CARA: Integrating even more pseudoscience into veterans’ healthcare

Every few years, Congress hands the Department of Veterans Affairs (VA) a new mission with a name that sounds like a
Marvel side quest. In 2016, that mission arrived as CARAthe Comprehensive Addiction and Recovery Act. On its face,
CARA is about substance use disorder prevention, treatment, and recovery. But tucked inside its VA-focused sections is a
very different storyline: expand “complementary and integrative health” (CIH) inside veterans’ care.^[1]

That sounds wholesomewho doesn’t want veterans to have more options than “here’s a pill, good luck”? The complication is
that CIH is a big umbrella. Under it you’ll find practices with decent evidence (like certain mind-body therapies for pain),
alongside ideas that range from “unproven” to “implausible” to “this was invented in a strip-mall office with a salt lamp.”
CARA doesn’t cleanly separate those categories. It accelerates integration, while the VA then has to build guardrails fast
enough to keep “more options” from becoming “more nonsense.”^[2]

What CARA actually asks the VA to do

The most quoted CIH-related piece is a section that lays out a sweeping VA plan: within 180 days, develop a strategy to
materially and substantially expand research, education, and delivery/integration of complementary and integrative health
services across VA care.^[3] This isn’t just “allow yoga in the rec room.” It’s an instruction to build infrastructure:
research priorities, training for VA clinicians, and metrics to measure whether any of this works.^[3]

CARA also pushes the VA toward pilots and evaluation. The idea is to test whether CIH and wellness-based programs can
complement pain management and related services (including mental health care), and then report outcomes and barriers.^[4]
The intentreduce suffering, improve function, and avoid overreliance on high-risk medicationsmakes sense in the context of
the opioid crisis and chronic pain burden.

The “COVER Commission” and the problem with open-ended lists

Here’s where the pseudoscience anxiety kicks in. In the VA portions of CARA, Congress calls for a commission to examine
VA’s evidence-based therapy model for mental health conditions and explore the potential benefits of incorporating CIH as
standard practice.^[1] The commission is asked to review a list of therapies that reads like a cross between a wellness
brochure and a late-night infomercial: music therapy, equine therapy, service dogs, yoga therapy, acupuncture therapy,
meditation therapy, outdoor sports therapy, hyperbaric oxygen therapy, accelerated resolution therapy, art therapy, and
“magnetic resonance therapy”plus “other therapies the Commission determines appropriate.”^[1]

Some items on that list are mainstream-adjacent or clearly “reasonable to study.” Yoga and meditation have plausible
mechanisms and growing evidence for certain outcomes. Service dogs can be profoundly meaningful for some veterans’ daily
function. But several entries are either (a) condition-specific and controversial (hyperbaric oxygen for certain mental health
claims), (b) ambiguous in the way legislative language can be (“magnetic resonance therapy” can be interpreted multiple ways),
or (c) so broad that the phrase “other therapies” becomes a gateway to… well, anything with a lobbyist and a brochure.
That’s not how you build an evidence hierarchy; it’s how you build a buffet line.^[1]

CARA does include a couple of “please don’t make this a cash grab” protections: the commission’s members are supposed to be
of recognized standing with experience treating mental health and working with military/veteran populations, and they should
not have a financial interest in the therapies being reviewed.^[1] That’s helpfulbut it doesn’t automatically sort
strong evidence from weak evidence, or plausibility from magical thinking.

Why CIH became attractive policy in the first place

To understand why CIH gained momentum, you have to remember what veterans’ health systems were trying to solve: chronic pain,
trauma-related conditions, sleep problems, anxiety, depression, and functional impairmentoften overlapping in the same person.
In that landscape, “one medication at a time” can snowball into polypharmacy, side effects, dependence, and disappointment.

Major public health guidance in the U.S. has increasingly emphasized multimodal pain care and the value of nonpharmacologic
options. The CDC’s 2022 opioid prescribing guideline points out that multiple noninvasive nonpharmacologic interventions can
improve chronic pain and function with small-to-moderate effects in specific conditions, generally without serious harmsand
it explicitly discusses approaches like acupuncture, massage, mindfulness-based interventions, tai chi, and yoga in the
broader context of pain management.^[5]

The National Center for Complementary and Integrative Health (NCCIH, part of NIH) also describes a reality clinicians already
live with: many complementary approaches show modest benefits, the evidence quality varies widely by condition, and
guidelines from mainstream professional organizations increasingly include certain complementary optionsespecially for
chronic low-back pain and other musculoskeletal problems.^[6]

Evidence check: what’s solid, what’s “maybe,” and what’s wishcasting

A useful way to think about CIH is to sort it into three buckets: supported, promising but limited,
and implausible/unsupported. CARA doesn’t do this sorting for youso the VA (and clinicians) have to.

