, item 4e).
Contrarily, another segment in the profession seeks an
expanded scope of practice and aspires to capture a new area of
jurisdictional expertise: wellness. Hawk (2004) analyzed college
mission statements and scope of practice definitions in all 50 states,
and found the common descriptors to be “primary-care providers
who emphasize health and help the body heal itself” (p. 46). An
international survey of practicing chiropractors found the most
desirable image of chiropractors (83%) to be “wellness doctors”
(WFC, 2005, Survey of the Profession section, item 4e).
But, even among those that advocate wellness there is
disagreement over how broad this scope should be cast: as patient-
centered, part of public health, as doctors of natural medicine, or as
personal well-being? Gatterman (2006) suggests “a patient-
centered paradigm that provides a model for health promotion
and wellness in the patient’s interest” (p. 95) that is soundly
restricted to only scientifically-verified techniques. A vocal segment
within the profession is pushing for chiropractic to become a part of
the American Public Health Association (APHA) (Hyland & Baird,
2005; Johnson et al., 2008; Murphy et al., 2008). This would
enable chiropractic to ride on the coattails of the APHA’s sizable
membership, resources and lobbying efforts and could expand the
range of insurance codes chiropractors could seek reimbursement
under to include preventive medical care. To do this, chiropractic
would need to expand their daily routines to include screening for
risk factors, health behavior counseling (e.g., weight reduction,
smoking cessation) and abandon a historically-held anti-vacci-
nationist stance. This becomes problematic when considering that
McDonald’s survey of practicing chiropractors found that 50.1%
believed the pro-immunization stance of medicine deserves to be
questioned (2003, p. 60).
Riggs (2007) proposes an even more aggressive scope to become
comprehensive doctors of natural medicine and suggests that
chiropractic merge with naturopaths and then focus on herbal,
nutrition and functional aspects of health care, women’s health and
gerontology. Still others propose a nearly all-inclusive usage of the
wellness platform. This segment sees wellness as an opportunity to
address any and every aspect of health, and a way to tie the vitalistic
roots of the profession by addressing “wellness, quality of life and
human potential” (Kent, 2009, p. 31). These chiropractors seem to
equate wellness with personal well-being and aim to address
concerns that go beyond physical symptomatology to include
emotional, spiritual and psychological aspects of health.
Application and treatment
Abbott (1988) states the essential feature of a profession is the
work that they do. For chiropractic, this involves debate over the
treatment of patients and whether a conservative or liberal set of
work prerogatives are more appropriate.
Chiropractors are debating the proper application of care. On
one end of the spectrum are chiropractors who advocate hands-
only adjustment of the vertebral spine. Winterstein, Phillips, and
Kremer (2004) suggest calling this traditional and conservative
segment “subluxation-based chiropractors” and contrasts it with
the more liberal and progressive “physicians of chiropractic medi-
cine:” who “provid[e] differential diagnoses, manual medicine,
nutritional products, natural and physical medicine services” (p.
20). The segment advocating chiropractic medicine has been
working legislatively to amend educational accreditation standards
to recognize this doctor title along with removing the phrase
“without drugs and surgery” which would open the floodgates to
prescription drug-writing abilities. Abandoning the drugless stip-
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
proponent states: “The fixed ‘single chiropractic concept’ [sublux-
ation] that some struggle to keep alive has for them unfortunately
past (sic) on, as has bloodletting, wooden teeth and the Flat Earth
Society” (Carter, 2005, p. 10).
The segment wishing to move to limited professional status
seems impatient and no longer willing to discuss the matter
because of the presumed size of their group and a history of
unsuccessful communication with the other side:
There can be no unity between the majority of non-surgical
spine specialist chiropractic physicians and the minority of
chiropractors who espouse metaphysical, pseudoreligious views
of spinal subluxations as ‘silent killers.’ The latter minority
group needs to be marginalized from the mainstream majority
group and no longer should unrealistic efforts be made toward
unification of these disparate factions within the profession
(Murphy et al., 2008; Podiatrists and Foot Reflexologists section,
para. 3).
Yet, polls of practicing chiropractors are strongly in favor of
retaining their distinctive lexicon. McDonald (2003) found:
For all practical purposes, there is no debate on the vertebral
subluxation complex. Nearly 90% want to retain the VSC as
a term. Similarly, almost 90% do not want the adjustment
limited to musculoskeletal conditions. The profession as a whole
presents a unified front regarding the subluxation and the
adjustment (p. 20).
The views of everyday chiropractors as indicated in surveys are
discrepant from the pronouncements by their chiropractic leaders.
Service
Parsons (1951) noted the key characteristic of a profession was
its service orientation. True professionals operated with fiduciary
obligation toward their clients, placing the client first (collectivity
orientation) regardless of the inconvenience or sacrifice this meant
for the professional (self orientation). One chiropractor, Kisinger
(2009) stated “pursuit of affluence, entitlement and personal
excess as the ultimate calling and reward.” has displaced
a commitment to beneficence (p. 44). Many within the profession
target practice-management groups where chiropractors are
taught hard-sell techniques aimed at achieving short-term wealth
for the individual. These techniques are unscrupulous because they
rely on intimidation and fear tactics and often dupe patients into
visits that are not needed or are excessively drawn-out so as to
financially exploit them. One chiropractor offers these concerns:
For example, some practice consultants promote the policy of
withholding administration of treatment on the first visit,
preferring to reschedule the patient for a report of findings on
a subsequent visit.Others promote the use of X-rays on nearly
every patient in order to determine biomechanical deviations
from a theoretical “model” of a normal spine implying that this
information is so essential to successful treatment that the
benefit outweighs the very real risk of radiation exposure. These
and other business practices promoted across the profession are
tolerated without challenge by the rank and file (Nelson et al.,
2005; The Search for Cultural Authority section, para. 5).
