Complementary and Alternative Medicine (CAM) in PsychiatryThe revo

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, shamanis m 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 addres ses
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, i ncreasing
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 i s 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 treatme nt 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 practi ce.
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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