Advances in medical research, the consumer empowerment, and rising cost of health care have demonstrated the need to treatment models that are holistic and client driven. Complementary and alternative medicine (CAM) offers consumers choices. It includes traditional healing practices, medical systems that are thousands of years old and new or innovative treatments that may be consider unconventional. Well known examples of CAM include herbal remedies, mindfulness, meditation, manipulative/movement therapies, and Chinese Medicine. Knowledge of CAM offers social workers in all settings the opportunity to provide education and advocacy in seeking client centered and culturally competent treatment options.

Monday, May 30, 2011


Acupuncture is a part of traditional Chinese Medicine (TCM).  It has been practiced for over 2,500 years (VanderPloeg & Yi, 2009).  According to Freeman (2009) the earliest text on the practice of acupuncture dates back to 282 AD.  The practice of acupuncture has waxed and waned in popularity.  In the sixteenth century it reached its height and then declined in popularity in the 19th century with the introduction of Western Medicine in China.  In the late 20th century, interest in complementary and alternative medicine (CAM) sparked a resurgence of interest in acupuncture. 
There are multiple theories regarding the mechanism by which acupuncture works.  According to TCM practice illness occurs when the qi, life force is blocked.  Acupuncturists restore the balance of health by applying needles to stimulate the flow of qi along the meridian points (Freeman, 2009).   Solid needles ranging from half an inch to four inches in length made from various materials including gold, silver, copper, stainless steel, or a combination of these are inserted into the skin to deep tissue (VanderPloeg & Yi).  The needles are left in place for approximately 20 minutes and can be stimulated by hand (twisting or twirling) or electrical current.  The insertion and manipulation can cause a sensation of numbness, heaviness, and radiating pain (known as “de qi”).  Western medical practices believe that acupuncture may influence the release of endogenous opioids to promote pain relief (Freeman; VanderPloeg & Yi).  Park et al (2008) conducted a systematic review of the clinical research applications of acupuncture and found a substantial amount of research that indicates that acupuncture is effective at treating a myriad of medical conditions.  Clinical studies utilizing randomized controlled trials (RCT) have found it to be effective in the treatment of premenstrual syndrome, dysmenorrhea, several pregnancy-related conditions, nausea, pain, asthma, and opiate withdrawal.  Its efficacy in the treatment of other women’s health and mental health conditions is promising given the limited amount of evidence.  Yet, conducting RCT remains problems.  Studies that utilize no treatment as a comparison group indicate promising results.  Studies that design a “placebo”  intervention known as “sham” acupuncture also run into difficulties making the detection of statistically significant finding increasingly difficult to determine (Linde, Niemann, Schneider, & Meissner, 2010).  Given the demand for CAM and evidence-based medicine, it is important for researchers to continue to explore the efficacy of acupuncture.
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby Elsevier Press.
Linde, K., Niemann, K., Schneider, A., & Meissner, K. (2010). How large are the nonspecific effects of acupuncture? A meta-analysis of randomized controlled trials. BMC Medicine, 875-88. doi:10.1186/1741-7015-8-75
Park, J., Linde, K., Manheimer, E., Molsberger, A., Sherman, K., Smith, C., & ... Schnyer, R. (2008). The Status and Future of Acupuncture Clinical Research. Journal of Alternative & Complementary Medicine, 14(7), 871-881. doi:10.1089/acm.2008.SAR-4
VanderPloeg, K., & Yi, X. (2009) Acupuncture in Modern Society, Journal of Acupuncture and Meridian Studies, 2(1), 26-33. doi:10.1016/S2005-2901(09)60012-1

Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is based on the philosophy of Tao which dates back to Ancient China in which the path or way of life involves harmony deriving from balance within the self and the environment.  The purpose of medical treatment is to restore harmony in the mind, body and behavior.  According to Freeman (2009), Chinese medical theory rests on certain assumption about the nature of the universe.  The yin and yang theory, two polar opposite forces that reside within living beings that complement each other and must be in balance.  The yin and yang form part of the eight principles theory of Chinese medicine which also include interior and exterior, deficiency and excess, cold and hot.  Other principles of the yin and yang theory include the five elements wood, fire, earth, metal, and water.  The physician in TCM observes the relationship between these elements, the yin-yang, and the three treasures, qi (life force),  shen (spirit) and the jing (substance of organic life) to diagnose and treat the individual. The shen brings light and joy to life.  The jing is the essence of being. When the flow of qi is blocked illness occurs.  Qi flows through 12 channels known as the meridians.  Each meridian corresponds with an organ or organ function including the lung, large intestine, small intestine, urinary bladder, kidney, pericardium, gallbladder and liver.  The meridian system also includes nerves, blood vessels, and lymph nodes, microscopic tissue gaps or spaces in the entire living organism (Xutian, Zhang, & Louise, 2009).  There are 365 points along the meridians. 
TCM includes acupuncture, Chinese herbal medicine, Chinese therapeutic massage (tuina), but also other modalities such as moxibustion and t’ai chi (Xue, Zhang, Greenwood, Lin, & Story, 2010).  It has been commonly used in China, Korea, and Vietnam and is gaining popularity in Western Countries.  Studies conducted in Italy, Canada, Australia, Japan, United Kingdom and the United States indicates that acupuncture is the most popular TCM intervention (Xue, et al).  Despite growing interest from the Western countries and increase in funding, research in TCM remains difficult.  Xue et al cite problems with lack of standardization of TCM medical practices, safety concerns in the uses of herbs, lack of evidence or efficacy in clinical trials, and limited number of random control trials.  Some areas of promising findings include the use of herbs for cancer treatment (Xue-Juan, L., De-Xin, K., & Hong-Yu, Z. (2010) and acupuncture (Barad, et al, 2008).


Barad, A., Maimon, Y., Miller, E., Merdler, S., Goldray, D., Lerman, Y., & Lev-ari, S. (2008). Acupuncture Treatment in Geriatric Rehabilitation: A Retrospective Study, Journal of Acupuncture and Meridian Studies, 1(1), 54-57. doi:10.1016/S2005-2901(09)60008-X
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby Elsevier Press.
Xue-Juan, L., De-Xin, K., & Hong-Yu, Z. (2010). Chemoinformatics Approaches for Traditional Chinese Medicine Research and Case Application in Anticancer Drug Discovery. Current Drug Discovery Technologies, 7(1), 22-31.
Xue, C. L., Zhang, A. L., Greenwood, K. M., Lin, V., & Story, D. F. (2010). Traditional Chinese Medicine: An Update on Clinical Evidence. Journal of Alternative & Complementary Medicine, 16(3), 301-312. doi:10.1089/acm.2009.0293
Xutian, S., Zhang, J., & Louise, W. (2009). New Exploration and Understanding of Traditional Chinese Medicine. American Journal of Chinese Medicine, 37(3), 411-426.

Sunday, May 29, 2011

Herbs for your Sex Life?

There is evidence that herbs have been used for medicinal purposes as far back as 60,000 years and have been used by all cultures (Freeman, 2009).  Herbal medicine involves the use of specific parts of the plant such as the bark, fruit, root, stem seed or entire plant.   The gathering, processing and distribution of herbs can vary greatly.  In CAM, herbs are used in traditional Chinese medicine, Avuyerdic medicine, Homeopathy and in folk remedies by different cultures.  In the United States herbs were identified as a “dietary supplement” in 1994 (AACE Nutrition Guidelines Task Force, 2003).   As such they are not subject to the rigorous scrutiny imposed on pharmaceuticals by the Federal Drug Administration.   Given the history and popularity of herbal medicine and supplements, it is not surprising their use is on the rise.  According to Rowland, Burek, and Macias (2007) products for men are more common than for women.  But what does the evidence tell us?  Two herbs commonly used for the treatment or enhancement of sexual functioning in men include yohimbine and ginkgo.  Yohimbine is derived from the bark of the yohimbe tree in Africa.  It has been used in the treatment of erectile problems and is pending (FDA) approval as a prescription medicine for pupillary dilation.  Yohimbine works by dialating the blood vessels in the penis and thereby increasing the blood circulation allowing for an erection.  A meta analysis including seven randomized trials of 400 men with ED found yohimbine (15-43 mg/day) more effective than placebo for all forms of ED (Ernst & Pittler, 1998).  Another herb gaining popularity is Ginkgo biloba extract (GBE).  GBE is widely used for the treatment of dementia and circulatory disorders.  It is believed to assist in the relaxation of vascular smooth muscles and assist with improved penile, clitoral, and vaginal vasocongestion helping with arousal disorders.  While there have been studies conducted to evaluate the efficacy of GBE, they have not yielded significant or promising results.  Additional herbs that have gained popularity in promoting sexual performance include damiana, ginseng, saw palmetto, tribulus terrestris, muira pauma, maca, Epimedium (horny goat weed), Black cohosh, and Dong Quai, Eurycoma Longiforia for males and chasteherry for females.  However, the studies supporting the efficacy of these remain poor and mostly anecdotal.  Consumers need to careful of claims made by companies and products promoting the claims of these supplements and aware of potentially negative or problematic interactions with other pharmacological treatments or medical conditions.


