The Integration of Complementary and Alternative Medicine (CAM)

Into
the Practice of Psychology: A Vision for the Future
Jeffrey E. Barnett and Allison J. Shale
Loyola University Maryland
Complementary and Alternative Medicine (CAM) has a long history of use with some modalities being
in existence for thousands of years. In recent years there has been a greater awareness of the many
benefits of CAM for promoting health and wellness as well as for ameliorating a wide range of conditions
and ailments treated by psychologists and other health professionals. One vision of the future of the
practice of psychology includes each psychologist developing and maintaining competence in CAM and
integrating it into each client’s care as is relevant and appropriate. Support is provided for the belief that
CAM will play an important role in the practice of psychology for years to come. Relevant issues
emphasized include an emphasis on Evidence Based Practice in Psychology, the needs and preferences
of a rapidly diversifying society, and the increasing focus on health promotion, wellness, spirituality, and
many non-Western traditions that are consistent with this approach. This article provides an overview of
each of the 14 most widely used forms of CAM, discusses limitations in the current body of scientific
evidence in support of CAM and makes recommendations for how psychologists should be integral in
addressing them, highlights ethical issues that each psychologist will want to be cognizant of and address
when integrating CAM into their practices, and makes recommendations for education, training, and
practice.
Keywords: complementary, alternative, medicine, practice, ethics
The profession of psychology is a vibrant one, with a history of
consistently moving forward and integrating new innovations into
existing practice. In their ongoing efforts to better meet the clinical
needs of clients, practicing psychologists engage in lifelong learning,
endeavoring to continually enhance their clinical competence
(Barnett, Doll, Younggren, & Rubin, 2007). Psychologists rely on
both clinical innovation and empirical support when considering
changes to how they practice (Goodheart, Kazdin, & Sternberg,
2006). Yet, one area of innovation and one vision for the future of
psychological practice involves looking back to the history
of health care and mental health care, tapping into the wisdom of
many hundreds of years of clinical experience. This vision of the
future of the practice of psychology involves integrating Complementary
and Alternative Medicine (CAM) into ongoing psychological
practice. It is important to recognize that some psychologists
may already be integrating many forms of CAM, such as
biofeedback, hypnosis, or progressive muscle relaxation, without
recognizing that they are a part of this growing field of integrative
health care.
We propose that each practicing psychologist should possess a
working knowledge of CAM and its many modalities; their uses,
strengths, limitations, and contraindications; the ethical dilemmas
and challenges psychologists may face when working with CAM,
and when it may be appropriate for clients, either through integration
into ongoing psychological treatment or through referrals to
appropriately trained CAM practitioners. As will be seen, support
is provided for the integration of CAM into ongoing psychological
practice and recommendations are made for doing so ethically and
competently. This focus on the integration of CAM into psychologists’
practices is consistent with major trends impacting the
profession of psychology and how many individuals conceptualize
health care and how they choose to live their lives. These trends
include Evidence Based Practice in Psychology (APA, 2005) with
its attention to client preferences, needs, and individual differences,
a greater focus on health promotion over disease management,
and a more holistic and integrative view of health care in
general. A vision of the future of psychological practice is presented,
which includes knowledge of and competence regarding
Editor’s Note. Miguel Gallardo served as the action editor for this article.
This article is one of 11 in this special section on Visions for the Future of
Professional Psychology.—MCR
This article was published Online First September 17, 2012.
JEFFREY E. BARNETT received his PsyD in clinical psychology from Yeshiva
University. He is a Professor in the Department of Psychology at
Loyola University Maryland and he maintains an independent practice in
Arnold, MD. His areas of professional interest include legal and ethical
issues, training, mentoring, professional development, self-care and psychological
wellness, integrative and holistic health care, and the role of
technology and the Internet in mental health practice.
ALLISON J. SHALE received her MS in clinical psychology from Loyola
University Maryland. She is currently a fifth year graduate student in the
doctoral program in clinical psychology at Loyola University Maryland
and she is presently a pre-doctoral intern at ANDRUS in White Plains, NY.
