As a PMH-APRN, you may have clients who use integrative therapies in conjunction with the conventional therapies prescribed by the health care provider. Identify issues that are important to assess, and discuss how you would ask about the use of these non-conventional practices.
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Complementary and Alternative Medicine (CAM) in Psychiatry
The revolution and re-conceptualization of health and healing that has occurred in the Western health care system in the last 20 years has given opportunity for a paradigmatic shift in health care education, research, and practice. More than one hundred years ago, the American health care system was dominated by the biomedical worldview. Today, this is no longer true. Support for complementary and alternative medicine (CAM), also called natural, alternative, and complementary (NAC) therapies, and holistic practices, has never been greater than at the present time.
CAM is a form of integrative care. Integrative care places the client at the center of care, focuses on prevention and wellness, and attends to the client’s physical, mental, and spiritual needs (Institute of Medicine [IOM], 2009). Integrative care is directed at healing and considers the whole person (mind, body, and spirit), along with the lifestyle of the person. Holism is described as involving (l) the identification of the interrelationships of the bio-psychosocial-spiritual dimensions of the person, recognizing that the whole is greater than the sum of its parts, and (2) understanding of the individual as a unitary whole in mutual process with the environment (American Holistic Nurses Association [AHNA], 2004). Because of growing interest in and use of holism and CAM in the United States, the National Institutes of Health (NIH) established the National Center for Complementary and Alternative Medicine (NCCAM) in 1998. The NCCAM supports fair and scientific evaluation of integrative therapies and dissemination of information that allows health care providers to make good choices regarding the safety and appropriateness of CAM. The holistic natural, alternative, and complementary (NAC) therapies that are commonly used today in the United States include:
· Chiropractic manipulation
· Diet-based therapies
· Deep-breathing exercises
· Energy healing therapy/Reiki
· Exercise therapy
· Guided imagery
· Herbal therapy
· Prayer and spiritual practices
Although research on the efficacy of CAM is increasing, studies in the field are minimal when compared to those of conventional medicine. According to Zahourek (2005), several reasons for CAM research challenges include:
· The relatively recent use of some of these therapies in the United States
· Individual, cultural, and environmental variables
· Lack of or limited funding sources
· Time as a variable to measure change
· Interpretation and meaning of an experience
· Impact of other intervening life experiences
· Effect and timing of a specific intervention or approach on a particular problem, specifically placebo and experimental effects
· Personality, belief systems, spiritual practices, and temperament of both the researcher and participants
· Difficulty trying to standardize modalities, variations in methods, approach and skill of the researcher
· Influence of studying a phenomenon or person within a naturalistic setting
· Interpretation of results
· The recognized value of both qualitative and quantitative results
· Acknowledging the importance of the re he relationship between the healer and the one being healed
If a pharmaceutical company studies and patents a drug, it can reap considerable financial return; however, an herb cannot be patented and exclusively marketed, so there is little incentive to invest in researching its uses and effects. Governmental sources of funding such as the NCCAM and NIH, as well as nonprofit groups, are continuing to sponsor research that should contribute to further understanding of CAM. Nursing groups such as Healing Touch International and the American Holistic Nurses Association (AHNA) are emphasizing research and are beginning to catalogue research on their websites.
Consumers and Integrative Care
Consumers are attracted to integrative care for a variety of reasons, including:
· A desire to be an active participant in one’s health care and engage in holistic practices that can promote health and healing
· A desire to find therapeutic approaches that seem to carry lower risks than medications
· A desire to find less expensive alternatives to high-cost conventional care
· Positive experiences with holistic, integrative CAM practitioners, who tend to spend more time with and learn about their clients as a whole
· Dissatisfaction with the practice style of conventional medicine (e.g., rushed office visits, short hospital stays)
· A need to find modalities and remedies that provide comfort for chronic conditions for which no conventional medical cure exists, such as anxiety, chronic pain, and depression
The knowledgeable consumer, relying on health information available through public libraries, popular bookstores, and the Internet, may question conventional health care. It is essential that PMH-APRNs maintain up-to-date knowledge of these modalities, continue to evaluate the evidence supporting the effectiveness and safety of CAM, and be able to guide patients in their safe use of these treatments.
