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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:

· Acupuncture

· Ayurveda

· Biofeedback

· Chiropractic manipulation

· Diet-based therapies

· Deep-breathing exercises

· Energy healing therapy/Reiki

· Exercise therapy

· Guided imagery

· Hypnosis

· Massage

· Meditation

· Herbal therapy

· Aromatherapy

· Reflexology

· Yoga

· 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.

B. Biofeedback

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  https://www.webmd.com/a-to-z-guides/biofeedback-therapy-uses-benefits#1

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.

D. Meditation

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:

· Energy Healing:  http://thefourwinds.com/energy-medicine-training/?gclid=COiF0vWpicoCFZEXHwodDk4Kiw

· Spiritual Healing:  https://www.spiritual-healing-for-you.com/spiritual-healing.html

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 prove to the FDA the effectiveness of drugs and herbs before they could be marketed (Lilley, Harrington, & Snyder, 2007).

Parts of herbs used in herbal therapies include leaves, flowers, fruits, seeds, stems, wood, bark, roots, and rhizomes. Herbal remedies are dispensed as brews and powders and can be used in cooking or making drinks. Herbalists known as shamans, or traditional healers, also make ointments and poultices out of herbs.

Herbal therapy has been the core of most systems of medicine from the beginning of civilization, and herbs are quickly becoming one of the most commonly used NAC therapies. Some commonly used herbs with therapeutic value are echinacea (immune stimulant and anti-infection agent); garlic (antihypertensive and antibiotic); ginger (anti-nauseant and antispasmodic); ginseng root (increased stamina and decreased fatigue); kava kava (calming effect); and St. John’s wort (anxiolytics and antidepressant).

  Information is Beautiful by David McCandless available at  http://informationisbeautiful.net/visualizations/snake-oil-scientific-evidence-for-nutritional-supplements-vizsweet/

Online Resources for Herbal Therapy:

· Herbal Remedies:  www.herbalremedies.com

· American Herbal Pharmacopoeia:  www.herbal-ahp.org

· HerbNET:  www.herbnet.com

C. Aromatherapy

Aromatherapy involves the use of essential oils (extracts or essences) from flowers, herbs, and trees to promote health and well-being. In the past decade, most people have turned to NAC therapies, such as aromatherapy, to treat stress and relieve disease symptoms. Aromatherapy can be used to promote sleep, alleviate anxiety or pain, and improve mood. Although the psychological benefits of aromatherapy have been shown, the physiological benefits of essential oils are still debatable. Two classic essential oils are lavender and peppermint. Lavender is used to reduce stress and depression and promote relaxation; peppermint is used to treat headaches, digestive disorders, and muscle aches.

 

Fig. 3: Aromatherapy

 

The Egyptians were the first true aromatherapists, having used the practice as far back as 6000 B.C. for religious and medicinal purposes as well as in embalming, perfumes, incenses, fragrances, and cosmetics (Bright, 2002; Thomas, 2002). In nursing, the use of aromatherapy can be traced back as early as 1859 when Florence Nightingale made use of the practice. Like Hippocrates, the father of modern medicine, Nightingale often talked about the use of aromatherapy in her practice. She burned rosemary and lavender for fumigation of the streets and hospitals. In her book Notes on Nursing, Nightingale (1859/1969) advocated for the use of different types of essential oils to create a healing environment and to promote healing in individuals, communities, hospital environments, and homes.

Research evidence exists that combining aromatherapy with massage reduces anxiety and fosters mood elevation and stress reduction (Maddocks-Jennings & Wilkinson, 2004). There are anecdotal reports that aromatherapy is useful for pain relief, memory improvement, and wound healing.

Online Resources for Aromatherapy:

· Aromatherapy Internet Resources:  www.holisticmed.com/www/aromatherapy.html

· National Association of Aromatherapy:  www.naha.org/

3. Manipulative Practices

Next group of treatments is based on physically touching another person. (Therapeutic touch is included among the energy therapies since it technically does not involve physical touching of a client.) The use of any physical touch in psychiatric mental health nursing practice continues to be controversial. Some believe it is not used enough, but most believe it should be used sparingly, with clear intent, recognizing that maintenance of therapeutic boundaries is extremely important, particularly with clients who have psychiatric disorders and might misinterpret touch.