Her areas of professional interest include clinical child/pediatric psychology,
ethical issues in practice, and the integration of complementary and
alternative medicine into mental health practice.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jeffrey
E. Barnett, Department of Psychology, Loyola University Maryland, 4501
N. Charles Street, Baltimore, MD 21210. E-mail: [email protected]
Professional Psychology: Research and Practice © 2012 American Psychological Association
2012, Vol. 43, No. 6, 576–585 0735-7028/12/$12.00 DOI: 10.1037/a0028919
576
CAM, as well as holistic and integrative health care trends, by all
practicing psychologists and the integration of selected CAM
modalities into psychologists’ practices when it is consistent with
their clients’ best interests to do so.
What Is CAM?
CAM is “a group of diverse medical and health care systems,
practices, and products that are not generally considered part of
conventional medicine . . . (also called Western or allopathic medicine)”
(NCCAM, 2011e, para 2). While often grouped together,
complementary and alternative medicine are actually two separate
forms of treatment, with complementary medicine used in addition
to conventional forms of medicine and alternative medicine used
instead of conventional medicine. Despite many CAM modalities
being in existence for thousands of years, it was not until 1991 that
the United States Congress passed legislation to provide two
million dollars to “establish an office within the National Institutes
of Health (NIH) to investigate and evaluate promising unconventional
medical practices” (NIH, 2011, para 6). In 1992, the Office
of Alternative Medicine (OAM) was established and in 1999, the
National Center for Complementary and Alternative Medicine
(NCCAM) was created as the 25th organizational component of
the NIH (NIH, 2011). At present, the NCCAM “is the Federal
Government’s lead agency for scientific research on complementary
and alternative medicine” (NCCAM, 2011d, para 1). NCCAM’s
mission “is to define . . . the usefulness and safety of
complementary and alternative medicine interventions and their
roles in improving health and health care” (NCCAM, 2011e, para
2). While much work remains to be done, recent research efforts
have begun demonstrating the effectiveness of many CAM modalities
for the treatment of a wide range of ailments and disorders.
A wide range of treatments and interventions exist under the
heading of CAM. The literature documents dozens of interventions
that are considered a part of CAM that fall within four main
categories: Mind-Body Medicine, Biologically Based Practices,
Manipulative and Body Based Practices, and Energy Medicine
(NCCAM, 2011e). Additionally, CAM may be viewed in the
context of Whole Medical Systems, which include Traditional
Chinese Medicine, Ayurvedic Medicine, Naturopathy, and Homeopathy.
Each of these areas encompasses a wide range of CAM
treatments. The CAM modalities included in this article, and
presented in the order of their frequency of use, are those reported
in a large national survey conducted for the National Institutes of
Health (Barnes, Bloom, & Nahin, 2008): dietary supplements,
meditation, chiropractic, aromatherapy, massage therapy, yoga,
progressive muscle relaxation; spirituality, religion and prayer;
movement therapy, acupuncture, Reiki, biofeedback, hypnosis,
and music therapy. Those modalities presented here that were not
included in the survey data provided by Barnes, Bloom, and Nahin
(2008) were chosen for inclusion after reviewing the relevant
literature on CAM based on their frequency of use. A brief review
of these 14 most frequently used CAM modalities is provided to
offer a basic introduction to each of these modalities.
Dietary Supplements
Dietary supplements are “intended to supplement the diet” and
they contain at least one of many “dietary ingredients (including
vitamins; minerals; herbs or other botanicals; Amino Acids; and
other substances) or their constituents” (Office of Dietary Supplements
[ODS], 2011, para 1). Additionally, dietary supplements
should be taken orally, “often in the form of a pill, capsule, tablet,
or liquid” (ODS, 2011, para 1). Commonly used dietary supplements
include gingko biloba, St. John’s wort, vitamin supplements,
and Echinacea. Many dietary supplements are used to
promote health and wellness as well as to treat pain, depression,
and anxiety (Geier & Konstantinowicz, 2004).
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/or effectiveness of any supplements
prior to them being sold. Thus, the potency or composition
of the supplements may vary between manufacturers or even
within a single manufacturer’s batches of a supplement. Much of
the research findings are variable with regard to dietary supplements
due to this lack of regulation. It is essential that psychologists
are aware of the potential risks that may come with utilizing
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, approximately 17.7%
of individuals surveyed had taken a dietary supplement in the past
year, according to Barnes et al. (2007). While psychologists might
educate clients on the substances themselves, they should be
making referrals to primary care physicians, because they are
capable of monitoring blood levels as well as watching for various
potential interactions. But, possessing sufficient knowledge about
the dietary supplements that many clients will be using is important
so that psychologists will be able to appropriately educate and
refer their clients as is needed.