Fournier (2001) found something similar in aromatherapy when
the idea of the “quack” was evoked implying an inappropriate
commitment to profit using any means necessary. Welsh et al.
(2004), too, seem to touch upon a similar phenomenon noting that
charismatic leaders were divisive within homeopathy in Canada,
pulling followers in divergent directions and toward alternate
visions and identities. In chiropractic, charismatic personalities that
offer practice-building seminars and life coaching, coupled with
allegiance to subluxation-based chiropractic have existed for
decades (Baer, 1996; Haneline, 2005; Keating et al., 2005). Kisinger
(2009) voiced concern that these practice-management organiza-
tions targeted the profession’s young, who are impressionable, or
those facing fiscal distress (Gleberzon et al., 2005).
The discourse surrounding intraprofessional identity is the most
contentious area for the chiropractic profession. No clear division of
camps can be noted. Those segments that are conservative in the
area of treatment/application may be liberal in the area of scope
and then once again conservative when it comes to autonomy. The
same segment that opposes another on the issues of scope of
practice may very well be united on issues of service. Some
segments are not well represented in the chiropractic literature at
all. They do not publish their views, but rather circulate them in
seminars and conferences led by charismatic leaders. Each issue is
a separate line of fault leading to dissensus on identity.
The issues scope of practice and lexicon are most contested, and
the profession as a whole cannot agree on whether to remain
alternative or join the mainstream. Service is much less debated
and there appears to be consensus on the issue of treatment but not
application. The discourse, itself, is characterized by the rhetoric of
threat, divisiveness and an appeal to the ideology of science. The
level of dissensus documents that there are multiple, contradictory
and heterogeneous voices within the discoursedparticularly a gulf
between chiropractic leaders and everyday chiropractors, as well as
subluxation-based chiropractors and those who advocate
becoming back/neck/pain specialists. This muddied notion of self
makes co-existing and competing at the macro level more difficult.
Discourse practice level
Fairclough notes the discourse practice level involves the
“production, distribution and consumption of texts” (1992, p. 78).
Specific genres of discourse (e.g., newspapers) contain conventions
and rules that operate to “control linguistic variability for particular
areas” (Fairclough, 2003, p. 24). The goal in this section is to
determine the dominant, contradictory and/or silent voices within
the texts and what functions they serve. The sources analyzed in
this research are 1) peer-reviewed chiropractic publications, and 2)
news stories from Dynamic Chiropractic, the major periodical of the
profession.
Texts are shaped discursively, so there is a controlled way in
which questions are asked, answers are presented and information
is expected to be conveyed. Imploring the chiropractic profession,
Hawk (2004, p. 45) notes: “if it is not published, it didn’t happen!”
which denotes the exclusionary character of publishing in the
academic press. What is unsaid here, is any author must have the
acumen to present, cite, research and organize ideas in a way that is
parallel, rigorous and worthy of inclusion into the peer-reviewed
marketplace of printed research. Peer-review also operates as
a filter where alternative voices and opinions may be rejected
because they lack alignment with the dominant discourse, lexicon
and method expected in a journal. In newspaper sources, column-
space, topicality and relevance are criteria held at the discretion of
editorial staff. Again, alternative voices (e.g., letters to the editor,
press releases) may or may not be published (Villanueva-Russell,
2009). The vast majority of texts in this research (78%) come from
peer-reviewed journals, so the bulk of analysis will be devoted to
that particular media source. Within this discourse the conventions
of journal publications elevate the academic chiropractor segment
and those advocating a science-oriented, back/neck/pain specialist
position while structurally limiting the ability of everyday chiro-
practors as well as subluxation-based segments from having their
views voiced.
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
Conventions of academic publishing
Welsh et al. (2004) note an increasing impetus for CAM
professions to accommodate medical science and research. But, this
endeavor has been difficult for chiropractic due to a lack of infra-
structural support necessary to fund and sustain biomedical
research (Keating, Green, & Johnson, 1995). Not only does chiro-
practic lack the institutional basis to conduct its own studies, the
outlets in which this is done are clearly structured toward
biomedical research that relies solely on a positivist methodology
in which randomized controlled trials are privileged. Research is
done without consideration of the epistemology of CAM. As Nelson
(1997) notes “clinical studies of the effectiveness of spinal manip-
ulation are conducted and reported without reference to the
presence or absence or even the existence of subluxations” (p. 46).
Young (1998) detailed that even after the Office of Alternative
Medicine (which eventually evolved into the National Center for
Complementary and Alternative Medicine e NCCAM) was created,
the initial funding went to major research institutes that proposed
allopathic research (such as evaluating cartilage products and
antineoplastons for cancer prevention and treatment) (p. 293). The
NCCAM and some researchers (c.f. Tataryn, 2002) classify chiro-
practic as a “manipulative and body-based therapy” rather than as
an “alternative medical system,” so a bias exists toward studies that
mechanistically focus on the effects of treatment, only (Redwood
et al., 2008, p. 362). This then adds ammunition for those
desiring limited professional status as back/neck/pain specialists.
Reductionist, positivistic research demanded by evidence-based
practice divorces the underlying philosophy (of which
subluxation-based chiropractors are advocates) to mere therapies
or procedures. Tang aptly writes that a similar process in
acupuncture is a: “process not unlike completing a jigsaw puzzle
using scissors” (2006, p. 259).
