Argumentation by Self-Model: Missing Methods and Opportunities in the Personal Narratives of Popular Health Coaches

Evidence-Based Medicine and Holistic Health

In 1998, the Journal of the American Medical Association published a special issue on CAM in which the editors state plainly, “There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data, or unproven medicine, for which scientific evidence is lacking” (Fontanarosa & Lundberg, 1998, p.1618). EBM became the gold standard of medical care in the 1990s, and the RCT quickly became touted as the most rigorous method for determining the efficacy of treatment plans (Derkatch, 2008). For perspective, in the late 1980s, only 5,000 RCTs were published per year, but by 1998, 12,000 were published per year (Devereaux and Yusuf, 2003, p.105). The RCT is prized for its ability to “eliminate bias in the choice of treatment assignments and provide the only means to control for unknown prognostic factors” (Devereaux &Yusuf, 2003, p. 107, emphasis added). Scholars of medical discourse and practice have noted that there are several issues with relying upon RCTs to determine standards of medical care. For example, selection criteria for RCTs are often constrained and trial populations are homogenous, making them clinically inappropriate (Cartwright, 2007, pp. 18–19; Derkatch, 2008, p. 380). Likewise, the “efficacy” of a particular treatment has nothing to do with its performance in real-life scenarios and everything to do with its performance in ideal circumstances (Derkatch, 2008, p. 381). Lastly, there are some protocols that are not conducive to RCTs (Derkatch, 2008, pp. 375–376). Despite the shortcomings of RCTs, scholars interested in the boundary-making practices of EBM have found that the EBM community’s arguments against integrative and holistic practices almost always invoke method. In particular, Derkatch (2008) argues that “in boundary disputes, method can be invoked rhetorically to position a given health practice or study within or beyond the borders of science” (p. 378). This is the case in the special issue of Journal of the American Medical Association mentioned earlier. Derkatch (2008) argues that EBM’s own methods are problematic, and that the study of boundary-making practices can shed light on issues within the modern medical system (pp. 374, 384).

As it turns out, the EBM community has begun to agree with these critiques of its methods, as evidenced by articles such as the Mayo Clinic Proceedings’ “The Necessity for Clinical Reasoning in the Era of Evidence-Based Medicine,” mentioned in the introduction to this paper. A collaborative piece written by two MDs, one MA, and one MD/PhD, the article delves into the current problems with EBM in great detail. The authors, Sniderman et al. (2013), begin by arguing that RCTs are problematic because “the evidence RCTs provide is too often incomplete, inconclusive, absent, or outdated,” and, furthermore, the results of a trial do not account for how individual patients will actually respond to treatment (p. 1109). Sniderman et al. explain how RCTs became the most trusted source of information, but were often written in inaccessible language, leading to a “guidelines process” being instated that culled evidence from multiple RCTs to present the “best” evidence available to doctors (p. 1108). Moreover, they explain that the results of RCTs are not generalizable to diverse populations (p.1110).

Most significantly, the authors directly state the link between the fallibility of RCTs and the limitations of EBM on the whole: “We contend that limitations in the evidence are a major limitation of EBM. For many clinical problems, there is simply no RCT evidence to apply” (Sniderman et al., 2013, p. 1109). The solution, Sniderman et al. argue, is employing clinical reasoning, which, as they define it, is “the disciplined, analytical, scientific approach that integrates all the relevant information in the search for the best approach to diagnosis and therapy for individual patients” (p. 1111). Thus, clinical reasoning is akin to holistic health principles in that it is entirely dependent upon each unique patient.

As explained by the American Holistic Health Association, “The healthcare professionals using the holistic approach work in partnership with their patients. They recommend treatments that support the body’s natural healing system and consider the whole person and the whole situation” (Walter, n.d.). Holistic health practitioners like Nakayama characterize their methods as predicated on having a “passion for the puzzle of biology and biochemistry” and taking the time to help each unique individual solve that puzzle (Nakayama, 2012). For example, in her talk on “Sparking the Change in Healthcare,” Nakayama gives an example of two women presenting similar symptoms but having very different root causes for those symptoms: One had hormonal imbalances and the other suffered from chronic inflammation. The women saw Nakayama after failing to heal with the advice of traditional medical doctors. Nakayama says of traditional medical doctors, “They mean well—really, they do—but they’re missing the point.” Nakayama’s point is that people require different treatments despite having similar symptoms, and they deserve to have health-care providers who are willing to treat the root causes of their symptoms. Nakayama’s description of her methods is, in essence, clinical reasoning.