Safety and Efficacy – People who use CAM therapies often do so withoutinforming their conventional health care providers, which poses some risk. In the United States, there are no standards or regulations that guarantee the safety or efficacy of herbal products. Herbs and other food supplements do not have to undergo the same safety review as over-the-counter and prescription medications. Some consumers may believe that if they purchase a natural substance at a health food store, it must be safe and effective; however, “natural” does not mean “harmless.” Herbal products and supplements may contain powerful active ingredients that can cause damage if taken inappropriately. Furthermore, the consumer cannot be sure that the amount of the herb or other active ingredient listed on the label is actually the amount in the product.
Consumers may waste a great deal of money and risk their health on unproven, fraudulently marketed, useless, or harmful products and treatments. Another concern regarding CAM therapies is that diagnosis and treatment may be delayed while clients try alternative interventions, which is common with mental health symptoms such as major depression and anxiety.
The US Food and Drug Administration (FDA; 2009) offers seven warning signs of fraud:
1. The product is advertised as a quick and effective cure-all for a wide range of ailments.
2. The promoters use words like “scientific breakthrough, miraculous cure, exclusive product, secret ingredient, or ancient remedy.”
3. The text is written using impressive terminology to disguise lack of good science.
4. The promoter claims the government, the medical profession, or research scientists have conspired to suppress the product.
5. The advertisement includes undocumented case histories claiming amazing results.
6. The product is advertised as available from only one source, and payment is required in advance. ·
7. The promoter promises a “no-risk, money-back guarantee.”
Cost – The growth in the use of CAM therapies is also linked to the rising cost of conventional medical care. There is mounting pressure to control health care spending in the United States and many other countries, and efforts are focused on the development of less expensive treatments. Before we can adopt alternative methods of treatment, however, even those that are less expensive, it is essential that we have reliable information about the clinical effectiveness of these treatment methods. Research on herbs such as St. John’s wort, valerian, and ginkgo biloba and mind-body interventions such as yoga and meditation is extensive, and results are available on the NCCAM website. These supplements and approaches may prove effective and less costly than prescription drugs that produce similar results; however, it is imperative that data be available to identify the desired and adverse effects of these treatments.
Reimbursement – Payment for CAM services comes from a wide array of sources, although third-party coverage is still the exception rather than the rule. Research in the 1990s revealed that more money was being spent out of pocket on CAM than on primary care visits (Eisenberg, 1993), and out-of-pocket payments remain the principal source of spending on CAM. Some health insurance companies include coverage for certain modalities, particularly chiropractic medicine, nutritional care, massage, mind-body approaches, and acupuncture (Dumoff, 2004). The covered benefits are quite narrowly defined, however. For instance, acupuncture can be used in some plans only as an alternative to anesthesia.
Placebo Effect – Some people make the claim that integrative therapies work through a mechanism known as the placebo effect. This placebo effect refers to a treatment which actually does nothing, yet the condition for which it is used improves. The improvement comes about based on the power of suggestion and a belief that the treatment works. Research continues and is necessary to refute or support this claim. Yet, integrative care is based on optimism; a positive approach and the use of positive suggestions, no matter what treatment modality is being implemented, has a greater chance of success than if communication is negative or fosters a poor response. The placebo effect can be most powerful when the need is greatest and a trusting relationship has been established between client and relationship has been established between client and care giver. Saying “This will hurt” (more negative) may result in a negative placebo effect; whereas, “This may cause some brief discomfort, but I know it can make you better” (more positive) may result in a positive placebo effect. A major report on the mechanism and value of the placebo as a mind-body response can be found in the CAM at the NIH newsletter (NCCAM, Summer, 2007).
