Integrating Complementary and Alternative Medicine into the Treatment of Anxiety and Related Disorders: Clinical and Ethical Issues - Jeffrey ...
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Integrating Complementary and Alternative Medicine into the Treatment of Anxiety and Related Disorders: Clinical and Ethical Issues Jeffrey Barnett, Psy.D., ABPP Loyola University Maryland Allison Shale, M.S. Loyola University Maryland
Some questions to begin with… • What do you currently know about CAM? • Where do you get information on CAM modalities? • Do you currently integrate CAM into your personal life? Your professional life? • How are the 2 related? • Why did you choose to attend this session?
What is CAM? • Complementary and Alternative Medicine (CAM) is “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (NCCAM, 2011, para 2). • Complementary Medicine versus Alternative Medicine
CAM’s History
• Traditional Chinese Medicine
• Ayurveda
• Naturopathy
• Homeopathic Medicine
• Office of Alternative Medicine
• National Center for Complementary
and Alternative Medicine (NCCAM)
CAM Modalities
We have focused on the 14 most
commonly used modalities,
according to Barnes et al. (2008)
1. Dietary Supplements
2. Meditation
3. Chiropractic
4. Aromatherapy
5. Massage Therapy
6. Yoga
7. Progressive Muscle Relaxation
8. Religion and Spirituality
9. Dance/Movement Therapy
10. Acupuncture
11. Reiki
12. Biofeedback
13. Hypnosis
14. Music Therapy
Dietary Supplements • A supplement to one’s diet which contains at least one dietary ingredient, such as a vitamin, which is taken orally (ODS, 2011). • Risks/Drawbacks: • Possible Interactions • Regulation Issues • http://www.ods.nih.gov
Meditation
• A process by which people use self-regulation as
a way of increasing their attention and self-
awareness in order to gain greater control of
one’s mental processes
• Risks/Drawbacks:
• Physical limitations
• May worsen symptoms of some
psychiatric conditions
• http://nccam.nih.gov/health/meditation/overview.htm
Chiropractic • A manipulative treatment that works to achieve alignment of the spine as a way to improve overall functioning. • Risks/Drawbacks: • Pain/Soreness/Discomfort • Headaches • Numbness • http://www.chiropractic.org/doctorfinder/ • Haldeman, S. (2005). Principles and practice of chiropractic, Third edition. York, PA: The McGraw-Hill Corporations, Inc.
Aromatherapy • “Aromatherapy is a therapy in which the scent of essential oils from flowers, herbs, and trees is inhaled to promote health and well-being.” (NCCAM, 2012b, para 1). • Drawbacks: • Risk of Toxicity • Dosing/Mixing Difficulties • Skin Irritation • Pregnancy / Children • http://www.NAHA.org
Massage Therapy • Massage therapy “involves the motions of gliding, kneading, friction, pressure, tapping, and vibrating. Massage therapists sometimes add heat or cold, for example, by using heated stones, as part of the massage” (Field, 2009, p. 24) • Drawbacks: • Pain/Bruising • Numbness/Swelling • http://www.amtamassage.org/index.html
Yoga • Yoga is “a holistic system of mind-body practices for mental and physical health and incorporates multiple techniques including meditation, breathing exercises, sustained concentration, and physical postures that develop strength and flexibility” (Khalsa et al., 2009, p. 279) • Drawbacks: • Pain/Discomfort • Dizziness • http://www.yogaalliance.org/teacher_search.cfm
Progressive Muscle Relaxation
• A technique that requires the client to
sequentially tense and relax various
groups of muscles with the aim being
to gain overall relaxation of the mind
and body
• Risks/Drawbacks:
• Heavy outside commitment of client
Cramps/Spasms/Tics
Intrusive Thoughts
• Lusk, J.T. (ed). (1993). 30 scripts for relaxation, imagery and
inner healing, volume 2. East Peoria: Versa PressSpirituality, Religion, Prayer • Spirituality is the not the same as religion and both can involve the use of prayer if wanted. • Risks/Drawbacks: • Value-Neutrality • Boundary Issues • Many religion specific resources are available • Many professions have resources as well: • http://www.division36.org
Dance/Movement Therapy
• “Based on the empirically supported premise that the
body, mind and spirit are interconnected, the American
Dance Therapy Association defines dance/movement
therapy as the psychotherapeutic use of movement to
further the emotional, cognitive, physical and social
integration of the individual” (American Dance Therapy
Association, 2012, para 1).
