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"Whatever works best for the athlete" : the use and experience of complementary and alternative medicine.. Bundon, Andrea Marie 2008-12-31

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“WHATEVER WORKS BEST FOR THE ATHLETE”: THE USE AND EXPERIENCE OFCOMPLEMENTARY AND ALTERNATIVE MEDICINE AMONG ELITE FEMALEATHLETESbyANDREA MARIE BUNDONB.Sc. The University of Calgary, 2006A THESIS SUBMITTED IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(Human Kinetics)THE UNIVERSITY OF BRITISH COLUMBIA(Vancouver)October 2008© Andrea Marie Bundon, 2008AbstractThis study examined how carded female members of Canadian national teams used andperceived Complementary and Alternative Medicine (CAM). The research was guided by thefollowing question: How do elite Canadian female athletes use Complementary and AlternativeMedicine? Additionally, the research was infonned by three subsidiary questions, namely: (1)How do they perceive and experience CAM?; (2) Why do they use/not-use CAM?; (3) Whatroles do they perceive CAM to play in their athletic development?; and (4) How is theuse ofCAM negotiated within existing sport structures?Using qualitative research methods, 12 female athletes were interviewed twice using asemi-structured interview format for a total of 22.5 hours. The athletes were questionedabouttheir first experiences of using CAM and the situations that lead themto explore new treatments.The athletes were also asked about their continued use of CAMand the reasons for the ongoingtreatments as well as the role they perceived CAM and CAM practitionersto have in theirathletic careers.Previously, the extant literature concerning CAM use among athletes indicatedthat 56%of varsity athletes used CAM although this research gave no indicationas to the frequency withwhich CAM treatments were utilized. The women in my study reported that,when carded, theyused CAM treatments extensively and frequently (from two appointments amonth up to twoappointments a day). At the same time, the women in this project revealedthat their ability toaccess services was highly contingent on their status as carded athletes and theassociatedmonthly stipend from Sport Canada. Within different sports organization,gendered, andhegemonic hierarchies further delimited access to CAM. Myfindings suggest that while injurymay have been the impetus for the first treatment, the ongoinguse of CAM was more closelyassociated with an effort to prevent chronic conditions and physicalimbalances from escalatingand thereby restricting their ability to fully participate in theirsport.These findings have theoretical implications for expandingour understanding of thevalue CAM holds for those who use it. The data also bridgethe gap between the existingliterature which has examined the influence of thesportsnet on an athlete’s belief, attitudes, andactions, and research into rates CAM utilization in special populations.Finally, this projectreveals that elite female athletes perceive CAM to be anessential part of their athletic training.11Table of ContentsAbstract .iiTable of Contents iiiList of Tables vAcknowledgements viDedication viiCHAPTER 1: Introduction 11.1 Situating the Research Project 4CHAPTER 2: Review of Relevant Research and Theory 62.1 Defining Complementary and Alternative Medicine 62.2 Prevalence of CAM Use by Population and Treatment Type 72.3 Discourses Regarding CAM Use 92.3.1 CAM and Holism 92.3.2 CAM and Biomedicine 122.3.3 CAM and Feminism 142.3.4 CAM and Social Identities 162.3.5 Athletes and CAM 162.4 Athlete Behaviours and the Sportsnet 192.5 Injury, Pain, and Risk in Sport 202.6 CAM and Qualitative Research 222.7 Symbolic Interactionism and CAM 222.8 Hegemonic Masculinity and Power Relations in Sport 242.9 Application to the Project 25CHAPTER 3: Methodology 273.1 Sample and Rationale 273.2 Sampling Challenges 333.3 Protocol and Rationale 353.4 Data Analysis383.5 Reflexivity 39111ChAPTER 4: Findings .434.1 What is CAM7 434.1 .1 Athletes Classify and Define Practitioners and Treatments 434.1.2 What is Meant by Holism7 464.2 Choosing CAM: What are Athletes Using7 474.3 Why CAM?: Athletes Describe the Reasons for Their First Use of CAM 514.3.1 Treating a New Injury 524.3.2 Trying Something Else 524.3.3 Everybody is Using It: Trying Out Sport Massage Therapy 554.3.4 “I Found a Lot More”: Curiosity About Naturopathy 564.3.5 Trusting the Practitioner 584.3.6 Reservations About Chiropractic 594.3.7 Willingness to Explore New Treatments 604.3.8 The Role of Family Members in Influencing Attitudes Towards CAM 614.4 Accessing CAM: How Access to CAM Services is Facilitated and Restricted 634.4.1 Being Carded: Stipends, Health Insurance, and Team Practitioners 634.4.2 Social Capital and Accessing Team Practitioners 684.5 The Right Person for the Job: Athletes Discuss Relationships with Practitioners ..744.5.1 Sources of Referrals 754.5.2 “A Couple of Things Working Together”: Practitioners as Team Players ...764.5.3 Practitioners as Collaborators and Confidants 784.5.4 “I Know When I Need a Massage”: Practitioners as Gatekeepers 824.5.5 Communicating with Practitioners 834.6 What is Achieved Through CAM?: Reasons for the Ongoing Use of CAM 854.6.1 Whenisitanlnjury?854.6.2 Maintaining the Body and Optimizing the Machine 914.6.3 Copingwith Stress 94CHAPTER 5: Discussion and Conclusions 975.1 Understanding Rates of Utilization in Athletic Populations 975.2 Carding and Status as a Predictor of CAM Use 1005.3 Is That an Injury?: New Reasons for the Continued Use of CAM 1025.4 Limitations of the Project 1055.5 Future Directions 107References109Appendices 114ivList of TablesTable 1: Sample Characteristics 32Table 2: Use of Practitioner Delivered CAM 49Table 3: Frequency of Treatments During Training Phases50VAcknowledgementsI would like to acknowledge those who have made this project possible.First I need to thank Dr. Laura Hurd Clarke, my supervisor, for her support and guidance. Iappreciate the opportunities you provided me that allowed me to develop the skills I needed forthis project. I am inspired by your work ethic and by your compassion for those around you.Thank you to Dr. Patricia Vertinsky and Dr. Brian Wilson, my committee members, forsuggesting new directions and providing insightful comments.Thank you to Jackie De Santis, the real ‘transcribing machine’ for volunteeringlong hours andshowing interest in the project.Thank you to the Faculty of Education for providing the fundsthat allowed me to travel tointerviews and present my findings.Thank you to Pacific Sport and specifically to Ben Sporer for facilitating the recruitmentprocess.Finally, thank you to my family, friends, and teammates for encouraging me inmy work andproviding whatever was needed— be it a sounding board for ideas ora welcome distraction.viDedicationI dedicate this work to the athletes who taught me nothing compares to startingthe day doing what you love.viiCHAPTER 1: IntroductionComplementary and Alternative Medicine (CAM) is a term best explained as an array oftherapies, modalities, health systems, practices, and practitioners that exist apart from (and yet inrelation to) the mainstream medical system (Barrett et al., 2003; Kaptchuk & Eisenberg, 2001 a,2001b). As such, the definition of CAM is one of exclusion (Doel & Segrott, 2003) as well asone that is in constant negotiation. The study of CAM practices requires an examination of thecontext in which the practices are being used, as well as consideration of the origins of thepractices, the training of the providers, the sites of delivery, and the degree to whichthe practicesare integrated into or excluded from allopathic medicine. In a Canadian context,CAM includes(but is certainly not limited to) the following: Alternative medical systems suchas TraditionalChinese Medicine (TCM) and Ayurvedic medicine; energy based therapiessuch as Reiki andelectromagnetic treatments; body based manipulations such aschiropractic treatments, massage,and visceral manipulation; nature-based or bio-based treatmentssuch as homeopathy; and anendless list of techniques used by a variety of practitionerssuch as active release therapy (ART),intramuscular stimulation (IMS), needling, cupping, herbal remedies,and meditative practices.The Canadian Health Network identifies over 300 forms ofCAM on their Web site and, eventhen, makes no claim that the list is exhaustive (CanadianHealth Network, n.d.).To further confuse the issue of definition, CAM practicesare not static and their positionin relation to Western medicine is not fixed. Some groupsof CAM practitioners have sought tolegitimize their practices through processes of self-regulation (Kelner, Weliman,Boon, & Welsh,2004) or the adoption of medical terminology and techniquesfrom the medical model, includingtaking a patient’s history, body temperature, or blood pressure (Bombardier& Easthorpe, 2000).Similarly, medical practitioners are becoming increasingly familiar with CAMtherapies andmany have adopted certain CAM techniques, or have begun to refer their patients to CAMpractitioners (Astin, Marie, Pelletier, Hansen, & Haskell, 1998).While many CAM practices are centuries, if not millennia, old (e.g. acupuncture), thestudy of CAM practices as a whole is fairly recent and not without complexities. CAM practiceshave emerged from a number of diverse sources including Eastern philosophy, techno-science,consumer culture, and folklore (Doe! & Segrott, 2003). Thus, it would be erroneous to presentthem as a unified and coherent set of practices. Further complexities arise from the “contested,value-laden, and politically charged” (Adler, 1999,p.215) beliefs and philosophies that areassociated with each health system and that culminate in a “lackof a consensual language withwhich to discuss alternative therapies” (Adler, 1999,p.215).Yet despite the absence of a consensual definition as to what CAM practices actuallyinclude, there is a general acknowledgement in the literature that theuse of these practices is onthe rise (Swartzman, Harshman, Burkell, & Lundy, 2002). In 1998, Eisenberget al. published alarge-scale survey of CAM in the United States that revealedthat the rate of patient-reportedCAM use had increased from 34% in 1990 to 42% in 1997.The most recent Statistics Canadadata, published in 2005 and based on the results of the 2003Canadian Community HealthSurvey, indicated that 20% of Canadians aged 12 and over hadused the services of at least oneCAM provider in the 12 months preceding the survey. Incomparison, 15% of adult Canadiansreported using CAM in a 1994/1995 survey (Park, 2005).’A growing body of quantitative and qualitative researchhas analysed the reasons thatpeople give for either choosing or not choosing CAM. Users ofCAM (as compared to non1 The difference in rates between the Statistics Canada data and Eisenberg et al. is likely doto differentdefinitions as to what constitutes CAM. Some studies include onlypractitioner delivered services whereas othersare much broader in scope and incorporate practices such as the use of herbalremedies or prayer.2users) have been characterized as having a holistic philosophical orientation towards health,being more likely to have had a life altering experience that changed their worldview, and beingmore likely to self-report poorer health status (Astin, 1998). Additional reasons given for usingCAM include the views that biomedicine is deficient and/or that CAM offers a safer and lessinvasive alternative to biomedicine (Singh, Maskarinec, & Shumay, 2005). Several reports havefound that CAM use is higher among women than men, higher in western regions of NorthAmerican than in eastern regions, and positively correlated with both income and education(Eisenberg et al., 1998; Esmail, 2007; Park, 2005).In addition to the increase in CAM use among the general population (leading one toquestion just how long alternative will remain an accurate descriptor), certain groups have beenshown to have particularly high utilization rates. Individuals with Alzheimer’s disease, multiplesclerosis, rheumatic diseases, cancer, acquired immune deficiency syndrome, back problems,anxiety, and chronic pain demonstrate high rates of CAM usage as compared to the generalpopulation (Astin et al., 1998) and as such have been the focus of much of the CAM-relatedresearch. Consequently, because of the focus on groups with chronic or terminal conditions, theliterature contains little information about the use of CAM in other populations.Recently a new group has been added to the list of populations usingCAM at particularlyhigh rates (Nichols & Harrigan, 2006; Pike, 2005). Indeed, a survey of varsityathletes at aDivision 1 National Collegiate Athletic Association (NCAA) college in Hawaiifound that 56%reported using CAM in the 12 months preceding the survey, with43% of respondents receivingtreatments from both physicians and CAM practitioners, and13% seeing CAM practitionersexclusively (Nichols & Harrigan, 2006). Similarly, Pike (2005) conducted a mixed methods3study on the use of CAM by British club rowers and found that 59% of the female rowers wereusing CAM compared to only 10% of the male athletes.1.1 Situating the Research ProjectTo date, the research concerning athletes’ use of CAM is limited, consisting of eithersurveys reporting the rates of utilization (see Nichols & Harrigan, 2006; Pike, 2005), orcasestudies on the effectiveness of certain treatments for specific injuries(see Kleinhenz et al., 1999;Straub et al., 2001; Weerapong, Hume, & Kolt, 2005). Combining surveyresearch and in-depthinterviews with rowers and their coaches, Pike’s (2005) study isthe only project that hasprovided a detailed look at why athletes utilized CAM. Together, thesestudies provide animportant platform for the exploration of CAMuse in sports but many questions remain to beaddressed. Like much of the research on health practicesamongst athletes, Pike (2005) focusedon injured athletes (see also Griffin, 2005; Young& White, 1995, 1999), but failed to recognizethat athletes might incorporate CAM into theirdaily training regimens regardless of their injurystatuses. Interestingly, Nichols and Harrigan (2006) theorized thatCAM use might not beconfined to the treatment of injuries, although their findings didnot differentiate between thereasons or situations that might lead athletes to seek CAM.As alternative care providers are increasingly includedin sports settings, it is important toinvestigate what experiences and understandings athleteshave of CAM practices, biomedicine,and the role of these practices in an athletic context. Using symbolicinteractionism andhegemonic power theories as a theoretical framework, this thesisproject addresses a gap in theliterature by investigating the experiences of female, Canadian nationalteam athletes. It offers aqualitative understanding of the meanings that these athletes attributed totheir use of CAM.4Specifically, the research examined the participants’ injury-related attitudes, if and how theywere using CAM while training and competing, and the role these womenperceived CAM tohave in their athletics careers. I further consider the way that health practitioners (both CAMand biomedical practitioners) were accessed by the athletes and how information regardinghealth treatments was transferred within athletic communities.The research questionThe investigation of these areas of inquiry wasguided by the following research questions:Central research questionHow do elite Canadian female athletes use Complementaryand Alternative Medicine?Subsidiary questions1) How do elite Canadian female athletes perceiveand experience CAM?2) Why do elite Canadian female athletesuse or not use CAM?3) What role do elite Canadian female athletes perceiveCAM to play in their athleticdevelopment?4) How is the use or non-use ofCAM negotiated within existing structures in the sportsystem?5CHAPTER 2: Review of Relevant Research and Theory2.1 Defining Complementary and Alternative MedicineIn order to facilitate research, the National Centre for Complementary and AlternativeMedicine (NCCAM) in the United States developed the following defmition of CAM:Complementary and alternative medicine (CAM) is a broad domain of healingresources that encompasses all health systems, modalities, and practices, andtheiraccompanying theories and beliefs, other than those intrinsic to the politicallydominant health system of a particular society or culturein a given historicalperiod. CAM includes all such practices and ideas self-defined by their users aspreventing or treating illness or promoting health and well-being. Boundarieswithin CAM and between the CAM domain and the domain of the dominantsystem are not always sharp or fixed. (Panel on Defmition and Description, 1997as cited in Adler, 1999,p.215)As broad as the above definition is, it does not fully encompass allof the existing formsof CAM practices. For example, the history and current practiceof acupuncture illustrates thecomplexities of researching CAM. Acupuncture wasfirst used within Traditional ChineseMedicine (TCM), a separate medical system that hasa history that dates back over 2000 years(College of Traditional Chinese Medicine Practitioners andAcupuncturists of British Columbia,n.d.). Originally, acupuncture involved insertingthin, long needles into acupoints according tothe theory of the meridians, and TCM practitioners manipulated theneedles to direct the flow ofQi or vital energy (College of Traditional Chinese MedicinePractitioners and Acupuncturists ofBritish Columbia, n.d.). In North America today,acupuncture is a technique employedby manydifferent types of practitioners in both biomedicaland alternative settings. The AcupunctureFoundation of Canada Institute (AFCI) offerscourses in acupuncture to health professionals(defined on their Web site as physicians, physiotherapists, chiropractors, dentists,naturopaths,6and others) who are already licensed and practicing in their respective areas. The AFCIWeb sitestates:Because these professionals already have an understanding of anatomy,physiology and pathology, they are able to learn enough at the introductory levelto begin applying simple acupunctures techniques in clinical practicewithexcellent outcomes. (Acupuncture Foundation of Canada Institute, n.d.)In this example, we have a specific practice being employedby a variety of practitioners whomay or may not subscribe to the associated belief system of TCM.The adoption of acupuncture by practitioners from diverse backgroundshas led to someinteresting developments in the ways in which the techniqueis being used. For example, theCollege of Traditional Chinese Medicine Practitionersand Acupuncturists of British Columbiahas recognized electro-acupuncture (wherebythe needles are attached to electrodes andstimulated) as a valid technique. Other variationson the technique include intramuscularstimulation (IMS) and dry needling, whichboth involve targeting deep muscle trigger points inorder to elicit muscle release. Thus, acupuncture exemplifiesthe myriad ways that a singlepractice can evolve within a contemporary North Americancontext resulting in traditionalpractitioners modifying their practice to incorporate newadvances in technology, and biomedicalpractitioners incorporating ancient techniquesinto a modern medical setting.2.2 Prevalence of CAM Use by Population and TreatmentTypeAccording to Statistics Canada, chiropractic isthe most commonly used practitionerdelivered form of CAM with 11% of adult Canadians reportinghaving used it in the 12 monthspreceding the survey (Park, 2005). In comparison, eightpercent of Canadian adults reported7using massage therapy, two percent used acupuncture, and two percent used homeopathy and/ornaturopathy (Park, 2005). With respect to age and gender differences, 23% of women reportedusing some form of alternative care as compared to 17% of men (Park, 2005) and the use ofCAM was highest in those aged 25 to 65 (Park, 2005). A study by the Fraser Institute (whichincluded practitioner and non-practitioner delivered services) found similar trends as 19% ofparticipants reported having used massage therapy and 15% indicated that they had usedchiropractic services (Esmail, 2007). Both Statistics Canada and the Fraser Institute foundthatresidents of British Columbia and Alberta had the highest ratesof utilization in the country(Esmail, 2007; Park, 2005).Income and education have also been found to be positively correlated withCAM use(Esmail, 2007; Park, 2005). For example, Statistics Canada reportedthat 26% of those in thehighest household income group had used CAM recentlycompared to only 13% of those in thelowest income group (Park, 2005). Statistics Canada data indicatedthat 26% of post secondarygraduates had used CAM compared to 16% of individualswith less than secondary graduation(Park, 2005).In line with Astin’s (1998) finding that CAM use washighest among those in poor health,Statistics Canada data suggest that individuals with achronic illness or condition tend to be morelikely to use some form of CAM. The highest rates ofCAM use were reported by individualswith fibromyalgia (3 7%), back problems (36%), multiple chemical sensitivities (33%), boweldisorders (29%), migraines (28%), and chronic fatigue syndrome(28%) (Park, 2005). Tncomparison, only 16% of individuals who did not report havinga chronic illness used CAM(Park, 2005).8Similarly, Nichols and Harrigan (2006) found that 56% of varsity athletes at an NCAADivision 1 College in Hawaii had used some form of practitioner delivered CAM in the 12months preceding the survey. While 38% of the athletes had used massage therapy, 29% hadused chiropractic, 14% had used lomilomi (a Hawaiian form of massage), and 12% had usedacupuncture (Nichols & Harrigan, 2006). Interestingly, although the rates of utilization weremuch higher among the athletes who were surveyed as compared to the general population, thesame forms of therapy were popular with both groups.Finally, Pike (2005) surveyed 200 rowers (male and female) during a regatta season inthe United Kingdom on topics related to risk, pain, and injury. The results of the survey showedthat 59% of female athletes had used CAM, compared to only 10% of male athletes. Althoughthe survey did not provide reasons for the difference between the use of CAMby males andfemales, Pike (2005) theorized that it might, at least in part, be due to the discrepancy inresources allocated to men’s and women’s teams. Specifically, Pike (2005)noted that the men’steams were more likely to have assigned medical staff whereas femaleathletes were required tofind their own practitioners and pay for the services by themselves.2.3 Discourses Regarding CAM Use2.3.1 CAM and HolismIn addition to the above mentioned socio-economic descriptionsof CAM users, CAM hasalso been associated with a holistic view of health or what is commonlydefined as a belief thatthe psychological, spiritual, and physical are interrelated (Barrett et al., 2003).Doel and Segrott(2003) described a holistic outlook as a view of health that encompasses the individual’ssocialsurroundings and social placement. Thus, Lowenberg and Davis (1994) havestated:9[Holism] presumes to enlarge the traditional sphere of medical (read ‘allopathic’)concerns from a narrow, largely technical focus on symptomatology and diseaseto a broadened domain including such health salient foci as nutrition,psychological and spiritual well-being, interpersonal relations and influencesemanating from the environment.(p.581)Holistic health is also said to reinforce individual and private responsibility for health inthat it assumes that the body has an innate equilibrium or healthy state that canbe achievedthrough changes to one’s behaviours, beliefs, or surroundings (Barrettet a!., 2003; Doe! &Segrott, 2003; Kelner & Weliman, 1997; Lowenberg & Davis, 1994; Williams, 1998).Itbecomes the individual’s responsibility to seek out the things in his or her lifethat have made thebody lose its equilibrium and to make the necessary changes inorder to restore balance. Aholistic view of health has proven to be an accurate predictorof CAM use as people whosubscribe to this philosophy more commonly reported thatthey were also CAM users (46%versus 33% of those who did not report a holistic orientationtowards health) (Astin, 1998).A holistic approach to health is also touted as a way to manage not onlythe specificillness or condition, but also the psychological stressassociated with illness and the disruption tothe individual’s sense of self (MacNevin, 2003; Pike,2005). In Pike’s (2005) investigation intothe use of CAM by female rowers, shereported that CAM provided the women with moreopportunities to engage in the treatment process— firstthey had to seek out the practitioner sinceCAM was not a service commonly providedto them and secondly, during the treatment processthey were asked to take specific actions to facilitate thehealing process. Pike (2005) contendsthat because athletes frequently identify themselves asactive beings, CAM helped them tomaintain their identity as athletes at a time when their participationin training and competition10was compromised. Pawluch, Cain and Gillett (2000) also commented on the potential for CAMto influence an individual’s sense of self when they conducted a project on the use of CAM bypersons with HIV. They found that CAM was frequently used by individuals belonging togroups that had been marginalized or oppressed by Western medical systems (or more generallyby Western white cultures) such as women, homosexual men, and individuals of African orNative American descent (Pawluch et aL, 2000). Many of the participants revealed that theytook pride in using healing traditions that were associated with their culturalheritage and thatconnection (or re-connecting) with this part of their identity was a sourceof comfort and a wayof coping with the stress of the illness (Pawluch et al., 2000).There is, however, considerable room for debate as to howCAM and holistic healthrelate to medicalization and demedicalization. On one hand,many CAM practices encourageindividuals to take a more active role in their own healthpractices and often use the term clientinstead of patient to indicate the greater degree of autonomyoffered by CAM. And yet, even asCAM empowers individuals, it can also result in patient-blamingwhen the treatments areunsuccessful (Lowenberg & Davis, 1994). Because a holistic approachto health suggests allindividuals have the potential to heal themselves, a failureto heal or achieve health can beviewed as a failure on thepart of the patient. Lowenberg and Davis (1994) have argued:The denial to patients of the privilege tobe absolved from responsibility for theirillnesses smacks strongly of demedicalization, whilethe application of a healthillness paradigm to nearly every domain of life represents,if anything, a massivethrust in the direction of medicalization.