Everyday chiropractors and the subluxation-based segment are
not represented well in the discourse. Not only are they not
engaged in research or authors of peer-reviewed publications, their
views are only indicated by proxy through surveys and unpublished
polls. Further, each of these sources are methodologically flawed
and suffer from small sample sizes (Smith & Carber, 2009), self-
reports of activities (McDonald, 2003) and non-random samples
(WFC, 2005) which mean that the views of this segment are partial
and incomplete, at best.
Discourse technologists
Fairclough notes that the underlying power relations and ideol-
ogy of society also underlies a discourse. His main emphasis is on the
effects of the “new capitalism” and how this has triggered the
“technologization of discourse” (1995, p. 102). Perhaps the “scien-
tization” of CAM seems to underlie much of what is occurring at the
discourse practice level found in this research. Fairclough (1995)
notes that the “discourse technologist” plays a crucial role in
disseminating this new orientation. “This is done through a process
of redesigning existing discursive practice and training institutional
personnel in these redesigned practices” (1995, p. 102).
Fournier (2001) notes in aromatherapy, those evoking a profes-
sional trope projected an image of “disinterested gentlemanly
scientist” (p. 124) who were objective, rational and solely in pursuit
of truth and knowledge. A similar stratification seems to be
developing within the chiropractic profession as a segment of
academic chiropractors serve as discourse technologists who are at
the root of the majority of articles in which science-oriented change
toward becoming back/neck/pain specialists is advocated They
evoke authority through their degrees, leadership positions and
institutional positions in education, journals and chiropractic
associations.
1833
This small group of researchers has worked with remarkable
cohesion and productivity: generating a research agenda, white
papers and a strategic plan to mark their future priorities (Lawrence
& Meeker, 2006; Triano et al., 2010). Their ideological underpin-
nings of integrative alignment with the medical model set the
foundation for efforts to standardize lexicon and research practices,
reform licensing and scope of practice standards profession-wide.
In this sense, the discourse practice level is dialectically linked to
the textual level. Professional identity is constructed agentially by
chiropractors, but is also constituted and constrained by the
activities at the discourse practice level, and specifically, the actions
of discourse technologists/academic chiropractors.
Two examples of this are separate efforts to reach “consensus”
on key terminology for stages of care (Dehen, Whalen, Farabaugh, &
Hawk, 2010) and on a strategic research plan (Triano et al., 2010). In
both cases, a select group of chiropractors made policy-level deci-
sions, then published and announced these in an attempt to stan-
dardize practice and “naturalize” activity (Fairclough, 1992) thus
rendering the discourse closed and ruled upon. But, by their own
admission, the strategic planning consensus conference began with
the “assumption that successful future [professional] growth
requires cultural change” (Triano et al., 2010, p. 396). So, tradition
and concerns of subluxation-based chiropractors were never rep-
resented, entertained or considered as valid viewpoints from which
to construct a future trajectory. In the case of a consensus confer-
ence to standardize terminology, the authors (Dehen et al., 2010)
admit that agreement on definitions to be used for terms such as
“wellness” and “acute” were determined by only 27 participants, of
which only three were non-chiropractors, two-thirds belonged to
one single chiropractic association and nearly a quarter also served
as consultants to third party insurance payers (p. 460). Establishing
lexicon or a research trajectory by a specialized subset of academic
chiropractors in isolate from the larger practicing population of
practitioners ensures that nothing close to an “ideal speech situa-
tion” (Habermas, 1990) or true “consensus” will result.
At the discourse practice level the conventions of peer-reviewed
journals privilege the voice of chiropractors that wish to become
limited professionals while silencing those who prefer to remain
marginal. The academic chiropractors assume a dominant voice in
the discourse not only because they use their degrees and positions
to legitimate their voices, but also because they are in gatekeeping
positions that control access to journals, the content of these arti-
cles, and the lexicon to be used within the profession. In this sense,
the discourse practice level is dialectically linked to the textual
level, as identity is both shaped yet constrained by the discourse.
Social practice level
Analysis at the social practice level situates the discourse in the
larger socio-political and historical context to see how ideology has
shaped the dialog. Discourse affects social relations and the iden-
tities of those within them. The focus of this section is to examine
the debates over identity as they are situated in a larger context of
existing power relations. The structural features of the US health
care landscape shape the discourse and efforts to project the
cultural authority of the profession, as well.
Public
Appealing to the public is important. Without clients and
patients, doctors cannot financially survive. However, the public
adjudication of claims cannot wholly be manipulated or predicted.
The public seems to have a long-term memory of professions, and
these images are not easily molded or altered (Abbott, 1988).
Claims of cultural authority must be projected in spite of unfa-
vorable stereotypes of chiropractors as “back crackers.” One
1834 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
professional segment has decided to turn the stereotype into
a more positive image as “spinal care specialists” (Briggance, 2005;
Murphy et al., 2008; WFC, 2005). Briggance (2005) reasons that
chiropractic should simply align themselves with the public’s
image because that is what chiropractors do, anyway. “One only has
to look at chiropractic office signs, advertising materials, websites
and so on, to see that practitioners already accept this fact and
continuously reinforce it in their public interactions” (p. 14).
The suggestions to model in the public’s preferred image are not
unilaterally supported within the profession. One critic argues “It is
merely a daisy chain of mind games. It would truly be a comedy of
errors e to say nothing of a tragic mistake e to cast the future image
of chiropractic’s potential exclusively on what one believes the
public wants to hear” (Rosner, 2005, pp. 43e44). Defensively
catering to the public’s misinformed image of the profession seems
contrary to asserting expertise through claims of cultural authority.