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 [DCIM],
2006) and was reported to be practiced by 9.4% of the adults
surveyed by NIH in 2007 (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,
p. 103). Presently, 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, para 5). While 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,
para 7). 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 wellbeing (Grossman, Niemann,
Schmidt, & Walach, 2007; Rainforth et al., 2007).
Meditation is an area of CAM that can be integrated into
ongoing psychological practice. But, it is important that clinicians
INTEGRATION OF CAM IN THE FUTURE 577
are appropriately trained and that clients are also trained prior to
attempting to meditate on their own. There are no qualifications
necessary for practitioners of general meditation; however, there
are a variety of organizations that offer certification in specific
forms of meditation such as mindfulness-based meditation and
transcendental meditation. Psychologists looking 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 the field of chiropractic is “that nerve
and organ dysfunction is often the result of misaligned vertebrae of
the spine” (Kuusisto, 2009, para 9). Doctors of Chiropractic use
noninvasive treatments such as spinal manipulations or chiropractic
adjustments (American Chiropractic Association [ACA],
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, para 3). An essential
component of chiropractic is that optimal functioning is achieved
when the spine is in alignment (Kuusisto, 2009). Thus, 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% of Americans each year to treat a range of ailments from pain
and headaches to stress and ADHD, among others (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 to earn.
Thus, while most psychologists will not likely also obtain the
doctor of chiropractic degree, it is important to recognize that even
if certification is obtained, serving as a client’s chiropractor at the
same time as serving as their psychologist would be 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, para 5). 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,
utilizes 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 aromatherapy has been increasingly
studied and has shown positive results when used to treat a
variety of symptoms to include 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 be aware of.
Massage Therapy
Massage therapy is a manual procedure that involves manipulating
the soft tissue of the body 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 their feet, as a way to
“relieve pain, rehabilitate sports injuries, reduce stress, increase
relaxation, address anxiety and depression, and aid general wellness”
(NCCAM, 2011b, para 8). 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% 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 symptoms that present to psychologists,
such as depression, anxiety, and stress, and thus it may be relevant
for integration into some clients’ treatment. However, this integration
must be done by referral to qualified massage therapists even
if the psychologist is appropriately trained, 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 (NCBTMB).
Yoga
Yoga is a form of CAM that 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 bring about relaxation while working to
“balance the mind, body, and the spirit” (NCCAM, 2011f, para 5).
There are many different types of yoga such as Hatha, Ananda,
Anusara, Bikram, Kundalini, and Viniyoga. In recent years, yoga
has been increasingly studied 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% of adults indicated that they had practiced a form of
yoga in the preceding year (Barnes et al., 2008). Since the practice
of 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.
Additionally, clients who might benefit from yoga in addition to
their ongoing psychological treatment may be referred to qualified
578 BARNETT AND SHALE
yoga practitioners. As with many other CAM modalities, certification
is required to practice yoga but the certification process is
not standardized.
Progressive Muscle Relaxation
Progressive muscle relaxation (PMR) is a technique in which
the client learns to sequentially tense and relax various groups of
muscles as a way of promoting greater relaxation. PMR is often
beneficial for clients who are experiencing anxiety, tension, or
stress-related symptoms. With these symptoms being common to a
variety of disorders, it is not surprising that PMR has a wide range
of applicability within the field of psychology. Despite the fact that
it has been accepted and integrated into practice by psychologists
for many years, results of the NIH study showed that only 2.9% of
adults had used PMR in the prior year (Barnes et al., 2008). PMR
is one aspect of CAM that does require significant effort and
outside time-commitment on the part of the client. PMR should not
be viewed as a simple solution to stress reduction and it is important
that clients are aware of the fact that their success with PMR
is highly dependent on the effort that they put forth in terms of
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
According to the U.S Religious Landscape Survey, 56% of
those surveyed indicated that religion was very important to them
while 26% reported that it was somewhat important to them (The
Pew Forum on Religion & Public Life, 2008), indicating that
spirituality, religion, and prayer are likely areas of CAM that
clients may already be relying on, without even realizing that they
are a part of CAM. Spirituality and religion are actually two
separate entities such that spirituality tends to be more personalized
while religion is often more formally organized. Clients may
identify themselves as only spiritual or religious, and not both.