Although clinical reasoning is touted in the Mayo Clinic Proceedings article as the saving grace of EBM, it is not a part of the medical school curriculum. Rather, Sniderman et al. (2013) argue that it ought to be:

Clinical reasoning is essential to integrate the knowledge from RCTs into a specific clinical context. We need to acknowledge this and value and teach clinical reasoning if we are to appropriately value ourselves as caregivers and meet our responsibilities to patients who have placed their trust in us. (p. 1113)

Argumentation by Self-Model and Narratives of Personal Transformation

Within the field of technical and professional communication, rhetoric is one of many methodological approaches, and within the realm of health communication, there are tensions between rhetorical approaches and critical-interpretive or critical-cultural approaches (Lynch & Zoller, 2015). In a special issue of Communication Quarterly, Lynch and Zoller highlight these tensions but argue that scholars stop “perpetuating needless disciplinary boundaries” (p. 501) and instead engage with different disciplinary approaches, as “drawing from an array of research methods can build stronger theories and result in complex findings” (p. 502). Rhetorical analysis can be employed for the purposes of improving technical communication (see, e.g., Kuehl & Anderson, 2015) and for advancing pedagogical approaches to technical and professional communication (see, e.g., Landau & Thornton, 2015). Analyzing health communication using Perelman and Olbrechts-Tyteca’s (1969) concepts can illuminate concerns regarding power and control in a troubled health-care system as well as prompt consideration of how such communication could be improved.

The concept of argumentation by model merits further expansion and elaboration to account for the distinct types of models available to rhetors. First, a bit of background on the concept. Whereas both argument by example and argument by illustration appear in classical rhetorical manuals, argumentation by model is a term introduced in The New Rhetoric. In Discourse on the Move, Biber et al. (2007) explain,

Another “new” subtype of argument developed by Perelman was the argument of Model. According to Perelman, this type of argument can be employed when the speaker tries to persuade the audience through presenting a specific case as a model to be imitated. Thus, Perelman, led by the necessities of contemporary discourse of argumentation, used Aristotelian theory of persuasion to develop his theory of “new” rhetoric. (p.123)

In The New Rhetoric, Perelman and Olbrechts-Tyteca focus mainly on historical figures and perfect beings as models, and, for the most part, so do current perspectives. For example, van Eemeren, Grootendorst, Johnson, Plantin, and Willard (2013) explain, “A model may consist of an idealized contemporary, but may also be a historical figure or a being represented as perfect” (p. 116). Foss, Foss, and Trapp (2014) offer a slight expansion in their characterization of Perelman and Olbrechts-Tyteca’s concept by mentioning legal precedents as models, considering events as models, in addition to people (p. 100). Argumentation by self-model, however, is given thorough consideration neither in The New Rhetoric nor in more current perspectives on the treatise. The closest consideration of the self as model is Perelman and Olbrechts-Tyteca’s mentioning, in passing, that “Descartes offers himself as model unto his readers” (p. 364). Similarly, in their depiction of argumentation by model, Gross and Dearin (2003) use a biblical example of the apostle Paul advising his followers to imitate him in Corinthians, but it is merely a passing reference (p. 72). The use of the self as model merits more consideration, as it is becoming ever more relevant in the digital age—not only socially, in an era of selfies and Facebook, but also professionally, in a climate of entrepreneurship and free-lance work. Holding oneself up as a model, in other words, could be the basis for one’s livelihood.

Argumentation by self-model differs markedly from its cognates (e.g., historical figures, perfect beings) in that it is more intertwined with the rhetor’s ethos. ² The use of the self as model intensifies the dependence of the argument on the rhetor’s ethos to the extent that it can overshadow, or even stand in for, the evidence for the claims being made. In the case of health communication examined here, the popular health coaches choose to elaborate on their experiences, such that the technique of argumentation by self-model takes on the form of a personal narrative. Narratives are pervasive, and, because of their tendency to pass as mere stories in the mainstream, they have the potential to be a particularly stealthy means of delivering an argument. For example, the fact that Nakayama’s story about her husband’s cancer diagnosis was a calculated persuasive technique may have gone unnoticed by untrained audience members; even Nakayama herself may have been unaware of her rhetorical choices. Scholars from across disciplinary boundaries have considered how and why narratives influence public perceptions and attitudes. As Fisher (1987) asserted, human beings are storytellers by nature—we are, as he puts it, homo narrans. Fisher’s narrative paradigm (elaborated in a monograph and series of articles in the 1980s) prompted widespread debate and led to the development of several rhetorical theories about narrative (see, e.g., Fisher, 1984, 1985, 1987).