Market
Others within the chiropractic profession advocate shaping
authority around what the public demands, but justifies this in
terms of economic exigencies. Greenawalt (2004) believes that
hiring a public relations firm to create a marketing “brand” for
chiropractic is the most prudent strategy. Utilizing a metaphor of
the nearly-bankrupt Winn Dixie chain of US supermarkets to
suppose a similar fate for chiropractic, Sportelli states: “Our success
(or lack of success) in establishing a credible, coherent, ethical
identity in the minds of the consumer is the only and final arbiter of
market share. Regardless of what we claim to be, unless our image
is congruent with public perceptionsdour customersdnothing
else matters” (2005, p. 26).
Insurance
Another major actor within the US system of health care
professions is third party insurance and managed care. Managed
care is an external force that directly impacts acceptance of chiro-
practic in the larger health care system. As managed care reim-
bursement is clearly set up to reflect the structure, diagnostic
language and practices of biomedicine, many chiropractors argue
that altering identity, lexicon and practices toward allopathic, pain-
oriented conditions is necessary for survival in today’s world. To
maximize insurance reimbursement, lexicon cleansing is necessary.
[F]or the theory [philosophy of chiropractic] to be embraced by
the greater social system, it should offer implementation that
can fit within constraints of the existing system. A theory that
requires the elimination of the two entire industries of medicine
and insurance will probably not be embraced in Western
cultures no matter how feasible and promising it might be
(Mootz, 2001, p. 7).
Others argue that chiropractic has been sabotaged by the very
attributes of professional status it fought so hard to attain.
Achieving reimbursement in third party insurance brought the
opportunity to obtain profit through creative billing and over
utilization (Gleberzon et al., 2005). The irony in becoming
a profession was that status was attained at the cost of a service
orientation, a self-limited scope of practice, and distortion of
application to appease others. As one chiropractor reflects:
The evidence to support my contention is clear to the field
practitioner who witnesses the erosion of economics, authority
and influence almost daily. Medicine and the insurance payers
pointed us to a set of diagnoses that we currently claim to be
experts for. We willingly took the bait in expectation of money.
We systematically abandoned the claims that we treated those
other diseases that they didn’t want us to treat. We did this with
little concern for the patient and not much more for our
profession. We did this for immediate satisfaction, mixed with
greed and low self-esteem, searching for something to create
our identity (Sportelli, 2006, p. 77).
The extent to which chiropractic seeks inclusion within third
party payment schemes remains undetermined. If chiropractic
seeks continued inclusion within managed care, this will surely
mean an increasingly narrow scope of practice and diminishing
returns in terms of reimbursement into the future (Hyland & Baird,
2005), unless perhaps it can gain authorization to utilize the
preventive medicine insurance reimbursement codes available to
public health.
Science
Science is an epistemic movement that is larger and external to
the system of health care professions. This demand for empirical
proof has triggered an “audit culture” (Shore & Wright, 1999)
obligating professions to demonstrate measurable health
outcomes. Evidence-based practice (EBP) is one indicator of this
movement within health care today.
Chiropractic has wedded itself to the ideal of EBP; however, this
benchmark has been difficult for the profession to meet, partly
because there is a lack of infrastructural support for research in
chiropractic educational institutions (see Section Discourse
practice level for more on this). The protocols of EBP are more
aligned with the segment of chiropractic that favors becoming
limited professionals (back/neck pain specialists) because EBP has
not been able to validate the philosophical orientation of
subluxation-based chiropractors, such as the existence of the
subluxation, Innate Intelligence, nor has there been enough valid
scientific study to provide support for such widespread practices as
wellness care, pediatrics and animal chiropractic (Villanueva-
Russell, 2005). This means that the majority of care actually
provided and deemed acceptable by the majority of chiropractors
reported in national surveys (GCC, 2004; McDonald, 2003) should
in theory, be deemed unacceptable and accompanied by the
disclaimer “this procedure does not have strong backing from high
quality systematic reviews of all available relevant scientific
studies” before being performed on any patient (Nelson et al., 2005;
The Acceptance of Evidence Based Healthcare section, para. 4).
The imperative for EBP from the larger health care environment
translates to pressure and constraints that impact the practice of
everyday chiropractors. Those advocating EBP also advocate for
chiropractic to evolve into a limited professiondone in which the
scope, application, treatment and lexicon are self-circumscribed to
be aligned with that which can be verified through science. This
process appears to be well underway internationally. Revisions by
regulatory bodies in both Great Britain and Australia have amended
the Code of Conduct standards for chiropractors to eschew use of
the term subluxation or VSC because they lack clinical research
evidence (Chiropractic Board of Australia, 2011; GCC, 2010). Addi-
tionally, the GCC’s revised code also calls for the allegiance to
science to trickle down to the practice of advertising and reiterates
a service-oriented imperative for the profession: “when adver-
tising, claims for chiropractic care. ‘must be based on best
research of the highest standard’ only” (GCC, 2010, n.p.).
Conclusion
The notion of Meeker and Haldeman’s (2002) “crossroads” is
still unresolved nearly a decade later. There is considerable
disagreement on scope, autonomy and lexicon. External pressures
create a need to remain financially viable while accommodating
science. Efforts to construct professional identity are made difficult
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
because of power struggles between intraprofessional segments.
Those advocating changes are differentially positioned and so have
a greater impact on the shape and content of the discourse.
