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

• 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?

Some questions to begin with…

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)

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

CAM Modalities

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 Press

Spirituality, 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.org

Hypnosis • 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).

• 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

Anxiety

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 rate

Ethical 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 Ethics

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