# 01 - 24 Complementary and Alternative Medicine in

# 24 Complementary and Alternative Medicine in Psychiatry

24

Complementary and Alternative Medicine
in Psychiatry
The science and art of “healing” as well as the concept of “illness” have always been
significantly influenced by the cultural context in which they developed. What most
Western medical practitioners conceive of as “health care” is actually quite in its infancy
compared with many practices aimed at curing or ameliorating illness that developed
across the world for many centuries past. Major advances in biomedical research and in
the scientific method in general over the past century have brought that discovery of
revolutionary medical interventions that have saved countless lives, most notably
through the treatment of infectious illnesses. Yet, many practitioners and patients alike
sense that the biological and reductionist concepts of illness and its treatment that have
come to guide much of Western medical care often minimize the role of psychosocial
factors in health and wellness. Psychiatry itself, supposed champion among medical
fields in addressing psychosocial etiologies of illness, has also become increasingly
biological in its focus. Although this approach has undoubtedly benefited persons with
mental illness and has increased public awareness that the brain is no less a physical
organ than the heart or kidney (susceptible to maladies at times through no fault of the
person suffering mental illness), some mental health practitioners worry that the
“listening care” in psychiatry will become increasingly marginalized. After all,
addressing psychosocial aspects of health is almost always more time-consuming than
biological interventions and thus, in a short-sighted vision of health outcomes, often
seems inefficient and expensive.
The term complementary and alternative medicine (CAM) refers to the various disease-treating or disease-preventing
practices whose methods and efficacies differ from traditional or conventional biomedical treatment. Other terms used to
describe these therapeutic approaches are integrative medicine and holistic medicine. This is not a new concept in
psychiatry. The idea of emphasizing the whole patient and the need to evaluate psychosocial, environmental, and lifestyle
factors in health and disease is subsumed under the heading of psychosomatic or mind–body medicine.
Traditional medicine, as practiced in the United States and elsewhere in the Western world, is based on the scientific
method—the use of experiments to validate a hypothesis or determine the probability of a theory being correct.
Traditional medicine presumes that the body is a biological and physiological system and that disorders have a cause that
can be treated with medications, surgery, and complex technological methods to produce a cure. Traditional medicine is
thus also referred to as biomedicine or technomedicine.
Traditional medicine is also known as allopathic medicine. The term allopathy, derived from the Greek word allos
(“other”), refers to the use of outside agents or medications to counteract the signs and symptoms of disease; for example,
antipyretics to treat fever. Allopathy is the type of medicine taught in medical schools in the United States. Samuel

Hahnemann (1755–1843), a German physician, coined the term to distinguish this form of medicine from homeopathy
(derived from the Greek word homos [“same”]), in which specially formulated medicinal remedies, different from
allopathic medicine, are used. Allopathy is the most prevalent form of medicine practiced in the Western world.
(Homeopathy is discussed more fully later in this chapter.)
NATIONAL CENTER FOR COMPLEMENTARY MEDICINE AND
ALTERNATIVE MEDICINE
The widespread adoption of CAM practices led the US government to establish the
National Center for Complementary Medicine and Alternative Medicine (NCCAM)
within the National Institutes of Health (NIH). NCCAM’s mission is to evaluate the
usefulness and safety of a broad range of unrelated, nonorthodox healing practices and
provide scientific explanations for their possible effectiveness, train CAM researchers,
and disseminate information to the public. NCCAM has proposed changing its name to
the National Center for Research on Complementary and Integrative Health Care
(NCRCI).
An NCCAM study in 2011 revealed that close to 40 percent of Americans used some form of CAM within a 12-month
period. When prayer was included, the percentage rose to more than 60 percent. Prayer for one’s own health was most
prominent, followed by prayer by others for one’s own health, natural products, deep-breathing exercises, group prayer,
meditation, chiropractic care, yoga, massage, and diet-based therapies. Echinacea, ginseng, Ginkgo biloba, garlic
supplements, glucosamine, and St. John’s wort were among the most common natural products used. Back, head, and neck
pain were the most common conditions treated. The CAM practices were most likely to be embraced by those with more
education, women, former smokers, and those who had been recently hospitalized. Most users of CAM practices believed
the greatest benefits were achieved in combination with conventional treatment.
NCCAM conducts clinical trials at the NIH and academic research institutions to investigate the benefits of various CAM
practices on a spectrum of diseases and disorders, ranging from psychiatric conditions to cancer, osteoporosis, and
multiple sclerosis, among others. Some completed studies have validated the following: acupuncture is beneficial to treat
functional impairment and osteoarthritic pain of the knee; no prophylactic benefit was found for low-dose Echinacea
augustifolia in the prevention of cold symptoms; combined glucosamine and chondroitin sulfate supplements do not
provide significant relief for osteoarthritic pain in most cases, but does benefit a smaller subset with more severe pain; and
St. John’s wort (Hypericum perforatum) is no more effective for treating major depression of moderate severity than
placebo. St. John’s wort is being further investigated as a treatment for posttraumatic stress disorder (PTSD), anxiety, and
minor depression (see “Herbal Medicine” below).
The NCCAM has compiled a classification of alternative medical practices designed to support research (Table 24-1).
Including a practice in the classification does not imply an endorsement of the method. Indeed, many complementary and
alternative health practices are based on no known scientific principles and are considered quackery.
Table 24-1
Complementary and Alternative Medicine Practices

Many systems of treatment discussed in this chapter are centuries old, and it would be presumptuous for traditional
biomedical practitioners to dismiss them lightly as worthless. Nevertheless, without rigorous scientific evidence to the
contrary, physicians must approach many of these treatments with skepticism. The influence of the mind on the body and
the effect of psychological factors in health and disease are well known to physicians, especially to psychiatrists.
Suggestion is a potent remedy, and the well-established placebo effect, in which an inert substance is effective in curing a
disorder, serves to confirm the importance of mind–body interaction in health and disease.
Currently, more than half of the medical schools in the United States offer some form of complementary and alternative
medicine education. Several have developed centers for alternative medicine research, with professors of mind–body or
integrative medicine drawn largely from the ranks of such traditional specialties as internal medicine and psychiatry. This
trend is likely to continue, with the goal of determining which of the many existing alternative medical systems have
scientific merit. Only when and if they can withstand rigorous clinical trials can these techniques be integrated into
traditional medicine.
Listed below in alphabetical order are some of the most visible complementary and
alternative health practices that have been used in the treatment of (broadly defined)
psychiatric conditions. The discussion of therapies should not be considered definitive;
new therapies continue to emerge. The number of alternative healing practices
available in the United States is unknown and probably soars into the hundreds and
their practitioners into the tens of thousands, and there are no national standards set to
credential such practitioners.
ACUPRESSURE AND ACUPUNCTURE
Acupressure and acupuncture are Chinese healing techniques that are mentioned in
ancient medical texts dating back to 5000 B.C. and continue to be an important medical

intervention in the East. A basic tenet of Chinese medicine is the belief that vital energy
(qi or chi) flows along specific pathways (meridians) that have about 350 major points
(acupoints) whose manipulation corrects imbalances by stimulating or removing
blockages to energy flow. Another fundamental concept is the idea of two opposing
energy fields (yin and yang) that must be in balance for health to be sustained. In
acupressure, the acupoints are manipulated by the fingers; in acupuncture, sterilized
silver or gold needles (some the diameter of a human hair) are inserted into the skin to
varying depths (0.5 mm to 1.5 cm) and are rotated or left in place for varying periods
to correct any imbalance of qi.
In the West, acupressure and acupuncture are explained on the basis of nerve stimulation that releases endogenous
neurotransmitters, endorphins, and enkephalins to help cure illness. The benefits of acupuncture have been validated in a
variety of conditions, most notably pain management, postoperative nausea and vomiting, osteoarthritis of the knee,
fibromyalgia, and headaches. Other conditions treated with these techniques are asthma, dysmenorrhea, cervical pain,
insomnia, anxiety, depression, and substance abuse, including smoking cessation (see the description of moxibustion
below). Most pain management clinics in the United Kingdom use acupuncture treatment. A variation of acupuncture,
which uses mild electric current to augment therapeutic effects (electroacupuncture), is most often used for analgesia or
during surgery. Acupuncture applied to the ear (auricolocupuncture) is also common.
ALEXANDER TECHNIQUE
The Alexander technique was developed by F. M. Alexander (1869–1955), who was born
in Tasmania and eventually became a well-known stage actor. After developing
aphonia, he experimented on himself by changing his body posture and eventually
regained his voice. Alexander developed a theory of the proper use of body musculature
to help alleviate somatic and mental illnesses. Alexander’s approach is an educational
process that reduces habitual, unnecessary muscular tension in everyday movements
(i.e., unintentionally straining the neck while sitting at a computer) by improving
sensory awareness and conscious control of these maladaptive physical habits (Fig. 241). Treatment improves cardiovascular, respiratory, and gastrointestinal functioning as
well as mood. A small, devoted group of Alexander practitioners is found in the United
States and throughout the world. The Alexander technique holds promise as an approach
to pain management; it has been shown to be effective in treating chronic back pain in
several recent independent studies (Fig. 24-1).

