Alternative techniques
Today’s psychologists are increasingly integrating complementary and alternative medicine techniques into their work with clients. Here’s an overview of the most popular treatments, the research on their efficacy and the ethical concerns they raise.
By Jeffrey E. Barnett, PsyD, ABPP, and Allison J. Shale, MS
April 2013, Vol 44, No. 4
Print version: page 48
People have used many CAM treatments for thousands of years, but it was not until 1999 that the National Institutes of Health (NIH) created the National Center for Complementary and Alternative Medicine (NCCAM) with a mission of defining "the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care" (NCCAM, 2011e).
Now, incorporating CAM into both daily life and health care is part of a larger movement that focuses on more integrative and holistic care. The psychology profession — with its strong history of integrating innovations — is among those embracing CAM.
Interestingly, Eisenberg et al. (1998) determined that people visited CAM practitioners 243 million more times than they visited primary-care physicians in the preceding year. According to 2007 data from NCCAM, 38.3 percent of adults and 11.8 percent of children reported having used a form of CAM in the preceding year (Barnes et al., 2008). This corresponds with nearly $34 billion being spent each year on CAM products and services (Briggs, 2007). Although this amount accounts for only 1.5 percent of the total amount spent on health care, it is nearly 11.2 percent of out-of-pocket health-care costs (Briggs, 2007).
While much more research remains to be done, studies have begun to demonstrate the effectiveness of many CAM modalities for treating a wide range of ailments and disorders. The literature documents dozens of CAM interventions that fall within four main categories: mind-body medicine, biologically based practices, manipulative and body based practices and energy medicine (NCCAM, 2011e). CAM may also be viewed in the context of whole medical systems, which include traditional Chinese medicine, ayurvedic medicine, naturopathy and homeopathy.
In this article, we describe 14 CAM modalities in the order of their frequency of use as reported in a large national survey conducted for the National Institutes of Health (Barnes, Bloom, & Nahin, 2008) and additional use data. They are dietary supplements, meditation, chiropractic, aromatherapy, massage therapy, yoga, progressive muscle relaxation, spirituality, religion and prayer, movement therapy, acupuncture, Reiki, biofeedback, hypnosis and music therapy.
Dietary supplements
Many dietary supplements are used to promote health and wellness as well as to treat pain, depression and anxiety. Commonly used supplements include ginkgo biloba, St. John's wort, vitamin supplements and echinacea. Dietary supplements are regulated by the Food and Drug Administration (FDA) but are held to very different quality standards than more conventional forms of medicine. Of specific note, the FDA does not review the safety and effectiveness of any supplement before it is sold to consumers. As a result, the potency or composition of the supplements may vary between manufacturers or even within a single manufacturer's batch. Much of the research on dietary supplements varies due to this lack of regulation.
It is essential that psychologists be aware of the risks that may come with using dietary supplements so that they are able to competently advise their clients about their use, such as by referring them to their physicians when indicated. Despite the risks, 17.7 percent of people surveyed had taken a dietary supplement in the past year, according to Barnes et al. (2008). While psychologists might educate clients on the substances themselves, they should be making referrals to primary-care physicians, who can monitor patients' blood levels as well as watch for potential interactions.
Meditation
Meditation is a process by which people learn to focus their attention as a way of gaining greater insight into themselves and their surroundings (Duke Center for Integrative Medicine, 2006). Meditation is used to treat a variety of symptoms, such as elevated blood pressure, anxiety, stress, pain and insomnia, as well as to promote overall health and well-being (Grossman, Niemann, Schmidt, & Walach, 2007; Rainforth et al., 2007).
In 2007, 9.4 percent of adults surveyed by NIH reported they practiced meditation (Barnes et al., 2008). When meditating, clients must focus their attention on "breathing, or on repeating a word, phrase or sound in order to suspend the stream of thoughts that normally occupies the conscious mind" (Mayo Clinic, 2010b).
There are several different forms of meditation, each of which falls into one of two categories: mindfulness meditation and concentrative meditation. Mindfulness meditation focuses attention on breathing to develop increased awareness of the present, while concentrative meditation aims to increase overall concentration by focusing on a specific word or phrase (NCCAM, 2011c). Although there are many different types of meditation in each category — such as Vipassana, transcendental and walking meditation — most forms of meditation have four elements in common: a quiet location; a specific, comfortable posture; a focus of attention; and an open attitude (NCCAM, 2011c).