AACE Nutrition Guidelines Task Force (2003). American Association of Clinical Endocrinologist Medical Guidelines for the Use of Dietary Supplements and Nutraceuticals. Endocrine Practice, 9(5), 417-470.  AACE Nutrition Guidelines Task Force (2003)
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby
Rowland, D. L., Burek, M., & Macias, L. (2007). Plant-Derivatives and Herbs Used for the Promotion of Sexual Health and the Treatment of Sexual Problems. Annual Review of Sex Research, 18225-257.

Wednesday, May 18, 2011


Medical systems, such as Traditional Chinese Medicine and Avuryedic Medicine are founded on alternative beliefs about health, wellness and disease.  Some Eastern healing traditions are founded on the premise that energy, ki (Japan), chi (China), and prana (India) flows through all living beings.  Illness can occur when this life energy is out of balance.  Reiki, an ancient Japanese form of healing, was developed by Dr. Mikao Usui in Japan in the late 1800s.  It is one of many biofield therapies used to promote balance.  The term Reiki is derived from two words Rei "the hidden force" and ki "life energy".  Reiki practitioners focus on manipulating the body’s energy field, ki, to aid in healing.  The practitioner accomplishes this by either placing their hands directly or slightly above the patient (Herron-Marx, Price-Knol, Burden & Hicks, 2008).  A full treatment typically includes placing the hands in twelve positions on the head and on the front and back of the torso that correspond to the body’s endocrine and lymph systems. As hands are placed on the body for 3 to5 minutes at each position, the energy flows according to the needs of the person receiving it (LaTorre, 2005).  There are three levels of Reiki practitioners. Level I Reiki involves learning to transmit healing energy through your touch for yourself or another. Level II Reiki involves learning to send the energy across a distance.  Level III Reiki involves advanced practice and master teaching.  Students wishing to progress in Reiki practice need to receive an “attunement”, which facilitates the alignment of the student’s own energy receptivity from a Reiki master (Freeman, 2009).  Reiki practitioners in California do not need a license to practice.
Research on the efficacy of Reiki is limited, despite these interesting findings.  According to Herron-Marx et al (p. 37), research conducted in the 1980s by Becker and Zimmerman revealed that brain wave patterns of the practitioner and the receiver enter into a synchronized state of relaxation and pulse in unison with the earth's magnetic field (Schuman Resonance).  In addition, the biomagnetic field around the practitioner’s hands is at least 1000 times greater than normal. Herron-Marx et al and vanderVaart, Gijsen, de Wildt, & Koren, (2009) completed an extended literature review of Reiki and independently found that the research studies available had a limited number of participants, control groups and/or were poorly designed.  Additional studies in the efficacy of Reiki on immune functioning (Bowden, Goddard & Gruzelier, 2010) and in treating cardiovascular disease (Friedman, Burg, Miles, Lee, & Lampert, 2010) both found that the participants in the control groups experienced improvement in symptoms, though their findings were not statistically significant.  Researchers in the cardiovascular study and in Herron-Marx review emphasize the importance of additional qualitative research studies focusing on patients’ experiences of Reiki.    

Bowden, D., Goddard, L., & Gruzelier, J. (2010). A randomized controlled single-blind trial of the effects of Reiki and positive imagery on well-being and salivary cortisol. Brain Research Bulletin, 81, 66–72. doi:10.1016/j.brainresbull.2009.10.002
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby Elsevier Press.
Friedman, R. S. C., Burg, M. M., Miles, P., Lee, F., & Lampert, R. (2010). Effects of Reiki on autonomic activity early after acute coronary syndrome. Journal of the American College of Cardiology, 56(12), 995-996. doi: 10.1016/j.jacc.2010.03.082
Herron-Marx, S., Price-Knol, F., Burden, B., & Hicks, C. (2008). A Systematic Review of the Use of Reiki in Health Care. Alternative & Complementary Therapies, 14(1), 37-42. doi:10.1089/act.2008.14108
LaTorre, M. (2005). The use of Reiki in Psychotherapy.  Perspectives in Psychiatric Care, 41(4), 184-187.
vanderVaart, S., Gijsen, V. J., de Wildt, S. N., & Koren, G. (2009). A Systematic Review of the Therapeutic Effects of Reiki. Journal of Alternative & Complementary Medicine, 15(11), 1157-1169. doi:10.1089/acm.2009.0036