FIGURE 24-1A. Position of pelvis, back, neck, and head in slumped position.
B. Standing in hunched position (left) and well balanced (right). (From Barlow W. The
Alexander Principle. London: Gollancz; 1973, with permission.)
ANTHROPOSOPHICALLY EXTENDED MEDICINE
Anthroposophically extended medicine is a form of healing developed by the Austrian
philosopher Rudolf Steiner (1861–1925). The healing process involves the use of
conscious understanding, which Steiner called anthroposophy, or the “wisdom of life.”
Anthroposophy focuses on mental exercises that enable persons to find a balance
between mind and body to ensure health maintenance. Steiner founded a school of
thought represented in this country by the Rudolf Steiner School, which teaches children
these concepts as they apply to civilization, besides a standard educational curriculum.
AROMATHERAPY
Aromatherapy is the therapeutic use of plant oils. Named by the French chemist Maurice
René-Maurice Gattefossé in 1928, aromatherapy is one of the fastest growing
alternative therapies in the United States and Europe. The essential oils of plants are
organic compounds that are benzene derivatives. Aromatic substances were used in
ancient civilization as both medicines and perfumes. Today, plant oils are inhaled using
atomizers or are absorbed through the skin using massage (aromatherapy massage).
Plant oils have many therapeutic effects—analgesic, psychological, antimicrobial—some
of which have been demonstrated scientifically. One NCCAM study, for example, found
the scent of lavender helped promote sleep. Aromatherapy is used to reduce stress and
anxiety and to alleviate gastrointestinal and musculoskeletal disorders. In psychiatry,
olfactory stimulation has been used to elicit feeling tones, memories, and emotions
during psychotherapy. Aromatherapy can cause skin irritation or allergic reactions in

some people. Table 24-2 lists the essential oils and their effects.
Table 24-2
Common Aromatherapies
Pheromones are chemical substances secreted and smelled by humans, which affect their physiological and behavioral
responses, usually related to sex. Women who are exposed to the smell of androstenol, which occurs in male underarm
sweat, show increased social exchanges with men, heightened sexual arousal, and improved mood. Androstenol also affects
the length and timing of the menstrual cycle as a result of changes in the level and release of gonadotrophic-releasing
hormone (GnRH) and luteinizing hormone (LH). Female pheromones, known as copulins, are present in female underarm
sweat and in vaginal secretions. Males perceive the odor of copulins as most pleasant during the woman’s ovulatory cycle
when such odors are most volatile. The synchronization of the menstrual cycle of women living together (a welldocumented phenomenon) is also related to the effect of copulins. Olfactory sexual signaling is being investigated
extensively, and whether these studies show therapeutic potential remains to be seen.

AYURVEDA
Ayurveda means “knowledge of life.” The technique originated in India about 3000 B.C.
and is believed to be one of the oldest and most comprehensive medical systems in the
world. Ayurveda is similar to Chinese medicine in its beliefs about energy points on the
body and a vital force (prana) that must be in balance to maintain health. Ayurveda
practitioners diagnose illness by examining the pulse, the urine, and the heat or coldness
of the body. Treatment relies on diet, medicines, purification, enemas, and bloodletting.
(See also “Tibetan Medicine” below.)
BATES METHOD
The Bates method, designed to treat vision problems, was devised by William H. Bates.
It is aimed at naturally strengthening the eye muscles and includes the following basic
exercises: splashing closed eyes 20 times with warm water, then 20 times with cold
water; alternately focusing on near and distant objects; focusing on an object while
gently swaying the body; remembering objects in the mind’s eye to facilitate the actual
perception of these objects in reality; and closing the eyes, cupping them with the palms
of both hands (without touching the eyes), and focusing on pleasant thoughts. Bates
practitioners claim that persons who need glasses to correct refraction errors will not
need them if these methods are followed rigorously.
BIOENERGETICS
Bioenergetics, based on the belief that dammed-up energy produces maladaptive
behavioral patterns, evolved from the work of the Austrian psychoanalyst Wilhelm
Reich (1897–1957), who studied with Sigmund Freud. Reich believed that energy fields
were propelled by sexual impulses called ergs and that satisfactory orgasms indicated
healthy bodily functioning. Modern-day practitioners look for areas of muscular tension
in the body that are thought to be associated with repressed memories and emotions.
Therapists try to bring these repressions to consciousness through a variety of relaxation
techniques, including massage.
CHELATION
Chelation therapy is a traditional medical procedure used to treat accidental poisoning
with heavy metals, such as lead, arsenic, and mercury. A chelating agent
(ethylenediaminetetraacetic acid [EDTA]) is infused into the bloodstream and binds to
the metal, which is then excreted from the body. As an alternative medical practice,
chelation therapy is used as a form of preventive medicine to remove lead, cadmium,
and aluminum from the body. These substances are presumed by some to be associated
with premature aging, memory loss, and the symptoms of Alzheimer’s disease. Chelation
therapy has also been used to treat atherosclerosis and coronary artery disease. One
NCCAM study showed that chelation treatments reduced cardiovascular events such as

heart attacks and death in patients with diabetes; however, chelation therapy is not yet
approved by the U.S. Food and Drug Administration (FDA) as a treatment for this
condition.
CHIROPRACTIC
Chiropractic is concerned with the diagnosis and treatment of disorders of the
musculoskeletal system, especially those of the spine. It was developed by a Canadian,
Daniel David Palmer (1845–1913) (Fig. 24-2), who moved to the United States in 1895.
Palmer believed that disease could be attributed to spinal misalignment, leading to
abnormal nerve transmission.
FIGURE 24-2Daniel David Palmer (1845–1913), the founder of chiropractic. (Reprinted
with permission from Shealy CN, ed. The Complete Family Guide to Alternative Medicine:
An Illustrated Encyclopedia of Natural Healing. New York: Barnes & Noble Books; 1996:39.)
Chiropractors diagnose illness by clinical examination and X-ray. Treatment involves manual manipulation of bones,
joints, and musculature to restore biomechanical function. Chiropractic is the largest independent alternative health
profession in the Western world, with more than 50,000 chiropractors in the United States. They are recognized by
government and insurance agencies and treat more than 20 million persons in the United States annually.
COLONIC IRRIGATION
Colonic irrigation is a technique known since antiquity that consists of flushing the
intestinal colon with large quantities of water, sometimes with minerals or other
substances (e.g., coffee) added. It is a method used to eliminate autointoxication, a
concept originating from the Pasteur Institute in France in 1908 that holds that retained
fecal matter and undigested food ferment in the bowel producing toxins that cause