(p. 584)Thus, while biomedicine offers patientsa genetic or biological basis for understandingtheir condition, thereby absolving them of any responsibilityfor the causation of the condition,11the holistic approach can be befter understood through Crawford’s 1980 concept of healthism.According to Crawford (2006), healthism describes the spread of health promotion intoincreasingly diverse spheres encompassing body, mind, and spirit(a holistic view) as well as theaccompanying moralization of heath related behaviours. The unfortunateconsequence of aholistic view of health is that poor health can thenbe viewed as a personal failure on the part ofthe individual or, according to Crawford (2006), “the failure to achieve health orto seek it [is]equated with a failure to embrace life, an inability to master one’s emotions or toappreciate thespiritual dimensions of being”(p. 411).2.3.2 CAM and BiomedicineAs the terms complementary and alternativesuggest, CAM is defmed in relation to, andagainst, biomedicine. Jam and Astin (2001) have arguedthat much of the existing researchconcerning the reasons that users give for selectingCAM contains an inherent bias.Specifically,they contend that the research implicitly suggeststhat the use of CAM is an appropriatearea ofstudy because it represents deviant behaviour or a rejectionof standard or conventional medicalcare. This is despite the fact that some of what are termedCAM practices are increasingly beingused by medical practitioners (Esmail, 2007), some practicesclassified as CAM are now coveredunder both public and private health care plans,and coverage for many forms of CAMhasincreased significantly in the last decade (Esmail,2007).The divide between CAM and biomedicineis perhaps best illustrated by the research intohow many individuals using both CAMand biomedicine disclose or discuss their use ofCAMwith their physician. For example, Eisenberg et al.(1998) reported that only 38% of CAM userswho also visited a physician discussed their use ofCAM with their medical doctors. Similarly,12the Fraser Institute found that 53% of participants did not discuss their use of CAM with theirphysicians (Esmail, 2007). When provided with a list of possible reasons for not discussingCAM use with their physicians, 61% thought that it was not important for their physicians toknow, 56% said that their physicians never asked about CAM therapies, 31% said they did notbelieve it concerned their physicians in any way, 11 % thought that their physicians would notunderstand or would disapprove, 10% thought that their physicians would discourage further use,and two percent thought that their physicians would refuse to continue to be their care providers(Esmail, 2007).To date, the research is divided with respect to whether or not the decisionto seek CAMis associated with dissatisfaction with or distrust of biomedical practices, or israther a belief inthe value and efficacy of alternative therapies— or if it is both factors actingin concert (Doel &Segrott, 2003). Astin (1998) reported that “the most influential or salientfactor in people’sdecision to use alternative health care may be its perceived efficacy”(p. 1552). Kaptchuk andEisenberg (1998) stated that “the attraction of alternativemedicine is related to the power of itsunderlying shared belief and cultural assumptions”(p. 1061). However, Doel and Segrott (2003)found that these theories were not supported in their reviewof how CAM was framed withinpopular British magazines, and they reported that, for many, “the veryact of deciding to useCAM is an act of resistance to dominant practices and a form of self-empowerment”(p. 137).MacNevin (2003) also cited “disenchantment” with biomedicine and its “invasive” and“mechanistic” (p. 285) techniques as contributing to the rise of CAM.The suggestion that CAM use is linked to both dissatisfaction with biomedical practicesand the attractiveness of alternative therapies is gaining ground. Doel and Segrott (2003) haveargued that viewing biomedicine as ineffective and deficient may “functionas a force for change13within the existing health care system” (Doel & Segrott, 2003,P.135), but that dissatisfactionalone does not sufficiently explain the need for an alternative form of medicine (when attentioncould just as easily be directed towards promoting change within the biomedical system). It isalso telling to note that the current research indicates that the majority of CAM users also utilizebiomedical services. Weliman, Kelner, and Wigdor (2001) reported, “typical alternativepathways demonstrate a combination of medical and alternative use. Moreover, thosewho usealternatives use several kinds of therapies and often many therapists until theyfind the one thatsatisfies their need” (p. 12). Indeed, a Statistics Canada report published in 2001found thatalternative health care users were more likely than non users to have a regularphysician, to havehad 10 or more visits with a physician in the past year, andto have recently had their bloodpressure checked or to have seen a specialist (Millar, 2001).As was previously mentioned,certain diseases and chronic conditions are associatedwith higher use of CAM, but Millar (2001)revealed that even when chronic conditions were adjustedfor, CAM users still accessedconventional health care services more frequentlythan those who did not use CAM.2.3.3 CAM and FeminismAstin’ s (1998) often cited paper on the reasons patientsuse alternative medicine reportedthat individuals who identified with feministsocial movements (as well as environmentalism,spirituality, and personal growth psychology) weremore likely to be CAM users. Biomedicineand the medical encounter have frequently been understoodas one domain in which masculinehierarchies are reinforced through theunequal relationship between patient and practitioner.Similarly, leaders of the feminist health movementhave argued that biomedicine ignores thesubjective experience of women and privileges insteadthe expert knowledge of the practitioner14(Scott, 1998). While it is always dangerous to generalize CAI\4 practices given the previouslydiscussed diversity of therapies, compared to the biomedical encounter, the alternative nature ofCAM practices does allow for a different type of practitioner/patient (or client) relationshipthereby disrupting the associated power hegemonies and allowing for a more feminist approachto health practices (Luff & Thomas, 2000; Scott, 1998). One example of a method used to createa more equal distribution of power during a visit with a CAM practitioner is seen during thecollection of patient histories. One practitioner in Scott’s (1998) study of homeopathy as afeminist practice explained it in the following manner:[What doctors] are taught is always to be paring down to what we want to know.And in homeopathy, the absolutely essential thing is to hear what the patientwants to tell you (p.205).The implication is that the narrative approach, more commonly employed by CAM practitioners,empowers the client and allows her some agency in the encounter as opposed to the reductionistand essentialist approach employed by physicians.Additionally, independent of the research relating political or worldviewswith CAM use,the literature indicates that women are more likely than men to use CAM (Eisenberg et al., 1998;Park, 2005). Unfortunately this has resulted in a conflation in the literaturewhereby thefeministnature of CAM (i.e. the opportunities that exists within the CAM encounterto recast the patientpractitioner relationship in more egalitarian terms) and thefeminine natureof CAM practices(i.e. the use of candles and scented candles by some CAM practitioners or the marketing of CAMproducts to women as primary caregivers for their families) are confused and usedinterchangeably to explain the higher rates of CAM use by women.152.3.4 CAM and Social IdentitiesRecently there has been a move to better understand the role that individuals’ beliefsystems, values, and woridviews have on their use of CAM. A study by Pawluch et al. (2000)investigated how individuals with HIV (a population with particularly high rates of CAMutilization) understood their use of CAM therapies. They concluded that the attractiveness ofCAM to HIV patients was multi-faceted and related to issues of maintaining health, enduringstress, coping with margmalization and oppression, and agency and control (Pawluch et al.,2000). The authors concluded that the use of CAM could oniy be understood within a contextthat also considered social identities such as (but not limited to) gender, sexuality, and ethnocultural background (Pawluch et al., 2000). They further contended that the use of CAM bywomen could not be separated from their care-giving roles, reproductive concerns, and thehistorical relationship between women and Western medicine (Pawluch et al., 2000).2.3.5 Athletes and CAMWhile the relationsip between social identities and CAM is well-documented in theliterature, some populations have been the focus of more attentionthan others. It is only veryrecently that athletic subcultures have been recognizedas frequent users of CAM althoughaccording to Nichols and Harrigan (2006) that the findingsare not totally unexpected:We are not surprised about the popularity of CAM amongst our subjects,ascompetitive athletes are typically highly motivated todo whatever it takes tohasten recovery from athletic injuries and illnesses that may hinderthe ability totrain and compete. (p. 235)16While their work did not directly elucidate the athletes’ reasons for using CAM, Nicholsand Harrigan (2006) drew attention to one of the key gaps in the scarce research on athletes andCAM. Namely, they acknowledged that the design of existing studies (including their own) haveso far failed to differentiate between CAM use in response to injury and illness, and thepossibility that athletes may be using CAM to prevent injury or even to enhance performance.There is some suggestion, at least anecdotally, that the use of CAM is linked to a desireto enhance performance and push the limits of athletic abilities. White (1998) claimed that“athletes may be leading the charge in exploring some alternative treatments” (para. 4) andquoted a sport physician as saying:The population that we deal with is pushing the edge ona regular basis. They’rea group that’s very susceptible to ideas that are on the fringe, that are hearsay.When you’re trying to optimize yourself, you don’t want the guy next toyoudoing something that would give him an advantage. It can make them[theathletes] vulnerable to a lot of crazy suggestions. (White, 1998,para. 5)Clearly, there is some concern that the popularity of CAMis in some ways comparable topreviously seen trends in the use of steroids and otherbanned substances and techniques thatwere designed to improve performance but that ultimatelyposed huge risks to the long termhealth of athletes (in addition to challenging the supposednotion of a level playing field in highperformance sport).At the same time, Pike (2005) described holistic health practicesas a more active form ofhealth care, and proposed that the engagement of the athletein the treatment process wasempowering to athletes who are accustomed to using and viewingtheir bodies as instruments.The assertion that the attraction of CAM is at least partially associatedwith its reputation as an17active form of health care is supported by Franzoi’s (1995) theory of the body-as-object or thebody-as-process. Franzoi’s work proposes individuals think of and describe their bodiesprimarily in one of two ways: those that view their bodies as static components and evaluatetheir bodies by judging each part discretely based on appearance (e.g. liking the appearance oftheir legs but having insecurities about their arms or torso) versus those that judge their bodiesbased on what they are able to do with their bodies (e.g. how fast they can run or how flexiblethey are). Franzoi (1995) reported athletes are more likely than non-athletes to subscribe to theview of the body-as-process rather than body-as-object. That is to say that, athletes considertheir bodies first and foremost in terms of physical performance and ability and valueopportunities that allow them to use their bodies (Franzoi, 1995).However, while the body-as-process theory is congruent with Pike’sobservation that therowers sought out health care that required their active participation,it does not necessarilyaccount for the discrepancy between the utilization of CAMby male and female athletes. In thesame way that women in the general population are more likelythan men to use CAM, Pike(2005) reported that 59% of female athletes in her study comparedto only 10% of the maleathletes had used CAM. The male athletes were more likely to choosetraditional pathways andseek treatment from doctors and surgeons when injured whereasthe female athletes were lessconventional in their treatment choices. While Pike’s study does notcome to any conclusionwith regards to the reasons for the observed differences between thegenders, she does proposetwo theories for consideration. The first theory is that resources are unequallyallocated to men’sand women’s sports and team practitioners were rarely available tothe female athletes.Consequently the women were more likely than the men to seek practitionerson their own and asa result were exposed to various types of practitioners (Pike, 2005). The secondtheory proposed18by Pike (2005) is more closely related to the previous discussion on CAM’s congruence withfeminism. Namely, she suggested that CAM maybe viewed by the female athletes as a moregender-appropriate form of treatment because it is perceived by many to empowerand engageindividuals more so than most biomedical treatments and, as such, may attractthose who havesuffered the most as the result of patriarchal structures in sportand biomedicine (Pike, 2005).2.4 Athlete Behaviours and the SportsnetPike’s (2005) work also provided insights into therole that teammates and the rowingsubculture had on the decisions that female athletes maderegarding seeking treatment anddisclosing information related to injuries andhealth status to coaches and teammates. Nixon(1994) described the network of significant others involvedin the athlete’s sporting subculture asthe sportsnet. The sportsnet can include coaches,athletic trainers, teammates, administrativestaff as well as sport specific support staff (e.g. bikemechanics or referees). The notion of thesportsnet is important when investigating the useof CAM in sport, as research has indicated thatathletes resort to their sportsnets for medical advice(Nixon, 1994; Pike, 2005). Nixon (1994)reported that 75% of athletes turned to trainers forhelp or encouragement with sports injuries,while 62% turned to teammates and 56% wentto their coaches. Nixon (1994) also proposed thatathletes made decisions regarding injuriesand medical treatment based on the relationshipsthatthey had within their sportsnet.Pike (2005) supported Nixon’s conclusion, and addedthat theathletes in her study indicated that they took medical advicefrom coaches and teammates evenwhen they knew the individual was not qualifiedto provide such information. Echoing Nixon’s(1992) concern, Pike (2005) suggested that the informationprovided by the sportsnet is19compromised because individuals in the sportsnet often have a vested interest in the health andperformance of the athlete.2.5 Injury, Pain, and Risk in SportThe role of the sportnets in socializing athletes to normalizepain, injury and risk in sport wasoften displaced in academic research by studies into the physiologicalaspects of sports injury.Early works were quick to observe the contradiction between the supposedlyhealthy nature ofsports participation and the reality— that high levelsport came hand in hand with an increasedrisk of injury (Roderick, 2006). While some earlystudies drew attention to the high degree ofrisk associated with professional sport and the waysin which athletes weighed the risk of injury(and permanent disability) against professional and/orathletic recognition, it was HowardNixon’s work that remains the most frequentlycited in the field. Nixon, along with developingthe previously discussed sportsnet theory,looked at the way in which sporting communitiesnormalized pain and formedwhat he called a “culture of risk” (Nixon, 1992,p.129). In thisculture of risk, a paradoxical situationoccurs whereby the athlete refuses to giveup trying toachieve performance goals even while the injury worsensand further reduces his or her chanceof future athletic success (Nixon, 1992).Young, White and McTeer (1994) made landmarkcontributions to the field when theyinterviewed male athletes in contactsports and analyzed the ways in whichthey referenced pain.Four different types of “injury talk”(p. 192) were identified: hidden pain where athletes deniedpain, disrespectedpain where they adoptedan attitude of irreverence towards the pain,unwelcome pain meaning pain and injurythat was ignored or mocked, and depersonalizedpain20where athletes spoke of the injured part as if it were separate from themselves (Young et al.,1994).The early work done by Nixon and Young and colleagues (as well as most of the workleading to that point) focused on the experiences of male athletes and usually those whoparticipated in contact sports with high rates of acute and traumatic injuries such as rugby,soccer, and hockey. As such, the work was deeply concerned with notions of masculinity andmale identities (Roderick, 2006). Young et al. (1994) explained the willingness of male athletesto risk injury and withstand pain at least in part because by doing so they lived up to genderednotions of what was expected of “real men” (p. 176). In this way, the male athletes affirmedboth their masculine and athletic identities by playing through pain (Younget al., 1994).Building on this research, Young and White (1995) made an importantforay into thestudy of female athletes’ attitudes towards injury and pain in sport. Theyinterviewed eliteCanadian female athletes in the sports of rugby, basketball, downhill skiing, football, andbodybuilding and concluded that the women displayed similar attitudes tothose exhibited by themen— they normalized risk of injury and developed narratives to makesense of how theirparticipation in sport compromised their health (Young & White,1995). Theberge (1997) usedthe work of Young and White as the basis for her study of female ice hockeyplayers and herfindings largely supported their earlier work. Theberge (1997) observedthat while the women’sparticipation in the masculine sport of hockey challenged the previouslyuncontested relationshipbetween aggressive sports and masculine identities, in other waysthe women reproducedexisting power structures in the sport. For example, while the women reported feelings ofaccomplishment and empowerment due to their participation in hockey, there was alsopressure21to adopt tough attitudes and violent behaviours in an effort to gain recognition within the broaderhockey subculture (Theberge, 1997).2.6 CAM and Qualitative ResearchWhile the study of subcultures remains largely the domain of sociological research andqualitative methods, at the present moment, there is a trend in CAM research towards morequantitative approaches. This shift towards an objective analysis ofCAM practices is a responseto the call for biological explanations for the practices (Adler, 1999). However,as reported byAdler (1999), CAM is a recent addition to scientific research andhistorically belongs to therealms of folk medicine and ethnomedicine rather than clinicaltrials. Without suggesting thatCAM practitioners are a homogenous group, the emphasisthat many CAM practices place on amore egalitarian client/practitioner relationship (when comparedto the traditional doctor-patientrelationship) is well documented (Adler, 1999), andthis client/practitioner partnership has a“primacy of meanings, relationships, and processesshared by traditional qualitative inquiry”(Adler, 1999, p. 2 19-220). Specifically, in both the interviewprocess and the CAMpractitioner/client encounter, there is an attemptto achieve a more egalitarian relationship wherethe client is acknowledged as the expert withregards to his/her own experiences and bodies(Adler, 1999).2.7 Symbolic Interaction ism and CAMSymbolic interactionism belongs to the theoretical schoolof interpretivism, whichstresses that our “knowing about the social world”(p. 7) is a result of not only our experiencesbut also the psychological, cultural, and historical contextof these experiences (Snape &22Spencer, 2003). Based on this premise, our attitudes and beliefs are shaped by our experiencesand more specifically by our understanding and interpretation of our experiences. Symbolicinteractionism as a theoretical framework was developed by Blumer (1969), and consists of threemain premises. The first premise is that our behaviours and actions towards things (includingpeople, objects, activities, or situations) are based on the meaning that these things havefor us(Blumer, 1969). The second premise is that meanings arise from oursocial interactions withthese things and with others (Blumer, 1969). Thirdly,symbolic interactionism proposes thatmeanings are modified through the interpretive processthat we employ to understand ourinteractions (Blumer, 1969).Blumer (1969) wrote that “to ignore the meaning of thethings toward which people act isseen as falsifying the behaviour under study”(p. 3). For example, without a better understandingof what patients/clients are seeking from their encounterswith various health practitioners wecannot understand if the increased use of CAM isthe result of growing dissatisfaction withbiomedicine or with the appealof a holistic woridview that is associated with CAM (Doel&Segrott, 2003). Symbolic interactionism allowsfor an investigation into the myriad of factorsrelated to health behaviours including healthbeliefs, social networks, access to care, andsymptoms (Barrett et al., 2003).Additionally, Denzin and Lincoln (2005) describedthe qualitative research process asblending of the researcher’s own observations withthe life stories of a “real subject, or realindividual, who is present in the world and able, insome form, to report on his or herexperiences” (p. 21). The focus in qualitative research onmethods that allow the participant toguide the direction of the interview and focus on issuesthey find relevant to the research topic iscongruent with the theory of symbolic interactionism.While a more detailed description of the23methods employed in this project is included in the following chapter, it is useful to note at thispoint that the self-narrative research technique has proven useful in helping individuals makesense of injury or illness and their experiences (Brock & Kleiber, 1994; Scott, 1998) and semi-structured interviews allows participants to direct the discussion towards issues they consider tobe relevant to the research topic but that may have been overlooked by the researcher.2.8 Hegemonic Masculinity and Power Relations in SportThe second and complementary theoretical framework for this project is theconcept ofhegemonic masculinities as proposed by Carrigan, Connell, and Lee (1985).Carrigan et al.presented a model where multiple power hierarchies and relations existedsimultaneously. Theydrew on Gramsci’ s work to describe cultural situations as placeswhere a hegemonic masculinity,that is to say the most normative and privileged masculine identity, existed butwas alwayssituated in relation to other subordinate and pluralistic masculinities and femininities(whichwere, of course, also hierarchically positioned in relation to each other) (Connell&Messerschmidt, 2005). The concept of hegemonic masculinities has provenuseful in theexploration of interpersonal relations in the fields of criminology,organizational behaviouralstudies, and educational studies. As an example, it hasbeen employed to investigate both thehierarchies that exist among teachers and those amongstudents on the playground (Connell &Messerschmidt, 2005).The theory of hegemonic masculinities has also been applied extensivelyin sportssociology to explore power in sports as something that is relationaland contested on ongoingbasis by participants (Pringle, 2005). The previously mentionedworks by Young et al., as wellas many other papers by such acclaimed sports researchers as Messner, Saboand Sparkes24(Messner 1990; Jansen & Sabo, 1994; Sparkes & Smith, 2007) have all used the theory ofhegemonic masculinity to explore human interactions in sporting subcultures. The strength ofusing the concept of hegemonic masculinity in the field of sport studies is, as statedby Pringle(2005), its potential to “[acknowledge] that some sportsmen [sic] enjoy greater ability to exercisepower than others and that sporting practices contribute to inequitable power relationsbetweenmales and females” (p.263). In my project, the concept of hegemonic masculinitieswas used toexplore how access to services and practitioners was negotiated, howthe status of the athleteswithin their sport systems restricted or enabled their access, the role authorityfigures played indetermining the services available to athletes, and howpower relations played out in thetreatments themselves.2.9 Application to ProjectThis project employed a symbolic interactionist approachto more fully investigate howthe athletes’ experiences in the sports systems, their relationsboth within and without thesportsnet, and their attitudes regarding biomedicine hadfactored into their use of CAM whiletraining as high-performance athletes. Hegemonic masculinitiestheory compliments theinterpretive framework and allowed foran exploration into how the hierarchal nature of boththesport and medical systems influenced thefemale athletes’ use of services with specific attentionpaid to issues of access, funding, and the legitimizationof certain health practices over others.The congruency between qualitative methodsand CAM practices in addition to the potentialprovided by hegemonic theory to understand how useof CAM is related to power structureswithin sport allowed this project to provide detailed andunique perspectives the lives of female25athletes. It provided a previously unexplored bridge between the literature related to the generalrise in the popularity of alternative health practices and investigations into elite sport subcultures.26CHAPTER 3: MethodologyThis project challenged and delineated the bounds of current CAM research by applyingexisting CAM theory to a currently under-represented population, namely, high-performancefemale athletes. It employed qualitative research methods to examine the behaviours andattitudes of these women with regards to CAM. Specifically, I investigated how the women’suse of CAM had (or had not) changed over the course of their athletic careers, if and how thesportsnet had influenced their use of CAM, and how CAM use was negotiated within the existingstructures of the Canadian sport system. In the following section, I describe the rationale behindthe selection