A. Chiropractic Medicine

Chiropractic medicine is one of the most widely used integrative therapies. The term chiropractic comes from the Greek wordspraxix and cheir, meaning “practice” or “treatment by hand.” Chiropractic medicine focuses on the relationship between structure and function and the way that relationship affects the preservation and restoration of health, using manipulative therapy as a treatment tool.

 

Daniel David Palmer, a grocery store owner, developed the method in the late 1800s in an effort to heal others without drugs. Palmer developed a series of manipulative procedures to bring health to muscles, nerves, and organs that had gotten out of alignment; he referred to these misalignments as subluxations. He believed that subluxations were metaphysical and at that they interfered with the flow through the body of “innate intelligence” (spirit or life energy).

Contemporary chiropractic medicine continues to be based on the theory that energy flows from the brain to all parts of the body through the spinal cord and spinal nerves. Manipulation of the spinal column, called adjustment, returns the vertebrae to their normal positions. Back pain is the most common reason people seek chiropractic treatment, but chiropractic manipulation is used to treat a variety of other conditions, including pain, allergies, and asthma (NCCAM, 2003). Manipulation is also helpful in reducing migraine, tension, or cervicogenic headache pain. Many chiropractors also treat clients with depression, anxiety, and chronic pain. Chiropractic treatment may be done in conjunction with herbs and supplements.

B. Massage Therapy

Massage therapy includes a broad group of medically valid therapies that involve rubbing or moving the skin. Massage therapists employ four basic techniques: effleurage (long, gliding strokes over the skin), pétrissage (kneading of the muscles to increase circulation), vibration and percussion (a series of fine or brisk movements that stimulate circulation and relaxation), and friction (which is decreased with the use of massage oils). Probably the best known massage technique in the United States is Swedish massage, which provides soothing relaxation and increases circulation. Japanese Shiatsu massage was strongly influenced by traditional Chinese medicine and developed from acupressure. It originated as a way to detect and treat problems in the flow of life energy (Japanese ki). The shiatsu practitioner uses fingers, thumbs, elbows, knees, or feet to apply pressure by massaging various parts of the body, known as acupoints.

C. Reflexology

Reflexology is a form of bodywork that focuses primarily on the feet. Each foot contains more than 7,000 nerve endings. The underlying theory behind reflexology is that there are “reflex” areas on the feet and hands that correspond to specific organs, glands, and other parts of the body. For example:

· the tips of the toes reflect the head

· the heart and chest are around the ball of the foot

· the liver, pancreas and kidney are in the arch of the foot

· low back and intestines are towards the heel

Fig. 4: Reflexology: Foot Chart

Practitioners believe that applying pressure to these reflex areas can promote health in the corresponding organs through energetic pathways. Dr. William H. Fitzgerald introduced this concept of “zone therapy” in 1915. American physiotherapist Eunice Ingram further developed this zone theory in the 1930’s into what is now knows as reflexology. A scientific explanation is that the pressure may send signals that balance the nervous system or release chemicals such as endorphins that reduce pain and stress. Most people find reflexology for the most part to be very relaxing. Reflexology shouldn’t be painful. Some areas may be tender or sore, and the reflexologist may spend extra time on these points. The soreness should decrease with pressure. Reflexology is recommended as a complementary therapy and should not replace medical treatment. A typical treatment is 45 minutes to 60 minutes long. The reflexologist applies firm pressure to the feet to treat the following conditions:

· Stress and stress-related conditions

· Tension headaches

· Digestive disorders

· Arthritis

· Insomnia

· Hormonal imbalances

· Sports injuries

· Menstrual disorders, such as premenstrual syndrome (PMS)

· Digestive problems, such as constipation

· Back pain

Online Resources for Reflexology:

· Association of Reflexologists:  www.aor.org.uk/

· Home of Reflexology: https://arcb.net/tag/reflexology-association-of-america/

Reflexology Research: www.reflexology-research.com/

4. Energy Therapies

Energy therapy is a growing field that includes therapies originating from many parts of the world. It is based on the belief that nonphysical bioenergy forces pervade the universe and people. Explanations vary as to the nature of this energy, the form of the therapies, and the rationale for how healing is believed to occur. Some cultures believe the energy comes from God. Those who practice shamanic healing rituals believe the energy comes from various spirits through a priest or shaman.