Although it is impossible to do justice to these theories here, ³ a few narrative concepts are pertinent to this discussion of argumentation by self-model and need to be mentioned: fostering identification (McClure, 2009), inciting audiences to action (Lucaites & Condit, 1985), and creating a rhetoric of possibility (Kirkwood, 1992). First, taking issue with Fisher’s concept of rationality in narratives, McClure emphasizes the necessity of Burkean identification to narrative persuasion in “Resurrecting the Narrative Paradigm” (2009), arguing that “identification is the prime mechanism through which acceptance of an argument or story works or does not” (p. 200). Second, in “Re-constructing Narrative Theory” (1985), Lucaites and Condit argue that “the primary goal of a rhetorical narrative is to advocate something beyond itself” (p. 99). In other words, a rhetorical narrative is aimed at enlisting its audience members to participate or to take action (Lucaites & Condit, 1985, p. 100). Lastly, Kirkwood (1992) explains how the concept of “a rhetoric of possibility” is central to the functions of narratives, particularly in terms of inciting audiences to action. According to Kirkwood, “a rhetoric of possibility must explain how rhetors can evoke possibilities that exist beyond the context in which they first arise, and it must show how rhetors can convince people that these possibilities are within their grasp” (p. 33). Kirkwood’s narrative rhetoric of possibility is predicated on a communicator’s ability to present “the capacity for certain states of mind” and to “create a compelling need” for these possibilities (p. 44). In addition, a study that has a great deal of significance to the do-it-yourself health-care movement is Woodstock’s “All About Me, I Mean, You” (2006), in which she explains that certain techniques remained remarkably consistent in self-help literature between the 19th and 21st centuries, one of them being the authors’ predication of their ethos or authority on their own personal transformations.

Even going as far as to invoke argumentation by model, perhaps unwittingly, Woodstock (2006) explains that self-help authors use their personal transformations “to encourage others to model their own life story on the author’s” (p. 330). As Woodstock puts it, “personal experience, based on successful personal transformation, is the most central of the self-help authors’ claims to knowledge and ability to help others” (p. 328). The narrative concepts mentioned here are essential to expanding Perelman and Olbrechts-Tyteca’s argumentation by model to include the use of the self as model, so long as the communicator chooses to use a personal narrative, as opposed to a brief nod to their achievements. Argumentation by self-model is the predominant technique in the personal narratives of popular health coaches, who have to prove that they are at the pinnacle of health and wellness and are therefore worth imitating. But, by zeroing in on personal achievements, these coaches overlook the larger social movement toward do-it-yourself healthcare of which they are a part. Thus, I argue that argumentation by self-model is effective, and even necessary, in the realm of popular health coaching, but that the technique requires reinforcement to incite meaningful changes in healthcare.

Argumentation by Self-Model in the Do-It-Yourself Healthcare Movement

The wellness coaches and practitioners mentioned in this article have achieved wide recognition through social media channels, best-selling books, podcasts, and TED (Technology, Entertainment, Design) talks, and they have developed wellness-oriented businesses out of their personal and professional endeavors. Whatever the source(s) of initial recognition and fame, podcasting is the primary means of maintaining a prospective client base; free information provided on podcasts typically connects interested listeners to protocols and methods that are not free. Those who have podcasts typically feature interviews with other holistic practitioners and coaches, or they feature the advice of experts in relevant fields, such as psychology and spirituality, to strengthen the burgeoning wellness community’s ethos. ⁴ Based on their social visibility in various digital spaces, I submit the examples here as representative of personal narratives in the field of “do-it-yourself healthcare” in its emerging and formative stage. The narrative strategies of these do-it-yourself health-care proponents become clear when we look at the wide range of backgrounds from which these holistic health experts hail: (a) a “biohacker,” (b) a fitness guru, and (c) a celebrity-chef-turned-functional-nutritionist. ⁵