Obtaining Credentials in Integrative Care
Nurses in any setting should have a basic knowledge of treatments used in integrative care for several reasons. One is that they care for clients who increasingly are using a variety of unconventional modalities to meet their health needs. To fully understand the needs of clients, it is essential that nurses ask questions about the use of CAM as part of a holistic assessment. Holistic assessments include the traditional areas of inquiry such as history, present illness, family medical history, history of surgeries, as well as medications taken and response to these medications. However, the holistic-integrative assessment also includes areas such as the quality of social relationships, the meaning of work, the impact of major stressors in the person’s life, strategies used to cope with stress (including relaxation, meditation, deep breathing, etc.), and the importance of spirituality and religion and cultural values in the person’s life. Clients also are asked what they really love, how this is manifested in their lives, what their strengths are, and to identify the personal gifts they bring to the world (Maizes et al., 2003). The use CAM as part of a holistic assessment is encouraged by both NCCAM (2008) and by newer standards of nursing practice.
Nursing education programs are including basic integrative modalities such as relaxation and imagery in nursing curricula, and some may include energy-based approaches such as therapeutic touch. In 2004, almost 75% of U.S. medical schools had some type of curriculum offering in the area of integrative care (Lee et al., 2004). Presently, there are five graduate programs in the United States that prepare nurses with a specialty in holistic nursing. Doctor of Nursing Practice (DNP) programs with an emphasis in holistic nursing are also now in development. Numerous post-masters certificate programs exist for advanced practice nurses (APNs) and clinical nurse specialists (CNSs) from other specialty areas. The American Holistic Nursing Credentialing Center (AHNCC) offers two levels of certification: the holistic nurse-board certified (HN-BC) and the advanced holistic nurse-board certified (AHN-BC). Credentialing procedures are also in place for many of the non-nursing modalities, such as acupuncture, chiropractic medicine, naturopathy, and massage therapy. Efforts are being made to legitimize integrative care through credentialing of integrative physicians and non-physician practitioners.
Classification of Integrative Care
Integrative care is classified according to a general approach to care and is separated into four domains: (l) mind-body approaches, (2) biologically based practices, (3) manipulative practices and (4) energy therapies. An additional category, alternative medical systems, includes comprehensive systems that evolved separately from conventional modalities (e.g., traditional Chinese medicine and Ayurvedic medicine).
1. Mind-Body (MB) Approaches
Mind-body (MB) approaches make use of the continuous interaction between mind and body. Most of these techniques emphasize facilitating the mind’s capacity to affect bodily function and symptoms, but the reverse (bodily illness affects on mental health) is also part of the equation. These approaches are based on the recent research advances in psychoneuroimmunology and psychoneuroendocrinology.
The MB relationship is well accepted in conventional medicine and probably is the domain most familiar to PMH-APRNs. Many of the MB interventions, such as cognitive-behavioral therapy, relaxation techniques, guided imagery, hypnosis, and support groups are now considered mainstream and have been the subject of considerable research (Anselmo, 2009; Schaub & Dossey, 2009).
A. Guided Imagery
The use of guided imagery has been in the nursing literature for at least 3 decades. Different forms of imagery include (l) behavioral rehearsal imagery, (2) impromptu imagery, (3) biologically based imagery, and (4) symbolic and metaphoric imagery. Imagery is a holistic phenomenon as a “multidimensional mental representation of reality and fantasy that includes not only visual pictures, but also remembrance of situations and experiences such as sound, smell, touch, movement and taste” (Zahourek 2002, p. 113)
Imagery is used as a therapeutic tool for treating anxiety, pain, psychological trauma, and PTSD. Imagery may be combined with cognitive-behavioral therapy to help war veterans and people who have survived natural disasters. Imagery is used to enhance coping prior to childbirth or surgery, augment treatment, and minimize side effects of medications. It may help people cope with difficult times if they can imagine themselves as strong, coping, and eventually finding meaning in their experience.