Spirituality, religion, and prayer are three areas that have been
difficult to study. Yet, despite various design issues, studies 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 each be integrated in psychologists’
ongoing practice and technically no certification is
required to do so. However, competence about the religion or
faith-based practices being addressed is essential. Additionally,
psychologists will want to be aware of the fact 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 role and take on the role of clergy. Clinicians who are
interested in integrating spirituality, religion, and/or prayer into
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, para 1). Often referred to as dance/movement
therapy (DMT), it focuses on “movement behavior as it emerges in
the therapeutic relationship” (ADTA, 2009b, para 1). 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 impact their mind and
therefore relieve a variety of symptoms (Levy, 1995). While
research in the field of DMT is rather limited and more research is
needed to support and guide the use of DMT the ADTA has
reported some support of DMT’s use to help treat a variety of
symptoms such as those associated with ADHD, dementia, depression,
and a variety of physical disabilities, as well as promote
overall wellbeing (ADTA, 2009a). With DMT being one of the
lesser known CAM modalities, only 1.5% of adults reported that
they had used DMT 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
Acupuncture is a technique used to improve health and functioning
“through stimulation of specific points on the body” that
has been in existence for thousands of years (NCCAM, 2011a,
para 1). Barnes et al. (2008) reported that 1.4% of adults indicated
having 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” which is also known as qi (DCIM, 2010, p. 464). 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. Additionally,
in some states, licensure is required to practice acupuncture
while others require certification through the National Certification
Commission for Acupuncture and Oriental Medicine
(NCCAOM) in addition to licensure. Psychologists, even if certified,
should not serve as a client’s acupuncturist as well as his or
her psychotherapist due to the fact that acupuncture often involves
the client removing articles of clothing, a clear boundary violation.
Additionally, 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”
(The International Center for Reiki Training, 2011, para 1). 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
INTEGRATION OF CAM IN THE FUTURE 579
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.
With only 0.5% of the population reporting use of Reiki (Barnes
et al., 2008), there is not a significant amount of research studying
its efficacy. Despite this, Reiki has been shown to help with stress
and pain management, as well as promoting relaxation (Bowden,
Goddard, & Gruzelier, 2010; Olson, Hanson, & Michaud, 2003).
To practice Reiki, certification is required. Referrals should be
made for Reiki services, as opposed to integrating into ongoing
practice, as the hand positions will likely result in a boundary
issue. Even though there is no direct contact, the clinician’s hands
are placed very close to the client’s body.
Biofeedback
Biofeedback utilizes various forms of equipment as a way of
feeding back information, which “enables an individual to learn
how to change physiological activity for the purposes of improving
health and performance” (Association for Applied Psychophysiology
and Biofeedback [AAPB], 2008, para 2). When using biofeedback,
the client is connected to various electrical sensors that
“measure and receive information (feedback) about the client’s
body” (Mayo Clinic, 2010a, para 1). 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% of adults utilize biofeedback (Barnes et al.,
2008) and the Association of Applied Psychophysiology and Biofeedback
reports having over 2,000 professional members (AAPB,
2008) and the Biofeedback Certification International Alliance
report having approximately 1,600 certified members (Judy Crawford,
personal communication, February 20, 2012).
Biofeedback is an area of CAM that can be integrated into
ongoing treatment with relative ease by appropriately trained psychologists
utilizing 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, para 14).
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, p.
89). With only a 0.2% rate of use (Barnes et al., 2008), it is not
surprising that the field of hypnosis is one that clients may not
associate with having health benefits; when many people hear the
term hypnosis, they think of it being used for entertainment purposes.
Thus, psychologists will want to educate clients about the
utility of hypnosis, while emphasizing that the purpose is not to
gain control over another human being. With that, clients should
recognize that they will not be made unconscious during the
hypnotic procedure and that they will remember what has taken
place.
As an example, hypnosis 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 must 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 advancedlevel
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,
para 2). Music therapy involves singing, writing music, making
music, listening to music, and lyric analysis, among many other
techniques (AMTA, 2011b). Psychologists will want to make their
clients aware that the quality of their music is not what impacts the
therapeutic process. Rather, the focus should be on helping clients
to explore their thoughts and feelings through the use of a music
intervention. Music therapy is a multidimensional approach in that
it 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, [BCMD], 2011, para 1).
Some evidence is provided that supports music therapy’s use to
reduce anxiety, depression, and pain although the literature is
limited (Castillo-Pe´rez, Go´mez-Pe´rez, Calvillo Velasco, Pe´rez-
Campos, & Mayoral, 2010; Lin, Hsieh, Hsu, Fetzer, & Hsu, 2011).