Should chiropractic sequester itself to become an evidence-based,
back and neck pain specialty that is integrated with medicine as
professional leaders have proposed? Pressure from insurance, the
market and science all operate to produce momentum toward this
end state. What are the potential consequences of this limited
professional status? Robbins notes that “political self-betrayal”
(1992, p. 3) may occur in which some are accused of selling out their
ideals and philosophy for status. Segmental differences may be
heightened rather than diminished, as was the case internationally
for acupuncture (Hollenberg & Muzzin, 2010) and homeopathy (Cant
& Sharma, 1996). If integration means limiting the scope, truncating
the application and abiding by only those aspects that can be scien-
tifically demonstrated, then assimilation and co-optation are much
more likely outcomes than integration.
Contrarily, everyday chiropractors are content with the current
status quo as marginal professionals, wishing to remain tied to the
traditionalist lexicon and an expansionist range of application and
treatment authority. Until the market position, self interest/profit,
or range of treatment prerogatives are affected, the identity crisis of
chiropractic will not become a true reality nor a cause for concern
for this segment of the profession.
While a heterogeneous and often contradictory discourse on
both identity and cultural authority is present, the ideological
underpinning of each segment and the timing of this “moment of
crisis” remains unpacked. It is worth asking why these debates are
occurring at this time. There is no ensuing crisis and no external
imperative to reshape or initiate discourse on this particular topic.
Redwood et al., echo this point:
No governmental body is demanding it. There is certainly no
groundswell in the CAM community to eject chiropractors (who,
after all, make up the largest cohort of CAM practitioners as
defined by NCCAM). Moreover, it would be a drastic over-
statement to assert that MM [mainstream medicine] is rolling out
a rainbow-colored welcome mat for chiropractors (2008, p. 368).
Analysis of the discourse suggests that debate over identity and
cultural authority seems largely a politically-motivated intra-
professional movement, focused more on paternalistic occupa-
tional control than over cohesion and unity. Hollenberg and
Muzzin’s (2010) work on paradigm appropriation of acupuncture
in Britain does not wholly seem to apply to the case of chiropractors
in the United States. Rather than seeing the dominance of
biomedicine engulf a subordinate marginal profession, the impetus
to engage in paradigm assimilation (integrative medicine or the
idea of becoming a back/neck/pain specialist) is being driven from
within the profession of chiropractic, itself. Rather, changes to
identity are being initiated internally by academic chiropractors as
a coup d’état using the commitment to science (seen operating at
the textual, discourse practice and social practice levels through
EBP, lexicon cleansing and reformed scope of practice laws) to
achieve intraprofessional control.
The growing divide between the everyday chiropractor whose
views are only available by proxy through methodologically flawed
surveys are being systematically silenced by the claims of academic
chiropractors, who utilize rhetoric, status, institutional position,
and their roles as gatekeepers to journals as a means to dominate
the discourse. As Harding (1998, p. 145) notes: “Truth claims are
a way of closing down discussion, or ending critical dialog, or
invoking authoritarian standards.” Perhaps the idea of crossroads
should more appropriately be replaced with “crosshairs.”
One could also ask whether the debate over professional iden-
tity and cultural authority has any actual basis at all, or whether it is
1835
mere a by-product of intellectual fashioning of academic chiro-
practors. Surveys provide a glimmer that everyday practitioners
vary in their views, although no systematic studies exist to date to
empirically document their voices. It could very well be that an
analysis of the discourse of everyday chiropractors (through in-
depth interviews, CDA of conferences attended by these practi-
tioners, etc.) would reveal an equally diverse, contradictory,
rhetoric-filled conversation. Good (2010a, 2010b) presents his
personal views as a “centrist” who is part of the “silent middle
majority” in chiropractic that wishes to take a more moderate
stance on issues of lexicon (p. 33). He suggests that this mass of
chiropractors could decide the future direction of the profession,
but at this point have not been mobilized to act as a collective unit.
“We must become vocal about directing our research ini-
tiatives.To sit by idly and hope that this is accomplished without
the centrists will only allow those at the fringes to continue their
destructive ways and continue to allow the profession to evolve
into an entity that does not represent the majority” (p. 38).
Whether these everyday chiropractors have something unique to
say that would reinforce or challenge the academic chiropractors
has yet to be determined.
However, to allow everyday chiropractors meaningful partici-
pation in the discourse over professional identity and cultural
authority would certainly be beneficial for the profession, as
a whole. The science-based research and EBP created by academic
chiropractors could be complemented by what Gabbay and Le May
(2010) describe as “mindlines” or tacit knowledge gained from the
practical clinical experience of the everyday chiropractors. Rather
than strong-arming change that may be contradictory to the pref-
erences of chiropractors, incorporating mindlines and insights from
actual practice could help to bring context, the complexities of the
real world and the challenges and exigencies of a clinical practice to
balance the more rational and purely scientific guidelines often
created by academics (that are just as swiftly ignored by practi-
tioners). Allowing everyday chiropractors to contribute to policy
decisions will ensure a more representative professional dialog, as
well as encourage buy-in. As Gabbay and Le May (2010) note,
a consideration of mindlines possessed by everyday practitioners
coupled with the more formal knowledge of academics could help
bridge gaps between theory and practice and encourage actual
implementation of guidelines. “Mindlines [should] reflect not
collective folly, nor coercive scientism but communal wisdom”
(Gabbay & Le May, 2010, p. 203).
