Alternative Health Care: An Overview

JOG”

CLINICAL ISSUES

Alternative Health Care: An Overview Linda Beth Tiedje, RN, PhD, FAAN

=

One-third of the patients seen in health care settings in a year also use alternative therapies. This article outlines ways to evaluate alternativetherapies, including general resources that may be used for future reference, and discusses implicationsfor practice and policy. Integrating alternative therapies into practice at several levels, from assessment to research, is examined, as are guidelines for helping patients chose alternative therapies. JOGNN, 27,

557-562; 1998. Accepted: April 1998

Principles of some of the alternative therapies, such as touch, already are cornerstones of nursing practice. In addition, principles of alternative therapies, such as health promotion, client self-care, mindbody interactions, and relationship-centered care, model affirm nursing’s bio-psycho-social-spiritual (Dossey, 1997).

S

ome commonly accepted principles in

nursing are philosophically congruent with Health and well being can best be achieved through the use of many therapies: pharmaceuticals, surgery/procedures, and self-care. This three-pronged approach has been termed the “three legged stool” (Benson, 1996) and represents a significant revision of conventional health care, which has focused primarily on two legs of the stool: provider-controlled drugs and surgerylprocedures. Alternative therapies have revolutionized health care during the past decade, in part because more autonomous self-care has focused the locus of responsibility for healtuhealing in the individual. This focus has made the development and use of such alternatives possible (Gordon, 1996). Alternative therapies also have revolutionized health care, as people are becoming more holistic in their approach to healing. The body-mind-spirit connections implicit in holistic health also mean people are more open to new, less traditional, therapies (Engebretson, 1996). Finally, alternative therapies have offered new options for people with chronic conditions for whom the medical community did not have much to offer. Some commonly accepted principles in nursing are philosophically congruent with many of these alternative therapies, sharing common holistic philosophies of health (Engebretson, 1996). SeptemberlOctober 1998

many alternative therapies.

In addition to the philosophic base for alternative therapies, nurses have pioneered the use of healing alternatives such as therapeutic touch (Krieger, 1979). Nursing’s tradition of dedication to continued learning, understanding situations from the patient’s point of view, and helping patients participate fully in their care (Anderson, 1997) puts nursing in a unique position to understand the many different alternatives patients use in their healing and to “add legitimacy to the use of alternative healing modalities” through research and advocacy (Engebretson, 1996).

Overview The purpose of this JOGNN Clinical Issues series on alternative therapies in women’s health, obstetric, and neonatal nursing is (a) to increase our awareness of a few of these therapies, (b) to address the wise use of these alternatives by presenting ways to evaluate their efficacy and safety, and (c) to help us to better integrate effective alterJOGNN 557

natives into general practice. Health care delivery currently focuses mainly on acute episodes of care. In the future, as the cost-saving outcomes of prevention are documented, the focus increasingly will be on prevention and the continuum of care. This focus is congruent with nursing philosophy and many Eastern, alternative models (Bendell, 1997; Cook & Wilcox, 1997). Yoga, musical care, and energy healing were the three alternative therapies chosen for particular description in this series on alternative therapies. They were chosen for two reasons: (a) there was scientific evidence of their effectiveness in the literature and (b)they were alternative therapies with clear practice implications. For each alternative therapy discussed, the author provides a history of use and theories on which the therapy is based, the scientific evidence that exists, and how the therapy is used. The authors are all nurses and have personal experience with the alternative therapy described. This introductory article outlines (a) ways to evaluate alternative therapies, including general resources (such as books and websites) that can be used for additional reference; and (b)practice and policy implications.

Definitions Alternative therapies, complementary therapies, and integrated therapies are three terms commonly used to refer to the growing number of interventions that are different from those used by conventional practitioners of Western medicine. It may be more accurate to call these therapies “complementary” because they are intended to complement, rather than replace, conventional health care (Fugh-Berman, 1996). A growing number of practitioners refer to “integrated” therapies as a way of indicating the true integration of traditional and alternative therapies in health care, although the acceptability of alternatives and degree of integration varies somewhat by geographic area. Either/or thinking is still very prevalent. The assumption is that health care providers use the “pills/surgery toolbox of Western medicine” or nontraditional therapies, but not both. Many feel that integration is clearly the way to go (Benson, 1996). Because “alternative” is the most commonly used term in the United States, it is the one that will be used in this introductory overview. The terms “alternative,” “complementary,” and “integrated” will be used interchangeably throughout the rest of the articles in this series to describe these therapies.