Music therapy may ethically and appropriately be 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 a Music
Therapist-Board Certified (MT-BC; AMTA, 2011a).
Why CAM Today?
Many forms of CAM have existed for centuries as most forms
of CAM were present in more traditional forms of medicine from
non-Western cultures (e.g., Traditional Chinese Medicine,
Ayurvedic Medicine). Consistent with demographic trends in the
United States the population of the United States has been rapidly
diversifying in recent years (U.S Census, 2010). Many immigrant
communities have brought with them their beliefs and practices
relevant to health promotion and health care. Further, these groups
have had and continue to have a profound impact on the general
population and culture around them. Additionally, the overall
population has exhibited a greater interest in general wellness and
health promotion in recent years with many individuals seeking
out CAM treatments as a result. Recent trends such as the signif-
580 BARNETT AND SHALE
icant focus on mindfulness, meditation, yoga, Buddhist principles,
and spirituality in daily life are but a few representative examples
(e.g., Kabat-Zinn, 1990, 2003; Serlin, 2007; Shafranske & Maloney,
1990), each of which emphasizes the connection between the
physical and the psychological or spiritual in contrast to Western
medicine’s general emphasis on physical conditions, and a greater
focus on well functioning and enhanced quality of life than on
disease management.
The use of CAM and its integration into both daily life and
health care are part of a larger movement in the United States (and
other Western nations) that focuses on more integrative and holistic
care. Many individuals now seek the use of these modalities
either instead of or in addition to modern industrialized medicine
and are making known these preferences to health care practitioners,
resulting in changes in how health care is practiced. In the
2009 national health statistics survey, 55% of all individuals surveyed
reported the belief that the use of various CAM modalities
in addition to conventional medical care results in improved health
(NIH, 2011).
The Current State of Research on CAM
Several CAM modalities have been in use for thousands of years
and many of them are widely accepted by the public for their
known benefits for promoting health and wellness as well as for
ameliorating a wide range of ailments. Yet, consistent with the
tenants of evidence based health care, in recent years, research on
the effectiveness and underlying mechanisms of the many CAM
modalities has greatly increased. While this is quite promising,
psychologists should be cognizant of the potential limitations
associated with some of this research, being thoughtful and critical
consumers of this literature who exercise caution in interpreting
research findings, as well as actively participating in the study of
CAM, bringing increased scientific rigor to this inquiry.
In the current research literature on CAM, there are numerous
issues related to participant recruitment as well as how participants
are assigned to treatment conditions. For example, in some studies
participants were simply grouped by where they lived, as opposed
to utilizing random assignment, and thus there were several extraneous
participant variables that may have impacted the results
(Rho, Han, Kim, & Lee, 2006). Other studies have utilized convenience
samples due to the difficulties that can be associated with
recruiting participants (Louis & Kowalski, 2002). While in some
ways these approaches may have been practical, it is important to
be aware of the limitations associated with the conclusions drawn
from the results of studies not using random sampling or random
assignment.
Further, much of CAM research utilizes case studies or the
sample sizes are very small. In fact, many CAM studies have
samples that are smaller than 10 subjects (Kunstler, Greenblat, &
Moreno, 2004). In many instances, the small sample sizes were a
result of strict recruitment procedures within various quantitative
studies, as much of the research on CAM tends to focus on a
limited set of symptoms. While focusing on a specific population
can provide beneficial results, issues of generalizability remain.
An additional area of concern is the lack of no-treatment conditions
in many studies, something that can contribute to stronger
conclusions than control groups alone.
There are also considerable issues related to a lack of longitudinal
studies. While many current findings are valuable and provide
helpful information for understanding the efficacy of various
CAM modalities, understanding their long-term effects is important
as well, something that can contribute to CAM’s use and
acceptance. Another difficulty when conducting research with
CAM is that certain modalities are easier to study than others. For
instance, one can easily study the impact of chiropractic on back
pain or the efficacy of PMR on stress. But, spirituality and religiosity,
for example, are harder to operationalize and measure and,
therefore, conducting research in this area is more challenging.
However, it is important to remember that a lack of studies, and
therefore a lack of support, does not mean that a particular modality
is not useful.