Practitioners of energy medicine believe that they are able to increase their awareness of the human energy field and enhance healing through meditation and centering (finding the calm space within yourself) (Zahourek, 2005). Practitioners believe they can then detect problems in others’ energy fields and adjust the quality or create balance. This is accomplished by placing one’s hands in or through these fields to direct the energy through visualized or actual pressure and/ or manipulation of the body. Therapeutic touch, healing touch, and Reiki are the most common energy therapies practiced by nurses.

A. Therapeutic Touch

Therapeutic touch is a modality developed in the 1970s by Dolores Krieger, a nursing professor at New York University, and Dora Kunz, a Canadian healer. The premise for therapeutic touch is that healing is promoted by balancing the body’s energies. In preparation for a treatment session, practitioners focus completely on the person receiving the treatment, without any other distraction. Practitioners then assess the energy field, clear and balance it through hand movements, and/or direct energy in a specific region of the body. The therapist does not physically touch the client. After undergoing a session of therapeutic touch, clients report a sense of deep relaxation.

While therapeutic touch has uncertain research support, practitioners of therapeutic touch believe that the therapy is useful in relieving premenstrual syndrome, depression, complications in premature babies, and secondary infections associated with human immunodeficiency virus (HN) infection; lowering blood pressure; decreasing edema; easing abdominal cramps and nausea; resolving fevers; and accelerating the healing of fractures, wounds, and infections.

B. Healing Touch

Healing touch is a derivative of therapeutic touch developed by a registered nurse, Janet Mentgen, in the early 1980s. Healing touch combines several energy therapies and is based on the belief that the body is a complex energy system that can be influenced by another through that person’s intention for healing and well-being. Healing touch is related to therapeutic touch in the belief that working energetically with people to achieve their highest level of well-being, and not necessarily relieving a specific symptom, is the goal.

C. Reiki

The Japanese spiritual practice of Reiki has become an increasingly popular modality for APNs to learn and practice. Reiki is an energy-based therapy in which the practitioner’s energy is connected to a universal source (chi, qi, prana) and is transferred to a recipient for physical or spiritual healing (Miles & True, 2003). Numerous hospitals, hospices, cancer support groups, and clinics are now offering Reiki in complementary programs. LaTorre (2005) describes its use as an adjunct in psychotherapy. People may be hesitant about using Reiki because (1) there is little scientific support for Reiki, and acceptance of its teaching about Reiki is a matter of faith; (2) the possibility exists that effects are due to a placebo effect; (3) it is incompatible with their religious beliefs; and (4) government regulation and licensing is controversial.

Alternative Medical Systems

1. Ayurvedic Medicine

Ayurvedic (pronounced “eye-yur-VEH-dik”) medicine originated in India around 5000 BC and is one of the world’s oldest and most complete medical systems. Ayurveda means “the science of life” and is a philosophy that emphasizes individual responsibility for health. It is holistic, promotes prevention, recognizes the uniqueness of the individual, and offers natural treatments (Pai et al., 2004).

2. Traditional Chinese Medicine

Traditional Chinese medicine (TCM) provides the basic theoretical framework for many CAM therapies, including acupuncture, acupressure, transcendental meditation, tai chi, and qi gong. TCM is derived from the philosophy of Taoism and emphasizes the need to promote harmony (health) or bring order out of chaos (illness). TCM is a vast medical system based on a constellation of concepts, theories, laws, and principles of energy movement within the body. Therapy is aimed at addressing the client’s illness in relation to the complex interaction of mind, body, and spirit.

Adherents of TCM say that it addresses not only symptoms but also what they call “cosmologic” events – events that relate to the dynamics of the universe. According to Taoists, the life force (qi, chi) is a two-part force (yin and yang); these parts are complementary and equally important. Health is the balance between yin and yang, and illness emanates from imbalances.

The goal of life is transformation – returning to and being reabsorbed into the qi, which circulates throughout the universe and in our bodies in precise channels called meridians. These meridians become significant in the practice of acupuncture, touch therapy, and the more recent energy-based therapies used to treat emotional symptoms and promote mental health.