disease. Special colon hydrotherapy machines force fluids via the rectum to clean the
colon of this matter, thus eliminating such toxins. Colon cleansing using powerful
laxatives and enemas is an alternative way of achieving the same result. Anecdotal
reports of improved general health as a result of such practices are common; however,
there are risks of electrolyte imbalance and intestinal perforation. The practice is poorly
regulated, although some states attempt to monitor therapists and equipment.
COLOR THERAPY
In color therapy, different colors are thought to affect mood, and this has been used to
address specific health problems. For example, blue is believed to be sedating, and red,
excitatory. A Swiss psychologist, Max Lüscher, devised a color test in which a subject’s
mood at a particular time is determined by exposing the subject to various colors.
Lüscher also experimented with the effect of color on the autonomic nervous system and
found that pure red is sympathomimetic and can cause an increase in blood pressure,
heart rate, and respiration. Blue is parasympathomimetic and produces the opposite
effects.
DANCE THERAPY
Dance therapy was formally recognized in 1942, with the hiring of pioneer dance
therapist Marian Chace (1896–1970) at St. Elisabeth’s Hospital in Washington, D.C. The
terms dance and movement are used synonymously; however, each actually describes a
point of view. Movement encompasses the world of physical motion, whereas dance is a
specific creative act within that world. The American Dance Therapy Association defines
dance therapy as “the psychotherapeutic use of movement which furthers the emotional
and physical integration of the individual.” Dance therapy sessions have four basic
goals: the development of body awareness; the expression of feelings; the fostering of
interaction and communication; and the integration of the physical, emotional, and
social experiences that result in a sense of increased self-confidence and contentment.
DIET AND NUTRITION
Nutritional methods to prevent or cure disease have an important place in modern
medicine, and their efficacy has been proved by scientific evidence. The federal
government has established recommended daily allowances (RDAs) to meet the
nutritional needs of average persons in the United States. Table 24-3 depicts the
recommendations for a 40-year-old sedentary man. Whole grain, lean meat, and green
vegetable consumption are encouraged, and excess intake of unrefined sugar products is
discouraged. Critics have faulted the federal guidelines for being unduly influenced by
the meat and dairy industries. Nutritional experts and dieticians have developed
alternate recommendations, especially for children, adolescents, diabetics, and pregnant
women.

Table 24-3
United States Department of Agriculture Food Guide for a 40-Year-Old
Sedentary Male
Many alternative diets exist, and specific vitamin and mineral supplementation
programs have been developed to deal with specific diseases or bodily processes. Diets
low in fat have been recommended for the treatment of cardiovascular disease and
diabetes. The Pritikin diet developed by Nathan Pritikin is extremely low in fat (less
than 10 percent of daily calories), high in complex carbohydrates, and high in fiber. The
Ornish diet, developed by physician Dean Ornish, is vegetarian: No meat, poultry, or
fish is allowed, and only 10 percent of calories are obtained from fat. The low
carbohydrate, high protein diet developed by Robert Atkins, M.D. (1930–2003) has
proved effective in short-term weight loss, most likely because of increased compliance.
Concern exists around the risk of ketoacidosis and the lack of long-term studies on
health. This diet has also been used to treat refractory childhood epilepsy. All of these
diets include an exercise program, a component proved to increase cardiac
performance. Studies have shown that weight loss alone can reduce cholesterol, decrease
blood pressure, and eliminate the need for drugs in newly diagnosed cases of adult-onset
diabetes.
Diets from other cultures may have certain health benefits. In Asia, diets are low in fat, and there is a low incidence of
cardiac disease; diets in Mediterranean countries are high in olive oil, garlic, and grains and are associated with a low
incidence of colon cancer and cardiac disease. Food allergies have been implicated in many conditions: arthritis, asthma,
hyperactivity, and ulcerative colitis, among others.
DIETARY SUPPLEMENTS
In addition to herbs (discussed below), a variety of dietary supplements are used to
promote health. Dietary supplements are products that contain vitamins, minerals, or
amino acids. In many cases, the supplement is actually an extract, metabolite, or
combination of those. They are intended to supplement a healthy diet; they do not
comprise a diet or meal. Nutritional supplements have long been familiar to Americans
in the form of multivitamins, but they are now available in a vast array of other

compounds that can be purchased in grocery stores, pharmacies, health food stores, and
over the Internet. Annual sales of dietary supplements in the United States exceeds $20
billion. Of Americans, 75 percent currently use some form of nutritional supplement on
a regular basis. Although medicinal benefits are well documented in some supplements,
especially vitamins, others vary greatly in safety and consistency. As a general rule,
supplements should not be taken by pregnant or lactating women. In psychiatry,
nutritional supplements are being used to treat a wide spectrum of illness including
cognitive, mood, psychotic, sleep, and conduct disorders; however, little scientific
evidence currently supports their efficacy. Table 24-4 lists some of the more common
supplements being used to treat psychiatric illness.
Table 24-4
Some Dietary Supplements Used in Psychiatry

Nutritional status has long been deemed important in mental health, and vitamin deficiencies can produce psychiatric
symptoms. Severe niacin deficiency results in pellagra with its characteristic triad of skin lesions, gastrointestinal
disorders, and psychiatric symptoms. The psychiatric symptoms include irritability and emotional instability progressing
to severe depression and then to disorientation, memory impairment, hallucinations, and paranoia. Folic acid deficiency is
associated with depression and dementia, whereas vitamin B12 deficiency is associated with cognitive impairment,
depression, and other affective symptoms. Severe malnutrition can result in apathy and emotional instability.
In 1968, the eminent chemist and Nobel Prize–winner Linus Pauling coined the term orthomolecular to refer to the
connection between the mind and nutrition. In his book Orthomolecular Psychiatry, research articles were compiled
supporting the notion that taking many times the recommended minimal daily dose of vitamins is useful in the treatment
of schizophrenia and other psychiatric disorders. As mentioned, some severe vitamin deficiencies can result in syndromes
with a psychiatric component; however, empirical data and an American Psychiatric Association (APA) task force failed to
find evidence supporting the notion that schizophrenia and other disorders respond to vitamin therapies.
Thiamine, Vitamin B12, and Folate
In industrialized societies, severe vitamin deficiencies are rarely encountered except in
certain populations. Those who are elderly, alcohol dependent, or chronically ill or who
have certain types of gastrointestinal surgeries are at greatest risk. Among the forms of
vitamin deficiency most commonly encountered in the emergency room is acute
thiamine depletion from alcohol dependence. Whereas the chronic forms of thiamine
deficiency that lead to beriberi are rarely seen in the Western world, the fulminant
depletion of already low stores of thiamine results in Wernicke’s encephalopathy and
Korsakoff’s syndrome.
Wernicke’s encephalopathy classically presents with the triad of ataxia, ophthalmoplegia, and mental confusion, but
confusion and a staggering gait are perhaps most common. Although Wernicke’s encephalopathy is an acute process,
Korsakoff’s syndrome may be the permanent residue of this encephalopathy. Patients with Korsakoff’s syndrome exhibit a
well-circumscribed retrograde and anterograde amnesia that results from destruction of the mammillary bodies, and
psychotic symptoms are also reported. Wernicke’s encephalopathy is a medical emergency that responds to short-term
treatment with 50 mg of thiamine intravenously followed by 250-mg intramuscular injections daily until a normal diet is
attained. The treatment of uncomplicated acute thiamine deficiencies usually involves 100 mg given orally one to three
times a day.
Vitamin B12 deficiency or pernicious anemia is often seen in elderly adults, patients who have had gastric surgery, and
malnourished depressed patients. The most typical psychiatric presentations include apathy, malaise, depressed mood,
confusion, and memory deficits. Vitamin B12 concentrations of 150 mg/mL of serum are sometimes associated with these
symptoms. Vitamin B12 deficiency is a more common cause of reversible dementia and is typically assessed in dementia
evaluations. The treatment of pernicious anemia usually involves daily intramuscular injections of 1,000 mg of vitamin
B12 for approximately 1 week, followed by maintenance doses of 1,000 mg every 1 to 2 months.
Folate deficiency has been associated with depression, paranoia, psychosis, agitation,
and dementia. Folate deficiency can result from anorexia in depressed patients and can
also contribute to depression by interfering with the synthesis of norepinephrine and