Psychologists are uniquely qualified to rectify these limitations
in the CAM literature, working to bring scientific rigor to the study
of CAM. Ultimately, whether psychologists will be using these
modalities in practice, recommending the modalities to clients, or
simply monitoring and observing and responding to the effects of
client-initiated CAM use on their clients, they must play a more
active role in conducting the needed research so that any conclusions
about the use of CAM may be made with sufficient confidence.
Research is needed not just to determine when CAM might
be appropriate and effective either as a primary treatment or
adjunct to psychotherapy, but when CAM treatments are not
appropriate and effective. To support this initiative, similar to
psychologists’ efforts with regard to other advances that have been
made in the scope of psychological practice, psychologists are
encouraged to participate in political advocacy efforts to help
ensure that needed support for research, to include funding, is
received.
Why Is CAM Important to Psychologists?
Psychologists are uniquely positioned to educate clients about
CAM, to monitor their use of CAM, to communicate with primary
care physicians (PCPs), and, if possessing the needed competence,
they are also able 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 when to make referrals to
CAM practitioners, and how to do this effectively, or to persuade
them away, are essential components of each psychologist’s competence.
In 2007, the NCCAM included a CAM specific addition to the
National Health Interview Survey, the first to solely focus on CAM
usage among children and adults. The survey’s sample consisted of
nearly 24,000 adults over the age of 18 and approximately 9,400
children (Barnes et al., 2008). Results of the survey indicated that
38.3% of adults and 11.8% of children reported having used a form
of CAM in the preceding year (Barnes et al., 2008). This corresponds
with nearly $34 billion dollars being spent each year “on
various CAM products and visits to CAM practitioners” (Briggs,
2007, para 1). Although this amount of money only accounts for
1.5 of the total amount spent on health care, it accounts for nearly
11.2% of out-of-pocket spending on health care (Briggs, 2007).
Further, Eisenberg et al. (1998) determined that there were 243
million more visits made to CAM practitioners than there were to
primary care physicians (PCP) in the preceding year.
INTEGRATION OF CAM IN THE FUTURE 581
Elkins, Marcus, Rajab, and Durgam (2005) assessed CAM use
among 262 people who were currently in psychotherapy. They
found that 65% 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 clients are likely to be
independently utilizing them. This further emphasizes that in order
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 additionally be of benefit to
them. Additionally, we 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 upto-
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 (EBPP; APA, 2005) which is described as “the
integration of the best available research with clinical expertise in
the context of patient characteristics, culture, and preferences”
(para. 2). 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 either independently or through their health practitioners.
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.
Ethics Issues and CAM
There are several ethical issues relevant to the use of CAM that
practitioners should be aware of and consider. Regardless of
whether a particular CAM modality is being used in session or a
referral is being made, these ethics issues must be addressed in
order to provide the highest standard of care. There are several
standards in the Ethical Principles of Psychologists and Code of
Conduct [APA Ethics Code] (APA, 2010) relevant to the use of
CAM. First, psychology practitioners must be knowledgeable
about CAM: its uses, limitations, interactions with other treatments,
contraindications, and its potential benefits. The fact that
one practices a form of CAM in one’s personal life should not be
considered an indicator of sufficient competence to provide CAM
treatments to clients. Standard 2, Competence, addresses the requirement
that psychologists possess the needed knowledge and
skills to be able to practice effectively and to not practice outside
areas of demonstrated competence. Further, psychologists are required
to maintain their competence through ongoing professional
development activities that include keeping informed about recent
developments in the field. Finally, psychologists are required to
base clinical decisions and treatments provided on “established
scientific and professional knowledge of the discipline” (APA,
2010, p. 5), further emphasizing the need to remain current on the
scientific literature relevant to clients’ treatment needs and helping
to ensure adherence with Ethical Standard 3.04, Avoiding Harm.
Ethical Standards 3.10, Informed Consent, and 10.01, Informed
Consent to Therapy, require that psychologists share sufficient
information with clients at the outset of the professional relationship
so that clients may make informed decisions about their
participation in the proposed treatment. Essential components of
the informed consent process include a review of reasonably
available options and alternatives along with a discussion of the
potential risks and benefits of each. Accordingly, to fulfill this
ethical obligation, each psychologist will want to include discussion
of reasonably available treatment options. For many presenting
problems, this discussion should include various CAM modalities
whose use for particular difficulties is supported by the
relevant scientific literature.
As has been highlighted, there are several CAM modalities that
are appropriate for psychologists to integrate into treatment with
their clients when appropriately trained and credentialed to do so.