Health problems can be compounded by stress.  Clients and patients can begin to experience improved health outcomes by learning to develop better coping mechanisms for stress management through relaxation.   One of the ways practitioners can assist with relaxation training is biofeedback.  Biofeedback is a complementary and alternative medical (CAM) treatment which has been scientifically demonstrated to improve health in a variety of ways.  It works by providing the patient direct information about bodily functions like temperature, heart rate, breathing rate, muscle tension through the use of special equipment.  Patients can use this information to learn to control their bodily functions.  Overtime this can be accomplished in the absence of the use of specialized equipment.  Different types of biofeedback modalities include the measurement and feedback of muscle tension (electromyography [EMG]), temperature or thermal biofeedback, skin-conductive and brain activity (electroencephalography [EEG]).  Biofeedback practitioners are certified in clinical, academic or technician tracks biofeedback modalities by multiple regulatory boards.  Certification involves course work and training in the assessment, theory and application of biofeedback equipment.  Recent advances in technology have increased the accessibility of biofeedback by reducing the cost, portability and modality of the treatment devices (Clough & Casey, 2011).  Biofeedback is often combined with other psychotherapeutic interventions for optimal benefit, like guided imagery or cognitive behavioral therapy (Freeman, 2009).  Biofeedback has been scientifically proven effective in the treatment of anxiety, chronic pain, , post traumatic stress disorder, fibromyalgia, asthma, hypertension, attention-deficit disorder with hyperactivity, temporomandibular disorder, headaches, urinary incontinence in men, chronic obstructive pulmonary disease, repetitive strain injuries, irritable bowel syndrome, and substance abuse disorders (Yucha & Gilbert, 2004). 
Clough, B. A., & Casey, L. M. (2011). Technological adjuncts to enhance current psychotherapy practices: A review. Clinical Psychology Review, 31(3), 279-292. doi: 10.1016/j.cpr.2010.12.008
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby Elsevier Press.
Yucha C., Gilbert, C. Evidence-based practice in biofeedback and neurotherapy, Wheat Ridge, Co, 2004, Association for Applied Psychophysiology and Biofeedback.

Mindfulness Meditation: Dr. Jon Kabat-Zinn

Dr. Kabat-Zinn has made significant contributions to the field of CAM by teaching and conducting research in the use of Mindfulness-Based Stress Reduction (MBSR), was developed at the University of Massachusetts Medical Center.  MBSR is different from other forms of meditation in that it is a clinically standardized practice, based on ancient healing practices.  Patients are encouraged to develop a specialized type of attention consisting of nonjudgmental awareness, openness, curiosity, and acceptance of their internal states.  MBSR includes a combination of 3 different techniques (Chiesa & Serretti, 2009).  The first technique, body scan, involves focusing attention through the entire body from feet to head and on any sensation or feeling in the body.  The body scan involves non-judgment of the sensations and use of breath awareness and relaxation as the patient continues their scan.  The second technique involves a sitting mediation.  During this meditation the patient pays attention to their breathing, rising and falling of their abdomen and any other sensations that flow through the mind.  The final step involves Hatha yoga practice, including breathing exercises, simple stretches, and posture, all designed to strengthen and relax the body.   Increased awareness can enable patients to use internal resources to manage stress, emotions pain management and improved immune function.  MBSR practices consist of eight to ten weeks of guided practices.  Patients start with 2.5 hours weekly classes along with a single all-day class to learn meditation skills, as well as homework to reinforce newly learned skills.
Meditation is practiced by healthy individuals.  The standardization of MBSR as a clinical practice has enabled researchers to study this intervention in multiple settings.  Grossman, Niemann, Schmidt, and Walach (2004) studied the effectiveness of MBSR by reviewing outcomes of twenty studies and concluded that MBSR can assist individuals to cope with multiple medical and psychosocial problems.  In healthy individuals MBSR has been effective in helping reduce stress, ruminative thinking, trait anxiety, increased empathy and self-compassion (Chiesa & Serretti).  Ledesma and Kumano (2009) conducted a meta-analysis of the effects of (MBSR) on the mental and physical health status of patients with different forms of cancer.  They identified ten studies demonstrating a significant effect size in helping improve psychosocial adjustment. 