Meditation can be integrated into ongoing psychological practice, but it is important that both clinicians and their clients are appropriately trained before attempting to meditate on their own. While there are no formal qualifications necessary for those who practice general meditation, a variety of organizations offer certification in specific forms of meditation, such as mindfulness-based meditation and transcendental meditation. Psychologists who want to integrate meditation into their practice will want to first assess the legitimacy of particular organizations before seeking certification through them.
Chiropractic
The main theory behind chiropractic practice is "that nerve and organ dysfunction is often the result of misaligned vertebrae of the spine" (Kuusisto, 2009). Chiropractic physicians use noninvasive treatments, such as spinal manipulations or chiropractic adjustments (American Chiropractic Association, 2011). The purpose of these manipulations "is to restore joint mobility by manually applying a controlled force into joints that have become hypomobile — or restricted in their movement — as a result of a tissue injury" (ACA, 2011). The ultimate goal of chiropractic is to realign the spine so that the body functions best and can in turn heal itself.
Chiropractic is used by 8.6 percent of Americans each year to treat a range of ailments from pain and headaches to stress and attention-deficit hyperactivity disorder (ADHD), among other conditions (Assendelft, Morton, Yu, Suttorp, & Shekelle, 2008; Bastecki, Harrison, & Haas, 2004; Tuchin, 1999).
To practice chiropractic, one must obtain a doctor of chiropractic degree, which takes several years of graduate work. While most psychologists aren't likely to obtain such degrees, it is important to recognize that serving as a client's chiropractor at the same time as serving as his or her psychologist is inappropriate due to the type of touch needed for spinal manipulations. This use of touch would likely constitute a significant boundary violation, a topic that will be discussed in further detail later.
Aromatherapy
Aromatherapy is "the art and science of utilizing naturally extracted aromatic essences from plants to balance, harmonize and promote the health of body, mind and spirit" (National Association for Holistic Aromatherapy [NAHA], 2010). There are three different types of aromatherapy: clinical, holistic and aesthetic (Metcalfe, 1989). Clinical aromatherapy focuses on relieving symptoms that are typically addressed in psychotherapy, such as stress and anxiety. Holistic aromatherapy focuses on the whole person, aiming to improve overall well-being and quality of life. Aesthetic aromatherapy, also termed nonclinical aromatherapy, uses aromatic essences in various oils and creams that are traditionally used in skin care (Metcalfe, 1989).
Using various scents and oils for therapeutic purposes has been in existence for thousands of years. In recent years, research finds that aromatherapy can help treat pain, anxiety and agitation specific to dementia (Han, Hur, Buckle, Choi, & Lee, 2006; Lehrner, Marwinski, Lehr, Johren, & Deecke, 2005; Lin, Chan, Ng, & Lam, 2007). Aromatherapy can be integrated into ongoing practice, and while certification is not required, it is recommended. Several organizations, such as the NAHA, offer certification to become a registered aromatherapist. There are risks associated with aromatherapy use related to toxicity, skin irritation and dosing regulations that competent professionals will want to be aware of.
Massage therapy
Massage therapy is a manual procedure that involves manipulating the body's soft tissue as a way to relieve tension and pain as well as anxiety and depression (Moyer, Rounds, & Hannum, 2004; Rich, 2002). Massage therapists use their hands, fingers and sometimes their forearms or feet as a way to "relieve pain, rehabilitate sports injuries, reduce stress, increase relaxation, address anxiety and depression, and aid general wellness" (NCCAM, 2011b). There are several different types of massage, each utilizing slightly different techniques. For example, Swedish massage, the most commonly used form of massage in the United States, involves "a combination of long strokes, kneading motion and friction on the layers of muscle just beneath the skin" (DCIM, 2006, p. 469). Other well-known forms of massage include sports massage, deep tissue massage and trigger point massage (NCCAM, 2011b). In 2007, 8.3 percent of adults were reported to have used massage therapy in the past year (Barnes et al., 2008).
