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.
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.
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.