Chiesa, A., & Serretti, A. (2009). Mindfulness-Based Stress Reduction for Stress Management in Healthy People: A Review and Meta-Analysis. Journal of Alternative & Complementary Medicine, 15(5), 593-600.
Ledesma, D., & Kumano, H. (2009). Mindfulness-based stress reduction and cancer: a meta-analysis. Psycho-Oncology, 18(6), 571-579. doi:10.1002/pon.1400
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57(1), 35-43. doi:10.1016/S0022-3999(03)00573-7

Friday, May 6, 2011

Migraines and CAM: The Use of Nutraceuticals

The use of herbal remedies, nutraceuticals, predates modern pharmacology.  According to Winslow and Kroll (1998) consumers use nutraceutical because of cultural reasons, religious reasons, and belief that they are healthier than pharmacological interventions.  There are fewer reports of negative effects with neutraceuticals.  It is therefore not surprising that migraine sufferers turn to neutraceuticals as a popular CAM intervention.  Nutraceuticals, considered a food supplement by the Food and Drug Administration are readily available in health food stores, pharmacies, and supermarkets.  They are inexpensive and do not require a referral from the specialist or general medical provider.  Taylor (2009) conducted a systematic review of neutraceuticals that included Petadolex, magnesium, feverfew and riboflavin.  This study is important because it compares the effectiveness of various nutraceuticals.  Petadolex, also known as P. hybridus or the butterbur root extract, has been used for migraine relief because of its combined anti-spasmodic, anti-inflammatory and calcium channel blocking effects.  Some pharmaceuticals prescribed by medical providers also have these properties.  Taylor reviewed the efficacy of magnesium.  In a clinical report (as cited by Teitelbaum, 2007) there is circumstantial evidence that some the migraine sufferers have low levels of magnesium.  Another nutraceutical that is popular for migraine relief is Feverfew, also called bachelor's button.  Feverfew is an anti-inflammatory, which may inhibit chemicals that cause the blood vessels in the brain to spasm (Agosti, Duke, J.E Chrubasik, & S. Chrubasik, 2006).  Riboflavin (Vitamin B2) has also been evaluated for its efficacy in migraine relief.  The theoretical basis for using riboflavin is its ameliorating effect on the mitochondrial dysfunction that might be involved in the pathophysiology of migraines.
Despite the evidence, the use of nutraceuticals is largely trial and error.  Consumers need to be aware of the potential hazards that neutraceutical pose, given the lack of quality control, information and research trials (Winslow & Kroll).  The dangers of nutraceutical increase when they are used in conjunction with other prescription and non-prescription medications.  In addition to nutraceuticals, consumers also turn to other CAM interventions in order to seek relief.
Agosti, R., Duke, R.K. Chrubasik, J.E. & Chrubasik, S. (2006).  Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: A systematic review.  Phytomedicine, 13(9-10), 743-746.
Taylor, F.R. (2009).  Lifestyle changes, dietary restrictions, and neutraceuticals in migraine prevention.  Techniques in Regional Anesthesia and Pain Management, 13, 28-37.  doi:10.1053/j.trap.2009.03.008
Teitelbaum, J. (2007). Natural Rx for migraines.  Townsend Letter:  The Examiner of Alternative Medicine, 292(4), 121.
Winslow, L. C., & Kroll, D.J. (1998).  Herbs as medicine.  Archives of Internal Medicine, 158, 2192-2199.

What so funny?

Berk, Felten, Tan, Bittmann and Westengard (2001), in their article titled “Modulation of Neuroimmune Parameters During the Eustress of Humor-Associated Mirthful Laughter”, explore how humor therapy and mirthful laughter enhances immune function and offers healing effects.  The authors note that there has been an increasing interest in the use of complementary and alternative medicine (CAM) by both medical providers and patients.  They had investigated the impact of humor on specific neuroendocrine components of the human stress response in prior studies.  Multiple studies in which the benefits of humor and laughter have yielded positive outcomes include cardiac rehabilitation, pain management, coping and immune enhancement.   The researchers designed a study that would assess the effects of laughter on neuroendocrine/neuroimmune modulation by reviewing specific neuroimmune parameters.  The researchers hypothesized that humor could affect the immune system in a variety of ways.  Laughter can lead to relaxation and positive imagery.  Use of relaxation and positive imagery can assist in increasing coping skills which can be employed to deflect stressful situations.  This can distract individuals from illness and pain, a strategy that is also used in other psychotherapeutic interventions such as cognitive behavioral therapy.  Laughter can also lead to positive affect which can potentially alter the mood of the individual and potentially assist in affect regulation.  Since laughter is also contagious, anyone exposed to someone with a vivid display of mirthful laughter will often smile and experience the benefits of distraction and relaxation.  The study to be conducted on fifty-two males consisted of five separate smaller studies based on a multivariate repeated measures design, with post hoc simple contrast analysis.  Due to the complex relationship between the signaling of hormones in the "stress hormone" profile and their independent regulation and separate signaling mechanisms, it is difficult to establish a causal relationship between the laughter and the immune response.  However, the study results NK cells (P < .01), immunoglobulins G (P < .02), A (P < .01), and M (P < .09), complement C3, functional phenotypic markers for leukocytes (P < .01), and levels of the cytokine interferon-gamma in plasma (P = .02) and total leukocytes (P < .05)] are significant to promoting the theory.  This study is important because it adds to a growing body of research on the impact of CAM, but it does give rise to more important questions such as how the researchers quantify “humor”.  How did the researchers select the specific video that the participants watched?  Was there a humor or laughter scale used.  Did the participants who laughed the hardiest gain the most immunological benefits?  If laughter is the actual cause of improved immunity, would something like tickling yield greater improvement in immunofuction?  And is there a point at which too much laughter could have a negative impact on the immune system?  The effect of humor on the mind, in turn, on the health of the rest of the body is merely one key to an entire room of new unanswered questions.
Berk, L., Felten, D., Tan, S., Bittman, B., & Westengard, J. (2001). Modulation of neuroimmune parameters during the eustress of humor-associated mirthful laughter. Alternative Therapies In Health And Medicine, 7(2), 62.