of my study sample and the methods employed. In addition, I will discussthelimitations and ethical concerns associated with the conducting of this researchproject.3.1 Sample and RationaleThe data for this study were collected from interviews with 12 female members ofCanadian national teams in the sports of cross-country skiing, cycling, kayak, rowing,and speedskating. I used the system of carding to determine and define national team status.The AthleteAssistance Program (AAP) is a program directed by Sport Canadathat provides national teamathletes with monthly stipends or cards, which are renewed on an annual basis.The specificselection process and requirements for cards are determined by the athlete’s respectivenationalsport governing body. The AAP program was developed to provide funding to Canadianathleteswho are ranked among the top 16 internationally in their event or who have the greatestpotentialof achieving this level of performance (Heritage Canada, n.d.).The stated objective of the AAPprogram is to permit athletes to train and compete year-round and further theirathletic goals27(Heritage Canada, n.d.). Carding can be awarded at several different levels and while each sportorganization has some discretion in how the funds are allocated and awarded, the list publishedby Sport Canada in 2008 indicated that funding ranged from $2,700 annually to$18,000(Heritage Canada, n.d.) depending on past athletic performances, years on the team, andexpected future accomplishments. The athletes who participated in my study were carded ateither a Senior (SR) level or a Development (D) level with stipends of either$10,900 or $18,000annually. th addition to the stipend, carded athletes are eligible for certain servicesand programsthat vary by region and by sport but typically include access to Canadian Sport Centres, careerand academic guidance, and health insurance2.Carded athletes are required to signcontractswith their national sport organization that contain general conditions, suchas abiding by SportCanada’s anti-doping policy, as well as sport specific conditions, suchas residing near a trainingcentre or attending training camps.The decision to recruit national team members was based on the two proposedtheories inthe existing literature regarding the reasons athletes have for usingCAM— namely, that athletesare willing to try anything that might provide them with acompetitive edge (White, 1998) or thatathletes will try anything that might minimize the time away fromtraining due to injury andfacilitate their return to play (Nichols & Harrigan, 2006). Becausenational team members haveso much more invested into their sport, it is further assumed that theywill have adopted attitudesrelated to athletic subcultures to a greater degree than athletescompeting at other levels in sport.It is supposed that, compared to other athletes, national teammembers face increased pressure totrain and compete even when injured and that the consequences of not trainingand competing (in2The most popular insurance policy provided to carded athletes is the Canadian Athlete InsuranceProgram(CAIP) but some national sports organizations use alternative plans.28terms of lost physical abilities, financial loss, challenges to their athletic identities, and socialstatus within the sports community) are greater.The sample size of one dozen athletes was based on previously conducted projectsinathletic populations that employed a similar research design (see Griffin, 2005; Pike, 2005;Young & White, 1995) and which reported that strong themes emergedin groups of this size thatwere sufficiently homogenous in nature. It is unlikely thatthe theory of data saturation asproposed by Glaser and Strauss (1967) could ever be completelyachieved given the scope of thetopic and unstructured format of the interviews. However,other studies of this nature, such asthe previously referenced work by Griffin (2005), Pike (2005),and Young and White (1995),reported that after in-depth interviews with 12 participantsthere were observable trends in thedata and that further interviews rarely lead to the developmentof new categories or novelinsights related to the research topic. My decisionto interview 12 athletes also took into accountthe resources available to me as a Master’s studentand the necessity of completing this studywithin the time allocated.The sports included in this project were selected forseveral reasons. First of all, therelatively low numbers ofwomen competingat an elite level of sport in Canada made itimpractical to recruit from a single sport. Even thoughBritish Columbia is home to a highproportion of Canada’s top athletes, manyof the national teams train in warmer climes or spenda significant portion of their season competing at WorldCups or other events in Europe.Consequently, the numbers of athletes in the provinceat any given time is unknown andconstantly in flux.Secondly, my choice of sports reflected my broaderresearch objectives. As previouslydiscussed, I wanted to select sports that were typicallyoverlooked in the literature concerning29sport injuries. Additionally, in order to consider Nichols and Harrigan’s (2006) suggestion thatCAM use was related to performance enhancement, I needed athletes with relatively long athleticcareers in sports that were not normally associated with traumatic and career ending accidents.In this way, I hoped to explore how injuries or issues (as will be discussed later) were managedover long periods of time. Finally, given the unstructured nature of the interviews, I made thedecision to limit the sample to athletes over the age of 18 in order to simplify the ethical reviewprocess.Taking all of the above mentioned factors into consideration, I approached Pacific Sport,the Canadian Sport Centre in British Columbia, and asked them to assist in the recruiting processby distributing letters of contact introducing the project as well as information and consent formslease see Appendix B) to carded female athletes in non-contactsports who were registered attheir training facilities and who were over the age of 18. From this mail-out,four athletes wererecruited and in each case these athletes forwarded the information toother teammates.Although some of the teammates they contacted had already receivedthe mail-out, the secondcontact by a teammate resulted in the recruitment of twoadditional participants. The samepackage in E-mail format was also sent to my friends, formerteammates, and co-workers whowere active in the sports community and they were askedto forward the information to anyfemale national team members with whom they were in contact.These B-mails helped to recruitan additional three athletes who did not live in British Columbia andwho were not registeredwith Pacific Sport, and who subsequently assisted with the recruitmentof the final threeparticipants.In addition to focussing on non-contact sports, I endeavouredto recruit a sample that wasdiverse in terms of ethno-cultural background, socio-economicstatus, age, and that included both30able-bodied and paralympic athletes. The objective was to find participants that enabled me tobroaden the categories of analysis and verify the limits of such categories by testing them againstoutlying cases (Glaser & Strauss, 1967). However, my ability to recruit a diverse sample washighly dependent on the diversity of Canada’s national teams. Since not all women have equalopportunities to participate in sport, and making a national team requires years of training,substantial financial resources, and social networks that support the athlete’s goals, it is notsurprising that there is limited diversity among the members of Canada’s national teams.Nevertheless, in the end I was satisfied that the women I interviewed represented the broadestsample possible given the circumstances of sport in Canada.31Table 1 — Sample Characteristics n= 12Age distribution n20-24 425-29 630-32 2Marital Status nCurrently Married/Common-Law 2Never Married 10Education flHigh School 2Some College/University 5College/University Degree 4Graduate Degree 1Income nUnder $10,000 4$10-20,000 5$20-30,000 1$30-40,000 1$70, 000+ 1Sport nCanoe/Kayak 1Cross Country Skiing 2Cycling (Road) 2Rowing4Speed Skating (Long Track)3Years on National Teamn2-4 years75-7 years 28-9 years 2The women in the sample ranged from age 20 to age 32 (averageage of 26) and hadspent between two and 16 years on national teams. All ofthe women self-identified as either32Caucasian or of northern European descent. Eleven of the athletes were able-bodied and oneathlete participated in the paralympic system. While two of the women indicated that they werein significant relationships (either marriage or common-law partnership), the remaining 10women stated that they were single. Nine of the athletes had some university level education(although in most cases their degrees were on hold or taking more than the standard four years tocomplete), one was currently pursuing graduate studies and two had completed high school. Thewomen’s incomes varied from under $10,000 a year to over $70,000 a year with two-thirds ofthe athletes reporting their income to be less than $20,000 a year (although in the course of theinterviews some athletes mentioned that were receiving additional financial support from parentsthat may or may not have been captured in the biographical data form).Injury status was not a criterion for participation in this project. Rather, the design of thisproject was meant to capture the myriad ways in which athletes were using CAM, potentiallyincluding the enhancement or improvement of performance. Limiting the project to injuredathletes risked overlooking the ways in which athletes were employing CAM therapies on a dailyand ongoing basis throughout their athletic careers.3.2 Sampling ChallengesEven though I was aware my potential pooi of athletes was limited, I was still surprised(and somewhat disappointed) when Pacific Sport reported that only 27 of their registered athletesmet my sampling criteria and had been sent information packages during the initial mail-out (afew more packages were sent in January when Pacific Sport updated their registration lists).Oneof the reasons for the low numbers was that the sports that met my criteria typically had verysmall teams. For example, road cycling sends three women to the Olympics and the total33number of carded athletes reflects this. Additionally, while all carded athletes have the option ofregistering at a Canadian Sport Centre in order to access services such as gyms, pools,physiological testing, massage, and physiotherapy, not all athletes do so (or they do not updatetheir mailing addresses). Some of the reasons athletes may not register include: They do notintend to access the services, they do not live near the facilities, or they have access to the sametype of services at other centres. It soon became apparent to me that the mail-outs would not besufficient to my needs and I would have to focus on snowball methods and personal contacts aspreviously described.Although I did eventually obtain my targeted sample size (12 athletes), it took fivemonths rather than the originally scheduled two months. I was most successful in recruitingwhen I was able to make a personal contact in the sport by way ofa former teammate or trainingpartner and then asked him or her to forward the recruitment packagesdirectly to their friendsand teammates in the sport. The mail-outs sent through PacificSport yielded some responses buteven then, the athletes that replied to the letters were people with whomI had anotherconnection— for example, they saw my name on the letter and contacted mebecause theyrecognized me as a former member of Team Saskatchewan.‘While the athletes I contacted proved to be a great resource— both interms ofvolunteering their own time but also in terms of recruitingtheir teammates— my contacts withcoaches and administrators were less productive. Indeed, only one of theathletes that Iinterviewed indicated that she had received the information package viathis avenue. Rather,many coaches and administrators expressed concern in either my E-mail or face-to-faceinteractions with them about the time demands associated with participationin the study. Someof these individuals also indicated that they not be willing to forwardthe information on to the34athletes as a result of their concerns about the time demands that participation in the study wouldplace on participants.3.3 Protocol and RationaleThe athletes who agreed to participate in the project were asked to commit to twointerviews each lasting approximately one hour. The second interview was scheduledfour toeight weeks after the first interview in order to allow time for transcription and preliminaryanalysis of the first interview. The timing of the second interview was often dependenton theathlete’s competition/training schedule as many athletes were competingoverseas or in trainingcamps during the period of data collection. The interview schedules (pleasesee Appendix A)asked participants to describe their history in their respectivesports, what practitioners theycurrently used or had used in the past, when and whythey had started using these practitioners,who or what had influenced their decisions tosee a practitioner, and the role they perceivedCAM to play in sport. The interview schedules wereused as guides only and the actual contentof the interviews was largely determined by the athletes’responses.The interviews were conducted at a location of the athlete’s choosing,with the majoritytaking place in coffee shops (although two were conductedin the participants’ home and twowere conducted at training facilities). Fourof the athletes were living and training in Alberta soIused a graduate student research grant to travelto Canmore and Calgary to conduct the first setof interviews. One athlete was interviewed inMontreal, Canada, while I was attending anacademic conference. For all five of these out-of-provinceathletes, the second interview wasconducted by telephone.35Before starting the first interview, the athletes were asked to read and sign theinformation and consent forms. They also filled out a biographical data sheet (please seeAppendix C). At the second interview, the participants were given a list of CAM practices andwere asked to identify all of the treatments they had tried using an additional form (please seeAppendix D). Used as a tool to ensure that each athlete identified all of the CAM treatments shehad previously used, the form was also employed as a prompt for discussion.The multiple interview format was selected in order to encourage ongoing self-reflectionon the part of the athletes (Ryen, 2004). In her own work, Hurd Clarke (2003) reported that:Interviewing the women two and three times also fostered rapport, as it gave thewomen a chance to talk about a wide variety of issues and affordedthem anopportunity to amend, return to, or elaborate on previously disclosed information.(p. 732)Having an opportunity to interview the women a second timewas particularly appropriatefor this project since existing research on CAM is limited andnew and unforeseen themes werelikely to emerge during the course of the project. The opportunityto question participantsregarding new themes that other athletes raised during interviewsis consistent with the principlesof grounded theory (Glaser & Strauss, 1967) and theory generation,as it encourages thediscovery of previously unexplored themes. The double interviewformat also permitted me, as anew researcher, time to review transcripts and modify my interviewtechniques, consider thedata, and familiarize myself with literature I had not previously considered.The decision to use a less structured interview format andto ask open-ended questionswas based on similar rationale. In addition to theory generation,open-ended interviewingtechniques minimize the researcher’s opportunity to imposeher own assumptions on the36participants’ accounts (Britten, 2006). Although a series of predetermined topics for discussionwas developed prior to conducting any interviews, the research was meant tobe inductive innature and grounded in the data, and, therefore, was designedto permit new topics and categoriesof analysis to emerge.The interview process began with the soliciting of life history narratives in orderto createa rapport with the participant, and also because allowing participantsto start the interview bysituating themselves in a social-historical context has provento be an effective method inengaging interviewees and easing into what may be moreintimate or difficult topic matters(Hurd Clarke, 2003). The self-narrative hasalso been identified as a useful method for“extract[ing] meaning from experiencerather than to depict the experience exactly as itwaslived” (Bochner, 2000,p.270). Bochner (2000) has described life narrativesas “not so muchacademic as they are existential, reflectinga desire to grasp or seize the possibilitiesof meaning,which is what gives life its imaginativeand poetic qualities” (p. 270). Rubin andRubin (1995)contend that the use of open-ended questionsallows the interviewee to presenthis/her own ideaswithout imposing the researcher’spredetermined themes, and yet sufficientlylimits the scope ofthe interview to the topicof interest. In this project, the interview schedulefor this project wasorganized in a way that allowed enoughfreedom in the interview format to pursuenewdirections and themes that the intervieweesintroduced, while still ensuringthat the key themeswere adequately covered. The secondinterview utilized follow-up and probequestions toelaborate on previously mentioned themesthat “lack[ed] sufficient detail, depth,or clarity”(Rubin & Rubin, 1995, p.145).373.4 Data AnalysisGrounded theory (Glaser & Strauss, 1967), in addition to guiding the structure of theinterviews, was also incorporated into the data analysis process. The objective of groundedtheory is “the achievement of a complex theory that corresponds closely tothe data” (Glaser &Strauss, 1967,P.113), through the use of a “constant comparative method”(p. 102). During thisproject, the interviews, transcriptions, and analysis were done in a concurrent fashionso thateach process interacted with and directed the others as is proposedby Glaser & Strauss (1976).More specifically, the first stage of data analysis occurred immediatelyafter I conducted eachinterview and started transcribing while making notes regarding potentialfollow-up questions forthe second interview or for interviews with other participants. Mysupervisor, Dr. Laura HurdClarke, also reviewed several of the transcripts and provided a critiqueof my interview style andsuggestions for future directions regarding the questions.More formally, the analysis of the data can be describedin three parts: data management,coding, and in-depth analysis (Miles& Huberman, 1994). Data management consisted of eachinterview being transcribed verbatim.I was very fortunate to have an undergrad seekingresearch experience volunteer to assist inthe transcribing process. As well as transcribing someof interviews, the undergraduate student also reviewedand proof-read the transcripts donebymyself. After being reviewed, each interview was loadedinto NVivo, a software program usedto manage and assess large quantities of qualitative data.Coding began with the reading and rereading ofinterview transcripts and the creation of acodebook. During the reading process, I identifiedmeaningful categories or recurrent themesand these, in addition to some codesdirectly related to the research objectivesand questions,formed the basis of the codebook. With theassistance of my supervisor, I developedthe38following 11 broad analytic groupings: the role of funding and health coverage, accessingservices, reasons for treatments, the role of practitioners, desired qualities in practitioners,communicating with practitioners, attitudes towards biomedicine, attitudes towards CAM,talking about the body, anticipated future use of CAM and other services, and theorizing on thefuture of CAM and sport. Using the process described by Strauss & Corbin (1998), these 11codes were further reduced into sub or axial codes until each analytical grouping containedbetween one and six sub-codes. Using the NVivo program, segments of interviews wereselected, assigned to a code, and thereby reduced into meaningful categories of analysis (Miles &Huberman, 1994). The formal analysis of the data consisted of reviewing the node reports fromeach of the codes and sub-codes and mapping out the relationships between them.3.5 ReflexivityIn order to more fully understand the end product of this master’s project, it is necessaryfor me to situate myself in relation to the topic and in relation to the population that wasinterviewed. As a White, educated, and middle-class individual who had had opportunities topursue athletic and leisure opportunities, I was very similar to my sample participantsin terms ofmy own social position. Additionally, my status as a highly competitive, varsity lightweightrower who competes nationally and internationally, in addition to my previous experiences asacompetitive cross country skier at a national level, meant that I had someshared experienceswith the women. That said, all of the women involved in this project wereCanada’s top athleteswho were at the height of their careers. In short, their athletic achievements had far surpassedmy own— a fact I remained cognisant of throughout the entire process.39At the same time, I was closely acquainted with two of the participants prior to the startof the project (they were at one time teammates of mine) and I had met several of the otherwomen prior to interviewing them. The large majority of the participants recognized me (and Ithem) because we had trained in the same gym or attended the same major multi-sport events(e.g. the Jeux du Canada Games). It was because of these existing relationships withinthesporting community that I was able to recruit participants for this project.In addition to helping me to recruit participants, my experiencesas an athlete proved vitalin being able to establish a rapport with the women. For example,when trying to set a time foran interview, I often suggested that I would wait for them at a coffeeshop near their trainingfacility and that they just come whenever practice ended.Many of them showed up in gymclothes and ate their post workout snack while we weretalking, and commented that they oftenexperienced difficulties making appointments because of last minutechanges to their trainingschedules and said that they appreciated that I understoodtheir schedules. Similarly, my abilityto use and understand sport jargon or acronyms that are popularin sport organizations helped toestablish my credibility. Finally, while I avoided makingcomments that would identify mypersonal attitudes towards specific Sport Canada initiativesor, for example, the state of sportfunding in Canada, some of the women only really startedto open up once they realized that Inot working for an organization and was not likelyto be offended by their criticisms of programsor of personnel within the system.However, while my experiencesmay have assisted in creating a rapport withthe athletes,in other ways they proved a hindrance. The main concernwas my tendency to take for grantedsome of what the women said because it closelyreflected my own opinions or attitudes (basedonmy own socialization within the sportsnet). Insome cases I did not follow up as I should have40because I assumed I understood what the athlete meant. In other situations the athletesthemselves cut their responses short because they assumed that as an athlete I would alreadyknow what they intended to say or was familiar with the issue. Three strategies were adopted toaddress these concerns. The first strategy was the soliciting of feedback from my supervisor onthe content of the interviews and her analysis of some of my initial transcripts. Thisoccurred inconjunction with the second strategy, which involved the previously discussedreading oftranscripts before the second interview in order to develop followup and probe questions. Thefinal strategy was to respond to the athletes’ comments in a way that indicatedthat although Iwas somewhat familiar with the phenomenon, I was primarily interested ingetting their thoughtsand opinions.My age and student status also proved to be anasset during the interview process. As a26 year-old, I was the same age as the average age of mysample. When they first contacted me,some of the younger athletes commented that they did notfeel they had a lot to contribute andthat their teammates would be better suited to participatingin the project. Once they realizedthat I was not much older than they were and that I wasstill a university student, they seemedmore comfortable.The final point to consider is my own attitudes towardsand experiences of CAM andhow they served informed my work.When starting this project I was largely unfamiliar withCAIvI practices and had had very little personalexperience with the various treatments. Withtheexception of a few sport massages severalyears ago, I had not used any CAM services. I was ofthe opinion that most CAM treatments were of littlevalue to athletes except as a type ofplacebo— that is to say that their value laymainly in the practitioners’ abilities to convinceathletes of the necessity of their respective treatmentsfor the healing process or sport41performance. Aware that my attitude towards CAM would limit my ability to hear what theparticipants were saying and at my supervisor’s urging, I made a commitment to try severaltherapies over the course of the project. Thus, I tried massage therapy, craniosacraltherapy, andvisceral manipulation treatments. In conjunction with the stories that I heardfrom the athletes,my own experiences with massage therapy and craniosacral therapy modifiedmy attitudestowards CAM. While I remain wary of the aggressive marketing of certainCAM practices toathletes and maintain that it is important to adopt a critical view of the ways in whichthesepractices and practitioners are adopted into sportsnets,I am now of the opinion that thesepractices and practitioners have something of value tooffer to athletes, even if that value is noteasily understood, reduced, or articulated. I entered the researchprocess curious and open tohearing what CAM offered the participants. At this finalpoint of the project I have come torealize that ultimately it is not my position (or anyoneelse’s) to decide what practices are ofvalue but that we must first consider “whatever worksbest for the athlete.”42CHAPTER 4: FindingsSimilar to the literature review, this section begins with an overview of how the athletesin the project defined CAM. Next, I examine the situations that lead themto seek treatment andwhat type of treatment they decided upon. Since continued use of CAMis not possible withoutthe financial wherewithal or the ability to access services, the nextsection