serotonin. Folate deficiency has been associated with anticonvulsant use, particularly
phenytoin (Dilantin), primidone (Mysoline), and phenobarbital (Solfoton), and the sex
steroids, including oral contraceptives and estrogen replacement. The most common
cause of folate deficiency is the malnourishment associated with alcoholism. Many folate
deficiencies respond to 1 mg of folate orally per day; however, some more severe forms
may require dosages of 5 mg up to three times a day. Folate deficiency in pregnancy is
associated with neural tube defects (e.g., spina bifida, anencephaly).
Mr. S was diagnosed with dysthymic disorder by a psychiatrist in his early 20s and
was started on sertraline (Zoloft). After 4 weeks Mr. S’s mood improved dramatically,
but he experienced night sweats and reduced libido. Over the ensuing years he was
tried on paroxetine (Paxil), citalopram (Celexa), and fluoxetine (Prozac). Although his
mood improved, his sex drive did not. Mr. S heard about an integrative mental health
clinic that offered conventional medications, herbal medications, acupuncture, and
Reiki. Mr. S was interviewed by a Western physician who had also studied Chinese
medicine. The Chinese pulse diagnosis of stagnant liver qi was consistent with his
Western diagnosis of moderate depressed mood. The doctor ordered a thyroid panel,
red blood cell (RBC) folate, and B12 levels and suggested an integrative treatment
plan including supplementation with folate, B12, omega-3 fatty acids, and S-AdenosylL-methionine (SAMe), regular exercise, and acupuncture. The initial treatment plan
consisted of daily exercise, SAMe (titrating to 400 mg twice daily), folate 5 mg, B12
800 μg, and omega-3s (eicosapentaenoic acid [EPA] 2 g per day). Three weeks later,
Mr. S was frustrated at his lack of progress, remained depressed, and had not started
to exercise. His RBC folate level was low, and the other studies were within normal
limits. Mr. S had been taking an inexpensive generic brand of SAMe and had stayed at
200 mg per day. He was encouraged to follow the original treatment plan. Two weeks
later, Mr. S appeared brighter. He was exercising daily and taking the B vitamins and
a quality brand of SAMe at 400 mg twice daily without significant adverse effects.
(Adapted from James H. Lake, M.D.)
ENVIRONMENTAL MEDICINE
The field of environmental medicine began to emerge in the 1950s when physicians such
as Theron Randolf, professor of allergy and immunology at Northwestern University
School of Medicine, began to examine some persons’ allergic reactions to various foods.
Other workers studied the effects on the body of pollutants in water and air, and
eventually the field expanded to include the total environment in which humans exist.
As a result, environmental medicine now concerns itself with issues such as food
additives; electromagnetic fields from electric utility wires; fertilizers and hormones used
in food production; microwaves from appliances such as microwave ovens, television
sets, and cellular telephones; and nuclear radiation. Practitioners of environmental

medicine believe that many persons are extraordinarily sensitive to environmental
contaminants that can trigger a disease process. Some issues are highly controversial.
For instance, despite claims to the contrary, studies fail to demonstrate a higher
incidence of cancer in persons exposed to electromagnetic fields; however, a correlation
exists between higher cancer rates and living near oil refineries and chemical plants.
Environmental medicine is a form of preventative medicine that focuses on increased
individual awareness of environmental hazards and the control or elimination of these
hazards. (See also “Naturopathy” below.)
EXERCISE
Exercise improves quality of life through better physical function, reduced morbidities,
and improved mental health. The positive effects of exercise on immune system
functions are well documented. These benefits extend to the cognitive and emotional
realms and, thus, validate the mind–body connection that is central to many CAM
physical practices—yoga, tai chi, qi gong. Exercise has been shown to ameliorate
depression, anxiety, and PTSD; improve cognitive function and self-esteem; and reduce
psychotic symptoms in schizophrenic populations. These effects can be accounted for
neurochemically, because exercise promotes secretion of neurotransmitters, such
serotonin, adrenaline, and endogenous opiates. Studies have also associated weight loss
with increased social interaction, distraction from stress, recreational enjoyment, and
mastery of challenge.
Exercise offers many benefits to people with serious mental illness because they more likely suffer from serious medical
conditions, such as obesity, diabetes, and hypertension; live sedentary lifestyles; and smoke. Studies of adults with
schizophrenia have shown a moderate exercise program reduces body mass index, improves aerobic fitness, raises selfesteem, and results in fewer psychiatric symptoms. Exercise may prove useful in remediating the weight gain from
antipsychotic medications and improve compliance.
Although presently underused, exercise holds significant potential benefit as a therapeutic intervention in the mental
health care setting. A structured aerobic exercise program consisting of 45-minute sessions three times per week showed
significant gains in cardiovascular fitness, self-esteem, and quality of life and in altering mood and depression.
Unstructured programs benefited those who adhere to the exercise regimen. No drawbacks are found to moderate exercise,
and the health gains are significant.
FELDENKRAIS METHOD
The Feldenkrais method was developed by Moshé Feldenkrais (1904–1984), a Russianborn physicist who developed a theory evolved from Freud’s work. Feldenkrais thought
that the body should be emphasized as much as the mind and that proprioception
(somatic sensations from muscles and other organs) can influence behavior. He believed
that posture and the positions of the body reflected conflict; therefore, retraining the
body was part of his treatment program. Practitioners of the Feldenkrais method are
active throughout the world. Those learning the Feldenkrais method are referred to as
students rather than patients, to reinforce the view that the work is primarily an

educational process. Lessons generally last from 30 to 60 minutes and consist of
structured movement that involves thinking, sensing, moving, and imagining. The
method has been used in central nervous system disorders, such as multiple sclerosis,
cerebral palsy, and stroke. Older persons who use the method claim that they retain or
regain their ability to move without strain or discomfort.
HERBAL MEDICINE
Herbal medicine relies on plants to cure illnesses and to maintain health. Probably the
oldest known system of medicine, it originated in China about 4000 B.C. Ancient texts
of Chinese medicine are still in use, and modern Chinese medicine relies on herbs in
addition to other methods, such as acupuncture, massage, diet, and exercise, to correct
imbalances in the body. A Greco-Roman medical text by Pedanius Dioscorides, De
Materia Medica, describes the use of more than 500 plants and herbs to cure disease.
The decline of herbal medicine in the late 20th century was related to scientific and
technological advances that led to the use of synthetic pharmaceuticals; nevertheless,
according to some estimates, at least 25 percent of current medicines are derived from
the active ingredients of plants. The examples are many: digitalis from foxglove;
ephedrine from ephedra; morphine from the opium poppy; paclitaxel (Taxol) from the
yew tree; and quinine from the bark of the cinchona tree.
Herbal medicine is becoming more and more popular. Approximately $4 billion a year is spent in the United States on
herbal medicines, which are classified as dietary supplements. Western herbalists use plants to treat various disorders
related to the respiratory, gastrointestinal, cardiovascular, and nervous systems; as with most prescription medicines,
these plants contain active compounds that produce physiological effects. As a result, they must be used in appropriate
doses if toxic results are to be prevented. They are not subject to FDA approval, and no uniform standards exist for quality
control or potency in herbal preparations. Indeed, some preparations have no active ingredients or are adulterated. Herbal
supplement producers need only prove safety and truth in labeling, not efficacy, to be sold. The herbal industry attempts to
regulate itself through organizations such as the Council for Responsible Nutrition and the American Herbal Association,
but according to the Federal Trade Commission, fraudulent practices and false advertising still exist. In 2003, the FDA
banned ephedra (ma huang)-based diet products because of significant risk to cardiovascular health. There is now a
Physicians Desk Reference for both herbal products and nutritional supplements.
One herb that has caught the attention of Western psychiatry is St. John’s wort
(Hypericum) for the treatment of major depressive disorders (Fig. 24-3). St. John’s wort
has been used in folk medicine for hundreds of years and is still commonly used in
Europe. In Germany, several million prescriptions for Hypericum are obtained annually
and covered by insurance for the treatment of depression, anxiety, and sleep problems.
Studies have compared St. John’s wort with placebo, tricyclic drugs, and selective
serotonin reuptake inhibitors (SSRIs) and found that Hypericum extracts were more
effective than placebo in the treatment of mild to moderate depression. Many of these
studies lacked rigor in the diagnosis of depression, sample size, and the assessment of
efficacy. NCCAM sponsored studies and other researchers are working to determine the

