COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR NURSING PRACTICE



COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR NURSING PRACTICE

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F o u r t h E d i t i o n

Karen Lee Fontaine Professor, College of Nursing, Purdue University Calumet,

Hammond, Indiana

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Many of the designations by manufacturers and seller to distinguish their products are claimed as trademarks. Where those designations appear in this book, and the publisher was aware of a trademark claim, the designations have been printed in initial caps or all caps. Library of Congress Cataloging-in-Publication Data Fontaine, Karen Lee, 1943–author. [Complementary & alternative therapies for nursing practice] Complementary and alternative therapies for nursing practice / Karen Lee Fontaine, professor, College of Nursing, Purdue University Calumet, Hammond, Indiana.—Fourth edition. pages cm Revision of: Complementary & alternative therapies for nursing practice.—3rd ed.—©2009. Includes bibliographical references and index. ISBN-13: 978-0-13-334650-3 ISBN-10: 0-13-334650-1 1. Nursing. 2. Alternative medicine. I. Title. RT42.F64 2015 610.73—dc23 2013045244

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ISBN-13: 978-0-13-334650-3 ISBN-10: 0-13-334650-1

Dedication

This book is dedicated to Peggy Gerard, Dean, and Kathy Nix, Undergraduate Coordinator, College of Nursing,

Purdue University Calumet for all their support and enthusiasm as complementary and alternative medicine

was integrated into the curriculum.

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CONTENTS

Preface ix

Acknowledgments xiii

Reviewers xiv

UNIT 1 Healing Practices: Complementary and Alternative Therapies for Nurses 1

Chapter 1 Integrative Healing 3

Chapter 2 Basic Concepts Guiding Alternative Therapies 19

Chapter 3 The Role of Evidence-Based Health Care in Complementary and Alternative Therapies 37

UNIT 2 Systematized Health Care Practices 47 Chapter 4 Traditional Chinese Medicine 49

Chapter 5 Ayurvedic Medicine 70

Chapter 6 Native American Healing and Curanderismo 90

UNIT 3 Botanical Healing 111 Chapter 7 Herbs and Nutritional Supplements 113

Chapter 8 Aromatherapy 133

Chapter 9 Homeopathy 149

Chapter 10 Naturopathy 162

UNIT 4 Manual Healing Methods 169 Chapter 11 Chiropractic 171

Chapter 12 Massage 183

Chapter 13 Pressure Point Therapies 202

Chapter 14 Hand-Mediated Biofield Therapies 217

Chapter 15 Combined Physical and Biofield Therapy 230

UNIT 5 Mind–Body Techniques 239 Chapter 16 Yoga 241

Chapter 17 Meditation 256

Chapter 18 Hypnotherapy and Guided Imagery 269

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Chapter 19 Dreamwork 286

Chapter 20 Intuition 301

Chapter 21 Music as a Therapeutic Tool 311

Chapter 22 Biofeedback 320

Chapter 23 Movement-Oriented Therapies 327

UNIT 6 Spiritual Therapies 339 Chapter 24 Shamans 341

Chapter 25 Faith and Prayer 352

UNIT 7 Other Therapies 367 Chapter 26 Bioelectromagnetics 369

Chapter 27 Animal-Assisted Therapy 378

Appendix Alternative Therapies for Common Health Problems 393

Index 417

vi Contents

TRY THIS

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Energy 34 Massage 88 Positive Thoughts 107 Herbal Remedies 128 Soothing Potions 144 Top 10 Remedies 157 Pet Remedies 158 Visualization 167 Energy Boosters 181 Massage 199 Foot Massage 213 Experience Your Energy Field 227 Emotional First Aid 235 Redirecting the Flow of Energy 236 Heart Breathing 252 Loving–Kindness Meditation 266

Renovating Your Day 283 Shrinking Antagonistic

Forces 283 Improving Dream Recall 298 Positive Affirmations 308 Practice Intuition 309 Music for Stress Reduction 316 Mind Control of Muscular

Strength 324 Feel Your Qi 335 Wave Hands Like Clouds (Water

T’ai Chi) 336 Shamanic Journey 349 Absorbing Earth Energy 375 Going to the Mountains 376 Interacting with Your Pet 389

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PREFACE

The profession of nursing has advanced beyond the Western biomedical model to incorporate many healing tools used by our Asian, Latino, Native American, African, and European ancestors. We are rapidly rediscovering that these ancient principles and practices have significant therapeutic value. Some see this movement as a “return to our roots.” Others believe it is a response to runaway health care costs, growing dissatisfaction with high-tech medicine, and increasing concern over the adverse effects and misuse of med- ications. The growth of consumer empowerment also fuels this movement.