The use of massage has been studied for its effectiveness in treating various psychological symptoms, such as depression, anxiety and stress, and thus it may be relevant for integration into some clients' treatment. However, even if the psychologist is appropriately trained, this integration must be done by referral to qualified massage therapists, due to boundary concerns mentioned previously.
The regulations for practicing massage vary from state to state. Presently, there are 43 states that regulate massage therapy, but national certification can be obtained through the National Certification Board for Therapeutic Massage and Bodywork.
Yoga
Yoga incorporates several techniques, such as meditation, breathing exercises, sustained concentration, and physical postures, which work to increase strength and flexibility (Khalsa, Shorter, Cope, Wyshak, & Sklar, 2009). A main focus of yoga is to relax the client while working to "balance the mind, body and the spirit" (NCCAM, 2011f).
There are many different types of yoga such as Hatha, Ananda, Anusara, Bikram, Kundalini, and Viniyoga. Yoga has been increasingly studied of late, and it has been shown to be effective at treating numerous symptoms including anxiety, depression and chronic pain (Harner, Hanlon, & Garfinkel, 2010; Mehta & Sharma, 2010; Sherman, Cherkin, Erro, Miglioretti, & Deyo, 2006). With such a wide range of uses, it is not surprising that in 2007, 6.1 percent of adults indicated that they had practiced a form of yoga in the preceding year (Barnes et al., 2008).
Since yoga does not require any physical manipulation of the client by the psychologist, it is an area that may be integrated into ongoing treatment, as appropriately trained psychologists may choose to begin a session by utilizing various poses to promote relaxation. Also, clients who might benefit from yoga in addition to their ongoing psychological treatment may be referred to qualified yoga practitioners. As with many other CAM modalities, certification is required to practice yoga, but the certification process is not standardized.
Progressive muscle relaxation
Through this technique, the client learns to sequentially tense and relax muscle groups to promote greater relaxation. Progressive muscle relaxation, or PMR, is often beneficial for clients experiencing anxiety, tension or stress-related symptoms. However, even though PMR has been accepted and integrated into psychologists' practices for years, results of an NIH study showed that only 2.9 percent of adults had used PMR in the prior year (Barnes et al., 2008).
PMR requires significant effort and outside time-commitment by the client. The technique should not be viewed as a simple solution to stress reduction, and it is important that clients are aware that their success with PMR is highly dependent on the effort that they put into learning the process and practicing in between treatment sessions (Lehrer & Woolfolk, 1993). Psychologists may want to take clients through various PMR exercises during a psychotherapy session followed by offering them a recording of a relaxation sequence that can then be used outside of psychotherapy. PMR is one area of CAM that psychologists can effectively integrate into their practices with minimal training.
Spirituality, religion and prayer
The U.S. Religious Landscape Survey found that 56 percent of those surveyed indicated that religion was very important to them while 26 percent reported that it was somewhat important to them (The Pew Forum on Religion & Public Life, 2008).
Spirituality and religion are two separate entities: Spirituality tends to be more personalized, while religion is often more formally organized. Clients may identify themselves as only spiritual or only religious, neither or both. Spirituality, religion and prayer are three areas that have been difficult to study. Some studies, however, have shown that they have been commonly involved in the treatment of addiction, depression and the symptoms of trauma (Cook, 2004; Nasser & Overholser, 2005; Vis & Boynton, 2008).
Spirituality, religion and prayer can all be integrated in psychologists' ongoing practice, and technically no certification is required to do so, but the psychologist will want to be competent about the religion or faith-based practices being used. Psychologists will also want to be aware that practicing a particular faith does not make one competent to utilize it into their psychotherapy practice. While spirituality, religion and prayer can be a part of ongoing practice, psychologists should not exceed their clinical roles and take on the role of clergy. Clinicians who are interested in integrating spirituality, religion or prayer into an ongoing practice will want to first obtain the education and training necessary to ensure their clinical competence.