Can Compassion and meditation improve your immune system?

Mindfulness meditations (MMs) and mindfulness-based interventions (MBIs) include a broad range of meditation practices and psychological interventions linked by the concept of “mindfulness” (Chiesa & Serretti, 2010).  Mindfulness involves awareness of one's inner and outer worlds, including thoughts, sensations, emotions, actions, or surroundings as they exist at any given moment.  The purpose of these practices is to increase positive emotions, like happiness and compassion, and decrease negative or destructive ones such as anger and hate.  According to Chiesa and Malinowski (2011) mmindfulness is based on the sati, memory, which has its origins in Buddhist philosophy.  These include Vipassana and Zen meditations, rooted in Tibetan Buddhism.  Other  mindfulness practices include Theravada Buddhism, mainly based on the Satipatthana Sutta, Anapanasati Sutta, , Mahasatipatthana Sutta, and Kayagata-Sati Sutta are rooted in a continuum of phases and practice.  Given the diversity of mindfulness meditation practices it is important to bear in mind the philosophical basis and practice that underlies research studies that evaluate the efficacy of mindfulness.
Pace, et al (2009) completed a study of the impact of compassion meditation on the immune system.  The long-term goal of compassion meditation is to develop altruistic feelings and behavior towards others.   Pace, et al designed a random control trial (RCT) which consisted of sixty-one participants with an intervention group of thirty-three and a control group of twenty-eight.  The intervention consisted of consisted of Tibetan lojong compassion meditation.  The training consisted of two fifty minute sessions a week for a total of 6 weeks, with a CD to help guide meditation practice at home.   The first 2 weeks consisted of training in concentrative (i.e. shamatha) and mindfulness (i.e. vipassana) meditation for focus and awareness.  Week 3 to 6 consists of compassion meditation training.  At the end of the 6 weeks the participants are expected to practice on a daily basis.  The control groups’ intervention involved weekly health discussions lasting twelve hours throughout the duration of the study and home practice consisting of reviewing self-improvement papers on health related topics.  All participants were given the Trier social stress test (TSST), a standardized laboratory psychosocial stress test that activates the hypothalamic—pituitary—adrenal (HPA) axis and sympathetic nervous system.  Participants were also given the Profile of Mood States (POMS) to evaluate general distress levels.   The researchers found that there was no main effect of the intervention on innate immune, HPA axis or behavioral responses to laboratory psychosocial stressors.  Pace et al concluded that it was possible that compassion mediation may have a limited impact on behavioral responses to psychosocial stress.  Participants may need to increase the amount of meditation in order to obtain benefits, or that the training and study duration may need to increase in order to see benefits.  This study has both strengths and limitations. The researchers were unable to demonstrate a main effect.  The researchers designed an interesting intervention which incorporated aspects of mindfulness and awareness with a form of meditation that had not been researched.  Researchers cited other factors which might have affected the outcome of the study which include biases of the participants in deciding to participate in a study utilizing meditation, the quality of the instructors or trainers and the commitment of the participants to practice at home.  One factor not mentioned by the researchers is the importance of cultural competence. 
Although meditation is gaining popularity in mainstream American culture as a desirable complementary and alternative medicine (CAM), it is difficult to ascertain whether Americans reap the same benefit from meditation than Tibetan or members of other groups were meditation is part of the cultural practices.  Even within those cultures, it is well established that there are levels of meditation practice that are outside the realm of the lay person. 