Analyzing this professional discourse within chiropractic
enables us to see who is participating and who is not; what is
being stated and what is left unstated. As Cheek (2004) notes,
CDA is a useful methodology to use in recognizing “the con-
straining effect of a particular discursive frame’s dominance
which then creates the possibility of a space to be opened up for
other discourses or ways of thinking” (p. 1143). What emerges
from the interpretation of available texts in the discourse
amongst chiropractors is that a rhetoric-filled, one-sided
conversation that is heavily weighted toward science-oriented
reform is not conducive to real interaction. It is the hope that
by bringing these underlying ideological power struggles to light,
that a more participatory dialog can commence with more
representation by everyday chiropractors and subluxation-based
chiropractors (who may not be one in the same group) whose
livelihoods will be impacted by implementing the policy deci-
sions and institutional practices (e.g., scope of practice laws,
insurance reimbursement, requirements for licensure and its
renewal, etc.) that are currently being decided by academic
chiropractors and the back/neck/pain specialist segment (who
may not be one in the same group) who will not, themselves, be
held accountable to these same standards.
1836 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
Acknowledgments
The author wishes to thank Mike Musselman and Nicole Min-
atrea for their assistance in locating several of the articles used as
data in this research. Additionally, the revisions made to the
manuscript by Heather Emory and the constructive suggestions for
revision from anonymous reviewers and the editor are greatly
appreciated.
References
Abbott, A. (1988). The system of professions: An essay on the division of expert labor.
Chicago: University of Chicago Press.
Allen, D. (2000). Doing occupational demarcation: the ‘boundary-work’ of nurse
managers in a district general hospital. Journal of Contemporary Ethnography, 29,
326e356.
Baer, H. (1996). Practice-building seminars in chiropractic: a petit bourgeois
response to biomedical domination. Medical Anthropology Quarterly, 10, 29e44.
Branson, R. (2009). Hospital-based chiropractic integration within a large private
hospital system in Minnesota: a 10-year example. Journal of Manipulative and
Physiological Therapeutics, 32, 740e748.
Briggance, B. (2005). A proposal regarding the identity of chiropractic: embrace the
centrality of the spine. Journal of Chiropractic Humanities, 12, 8e15.
Bucher, R., & Strauss, A. (1961). Professions in process. American Journal of Sociology,
66, 325e334.
Cant, S., & Sharma, U. (1996). Demarcation and transformation within homoeo-
pathic knowledge. A strategy of professionalization. Social Science & Medicine,
42, 579e588.
Carter, R. (2005). Chiropractors struggle with change. Journal of the Canadian
Chiropractic Association, 49, 9e12.
Cheek, J. (2004). At the margins? Discourse analysis and qualitative research.
Qualitative Health Research, 14, 1140e1150.
Chestnut, J. (2008 February 6). Designing, conducting and publishing research within
the chiropractic wellness paradigm e part 2. Journal of Vertebral Subluxation
Research, . Retrieved from. http://www.jvsr.com/1487/2008-1040_valid.pdf.
Chiropractic Board of Australia. (2011 January 28). Codes and guidelines. Retrieved
from. http://www.chiropracticboard.gov.au/codes-and-guidelines.aspx.
Clum, G. (2010 September 1). A discussion of a limited number of changes in the
CCE’s 2007 version of the Standards for Doctor of Chiropractic programs and
proposed revisions to the same. Retrieved from. http://www.lifewest.edu/pdfs/
CCE%20revision%20concerns%209%201%2010.pdf.
Collins, P. H. (1986). Learning from the outsider within: the sociological significance
of black feminist thought. Social Problems, 33, S14eS32.
Dehen, M., Whalen, W., Farabaugh, R., & Hawk, C. (2010). Consensus terminology for
stages of care: acute, chronic, recurrent and wellness. Journal of Manipulative
and Physiological Therapeutics, 33, 458e463.
Dengele, N. (2005). On the margins of everything: doing, performing and staging
science in homeopathy. Science, Technology and Human Values, 30, 111e136.
Duenas, R., Carucci, G., Funk, M., & Gurney, M. (2003). Chiropractic-primary care,
neuromusculoskeletal care, or musculoskeletal care? Results of a survey of
chiropractic college presidents, chiropractic organization leaders and
Connecticut-licensed doctors of chiropractic. Journal of Manipulative and Phys-
iological Therapeutics, 26, 510e523.
Fairclough, N. (1992). Discourse and social change. Cambridge: Polity.
Fairclough, N. (1995). Critical discourse analysis. London: Longman.
Fairclough, N. (2003). Analyzing discourse: Textual analysis for social research.
London: Routledge.
Feise, R. (2005). Further decline in chiropractic popularity projected. Journal of the
American Chiropractic Association, 42, 19e22.
Filippi, M. (2005 July 12). Chiropractic unmasked: how shame and self loathing are
driving DC’s into extinction. Journal of Vertebral Subluxation Research, . Retrieved
from. http://www.jvsr.com/index.asp%3D265.
Finlay, L. (1998). Reflexivity: an essential component for all research? British Journal
of Occupational Therapy, 61, 453e456.
Finlay, L. (2002). “Outing” the researcher: the provenance, process and practice of
reflexivity. Qualitative Health Research, 12, 531e545.
Fournier, V. (2001). Amateurism, quackery and professional conduct: the consti-
tution of ‘proper’ aromatherapy practice. In M. Dent, & S. Whitehead (Eds.),
Managing professional identities: Knowledge, performativity and the ‘new’
professional (pp. 116e137). London: Routledge.
Frank, R. (2002). Integrating homeopathy and biomedicine: medical practice and
knowledge production among German homeopathic physicians. Sociology of
Health and Illness, 24, 796e819.
Freidson, E. (1970). Professional dominance: The social structure of medical care. New
York: Atherton Press.
Gabbay, J., & Le May, A. (2010). Practice-based evidence for health care: Clinical
mindlines. London: Routledge.
Gatterman, M. (2006). The patient-centred paradigm: a model for chiropractic
health promotion and wellness. Chiropractic Journal of Australia, 36, 92e96.
