Comments on complementary and alternative healing modalities
A first year African American nursing student was assigned to care for a very religious elderly African American woman who refused pain medication on her first post-operative day after a radical mastectomy. Visually, the patient's facial expression was very serene and she appeared to be resting comfortably. When asked her about pain and offered pain medication she said ‘I don't need any, I'm fine’. The student knew intuitively that the patient was praying and believed that God would comfort her. The student's instructor who was from another culture gave a clinical low grade for that day because the student did not administer pain medication. Was the instructor or the student wrong? What concepts were the instructor ignoring and the student unable to articulate?
One of the common themes in reading the literature on healing practices is the need to assess the complementary or alternative modalities used by patients. The vignette above is an example of a patient using prayer as an alternative for pain management and an inadequate preoperative health history. The use of complementary and alternative medicine (health care) (CAM) is reported to be increasing exponentially globally by consumers, health professionals and health-care organizations.[1-4] One contributing factor is the global immigration of diverse cultures from countries who for centuries were homogenous, and the use of CAMs was common. However, in most Western countries such as such as the United States (USA), the majority of health care is biomedical (Western) in nature. Western medicine treats disease with prescription medications, surgery or various biotechnological products.
The increased use of CAM has occurred despite the lack of health insurances coverage in some countries, inadequate systematic regulation, limited research clinical trials and evidence-based practice guidelines. Global statistics indicate a range of 20–80% or more of patients report use CAM in the past year.[1-7] For example, studies report that over 65% of Japanese, 48.5% of Australian, 20–50% of European, the majority (80%) of the Chinese, and 42.1% of people from the United States (USA) used CAM in the past year.[1-7] Over half of patients use home remedies, over-the-counter drugs and diverse complementary or alternative therapies.[1, 4, 5]
This editorial highlights the topic of CAM and its increasing prevalence. Lastly, it provides a list of selected resources to assist health professionals to become knowledgeable about CAM therapies specific for patients from diverse cultures and various health concerns.
Four papers in this issue address complementary and alternative medical care (CAM) used by consumers, patients and health professionals for healing and wellness. Often, the term medicine is used interchangeably with health care, therapies or modalities. Complementary modalities are a group of diverse medical, health systems, practices, products and procedures used along with conventional medical treatments.[1, 8-11] Alternative modalities are treatments, supplements, or practices that are used instead of conventional health care to promote healing or well-being.[1, 8-11] Conventional health care is provided by medical doctors or doctors osteopathic medicine and other health professionals such as pharmacists, physical therapists, psychologist, registered nurses and others. Integrated system of care is health care that includes the use a combination of conventional health care with complementary therapies to treat a person's health issues.[10, 11] For example, the use of antihypertension medication and Tai Chi to treat hypertension is integrative health care.
Internationally, in all cultures professionals and consumers use therapies, products, beliefs and viewpoints, and devices to promote healing or well-being independent of conventional health care. This includes the use of herbs and supplements and providers ranging from traditional medicine men herbalist and naturopathic physicians. CAM is used for diverse health conditions and issues such as treatment of acute and chronic diseases; relief of stress and pain; enhance coping with grief, stress, and depression; provide palliative and end of life care; support the grieving; and promote health and well-being.[1, 2, 7-11]
Although, the use of medical herbs dates back to the prehistoric ‘ice man’, in the USA, until the early 1990s, CAMs were not recognized fully by majority of health professionals as ‘legitimate’. The reasons for increased use of CAMs are (i) acceleration in the cost of health care; (ii) a desire for increased health autonomy by consumers; (iii) interest in new CAM health care options; (iv) belief in holistic values and wellness promotion; and (v) Western Medicine/main stream medicine is not completely effective in meeting the consumers' body–mind–spirit needs.[2, 10, 11] At the same time, many clinicians, researchers, therapists and spiritualist observe subjectively that individuals and families are sometimes healed or report improved sense of well-being by acupuncture, massage, meditation, mindfulness, prayer, touch therapies, herb and vitamin therapies and others.[1, 2, 7-11]
History of CAM in Western Health Care
In nursing, healing practices were reported as early as the 1860s by Florence Nightingale the founder of nursing. Nightingale emphasized holistic care and the importance of the environment particularly cleanliness, fresh air, good nutrition, massage and caring for the whole person and family. For hundreds of years, CAM therapies were neglected by most Western health professionals. As the interest and use of CAM by consumers increased in the USA, leaders in the field spurred the launching of a federal agency in 1991. The purpose of the new agency was to (i) promote research; (ii) disseminate authoritative information to professionals and consumers about CAM; and (iii) to ensure the content in professional curricula about CAM and into health professionals' practice.[2, 13] As a result, the National Center for Complementary and Alternative Medicine (NCCAM) was established 1998 by the United States Congress. At the same time, in many Asian countries such as China and Japan, the use of very advanced modern Western medicine coexists with traditional Eastern medicine. For example, acupuncture is covered by insurance in Japan. The reader is encouraged to explore history, and the policy and regulations of CAM in their country and region.