Below are snapshots of these three health coaches’ personal narratives that illuminate the technique of argumentation by self-model. The coaches all make two major moves to carry out this technique: First, they claim to be able to help audience members, and they give the impression that their personal situations were, at the start, similar to that of their audience members, which fosters identification. Second, the coaches present their own transformations as possible for their audience members (creating a rhetoric of possibility), thereby inspiring them to subscribe to their protocols (i.e., take action). A paraphrase of the overall argument is, “If you follow my lead, you can heal as I did,” which is an example of eductive reasoning. In Rhetorical Style (2011), Fahnestock explains that eduction is distinct from induction in that it reasons from parallel cases, predicting a new occurrence from a similar preceding one, as opposed to making a generalization (pp. 228–229). Using eductive reasoning, the health coaches argue that if something worked in a particular case (theirs), it will work in the prospective client’s case. Of particular interest in the following analysis is the way in which the coaches predicate their personal transformations on their decisions to abandon traditional medicine. The technique of argumentation by self-model therefore opens up the opportunity to the communicators to advance the tenets of holistic health and to invite audiences to take action in their own health matters.

Discussion

The rhetorical analysis in the previous section provides insight into the communicative choices of popular health coaches in their efforts to persuade audiences to abandon traditional medicine. In this section, I offer recommendations for improving these types of health communication efforts. Framing this article with Andrea Nakayama’s personal narrative was a calculated choice, as her narrative can stand as a model for the other popular health coaches. She, too, employs argumentation by self-model, but she supplements it with a statement of her methods for helping clients. In her narrative, Nakayama explains, “Using food and supplemental therapies, we work from the core of the body to heal the gut, balance hormones, and support the detoxification of organs” (Nakayama, 2016). By way of comparison, Stevenson actually refers to a “secret sauce” for helping his clients: “In order to become this incredible, strong, happy, healthy version of yourself, you first have to identify WHY you need to become it. And that’s where my secret sauce comes in” (Stevenson, 2015). The key distinction between Nakayama and the others is that she places value on her methods and thus presents her clients with a clear alternative to institutionalized medical care. When faced with a “secret sauce” and a brief, but concrete statement of methodology, an ailing person who is desperate enough for a cure might be persuaded either way. However, those who are in any way skeptical of alternatives to institutionalized medicine would be more likely to dismiss the “secret sauce,” and, possibly, holistic health in general. Rather than using argumentation by self-model as an advertisement or a “teaser”—and running the risk of losing prospective clients who are not already willing to agree with their premises—the coaches could elaborate on and highlight personal experiences and methods, as Nakayama does. The distinction between Nakayama and the others can be explained by Jensen et al.’s (2010) concept of a transcendent persona, which has argumentation by self-model at its core, though the authors do not explicitly mention it.

As I see it, the three main qualities of a transcendent persona, as explained by Jensen et al. (2010), overlap with the theories of narrative elaborated earlier in this article: (a) “the rhetor speaks from the position of having done that which others assumed was impossible, thus establishing credibility by proving wrong basic assumptions about the world”; (b) the rhetor must be able “to balance distance from audiences—the mystery—with similarities to them—identification”; and (c) the rhetor creates a “tool box from which audiences can draw to begin communicating and acting in transformative ways” (pp. 5–6). In the particular case examined in this essay, the personal narratives of health coaches follow a truncated version of this template; that is, they hold themselves up as models worthy of imitation, attempt to identify with their audiences, but stop short of creating a “tool box” for their audiences. By both describing traditional medicine as inadequate or misguided at best and damaging at worst, and championing holistic health principles, the coaches set up an opportunity to describe their protocols to prospective clients, but they do not follow through. Nakayama, however, does offer tools in the form of a brief statement of her methods. Although this distinction may seem minor, it could mean the difference between preaching to the choir, so to speak, and reaching audience members who may be skeptical about alternative or holistic health. In other words, the variable of a presentation of methods—the equivalent of a “tool box,” in Jensen et al.’s terminology—might be the key to inciting social action and creating change in the context of the tensions between holistic health and traditional medicine.

To capitalize on the opportunity, the coaches would have to configure their values, which, in many instances, align with the Mayo Clinic Proceedings article’s description of clinical reasoning, into a statement of their methods. For example, the practices that the health coaches used to heal themselves, such as attending to their unique physiologies, taking into consideration their whole bodies when addressing issues, and integrating mental wellness into healing processes can all be seen as aspects of “clinical reasoning.” Jamieson, for instance, characterizes the “world of health” as “body-shaming, nutrition-crazy, upside-down” and distinguishes her approach by emphasizing “a positive mindset” to reconnect the mind with the body (Jamieson, 2015). Casting their strengths explicitly as the very weaknesses of EBM, elaborating on how their approaches differ from the treatment they received from traditional doctors, might assist communicators in persuading more skeptical audience members, but, more importantly, it would position them to make a broader social argument for trying holistic health protocols.