Bucket 1: Supported enough to be in real guidelines

For chronic low-back pain, professional guidelines have encouraged nonpharmacologic first-line treatments that include options
such as acupuncture, mindfulness-based stress reduction, tai chi, yoga, progressive relaxation, biofeedback, and spinal
manipulationalongside conventional approaches like exercise and cognitive behavioral therapy.^[6] That doesn’t mean
these methods are miracle cures; it means they’re reasonable tools, with benefits that may be meaningful to some patients and
generally low risk when delivered appropriately.

NCCIH’s summaries are blunt in a very science-y way: effects are often small to moderate, and the quality/amount of evidence
varies by condition and intervention.^[7] But “small” can still matter if it helps someone sleep, move, and function
without escalating medication risk.

Bucket 2: Promising, but easily oversold

Acupuncture is a good example of “promising but frequently oversold.” NCCIH notes evidence for certain painful conditions,
including findings where acupuncture outperformed no treatment and sometimes sham acupuncture, with benefits that can persist
after treatmentwhile also showing that effect sizes and certainty vary by condition and study design.^[8] Translation:
it may help, especially for some pain syndromes, but it’s not a universal remote for the nervous system.

Yoga is similar: evidence suggests it can improve pain and function for chronic low-back pain, sometimes with effects similar
to exercise, and it may help related issues like distress and sleep for some people. But it’s not automatically superior to
physical therapy, and outcomes depend on the program, adherence, and patient fit.^[9]

Bucket 3: Implausible/unsupported (a.k.a. “please don’t bill the VA for vibes”)

This is where the word “pseudoscience” earns its keep. The more a therapy relies on claims that contradict basic biology
(“memory water,” invisible energy fields that only the practitioner can sense, detox pathways that don’t exist), the higher
the evidentiary bar should bebecause extraordinary claims require extraordinary evidence. CARA’s open-ended language (“other
therapies”) creates a risk: once a health system publicly commits to “integrating CIH,” vendors of dubious modalities can
argue they deserve a seat at the table.^[1]

It’s also easy to confuse “low risk” with “worth funding.” A therapy might be physically safe but still waste resources if it
crowds out evidence-based care, delays effective treatment, or drains budgets that could have paid for more mental health
clinicians, physical therapists, or pain psychologists.

The VA’s guardrails: how it tries to integrate CIH without abandoning science

Whatever critics fear Congress might accidentally unleash, the VA has tried to define CIH in a controlled, policy-driven way.
In its directive governing CIH approaches, the VA states clearly that CIH must be offered as a complement to
conventional carenot as an alternativeand that appropriateness is still a clinical judgment with contraindications and
patient preferences in view.^[10]

The same directive also defines a required list of CIH approaches that must be made available across the VA
health care system (through VA facilities or community networks): acupuncture, biofeedback, clinical hypnosis, guided imagery,
massage therapy, meditation, tai chi/qigong, and yoga.^[11] Notice what’s missing: homeopathy, “energy healing,”
detox regimens, and other high-implausibility greatest hits.

Even the required list comes with caveats: the VA describes the list as guidance, emphasizes evidence alongside conventional
care, and notes the list can evolvemodalities can become conventional over time or be removed later based on emerging
evidence and practice changes.^[12] That is what a science-aligned system should do: treat the benefits package as a
living document.

So… is CARA integrating pseudoscience, or integrating options?

The honest answer is: it depends on implementation. CARA’s language pushes expansion and exploration. That
can be good when it funds pragmatic research, clinician training, and careful measurement. It’s risky when it treats “CIH”
like a brand identitysomething you adopt to appear progressiverather than a set of interventions that must individually
earn their place.

Critics have argued that CARA’s VA provisions create a pathway for pseudoscience by bundling credible and questionable
therapies together and by encouraging broad integration without a built-in filter for plausibility.^[2] Supporters
counter that veterans deserve more toolsparticularly for pain and mental healthand that studying a wider menu is reasonable
as long as the system protects patients from false claims and tracks outcomes.

The VA’s own policy stance suggests it’s aiming for a middle path: expand access to a defined set of generally accepted CIH
practices; keep them adjunctive; require training standards; and maintain the ability to add or remove approaches as evidence
changes.^[10]

How to keep “integrative” from becoming “anything goes”

If you want CIH to help veterans without funding pseudoscience, here are the practical rules of the road:

• Demand condition-specific evidence, not vibe-based marketing. “Helps pain” is not a diagnosis, and “holistic”
  is not a mechanism.
• Use stepped care. Start with low-risk, evidence-aligned options (movement, sleep support, CBT approaches,
  mindfulness-based interventions) and escalate thoughtfully.
• Measure outcomes that matter. Pain intensity is one metric, but function, sleep, mood, and quality of life
  often matter moreand can be tracked.
• Train and credential practitioners. “Certified” should mean trained in a way that stands up to peer review,
  not just membership in a trade association with a nice logo.
• Be willing to de-adopt. If an intervention doesn’t work in real-world VA settings, or if the benefit is too
  small for the cost, it should be removedno matter how trendy it was on morning TV.