• Risks/Drawbacks:
• Emotional difficulties
• Physical discomfort/Injury
• http://www.adta.org/Acupuncture • Acupuncture aims to restore and maintain health through the stimulation of specific points on the body. It involves the use of needles at specific acupoints along the body with the aim being to rebalance the body’s flow of energy, known as qi. • Risks/Drawbacks: • Pain/Soreness • Complications due to unsanitary conditions • http://www.nccaom.org/applicants/certifications.html
Reiki • Reiki is “a meditated state in which a practitioner channels Reiki energy from a universal source to another human being” (Plodek, 2009, p. 534). • Risks/Drawbacks: • No serious side effects reported • Potential for emotional release • http://nccam.nih.gov/health/reiki/introduction.htm
Biofeedback
• Using feedback from one’s body as a way of learning to
control and change various innate processes (such as heart
rate and brain waves) with the intention of improving
overall health and functioning.
• Risks/Drawbacks:
• Relatively safe because non-invasive
• Could impact pacemakers or
other internal devices
• http://www.aapb.org
• http://www.bcia.orgHypnosis • A practice by which a client is guided to “a trance-life state of mind” in which he or she “can concentrate intensely on a specific thought, memory, feeling or sensation while blocking out distractions.” (Mayo Clinic, 2009, para 1). • Risks/Drawbacks: • Lack of public knowledge • Expression of underlying emotions • Participat/Hypnotist/Environmental variables • http://nccam.nih.gov/health/meditation/overview.htm
Music Therapy • “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” (American Music Therapy Association, 2011, para 1). • Risks/Drawbacks: • Limited available data • http://www.musictherapy.org/about/
Treatment of Anxiety and Related Disorders
• Many symptoms related to mood and overall
well-being have been shown to improve with the
use of a variety of CAM modalities…Anxiety • Dietary Supplements: Kava has been studied in treating anxiety and has been shown to be more effective than placebos (Lehrl, 2004). • Meditation: Mindfulness meditation vs. Sham meditation has been shown to have an increasingly positive reduction on anxiety and negative mood (Zeidan, Johnson, Gordon, & Goolkasian, 2010). • Aromatherapy: Lavender oil can help to reduce anxiety in dentist’s offices and to patients in hospice care (Lehrner, Marwinski, Lehr, Johren, and Deecke, 2005; Louis & Kowalski, 2002).
Anxiety • Yoga – Twice weekly group Iyengar yoga provided over 12 weeks led to significant reductions in anxiety (as well as depression and yoga (Harner, Hanlon, & Garfinkel, 2010) • Progressive Muscle Relaxation – Meta-analysis of 27 studies showing that PMRT is more effective at reducing anxiety than control conditions (Manzoni, Pagnini, Castelnuovo, and Molinari, 2008) • Movement Therapy – Literature review showed that DMT could have a positive impact on anxiety; more research is needed
Depression • Dietary Supplements - St. John’s Wort has a similar degree of effectiveness with tricyclic antidepressants and SSRIs when treating mild to moderate depression. (Linde & Mulrow, 2000; Schrader, 2000). • Yoga – Review of 18 studies showed that patients who participated in 8 week s of Vinyasa Yoga had significant decreases in depression (Mehta and Sharma, 2010) • Reiki - Bowden, Goddard, and Gruzelier (2011) found a significant impact of Reiki on depression, and anxiety, on college students both immediately after treatment and 5 weeks post-treatment.
Depression • Acupuncture – There are mixed results with regard to treating depression and further research is needed (Allen et al., 2006; Roschke et al., 2000). • Movement Therapy – Dance/Movement Therapy was the only treatment condition (when compared to music-only therapy, and a movement-only control ) to show a sigifniciant decrease in depressive symptoms (Koch, Morlinghaus, and Fuchs, 2007). • Biofeedback – Significant reduction in depression have been seen, even if the symptoms are mild to moderate (Karavidas et al., 2007).