active ingredients, effective dosing, and toxicities associated this plant and other
biologically derived supplements using spectrographic and other scientific analyses.
FIGURE 24-3St. John’s wort (Hypericum perforatum).
Mrs. J, a 68-year-old retired schoolteacher in good health, was experiencing
anhedonia after the death of her spouse and was started on a low-dose SSRI by her
psychiatrist. After several weeks, her symptoms began to improve. One morning,
while at the local health food store, she inquired if there were any natural products
that improved mood. The store manager informed her that St. John’s wort “works just
like an SSRI.” The patient proceeded to take the recommended daily dose of three
capsules that day, each containing 300 mg of 0.3 percent Hypericin. Later that
evening, she began to feel anxious and could not fall asleep. After several hours of
doing needlework to pass the time, she began to sweat profusely. She became
concerned for her health when she felt her heart racing. She drove herself to the
emergency room of a local hospital. On examination, she was observed to be
extremely anxious and hyperactive, tachycardic, and mildly hypertensive. She was
given a short-acting, fast-onset benzodiazepine. After 4 hours, the patient reported
feeling calm and her vital signs had returned to baseline. The emergency room
physician informed Mrs. J that although she had only taken a single daily dose of St.
John’s wort, she had most likely experienced the side effects of an interaction between
the plant extract and the SSRI. Known interactions include a manic reaction and
serotonin syndrome. The patient agreed to discontinue the St. John’s wort. She was
discharged and a follow-up appointment was scheduled with her psychiatrist to
discuss treatment options.
Psychoactive Herbs
Many phytomedicinals (from the Greek phyto, meaning “plant”) have psychoactive
properties that are used, or have been used, to treat a variety of psychiatric conditions.
Adverse effects are possible, and toxic interactions with other drugs can occur with all

phytomedicinals. Clinicians should always attempt to obtain a history of herbal use
during the psychiatric evaluation. Adulteration is common, and no consistent standard
preparations are available for most herbs. Safety profiles and knowledge of adverse
effects of most of these substances are lacking; many, if not all, of these herbs are
secreted in breast milk and are contraindicated during lactation and should be avoided
during pregnancy.
Many cultures have used hallucinogens, including mescaline, psilocybin, and ergots,
for thousands of years to gain spiritual and personal insight. Lysergic acid diethylamide
(LSD), synthesized in the 1930s, was marketed to psychiatrists and other practitioners in
the late 1940s under the trade name Delysid as a tool for understanding psychosis and
for facilitating psychotherapy. Using LSD reportedly helped patients capture repressed
memories and deal with anxiety, and it allowed patients to gain insight through an
analysis of the primary process induced by the hallucinogen. Oral doses of 150 to 250
mg were administered occasionally by psychiatrists throughout the 1950s and early
1960s to facilitate psychotherapy with some patients. In the 1960s, Timothy Leary
advocated the widespread use of hallucinogens, but the drugs were outlawed as class I
controlled substances in 1965.
Although no longer used for therapeutic purposes in the United States, LSD has fulfilled part of its early promise as a
probe for psychosis. More recent understanding of the pharmacology of LSD and its affinity to serotonin (5hydroxytryptamine [5-HT]) type 2 (5-HT2) receptors has supported the interest in developing serotonin-dopamine
antagonists (atypical antipsychotics) with the 5-HT2-receptor blocking properties. Recently, studies using
methylenedioxymethamphetamine (MDMA, “ecstasy”) have been approved by the NIH to determine whether
psychotherapy is facilitated when the patient is under the influence of the drug, which can affect interpersonal
relationships positively by promoting feelings of empathy.
It is important not to be judgmental in dealing with patients who use phytomedicinals. They are used for various
reasons: (1) as part of their cultural tradition, (2) because patients mistrust physicians or are dissatisfied with
conventional medicine, or (3) because they experience relief of symptoms. If psychotropic agents are prescribed, the
clinician must be extraordinarily alert to the possibility of adverse effects as a result of drug–drug interactions, because
many phytomedicinals have ingredients that produce physiological changes in the body. More than 200 herbal drugs are in
use; only those with psychoactive properties are listed in Table 24-5.
Table 24-5
Phytomedicinals with Psychoactive Effect

HOMEOPATHY
Homeopathic healing was developed in the early 1800s by Samuel Hahnemann, a
German physician (Fig. 24-4). It is based on the concept that self-healing is a basic
characteristic of human life and that special medications can aid this inherent process.
The homeopathic pharmacopoeia is unique in several ways. First, it contains more than
2,000 medications, including those from plants, such as aconite, ergot, and hellebore;
minerals, such as silver, copper, gold, and iodine; and animals, such as snake and
jellyfish venom and tissue extracts. Second, medications are prepared as tinctures (i.e.,
mixed with 95 percent grain alcohol) or as pills with lactose fillers. Finally, medications
are dispersed in infinitesimally dilute solutions, such as 1 to 1,020,000, which prevents
the medication from being detected by conventional chemical methods. Homeopaths
claim that the therapeutic effect is based on “molecular medicine.”
FIGURE 24-4Samuel Hahnemann (1755–1843). (From the New York Academy of
Medicine, New York, NY, with permission.)
Hahnemann based his drug treatment on the following assumptions: medical substances elicit a standard array of signs
and symptoms in healthy people, and the medicine whose effect in normal persons most closely resembles the illness being
treated is the one most likely to initiate a curative response. Thus, a medication that produces nausea would be used to
treat nausea, except that it would be given in dilute amounts. This law of similars—Similia similibus curantur (“Let like be
cured by like”)—led to coining of the word homeopathy (“similar experiences”). In traditional medicine, such highly
dilute substances are considered to have no effect, and no pharmacological research studies demonstrate otherwise.
Homeopathic medical schools are no longer found in the United States (the last one was Hahnemann University Medical
School, which closed in 1994); nevertheless, the practice of homeopathy is increasing in the United States and around the
world. In Europe, homeopathy is extraordinarily popular. Homeopathic medicines are sold over the counter in the United
States. Homeopathic remedies sold in the United States must meet the standards of monographs in the Homeopathic
Pharmacopoeia of the United States (HPUS), which was recognized in the Food, Drug and Cosmetic Act with authority
equivalent to that of the United States Pharmacopeia (USP). To date, no NCCAM studies have been done on homeopathic

methods.
LIGHT AND MELATONIN THERAPY
Light therapy is based on the concept that humans are subject to circadian rhythms
(from the Latin words circa [“around”] and dies [“day”]) that affect physiological
processes in predictable ways. There are 24-hour cycles of rest and activity that include
changing levels of corticosteroids, electrolyte excretion, and physiological processes; for
instance, blood pressure is higher during the day than at night. By varying light
exposure, circadian rhythms can be altered. The concentration of the hormone
melatonin, produced by the pineal gland, is highest in the bloodstream at night and is
low or absent during the daylight. Melatonin is believed to regulate sleep, and
exogenous melatonin (available over the counter) produces drowsiness in normal
people. Artificial bright-light therapy (over 2,500 lux) is a proven method used to treat
depressive disorder with seasonal pattern, which is seen during the winter months when
daylight hours are reduced.
MACROBIOTICS
Macrobiotics (from the Greek words makros [“long”] and bios [“life”]) is a health
practice that focuses on living in harmony with nature, using mainly a balanced diet.
Macrobiotics became associated with the biblical patriarchs, the Chinese sages, and the
Ethiopians of Africa, who were said to live 120 years or more. In 1797, a German
physician and philosopher, Christoph W. Hufeland wrote an influential book on diet and
health, Macrobiotics or the Art of Prolonging Life.
Macrobiotic foods are classified as yin (cold and wet) and yang (hot and dry); the goal is to keep yin and yang in balance.
The diet consists of 50 percent grain products, 25 percent cooked or raw vegetables, 10 percent protein, 10 percent
vegetable or fish soup, and 5 percent teas and fruits. Prolonged use of the diet can result in vitamin and mineral
deficiencies.
MASSAGE
Massage is a treatment that involves manipulation of the soft tissues and the surfaces of
the body. It was prescribed for the treatment of diseases more than 5,000 years ago by
Chinese physicians, and Hippocrates considered it to be a method of maintaining health.
Massage is believed to affect the body in several ways: it increases blood circulation, improves the flow of lymph
through the lymphatic vessels, improves the tone of the musculoskeletal system, and has a tranquilizing effect on the
mind. Massage techniques have been described in various ways: stroking, kneading, pinching, rubbing, knuckling, tapping,
or applying friction. Massage is most often done with the hands and fingers, but vibrating machines and electrical
stimulation are also used. The different types of massage therapies that have evolved over the years are more similar than
different. These include Swedish, Oriental, Shiatsu, and Esalen massages. Studies have proved massage useful to reduce
anxiety and pain perception. Most persons who experience massage find it physically and mentally restorative. NCCAM
studies have shown massage to be of benefit in the treatment of pain, especially pain related to joint disease.