Yoga and Chinese herbal medicine therapies are thousands of years old. Alternative therapies are very diverse, ranging from nutritiodife-style changes (macrobiotic diets, exercise programs) to m i d b o d y programs (biofeedback, guided imagery, music therapy, meditation, prayer) to ethnomedicine (acupuncture, Chinese herbal medicine) to structure/energy therapies (therapeutic touch, osteopathy) to pharmacologic/biologic treatments (antioxidants) (Jacobs, 1997). Progressive muscular relaxation and breathing for childbirth were alternatives introduced long ago by Dick-Read ( 1933), Lamaze (1965),and Bradley (1981). Cultural changes in the 1960s also made alternative therapies, such as massage and meditation, more acceptable. Biofeedback and hypnosis are alternatives that have developed into mainstream therapies (Gordon, 1996). Surgery preparation using techniques such as relaxation, support, and guided imagery also is not new; a recent meta-analysis attests to the benefits of such psychologic surgical preparation (Johnston & Vogele, 1993). Alternative therapy articles regularly appear in nursing journals about meditation (Roth & Creaser, 1997); body work and childbirth (Stephens, 1997);aromatherapy/ herbal medicine and childbirth (Kane, 1997a, 1997b); common herbs (Youngkin & Israel, 1996); alternative pharmacologic approaches to perimenopause (Shaw, 1997);and acupressure for labor pain management (Cook & Wilcox, 1997). In addition, one new journal, edited by a nurse, features alternative therapies and ways to incorporate them into traditional practice: Alternative Health Practitioner: The Journal of Complementary and Natural Care (Springer Publishing Company). Alternative therapies are gaining acceptance by the health care community and becoming part of its institutions. In 1992, the National Institutes of Health (NIH) established the Office of Alternative Medicine (OAM)to evaluate alternative treatments. A consensus conference convened by NIH in November 1997 officially endorsed acupuncture for the first time. The 12-member panel concluded that acupuncture was clearly effective in treating nausea in pregnancy, chemotherapy nausea and vomiting, and postoperative dental pain (Cockey, 1997). Two Los Angeles-based hospitals now offer acupuncture for pain and symptom management along with other traditional services, perhaps indicating a trend in the blending of alternative and traditional health care.

A l t e r n a t i v e therapies are gaining acceptance

A Growing Body of Evidence Concepts such as healing partnerships and self-care are not new, and neither are at least some of the 200 alternative therapies currently used in the United States. 558 JOGNN

by the health care community and becoming part of its institutions.

Volume 27, Number 5

Patients also are embracing alternative therapies. One-third of the patients seen in health care settings have used one of these alternatives during the past 12 months, with highest use in persons from 25 to 49 years of age who have more education and income. Approximately $13.7 billion is spent annually on alternative therapies (Eisenberg et al., 1993). However, most people (72%in the Eisenberg et al. study) will not reveal that they are using alternative therapies to their health care provider. Maybe that is because they fear the health care provider’s reaction. Maybe it is because we do not ask. Although many nursing curricula currently include alternative therapies, most of us did not receive information about alternative therapies as part of our nursing education. To remedy that, OAM recently made a recommendation for the inclusion of alternative therapies in the education of all health care providers (Jacobs, 1997). Dossey and the American Holistic Nurses’ Association also have proposed a Core Curriculum for Holistic Nursing (1997),pioneering curriculum revision to include alternative therapies. Continuing education conferences also provide opportunities for health care providers to increase knowledge of alternative therapies. In the spring of 1998, a state-of-the-science symposium was hosted by Harvard Medical School on alternative medicine and implications for clinical practice.

Ways to Evaluate Gordon (1996) suggests three strategies for practitioners and patients to use in evaluating all therapies, traditional or alternative:

Approximately $1 3.7billion is spent annually on alternative therapies.

1. Let me see the research studies-the evidence that these therapies work. 2. Let me talk with other patients who have conditions similar to mine and have improved with this treatment. 3. Let me bring along a friend or relative to help me better assess the provider and treatment provided. Another way to approach evaluation of alternative therapies is caveat emptor, let the buyer beware. Because the responsibility for evaluation is that of the consumer, who at times may want to believe in miraculous treatments, certain red flags should warn us to avoid a therapy, alternative or otherwise. Benson (1996)suggests the