Stress/Overall Quality of Life • Movement Therapy - Hui, Chui, and Woo (2009) determined that a structure ddance program for older adults, “is effective in improving aspects of physical and psychological health” (Hui et al., 2009, p. e49). Chiesa and Serretti (2009) conducted a meta-analysis of all relevant studies published prior to 2008. They found that healthy individuals who participate in mindfulness based stress reduction treatment experienced a significant reduction in their level of stress overall. • Dietary Supplements: Kava has been shown to treat stress more effectively than placebo (Lehrl, 2004)
Stress/Overall Quality of Life • Progressive Muscle Relaxation - A wide range of research showing increased relaxation and decrease stress and anxiety. • Meditation: Many meta-analyses have been conducting and found that in addition to reducing stress, meditation often improves overall quality of life and social functioning (Grossman, Niemann, Schmidt, & Walach, 2004; Ledesma & Kumano, 2009). • Aromatherapy: 60 minutes of humidified inhalation of lavender oil had a greater effect on QUL than a no treatment condition or aromatherapy with humidified water. (Louis & Kowalski, 2002).
Research Limitations • Outcome expectancy • Hawthorne Effect • Assignment of participants • Sample sizes • Strict inclusion/exclusion criteria • Case studies • Lack of no-treatment conditions • Lack of longitudinal studies
But, are these treatments really not a part of Conventional Medicine?
No matter what you call the
modalities, or whether you
consider them a part of CAM,
the ethical and clinical issues
remain the same.Statistics on Rates of Use
• NCCAM included a supplement on
CAM in the 2007 national health
Interview Survey (Barnes et al.,
2008)
• 23,393 adults and 9,417 children under
18 were surveyed
• 38.3% of respondents reported
using at least one form of CAM
• A 2002 survey garnered a 36% usage rateEthical Considerations
No matter what your profession is, you
must consult with the relevant ethics codes
and state laws and regulations in order to
ensure that you are providing the highest
quality of service.Ethical Considerations • Competence • Am I competent to perform this service? • Do I possess the necessary training and credentials or certification? • Are there limits to my competence? • How and when should I make a referral? • Cooperation with other Professionals • Multicultural Competence
Ethical Considerations • Informed Consent • Limits to Confidentiality • Treatment Alternatives • Expected outcomes, risks, and benefits • Any additional fees that may be accrued with added services • ***This should be an ongoing process, not a one- time discussion!***
Ethical Considerations • Multiple Relationships – any additional relationship outside of the primary treatment’s relationship. • Boundary Issues – “the slippery slope” • Open discussions about possible boundary issues • Is the multiple relationship necessary? Beneficial? Unavoidable? • Making referrals when necessary
Ethical Considerations • Bases for Making Decisions • One must consult the relevant literature • Making decisions based on research when possible • Using established treatments and ideas • Honesty and openness when sharing research results and effectiveness • CONSULT!
Ethical Considerations • Avoiding Harm • Minimize risk and harm • Do the greatest good possible • Work to provide the highest standard of care • Avoiding false and deceptive statements • Self-care and self-reflection!
What are your Options? • Offer the CAM treatment by integrating it into ongoing psychotherapy • Seek out additional training and ongoing supervision and then integrate the CAM treatment into ongoing psychotherapy • Refer the client to an appropriately trained CAM practitioner (need to coordinate care with that practitioner with the client’s consent – Cooperation with Other Professionals).
What is Your Role? • What are some questions you should ask yourself when considering integrating CAM into a client’s treatment? • What should you ask the client? • What should you tell the client? • When should you refer and when should you be the CAM practitioner?
Decision Making Model: Questions you should ask yourself… • Am I competent? • Do I need to obtain further training? • Who can I make referrals to? • How will our relationship be impacted if I do or not serve as the CAM practitioner? • How can I avoid harm? • If harm is unavoidable, how can I minimize it? • What does my profession’s ethics code say? • Are there are relevant state laws and regulations? • Can I be objective in my assessment of the situation? • Did I consult with others?