Chiesa, A., & Malinowski, P. (2011). Mindfulness-based approaches: are they all the same?. Journal of Clinical Psychology, 67(4), 404-424. doi:10.1002/jclp.20776
Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. Journal of Alternative & Complementary Medicine, 15, 593600.
 Pace, T. W.W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., Brown, T.D., Issa, M. J. & Raison, C. L. (2009).  Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress.  Psychoneuroendocrinology, 34, 87-98.  doi:10.1016/j.psyneuen.2008.08.011

Tuesday, May 3, 2011

Guided Imagery

One popular CAM intervention that is being used by therapist and social workers is Guided Imagery (GI).  Did you know that GI is an evidence-based practice? GI is a mind-body therapy.  It has been defined as a “the thought process that invokes and uses senses: vision, audition, smell, taste, movement, position, and touch” (Trakhtenberg, 2008, p. 3).  GI incorporates a variety of techniques which can include visualization, suggestion using imagery, and story-telling or narratives.  Other forms of guided imagery involve evoking elements of the unconscious to consciousness via the imagination.  GI is used to promote relaxation and positive health outcomes.  Van Kuiken (2004) described four types of guided imagery:  pleasant imagery (imagining a calm place), physiologically focused imagery (focusing on a bodily function or part of the body and needs healing), mental rehearsal or reframing (imagining a specific task or event before it happens), and receptive imagery (scanning the body to direct healing).  Although GI has been used in alternative medical systems since ancient times, it was re-introduced into Western Medicine in the 1960’s.  It has also been used in conjunction with hypnosis, relaxation techniques, and mindfulness meditation.  GI is used in many settings.  During GI sessions patients are taught to use either positive or negative images to combat illness.  Positive thinking or images can be used to evoke relaxation and decrease pain.  Aggressive or violent images can be used to fight disease or pain.  Practice is encouraged in between sessions and can be supported with the use of audio tapes.   The ultimate goal is for the patient to be able to conjure up an image which evokes the desired result as quickly as possible.  GI is believed to work in different ways.  It can evoke neurohormonal changes in the body that mimic the changes that occur when an actual event occur.  By helping induce relaxation, it can promote a positive immunological response.  Trakhtenberg completed a critical review of the immunological impact of GI.  Donaldson (2000) hypothesized that GI may stimulate certain thoughts, which in turn could produce physiological outcomes that have an effect on the immune system.  His findings indicated an increased in white blood cell counts after GI intervention.   Hall et al. (1996) findings indicated that GI and relaxation was associated with decreases in neutrophil adherence.  Rider and Achterberg (1989) were able to determine that cell-specific imagery was associated with statistically significant decreases in lymphocyte and neutrophil counts.  Additional studies have been conducted utilizing GI with specific health problems including psychiatric disorders, cancer, pain, and to reduce stress associated with medical procedures and hospital stays (Hart, 2008). Given the research that supports the use of GI as an evidence-based practice and its portability how do you see being able to integrate GI into your practice?
Hart, J. (2008). Guided Imagery. Alternative & Complementary Therapies, 14(6), 295-299. doi:10.1089/act.2008.14604
Trakhtenberg, E. C. (2008). The Effects of Guided Imagery on the Immune System: A Critical Review. International Journal of Neuroscience, 118(6), 839-855. doi:10.1080/00207450701792705
Van Kuiken, D. (2004). A meta-analysis of the effect of guided imagery practice on outcomes.  Journal of Holistic Nursing, 22, 164–179.