SeptemberlOctober 1998

following principles in evaluating therapies and healers. Beware of healers with all the answers who insist their therapy is the only way to handle a health problem (all others are charlatans, they may insist). Products that promise to cure a variety of ailments quickly, help you look years younger, promise overnight weight loss, or increase sexual powers are particularly suspect (Rosenfeld, 1996). Be wary if healers will not agree to include other health care providers as part of the healing team. An advertisement for a therapy that condemns the medical “establishment” or claims “persecution” by the Food and Drug Administration should be read with caution (Rosenfeld, 1996). Indeed, Benson (1996) says the biggest risk in using unconventional medicine is the lack of a team approach, which can lead to serious medical conditions being overlooked; better traditional medicine treatments being ignored; or potential adverse interactions between herbal and prescription medications. These risks can be avoided by good communication between traditional providers and alternative healers. Beware if the healer or clinic seems more interested in financial gain than your health and welfare. Beware of the scantily trained alternative practitioner. As in traditional health care, training and educational background of the provider are important. Ask for credentials, licensure, and certification. Additional information on credentialingof practitioners is available from the programs listed in Table 1. Some basic background information is essential in evaluating alternative therapies and the clinidhealer: the principles undergirding the therapy, how training of practitioners occurs, how long treatment generally lasts, how soon effects can be expected, what evidence of effectiveness is available, what side effects can be expected, and the usual costs of the treatment. Table 1 provides a sampling of programs recommended by reputable experts that offer medical care or referrals along with mind/body strategies to promote good health. In addition, the OAM has funded 10 Specialty Research Centers to study complementary and alternative treatments (see Table 2).Table 3 includes reference books on alternative therapies that are suggested for health care professionals and that provide background information critical to the evaluation of such therapies. Eisenberg, who first published the study documenting the use of alternative therapies (1993),recently published guidelines for health care providers in advising patients who seek alternative therapies (1997).Eisenberg outlines guiding principles, such as: 1. We need to help patients identify suitable reputable alternative clinicians. 2. We need to help patients ask the right questions and evaluate alternative clinicians. 3. We need to monitor and coordinate with alternative clinicians about patients’ outcomes/responses to treatment. JOG“

559

TABLE 1

Programs Offering Alternative Therapies‘” Palo Alto, CA. Stanford Health Services, Preventive Cardiology Clinic (telephone: 4 15-725-5027); Health Improvement Program (telephone: 415-725-7778) Los Angeles, CA. University of California at Los Angeles Medical School, UCLA Center for East-West Medicine (telephone: 310-206-1895) Phoenix, AR. Arizona Center for Health and Medicine (telephone: 602-406-9050) Houston, TX. Mind/Body Medical Institute, Memorial Healthcare System (telephone: 713-776-5020) Nashville, TN. Baptist MindlBody Medical Institute, Baptist Hospital (telephone: 615-329-5433) Morristown, NJ. Mind/Body Medical Institute, Morristown Memorial Hospital (telephone: 201-971-4757) New Brunswick, NJ. Mind/Body Medical Institute, St. Peter’s Medical Center (telephone: 908-937-605 1) Boston, MA. Mind/Body Medical Institute, Beth Israel Deaconness Hospital (telephone: 61 7-632-9525) Boston, MA. Mind/Body Center for Women’s Health Beth Israel Deaconness Hospital (telephone: 617-632-9525) Chicago, IL. Mercy Hospital and Medical Center (telephone: 312-567-2600) Columbus, OH. Riverside Methodist Hospital (telephone: 614-566-5354) * Not an exhaustive list. Meant only to list a sampling of programs recommended by reputable experts and representing different geographicregions.

Eisenberg (1997) reaffirms our need to understand and respect patient values by assessing for the use of alternative therapies and coordinating care.

Online Resources Information on alternative therapies also is available online. Information on traditional Chinese therapies and insurance companies that cover acupuncture is available at http://acupuncture.com. The University of California at Berkeley Wellness Letter, rated the best newsletter on preventative health, is available

online at http://www.enews.com/magazines/ucbwl. The Food and Drug Administration has updates on food, medicine, and other regulated items at http:// www.fda.gov, and the NIH website for OAM is http:// altmed.od.nih.gov/oam/cam.