Conclusion

CARA’s push for complementary and integrative health inside veterans’ healthcare is a classic policy trade: it opens doors to
potentially helpful, lower-risk options for pain and mental health, while also creating a wider entrance for therapies that
may be unproven, oversold, or scientifically implausible.^[1] The difference between “innovation” and “pseudoscience”
isn’t your brandingit’s your evidence, your outcomes, and your willingness to say “no” when something doesn’t deliver.

The best-case scenario is a VA that uses CARA’s momentum to fund real research, expand access to carefully vetted CIH
services, and give veterans more ways to regain function and quality of lifewithout replacing evidence-based medicine with
wishful thinking. The worst-case scenario is a slow drift toward “anything that feels good must be good,” paid for at scale.
Guardrails decide which future you get.^[10]

Postscript: experiences on the ground (what veterans and clinicians often describe)

When people debate “integrative health,” the conversation can get abstract fastpolicy language, evidence grading, and the
eternal tug-of-war between “keep an open mind” and “please keep your mind attached to your brain.” But veterans don’t live in
abstracts. They live in bodies that hurt, nervous systems that stay on high alert, and schedules that don’t always make room
for weekly appointments across town. The experiences below are composite snapshots based on common themes reported in
veterans’ care discussions: what it feels like when CIH is offered well, and what it feels like when it isn’t.

1) The relief of being treated like a whole person. Many veterans describe a moment of surprise when a
clinician asks, “What matters most to you?” instead of launching straight into symptoms. For some, a yoga or tai chi class
isn’t primarily about flexibilityit’s about reclaiming agency. The win isn’t “my pain vanished.” The win is “I slept six
hours,” “I walked the dog,” or “I made it through a crowded grocery store without feeling like my chest was a siren.”
Even modest gains can feel huge when the baseline has been months (or years) of grinding discomfort.

2) Skepticism that melts only when outcomes show up. A common attitude is: “I didn’t join the military to do
breathing exercises.” Fair! Plenty of veterans walk into meditation or guided imagery expecting nonsenseand walk out saying,
“Okay, I hate that this helped.” That kind of reluctant buy-in matters because it’s grounded in lived results. When clinicians
present CIH as an optional tool (not a moral virtue) and set realistic expectations (“this may modestly reduce symptoms and
improve coping”), veterans are more likely to try it without feeling patronized.

3) Frustration when CIH is used as a substitute for real access. The experience flips when CIH feels like a
diversion: “We can’t get you into physical therapy for six weeks, but here’s a handout about mindfulness.” Mind-body tools
can be valuable, but veterans often notice when systems use them to paper over staffing gaps. Integrative care works best when
it’s additivepaired with physical therapy, behavioral health, and medical managementnot when it’s deployed as a budget
Band-Aid.

4) Trust rises when the VA is transparent about evidence. Veterans tend to respond well to straight talk:
“Here’s what we know, here’s what we don’t, and here’s what we’ll track.” When clinicians explain that benefits are usually
modest, that not every approach fits every condition, and that the goal is improved function (not mystical healing),
skepticism becomes collaboration. In contrast, when anyoneVA or outside vendorsclaims a therapy “treats everything,” veterans
often read that as salesmanship, not healthcare.

5) Clinicians describe a practical upside: fewer ‘only two tools’ conversations. Providers working with pain,
trauma, and insomnia often describe the grind of limited options: escalate meds, refer out, repeat. A well-run CIH program can
give clinicians additional off-ramps: massage for muscle tension, biofeedback for autonomic regulation, acupuncture as an
adjunct for certain pain patterns, tai chi/qigong for safe movement, and structured hypnosis or guided imagery for coping and
sleep. The best clinician experiences aren’t about ideology; they’re about having more levers to pull when the usual ones
aren’t enough.

6) The red line veterans often draw: don’t insult our intelligence. Veterans may be open to trying many
thingsespecially low-risk optionsbut they’re quick to reject anything that sounds like magical thinking. The programs that
earn trust tend to be the ones that respect veterans as adults: explain the rationale, encourage questions, and never imply
that pain is “all in your head.” When CIH is delivered with humility and data, it can feel empowering. When it’s delivered
with hype and certainty, it can feel like pseudoscienceno matter how soothing the music is.