General Chiropractic Counsel. (2004). Consulting the profession: A survey of UK
chiropractors, 2004. Retrieved from. http://www.gcc-uk.org/files/link_file/
ConsultTheProfession.pdf.
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_
18August10.pdf.
Gieryn, T. (1983). Boundary-work and the demarcation of science from non-science:
strains and interests in professional ideologies of scientists. American Socio-
logical Review, 48, 781e795.
Gleberzon, B., Cooperstein, R., & Perle, S. (2005). Can chiropractic survive its
chimerical nature? Journal of the Canadian Chiropractic Association, 49, 69e73.
Good, C. (2004). The subluxation syndrome: a condition whose time has come.
Journal of Chiropractic Humanities, 11, 38e43.
Good, C. (2010a ). A criticism of an epidemiological examination of the subluxation
construct using Hill’s criteria of causation: limitations, suspect conclusions and
an opportunity missed. Chiropractic and Osteopathy, 17. doi:10.1186/1746-1340-
17-13.
Good, C. (2010b). The great subluxation debate: a centrist perspective. Journal of
Chiropractic Humanities, 17, 33e39.
Greenawalt, K. (2004, July 29). Our profession needs an identity. Dynamic Chiro-
practic, 16, 20.
Habermas, J. (1990). Discourse ethics: notes on a program of philosophical justifi-
cation Moral consciousness and communicative action. Cambridge: MIT Press.
Hafferty, F., & Light, D. (1995). Professional dynamics and the changing nature of
medical work. Journal of Health and Social Behavior, 132e153, extra issue.
Halpern, S. (1992). Dynamics of professional control: internal coalitions and
crossprofessional boundaries. American Journal of Sociology, 97, 994e1021.
Haneline, M. (2005). What is evidence? Journal of the American Chiropractic Asso-
ciation, 42, 15e19.
Harding, S. (1998). Is science multicultural? Postcolonialisms, feminisms and episte-
mologies. Bloomington: University of Indiana Press.
Haug, M., & Lavin, B. (1983). Consumerism in medicine: Challenging physician
authority. Beverly Hills: Sage.
Hawk, C. (2004). Evidence of chiropractors’ views on identity: who do we think we
are? American Journal of Chiropractic, 41, 45e50.
Hollenberg, D., & Muzzin, L. (2010). Epistemological challenges to integrative
medicine: an anti-colonial perspective on the combination of complementary/
CAM with biomedicine. Health Sociology Review, 19, 34e56.
Hyland, J., & Baird, R. (14 August 2005). Dynamic chiropractic. 34e35.
Johnson, C., Baird, R., Dougherty, P., Globe, G., Green, B., Haneline, M., et al. (2008).
Chiropractic and public health: current state and future vision. Journal of
Manipulative and Physiological Therapeutics, 31, 397e410.
Kamler, B. (1997). An interview with Terry Threadgold on critical discourse analysis.
Discourse: Studies in the Cultural Politics of Education, 18, 437e451.
Kaptchuk, T., & Eisenberg, D. (1998). Chiropractic: origins, controversies and
contributions. Archives of Internal Medicine, 158, 2215e2224.
Keating, J., Charlton, K., Grod, J., Perle, S., Sikorski, D., & Winterstein, J. (2005).
Subluxation: dogma or science? Chiropractic and Osteopathy, 17. doi:10.1186/
1746-1340-13-17.
Keating, J., Green, B., & Johnson, C. (1995). ‘Research’ and ‘science’ in the first half of
the chiropractic century. Journal of Manipulative and Physiological Therapeutics,
18, 357e378.
Kent, C. (2009 November 18). Chiropractic: a glorious future. Dynamic Chiropractic,
28e31.
Kisinger, F. (2009). Beneficence and the professional’s moral imperative. Journal of
Chiropractic Humanities, 16, 44e46.
Lawrence, D., & Meeker, W. (2006). Commentary: the national workshop to develop
the chiropractic research agenda: 10 years on, a new set of white papers. Journal
of Manipulative and Physiological Therapeutics, 29, 690e694, 24.
Lehman, J., & Suozzi, P. (2008). Founding integrative medicine centers of excellence:
one strategy for chiropractic medicine to build higher cultural authority. The
Journal of Chiropractic Education, 22, 29e33.
Luke, A. (2002). Beyond science and ideology critique: developments in critical
discourse analysis. Annual Review of Applied Linguistics, 22, 96e110.
McDonald, W. (2003). How chiropractors think and practice. Institute for Social
Research, Ohio Northern University.
Meeker, W., & Haldeman, S. (2002). Chiropractic: a profession at the crossroads of
mainstream and alternative medicine. Annals of Internal Medicine, 136, 216e227.
Mills, S. (2004). Discourse. London: Routledge.
Mootz, R. (2001). Professional identity: the role of chiropractic theory. Topics in
Clinical Chiropractic, 8, 1e8.
Mootz, R. (2007). Chiropractic’s current state: impacts for the future. Journal of
Manipulative and Physiological Therapeutics, 30, 1e3.
Morgan, L. (2005). Is chiropractic a CAM therapy or is it a separate profession?
Journal of the Canadian Chiropractic Association, 49, 133e136.
Murphy, D., Schneider, M., Seaman, D., Perle, S., & Nelson, C. (2008). How can
chiropractic become a respected mainstream profession? Chiropractic and
Osteopathy, 16. doi:10.1186/1746-1340-16-10.
Nelson, C. (1997). The subluxation question. Journal of Chiropractic Humanities, 7, 46e55.
Nelson, C., Lawrence, D., Triano, J., Bronfort, G., Perle, S., Metz, R. D., et al. (2005).