Classifications of CAM
The classification of CAM varies and usually includes (i) alternative medical systems (Chinese medicine, homeopathy, naturopathy, osteopathy, etc.); (ii) mind–body–spirit modalities (yoga, exercise, meditation, spirituality and prayer); (iii) biological-based therapies (foods, supplements and herbals, others); (iv) manipulative and body based methods; (v) energy and biofeedback therapies (biofeedback, reiki, magnets, therapeutic or healing touch); and (vi) others.[1, 3, 7-10] Within each of the modalities are a variety of approaches that are too numerous for this editorial. For in-depth information readers are referred to the websites, journals and references such as listed in Table 1.
Table 1. Selected resourced for authoritative information about complementary and alternative health care modalities
CAM organizational websites
Libraries and data bases
Websites and journals
Most reviews and literature caution that although there are many CAMs, the scientific evidence to support their safety and effectiveness remains sparse or the findings are not always convincing .[1, 3, 12, 13, 15] At the same time, since the establishment of NCCAM, CAM organizations and the Cochrane Collaboration, the number of systematic reviews, randomized clinical trial studies and meta-analyses about specific CAMs are more prevalent.[1, 13, 15] CAM organizations and professional groups provide resources to inform consumers and professionals, evaluate CAMs, and provide education, certification and consultation on CAM.[13, 16] For example, complementary medicine is one of the Cochrane groups for systematic review of topics.
Spirituality as a CAM
Throughout the world, over 22 major religions are reported. The majority of people has a religious belief and only ≈16% describe themselves not religious.Although the majority of people believe in a higher power, spirituality is one of the most ignored variables in providing holistic health care. Spirituality is a broad term that included both religion and spirituality.[8, 9, 12, 17-20] It is associated with transcendence and the essence of life separate from the body. Religion is defined as one's beliefs and ‘reverence for God or some supernatural power that is believed to be the creator or ruler of the universe’. Numerous scholars and scientific reviews report positive relationships between spiritual well-being or religiosity and hospice care, pain management, support of HIV/AIDS issues, stress, chronic disease, care giving, coping with major disasters and other life issues.[15, 18, 19] Some systematic reviews note significant relationship between religious participation, spirituality, healing and well-being. However, sometimes the findings are inconclusive due to small samples or lack of rigor in the research design.[15, 18] Common terms used to conceptualize religion or spirituality are alternative and complementary medicine, contemplative space, healing or therapeutic touch, sanctuary, reflection, labyrinth walks, meditation, mindfulness and so forth.[19, 20] Knowing the likelihood of a high degree of spirituality in patients, health professionals should include in their assessment of the health history the patient's and family's spirituality and acceptable spiritual support.
Over 30 years since the academic, policy, and academic peaked interest in CAM in the West, one notes an increasing integration of complementary, alternative and mainstream modalities in health centers (medical and nursing), journals, research grant support foundations and academic professional careers in CAM.[1, 10, 11, 21] Also increasingly health professional curricula include CAM content that encourages future providers to respect and integrate complementary and alternative health practices into main stream health care. In the USA, there are over 50 integrative health centers that combine the three modalities to provide total care for the patients' body, mind and spirit.