Biofeedback is the use of some form of external equipment or method of feedback (some as simple as a handheld thermometer) that informs a person about his or her psychophysiological processes and state of arousal (Anselmo, 2009). This process enables the person to begin to voluntarily control reactions that were previously outside conscious awareness. Biofeedback has been extensively practiced and researched since the 1960s, and many nurses now hold certification in this modality.
What is Biofeedback therapy? See at
C. Hypnosis and Therapeutic Suggestion
Hypnosis is both a state of awareness (consciousness) and an intervention. As a state of consciousness, hypnosis IS a natural focusing of attention that varies from mild to greater susceptibility to suggestion. In stress states, people are more susceptible to suggestion because their focus of attention is narrowed. People who dissociate in traumatic situations are in a trance-like state. When we use relaxation and imagery techniques, individuals frequently will enter a similarly altered state of awareness, or trance-like state.
Several forms of meditation are available to people and have in recent years become popular self-help methods to reduce stress and promote wellness. Meditation practices include such simple behaviors as consciously breathing and focusing attention while walking. There are various meditation video clips posted on YouTube.
E. Deep Breathing Exercises
Deep breathing is important from the standpoint of both health and spiritual development. Deep breathing increases our vitality and promotes relaxation. Unfortunately, when we try to take a so-called deep breath, most of us do the exact opposite: we suck in our bellies and raise our shoulders. This is shallow breathing. To learn deep breathing we need to do far more than learn new breathing exercises. Before deep breathing exercises can be of any lasting value, we need to experience and understand through the direct inner sensation of our own bodies the function of the chest and diaphragm in breathing, as well as the function of the belly, lower ribs, and lower back. We also need to observe how unnecessary tension in our muscles impedes our breathing.
The Mechanics of Deep Breathing – The diaphragm is a dome-shaped structure that not only assists in breathing, but also acts as a natural partition between our heart and lungs on the one hand, and all of the other internal organs on the other. The top of the diaphragm, located about one and one-half inches up from the bottom of the sternum, actually supports the heart, while the bottom of the diaphragm is attached all the way around our lower ribs and connects also to our lower lumbar vertebrae. When we breathe, the surface of our diaphragm generally moves downward as we inhale and upward as we exhale. (See if you can sense these movements periodically throughout your day.) When we breathe fully and deeply, the diaphragm moves farther down into the abdomen and our lungs are able to expand more completely into the chest cavity. This means that more oxygen is taken in and more carbon dioxide is released with each breath. Deep breathing takes advantage of the fact that the lungs are larger toward the bottom than the top.
The Impact of Deep Breathing on Our Health – Deep breathing can have a powerful influence on our health. To understand how this is possible, we need to remember that the diaphragm is attached all around the lower ribcage and has strands going down to the lumbar vertebrae. When our breathing is full and deep, the diaphragm moves through its entire range downward to massage the liver, stomach, and other organs and tissues below it, and upward to massage the heart. When our breathing is full and deep, the belly, lower ribcage, and lower back all expand on inhalation, thus drawing the diaphragm down deeper into the abdomen, and retract on exhalation, allowing the diaphragm to move fully upward toward the heart. In deep, abdominal breathing, the downward and upward movements of the diaphragm, combined with the outward and inward movements of the belly, ribcage, and lower back, help to massage and detoxify our inner organs, promote blood flow and peristalsis, and pump the lymph more efficiently through our lymphatic system. The lymphatic system, which is an important part of our immune system, has no pump other than muscular movements, including the movements of breathing.
Deep Breathing for Relaxation
Many of us breathe too fast for the conditions in which we find ourselves, that is, we actually hyperventilate. This fast, shallow breathing expels carbon dioxide too quickly and has many bad effects on our physical and emotional health. When our breathing is deep, however–when it involves in an appropriate way not only the respiratory muscles of the chest but also the belly, lower ribcage, and lower back–our breathing slows down. This slower, deeper breathing, combined with the rhythmical pumping of our diaphragm, abdomen, and belly, helps turn on our parasympathetic nervous system–our “relaxation response.” Such breathing helps to harmonize our nervous system and reduce the amount of stress in our lives. And this, of course, has a positive impact on our overall health.