As nurses, how do you begin to assimilate thousands of years of healing knowledge? How do you begin this journey of integrating practices into your own lives? In your professional practice, how do you model healthful living? How do you help clients choose their own healing journeys? How do you break down the barriers between conventional and complementary and alter- native medicine (CAM)? Learning about CAM practices, like anything else, is a slow process involving a steady accumulation of bits of information and skills that eventually form a coherent pattern called knowledge. Although it is possible to learn a great deal about healing practices from reading, thinking, and asking questions, you must in the long run learn about healing through participation. Without hands-on experience, you can be a good student, but you can never be a great nursing practitioner of the healing arts. I trust this book will be one step in a lifelong exploration of and experiences with healing practices.

Consumers do not wish to abandon conventional medicine, but they do want to have a range of options available to them including herbs and nutri- tional supplements, manual healing methods, mind–body techniques, and spiritual approaches. Some CAM practices, such as exercise, proper nutrition, meditation, and massage, promote health and prevent disease. Others, such as herbs and homeopathic remedies, address specific illnesses. Many other CAM practices do both. The rise of chronic disease rates in Western society is increasingly motivating consumers to consider self-care approaches. As recently as the 1950s, only 30% of all disease was chronic, and curable—largely infectious—diseases dominated, for which medical interventions were both appropriate and effective. Now, 80% of all disease is chronic. Western medi- cine, with its focus on acute disorders, trauma, and surgery, is considered to be the best high-tech medical care in the world. Unfortunately, it is not responding adequately to the current epidemic of chronic illnesses.

Ethnocentrism, the assumption that one’s own cultural or ethnic group is superior to others, has often prevented Western health care practitioners from  learning “new” ways to promote health and prevent chronic illness. With consumer demand for a broader range of options, we must open our minds to the idea that other cultures and countries have valid ways of preventing and curing diseases that could be good for Western societies.

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Although the information may be new to us, many of these traditions are hun- dreds or even thousands of years old and have long been part of the medical mainstream in other cultures.

I have titled this book Complementary and Alternative Therapies for Nursing Practice because I believe we need to merge CAM approaches with Western- based nursing practices. I have tried to provide enough information about alternative therapies to help guide practice decisions. This text, as an over- view and practical guide for nurses, does not pretend to be an exhaustive col- lection of all the facts and related research in CAM, nor does it offer meticulous documentation for all claims made by the various therapies. The goal of the text is to motivate you, the reader, to explore CAM approaches, increase your knowledge about factors that contribute to health and illness, and expand your professional practice appropriately.

It is possible to classify alternative practices in any number of ways. I  have chosen to present more than 40 approaches categorized into seven units. In Unit 1, I introduce the philosophical approaches to both Western bio- medicine and complementary and alternative medicine, as well as evidence- based health care in CAM therapies. Concepts common to many approaches are defined and discussed, such as energy, breath, spirituality, and healing. Unit 2 presents a number of health care practices that have been systematized throughout the centuries worldwide. These typically include an entire set of values, attitudes, and beliefs that generate a philosophy of life, not simply a group of remedies. The chapters cover Traditional Chinese Medicine, Ayurvedic medicine, and Native American healing and curanderismo. Unit 3 comprises chapters relating to botanical healings used by 80% of the world’s population. Chapters cover herbs and nutritional supplements, aromather- apy, homeopathy, and naturopathy. Unit 4 presents manual healing methods—some from ancient times and some developed in the latter half of the 20th century. The chapters discuss chiropractic, massage, pressure point therapies, hand-mediated biofield therapies, and combined physical and biofield therapies. The chapters in Unit 5 cover types of mind–body tech- niques for healing and include yoga, meditation, hypnotherapy and guided imagery, dreams, intuition, music as a therapeutic tool, biofeedback, and movement-oriented therapies. Unit 6 presents two spiritual approaches to therapeutic intervention: working with shamans and the use of faith and prayer. Unit 7 includes two chapters on miscellaneous practices: bioelectro- magnetics and animal-assisted therapy.

The appendix provides specific information on managing the types of common health problems that respond well to alternative therapies and life- style modification.

This book does not recommend treatments but, rather, describes alterna- tive practices, their backgrounds and claims, preparation of practitioners, con- cepts, diagnostic methods, treatments, and evidence from research studies. “Integrated Nursing Practice” is an important section of every chapter designed to help you, the nurse, expand your practice by providing you with specific information and suggestions. “Try This” features throughout the

Preface xi

chapters provide you with examples of how you can integrate these practices into your own life and also give you ideas for client education. A list of resources is also included in the chapters.