On the flipside, the concept of argumentation by self-model could prove useful to the communicative efforts of traditional medical doctors, who perhaps focus too much on methods at the expense of cultivating personal connections with clients. Although traditional medical doctors consider their approaches to be evidence-based, as opposed to the “non-scientific” approaches of holistic health practitioners, their methods are just as rhetorical as their holistic counterparts. Still, doctors may resist using appeals from pathos, likely thanks to the longstanding tradition of shunning emotional discourse in scientific studies, which privilege “objectivity” (see, e.g., Waddell, 1997). The traditional concept of a good doctor as resolute and reliant on “objective” data is an example of the rhetorical techniques embraced by evidence-based medicine. In studying autism rhetorics, Jack (2014) has noted that doctors have had to learn to use emotional appeals in order to respond to what she calls “mother warriors,” who are opposed to vaccinating their children:

Responding to mother warriors has required scientists and doctors to develop new forms of authority and appeal, including emotional appeals not usually considered appropriate for the character of the paternalistic, disinterested scientist. (p. 103)

Argumentation by model could offer a new way of approaching these fraught relationships. For example, doctors could use their own experiences as patients in order to create a sense of identification with their patients, or they could use their experiences with other patients (without using names and identifiers, so as to prevent ethical breeches) to explore treatment options. One could argue that evidence-based medicine will eventually need to engage with the emotional appeals used by holistic health practitioners in order to maintain its privileged status in society.

Conclusion

Popular health coaches leading the do-it-yourself health-care movement are, at least in the short term, profiting from personal narratives that employ argumentation by self-model to stand in for their methods for helping clients. Considering their narratives in the larger context of EBM’s recent self-critique, however, we could argue that, in the long term, over-valuing personal experience and under-valuing methods will be insufficient for sparking the change in healthcare that Nakayama advocates for in her talk mentioned at the beginning of this essay. The use of argumentation by self-model serves the individual projects of the coaches, but, when used on its own, it also suggests a lack of awareness of the larger social issues regarding healthcare. Like the other health coaches, Nakayama does use herself as a model for her audience, but unlike the other health coaches, she also discusses her methods for helping clients and explicitly distinguishes them from mainstream medical practice. Put differently, seizing the rhetorical moment entails engaging with the realization in the EBM community that over-reliance on “logical,” “objective” data is ineffective and that treating the unique individual ought to be paramount.

In addition to showing a persuasive trend in popular health communication, this article has introduced a new way of looking at Perelman and Olbrechts-Tyteca’s concept of argumentation by model by considering the persuasive effects of the use of the self as model. Whereas Perelman and Olbrechts-Tyteca and scholars of their work have mentioned the possibility of using the self as model in passing, there has not yet been a full consideration of this iteration of the technique. Argumentation by self-model can range from communicators giving a brief mention of their personal achievements to elaborating on their experiences to create a narrative, the latter being the focus of this paper. By analyzing the usage of argumentation by self-model in the context of the do-it-yourself health-care movement, I have hoped to provide insight into what the technique can offer communicators, in addition to considering its limitations.

Argumentation by self-model will likely have a different set of advantages and disadvantages in other situations. The technique could be used as a theoretical apparatus for analyzing discourse in online forums—health forums, to be sure—but also forums used for other purposes, such as product or business reviews. Further exploration of the concept might consider cases in which it is used in conjunction with other means of persuasion to bring about positive (or negative) effects. If used purposefully and in conjunction with other forms of evidence, argumentation by self-model could be quite advantageous in the digital era. For example, the use of argumentation by self-model is likely prolific in the business sector, especially by entrepreneurs and free-lancers who rely on their carefully constructed presentation of their previous experiences for employment opportunities. Moreover, studying the ways in which successful entrepreneurs hold themselves up as models can be of pedagogical use, particularly in technical and professional communication. Acknowledging the technique of argumentation by self-model as a unique iteration of Perelman and Olbrechts-Tyteca’s concept of argumentation by model affords scholars and teachers a new way of exploring the boundaries between personal and professional communication.