F. Prayer/Spiritual Practices
The practice of spiritual healing is very common. The use of spiritual healing practices, especially prayer, and energy healing practices is growing (Eisenberg et al., 1998). The practice of spiritual healing is not limited to any one religion. Spiritual healing can involve such activities as going to a church or mosque, worshipping an idol or a mountain, using prayer wheels, (such as in Buddhism), visiting a hospital chapel, and meditating. It can also involve spiritual interventions, such as going to a group bible study or prayer group; reading the Bible, Koran, or other religious book; receiving pastoral visits in a hospital; confessing; and any other spiritual activity or intervention intended for the purpose of worshipping, fellowshipping with a group, or individual healing.
Spiritual healing practices can be found in every culture (Jonas & Crawford, 2003). These holistic practices allow devoted practitioners to transcend the ordinary world to a space where they are able to communicate with a higher being. Spiritual healing practices are sometimes examined in the same context as energy therapies, and the NCCAM often classifies these therapies together.
Spiritual healing practices are therapeutic healing practices that have been in existence since the beginning of civilization. They are a part of every culture’s healing practices (Jonas & Crawford, 2003). These practices are holistic because they are designed to connect the body with the mind and spirit. In addition, spiritual healing practices allow devoted practitioners to transcend the ordinary world to a place where they are able to communicate with a higher being, such as God, or the object of their belief.
Spiritual healing is sometimes referred to as faith, energetic, mystical, and shamanic healing. However, shamanism is not simply spiritual healing. In many cultures, shamans are herbalists and community leaders that fulfill certain social and cultural non-health-related obligations. Although shamanism is not a religion, it is a form of spiritual tradition that addresses key elements, such as marriage, rites of passage, death and dying, and parenting. In many cultures, shamans operate based on a state of consciousness. They may also be called imaginative healers, voodooists, native doctors, wise men, priests, and witch crafters, among other names. Some of these names have resulted in shamans being perceived in a negative light (Rankin-Box, 2001; Hung-Youn, 1999; Townsend, 2001).
Spiritual healing practices and religions are not one and the same. Every religion, however, has specific ways of practicing spiritual healing. The majority of the time, such practices are guided by the beliefs and assumptions of that particular religion, and not all citizens of a particular culture share the same religious beliefs. The relationship between spirituality and spiritual healing practices and health has been an integral part of the nursing profession since its inception. Although the use of spiritual healing practices started during the time of Florence Nightingale and these practices were popular in the nursing care approaches of early nursing schools, only recently, with the resurgence of NAC therapies, have they begun to gain increasing attention in modern nursing and medicine.
Of all the spiritual healing practices, prayer is the one most commonly used. Prayer is defined as “healing intentions or appeals directed toward a higher being, force, or power” (Ameling, 2000). To pray is to ask for something with earnestness or zeal or to supplicate, beg, or give thanks to an object of worship. Prayer can also be defined as “the act of asking for a favor with earnestness or a solemn petition addressed to an object of worship.” It can take place in public or private.
Prayer is not unique to one religion; it is practiced by most of the world’s major religions, including Christianity, Judaism, Islam, Hinduism, and Buddhism. In these various religions, beliefs do not always relate to the same god. Some religions may worship more than one god or another higher power. In addition, some religions are guided not by the word of God but by prophets, religious founders, and the traditions of the cultures in which they originated. True prayer with dedication can help to achieve moments of transcendence.
Online Resources for Prayer/Spiritual Practices:
· Spiritual Healing:
2. Biologically Based Therapies
Biologically based therapies include the use of dietary supplements such as vitamins, minerals, herbs or other botanicals; amino acids; and substances such as enzymes, organ tissues, and metabolites. With the proliferation of literature on herbal remedies and the accessibility of the products, increasing manage symptoms. Purchasing over-the-counter medications allows people to bypass a visit to a health care provider, thereby eliminating the cost and inconvenience of a visit, as well as the real or perceived stigma on the part of the health care provider and others of a psychiatric label. PMH-APRNs need to be aware of therapies available and in common use, and they must also consult state board of nursing regulations.