MEDITATION
Meditation is a technique that involves entering a trance state by focusing thought on a
word or sound (a mantra), an object (e.g., a burning candle), or a movement (e.g., an
oscillating disk). During the trance, the person experiences a state of calm. A meditative
trance has physiological effects, all associated with decreased anxiety: heart and
respiratory rates slow, blood pressure decreases, and alpha brain waves increase.
Transcendental meditation (TM), developed by the Indian mystic Maharishi Mahesh Yogi, was introduced into the
United States in the 1950s. TM uses mantras based on personal characteristics to induce a trance state. In the 1960s, a
physician, Herbert Benson, developed the relaxation response, which used mantras and breath control as a treatment for
stress and stress-related disorders.
Mindfulness Meditation
Mindfulness meditation is derived from Buddhist practices of meditation and refers to paying attention to the present and
being aware of the present using all sensory modalities. As thoughts flow through the mind during meditation, they are
viewed nonjudgmentally, accepted for what they are, reflective of our “true nature.” It is a process of self-exploration and
self-inquiry. NCCAM studies have shown changes in brain, particularly left side anterior activation during meditation also
associated with significant improvement in subjective and objective symptoms of anxiety and panic. One study reported
improvement in women with irritable bowel syndrome.
Mindfulness Therapy
The concept of mindfulness and has been translated into a type of psychotherapy in which therapist and patient focus are
on the here and now rather than past events. Patients are encouraged to become aware of how they are feeling and what
they are thinking in the moment. As they examine their experienced emotion about current events or conflicts, insights
leading to change in behavior or attitudes occur.
MOXIBUSTION
Moxibustion is based on theories of Oriental medicine in which energy forces are
balanced by applying heat to stimulate specific acupoints. The heat is generated by
burning dry mugwort leaves (Artemisia vulgaris, known as moxa). Heat is applied either
directly or indirectly. In the direct method, dried moxa is rolled into small cones and
placed on the skin. The tops of the cones are lit, but they are extinguished as soon as
heat is felt. In the indirect method, a burning cigar-like moxa is held near the skin at
acupoints.
Moxibustion is used in musculoskeletal disorder, arthritis, asthma, and eczema. As
with many other alternative therapies, however, no scientific clinical trials are available
to show its effectiveness.
NATUROPATHY

Naturopathy is a health care system intended to ensure a healthy mind and body based
on maintaining healthy nutrition, pollution-free air and water supplies, and exercising
regularly. The treatment is based on the belief that the body has the power to heal itself;
it requires the patient’s active participation in the health maintenance program.
Naturopathy developed in Germany in the later 19th century under the guidance of Benedict Lust, who prescribed
hydrotherapy (alternating hot and cold water) as a form of natural healing. Lust came to the United States, became an
osteopathic physician, and founded the American School of Naturopathy in 1902. Since then, naturopathic medicine has
grown into a major form of health care, which uses an eclectic group of methods in addition to hydrotherapy. These
methods include eating specialized diets, homeopathy, breathing ionized air, using fomentations (the application of hot
and cold compresses), taking colonic irrigations and enemas, drinking pollution-free water, eating foods grown organically,
and using massage therapy, herbs, and rest therapy. Naturopathic physicians are licensed in several states (Alaska,
Connecticut, New Hampshire, among others), but because no standard regulation of the field exists, persons with minimal
or no educational background set up practices.
ORIENTAL MEDICINE
Oriental medicine is a broad term covering the traditional medicines of China, Korea,
Japan, Vietnam, Tibet, and other Asian countries. In general, the techniques of Oriental
medicine were first developed in China and include acupuncture, moxibustion,
herbology, massage, cupping, gwa sha (scraping away toxins), breath work, qi gong (see
below), and exercise (tai chi). Chinese medicine is a coherent and independent system of
thought and practice based on ancient texts. It is the result of a continuous process of
critical thinking, extensive clinical observation, and testing, and it represents a
thorough exposition of material by respected clinicians and theoreticians. It is rooted in
philosophy, logic, sensibility, and habits of civilization foreign to Western civilization
and, therefore, is difficult for Western physicians to understand. The basic theory is that
a life force, called chi energy, flows in us in a harmonious, balanced way. This harmony
and balance signify health. When the life force does not flow properly, disharmony and
imbalance, or illness, result.
OSTEOPATHIC MEDICINE
The scope of osteopathic medicine is similar to allopathic medicine and is best indicated
by the fact that doctors of osteopathy (DO) are licensed to practice in every state and
are accepted into medical, surgical, and psychiatric residency programs and the military
on the same basis as medical doctors (MD); they are qualified to practice in every
branch of clinical medicine and take the same licensure examinations as MDs. Their
medical education is identical to that of MDs, except that they have additional training
in disorders of the musculoskeletal system, in which DOs consider themselves more
knowledgeable than MDs.
As of 2012 there were 29 osteopathic medical schools in the United States. Approximately 82,000 osteopaths treat about
30 million patients each year. Osteopathy was developed by Andrew Taylor Still, M.D. (1828–1917), who founded the

American School of Osteopathy in Kirksville, Missouri (now Kirksville College of Osteopathic Medicine), in 1892. Disease
is viewed in the same way as in allopathic medicine; however, special emphasis is placed on proper musculoskeletal
alignment as a prerequisite for health maintenance. Osteopaths may rely on the manipulation of body parts, particularly
the craniosacral spinal axis, as part of a treatment plan. Osteopathic manipulation therapy is perceived as an adjunct, not a
substitute, to traditional medical, surgical, and pharmacological intervention.
OZONE THERAPY
Ozone, which acts as an antioxidant and disinfectant, is used conventionally for water
purification, odor control, and air purification. Ozone therapy is based on the
assumption that most illness is caused by viral and bacterial infection; ozone is used to
treat medical conditions that range from influenza to cancer and acquired
immunodeficiency syndrome (AIDS). The first ozone generators were developed by
Werner von Siemens in Germany in 1857, and ozone was used therapeutically to purify
blood shortly thereafter in Germany and other European countries.
Ozone therapy introduces ozone into the body in various ways. These include drinking ozonated water; ozone limb
bagging, in which ozone is pumped into an airtight bag that covers an arm or leg; breathing ozone bubbled through olive
oil or topically applying ozonated olive oil; insufflations, in which a catheter is inserted into the rectum or vagina with
ozone administered at a slow flow rate; and autohemotherapy, in which a person’s own ozonized blood is reintroduced
into the body.
PAST LIFE MEDICINE
In past life medicine, the healing process is aided by contact with spiritual beings that
are believed to have the ability to reverse illness and maintain health. The spirits are
approached through the use of altered states of consciousness, so-called channeling,
higher states of awareness, and transmissions from spiritually evolved beings. Past life
regression using hypnosis allows a person to experience past life events (via imagery).
A 40-year-old man, in good health, with an obsessive fear of death was referred to
an integrative psychiatrist to deal with his preoccupations about dying. The patient
was placed in a trance state under hypnosis and asked to imagine and describe a past
life. He described himself as an itinerant silk merchant living in 16th-century France.
He was married, had eight children, and was content with his life. He was asked to
describe his death and proceeded to do so. He was 90 years old when he died,
surrounded by his family who were at his bedside. He knew he was dying and
described the process as a “peaceful falling away.” Following the session, his fears
about dying diminished; when he became anxious about death, he remembered the
past life narrative and was able to relax.
PRAYER