Federal Evaluation Efforts In addition to individual efforts to evaluate alternative/complementary therapies, the federal government is getting involved. The Presidential Commission on Dietary Supplement Labels recently called for more re-

TABLE 2

O M- F und e d Specialty Research Centers center

Locution

Specialty

Bastyr University

Seattle, WA

Beth Israel HospitalRIarvard Medical School Columbia University of Physicians and Surgeons Kessler InstituteNniversity of Medicine and Dentistry

Boston, MA New York, NY West Orange, NJ Newark, NJ Minneapolis, MN

Human immunodeficiencyvirus/ acquired immune deficiency syndrome General medicine Women’s health Stroke, neurologic conditions

Hennepin County Hospital Minnesota Medical School Stanford University University of California at Davis University of Maryland School of Medicine University of Texas Health Science Center University of Virginia School of Nursing

560 JOG”

Palo Alto, CA Davis, CA Baltimore, MD Houston, TX Charlottesville, VA

Addictions Aging Asthma, allergy immunology Pain Cancer Pain

Volume 27, Number 5

TABLE 3

Suggested References of Alternative Therapies Benson, H. B. (1996).Timeless healing: The power and biology of belief. New York: Simon & Schuster. Duke, J. A. (1997).The green pharmacy. Ernmaus, PA: Rodale Press. Fugh-Berman, A. ( 1996). Alternative medicine: What works. Tucson: Odonian Press. Gordon, J. S. (1996).Manifesto for a new medicine: Your guide to healing partnerships and the wise use of alternative therapies. Reading, MA: Addison-Wesley Publishing. Rosenfeld, I. (1996).Dr. Rosenfeld’s guide to alternative medicine. New York: Random House. Shames, K. H. (1996).Creative imagery in nursing. Albany, NY: Delmar Publishers. Shandler, N. (1997).Estrogen: The natural way. New York: Villard. Sobel, D. S., & Ornstein, R. (1996).The healthy mind, healthy body handbook. Los Altos, CA: DRX.

search on all dietary supplements such as vitamins and botanical supplements to replicate the extensive research already done abroad. Scientists at Duke University are involved in a 3-year, NIH-sponsored study of St. John’s wort and depression, widely used in the treatment of depression in Germany. A Food and Drug Administration panel is expected to begin reviewing safety and labeling of botanical agents used as folk remedies to better establish ideal dosage, length of use, and adverse health reactions (Hellmich, 1997).

Practice and Policy Implications What Does This Mean for My Practice? As health care providers, we can participate in alternativekomplementary therapies on many levels, from merely assessing what alternative therapies a patient has tried, to helping patients evaluate and identify suitable alternative providers, to referring patients to alternative providers, to forming a health care team that includes alternative providers, to becoming trained in an alternative therapy, to doing research on the effectiveness of alternative therapies. All of these levels of participation in alternative therapies presuppose that we are continuously learning about them and the more traditional therapies we may more routinely apply. Chances are we may already have provided advice about alternative therapies because of advice shared from a personal yoga or meditation practice. All of us must find reputable clinics and clinicians in our communities for appropriate referral in areas beyond our expertise. Another challenge is evaluating and incorporating forms of ethnic medicine into treatment plans. When we are open to alternative therapies, we routinely ask what alternative therapies are being used. This enables patients to talk about their own forms of ethnic medicine.

SeptembedOctober 1998

What About Health Care Policy and Alternative Therapies? In an era of cost containment, third-party payers are becoming more interested in alternative therapies, which often are less expensive because of the economic benefits resulting from fewer provider visits and less use of expensive technology. Chiropractic therapy now is covered by 85% of insurance companies and by Medicare, and many other third-party payers cover massage therapy or acupuncture when prescribed by a traditional health care provider (Fugh-Berman, 1996). Indeed, the recent NIH consensus panel that concluded acupuncture was safe and effective for nausea and pain encouraged insurance companies and federaustate health programs to expand their insurance coverage (Cockey, 1997). Expanded insurance coverage, including Medicare and Medicaid, means that alternative therapies will be more available to people of low income. In 1995, Medicare agreed to study a demonstration project on a nonsurgical, nonpharmacologic, alternative approach to heart disease developed by Dr. Dean Ornish. The program was based on a strict regimen featuring exercise, stress management, and a low-fat diet. At the time, 45 insurance companies already paid for the relatively inexpensive program, costing $6,000 to $7,500 per year. More recently, Ornish has been joined by Dr. Herbert Benson, Harvard Medical School and the Deaconness Hospital, Boston, MA, in a study to evaluate adherence to and results of self-care components in heart disease. The Ornish/Benson study is funded by two major insurance companies (Benson, 1996). Others have suggested alternative therapies may be used to counteract current “overdrugging” trends in health care (Huebscher, 1997). This overdrugging refers to overdependence on drugs by both patients and health care providers. More than 1.2 billion drug prescriptions are written each year in a culture conditioned to expect quick fixes and a health care environment increasingly JOG”

561

time conscious. Writing a prescription is less time consuming than teaching about self-care or alternative therapies. This overdrugging tendency suggests that even when alternative therapies are reimbursed as a matter of health policy, caution should be exercised in prescribing quick solutions, be they traditional or alternative. In summary, government and institutional policy changes regarding alternative therapies suggest that these therapies are going mainstream, another compelling reason for us as traditional health care providers to know more about them.