A. Diet and Nutrition
Because psychiatric illness affects the whole person, it is not surprising that clients with mental illnesses frequently have nutritional disturbances. Often their diets are deficient in the proper nutrients, or they may eat too much or too little. Obesity and diabetes coexist at a greater than average rate in people with psychiatric disorders. Nutritional states may also cause psychiatric disturbances. Anemia, a common deficiency disease, is often accompanied by depression.
It is essential that PMH-APRNs assess the client’s nutritional status and practices and address this area in health teaching. Assess for the use of nutrients such as vitamins, protein supplements, herbal preparations, enzymes, and hormones that are considered dietary supplements. These dietary supplements are sold without the premarketing safety evaluations required of new food ingredients. Dietary supplements can be labeled with certain health claims if they meet published requirements of the U.S. Food and Drug Administration (FDA) and may contain a disclaimer saying that the supplement has not been evaluated by the FDA and is not intended to diagnose, treat, cure, or prevent any disease.
Some nutritional supplements interact with medications. There are well-known interactions with vitamins (e.g., vitamin E and anticoagulants), but interactions with other supplements are not as easily recognized. PMH-APRNs should specifically ask about the use of supplements during the assessment and should not expect clients to share this information without being asked. PMH-APRNs can review the use of the supplements and the potential interactions with foods, drugs, and other supplements to reduce risks. An example of a serious hypertensive reaction can occur when a client who is taking a monoamine oxidase inhibitor (MAOI) for depression ingests a food that contains tyramine, such as aged cheese, pickled or smoked fish, or wine.
Megavitamin therapy, also called orthomolecular therapy, is a nutritional therapy that involves taking large amounts of vitamins, minerals, and amino acids. The theory is that the inability to absorb nutrients from a proper diet alone may lead to the development of different illnesses. The earliest use of megavitamin therapy was for the treatment of schizophrenia, for which niacin was recommended.
Nutritional therapies are used to treat a variety of disorders, including depression, anxiety, attention deficit hyperactivity disorder (ADHD), menopausal symptoms, dementia, and addictions. For instance, lower rates of anxiety and depression are reported among vegetarians than among non-vegetarians. An analysis of the vegetarian diet found a higher antioxidant level compared with the non-vegetarian diet, which suggests that antioxidants may play a role in the prevention of depression. In. Eating breakfast regularly improves mood, enhances memory, Increases energy, and promotes feelings of calmness (Mehl-Madrona, 2004). The efficacy of Omega-3 fatty acids continues to be studied in the treatment of depression and bipolar depression. It is recommended that clients with mood disorders, impulse-control disorders, and psychotic disorders consume at least 1 gram of omega-3 fatty acids a day (Chiu et al., 2008). Certain nutritional supplements, including S-adenosyl methionine (SAMe) and the B vitamins, especially vitamin B6 and folic acid, also appear to improve depression (Mehl-Madrona, 2004). Currently, B vitamins and folic acid are also being seen more favorably for the management of bipolar illness and schizophrenia.
B. Herbal Therapy
Herbal therapy is the use of an herb or any part of a plant for culinary or medicinal purposes. Herbal therapies are also sometimes referred to as ‘’botanicals,” “nutraceuticals,” or “phytomedicines.” Dietary supplements are considered a part of herbal therapy.
Fig. 2: Herbal Medicine
Until the 1950s, the United States federal government regulated herbs as drugs. For example, in 1938, the U.S. Food and Drug Administration passed the Food, Drug, and Cosmetic Act, which required all drugs, including herbs, to be proven safe before they could be sold. In 1962, the Food, Drug, and Cosmetic Act was amended by the Kefauver-Harris Drug Amendments, which required manufacturers to also p