The pervasive interest in faith healing, the curative anecdotes of television evangelists,
and the millions of hopeful individuals visiting religious shrines in search of relief give
witness to the continuing interest in, and prevalence of, prayer and spirituality in the
process of healing. Some religious groups specifically recommend against standard
psychiatric therapies and offer their own approach as the only valid alternative for
mental and spiritual health. Others view prayer as a form of distant healing defined by
the psychic Elizabeth Targ as any purely mental effort undertaken by one person with
the intention of improving the physical or emotional well-being of another.
Some advocate the use of shared prayer, silent prayer, and distant or “intercessory” prayer (praying on behalf of
someone else for a specific purpose) to benefit patients. Studies to date are inconclusive, however, on the impact of prayer
on medical outcomes. Surveys indicate that 92 percent of a sample of inner-city homeless women reported one or more
spiritual or religious practices. Some 48 percent reported that prayer was significantly related to less use of alcohol or
street drugs or both and fewer perceived worries and depression. Recent epidemiological research indicates that religious
beliefs and practices are negatively correlated with substance abuse and positively correlated with health status. Also 12step programs have a long history of successfully incorporating prayer and spirituality in the treatment of addictive
behavior. Personal belief in religion and active attendance at worship has been correlated with a moderately decreased
incidence of depression and hypertension.
QI GONG
Chinese qi gong has been practiced for more than 2,000 years. Translated directly, qi
gong means the skill or work (gong) of cultivating energy (qi). It is a Chinese exercise
system that attracts and directs the vital life energy (see “Oriental Medicine” above),
enabling practitioners to build up their health, prevent illness, and increase vitality.
“Still” qi gong is practiced as a motionless meditation with the emphasis on breath and
intentional thoughts. “Moving” qi gong involves external movements under the conscious
direction of the mind. Electroencephalogram studies have detected measurable
differences in the brain patterns of practitioners. Purported benefits include increased
autoimmune cell production, reduced hypertension, and decreased incidence of falls in
the elderly.
REFLEXOLOGY
Reflexology is the gentle massaging of the feet, hands, and ears to stimulate the body’s
natural healing power. It is used to alleviate tension by clearing crystalline deposits
under the skin that may interfere with the natural flow of the body’s energy.
Reflexologists believe that all body parts can be mapped out on the soles or sides of the
feet; for instance, the tip of the second toe represents the eye. Applying pressure to a
particular area of the foot can relieve disorders related to the represented body parts.
NCCAM studies have shown some benefit from reflexology in patients with irritable
bowel syndrome.
REIKI

Reiki is a Japanese word with the general meaning of “healing.” (Rei means “universal”
or “spiritual,” and ki is “life force energy.”) It was developed by Mikao Usui in 1922
(Fig. 24-5). The two degrees of Reiki healing are as follows. First-degree Reiki
practitioners use light, nonmanipulative touch to the head and torso to precipitate a
flow of healing energy, called Reiki, drawn and into the patient according to the
recipient’s needs. Second-degree healing enables practitioners to access this energy for
distant healing when touch is impossible. Reiki treatment typically creates an almost
immediate feeling of relaxation, which may reduce the biochemical effects of prolonged
stress. First-degree Reiki is easily learned and is a method that patients use to decrease
stress, anxiety, insomnia, and pain. Reiki is also used in hospices for pain management,
to support a peaceful death, and to provide emotional support for family members. It is
also beneficial in cardiovascular disease as a means to lower blood pressure and reduce
cardiac arrhythmias. The mechanism of action is unknown, however, the autonomic
nervous system is involved, especially parasympathetic impulses.
FIGURE 24-5Mikao Usui (1865–1926), a Japanese philosopher who was the founder of
Reiki healing.
ROLFING
Rolfing is a type of massage that was developed by an American biochemist, Ida Rolf
(1896–1979), to relieve tension in muscle, connective tissue, and fascia, which she
believed caused musculoskeletal diseases, such as arthritis and fibromyalgia. Therapy
consists of deep, sometimes painful, massage to produce flexible planes between muscle
groups throughout the body. Rolf discovered that she could achieve remarkable changes

in posture and structure by manipulating the body’s myofascial system; as various parts
of the body are massaged, past memories and emotional states are often released. In
this sense, Rolfing is a psychophysiological experience. No NCCAM studies on Rolfing
have been performed.
SHAMANISM
A shaman (Fig. 24-6) is an individual who is believed to have the power to heal the sick
and communicate with the spirit world. Individuals having this designation can be found
in many parts of the world, including American aboriginal groups (Native Americans
and Alaskan natives). Qualifications of a medicine man (or woman) are determined by
a series of initiatory trials and teaching and “certification” by qualified, recognized
elders. Shamanistic practices often include cleansing ceremonies, such as fasting or
sweating, and so-called vision quests, which are accompanied by hallucinations. The
ceremony is sometimes facilitated by rhythmic sounds, dancing, physical pain or
privation, and the use of “spiritual herbs.” Through this process, the shaman escorts the
soul of the dying to the afterlife. Shamanistic practices are also used to provide solutions
to insolvable personal or social problems.

FIGURE 24-6Wooden statue of shaman. North Pacific coast.
SNOEZELEN
This is a term for a system of multisensory stimulation (e.g., lighting effects, tactile
surfaces, meditative music, and smell of essential oils) generally conducted in special
rooms for 30 to 60 minutes per session. Snoezelen originated in the Netherlands in the
field of learning disability and autism with children but has been adapted for use in
dementia. Snoezelen may also improve behavioral disturbances such as apathy, mood,
and restless or repetitive behaviors. One study showed Snoezelen to be comparable to
“reminiscence therapy” (e.g., using newspapers of nostalgic items to allow a person to
talk about old memories) for acute agitation in dementia. Lack of widespread
availability and potentially high costs for maintaining the therapy may limit its
applicability.
SOUND AND MUSIC THERAPY
Sound therapy is an ancient technique in which sounds (e.g., chants, bell rings, or drum
beats) are used to create vibrations in the body and believed to have healing powers.
Practitioners claim that a sense of relaxation can also be achieved. Sound therapy is
used in Ayurveda to promote health, with claims of reducing tumor growth by using
certain sounds known as Sama Veda. Music therapy uses the sound of musical
instruments, such as the flute, to achieve similar results. In the Bible, David attempted to
treat King Saul’s depression by playing the harp. The effect of music and sound on
psychophysiological processes is under investigation at various academic centers.
TAI CHI
Tai chi, or tai chi chuan, is one of the most popular Asian movement arts used in the
West. This ancient Chinese technique is designed to increase the life force in the body
through a series of slow circular movements. It is a moving form of meditation and is
based, as are other Chinese methods, on the search for perfect balance between yin and
yang energies.
The practitioner performs sequences of movements that last from 5 to 30 minutes. A session may last a couple of hours
and is typically performed in early morning. The practitioner is expected to focus on breathing and its precise
synchronization with the movements. Tai chi chuan is believed to help mainly stress-related problems and conditions and
so is primarily used to treat anxiety, depression, muscular tension, high blood pressure, and other cardiovascular
conditions. NCCAM studies have shown improvement in exercise tolerance in patients with cardiovascular disease who
practice tai chi.
THERAPEUTIC TOUCH
Therapeutic touch is the technique of healing with hands. It was developed by a nurse,
Dolores Krieger, in the 1970s. Energy is believed to be transferred by laying the hands

over specific parts of the body to aid in the process of healing. Therapeutic touch has
gained popularity in the nursing profession, as well as among some physicians. NCCAM
studies have shown therapeutic touch to be of value in patients with chronic neck pain.
TIBETAN MEDICINE
The Tibetan health system dates to about the 7th century A.D. The Tibetan king Songsten
Gampo is credited with its creation from the synthesis of various, more ancient sources.
It has elements of Arabic, Indian, and Chinese health systems. In Tibet, its practice is
closely related to religion and magic. Disease is believed to be the result of imbalance
between the three components or humors of the living organism: wind (breathing and
movement in general), bile (related to digestion and temperament), and phlegm
(related to sleep, joint mobility, and skin elasticity). Imbalance can be caused by
ignorance of health principles, environmental assaults, or improper diet. Treatment
consists of restoring the balance between the different humors through the use of herbal
medicine and accessory therapies, such as massage, moxibustion, acupuncture,
appropriate diet, religious rituals, and purification techniques.
TRAGER METHOD
The Trager method, developed by Milton Trager, a Chicago physician, is a technique of
movement reduction to aid individuals suffering from polio and other neuromuscular
disorders. The client, typically in 60- to 90-minute sessions, is instructed to relax all
conscious muscles and to allow the unconscious to choose natural, less restrictive body
movements, as guided by the practitioner. This method is particularly suitable to
individuals with back pain and severely restricted movement.
YOGA
Yoga (“yoking” or “union” in Sanskrit) is a comprehensive philosophical system with the
goal of preparing an individual to unite with the supreme being. The technique of early
yoga seeks to bring into balance all the disparate aspects of body, mind, and
personality. Early evidence of yoga practice dates back to 5,000 years ago in India, and
it has been practiced as a religion and health system ever since. The West grew familiar
with yoga through the practice of Hatha Yoga and an emphasis on the physical
collection of asanas (postures). The other aspects of the system, pranayama (breathing
exercises) and dhyana (meditation), and other forms of yoga are gaining adoption.
Recent studies in people with chronic low-back pain suggest that yoga poses may help reduce pain and improve
function. Other health benefits such as reducing heart rate and blood pressure and reducing anxiety and depression have
been reported.
According to the 2007 National Health Interview Survey (NHIS), yoga is the sixth most commonly used complementary
health practice among adults. More than 13 million adults practice yoga. There are many training programs for yoga
teachers throughout the country. These programs range from a few days to more than 2 years. Standards for teacher