illustrates the role ofcarding, the cost of CAM, and other forms of social capital within thesportsnet (e.g. athleticsuccesses and years on the team) that factor into the athletes’ use of healthservices. Therelationship with specific practitioners and the role practitionersplay in an athlete’s career arealso presented along with observations related to how theathlete found the ideal practitioner andthe role of referrals from within and without the sportsnetare explored. Of central importance tothis study was an exploration of why athletesuse CAM on an ongoing basis and how CAMfigured into their athletic careers, if at all. Accordinglythe findings conclude with an elucidationof the three themes that emerged relatedto the purpose of CAM: How the athletes definedinjuries, how the use of CAM was partof a strategy to prevent the body from “breaking,”andhow the use of CAM enabled them todeal with stress.4.1 What is CAM?4.1.1 Athletes Classify and Define Practitionersand TreatmentsWhen asked to define the term ‘Complementaryand Alternative Medicine,’ it becameapparent that although the athletes were largelyunfamiliar with the term, they were well versedin the practices and practitioners commonly associated withCAM. Indeed, four distinctresponses to the question “what is CAM?” emerged. Thefirst type of response consisted of43defining CAM by comparing and contrasting it with biomedicine, which the women referred tovariously as “Western medicine,” “allopathic medicine,” and/or the “traditional medical systemin our society.” Half of the athletes described CAM as “outside the norm,” “not Westernmedicine,” and “not from North America” as exemplified by Nicole3who wasnot only able todefine CAM but who was also able to classify different practitioners:Alternative medicine to me is stuff that most people would consider tobe outsideof the traditional medical system. To me, the traditional one is like your hospital,your GP who has gone to a traditional medical school— I think physio would bein there but I think probably massage would be complementary. Nutritionistwould be traditional. Outside of that would be stuff like naturopathsandacupuncture where you know it’s not considered to be traditional medicalpracticein our society.Similary, Claire defined CAM by giving examplesof practices she considered to be alternative:The first things that pop into my head were things like TraditionalChineseMedicine. Or I was wondering ifwe were goingto talk about naturopathymedicine. I definitely thought about needles... Just moreof that. Like just thingsthat maybe are outside the norms but now havebecome mainstream.The second group of responses included a further description ofthe perceived nature ofCAM. Two of the athletes stated that in order fora practice to be considered CAM, it needed toinclude a “holistic” element. For example, Briestated:Throughout the findings and discussion portions of my thesis, I will referto the participants usingpseudonyms. I have taken several steps to ensure the anonymity of theparticipants especially considering the factthat I recruited from a very small, closely knit sport community.It is for this reason that I have not included a tablethat links the pseudonyms, sports, ages, or years on the national teamfor each subject choosing instead to use tablesthat show the range and distribution in ages, years on team, and sport.44I would say alternative medicine would not include the three that I talked aboutwhich were chiro, massage, and physio. I would define alternative as acupunctureand more like [a] holistic kind of approach... I would say holistic would be kindof... not necessarily looking at where the pain is but looking at the entire package.Like your body as a whole as opposed to just ‘This is where it hurts.’Hilary suggested that it was the attitude and perspective of the practitioner that made a practicealternative and when asked to classify practitioners as either allopathic or alternative explained:I think that really depends on their outlook as a practitioner. So yeah, I think Icould look at a physio and say that they are an alternative practitioner becausethey actually listen to their patients. And they’re listening to all the symptoms... Iguess maybe that’s more my definition of holistic but I kind of define it alltogether. Maybe I stereotype the standard practitioner as somebody who listens tosymptoms and prescribes the treatment or gives the treatment and somebody whois alternative is alternative to that and listens holistically.Three athletes were less familiar with the term CAM and did not compare it tobiomedicine but still classified practitioners in order to illustrate whatthey perceived to be thedifferences between practices. A key factor in their definition was howpopular or “mainstream”the practices were. Thus, Jody asserted: “Alternative. I don’t know... I’msure there’s tons... Ithink of it as something newer. I guess originally Chinese Medicinewould have beenalternative, right? It’s becoming more mainstream now.”Similarly, Kathy stated:I guess it makes me think of naturopaths and acupuncture and thingskind of likethat... I guess I think of chiro and massage more as mainstreambut I don’t knowif it is... Maybe it’s because we’ve worked with thesepeople for a long time.Finally, several of the participants provided a literal consideration ofthe term“complementary” in their definitions of CAM. These athletes wereunfamiliar with the term45CAM and so deduced that this would include anything they thought might “complement” theirtraining. For example, Audra gave the following response:Ijust think that means anything above and beyond the normal training. I think ofnormal training as how I start out— you have a coach, you go ride your bike.That’s it. Like you sleep, you eat, you ride your bike. And then I think anythingabove and beyond that would be like going to a naturopath, getting that nutritionaladvice, going to physio, finding out what you can fix about your body to makeyourself go faster. It’s all about getting that extra stuff that can make a hugedifference... like psychology or massage.4.1.2 What is Meant by Holistic?As is seen in the above quotes, the term holistic was usedby a few of the athletes todefine CAM. As stated in the literature review, holism is oftenassociated (rightly or wrongly)with CAM practices and while holism is another term lackinga consensual definition it is mostcommonly described as a woridview that encompassesmind, body, and spirit (Barrett et al.,2003). While interviewing the participants I was cautiousnot to use the word holistic to describeCAM since I wanted to be open to the possibility that this wasnot how everyone views CAM.However, when five of the participantsused the words holistic or holism, I took the opportunityto ask them to clarify their definition of the term. Their responseswere fairly unanimous andconsistent with existing definitions— they describedholistic as an approach that was “balanced”(Jody), that “addresses everything” (Kathy),and one that looks at “the entire package” (Brie).When asked to elaborate and describe what wasmeant by “everything” and the “entirepackage,” none of the participants mentioned emotionalor spiritual components choosing insteadto focus on different physical factors such as nutrition andsleep. For example, Brie responded inthe following manner:46I would say holistic would be kind of approaching a diagnosis from notnecessarily looking at where the pain is but looking at the entire package... Likeyour body as a whole as opposed to just ‘This is where it hurts, what’s going on inthis area?’Hilary had a similar description but included a comparison to allopathic medicinein her responsewhen she said:[Holistic is] having a medical practitioner that can lookat you as a whole.They’re not looking at your symptoms. They’re lookingat where your symptomscame from... Drives me nuts nine times out often goingto allopathic doctors whojust kind of ask for your symptoms and then give you aprescription.., as opposedto looking at the body as a whole.The only athlete to give a definition of holistic that includedanything other than physicalelements was Kathy and even then she focused mainly onthe body:It’s addressing everything... I guess trying to increaseyour performance... Yeah,I guess the way I would look at it is trying to attackeverything at once. Likesaying that if I have a back problem... I don’t necessarilyjust need somethingdone to my back. I need maybe different kinds of treatmentson all different partson my body. Even mentally I might need something.I might need differentnutrition. I might need needling... I might need massage...So I think kind oflooking at each injury or each thing from a wholebunch of differentperspectives... Yeah, I would say holistic means tryingto look at every angle.4.2 Choosing CAM: What are Athletes Using?Given that not all of the participants definedCAM in the same manner or classifiedpractices using the same criteria, the questionsin the interview were designed in a way that47encouraged the participants to include all practitioners that they had used or were using.4 Table2 illustrates the range of CAM practices engaged in by the athletes as well as the number ofathletes that had tried each form of therapy and the number of athletes that were using them atthe time of the interviews. All 12 of the participants were using some form of CAM5at the timeof the interviews. When asked how many forms of CAM they had tried— both those theyhadtried and continued to use, and those they had tried and discontinued—the responses rangedfrom three types of CAM to 12 types of CAM.4As seen in the interviews guides (Appendix A), the athleteswere first asked ‘what types of healthpractitioners are you using?’ and only later asked‘how would you define Complementary and AlternativeMedicine?’ The intent of this structure was to ensure valuable informationwas not omitted because the athletes didnot all classify practitioners in the same way. For example, anathlete that did not consider massage to be alternativemay not have included a massage therapist in theirresponse if asked ‘what CAM practitioners are you using?’Italso meant that physiotherapists and physicians wereusually included in the athletes’ responses. Throughoutthedocument the use of and experiences with these biomedical practitionerswill be discussed and will provide a meansof contrasting and comparing the athletes attitudestowards CAM to their attitudes towards biomedicine.When asked what practices they used, the athletes were given alist of therapies to select from and theoption of writing in additional therapies (Appendix D).Given the highly contentious and complex process oflabeling CAM practices (especially given the ways in which individualpractitioners borrow from other traditions orcombine a therapies), I chose to accept the classificationsand definitions provided by the participants and not to tryand classify the treatments they were using myself.48Table 2 — Use of Practitioner Delivered CAIVI n = 12Number of CAM Treatments Tried nTwo 3Four 4Five 3Seven 1Twelve 2Treatments TriednAcupuncture 12Aromatherapy 1Ayurvedic Medicine 2Chiropractic 10Craniosacral Therapy 4Homeopathy3Hypnosis2Massage12Meditation4Naturopathy8Osteopathy3Qi Gong1Reflexology3Reiki 2Traditional Chinese Medicine2Treatments Regularly Used at Timeof Interviews nAcupuncture5Chiropractic6Craniosacral Therapy4Massage11Naturopathy8Osteopathy3Traditional Chinese Medicine1At the time of the interviews, 11 athleteswere using massage and their use rangedfromonce a week to once a month. Additionally,these 11 participants reported that theyreceivedmore frequent massages while attendingcompetitions or training camps when their use increased49to between twice a week to twice a day (although the massages were usually much shorter induration). Acupuncture6treatments were regularly received by five of the athletes and used “asneeded” by two of the athletes. Half of the participants reported that they saw a chiropractoralthough the frequency of their visits varied depending on which phase of the training orcompetition cycle they were in and whether or not they had any injuries or conditions thatnecessitated additional visits. For these six athletes, the number of treatments ranged from oncea month to twice a week. Naturopathy was the fourth most popular form of CAM witheight ofthe women stating that they had worked with a naturopathic practitioner in the recentpast.Compared to other CAM practices, the athletes did not report regular appointments withanaturopath. Rather, after a few visits, the practitioner had provided themwith individualizedprograms (usually nutritional guidelines but occasionally including otherelements) that theathletes continued to follow. Table 3 summarizes the frequencyof the visits as reported by theparticipants.Table 3 — Frequency of Treatments During TrainingPhasesType of Treatment Frequency of Treatments(range)Massage 1to 4 treatments per monthAcupuncture As neededChiropractic 1 to8 treatments per monthNaturopathy2 — 3 treatments totalPhysiotherapy 2—4 treatmentsper month6Although an attempt was made to differentiate between differentforms of acupuncture (for exampletraditional Chinese acupuncture, dry needling, or intramuscularstimulation), in many cases the athletes were notable to categorize the type of treatment they had received orsuspected the practitioner combined forms ofacupuncture — as a result the total reflects all formsof needle therapies used.50In addition to enumerating the types of CAM practitioners used by the athletes, theinterviews also explored different types of treatments or techniques employed by thepractitioners. While this list is far from exhaustive (in many cases the athletes were not abletoname or identify specific techniques), many of the athletes reported having received activerelease treatments (ART), Graston Therapy®, needling, intramuscular stimulation(IMS),cupping, Bowen Treatment, and myofascial release treatments from physicians, physiotherapists,chiropractors, osteopaths, and/or athletic trainers.At the same time, 11 of the athletes reported that they made regular visits toaphysiotherapist. Five of these individuals saw a physiotherapistas needed, while six receivedtreatments once a week or once every two weeks. Finally,all of the participants reported thatthey accessed the services of a physician periodically throughoutthe season.4.3 Why CAM? Athletes Describe the Reasonsfor theirFirst Use of CAM PracticesOne key finding in the analysis of the data wasthat there were four situations orconditions that initially lead the athletesto try a form of treatment within the scope of what theydefined as being CAM. Specifically, the athletes identifiedthe following four reasons: (1) anew injury or condition required treatment; (2) an injuryor condition that was not improvingwith the existing treatment; (3) an awarenessof the popularity of a specific form of treatmentwith their teammates in conjunction with the treatmentbeing made available to them; and (4)curiosity about a new type of therapy and an openness toexperiment with something that had thepotential to improve their performance.514.3.1 Treating a New InjuryWhen faced with a new athletic injury, it was physiotherapy that the athletes most oftenturned to. While physiotherapy is more commonly understood as a biomedical practice and partof the medical model, it has been included in this work because most of the athletes reported thatmany of the physiotherapists they worked with employed various CAM techniques (such asacupuncture) or were the athletes’ primary source of referrals to CAM practitioners. As such, inorder to fully understand how the participants utilized CAM, it is necessary to include somediscussion of physiotherapy.The use of physiotherapy was usually the first time the women had ever soughtprofessional treatment for a sport-related health matter. For example,Caroline described herfirst use of physiotherapy by saying: “I had SI [sacroiliac] joint problems. The firstinjury I canactually recall having was my SI joint slipping a bit, so that was the first, myfirst visit.” Forsome of the athletes, their first physiotherapy treatment (and their first injury) wasfar enough inthe past that they were unable to recall the exact injury or circumstances. Such wasthe case forJody who, when asked about her history with physiotherapy, respondedin the following manner:Oh, I don’t know. I’ve sprained my ankle so many times. It probably started withthat when I was 18. And just trying to help my ankles because we kind of needagood range for my sport. And then because we had access [to practitionersat thetraining centre] I would go for various things that were probably just caused frombeing in my sport my whole life... I don’t remember how often I went. SinceIwas 18 I’ve been going all the time.4.3.2 Trying Something ElseContrary to the trends seen in physiotherapy use, acupunctureand chiropractic treatmentswere not the first treatments the athletes tried when injured. Instead, the athletesreported that52these were practices they turned to in frustration when existing conditions were not improvingdespite regular treatments (which included physiotherapy, and drugs, but also occasionally otherforms of CAM). Two-thirds of the participants reported that it was a physician or aphysiotherapist who was currently treating them who first suggested acupuncture or needling.For example, Kit described an ongoing problem with her Achilles tendon:We couldn’t figure out the problem for quite some time and then we found someexercises and stuff to strengthen it and then that helped out but it took probablyfive months... It was just mostly using the machines. I didn’tget acupuncture forquite some time. It was mostly ultrasound and the stimulation andthe laser...Acupuncture was introduced at physio and he was just like, ‘Do you wantto trythis, it might help out?’... And it was fine. I really actually like it. I could feel itimmediately.These eight athletes all reported that they had heard from other teammatesthat a practitionerassociated with the team practiced acupuncture and needling. Assuch, the athletes wereprepared when the practitioner suggested this manner of treatmentas explained by Kathy:I went in for my back and I had seen her for a whileand I knew she did that stuff.I guess I heard about it from other athletes. She said,‘Do you want me to tryneedling?’ So I said ‘okay.’Only two of the athletes reported specificallyseeking out practitioners specialized inacupuncture. For example, Michelle received treatmentsat a school of acupuncture to treattension related headaches after trying both drugs and chiropracticservices. At the time of theinterviews, Brie had just started seeing a doctor of TCMfrom whom she was receivingacupuncture treatments and cuppingto treat inflamed tendons. Once again, these two athletesindicated that their decisions to seek out acupuncturewas strongly influenced by friends and53teammates who had suggested that acupuncture could be useful in treating their specificconditions.The reasons given for first use of chiropractic treatments were more varied than thosereported for the first use of either physiotherapy or acupuncture. As was the case withacupuncture, three of the women made the decision to explore chiropractic treatments whenother forms of therapy were not successful in treating their conditions. Kathy explained herexperiences:I was having back problems all year and at that time we only traveled with aphysiotherapist and she was working really hard on things and it justwasn’thelping at all. And I was really frustrated and, actually, our massage therapistatthe time was more helpful... but he said that it was a structural thing thathecouldn’t get at. Eventually, at the end of the year he recommendedI go see achiropractor and he recommended this specific chiropractor because he hadworked with him in the past.Rather than performing the treatments themselves(as was the case with acupuncture),practitioners often referred athletes to specific chiropractors.Additionally, one individual wasapproached directly by the team chiropractor when heobserved her receiving other forms oftreatment. Similarly, another athlete beganto receive treatment from the team chiropractorbecause the team physiotherapist was absent.Although the athletes very rarely reported using telephonebooks or directories to findpractitioners (this issue is elaboratedupon later in this document), three athletes who were notnational team members and did not have the sametypes of team networks as the otherparticipants reported finding chiropractorsin this manner. Two athletes sought out chiropracticwhen biomedical options proved ineffective for the treatmentof headaches. Another athlete,54who injured her back while training for a triathion (not her current sport), stated: “He was closeby and I didn’t know anything at that point so I was just like ‘Chiropractors fix backs so I’mgoing to go to them.”4.3.3 “Everybody ‘s Using It”: Trying Out Sport Massage TherapyWhile the first use of physiotherapy, acupuncture, and chiropractic therapy wereassociated with the treatment of injuries, the most frequently cited reason forfirst trying massagetherapy was that other members of the national team actively engagedin the practice. All of thestudy participants had tried massage therapyand 11 were regularly using it at the time ofinterviews, making it the most popular form of CAMused by the athletes in this project. Forone-third of the athletes their first massage coincided with their makingthe national team andhaving access to the team’s practitioners.Kathy stated:I first started using it [massage] the first year I madethe team... And I justbasically started using it because it was free and everyonegot massage. Iwouldn’t have gotten one if I had to pay in the past.And I thought, ‘Well,everybody does this so I’ll try it.’ And I didn’t reallyknow what I was doing...We were at a [training] camp... and they had a massage therapistwith us and itwas hard and I was sore and peoplewere like ‘get a massage.’Audra had a similar experience when she firsttravelled with her team and reported that, “Lastyear in 2007 was probably my first year using it... Whenyou’re on a team you have a massagetherapist travel with you... and you usually get 15,30 minutes after a race every time.”These athletes reported that not only was massage madeavailable to them as members ofa national team but also that they felt there was an expectationthat they would make use of theservice. This was the case for Kit, who toldthe following story:55After I made the team I was allowed to get massage for free. And they [thepractitioners] kind of hunted me down to get a massage— they approached me todo it. I didn’t go to them... I was kind of unaware of what I could get so theykind of approached me and [said] ‘Hey, you could get a massage from us’... I wastold I was given half an hour so I only got massaged half an hour once a week.For the remaining two-thirds of the athletes the use of massage predated their making thenational team, but not their involvement in competitive sport. Often it was while training at aprovincial or varsity level that they first tried massage. This was the case for Brie:It was probably the first summer that I was competing all summer... Second-year[university] I spent a lot of time trying to improve.., and I think I was just trainingso much... and I remember hearing a teammate say something about massage.As is evidenced by the above quotes, the ubiquitous use of massage therapy by teammatesaswell as the ease with which athletes were able to access the service was a key factorin thedecision to try massage for the first time.4.3.4 “I Found a Lot More “. Curiosity About NaturopathyCompared to the other forms of CAM that the athletes tried, the reasons andcircumstances that the athletes reported for first trying naturopathic medicinewere the mostvaried. Four atifietes had been referred by a coach, and the other half had beenreferred byfamily members or friends. However, one common element expressedby all of the athletes wasthat they were already open to the idea of trying out naturopathy andmost had a family memberwho was familiar with the practice. In three cases naturopathy was triedas an attempt to addressan unresolved health matter (difficulties with digestion for two athletesand breathing/bronchial56issues for the third) but in most cases the athletes were unable to identify a specific incident orissue that provided the impetus for the first visit. For example, Audra explained that she wasfirst introduced to naturopathy by a coach who was himself training to become a naturopathicpractitioner. Despite having no defmed reason for first trying naturopathy, she was veryenthusiastic regarding the benefits of the therapy to athletes and said:I knew not a single thing about nutrition before I meet him. Ijust thoughtI was eatinghealthy by not eating chips and candy, you know. But then... I found a lot more...Itkind of gave me clear-cut answers and that was really helpful cause I foundout that I’mextremely allergic to dairy and wheat... So just those things that like they’ll helpmearound races... So those things [are] like extremely helpful. Like I wouldn’t evenbenearly the same [athlete] with eating those foods, that’s how serious itis...In addition to nutritional advice, Audra also valued the adviceshe received regarding the use ofvitamins and supplements and stated, “I’ll bring my blood resultsto her and she’ll look at themand say, ‘Okay, your B12 is low.., take this.’ She’ll givea brand recommendation ‘cause youknow not all brands are [a] 100 percent clean.” Thiswas echoed by several of the athletesincluding Michelle who reported that she initially sawa naturopath for dietary advice but wasnow going for other treatments that included acupuncture,herbal supplements, and guidedrelaxation sessions:I would like to go and see her right now actually becauseI’m feeling a little bit drainedand I think.., she shoots me full of [vitamin] B12...We’re going once a week for that...just with the energy thing and there’s somethingthat is probably lacking and I’m notgetting enough so we’re going to try it and see if it helpsat all.574.3.5 Trusting the PractitionerWhile all of the participants were regularly seeing at least one CAM practitioner, and hadtried at least two different types of CAM practitioners and several different types of CAMmodalities, not all of the athletes described themselves as being equally open to exploring newforms of health practices. Approximately one-third of the participants said that it was becausethey trusted the practitioner they were working with that they were willing to try newtypes oftherapy even when they did not fully understand what was being proposed, or endorse theunderlying theory behind the treatment. For example, one group of participants spokeof apractitioner associated with their team that was hired as an athletic therapist but hadadditionaltraining in osteopathy and craniosacral therapy. While the athletes were unfamiliarwith the fullrange of her practices, they all reportedthat she had included energy-based treatments in theirsessions and that they were willing to permit her todo so because of their existing relationship.Caroline described it in the following manner:She’s trained in osteopathy as well so she woulddo some like, crazy energy stuffwhere she like held your head, worked with your dura and loosened upyourdiaphragm... sort of energy manipulation... I thought itwas pretty cool. Youknow I, at first, was a little bit wary. I’m like ‘What’sgoing on here?’ but youknow, I always felt better so I let her do her thing and boughtinto it and it seemedto work for me.Claire, who had tried at least 12 different types of practitionersand many more types oftreatments and modalities), explainedthat it was her trust in the advice offered by thepractitioners she worked with that lead her to explorenew options. When asked if there was anyform of CAM someone had recommendedto her that she was not comfortable trying she replied:58No, because my trust level is through the roof. Some of these people I’ve beenwith for years... There’s some osteopaths around the corner here— they’re new intown so my physio goes in there and susses it out [and tells me] ‘It might besomething you want to think about.’ Or myofascial [treatments] was somethingnew that I never heard of, I didn’t understand. Even for the first few treatments Ididn’t know what we were doing but [the referral] comes from this panel ofexperts. If they recommend something to me, I’m absolutely willing to try it.4.3.6 Reservations About ChiropracticAlthough ten of the participants had tried chiropractic treatments at some point in theirathletic careers, it was the one form of CAM that evoked the most concern. Indeed, sevenathletes expressed reservations about the risks and/or benefits of the practice.The two athleteswho had not tried chiropractic before said that they were uncomfortable with the ideaof“cracking” and concerned about how the frequency with which their teammateswent fortreatments. Nicole explained her concerns this way:The concept is, to me, weird... I have known athletes that have goneand theyswear up and down that it helps. But they also end upgoing back on a semi-regular basis. And I’m thinking... ‘If you have to keepgoing back to somethinglike that, there’s something not right.’... You know that you sawimprovementthen it declines and then you need to go back againand it declines. So I thinkthere’s probably else at play as opposed to that yourskeleton is just out ofalignment.Of the athletes who were seeing a chiropractor, a few also expressedconcerns about thefrequency of their own visits and the possible “addictiveness”of the treatments. For example,Kit described how she felt she had to rationher chiropractic treatments:I haven’t used chiro since World Cup. And it’s good,I really like chiro. I getaddicted to it almost because, I don’t know, youfeel so good after you get yourback cracked or your neck and everything... You justfeel like your body just59works properly... My lower back would always kind of be tweaked and stuff so Iwould go to see chiro probably once a week [during competition season] to go getthat fixed... It would always seem to reoccur. So maybe that’s why it wasaddictive, because I had to always go back? So I guess it was never like a problemsolved completely.Two athletes who used chiropractic services specified thatthey did so with some conditions.Jody would go for Graston® treatments7but told the practitioner that she wasnot comfortablewith other manipulations. Kathy found the frequent visitsrecommended by chiropractors to beexcessive:There’s some chiropractors that will tell people to come oncea week orsomething and I also just don’t feel like I need it thatoften. I haven’t seen thechiropractor now for like three weeks... and my backis perfectly fine. And Iprobably won’t see him again for another probablythree weeks and then I mightneed to... I go when I feel like I need it.4.3.7 Willingness to Explore New TreatmentsDespite some of the participants’ expressedconcerns about chiropractic manipulations,the athletes generally described themselves as beingvery open to trying new types of therapiesand curious about what other athletes wereusing. Their attitudes towards CAM rangedfromcurious yet cautious to very open and eagerto experience new treatments. Audra was oneof twoathletes who had not tried chiropractic andwas uncomfortable with the idea although shehadthis to say:7During Graston Technique® practitioners pull a metal instrumentover the skin and soft tissue of theathletes to break down scar tissue.60I don’t know if I’m really agreeing with cracking that much... just like from thewhole natural point of view of things I don’t think cracking sounds like somethingyour body really wants. So it’s something I’ll resort to if they, you know, canshow me why it will help or something... Because who knows? Maybe they’llknow something about how to fix this stupid bone in my ankle that never stays inplace... like I’ve heard of one recommended here so I might give her a try.... Iprobably will.Audra’ s comments illustrated that athletes were reluctant to rule out any type of treatment iftheythought it could benefit them. As Brie explained there is “the tendency to see what’sout thereand what’s going to make me go faster. So if there’s new techniques that are beingused,everybody wants to see how they’re working and if it makesthem feel better.” Participants whohad not tried as many types of treatments as others oftenstated that they were satisfied with thetreatments they were receiving already and did not feel they hadreason to look for anything new.Caroline reported that she was “happy with what I have... I’vekind of found my magic potionand so I’ll just stick with that.”4.3.8 The Role ofFamily Members in Influencing AttitudesTowards CAMWhile the participants were unanimous in statingthat the main source of their referrals topractitioners was other athletes, one-quarterof the athletes attributed their openness to CAM totheir upbringing and their parents’ attitudes.Claire described her mother’s woridview as “beliefsthat are her own amalgamation of whatever she wantsto believe” and described herself and hersiblings as growing up with a “spiritual sideto our brain.” It was Claire’s opinion that beingopen to new treatments was a desirable quality in a high-performanceathlete:People will talk to me about the physiology of my bodyand they’ll talk to meabout energy or they’ll say energy or chi or whateveryou want to call it. Both my61myofascial release therapist and my physiotherapist use different things—I love it.I think that’s so cool that their minds are open and my mind is open... I would saythere’s so many different ways to accomplish things and I’m glad that I havepeople who within themselves have everything integrated... There’s science andthere’s energy flow and these things are not separate.Kathy also credited her parents with introducing her to some forms of CAM and teachingher to be open to different practices. However she also stated that although her general attitudetowards CAM was likely due to her parents, it was in her role as an athlete that she had theopportunity to learn about and try new therapies. As she explained it:I think I’d probably be open anyways just ‘cause of my parents... I probably seemore things just because of the people I that talk to from being an athlete and theteam, and things kind of getting passed down through the team and stuff. Andthen just ‘cause I have more injures and issues from being an athlete.Hilary, who was the other participant who had tried a dozen different forms of CAM, alsodescribed her family as having a holistic orientation towards health and an interestin CAM. Sheagreed that it was her career as a high-performance athlete that promptedmost of her visits toCAM practitioners even though she felt she had always hadan open attitude towards lessmainstream practices:I would say that as an athlete I’ve tried more things than the typicalperson...Because we rely on our bodies to perform and we are so body-aware interms ofour sport... we know what it is supposed to feel like or what it feels liketo be100%. So when that’s not there you know that something’s wrong and there’s gotto be a way to fix it.62These athletes suggested that their families’ attitudes factored into their general perceptions ofCAM but it was their athletic careers that provided the impetus and opportunity to explore newtherapies.4.4 Accessing CAM: How Access to CAM Services is Facilitated and RestrictedWhile the previous section examined the first use of CAM therapies and general attitudestowards CAM, this section investigates the factors that encouraged or discouraged the ongoingutilization of CAM. Of central importance to the discussion is an understanding of theissuesthat assisted or inhibited the athlete’s ability to access various forms of treatment. Financialcosts, social capital, and social networks all influenced how the negotiated the structures of thesport organization to which they belonged.4.4.] Being Carded: Stipends, Health Insurance, and Team PractitionersAs previously explained, carded athletes receive monthly stipends fromSport Canada andthey are also eligible for extended health care coverage through programs suchas the CanadianAthlete Insurance Program (CAP) or other insurance policies obtainedby their national sportsorganization. Additionally, practitioners (both CAM and biomedical) oftenoffer discounts tocarded athletes especially if their clinics are located near or in national teamtraining centres.Many national teams with large concentrations of athletes at one facilitychoose to employpractitioners either on salary or on contract, and carding is often, if not always,used as acriterion for determining who is eligible to book appointments withthese team practitioners.Because of the high cost associated with many CAM treatments, all of theparticipantsdiscussed how being carded affected their use of services and all reportedthat their CAM use63had increased when they achieved carded status. Audra explained how carding influenced heruse of treatments:This is the first year I’ve really taken advantage of it— well second year I guess— thatI’ve had insurance through CAIP. So that’s the main.., yeah without CAIP I wouldn’t beprobably going to any of them... If I had a lot of money then [the treatments are]probably worth it but Ijust don’t and I probably spend most of my money on food...Yeah, cost is huge...When discussing how funding influences CAM use, it is crucialto remember that most ofthe athletes reported having multiple appointmentsa week and that even when the treatmentswere being subsidized or provided at a reduced cost, the totalcost was often quite substantial.Audra elaborated on her previous comments as she stated:We get $40 a session covered so most of the placeshere I get referred to from athletes—generally you go to them because they’ll do special things for us.Like they’ll either giveus a rate of $40 an hour or $40 per session or they’ll tryand cut it onto two receipts forus... Even if you go for a $60 massage you’re still paying$20 a time and it sounds likenot much but it really is when you’re not making verymuch money.Most of the athletes were unable to provide a total of how muchthey had spent annuallyon treatments given the complexity of funding(e.g. some treatments by team practitioners werefree, some costs were reimbursed, and some treatmentswere received at a reduced cost). At thetime of the interviews Michelle hadjust finished totalling her expenditures on massagefor 2007,a year in which she was not carded and, therefore, received no reimbursement.In one year shehad spent $1,900 on massage alone which at$56 an appointment (the discounted rate for cardedathletes) translated into 34 massages a year, which wasfar fewer than the weekly or twice64weekly appointments reported by other participants. Kristina estimated that the associated costfor all of the treatments she had received in the 12 months leading up to the 2008 Olympicselections was between $3,000 and $4,000, although much of that would eventually be recoveredthrough CAIP. According to Hilary, her coach had recently increased their training sessionsfrom six days a week to seven and Hilary had seen a dramatic increase in her use of practitionersas a result. She explained that she typically submitted receipts every three months and that thelast bundle she had submitted totalled nearly $700, almost double her usual expenditure. Shealso reported that because CAIP did not cover the entire cost of the treatments she hadtoreconsider her use:Actually for the first time, in the past few months there has been a hesitancy...I’ve started keeping track of budget on everything and there’s a lot going into myhealth. Paying $20 each week adds up obviously... The biggest thing for mepersonally as an athlete is not being injured.., if it’s not crucial, there’s timeswhen I’ll call and cancel.Additionally, some carded athletes reported having to pay for service first and thenwait for theclaims to be processed, which caused them financial stress and limited theiruse of services.Other athletes charged visits to credit cards or borrowed money from parentsto cover the costuntil they were reimbursed.At the same time, athletes who lost their carding described trying to access servicesasdifficult and stressful. Three participants reported that they had at one time losttheir cards—one while the interviews were in progress. Carding is awardedon an annual basis and althoughthe criteria for selection are sport specific and elaborate, one key determinantis the athlete’ssuccess at international competitions in the past year. Failuresto achieve certain results or the65onset of an injury or an illness are the most common reasons for losing carding. For example,when Jody suffered a series of illnesses and minor injuries during a single season, she wasunable to compete overseas at international events and this eventually resulted in her carding notbeing renewed. Caroline made the decision to switch events and classifications within her sportand lost her carding during the process because she had yet to produce any results in the newevent but was no longer competing in her former event. At the time of the first interview,Nicole’s status as a carded athlete was being reviewed. Although she had performedwell atinternational events, her final competition at the season fellshort of the carding criteria. Here iswhat she had to say about her use of massage therapy duringthis waiting period:I’m not training right now because it is my monthdown. I don’t know if I’mcarded or not anymore. So it’s like if I’m not carded,I need to save that moneyfor when I’m training as opposed to when I’m off...I can’t afford to be paying forit now and find out after that I’m not carded... I’d ratherbe missing massage now[rather] than leading up to a major competition.Losing carding had serious implications on theathletes’ use of services both in terms ofbeing able to pay for treatments and in termsof having access to team provided practitioners.For example, as a carded athlete Jody had a weeklyregimen of massage therapy, chiropractic,and physiotherapy, but when she lost her card heruse decreased dramatically:I went to a physio once at the beginning of the seasonwhen I started trainingagain [after the injury]. You know,to see where I was at and what might needstrengthening and then Ijust did my exercises andstuff. And I saw a massagetherapist a couple times when my adductor tightenedup. I mean I paid for it allso I went a minimal amount.66Athletes attempted various strategies when cost became an issue (either prior to beingcarded or when carding was not renewed) and prevented them from seeing practitioners asfrequently as they would have desired. Several reported that they tried to stretch out the periodof time between appointments, as was the case with Michelle:When I moved out here everything was self-funded... I tried to go without but I[was] shooting myself in the foot... My body would get worse and worse and Imight as well not be [training]. So it is pretty important to take care of my body.And it was worth the money... You try to stretch it out and only go like once amonth. But then you end up the last week you’re in pain. And it’s just not worthit. You might as well just spend the money and go as often as you need to.As the above quotation evidences, this strategy was not seen to be entirely successfulby theathletes and ultimately they found the money for treatments.Another method for reducing the cost associated with CAM was to ask thepractitionersfor extra exercises or techniques that the athletes could perform ontheir own. For example,when she lost her carding, Jody reported that she practicedyoga regularly since most of hertreatments were to increase strength and mobility in her injuredankle joint. Hilary explainedthat when she and her teammates were denied access to team practitioners(an event that isdiscussed later in this document) they ‘treated’ themselves andeach other:We treated ourselves. I’m not joking... I’ve had a massage therapistoffer to holda little workshop to show us some basic techniques so that wecan do thatproperly. So we’ve treated ourselves. I treat myself. Like I havemy little ballsthat I roll on, roll onto my back to release different areas. When I go tothe physioI often ask ‘Is there any way I can do this myself?’... Andso [my physiotherapist]has been really good in sort of instructing me.674.4.2 Social Capital and Accessing Team PractitionersIn addition to carding and other forms of financial support, the athletes also spoke of theways in which forms of “social capital” (Bourdieu, 1991,p.372) impacted their ability (or thatof their teammates) to access provider-delivered CAM. In a sport (as in any social setting) thereare many factors that can lead to hierarchal relationships between group members and the statusof the group member is determined by a variety of factors that constitute their social capital(Bourdieu, 1991). The participants of this project referred to age, years on the team, athleticsuccesses, and the position of their team or training group in relation to other groups within theassociation as factors that influenced their access to services.On the one end of the spectrum, was Claire who had achieved success at the highest levelin her sport, winning multiple medals at international events including worldcups, worldchampionships, and the Olympics and was the least likely to report barriersto accessing services.When asked if she had ever had her use of services limited she replied:No because even as a struggling athlete. Ijust knew that mybody matters above all elseand I was quite aggressive at finding sponsors... I never wantedto compromise... I wasjust really lucky with my sponsors... I’ve never been limitedby cost.Not only was she never limited by cost but she had also taken controlof her situation to adegree not seen with any of the other participants. She discussed howas part of the 2010 Ownthe Podium project, a concept named Performance EnhancementTeams (PET) was introduced(two other participants in different sports also used this term).PET, as described by the athletes,was meant to be a team of practitioners, coaches, physiologists,psychologists, and others whoworked together in an integrated model to provide serviceto the athletes. However, at least for68this athlete, the promise of PET did not deliver. In her words, “There are so many egos that arecompletely incapable of following through and actually initiating and actually communicating.”This is how she described her response to the situation:As an athlete who wants the best Ijust decided that I was going to make ithappen. I started calling meetings... And I wanted psychology, physio, coach,strength coach, altogether... like if everyone’s on the same page I can justimprove so much faster. . . Instead of like ‘Wow, she really wants to do thingswell’ it was just perceived in a different way. Like ‘This athlete is reallydemanding.’... I didn’t waste a lot of their time on it but [it] definitely shows thatdisconnect between like listening to an athlete and thinking you know what anathlete needs without asking.This was an example of how an athlete was able to draw upon her athletic successes to demandthe types of services she believed necessary to her continued performance. She reported:Overall things work for me and I don’t get too much opposition convincingpeople of my vision and where it’s going and why it’s important andgetting thesupport I need. I’m really good at drawing on the resources and drawingeverything out of them I can.In addition to pressuring team staff to adopt a more integratedapproach, she was alsoproactive in finding her own therapists when she felt the practitionersprovided by herassociation were not meeting her needs. Instead of the assignedphysiotherapist, she was seeinganother practitioner who offered 90 minutes appointments and onlytreated one athlete at a time(many physiotherapists treat several clients at the same time) and she was alsousing a CAMtherapist for a variety of treatments including myofascial release— a treatmentthat costs $175 anhour and that her association agreed to pay for directly.69One group of teammates interviewed in the project found themselves in quite a differentsituation. While they were carded athletes training at a national training centre with a nationalteam coach, they were not on the shortlist of athletes being considered for the upcomingOlympics. According to these athletes, as a consequence of not making the cut for the Olympics,their access to services was severely restricted and services that had been available to them inprevious years were suddenly withdrawn. The most frequently cited consequence of not beingan Olympic camp athlete was that they were no longer permitted to see the practitioners hired bytheir national organization who were working onsite at the training centre. Specifically, whilethey were still carded and had CAIP, they no longer had the ability to drop by the treatment roombefore or after practice to see the team’s chiropractor, physiotherapist, athletic therapist, andpsychiatrist. The women all agreed that the lack of access to practitioners wasnot onlyinconvenient, it was also insulting and symptomatic of the lowesteem in which their programwas held within the organization. They also expressed frustrationthat the same standards hadnot been applied to the men’s team— not only was the men’sOlympic camp list considerablylonger than the women’s (corresponding to the greater numberof events in the sport open to menat the Games) but they also frequently reported seeingmale athletes who were not beingconsidered for Olympic events using the services.They were animated and passionate in theirdescription of what had occurred and as one athleteexplained:We were allowed to see ... the athletic therapist, the chiropractor,they physio, thedoctor... last year it was a free-for-all. You came, youwaited in line witheveryone else and got to see them. Somehow, though, itwas decided this fall thatthat those practitioners were overworked and so theysaid only the Olympic campinvitees are allowed to come up here and you have to signup... The chiropractorand the physio said ‘If when I’m here... it’s notbusy I will work you guys in. It’sokay, it’s no problem, I don’t mind doing this.’So the next week a couple of us70went to go do that and we were told, ‘No, we’re not allowed to touch you.’... butthe frustrating part is there were still men that aren’t on the Olympic camp list thatwould go see those practitioners but we weren’t allowed to go see them.In the second interview, the participant returned to the subject, further explaining that it was theway in which the access to the services was terminated that was the most infuriating:Having it pulled away from you makes you feel like crap. Like ‘What did I dowrong? I’ve gotten faster. I’ve gotten a medal under my belt. Why are youpulling this away from me? I don’t understand. And how do you expect us to getbetter when we don’t have access to this like everybody else does.’ It almostmakes you feel like ‘Okay, we’re not important and you really don’t care how weperform.’During the course of this project, Caroline was put in an unusual situation. Afterhavingbeen told she was not on the Olympic camp list in November, the national associationreconsidered in the spring and gave her and one other woman a second opportunityto trial forthe Olympic team. As a result, at the timeof the first interview she was not eligible for theservices provided to Olympic camp members but shortlybefore the second interview she wastold that she could start using them again. Despite ultimatelygaining access to the therapists, shewas still very critical of the way in which the decisionswere made saying that, “It was too littletoo late.” She continued to sympathize withher teammates who were not up for reclassificationas she asserted the following:Our status has changed from just a training centreathlete to an athlete who is nowbeing tried for a higher calibre position. And I think that’s unfortunatebecause Idon’t think I now deserve that anymore than anothergirl who is in my traininggroup... I understand... the therapists are really busybut if you’re trying to run anational team— the importance of therapy— you can’texaggerate it. It is socrucial and until I had access to this therapist I wasputting out... probably about a71$150 a week on a massage and chiro and I’m not surprised if these girls [those noteligible for team services] are paying the same thing... I think that if you come toa training camp, if you come to a national centre and you’re training at that leveland you’re expected to train at that level and be at every workout, then in return...I think it’s the organization’s responsibility to say ‘We will provide you withsomeone who is going to keep your body in order because we are asking you tocome out here.’She also pointed out the dilemma faced by athletes on the verge of making a team— namely thatthey faced the same demands as the top ranked athletes and yet they are expected to perfomiwith far less support. She used her own situation as an example:If I’ve been training all year and you [the national association] didn’tthink inNovember I was worthy of being named an Olympic athlete, suddenlyI’m goingto Beijing in August and I’ve missed a year of treatment because youneverforesaw in November what I was capable of. So that’s really tough...I meanthat’s the reason why everybody should get treatment, right? Becauseyou neverknow what someone could be capable of if they’re really taken careof from theget go.Participants in all of the sports reported some variationon the theme of an athlete’s statuson the team impacting their use of services. While technicallyall carded national team membershad access to practitioners who worked at the national trainingcentres or who travelled with theteam, the practitioners were in high demand andpriority was given to certain athletes on theteam. As the youngest and least experienced member ofthe team this past year, Kit was veryaware of issues of seniority especially asit related to her use of massage therapy immediatelybefore racing or between racesat the world cup events:It [pre-race massage] didn’t happen very consistentlybecause there’s lots ofdifferent [athletes] and they are more prioritized becauseI was like first year onthe team... I felt like I should let them go ahead of me...I was new to72everything... I was a follower a little bit throughout the World Cup, just likelearning and everything. And people would call me the ‘rookie,’ right? It waskind of ajoke.According to Tanya, while the practitioners working with her team were givena list of whichathletes to prioritize and would be sure to book those appointments first, the athletes themselveswere willing to assist a teammate as needed:There’s like a priority list so people that qualified for the Olympics lastyear arefirst, and then it’s people who went to Worlds, and then it’s people who weresenior carded and d-cards... [The massage therapist] would take hislist to thequalified athletes and they get first dibs to sign up. And then after that he justleaves it out and you come and sign up whenever you want. But ifyou’re belowsomebody, the people above you can bump you... It doesn’t happen veryoften.And I mean we’re all friends so you can go up to somebody and say‘Look, Iknow you had a massage four days in a row, can you just giveme your massagetoday?’ And usually they’ll go, ‘Yeah, it’s fine.’In this way, Kit, like the other athletes in my sample, normalizedthe hierarchal relationshipbetween athletes on the same team. In another instance, Claireexplained that in order for arecovery massage post competition to be most effective, timingwas critical. When asked how itwas determined which athletes were given the most desirable time slotsshe answered:The priority is on those who are racing the most.Second priority are people whoare racing the best... It is definitely very equitable.It’s just that, you know, ‘Youwere second today and you were45thWe are going to take care of the guy whois second first and help him recover because he’sperforming.’While most of the women described barriers to accessing serviceson an organizationallevel, one athlete had a particularly distressing exampleof an individual coach restricting heraccess. When the project started she was working witha national team but was not happy with73the current training environment and was considering switching to another program. However,one reason she was reluctant to make the change was that her current coach had some controlover discretionary funds that were used to provide additional health services not normallycovered by the team’s insurance. During the second interview, she described the decision tochange programs and her coach’s reaction:Remember I told you they were paying for nutrition and psychology and stuff likethat...I knew he was going to cut it. And so he did. It was like his way of getting backat me...I guess it’s up to his discretion to use it because that’s his job... At the meeting when Iwas telling him I wasn’t going to be coached by him anymore... He’s just trying tolikego off and tell me how I’m such a difficult athlete... So it’s just all this really immatureshooting things at me and I’m just like sitting there like ‘Okay, can I leavenow?... Andthen during the meeting he’s like ‘Oh, and you know thoseextra available funds?’... Iknew he would probably try and pull them away. But he’s like ‘You knowthose aren’tgoing to be available when you get back— not because of this meeting.’Like ‘Oh yeah.’This athlete was stressed by the situation and felt that thecoach had inappropriately used accessto practitioners as a way of trying to influence herdecision to work with him.4.5 The Right Personfor the Job: Athletes Discuss Their Relationshipswith PractitionersOnce the athlete had the financial and social resourcesnecessary to access services andhad made the decision as to what types of treatments topursue, the next stage was finding apractitioner. This section will explore the role of referrals fromwithin the sportsnet, the ways inwhich practitioners worked as teams, the differenttypes of relationships athletes had withpractitioners, and issues of trust and communication inthe therapeutic encounter.744.5.1 Sources ofReferralsAs is apparent from much of the previous discussion of how athletes started using CAMor accessed services, the participants who trained at training centres with teams that employedpractitioners rarely spent time searching for therapists and even reported it was occasionally thetherapists who found them and suggested treatment. Only if a team practitioner wasunavailable— for example, travelling with another team— did they even consider lookingoutside their sport organization for a practitioner and when this occurred they usually asked theteam practitioner to recommend someone.The athletes training in less structured environments or on team that did not employpractitioners reported two main sources of information when seeking out a new practitioner. Thefirst source of information was other athletes (most commonly theirteammates but occasionallyretired athletes or athletes from other teams who trained in the samefacility) and the second waspractitioners they were already working with. A couple of the athletesreported that they hadtried practitioners they found in the phonebook, but were not satisfiedwith the treatments thatthey had received. Consequently, these athletes had begun to relyeven more heavily on referralsfrom within their sportsnet. For example, Audra said:I don’t feel like wasting my time looking in the phonebook... I’m not going to gosomewhere just ‘cause it says ‘athletic therapist.’ Like thatmeans nothing tome... I probably will just go see somebody if they’re recommendedto me bysomebody who I trust. So generally athletes because mostof them have hadinjuries at some point in their life.., mostly it wouldbe teammates and people Itrain with.Michelle agreed, and when asked why she was more likelyto take referrals from teammates thanfrom anyone else replied, “Well just ‘cause we usually havethe same problems and they75recommend someone that has fixed them.” In addition to referrals from teammates, practitionerswere considered to be a reliable source of information and often directed the participantsto otherpractitioners who worked in the same clinic or with whom they had workedin the past. Michelleexpanded on her response and said:Besides teammates... a lot of it is one practitioner recommendinganother one.Like the athletic therapist recommending my naturopathor like one physio istelling you to go see a chiropractor in the office or the massage therapists.That’spretty much it. It’s a small little integrated world for getting treatment.4.5.2 “A Couple of Things Working Together”:Practitioners as Team PlayersIn addition to directing the participants to other practitioners,the athletes also revealedthat it was highly desirable to find practitionerswho were willing to collaborate with each other.When Kristina was suffering from a debilitatingknee injury, she credited the combined abilitiesof several therapists for enabling her to return to full-timetraining and competition:I don’t think you can say one in particular[was the most beneficial]. I think, forme, the use of all of them and just taking what I couldfrom them all was the mostbeneficial because I was seeing one ata time, and two at a time and it wasn’t untilI kind of got everybody involved andthey were all talking and communicating...and working together. That’s when we could figureout a good program for me toget the injury to get better.Jody’s team employed massage therapists, physiotherapists,chiropractors, and strengthcoaches and she described the relationshipbetween the practitioners in this way:They’re integrated and work together. For example,if the massage therapistknows I see a chiropractor and he’ll be like ‘Okay, tellhim this.’ Or ‘What daydid you see them?’... So I think they actually workpretty well together. And theykind of have an understanding. Well I think the physioand massage therapist are76pretty good at having an understanding that you probably need a few things morethan just what they offer. A couple of things working together.While therapists who were able and willing to work collaboratively with practitioners in otherfields were seen as desirable, several of the athletes noted that the interactions between thedifferent practitioners were not always collegial. Tensions between physiotherapists andchiropractors were particularly erident. Michelle stated that, “I’ve had a chiropractor...talkabout physio. That he didn’t think it was very beneficial and they were a rip-off,blah, blah,blah. And then there’s also the physios that feel chiropractors shouldn’t be coveredunder healthcare.” In keeping with the theme that the ideal was for practitioners to work inconcert, shepurposely sought out those individuals who were able to worktogether and contended that it wasa “bad practitioner” who could not acknowledge the value in another’s treatment.However, while the athletes thought it was ideal if the practitioners were willingto worktogether, it was not perceived to be essential. Rather, the participants were comfortablemixingtreatments that they felt were complementary withor without the support of the therapists. Forexample, Kit explained that becauseshe was aware of the tensions between practitioners she didtell her chiropractor about the physiotherapy appointmentsbut did not tell the physiotherapistabout the chiropractic treatments. She felt the chiropractorwould not criticize her decision touse both and thought it was necessary to share the information withat least one practitioner sothat he did not give a treatment that wouldbe counterproductive to what she had alreadyreceived— for example, both therapists used acupuncturein their practice and she wanted toavoid two consecutive acupuncture sessions. As Kit describedit:77I think it’s just whatever works best for the athlete. Cause if they like try it onceand they saw that it was starting to work, obviously they’re going to continue it.And even though I think the physio and chiro are two different practices, they canwork well with each other... I don’t know if they realize it or not. Obviously itworks for a bunch of people, combining it. And I think if it heals or ifit helps theathlete with whatever then they’re going to continue with it.4.5.3 Practitioners as Collaborators and ConfidantsIn addition to valuing a practitioner’s ability to work with others, theathletes alsodescribed two types of relationship that they wantedto establish with their practitioners: thepractitioner-as-confidant and the practitioner-as-collaborator.To begin, the practitioner-as-confidant was an individual to whom the athlete couldconfide about her experiences of stress orother difficulties associated with participation in her sport.Five of the participants reported thatbeing able to talk to a practitioner or havinga practitioner who was a good listener wereimportant criteria by which they selected therapists. Hilarydefined CAM practitioners as thosepractitioners who were ready to “listen holistically”:They’re listening to me list off theingredients of a recipe but they’re notnecessarily saying ‘This is purely comprising thisdisorder.’ They’re... taking allthe individual components and thinkingabout each one individually andalsotying them all together. So reallyjust listening with the intent of findingout aroot problem.Hilary also stated that as a result ofthe practitioner’s willingness to spend moretime listening toher, she was likely to share more informationwith a CAM practitioner than with an allopathicpractitioner.78For Nicole it was important to find a female practitioner since she felt that she felt betterable to communicate with a woman and that communication was an important component of thetreatment process. She said:I want to be able to say and feel comfortable saying, ‘This is really sore, this is why it’ssore, and can we do something about it?’... I always hate feeling.., awkward aroundthem... So I guess if you can’t communicate effectively with them then it’s hard to get tothat point where you can say, you know, where you can be totally open... You can bemore open communication-wise and not feel like anybody is judging you... It’s just niceto feel that comfortable with someone that you can just let loose and know that they’ll dothe best job they can to figure it out for you.The practitioner-as-collaborator was similar to the practitioner-as-confidantbut had anadded element. In addition to being a good listener, the practitioner-as-collaboratorwassomeone who was perceived to be fully engaged in thetreatment process and committed tohelping the athlete achieve her goals. Two-thirdsof the athletes referred to the collaborativenature of their relationship with practitioners. Claire describedher relationship with a massagetherapist that she had worked with for many years in thisway:I really like someone who matches my intensity level...I started babysitting forher and then we started trading massage and babysitting...It was a great set-up...And there also was kind of a really personal connection.Like this space that Iwas in where she was healing my body andalso hearing me out... I think all ofmy practitioners that I rely on are people that genuinelycare about me. I thinkthat’s a quality to seek-out... If you canjust feel that extra caring that helps you toactually improve. You’re not just beingstamped and passed along. It’s really anexperience were you’re both dedicated to improvingsomething.A key feature of the collaborative relationshipwas the willingness by practitioners to gobeyond their job description and take an interestin the athlete and their team. For example, one79group of participants reported some practitioners had asked the coach if they could attendpractices to gain knowledge of the particular movements in the sport and the demands on theathletes’ bodies. Other practitioners offered value-added services as was the case with one of thechiropractors associated with one of teams:He’s very, very good at what he does... He’s organized a session with us nextweek to do strengthening. So not only does he go in and do the treatment but he’salso offered to keep us out of there. Keep us healthy so that we don’t need to seehim quite as much.Not all of the additional services offered by the practitioners were directly related to their area ofspecialty. For example, athletes from another sport reported that team practitioners would makean effort to cheer them on during races or would operate the video camera to film racesillustrating that the role they played for these athletes was multifaceted. Jody described thepractitioners as if they were members of the team:You know you have all these people behind you and helping you out and it’s justa good feel... They just want to make you as healthy and as strong as possible...It’s like they want you to do well, to succeed. And obviously if we do well it doesreflect on them... The guys on our team are always trying to watch theraceswhen they can... They’re pretty good... in that way to create that support system.Practitioners also helped the athletes negotiate issues related to fundingand carding. Severalathletes reported that practitioners offered special rates, broke receipts down so that they werecovered by insurance, or provided service even though the athlete was notstrictly eligible fortreatments by team staff80One final variation on the theme of a collaborative relationship was the way in whichCAM practitioners were becomingly increasingly familiar with sport injuries and more generallywith sport settings. To set the scene, Jody was one athlete who had the opportunity to try severalmassage therapists and provide feedback when her association was hiring a new practitioner andshe described the process as follows:Everyone was very different... You can tell the difference between someone who reallylike works with athletes and [someone who] just kind of works at their clinic... I don’tknow, an average massage therapist... You can just tell.While this quote does not immediately seem relevant to the discussion of practitioners-as-collaborators, when the athletes were asked to more broadly theorize on the relationship betweenCAM and sport, they all referenced the growing popularity of CAM treatmentswithin theirsports organizations and a couple women asserted that the relationship wentboth ways. That isto say, even as athletic populations were increasingly adoptingCAM practices, CAMpractitioners were also modifying their practices in orderto delivered more sport specifictreatments. As Tanya explained:I think 10 years ago if somebody said they were going toa naturopath, peoplewould have thought they were nuts... Same with acupuncture—that was just wayout in left field... And now whether it’s just athletes are learningmore about itbut it seems like the practices are getting more and more sport related...Ten yearsago when you thought of massage you [thought of] aspa with nice candles... butnow you talk about myofascial release and deep massageand that if you have adeep massage you can’t sprint for two days... So whether it’sjust athletes aregetting more educated about it or whether the scienceof these professions hasactually expanded that much that it now includes all thosedifferent things, I don’tknow.81This quote clearly indicates that, as is the case with a truly collaborative relationship, all theinvolved parties were impacted by the experience.4.5.4 “IKnow When INeed a Massage”: Practitioners as GatekeepersIn contrast to the collaborative relationship, physicians were frequently described asgatekeepers when it came to accessing treatments. While athletes on teams with dedicatedpractitioners on salary or contract could access chiropractors, massagetherapists,physiotherapists, and others without a referral, not all national teamsfollowed this model. Forathletes on teams without practitioners, they usually had to payup front for service and thensubmit receipts either to the national sports organization orto their insurer. Many of theparticipants further reported than in order fortheir appointments to be covered they wererequired to have a prescription from a physicianbefore they received treatment from anotherpractitioner. As a result, athletes on theseteams stated that their use of physician services wasmost often because they were seeking referrals.This was a source of frustration as conveyed byNicole:If I want to go and get a massage, or I wantto go to physio, I have to go to mydoctor first, get a referral, then go to the practitionerand then I can submit half ofwhat it usually costs to CAIP. It’s an annoyingstep that I have to go to my GP...Because I am an athlete I know when I needa massage and I know when I need togo to physio... If I get injured on a Fridayand I want to go in and see a physioSaturday or Sunday... if I want to submitthat I either have to get my doctor to getme a retroactive one [prescription]which sometimes they don’t want to do.This was also an issue raised by an athletewho was among the last group tobe carded thisyear— she had been short listed for cardingbut did not receive confirmation of it untila few82months after her teammates had been notified. During this waiting period she had no healthcoverage and paid for health services directly. She explained:I just started getting my coverage in January... but I didn’t find out aboutit untillike March or April... So then I had to go see if I could get a prescriptionbackdated. And our doctor had morals apparently that day. And she wouldn’t backdate my prescription.It was experiences like this one that shaped Michelle’s opinion of physiciansand lead her toconsider how she used their services:You’d go to them for CAIP forms and for referrals togo to massage and physio.Cause they’re the ones that hold that key. But I don’t actually go thereseekingany advice from them. Cause I think being an athleteyou know what’s wrongwith your body and you don’t go in and say ‘Idon’t know what’s happening, myarm hurts.’ You go in and say ‘I have tendinitis, I knowI have tendinitis.’4.5.5 Communicating With PractitionersThe comments made by the womenabout knowing their own bodies’ needs and notfeeling that they required a practitioner to tellthem when to go for treatment were part of abroader theme in the data. The largemajority of the participants reported that the mannerinwhich they communicated their needs topractitioners of all types had changed over the courseoftheir athletic careers. For example, Claire explainedthat she had had a very “scattered”approach as a young athletesuch that she had tried every type of practitioner availablebefore“streamlining” her use. Kit described howthe team practitioners approached her when theybelieved that she needed treatments ratherthan the other way around. The majorityof theparticipants stated that over time they hadtaken more control of the relationshipsand become83more forthright in requesting specific treatments. They still took advice from practitioners(including trying a new therapy) but they also had a better understanding of what they wanted tobe achieved during the therapeutic encounter and felt comfortable communicating this topractitioners.One example of this was given by Claire who had found a massage therapist in thetelephone book. Describing herself as having “confidence and awareness of whatI do need andI’m not very shy about saying it”, Claire told the following story:I booked 90 minutes with a random dude. I went in there and said, ‘Buddy, youare going to have to give the deepest massage of your life so justget ready.’ Andhe’s giving me this super soft, basically just rubbing oil around... Ipretty muchcoached him for half an hour — ‘Deeper, that’s okay, morepressure. Can you giveme more pressure?’ And I needed that massage (laughs) so I wasable to give hima ton of feedback and at the end he was like, ‘Wow, I feellike I know how tomassage an athlete now. Come back here!’ AndI’m like, ‘Yeah right.’... BeforeI would go in and just be like ‘Yeah, you’re the pro.Do what you’re doing.’Now I’ve seen a ton of pros and I’ve seen what’s given meresults so I like to be apart of it for sure.Nicole focused less on directing the encounter andexplained it instead in terms of how she wasincreasingly able to provide more detailed information tothe therapist when she said:I have a much better understanding of what feels rightand what feels wrong inmy own body... So I think I can better givethem the information they need tomake a better-educated decision on what’sgoing on.Finally, Caroline spoke of how her increased awarenessof her body factored into the treatments:I probably make their jobs pretty easy becauseI go in and I know exactly what Iwant worked on... I’m very direct about whatI want and I give a lot of dialogue84during the treatment... I think I make it probably pretty easy to work with becauseI’m very conscious of my own body... I think you become more and more andmore aware of what’s going on just as you use your body more and as youbecome more attuned to what’s happening.4.6 What is Achieved Through CAM?: Reasonsfor the Ongoing Use ofCAMThe previously discussed literature pertaining to the reasons that individuals in thegeneral population give for using CAM has focused on the dual themes of dissatisfaction withbiomedicine and the perceived congruency between the individual’s worldview and CAM-related philosophies. These two discourses combined with serious health conditions such ascancer and HIV!AIDS are often cited as the impetus for seeking out CAM practitioners. In thecase of the elite athletes I interviewed, life-threatening illnesses and chronic conditions were nota factor in their use of CAM. Rather, the high rate of injury sustained during athletic trainingand competition was the phenomenon that precipitated their initiationinto CAM.4.6.1 When is it an Injuiy?The explanations for why athletes first sought practitionersclearly revealed that injurieswere often a factor when deciding to try a new practitioneror a new treatment, with massagetherapy and naturopathy being exceptions. However, overthe course of the interviews aninteresting theme emerged. While the athletes were quickto cite injuries as the reason for theirfirst visit, injuries were not necessarily the reason for their continueduse of treatments. In fact,all of the athletes stated that they were injury-free at the timeof the interviews even as some ofthe participants revealed that they had four appointments withpractitioners each week. Thisdiscovery necessitated that additional questions be included in theinterview schedule.Specifically, athletes were first asked if they had any injuriesat the time of the interview and85then asked how they would define an injury. Of particular interest was the participants’ apparentreluctance to discuss injuries in the present tense. For example, while athletes were comfortabledescribing past injuries or using phrases such as ‘injury-prone’ to describe teammates or otherathletes, they were far less likely to describe themselves as currently having any injuries. Whenasked “What do you consider to be an injury?” or “When is something considered an injury?”their responses included: “When it stops you from training, from racing,” (Caroline); “Aninability to do my sport,” (Brie); “Everything that inhibits you from training at your fullcapacity,” (Kit); and “Something that is preventing you from using your body in the sense thatyou normally could” (Hilary). Thus, injuries were described as impairments to the body orimpediments to sports performance. Since all of the participants were training full time or in themidst of a competitive phase at the time of the interviews, they were by their own definition notinjured.When discussing their present conditions, instead of referring to injuries, theathletesspoke of “imbalances” and “tightness.” When one athlete was asked “When doessomethingbecome an injury?” she replied:When I can’t participate in my sport. Yeah, like I know I haveto go get massagesfor my lower back. Otherwise it will become an injury. But as longas I keep ongoing [every] 10 or 12 days it will keep it loose. Fine,but that’s not an injurybecause I can still do my sport.When asked if she presently had any injuries, Kristina turned the questionback on me andreplied:No, not really. I don’t know. What would you call an injury? (laughed)...My Achillestendon hurts sometimes. I don’t know— yeah, like your back hurts, my neck hurts.But86those are not injuries. I think that’s just more a sore back... It’s just normal aches andpains... I do exercises for my Achilles tendon and if I don’t do those it starts hurting. Sothat’s I guess more of an injury... It’s just general pain that every [athlete] goes through Ithink.., there’s nothing you can do about that. But it’s not an injury.When pressed to further elaborate on certain conditions, some athletes revised their responses toadmit that strictly speaking some of their “issues” might be considered injuries. However, theseathletes were quick to qualify that statement. For example, Hilary described having had stress-fractured ribs and, when asked specifically if these constituted an injury, she replied:No, I guess those were injuries. Like they put me out. But never anything majorin the sense of becoming chronic. I think you have an acute sort— ‘Iputsomething out, boom, it’s gone.’ Where something that’s kind of nagging... for along time— to me those are the ones that more affect me so I focus moreonthose. But the other [acute] ones are still injuries but [they] mightlast a day ortwo and then [they’re gone] and it’s fine. But the truechronic injuries are theones I think really affect performance as an athlete.Careful review of the interview transcripts revealed that themajority of participants heldambivalent attitudes towards injuries. On the one hand, as previouslystated, the athletes werecomfortable discussing past injuries, both serious and minor,in great length and detail. Theyalso frequently acknowledged the risk of injuryinherent in their sports especially when referringto the role of practitioners on their teams. For example, whenasked why it was important tohave practitioners travel with her team, Kristina responded:If you are on the road and you get an injuryor a sore back or a crash or anything,that’s when it’s different [from not havingpractitioners around]. If you havesomeone that can actually help you heal fromthat, that’s where it’s going to bedifferent. You can heal faster.87Other athletes also clearly stated that they understood the high risk and the high rate of injuryassociated with their sports. Michelle spoke of the team practitioners seeing the “same injuriesover and over and over again,” Hilary talked about how she and her teammates had experienceda number of injuries in their small training group, and when Kit was injured she was reassured byher teammates that they all had lots of “experience getting injuries and told [her] it was prettynormal.”However, despite the apparent normalization of injury and the nonchalance withwhichthey discussed the risk of injury, none of the athletes willingly labelledthemselves as injured atthe time of the interviews. Further questioning into the subject revealed some ofthe emotionalrisks the athletes associated with being classfied as injured.Tanya was the most eloquent in herdescription of how admitting one was injured challengedher athletic identity:I struggle with it a lot mentally... I have a hard time admitting that I’m notokayand things aren’t right... I put all my time and effort prettymuch into this. It’smy life, it’s what I love to do. I’ve really passionate about it. And admittingthatyou have an injury means that you might not be able to do this thing thatyouspent so much effort— you might not be able to do whatyou love... I’ve tried tocome to terms with ‘I have to make myself better.’Like I have to be healthybefore I can do it... So I try to remind myself that it wouldn’tbe the end, it’s justenabling myself to continue.Caroline thought she was better able to handleand accept being injured now than she had in thepast but stated that it was still “tough.” Asshe explained, she found not being able to train at herfull capacity very frustrating: “You have a routine andyour body is used to doing a certainamount of training... I feel like crap because I’mso used to training and keeping my body goingthat you go into like almost a depression.” Her strategy,taught to her by a coach when88competing on a university team, was to use the time off due to an injury to work on another bodypart that she might otherwise not spend much time on. Caroline explained as follows:She [the coach] was really good cause she was like ‘Whenever I injured my upper body Itook the time to strengthen my legs... use this as an opportunity to strengthen somethingthat otherwise you might not pay attention to.’ It helped because then I could put myfocus somewhere else because you have all this energy.While the participants agreed that being injured was difficult on an emotionallevel andthis was related to their reluctance to admit an injury, they had varying opinionsregarding whenit became necessary to discuss a conditionlinjury/issuewith coaches and teammates. Mostdescribed their communication with coaches as very open, aswas the case with Tanya who said,“I’m completely up front and honest with [my coaches].They’re very, very supportive. Theytotally support me taking the time I need... They’re verycautious with that.” Brie had adifferent opinion. At the time of the interview she washeaded back to the training centre after abreak and was deliberating as to whether or not she wouldtell her coach about an inflamedtendon. This is how she explained her situation:If I told my coach... right now thatI am injured, I would be under the assumptionthat I can’t do anything. I couldn’t [train]. Which isn’tthe case... The tendinitisthing I will probably keep to myself andsee how it goes... and if it acts up, I’llprobably say something... I don’t know, I feellike coming into camp... Iwouldn’t want to be the one personthat comes in and is like ‘Well, I’m here butI’m not 100%.’In addition to not wanting to informher coach, Brie was reluctant to tell other team membersabout injuries. As she described it:89I would say you want to appear as strong as you can. You don’t want to get thestereotype of being the person who’s always injured or I don’t know, complainingor not [working] because you’re not feeling a 100%. Most of athletes all agreethat if you’re not feeling a 100% you shouldn’t be [training.]... I mean you try tobe supportive but... it’s a competitive environment.While a couple of the athletes asserted that there was a risk associated with being labelledinjury prone, the majority of the participants reported that their teammates and coaches werelikely to be supportive. Hilary elaborated on this theme explaining thatthe group she wascurrently training with was different from those she had trained withpreviously. Whereasformer groups avoided discussing injuries, her current teammates and coachesperceived thediscussion of injuries to be a way of sharing knowledge:I know in the past... it was very hush, hush. ‘Somebody’sinjured—don’t talkabout the injury, we don’t want to hear about it.’ Whereasus, we’re totally openwith it... We’re all very open with it because I thinkwe’re unique and really wantto learn about it as well... so that’s good.Hilary’ s comments reference the earlier discussionregarding teammates as a source ofreferrals but include an added nuance— specificallythat coaches and teammates were a sourceof information and support when an athlete was injured.One athlete in particular providedadditional insights into this theme. Unlikethe other participants, Nicole trained witha verysmall group, and felt she was disadvantaged by not havingother teammates’ advice to drawupon. When asked how athletes learned aboutwhat types oftreatments were most effectiveintreating injuries, she replied:Unfortunately I think a lot of it is just experience. Youknow, you go and you do it andyou go ‘That didn’t work.’ Or ‘That really worked’and you learn from it. I think though90that you learn a lot from other athletes and their experiences and if you talk to otherathletes and say ‘Hey, I had a similar problem and I did this, and this, and this, and itreally helped.’ Or I saw this guy and it really helped.’ They can be really important inhelping you do that.In this way, the participants revealed that different training centres adopted different attitudestowards injury-talk and that the training environment impacted how athletes dealt with injuries orsought treatment.4.6.2 Maintaining the Body and Optimizing the MachineBeing able to avoid injury and continue participating in their sport at the highest possiblelevel was the most frequently cited reason for ongoing visits to CAM practitioners.While theathletes were reluctant to admit that they had injuries, all were graphic in their descriptions ofconditions that had to be carefully monitored and maintained, and it was these conditionsthatthey felt necessitated the involvement of various health professionals. For Tanya, treatments forher shoulder muscles had been the main reason for her visits to various practitioners sinceage 13:I’ve had shoulder problems pretty much my whole life. I have really looseshoulder joints and they cause a lot of problems... So I’ve had trouble all my lifeand so I started seeing a massage therapist when I was really young... Myproblem is that the small muscles aren’t quite strong enough to hold everything inplace so if I can have a massage on my pecs and on my rhomboids and those sortof things to make sure that they’re all relaxed... my shoulder don’t get as sore.All of the athletes used words such as “maintenance” and “tune-ups” to describethe purpose ofongoing treatments from CAM practitioners. For example, some athletes spoke of a common91injury in their sport and described the importance of regular “maintenance” work in preventingthis injury. One explained her maintenance strategy in the following manner:I have a rib that likes to jam-up quite often. I go [to massage] for that and theycan loosen everything around there so that my rib will pop back out. So it’s justgeneral maintenance and making sure everything is loose and moving and themuscles aren’t tightening up so that they tighten around the bones and then youget fractures.Another participant described how her body “broke-down” in the absenceof regular treatments:You are pushing your body to limits that it’s not necessarily comfortabledoing allthe time. And I think every rower has seen someoneat some point. And probablysees them quite frequently. And I mean it happenedto me last summer— I wasn’tseeing anybody and my body just like, it brokedown. So they [practitioners] playa huge role in keeping us going, in keeping us healthy,and keeping us frombreaking.“Breaking” was used by the athletes as a euphemism forinjury and once again was discussed interms of performance rather than in terms of the physicalpain associated. Hilary normalizedtherisk of injury by saying, “You’re pushing yourbody so hard that someone’s going to break andthe people who are in that Olympic [team] arethe people who haven’t broken.”The vocabulary used by the athletes, including wordssuch as “maintenance,” “tune-ups,”and “broke down,” was consistent with the existing literature,which states that athletes oftendescribe their body in terms that could equally be appliedto a machine (Messner, 1990, Smith&Sparkes, 2004). Key to the discussion of the body-as-machineis the concept of functionality andperformance. The well-maintained machine isnot only one that is not broken; it is also onethatis performing optimally. Optimization, or performanceenhancement (to use a term commonly92employed when discussing elite athletes), was a theme raised by all of the participants to somedegree or another when discussing their use of CAM. However, the strength of this theme wasmore evident in some interviews than in others. One long time national team member, Claire,described her use of various practices over the course of her athletic career in this way:As a teenager, with injuries and imbalances and a desire to be optimal, I had avery scattered approach. So I went to see everyone, all the time. I was packing inchiropractor, active release, physio, massage... The last three years, theystreamlined it... we have a team of professionals. We will help you decide whichof these people you need so that I’m not going to everyone.., now Ijust feel like Iknow which ones I need and I dedicate my time to ones that give me return.Andthere are some that give me no return so I don’t spend any time thereanymore...I’m extremely grateful to all the practitioners I have worked with over my entirelife because they’ve made me able to go out there and give ‘er.One of the older participants in the project was also the athleterepresentative on theboard of her national sports organization. She spoke about the roleof practitioners in enhancingperformance:We’ve talked a lot about this in our meetings... hithe past, I think it’s been moreof a like fixing people once things are broken role. Whereaswe’re really trying topush it more towards a maximizing your performance role...they should be thereto make us better.For one woman, there was no doubt in her mind of the rolehealth practitioners played in herathletic career and she reinforced the theme of the“body-as-machine” (Franzoi, 1995) when shesaid:It [the use of practitioners] is very important to mebecause I think of my body as amachine and I think it’s important that it’s running verysmoothly for [my sport]. And93it’s my job. So I think it I’m not maintaining the machine the way I should I’m not goingto perform the way that I can.When asked about the role of therapists in an athletic environment, all of the athletesagreed that they had the potential to improve the overall success of the program. Carolineexplained:I definitely need them. I’m definitely the better athlete for having them becausethen I can go into workouts with my body feeling better, I can push myself harderand I’ve seen my scores getting better, my... performance getting better and Ithink they have a lot to do with that.Claire was in agreement and her response included elements of the broken bodytheme when shesaid, “I just don’t think I could do the same level of work without this stuff keepingmy bodytogether. It would just wear down and break down. I think that’s what happens..4.6.3 Coping with StressIn addition to treating injuries, preventing “breaking,” and enhancing performance,thethird and final reason for the use of CAM therapies identifiedby the participants was that ofmanaging stress. Half of the participants indicated that the treatments prescribedby their CAMpractitioners were intended to induce an emotional response. For example, Hilarydescribed asituation where a physician who was treating her by using acupuncture“snuck in a couple of pinsfor some emotional things that she could read... she said ‘Oh, Ican tell you are upset, that’s yourhappy one.” Hilary described a second occasion where a co-worker whopracticed Reiki offeredher a treatment. As she described it, “I think I was just really—had not made a team orsomething and I was very emotional. And he laid medown and gave me this energy Reiki94massage. It was very nice.” Similarly, Michelle described a situation where a naturopathpractitioner incorporated relaxation exercises into the visit and prescribed high dose injections ofvitamin B12 as a means of addressing stress. In Michelle’s words:B12 is if you’re not happy or you’re feeling stressed out of kind of tired...I thinkit is 900mg that you get in one shot... I think it definitely reduces yourstresslevels. For the first couple of days you’re kind of like ‘Oh, my bodyneeded that.’But it doesn’t stay with you for too long.The same practitioner ended the visit with 10 minutes ofa relaxation exercise that Michelledescribed as “nice because how often do youjust sit there and be like ‘okay, relax.’... I felt a lotbetter after.” Other participants described practitionersdiscussing the flow of energy or “chi”and the relation between the physical treatments theywere providing and the emotional response.The second manner in which CAM practitioners contributedto the emotional well-beingof the athletes was through the provision ofa space for the athletes that was stress-free andcomfortable. Nicole tried massage at the recommendationof a teammate but instead of going tothe recommended therapist made thedecision to seek out a female practitioner.Her reason forthis selection was that she felt she wasbetter able to communicate with a female therapistandthat this communication made the treatmentsmore enjoyable and more effective.It’s hard to get to that point where you...can be totally open about what yourworkouts are... what it feels like..,you can just be more open communicationwise and not feel like anybody is judgingyou... It’s just nice to feel thatcomfortable with someone. You canjust let loose and know that they’ll do thebest job they can to figure it out for you.95Tanya made similar coniments when she contrasted the high-stress training environment with theatmosphere in the treatment rooms:As athletes you put so much pressure and strain on yourself and I think thesethings allow you to find a way to relax your body and help it get into thatrecovery state. And I think it’s a low-key atmosphere... I mean sometimes it’sstressful because you’re injured, but for the most part it’s not stressful... youcanjoke around and have a lot of fun and that’s not something you run into all thetime within your sport.In this way, the CAM practitioners were perceived to support the athletes inboth the physicaland the emotional aspects of their training and were consideredby women to be a vital part ofthe support team.96CHAPTER 5: Discussion and ConclusionsThis project has investigated the experiences of, and attitudes towards CAM as expressedby 12 female members of Canadian national non-contact sports teams. My findings haverevealed the processes by which high-perfonnance athletes first came to try CAM, the factorsunderlying their decisions to use CAM treatments on an ongoing basis, the evolution of theirattitudes towards alternative health practices, and the role they perceived CAM practicesandpractitioners to have in their athletic careers. Furthermore, the findings elucidatedtheconnections between the athletes’ use of CAM, the behaviours of their sportsnets,their access tofunding and extended healthcare coverage, and their views on the athleticbody as a machine thatneeds to be maintained and managed. My study buildsupon existing research which indicatesthat CAM utilization is linked to socio-economic status (SES), anda holistic orientation towardshealth. Additionally, my research extends the sociology of sport researchinto the behavioursand actions of high performance athletes and the theorizing around the sportsnetas a primarymeans by which risk and injury in athletic subcultures are normalized. Thischapter will discussthese findings as they relate to the extant literature and willfocus on the themes that haveemerged from my study which have the potential to further informour understandings of theexperiences of elite female athletes and the role of CAM ina sport, thereby developing aknowledge base for the delivery of therapeutic services that are athlete-centredin their approach.5.1 Understanding Rates of Utilization in Athletic PopulationsThe surveys by Nichols and Harrigan (2006), and Pike (2005)were the first indicationthat athletes were using CAM at rates much higher than the 20 to42% seen in the generalpopulation (Eisenberg et al., 1998; Park, 2005). Indeed,Nichols and Harrigan (2006), and Pike97(2005) reported that varsity level and competitive club level athletes were trying CAM at ratescomparable to those of individuals who were terminally ill or had multiple chronic conditions(Astin et al., 1998; Park, 2005). These findings suggested to me an opportunity for asociological study exploring the reasons that athletes had for using CAM and examined how andwhy a sport milieu could foster such high utilization rates.Since previous research projects had successfully employed Nixon’s (1994)conceptualization of the sportsnet as a means for understanding the behavioursof athleticsubcultures related to health behaviours and attitudes towards pain andinjury (Young & White,1995, 1999; Young et al., 1994), I also adopted thesportsnet as a means of focusing myinvestigation. The sportsnet theory draws attentionto the ability of group practices in a sportsetting to modify the behaviours of individual members. Assuch, it is congruent with symbolicinteractionism, which draws attention to the influenceof past experiences and currentenvironments on the athletes’ values, beliefs, behavioursand interactions as well as the meaningsthey attribute to CAM, injury, and sport participation(Blumer, 1969). My findings revealed thatthe sportsnet’s sphere of influenceincluded how CAM was used and portrayed within thegroups. While the athletes reported individual preferencesfor certain types of treatments orpractitioners, the words that the athletes used todescribe CAM or describe the purpose of CAM,was remarkably consistent not only among athletesin the same sport, but also between athletesfrom different sports. The sportsnet servedto construct particular narratives related to CAM andthe first and strongest of these narratives was thatCAM practices and practitioners provided vitalservices by helping to maintain the athletes’ bodiesand ensuring their continued participationintheir sport. In addition to normalizing the use oftherapies, the sportsnet also normalized the role98of the CAM practitioners hired by national sports organizations and cast them as team membersinterested in contributing to the overall success of the program.In addition to the importance of social interactions with members of sportsnet, one of themost important and surprising findings from my research was the actual rates of CAM utilizationby the athletes I interviewed. Based on my reading of the work by Nichols and Harrigan(2006),and by Pike (2005), I expected to find that the athletes had tried a number of practices andwereconsistently using one or two forms, with massage therapy, chiropractic,and acupuncture beingthe most popular (and indeed this was supported by the data). However,nothing in the existingliterature— neither that related to the rates of CAM use inspecial populations nor thequantitative work on CAM use by athletes— gave anysuggestion that athletes were receivingmultiple CAM treatments every week and sometimesevery day. In fact, athletes spoke of goingfor CAM treatments in the same way that they describedgetting a good night’s sleep,maintaining a healthy diet, and showing up for training. Moreover, theparticipants indicatedthat the use of CAM therapies was integral and routine part oftheir larger training programs andpractices.Given that the use of massages, chiropractic adjustments, needling,ART, and other CAMtreatments went far beyond simply being popular,and might better be described as ubiquitous, itis important that we reconsider existing theories regardingthe use and allure of CAM. Thenarratives of the women revealed that althoughthey were using CAM all the time, they were notinjured all the time. That is to say, at least as it wasunderstood by the athletes, that theextremely high rates of CAM use cannot besolely attributed to the increased rate of injuryassociated with high level sport. The broader implicationof this finding is that the extantresearch has overlooked the extent and nature ofCAM use among athletes and has not fully99elucidated the reasons that athletes turn to CAM practices and practitioners. From amethodological perspective, my findings illustrate the importance of combining quantitativework with qualitative projects that are more suited to uncovering nuances of athletes’ behavioursand socially constructed meanings. Additionally, my research suggests that future surveyresearch needs to measure the usage of CAM not just in terms of what athletes use but also thefrequency with which they engage in CAM therapies on a daily and weekly basis in order tomore fully capture the ways in which CAM has permeated sport subcultures.5.2 Carding and Status as a Predictor of CAM UseIn order to fully understand how the athletes came to be using CAMat such anastonishing rate, it is necessary to comprehend how the Sport Canada system of cardingfunctions, as well as how it intersects with other hierarchal structures at the levelof nationalsports organizations. The existing literature has indicated that CAM use is positively correlatedwith income (Eisenberg et al., 1998; Esmail, 2007; Park, 2005), and canmore broadly bedescribed as influenced by the socio-economic status (SES) of the individual(Conboy et al.,2005). The implication is that because CAM exists outside of conventionalmedical pathways, itis not often covered by standard health care plans (although thisis changing), and thereforeindividuals must have either extended health insurance or the financialresources to pay out ofpocket for treatments.Although socio-economic status is typically defined either in termsof income oreducation, my findings revealed that carding was the primary financiallylinked factor delimitingthe athletes’ use of CAM. Certainly those individuals who hadhigher incomes and families whowere willing to offset their costs were able to access CAM more easilythan those athletes on100restricted incomes. However, carding offered the athletes several avenues for accessingtreatment irrespective of their annual incomes. The monthly stipend provided them with some(albeit limited) income; the status associated with carding meant they were permitted to booktreatments with practitioners hired by their sport organizations; and the extended health careplans (usually CAP) associated with carding reimbursed them for treatments. Allof the athletesreported that their use of CAM services started or significantly increased whenthey were firstcarded, and those that had had their carding terminated orsuspended reported a correlateddecrease in the number of treatments by practitioners. The implicationfor future research is that,while financial resources are a factor in determining therates of CAM use in elite populations,the socio-economic status (Conboy et al., 2005) or socialcapital (Bourdieu, 1991) of athletes isnot captured using standard models.Additionally, this project reveals that a nationalteam member’s ability to access servicesneeds to be multi-dimensional and include consideration,not only of how she pays for treatments(or does not pay as the case may be), but also how thegendered and sporting hierarchies withinwhich she is situated influenceher ability to obtain CAM treatments. Carding is an exampleof ahierarchal structure in the Canadian sport system,with the most obvious division being betweenthose that receive carding and those that do not. However,as evidenced by the experiences ofthe women I interviewed, even among cardedathletes, resources are not distributed equitably.For example, participants from some sports indicatedthat their organizations were ableto hirefull-time practitioners who worked with allteams members, whereas participants from differentorganizations had to spend their carding stipendon treatments from providers outside of theorganization. Still other athletes described hierarchieswithin