A. Acupuncture

Introduction to Acupuncture by Mazuremedia:

The term “acupuncture” describes a family of procedures involving the stimulation of anatomical points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of TCM. In TCM, the body is seen as a delicate balance of two opposing and inseparable forces: yin and yang. The concept of two opposing yet complementary forces described in traditional Chinese medicine. Yin represents cold, slow, or passive aspects of the person, while yang represents hot, excited, or active aspects. A major theory is that health is achieved through balancing yin and yang and disease is caused by an imbalance leading to a blockage in the flow of qi (pronounced “chi” [chee]). Yin represents the cold, slow, or passive principle, while yang represents the hot, excited, or active principle.

According to TCM, health is achieved by maintaining the body in a “balanced state”; disease is due to an internal imbalance of yin and yang. This imbalance leads to blockage in the flow of qi. In TCM, the vital energy or life force proposed to regulate a person’s spiritual, emotional, mental, and physical health and to be influenced by the opposing forces of yin and yang (vital energy) along pathways known as meridians. Qi can be unblocked, according to TCM, by using acupuncture at certain points on the body that connect with these meridians. Sources vary on the number of meridians, with numbers ranging from 14 to 20. One commonly cited source describes meridians as 14 main channels “connecting the body in a weblike interconnecting matrix” of at least 2,000 acupuncture points.

B. Yoga

Yoga is a unique holistic practice and way of life that incorporates meditation, poses (asanas), and breathing. The term YOGA stands for “Your Own relation to God Always.” A psycho-physiological discipline with roots that date back 5,000 years, yoga can be used to improve our relationships with ourselves and with God. Founded by Patanjali, the practice includes standing, sitting, balancing, and breathing poses, as well as twists and inversion movements, each designed to offer particular health and spiritual benefits. By controlling breathing and holding the body in steady poses, yoga creates body, mind, and spirit harmony and promotes relaxation. There are numerous schools of yoga. Hatha yoga, the most commonly practiced in the United States and Europe, emphasizes postures (asanas) and breathing exercises (pranayama). Some of the major styles of hatha yoga include Iyengar, Ashtanga, Vini, Kundalini, and Bikram yoga. People use yoga for a variety of conditions and to achieve fitness and relaxation.

Online Resources for Yoga:

· American Yoga Association:  http://www.americanyogaassociation.net/

· Introduction to Yoga:  www.introductiontoyoga.com

3. Homeopathy and Naturopathy

Homeopathy and naturopathy are examples of Western alternative medical systems. Homeopathy uses small doses (dilutions) of specially prepared plant extracts, herbs, minerals, and other materials to stimulate the body’s defense mechanisms and healing processes. Infinitesimally small doses of diluted preparations that produce symptoms mimicking those of an illness are used to help the body heal itself. Homeopathy is based on the Law of Similars (“like cures like”), and dilutions are prescribed to match the client’s illness/symptom and personality profile. Healing occurs from the inside out, and symptoms disappear in the reverse order they appeared.

Homeopathy has been used in the treatment of short-term acute illnesses, migraine pain, allergies, chronic fatigue, otitis media, immune dysfunction, digestive disorders, and colic. It has also been used in the treatment of emotional disorders such as depression and anxiety. It is contraindicated as a treatment for advanced diseases, cancer, sexually transmitted diseases, conditions involving irreparable damage (e.g., defective heart valves), or brain damage due to stroke (Freeman & Lawlis, 2008).

Homeopathic remedies are available over the counter, but consumers should have a full evaluation by a homeopathic practitioner before using any treatments. Consumers who are given what is called a “constitutional remedy” to treat a specific symptom should be informed that occasionally the symptom will worsen before it gets better (e.g., a client with anxiety should be warned not to fear a panic attack if anxiety worsens).

Naturopathy emphasizes health restoration rather than disease treatment and combines nutrition, homeopathy, herbal medicine, hydrotherapy, light therapy, therapeutic counseling, and other therapies. The underlying belief is that the individual assumes responsibility for his or her recovery. While few PMH-APRNs practice in these traditions, knowledge of the basic premises can be useful when assessing, treating, and referring clients. Such holistic concepts are also useful in considering the body-mind-spirit nature of mental health and illness.

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