training vary and certification differs depending on the style of yoga.
INTEGRATIVE PSYCHIATRY
A new type of psychiatry, called integrative psychiatry, selectively incorporates elements
of complementary and alternative medicine into practice methods. It emphasizes
treatment rather than diagnosis and views the patient holistically, taking into account
not only mind–body issues and interactions but spiritual values as well. Integrative
psychiatry is also concerned with prevention of illness, emphasized by having the
patient pay attention to lifestyle factors such as diet and exercise. Stress reduction
involves use of yoga, meditation, or other relaxation exercises. Attention is paid to stress
factors related to work and interpersonal relationships.
History
At one time, hypnosis and biofeedback were considered alternative therapies out of the mainstream of traditional
psychiatric practice. These modalities are now incorporated into standard psychiatric practice. Hypnosis, for example, is
used by psychiatrists for a variety of disorders, and dynamically oriented psychiatrists use hypnotherapy in their work to
enable a patient to recover feelings and memories that are repressed and not otherwise available for analysis. In the middle
of the 20th century, workers such as Paul Schilder, in his book The Image and Appearance of the Human Body, described
how one’s physiology and physiognomy could be influenced by psychological experiences during various developmental
stages. More recently, mainstream psychiatrists, such as Brian Weiss, have described their use of past life regression as a
therapeutic method and a means of accessing unconscious material.
Methods
Any of the complementary methods described in this section can be integrated into
standard psychotherapeutic practice, although some lend themselves better than others.
For example, during a Reiki treatment, a patient tends to be in a relaxed state and may
have feeling tones, images, or thoughts that would not ordinarily be discussed. In an
integrative therapy session, those mental and physical phenomena would be verbalized
and subject to analysis and interpretation. Similarly, a patient having past life
regression may have an elaborate narrative about his or her past life that would be
carefully examined by the integrative psychiatrist for its relevance to current life
experiences. Most integrative psychiatrists view past-life narratives as dynamic
representations of the patient’s unconscious wishes and fears; some view them as
representations of actual past lives. In either case, the material is used to help patients
gain greater insight and understanding of themselves in their current life.
Complementary and alternative techniques that involve body manipulation (e.g., craniosacral manipulation, massage, or
the Alexander technique) lend themselves to integrative psychiatric therapy. As mentioned, the image persons have of
their body and the way in which the body is held (e.g., stooped posture) are heavily influenced both by genetics and by life
experiences. Depressive facies, Veraguth’s folds, and other physiologic correlates of mood have long been recognized in the
psychiatric literature. The integrative psychiatrist uses this and other bodily markers as a way to gain access to previously

unrecognized neurotic conflict. Patients with somatic symptom disorders or dysmorphophobia are often helped by such
approaches, as are patients with eating disorders who have major body image distortions.
Any technique that involves manipulation of a body part can potentially elicit an image, thought, or feeling related to the
experience. A patient experiencing a back rub may have myriad associations to the experience that are examined in the
session. Some patients cannot tolerate being touched, a trait that is almost always related to some past traumatic
experience. Body manipulation can be geared to correcting abnormalities. In the Alexander technique, careful attention is
paid to posture and body alignment. As the corrective procedures unfold, patients may gain understanding and insight into
what caused the defective or inefficient postural attitude in the first place.
Finally, spiritual beliefs derived from Judeo-Christian, Native American, and Eastern
religious thought can be integrated into traditional psychotherapy. Workers such as Alan
Watts incorporated Zen Buddhism into Western psychotherapy more than 50 years ago.
Psychiatrists are working with Native American healers to help patients diminish
anxiety, especially regarding death and dying.
Other Issues
Ideally, the psychiatrist practicing integrative therapy should be schooled in one or
more of the complementary methods he or she plans to employ. In some cases, a
complementary practitioner may work in conjunction with the psychiatrist, especially if
the psychiatrist is not schooled in a particular method. At times, patients may be expert
in a field (e.g., yoga) and seek out the integrative psychiatrist to enlarge on their
experience. Integrative psychiatrists may use psychoactive herbs and homeopathic
medicinals alone or in conjunction with traditional psychopharmacologic agents,
mindful of the possibility of adverse drug–drug interactions.
Ethical Issues
The same standards that apply to traditional psychiatric practice and psychotherapy
apply to integrative psychiatry. Because some of the techniques involve a laying on of
hands or place the patient in a more dependent and vulnerable state than traditional
psychotherapy techniques, boundary issues must be carefully evaluated. Currently, no
standards of practice exist for this method other than those to which physicians have
always been held, including doing no harm. As in complementary and alternative
medicine generally, careful outcome studies are needed if this new amalgam is to prove
its worth.
REFERENCES
Barry DT, Beitel M, Cutter CJ, Joshi D, Falcioni J, Schottenfeld RS. Conventional and nonconventional pain treatment
utilization among opioid dependent individuals with pain seeking methadone maintenance treatment: A needs
assessment study. J Addict Med. 2010;4:81.
Bystritsky A, Hovav S, Sherbourne C, Stein MB, Rose RD, Campbell-Sills L, Golinelli D, Sullivan G, Craske MG, Roy-Byrne
PP. Use of complementary and alternative medicine in a large sample of anxiety patients. Psychosomatics. 2012;53:266.
Davidson JR, Crawford C, Ives JA, Jonas WB. Homeopathic treatments in psychiatry: A systematic review of randomized

placebo-controlled studies. J Clin Psychiatry. 2011;72(6):795.
Davies RD. Wading through the flood of nontraditional therapies. J Nerv Ment Dis. 2013;201(7):636–637.
Freeman MP, Fava M, Lake JH, Trivedi MH, Wisner KL, Mischoulon D. Complementary and alternative medicine in major
depressive disorder: The American Psychiatric Association task force report. J Clin Psychiatry. 2010;71:669.
Freeman MP, Mischoulon D, Tedeschini E, Goodness T, Cohen LS, Fava M, Papakostas GI. Complementary and alternative
medicine for major depressive disorder: A meta-analysis of patient characteristics, placebo-response rates, and treatment
outcomes relative to standard antidepressants. J Clin Psychiatry. 2010;71:682.
Lake JH. Nonconventional approaches in mental health care. In: Sadock BJ, Sadock VA, Ruiz P eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2592.
Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine in VA specialized PTSD treatment programs.
Psychiatr Serv. 2012;63:1134.
Little P, Stuart B, Stokes M, Nicholls C, Roberts L, Preece S, Sharp D. Alexander Technique and Supervised Physiotherapy
Exercises in Back Pain (ASPEN) Feasibility Trial. J Altern Complement Med . 2014;20(5):A60–A60.
Sarris J, Lake J, Hoenders R. Bipolar disorder and complementary medicine: Current evidence, safety issues, and clinical
considerations. J Altern Complement Med. 2011;17:881.
Serby MJ, Burns SJ, Roane DM. Treatment of memory loss with herbal remedies. Curr Treat Options Neurol.
2011;13(5):520.
Upchurch DM, Rainisch BK. A sociobehavioral model of use of complementary and alternative medicine providers,
products, and practices: Findings from the 2007 National Health Interview Survey. J Evidence Based Complement Altern
Med. 2013;18(2):100–107.
Vandergrift A. Use of complementary therapies in hospice and palliative care. Omega J Death Dying. 2013;67(1–2):227–
232.