Conclusion As a result of this series of articles on alternative therapies, you may begin asking your patients about which alternative therapies they use. You may incorporate a few ideas about music therapy into your practice. You may refer a pregnant patient to a yoga class. You may decide to do research into the use of energy healing in women’s health. At the very least, it is hoped this series creates an openness to the ideas of alternative therapies in your practice, learning, or research.

REFERENCES Anderson, C. A. (1997). What is nursing anyhow? Nursing Outlook, 45(6), 249-250. Bendell, A. (1997). Health care in the 1990’s: Changes in health care delivery models for survival. ] O C N N , 26, 212-216. Benson, H. ( 1996). Timeless healing: The power and biology of belief. New York: Simon & Schuster. Bradley, R. A. (1981).Husband-coached childbirth (3rd ed). New York: Harper and Row. Cockey, C. D. (1997).NIH panel comes to consensus on acupuncture. Lifelines, 1(6), 20. Cook, A., & Wilcox, G. (1997).Pressuring pain: Alternative therapies for labor pain management. Lifelines, 1(2), 36-41. Dick-Read, G. (1933). Natural childbirth. London: Heinemann. Dossey, B. M. (Ed). (1997). Core curriculum for holistic nursing. Gaithersburg, MD: Aspen Publishers, Inc. Eisenberg, D. M. (1997).Advising patients who seek alternative medicine therapies. Annals of Internal Medicine, 127(1),61-69. Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., & Delbanco, T. L. (1993). Unconven-

tional medicine in the United States: Prevalence, costs, and patterns of use. The New England]ournal o f Medicine, 328, 246-252. Engebretson, J. (1996).Comparison of nurses and alternative healers. Image: Journal o f Nursing Scholarship, 28(2), 95-100. Fugh-Berman, A. (1996).Alternative medicine: What works. Tuscon: Odonian Press. Gordon, J. S. (1996).Manifesto for a new medicine: Your guide to healing partnerships and the wise use of alternative therapies. Reading, MA: Addison-Wesley Publishing. Hellmich, N. (1997, Nov. 25). Herbal remedies under the microscope. USA Today, pp. 6D. Huebscher, R. (1997). Overdrugging and undertreatment in primary care. Nursing Outlook, 45, 161-166. Jacobs, J. J. (1997, April 15). What is alternative medicine?Paper presented at the Speaker Series, The Center for Humanities and Medicine, Sparrow Hospital, Lansing, MI. Johnston, M., & Vogele, C. (1993).Benefits of psychological preparation for surgery: A meta-analysis. Annals of Behavioral Medicine, 15, 245-256. Kane, A. (1997a).Childbirth and aromatherapy. International Journal of Childbirth Education, 12(l ) , 14-15. Kane, A. (1997b).Herbal medicine and childbirth-Do they mix? International Journal of Childbirth Education, 12(2),22-24. Krieger, D. (1979).Therapeutic touch: How to use your hands to help or heal. Englewood Cliffs, NJ: Prentice Hall. Lamaze, F. (1965).Painless childbirth. New York: Simon and Schuster. Rosenfeld, I. (1996).Dr. Rosenfeld’s guide to alternative medicine. New York: Random House. Roth, B., & Creaser, T. (1997).Mindfulness meditation-based stress reduction: Experience with a bilingual inner-city program. The Nurse Practitioner, 22(3), 150,152,154, 157,161-162,164,170-171,174,176. Shaw, C. (1997).The perimenopausal hot flash: Epidemiology, physiology, and treatment. The Nurse Practitioner, 22(3),55-56, 61-62, 64-66. Stephens, S. (1997). Body work and childbirth, proven wonders. International Journal of Childbirth Education, 12(4),20-21. Youngkin, E. Q., & Israel, D. S. (1996).A review and critique of common herbal alternative therapies. The Nurse Practitioner, 21(10),39-62.

Linda Beth Tiedje is an adjunct p m f m w in the Department of Epidemiology at Michigan State University in East Lansing,MI. Address for correspondence: Linda Beth Tiedje, RN, PhD, FAAN, A220 East Fee Hall, Michigan State University, East Lansing, M I 48824-1316.

For information about earning continuing education credit using this and other Clinical Issues articles, call AWHONN, 800-6738499, extension 1623. 562 JOGNN

Volume 27, Number 5