their organizations with respecttowho could access services and when.Some athletes indicated that these hierarchies werebased101on the success of particular athletes while others described gendered hierarchies. Both of theseconditions can be understood through the application of hegemonic masculinity theory whichasserts status is always relational and exists both within groups and between groups. Thesefindings call for a more comprehensive analysis of the services in place within each nationalsports organization. It would be particularly informative to consider how the pastsuccesses ofthe different sports (e.g. at the Olympics) and the status of the individual sportswithin Canadaimpacts an organization’s ability to offer services to their athletes. Additionally,it would beimportant to further investigate how the privileging of certaingroups over others shapes accessto CAM.5.3 Is That an Injury?: New Reasonsfor the Continued Use ofCAMIn addition to exploring how athletes accessed and utilizedCAM, this project drawsattention to the reasons that the women had for continuing/discontinuingpractitioner-deliveredtreatments. Pawluch et al. (2000) studied the use of CAMby individuals living with HIV/AIDSand concluded that there was no simple or singularexplanation for the appeal of CAM. Theyreported that the use of CAM was interpreted in many differentways by their participants andthat it was possible for an individual to explain his/heruse by adopting a variety of narratives(both sequentially and concurrently). Similarly, the womenI interviewed described CAM as away of treating new injuries, managing chronic conditions,pro-actively preventing injury,coping with stress, and/or enhancing performance. The strongesttheme in the data was theemployment of CAM therapies to maintain the body as it was beingsubjected to high trainingloads, in terms of both the intensity of the training sessionsand the frequency/duration of thesesessions. Athletes from different sports and different traininglocations used remarkably similar102language when discussing the role of CAM as they stated that the treatments addressed“imbalances,” relieved “soreness” and “tightness” and, most importantly, kept the athletes from“breaking.” The women understood regular CAM use to be a necessary meansof dealing withwhat they called “issues” before they escalated and became “injuries.”The observation that the participants were reluctant to usethe word injury to describetheir current condition is supported by existing research on the meaningsathletes attribute toinjury and their subsequent “injury-talk” (Young et al.,1994). Previous works have alsoreported that athletes “disrespected pain” (Younget al., 1994,p.184) by questioning thedefinition of injury, referencing pain as an everyday occurrencethat can exist independent oftrue injury, and differentiating betweenconditions that were painful and conditions that limitedtheir sport participation (Young& White., 1994, 1999; Young et al., 1995). I argue that thereluctance to admit being injured is at leastpartially attributable to the poor reception that suchadmissions received from other membersof the person’s sportsnet (Young et al., 1995). Theaxiom “no pain, no gain”(p. 182) was used by Young et al. (1994) as an exampleof how asportsnet, especially one imbued with hegemonicmasculine ideals, can reproduce narrativesthatencourage athletes to hide injury andplay through pain. This theory was not supportedin mydata, which illustrated instead that althoughthe women normalized pain and injury, they felt thatthe members of their sportsnetwere supportive of them when injured and encouragedthem totake time off and go for treatments. Incontrast, the athletes were the ones whofelt that it was“tough” to take time off and struggledemotionally with not being able to fully participatein theirsport. While this could be explained as an internalizationof the pressures in a sport subculturetovalue and reward athletes who are winningrather than those who are injured, anotherpossible103explanation could be that the athletes in this project were involved in individual sports8.Assuch, their sportsnets differed from those explored in previous works (Theberge, 1997; Young&White, 1995) because the other athletes in their training groups did not have the same level ofvested interest in their continued participation. On a team, the pressureplaced on an athlete toignore injury could be attributed to a reluctance on the part of the teamto admit the group as awhole is not functioning at full capacity whereas recognizing or labellinga training partner asinjured does not have the same consequences.In addition to observing commonalities related to how the athletes defined injury andresisted describing themselves as injured, certain words and phrases wererepeated by athletes indifferent sports and different training locations. For example,in addition to the previouslymentioned “not breaking,” being “sore,” and feeling “tight,” theathletes spoke about ribswanting to “j am-up,” going to the chiropractor to “get cracked”or needing the “release” from amassage. I contend that, in the same maimer corporateenvironments develop jargon tosummarize and communicate practices and ideas commonto their work (Chisalita, PuertaMelguizo, Hoorn, van der Veer, & Kok, 2005) so toohave athletes and their various sportsnetsadopted phrases to describe their reasons for using CAMor the benefits of certain treatments toathletes. Particularly fascinating is the observation that thesewords and phrases were repeatedby athletes in different sports and training in different localessuggesting that Nixon’s (1994)concept of the sportsnet as the individuals that surroundan athlete needs to be expanded andfurther elucidated to better explain how behaviours and practicesare transmitted betweensportsnets. I assert that, based on the descriptions that the participantsprovided of the CAMWhile there is a team component to rowing and canoe/kayak,all of the participants in this project werecurrently training in single person boats and did not stronglyidentify as members of a crew.104practitioner as a collaborator, we need to first recognize that practitioners have/are moving fromthe periphery of the sportsnet towards a more central role where they are better situated to informthe attitudes and behaviours of the athlete. Additionally, the shared language between thesportsnets speaks to the interplay between sport and the broader social context and the ways inwhich socially constructed meanings are acquired through and influenced by interactions withother social actors. Furthermore, it is important to underscore the fact that team practitionerswere often a key source of information and referrals to CAM practitioners. What makes thepractitioners unique is that, unlike most other sportsnet members, their work is not sport-specificand many therapists are in fact employed by several national teams at onceor treating athletesfrom a variety of sports at their clinics. As such, they are in the rare positionof being able toobserve the practices in one sportsnet and facilitation the transmissionof these practices to othersportsnets. The role of the CAM practitioner in the consolidationof practices between sports,transmission of knowledge from one group to another, orcommunication of a standardizedmessage has not yet been studied and represents a novel directionfor future work.5.4 Limitations ofthe ProjectWhile the data from this project are sufficiently rich to providenew and substantiveinsights into the experiences of elite female athletes ina Canadian context, the design of thestudy is not conducive to making overly broad claims. In other words,the generalizability of thefindings is limited by the small sample size. Another limitationis the fact that all of theparticipants were white, Canadian born, and middle-class.As explained earlier in the document,my sample reflects the barriers that women of colour and lowsocio-economic status face whentrying to access sport. Another inadvertent limitation is thefact that I did not interview male105athletes. I purposefully made the decision to recruit only female athletes because so much of theexisting research has used males as the normative sample and I wanted in my own small way toaddress this imbalance. While I remain committed to this decision and feel incredibly fortunateto have had the opportunity to meet so many inspiring, strong women, I recognize that thisdecision limited my ability to fully examine certain topics. For example, whileI had hoped toaddress the research that suggested that CAM was a gendered practice and wasparticularlyattractive to women because of the alternative it offeredto a paternalistic medical model, I nowwould argue that to fully explicate the gendered natureof CAM use among athletes, it isimportant to investigate both men’s and women’sexperiences.The final limitation of this project is a practical one. Theproject was done in partialfulfillment of my Master’s program andas such was limited by my own abilities and by theresources available to me as a student. WhileI certainly would have loved to interview morewomen from a broader range of sports and geographicallocations, I worked within predetermined parameters to ensure that thestudy was one I could feasibly complete in the 12-month period. I also recognize that my interviewand data analysis skills are still developingandI may, at times, have missed follow-upquestions or overlooked themes significant to thelivedexperiences of the participants in thisproject despite my best efforts (and those ofmysupervisor) to adopt a constantly reflexiveapproach. To that my only response is thatthe entireprocess has been one of learning and Iam grateful to the women for providingme with theopportunity to improve upon my abilitiesas a researcher.1065.5 Future DirectionsHaving now identified CAM as a vital component to the training of many female nationalteam members, I propose that a more systematic analysis of what types of services are beingoffered to athletes is needed. The data from this project lead me to conclude that despite the factthat all the women were carded and received similar monthly stipends, the services that theywere able to access varied from sport to sport, and even within sports. Given that theAthleteAssistance Program is meant to be a national initiative that is intended to supportCanada’s highperformance athletes and deliver services deemed essential to their international success,itseems practical, if not imperative, to expect that a minimumstandard of services is being offeredand that a means of evaluating the success of each organization in deliveringthese services to theathletes is in place. An examination of the efficacy and success of the individualorganization’sservice delivery structures would also provide a starting point forinvestigating whether or notthe hegemonic relationships observed in this project can be projectedto an organizationallevel— for example, by questioning whether or not sports witha higher profile in Canada wereable to offer more services to their members.My findings revealed that some athletes were expectedto use their stipend to pay fortherapeutic treatments (although some of the expenseswould eventually be reimbursed by CAIP)while others were able to save their moneyand access team practitioners. This data suggests thatthere is a lack of a common understanding amongsports organizations as to the purpose of thestipend with respect to which expenses the organizations are expectedto cover and whichexpenses are the responsibility of the individual athlete. Exploringthe different models used byvarious teams across Canada would not only further our understanding of whatathletes are107using, but it would be the first step in determining which sports are meeting the needs of theirathletes and which organizations need to reconsider the configuration of their programs.It is painfully evident from the narratives of the women that they considered access toCAM services to be essential to their continued participation and success as athletes. Given thepotential that the women saw in CAM to prevent injury and enhance performance, it follows thatwe need to do a better job of ensuring that the athletes have the services they consider the mostbeneficial when they most need them. This means not only setting standards of practice fororganizations but also assisting them in expanding their capacity to deliver services so no athleteis left waiting for treatment since, as Caroline so eloquently stated, “You never know whatsomeone could be capable of if they’re really taken care of from the get go.”In conclusion, through the use of in-depth interview data with a dozen of Canada’s topfemale athletes, this project has challenged us to consider new possible explanations for the useof CAM. The athletes in this project did not turn to CAM out of frustration with biomedicine orin a desperate search for a cure, they turned to CAM because they felt it had the potential toenhance, if not their performance, certainly their daily lives as athletes. 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Alternative sports medicine. The Physicianand Sportsmedicine 26(6), 92-105.Williams, A. (1998). Therapeutic landscapes in holistic medicine.Social Science & Medicine46(9), 1193-1203.113Young, K., & White, P. (1995). Sport, physical danger and injury: The experiences of elitewomen athletes. Journal ofSport & Social Issues 19(1), 45-61.Young, K., & White, P. (1999). Threats to sports careers: Elite athletes talk about injury andpain. In J. Coakley & P. Donnelly (Eds.), Inside sports (pp. 203-2 13). London:Routledge.Young, K., White, P., & McTeer, W. (1994). Body talk: Male athletes reflecton sport, injury,and pain. Sociology ofSport Journal 11(2), 175-194.114APPENDIX AStudy: The Use and Experience of Complementaryand Alternative Medicine by EliteFemale AthletesThe following questions will be the guide for the twointerviews. The interview style issemi-structured and the questions willbe open-ended and may be changed as new themesemerge in the data and require further clarification.Prompts, probes, and follow-ups willbeadded as required. Furthermore, questionsfrom Interview #1 could be asked in Interview#2and vice versa should the need arise. Theorder of the questions will be guided largelyby theresponses of the participants.Interview #1Background/Personal History1. Can you tell me a bit about yourselfand how you got involved insport?2. Can you tell me more aboutyour more recent sport experiencesand your current trainingsituation (where, with who, for whatcompetition, etc.)Health Care Practitioners1. Can you tell me what you doto stay healthy while training/competing?• Who is involved in this?What health professionalsdo you see, if any?• What do you see eachof them for?• Are there others you havetried in the past but are no longerseeing?• Why did you first see themand why have you since stopped?• How much money do you spendon visits to health careprofessionals (in a month, ina year)?• Are you reimbursed for anyof these visits? If so, how? (healthplan — parents, work,student, etc.)• Has cost ever affected yourdecision to see a health carepractitioner? How so?Team Staff1. Does your team havemedical staff?• Can you tell me about thepractitioners affiliated with yourteam?• Who are they?• What is their area of practice?115• Can you describe the role they play on your team?2. Are there any health practitioners that are closely affiliated with your team but aren’tofficially employed by your team? Please describe their involvement to me.3. Of all these people, which ones have you seen?Use of CAM1. When you hear the term ‘Complementary and Alternative Medicine,’ what do you thinkof? What types of treatments would you include in this?2. What types of CAM have you tried?3. Why did you first try these therapies?• What made you decide to try them?• Had you already tried something else first?4. What do you think of the CAM practices that you have used?• Of all the practices/therapies you use, which do you see as being the most beneficialto you? The least?5. Are there any CAM practices you’ve been considering but haven’t tried yet?• Any that you are interested in learning more about? Why or why not?• What do you recommend/warn against in terms of CAM, if anything?6. Do any of your family members use CAM?• If so, what forms of CAM do they use?• Do you talk to them about their CAM use? Your CAM use?• If one of them came to you and said they were thinking of trying out a new form oftreatment, what would you say to them?Interview #2Attitudes regarding CAM1. Do any of your family members use CAM?• If so, what forms of CAM do they use?• Do you talk to them about their CAM use? Your CAM use?• If one of them came to you and said they were thinking of trying out a new form oftreatment, what would you say to them?2. How do you think CAM practitioners differ from Western medicine practitioners,if atall?116Referrals1. Who influences your decision to see health care practitioners?2. What factors do you consider when you’re picking a practitioner or a treatment type?3. Where would you say you get most of your health related information?Sportsnet1. How open are you with people about all the health practitioners you visit?• Coach, teammates, family members, friends• Do you believe it’s important that he/she has this information? Why or why not?2. Do you ever feel encouraged or discouraged to visit a specific practitioner or try a certaintreatment? By whom? Can you tell me about this?3. What are the expectations regarding your use of practitioners associated with your teamor sport association? Are you encouraged or discouraged to seek other practitioners?4. What do you see as the advantages andlor disadvantages of visiting practitionersassociated with your team or sports association?5. If you visit a practitioner associated with your team or sport association, what kind ofexpectations do you have regarding the confidentiality of your visit?Use of CAM by Athletes1. What advantages or disadvantages do you see CAM having specifically for athletes? Arethere any?2. Do you think the types of CAM you use (or don’t use) wouldbe different if you weren’tan athlete? How so? Do you think you are more or less likely to try out new forms ofCAM because you are an athlete?3. Do you see your use of CAM changing in the future? Can you describe a situation thatmight make you stop using a specific type of treatment?3. When you retire from your sport (at least from competing internationally), will you stillcontinue to use the same practitioners, the same therapy types? Why or why not?4. What do you think is the future of CAM specifically as it relates to athletes?Do youthink it will become more or less popular? Why?117APPENDIX BINFORMATION SHEET AND CONSENT FORM: ELITE FEMALE ATHLETES ANDCOMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)Study Title: The Use and Experience of Complementary and Alternative Medicine Among EliteCanadian Female AthletesBrief Description of the Study: This study seeks to explore how female membersofCanadian National Teams are using CAM. In particular, we are interested in findingout moreabout:• What types of practitioners and therapies athletes are using.• How this usage has changed over the course of athletes’ careers.• How athletes make the decision to try a new therapy.• Who they consult during this decision making process.• What role (if any) athletes perceive CAM to have in their training and competitionregimen.The results of this study will help understand how athletesselect health care services andthe role they see these services playing in their athletic experiences. The informationgeneratedin this project may help guide policy makers in their decisions regarding whatservices nationalteam members are interested in accessing and how programs can better meetthe needs of theathletes.Andrea Bundon, a graduate student in the School of Human Kinetics at theUniversity ofBritish Columbia, will be conducting the research as part of her Master’sthesis. Her supervisor,Dr. Laura Hurd Clarke, an assistant professor in the Schoolof Human Kinetics, will oversee theproject.The Interviews and Your Participation: Yourperspectives on CAM, Western medicine, andthe role these therapies play in the lives of elite femaleathletes would be extremely helpful andvery much appreciated as we research the topics mentionedabove. You would be asked toparticipate in two interviews, each lasting approximately60 minutes and scheduledapproximately six weeks apart. Interviewscan be conducted at your training facility, acommunity centre, at the UBC campus, or another location ofyour choosing. The interviewswill be recorded on a MP3 player.Confidentiality and Anonymity: All information resulting fromthe interview will be keptconfidential and your name will not be used in anyof the documents resulting from this study(e.g. Master’s thesis, published articles, conference presentations).The transcripts from theinterviews and the digital audio files will be stored on a passwordprotected computer. Consentforms (see below) will be kept in a sealed envelopein a locked filing cabinet and stored118separately from interview transcripts. According to university policy, all transcripts, audio files,and consent forms will be stored for five years and then destroyed.Interview Feedback: Participants may request copies of personal interview transcripts to ensurethe researcher has accurately captured ideas and opinions.Interview Results: Information generated from these interviews will be published as part of aMaster’s thesis and in scholarly journals. Participants may request a summary of the researchfindings following the completion of this project as well as copies of published articles.Your Voluntary Participation: Your participation is entirely voluntary and you have the rightto withdraw from the project at any time. You are also free to not answer any question. If youhave any concerns about your treatment or rights as a research participant, you are encouraged tocontact the Office of Research Services at the University of British Columbia, at (xxx) xxx-xxxx.Risks and Benefits: Although this project is considered to be of minimal risk, you may feeluncomfortable with some of the questions asked. If you do not wish to answer any question, justsay ‘pass’ and we will move onto the next section. There may be no direct benefitto you byyour participation in this study but your involvement will contribute to our understanding of thehealth behaviours of high-performance athletes.Further Contact Information or Concerns: If you have any questionsor require furtherinformation regarding the project, please contact Andrea Bundon at (xxx) xxx-xxxx or hersupervisor, Dr. Laura Hurd Clarke, at (xxx) xxx-xxxx.CONSENTI have read the above information and understand the nature of thestudy. I understand thatparticipation in this study is voluntary and I may refuse to participatein or withdraw from thestudy at any time.I hereby agree to the above stated conditions and consentto participate in this study.Your signature below indicates that you have receiveda copy of this consent form for your ownrecords. Your signature also indicates that you consent to participatein this study.Signed:Date:______________________119APPENDIX CThe Use and Experience of Complementary and Alternative Medicine by Elite FemaleAthletesThe following questions are used to obtain background information about you. Pleaseanswer all questions as accurately as possible.1. Date of birth:____________ Place of birth:_____________________________2. Marital/partner status:________________________________________________3. Number of children, if any:________________________________________________4. Please indicate the highest level of education you have obtained:o Public schoolo Some high schoolo High school diploma0 College or university - undergraduateo Technical schoolo Graduate schoolo Other — please specify:_________________________________________________5. What is your current occupation?______________________________________6. What is your religious affiliation?__________________________________________7. Which income bracket do you fall under?o Under $10,000o $ 10-20,000o $20-30,000o $3 0-40,000o $40-50,000o $50-60,000o $60-70,000o $70,000 +8. What is your ethnic or cultural background?________________________________9. What sport do you compete in?_______________________________________10. At what level are you carded?___________________________________11. How many years have you been competing on a nationalteam?_______________120APPENDIX DCOMPLEMENTARY AND ALTERNATIVE MEDICINE USAGEPlease indicate which therapies or practices you have used on at least one occasion.LIAboriginal healing practicesElAcupunctureElAromatherapyElAyurvedic medicineElCraniosacral therapyElChinese herbal medicineElChiropracticElHomeopathyLIHypnosisElMassageElMeditationElNaturopath medicineElQi GongElReflexologyElReikiElReligious healing traditionsElOther1214pQvdYUCThe University of British ColumbiaOffice of Research ServicesBehavioural Research Ethics BoardSuite 102, 6190 Agronomy Road,Vancouver, B.C. V6T 1Z3CERTIFICATE OF APPROVAL- MINIMAL RISKPRINCIPAL INVESTIGATOR:INSTITUTION I DEPARTMENT:UBC BREB NUMBER:Laura Hurd ClarkeUBC/Education/Human KineticsH07-02465INSTITUTION(S) WHERERESEARCH WILL BE CARRIEDOUT:InstitutionSiteUBCVancouver (excludes UBC Hospital)Other locations where the researchwill be conducted:Interviews will take place at thelocation of the participants’ choosing.Possible sites will include the following:*Trainingcentres(i.e., gyms, fitness facilities,Canadian Sport Centres)*Interviewrooms on UBC campus*CommunityCentresCO-INVESTIGATOR(S):Andrea M. BundoriSPONSORING AGENCIES:N/APROJECT TITLE:The Use and Experienceof Complementary andAlternative Medicine Among EliteCanadian FemaleAthletesCERTIFICATE EXPIRY DATE:December 3, 2008DOCUMENTS INCLUDEDIN THiS APPROVAL:DATE APPROVED:December 3, 2007Document NameVersion DateConsent Forms:Appendix A - Informationand Consent Formv. Nov.15 November15, 2007Advertisements:Appendix B - RecruitmentPosterv. Oct.12 October12, 2007Questionnaire, QuestionnaireCover Letter, Tests:Appendix C - InterviewSchedulev. Oct.12 October 12, 2007Letter of Initial Contact:Appendix D - Letter ofContactv. Nov.15 November 15,2007Other Documents:Appendix F - CAM practicesv. Oct.12 October12, 2007Appendix E - BiographicalDatav. Oct.12 October12, 2007Appendix H - Memo to UBCN/A November 15,2007Appendix G - PeerReview FormN/A October 12,2007The applicationfor ethical review and thedocument(s) listed abovehave been reviewed and theprocedureswere found to be acceptableon ethical groundsfor research involving humansubjects.Approval is issued on behalf ofthe Behavioural ResearchEthics Boardand signed electronically byone of the following:Dr. M. Judith Lynam, ChairDr. Jim Rupert, Associate ChairDr. Laurie Ford, AssociateChair1.23


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