From an empowerment and collaboration perspective, patients and consumers should be encouraged to learn: about the their CAM therapies; the risks/interactions of herbs and supplements, and assess what is required for learning; certification and license and who provides the certification for CAM practitioners.[16, 22, 23]
One of the common themes in systematic reviews is that many CAM research studies lack rigor, are not always well designed and that the results of many studies are inconclusive. Therefore, there is a needed to plan and implement CAM research studies with rigorous controls. Also, it is crucial to disseminate and evaluate the scientific evidence generated by randomized clinical trials. Researchers also need to cooperate with cultural groups to understand the culturally specific healing practices or beliefs.[22-26]
There are over 2000 herbs and supplements reported available to consumers from a variety of cultures. Some are reported to have significant and positive effects. Although others have the potential for adverse interactions with prescribed medication and foods, allergic interactions, impurities and sensitivity in unborn children, children and older adults, toxicity, etc.[1, 27, 28] Because CAM is a very broad field, knowledge of sources for acquiring a general knowledge of the therapies, evidence base recommendations and research about the therapies used by clients is prudent. Most professionals do not have the time or resources to become experts in each CAM modality. The support of a CAM referral network or team is useful. Another strategy is knowing a minimum of two resources that provide comprehensive information about a specific CAM, systematic reviews, meta-analysis of studies, best practices and the culture of the patient.[11, 20, 27] Examples of resources are the (i) the Cochrane Collaboration, Library and Database provide that systematic review and meta-analysis reports of published CAM research studies about a specific health topic; (ii) the resources link from CAM organizations; (iii) CAM journals and books; (iv) annual CAM organization conferences; and (v) for credit university or continuing professional education courses (see Table 1).
Internationally, an increasing number of conventional health professionals intertwine complementary and alternative therapies and collaborate with CAM professionals to better meet the holistic need of patients. For example, professionals from oncology, palliative and long-term care, hospice, diabetic care, etc. might incorporate healing/therapeutic touch, footbaths, massage or meditation into their therapies.[3, 10, 19, 22] Some Japanese nurses incorporate warm evening baths and foot baths into care to promote the relief of headaches or to aid sleeping. Thai nurses might incorporate meditation and massage into routine patient care. If requested, Muslim clients and families should be provided privacy to pray several times a day. Many medical centers hire CAM specialists and/or chaplains or priests to meet the spiritual needs of patients and families. Some provide private spaces (such as chapels, gardens, and labyrinths) for prayer, meditation and reflection. Agencies with a large Chinese population should know the common Chinese medicine therapies and the CAM of choice for this culture. For example, knowledge of the belief in ‘coining or cupping’ for colds could prevent the accusation that a child was abused when one observed bruises on the back or chest.[22, 25, 27]
An essential aspect of the health professionals role regarding CAM is to encourage consumers and professionals to seek authoritative sources to obtain accurate information and up to date knowledge based on research about the CAM of interest.[27, 29] Also, CAM is regulated mostly by the professional standards; therefore, patients should be encouraged to inquire about CAM practitioners' training, certification and licensure. Finally, many alternative and complementary therapies do not have adequate randomized clinical trials to provide adequate scientific evidence of the efficacy of the therapies. There is a need for additional multidisciplinary health professional teams to conduct rigorous randomized controlled trial research studies and publish quality systematic reviews about CAM.
Globally, health care of the 21st century is increasingly a convergence of Western and Eastern health care (pharmaceutical, surgical and biotechnical) and complementary and alternative modalities (body, mind and spirit). At the same time, healthy consumers and those with acute and chronic pain, cancer and other health issues are turning to CAM in record numbers and reporting positive results especially in well-being and stress reduction. Therefore, health professionals are encouraged to (i) respect the patients' right to request CAM; (ii) know the common CAMs used for consumers in their area of practice; (iii) create a network with CAM professionals who collaborates with referrals; (iv) evaluate systematic reviews of CAM research; and (v) conduct CAM research with rigorous controls. Lastly, when feasible, each health professional is encouraged to explore ways to provide individualized holistic patient care by combining evidence-based CAM modalities with conventional health care to empower culturally diverse individuals and families to prevent disease, promote healing and maximum well-being.