Movement therapy
Movement therapy is the "psychotherapeutic use of movement to promote [the] emotional, cognitive, physical, and social integration of individuals" (American Dance Therapy Association [ADTA], 2009b). Often referred to as dance/movement therapy (DMT), it focuses on "movement behavior as it emerges in the therapeutic relationship" (ADTA, 2009b). A goal of DMT is to use the body's movement as a way of expressing the unconscious (Levy, 1988). Dance/movement therapists believe that the mind and the body do not function separately and that by focusing on the body, one should be able to affect his or her mind and therefore relieve a variety of symptoms (Levy, 1995).
More research is needed to support and guide the use of DMT. However, the ADTA has reported some support for using the therapy to help treat a variety of symptoms such as those associated with attention-deficit hyperactivity disorder, dementia, depression and a variety of physical disabilities, as well as to promote overall well-being (ADTA, 2009a). DMT is one of the lesser-known CAM modalities, with only 1.5 percent of adults reporting that they had used the therapy in the previous year (Barnes et al., 2008). Certification is required to practice DMT and it requires a graduate degree from an ADTA-approved program.
Acupuncture
This technique to improve health and functioning "through stimulation of specific points on the body" has been used for thousands of years (NCCAM, 2011a). Barnes et al. (2008) reported that 1.4 percent of adults said they have used acupuncture in the preceding year.
Typically, acupuncture involves penetrating the skin with needles, which are then manipulated by the acupuncturist's hands or by a form of electrical stimulation (NCCAM, 2011a). The needles are inserted into specific locations on the body as a way of balancing "the flow of life energy," also known as qi (pronounced "chee"). Acupuncture has been shown to be effective at relieving symptoms of depression and anxiety, as well as migraines and other forms of chronic pain (Furlan et al., 2010; Roschke et al., 2000).
Certification is required to practice acupuncture, and only physicians who have completed additional training, acupuncturists and doctors of oriental medicine can practice acupuncture. Some states require licensure to practice acupuncture, while others require certification through the National Certification Commission for Acupuncture and Oriental Medicine in addition to licensure. Psychologists, even if certified, should not serve as a client's acupuncturist as well as his or her psychotherapist since acupuncture often involves the client removing articles of clothing, a clear boundary violation. Also, in some states, it is illegal for psychologists to provide any forms of treatment that involve piercing of the skin.
Reiki
The term Reiki means "spiritually guided life force energy" (International Center for Reiki Training, 2011). Reiki involves the passing of energy from a trained Reiki practitioner's body to the client's body as a method of healing. The client can remain fully clothed, as it is believed that the Reiki energy can easily pass through clothing or other objects (Plodek, 2009). The Reiki practitioner utilizes a series of established hand positions as a means for allowing the energy to move freely between the bodies.
Only 0.5 percent of the population report using Reiki (Barnes et al., 2008), and there is little research on its efficacy. Despite this, Reiki has been shown to help with stress and pain management, as well as to promote relaxation (Bowden, Goddard, & Gruzelier, 2010; Olson, Hanson, & Michaud, 2003).
Certification is required to practice Reiki. Referrals should be made for Reiki services, as opposed to integrating them into ongoing practice, as the hand positions will likely cross psychologists' ethical boundaries: Even though there is no direct contact, the clinician's hands are placed very close to the client's body.
Biofeedback
This technique uses electrical sensors to provide information to a client that can help him or her improve health and/or performance (Association for Applied Psychophysiology and Biofeedback [AAPB], 2008). The three most common forms of biofeedback are electromyography (EMG), which focuses on muscle tension; thermal biofeedback, which focuses on skin temperature; and neurofeedback, or electroencephalography (EEG), which focuses on brain activity (Ehrlich, 2009). A fourth form of biofeedback, heart-rate variability (HRV), is becoming increasingly popular and is growing in use.
Biofeedback has been shown to be effective in the treatment of ADHD, pain, depression and headaches, among other symptoms (Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003; Hawkins & Hart, 2003; Karavidas et al., 2007; Nestoriuc, Martin, Rief, & Andrasik, 2008). It is reported that 0.2 percent of adults use biofeedback (Barnes et al., 2008). The Association of Applied Psychophysiology and Biofeedback reports having more than 2,000 professional members (AAPB, 2008), and the Biofeedback Certification International Alliance reports having approximately 1,600 certified members (Judy Crawford, personal communication, Feb. 20, 2012).