Use of CAM by African Americans

Reports from the National Center for Complementary and Alternative Medicine (NCCAM) indicate although individuals from different ethnic groups use CAM, the highest consumers include women, and individuals with higher educational achievement and income.  Barner, Bohman, Brown & Richards (2010) conducted a review of the use of CAM by African Americans. The researchers conducted a cross-sectional analysis utilizing data obtained from the National Health Interview Survey of 2002. The sample size consisted of 16,113,651 participants ages 18 and over who had used CAM in the last 12 months.  The researchers reviewed the following independent variables: predisposing (age, gender, and education), enabling (income, employment, and access to care), need (health status, physician visits, and prescription medication use) and disease-state factors (most prevalent conditions among African-Americans) that affects the type and choice of interventions.  Their results indicated that at least 20% of the participants had used CAM in the last 12 months.  CAM interventions of choice included alternative medical systems, manipulative and body-based therapies, biofeedback, and energy therapies.  Prayer and folk remedies were amongst the most widely used.  Folk remedies include traditional cures and herbs used to treat medical conditions.  African Americans with higher socio-economic status tended to use CAM interventions for prevention as well as treatment.  The results of this study are important for multiple reasons.  The researchers found that African American used CAM to treat a specific medical condition and do not often disclose their use of CAM with their medical providers for lack of trust.  It is important for medical practitioners to inquire about the use of all therapeutic interventions and their efficacy from the patient’s perspective.  Researchers noted that African American women are more likely to use prayer.  According to Freeman (2009) prayer is difficult to conceptualize and research.  Theologians and researchers conceptualize prayer into distinct types.  Prophetic, verbal, prayer can be used to either request a desired outcome or improve one’s relationship with God. The exact role of prayer was difficult to determine.  Prayer can be used for treatment, as prevention, in conjunction with other treatments.  These research findings are especially important for social worker to take into consideration.  On an individual level, how do social workers incorporate discussions and the use of prayer in their practice with clients?  How does the importance of prayer, as CAM intervention, affect the use or choice of faith-based practitioners in the field of mental health and substance abuse?     
Barner, J. C., Bohman, T. M., Brown, C. M., & Richards, K. M. (2010). Use of complementary and alternative medicine for treatment among African-Americans: A multivariate analysis. Research in Social and Administrative Pharmacy, 6(3), 196-208. doi: 10.1016/j.sapharm.2009.08.001
Freeman, L.W. (2009) Mosby's complementary & alternative medicine: A research-based approach (3rd ed.). Mosby
National Center for Complementary and Alternative Medicine (2009).  What is complementary and alternative Medicine? (March 12, 2011)

Is CAM Evidence-Based Medicine?

Is complementary and alternative medicine (CAM) evidence-based medicine?  CAM has been defined as a group of diverse medical and health systems, practices and products that are not presently considered part of conventional medicine (NCCAM, 2009).  CAM includes but is not limited to Chinese Medicine, Ayuverdic Medicine, homeopathy, spinal-manipulative medical practices as well as mind/body Practices.  Evidence-based medicine consists of an approach and/or attempt by professionals (social workers, therapists, health providers) to integrate clinical expertise with the best available external clinical evidence from systematic research (Sackett, et al, 1996).  The level of clinical expertise for CAM interventions varies depending on discipline, licensure and regulatory bodies.  CAM practices are evaluated in the same way that other interventions in the field of psychology, social work and medicine are evaluated.  In evidence-based medicine, there is a standard and hierarchy.  The gold standard for scientific evidence is the systematic review of several double-blind, randomized controlled trials (RCT).   The next level of scientific evidence consists of quasi-experimental studies, open clinical trials, systematic observations, and unsystematic observations.  It is also important to take into account number of studies, treatment effects, the importance of outcomes, the generalizability of studies, and other factors (Drake et al, 2003, p. 812).  Problems inherent in conducting gold standard CAM interventions include the consideration of individualized treatment plans, difficulty associated with the creation of control groups, and blinding or double blinding researchers and participants (Satterfield et al & Baranowsky, 2009).  Verhoef, Casebeer and Hilsden (2002) argue that an effective evaluation of CAM interventions need to include qualitative research designs that assess the understanding, significance and beliefs patients hold about the treatment and expectations of the outcome.  Despite these difficulties thousands of RCT evaluating the effectiveness of CAM treatments in general and for specific diseases have been conducted (NCCAM, 2009). 

Drake, R.E., Latimer, E.A., Leff, H.S., McHugo, G.J., & Burns, B.J. (2004). What is evidence? Child and Adolescent Psychiatric Clinics of North America, 13(4), 717-728. doi: 10.1016/j.chc.2004.05.005.
NCCAM (2009). What is complementary and alternative Medicine? (March 12, 2011)
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R. Richardson, W.  (1996). Evidence-based medicine: what it is and what it isn't.  British Medical Journal, 312, 71-72.  
Satterfield, , J. M., Spring, B., Brownson, R. C., Mullen, E. J., Newhouse, R. P., Walker, B. B., & Whitlock, E. P. (2009). Toward a Transdisciplinary Model of Evidence-Based Practice. Milbank Quarterly, 87(2), 368-390. doi:10.1111/j.1468-0009.2009.00561.x
Verhoef, M. J., Casebeer, A. L., & Hilsden, R. J. (2002). Assessing Efficacy of Complementary Medicine: Adding Qualitative Research Methods to the "Gold Standard". Journal of Alternative & Complementary Medicine, 8(3), 275-281. doi:10.1089/10755530260127961