Yet, with several of these modalities, administering these treatments
to current psychotherapy clients would constitute an inappropriate
multiple relationship (Standard 3.05) and a boundary
violation. When a CAM modality is implemented through physical
contact, such as with Massage Therapy, Chiropractic, and Reiki,
psychologists should be especially sensitive to boundary issues
that make their use by the psychologist with a psychotherapy client
inappropriate.
Ethical Standard 3.09, Cooperation With Other Professionals, is
also relevant since many clients will need their psychologist to
communicate and coordinate treatment with their primary care
physician. When referrals are made to CAM practitioners to provide
treatment complementary to the psychological treatment, it
will typically be in the client’s best interest to coordinate this care
and at times to work collaboratively with the CAM practitioner.
The Future of CAM and Psychology
With so many consumers of psychological services already
utilizing CAM in their lives (both with benefit and with potential
risks) and with so many clients’ presenting problems being potentially
amenable to various CAM modalities, and consistent with
current trends in holistic health care, wellness, and health promotion,
we envision that psychology in the future will have every
practitioner psychologist assessing for past and current use of
CAM with clients as well as assessing each client’s needs for
integrating CAM into their treatment, when its use is supported by
relevant research. Thus, ethical psychologists will know about
CAM regardless of whether or not they personally offer CAM
services so they can best meet the needs of a diverse clientele.
Accordingly, all practicing psychologists should have at least a
basic level of familiarity with CAM and the relevant literature
about its uses, benefits, limitations, and contraindications. Not all
psychologists will wish to become licensed or certified in each
specific CAM modality, or even possibly in any of them, but all
psychologists should have a working knowledge of a wide range of
CAM modalities. Psychologists should possess sufficient
knowledge to be able to share viable treatment options and
alternatives with clients, thoughtfully discussing their relative
merits and limitations, making appropriate referrals when indi-
582 BARNETT AND SHALE
cated and integrating the preferred CAM modality into the
client’s ongoing treatment when indicated by the scientific
literature and when the psychologist possesses the needed training
and clinical skill to do so.
Psychologists wishing to integrate selected CAM modalities
into their ongoing treatment of clients will need to possess higher
levels of competence and training. For some CAM modalities this
will involve extensive training and culminate in licensure and
certification (e.g., massage therapy, dance/movement therapy). For
others, additional training in the form of continuing education
courses will be needed (e.g., progressive muscle relaxation).
Consistent with a focus on Evidence Based Practice in Psychology
as well as with the needs and preferences of our rapidly
diversifying population, in the future, we hope that all training
programs will integrate training on CAM into their curriculums
through coursework and supervised placements to help promote
the competence needed for addressing CAM with these clients. It
is also hoped that psychologists will increasingly focus their research
efforts on CAM and that this research will hopefully include
larger studies with increased scientific rigor so that psychologists
will have a better understanding of the effective uses and
limitations of CAM to better assist their clients. We hope that this
article will stimulate greater interest in CAM and that practicing
psychologists and those who train future psychologists will see the
importance of educating themselves in this ever-growing area.
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15426430802113814
Received October 31, 2011
Revision received February 20, 2012
Accepted May 8, 2012 _
Call for Papers: Special Issue
Ethical, Regulatory, and Practical Issues in Telepractice
Professional Psychology: Research and Practice will publish a special issue on recent ethical,
regulatory and practical issues related to telepractice. In its broadest definition the term telepractice
refers to any contact with a client/patient other than face-to-face in person contact. Thus, telepractice
may refer to contact on a single event or instance such as via the telephone or by means of electronic
mail, social media (e.g., Facebook) or through the use of various forms of distance visual
technology. We would especially welcome manuscripts ranging from the empirical examination of
the broad topic related to telepractice to those manuscripts that focus on a particular subset of issues
associated with telepractice. Although manuscripts that place an emphasis on empirical research are
especially encouraged, we also would welcome articles on these topics that place an emphasis on
theoretical approaches as well as an examination of the extant literature in the field. Finally,
descriptions of innovative approaches are also welcome. Regardless of the type of article, all articles
for the special issue will be expected to have practice implications to the clinical setting. Manuscripts
may be sent electronically to the journal by means of journal box office www.jbo.com to the
attention of Associate Editor, Janet R. Matthews, Ph.D.
INTEGRATION OF CAM IN THE FUTURE 585