Biofeedback is an area of CAM that can be integrated into ongoing treatment with relative ease by appropriately trained psychologists using biofeedback equipment. While formal certification is not required, it can be obtained through the Biofeedback Certification International Alliance (BCIA), "the certification body for the clinical practice of biofeedback" (BCIA, 2011).
Hypnosis
The Society of Psychological Hypnosis defines hypnosis as a process by which "one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior" (Green, Barabasz, Barrett, & Montgomery, 2005).
Only 0.2 percent of people use hypnosis (Barnes et al., 2008). In fact, when many people hear the term hypnosis, they think entertainment, not health care. As a result, psychologists will want to educate clients about the utility of hypnosis, which is commonly used to treat pain and fatigue, as well as nausea and vomiting that occur as a side effect of cancer treatments (Castel, Salvat, Sala, & Rull, 2009; Jensen et al., 2011; Montgomery et al., 2001).
Hypnosis can be integrated into ongoing practice and one may obtain certification, although this is not standardized. Several organizations offer certification, with one of the most well-known being the American Society of Clinical Hypnosis (ASCH), which offers entry-level and advanced-level certifications (ASCH, 2011).
Music therapy
The American Music Therapy Association (AMTA) defines music therapy as "an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals" (AMTA, 2011a). Music therapy involves singing, writing music, making music, listening to music and lyric analysis, among many other techniques (AMTA, 2011b).
Music is not what affects the therapeutic process. Rather, the focus is on helping clients to explore their thoughts and feelings through the use of a music intervention. Music therapy is a multidimensional approach that focuses on a variety of "facets — physical, emotional, mental, social, aesthetic and spiritual" as a means to improve health (Boyer College of Music and Dance, 2011).
Some evidence supports music therapy's use in reducing anxiety, depression and pain, although the literature is limited (Castillo-Pérez, Gómez-Pérez, Calvillo Velasco, Pérez-Campos, & Mayoral, 2010; Lin, Hsieh, Hsu, Fetzer, & Hsu, 2011). Music therapy may be ethically and appropriately integrated into ongoing psychological treatment by appropriately trained psychologists. Certification is required and can be obtained after earning a graduate or undergraduate degree from an AMTA-approved program, plus 1,200 hours of supervised music therapy experience. Additionally, there is a written exam required to become board certified as a music therapist (AMTA, 2011a).
Why CAM is important to psychologists
Psychologists are uniquely positioned to educate clients about CAM, to monitor their use of CAM, to communicate with primary-care physicians, and, if possessing the needed competence, to make crucial decisions about when CAM may be appropriate to include in a client's treatment. Recognizing when it is appropriate to integrate a specific modality into a client's psychological treatment as opposed to making a referral to a CAM practitioner, and knowing how to do this effectively are essential components of each psychologist's competence.
Elkins, Marcus, Rajab, and Durgam (2005) assessed CAM use among 262 people who were currently in psychotherapy. They found that 65 percent of respondents indicated that they had used at least one form of CAM in the past year. This finding specifically highlights the relevance of CAM in psychological practice because even if professional psychologists are not the ones presenting the modalities as treatment options, many of their clients are likely to be independently utilizing them. This further emphasizes that to provide the highest quality of care, psychologists will find it important to be educated on various forms of treatment, both those that many clients may already be using when they enter a psychologist's care and those that may be additionally beneficial to them. Also, psychologists must be aware of when clients should or should not continue with a CAM modality that has been previously implemented. Thus, psychologists must remain educated and up-to-date on the field of CAM as well as the various modalities and their diverse uses.
CAM is also relevant to psychologists and the care that they provide to their clients in the context of evidence-based practice in psychology (APA, 2005), described as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences." The emphasis on the consideration of "patient characteristics, culture and preferences" when selecting treatment strategies and techniques is directly relevant to earlier reported data on societal trends toward health promotion, wellness and spirituality, as well as the data on how many Americans are now seeking out CAM treatments. The emphasis on "the best available research" highlights the need for psychologists to focus their research efforts on the many uses of CAM to create an expanded knowledge base about CAM, its uses and its limitations. The emphasis on "clinical expertise" makes clear the need for psychologists to develop competence regarding CAM so that it may be appropriately applied to meet clients' ongoing needs.