Chiropractic as spine care: a model for the profession. Chiropractic and Oste-
opathy, 13. doi:10.1186/1746-1340-13-9.
Parsons, T. (1951). The social system. New York: Free Press.
Pelletier, K., & Astin, J. (2002). Integration and reimbursement of complementary
and alternative medicine by managed care and insurance providers: 2000
update and cohort analysis. Alternative Therapies in Health and Medicine, 8,
38e39, 42, 44.
 Y. Villanueva-Russell / Social Science & Medicine 72 (2011) 1826e1837
Pescosolido, B. (2006). Professional dominance and the limits of erosion. Society, 43,
21e29.
Pescosolido, B., Tuch, S., & Martin, J. (2001). The profession of medicine and the
public: examining Americans’ changing confidence in physician authority from
the beginning of the ‘health care crisis’ to the era of health care reform. Journal
of Health and Social Behavior, 42, 1e16.
Phillips, R. (2004). The battle for innate: a perspective on fundamentalism in
chiropractic. Journal of Chiropractic Humanities, 11, 2e10.
Redwood, D., Hawk, C., Cambron, J., Vinjamury, S. P., & Bedard, J. (2008). Do
chiropractors identify with complementary and alternative medicine? Results
of a survey. The Journal of Alternative and Complementary Medicine, 14, 361e368.
Rehm, W. S. (1986). Legally defensible: chiropractic in the courtroom and after,
1907. Chiropractic History, 6, 50e55.
Riggs, J. (2007 August 13). Spinal health specialist? Oh my! Dynamic Chiropractic,
48e49.
Robbins, B. (1992). Secular vocations: Intellectuals, professionalism, culture. London:
Verso.
Rosner, A. (2005 June 4). Identity crisis: a profession at the crossroads. Dynamic
Chiropractic, 42e44.
Shore, C., & Wright, S. (1999). Audit culture and anthropology: neo-liberalism in
British higher education. Journal of the Royal Anthropological Institute, 5,
557e575.
Smith, J. (2007). Critical discourse analysis for nursing research. Nursing Inquiry, 14,
60e70.
Smith, M., & Carber, L. (2009). Survey of US chiropractors’ perceptions about their
clinical role as specialist or generalist. Journal of Chiropractic Humanities, 16,
21e25.
Sportelli, L. (2005 May 21). No identity ¼ bankruptcy. Dynamic Chiropractic, 18e20, 26.
Sportelli, L. (2006). Commentary: what identity for chiropractic? Chiropractic
Journal of Australia, 36, 76e79.
Starr, P. (1984). The social transformation of American medicine. New York: Basic
Books.
Tang, S. (2006). ‘From outcast to inboard’: the transmission, professionalization and inte-
gration of acupuncture Into British medical culture. Asian Medicine, 2, 254e276.
Tataryn, D. (2002). Paradigms of health and disease: a framework for classifying and
understanding complementary and alternative medicine. The Journal of Alter-
native and Complementary Medicine, 8, 877e892.
1837
Taylor, D. (2006). Health care industry shaping chiropractic’s future. Journal of the
American Chiropractic Association, 43, 19e23.
Triano, J., Goertz, C., Weeks, J., Murphy, D., Kranz, K., McClelland, G., et al. (2010).
Chiropractic in North America: toward a strategic plan for professional
renewaldoutcomes from the 2006 chiropractic strategic planning conference.
Journal of Manipulative and Physiological Therapeutics, 395e405.
Villanueva-Russell, Y. (2005). Evidence-based medicine and its implications for the
profession of chiropractic. Social Science & Medicine, 60, 545e561.
Villanueva-Russell, Y. (2009). Chiropractors as folk devils: published and unpub-
lished coverage of a moral panic. Deviant Behavior, 30, 175e200.
Wardwell, W. (1994). Alternative medicine in the United States. Social Science &
Medicine, 38, 1061e1068.
Wardwell, W. (1996). Chiropractic’s unique evolution and its future status. Journal of
the Canadian Chiropractic Association, 40, 34e39.
Warnock, S. (2005). The optometrist’s rise to power in the health care market, or
‘it’s optometric physician, to you. Science Communication, 27, 100e126.
Welsh, S., Kelner, M., Wellman, B., & Boon, H. (2004). Moving forward? Comple-
mentary and alternative practitioners seeking self-regulation. Sociology of
Health and Illness, 26, 216e241.
Willis, E. (2006). Introduction: taking stock of medical dominance. Health Sociology
Review, 15, 421e431.
Winterstein, J. (2002). Intraprofessional concerns. Journal of Chiropractic Medicine, 1,
171e174.
Winterstein, J., Phillips, R., & Kremer, R. (2004 September 1). To tier or not to tier
chiropractic? Dynamic Chiropractic, 18, 20, 36.
Wolinsky, F. (1993). The professional dominance, deprofessionalizatoin, proletari-
anization and corporatization perspective: an overview and synthesis. In
F. Hafferty, & J. Mckinlay (Eds.), The changing medical profession (pp. 11e24).
New York: Oxford University Press.
World Federation of Chiropractic. (2005). Final report of the identity consultation task
force. Retreived from. http://www.wfc.org/website/images/wfc/docs/as_tf_
final_rept-Am_04-29-05_001.pdf.
Yoshida, M. (2002). A theoretical model of biomedical professionals’ legitimisation
of alternative therapies. Complementary Health Practice Review, 7, 187e208.
Young, J. H. (1998). The development of the office of alternative medicine in the
national institutes of health, 1991e1996. Bulletin of the History of Medicine, 72,
279e298.