Decision Making Model: Questions you should ask the client… • What other treatments have you considered? • Are they interested in alternative treatments? • What is their comfort with having a possible multiple relationship? • What do they know about CAM and the treatments being discussed?
Decision Making Model:
Questions you should ask a CAM clinician
• What is your level of certification and training?
• If not the highest level, ask why they have not pursued
additional training
• What does the research say on efficacy related to the
client’s specific symptoms?
• Possible risks and benefits?
• What does the treatment entail?
• What is the typical length of treatment?
• What are the fees associated with the service?
• How comfortable is the CAM clinician in consulting
with you about the treatment they are providing?Integrating CAM into Practice:
Clinical Implications
• Licensing and certifications vary both
between modalities and within a
modality
• Not all certifications are standardized
• Remember to consider ethics
• Remain current on the literature
• You don’t need to be an expert, but
you need to be knowledgeable
enough to make appropriate referrals
when needed!Case Presentations: Questions to Consider • Ethical Issues and Obligations? • Questions to ask your Client? • Could the Therapeutic Relationship be Impacted by Using CAM? • Clinical Considerations • What types of treatment may you consider and why?
Case Presentation 1 • You have been seeing a client for weekly psychotherapy for the past 6 weeks. You went through an extensive intake process and learned that your client was taking an antidepressant for her symptoms of depression and that she was looking to augment her treatment with psychotherapy. You asked if she was using any other forms of treatment and she denied this. • When with this client, you notice that she often complains of feeling “itchy” - After this goes on for several weeks, you ask your client if she could be having an allergic reaction. She denies this, but adds, “I think my skin is just sensitive to those oils I am using - they help me to relax.”
Case Presentation 2 • You were in a car accident several years ago and found that chiropractic helped even more than than the conventional pain medications that your doctor provided for you. Because of the relief that you felt, you asked some of your colleagues if they knew of other uses for chiropractic and someone suggested that it can be used to treat depression. • You return to your practice, where you are a medical doctor, and you meet a client who is reporting symptoms of depression. While in the past you often referred these clients to a psychiatrist, you decide that chiropractic may be the best avenue for this client and you tell her to call the chiropractor whom you saw, citing, “Research shows that chiropractic can be more effective at reducing symptoms of depression than medication alone.”
Case Presentation 3 • You are a licensed mental health clinician who regularly treats clients for anxiety, depression, and stress-related disorders. You have found that yoga and meditation have significantly improved your life and you practice them regularly. Your practice is called the Center for Holistic Wellness. You use various aromas in your waiting room and treatment room, softly play meditative chants in your waiting room, and recommend yoga and meditation to all your clients in addition to the counseling you provide. As a deeply religious person who has realized the healing power of prayer, you regularly recommend this to clients and often suggest to them that you both pray together at the end of each counseling session.
Interested in Using CAM? • The NCCAM encourages all users, both consumers and practitioners, to be informed and they provide an FAQ page: • http://nccam.nih.gov/health/decisions/consideringcam.htm • Some questions addressed: • Where can I get reliable information about forms of CAM? • How do I select a practitioner? • Are CAM modalities studied and tested for effectiveness?
How To Find a CAM Provider • Look into licensing requirements • Most organizations have “Find a Practitioner” resources • Be aware of false-advertising! • NCCAM can be a good starting point
What is Needed in the Future?
• Increase education and training
• Increased research and research funding
• Uniform licensing and certification standards
What do you see as a future need for the field of CAM?Resources
• National Center for Complementary and Alternative
Medicine (NCCAM): http://nccam.nih.gov/health
• Federal Trade commission:
http://www.ftc.gov/bcp/menus/consumer/health.shtm
• For research on various modalities: www.medlineplus.gov
• Modality specific information is widely available
• Licensing boards and national organizations exist for
most of the modalities.
• Professional Codes of EthicsReferences
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Manber, R. (2006). Acupuncture for depression: a randomized
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Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and
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