In this new fourth edition, I have continued the “Considering the Evi- dence” feature with all new research relating to the chapter topic. Eight of these features present a systematic review of randomized control trials, while two present primary research . “Considering the Evidence” boxes not only present current studies but also are designed to further critical thinking and perhaps inspire you to design studies to answer your own questions. Each study answers the following questions: What was this study about? How was the study done? What were the results of the study? What additional ques- tions might I have? And how can I use this study?

Changes to the fourth edition:

• Updated all research sections and greatly increased the number of sys- tematic reviews of randomized controlled trials

• Changed the focus of the chapter on music from music therapy to music as a therapeutic tool to broaden the focus for the practicing nurse

• Expanded the lists of resources to include more international resources • Deleted polarity therapy and crystal healing for lack of research and

evidence • Added sections on

• Music thanatology • Aromachology • Restorative yoga • Latest technology for biofeedback self-tracking

• Expanded cautions for pregnant women and young children

Nurses are in a unique position to take a leadership role in integrating alternative healing methods into Western health care systems. Nurses have historically used their hands, heart, and head in more natural and traditional healing interactions. By virtue of their education and relationships with clients, nurses can help consumers assert their right to choose their own healing journey and the quality of their life and death experiences.

My dear friend and colleague has written the following letter to you about her lived experience uniting biomedicine with CAM approaches.

Dear Reader,

It is both a pleasurable and enlightening experience for me to contribute to your text, Complementary and Alternative Therapies for Nursing Practice , through the development of the “Considering the Evidence” feature. I approach this work hopeful that it may inspire you, the reader, to engage in critical thinking, assist in your understanding of the significance of research to inform your  nursing practice and, perhaps, propose studies to answer your own researchable questions. However, with this edition, I have asked Karen Lee Fontaine to allow me the privilege of sharing with you my personal journey with complementary and alternative therapies. I hope I can thus inspire you

xii Preface

to reflect on and embrace the important content of this text. After learning of my diagnosis of bilateral breast cancer, I actively participated in myriad Western medicine therapies while integrating complementary and alternative therapies. Although the chemotherapy experience was both mentally and physically challenging, I considered the massage therapist as part of “my team,” and I looked forward to this dimension of comfort during this challenging time. Engaging in yoga enhanced “restful sleep” as a response to the overwhelming fatigue that frequently accompanies Western therapies such as chemotherapy and radiation and just the daily awareness that “you have cancer.” Acupressure relieved uncomfortable postoperative symptoms. T’ai chi continues to be an opportunity to focus on myself and reflect on the positives associated with this journey. Reiki and reflexology is my specified “me time.” As I engage in the associated deep breathing exercises, it stimu- lates my mind to drift to affirmative thoughts and so many positive memories from my life. For me, “living with cancer “is more of an “inconvenience” in my life’s journey. I can appreciate this may not be the experience for every- one, but I can personally assure you that integrating many of the therapies discussed in this text allows me a “quality of life” while simultaneously working with conventional medicine’s goal for a “quantity of life.” With the combination of both, I feel I have been given the power to survive!

I hope my story gives you a sense of hope and empowerment in caring for persons both professionally and personally who are embarking on a stren- uous journey related to their health. I can recall in my nursing practice experi- encing feelings of helplessness when caring for persons undergoing complex t reatments with so many uncertainties related to their health outcome. I can attest that your understanding, knowledge, and support in the implementa- tion of complementary and alternative therapies can significantly affect their “quality of life” and allow you the privilege of making a difference in their health journey.

Warm regards, Dolores M. Huffman, RN, PhD

ACKNOWLEDGMENTS

I would like to express thanks to the many people who have inspired, com- mented on, and in other ways assisted in the writing and publication of the fourth edition of this book. On the publishing and production side at Pearson, I was most fortunate to have an exceptional team of editors and support staff. My thanks go to Julie Alexander, Publisher, and Erin Rafferty, Program Manager, who provided support and guidance throughout this project. Maria Reyes, Project Manager, kept this book on schedule and dedicated her time and skill to its completion.

I would like to thank all those who reviewed this text and provided sug- gestions and guidance for the fourth edition.

Karen Lee Fontaine Purdue University Calumet

Contributors Dolores M. Huffman, RN, PhD

Associate Professor College of Nursing Purdue University Calumet Director of Transfer: Northwest Indiana Center for Evidence Based Practice: A Joanna Briggs Institute Collaborating Centre Hammond, IN

Sheila O’Brien Lewis, BScN, MHSc Associate Lecturer Department of Nursing, Faculty of Health York University Toronto, ON, Canada

Leslie Rittenmeyer, PsyD, CNS, RN Professor Collegel of Nursing Purdue University Calumet Research Associate: Northwest Indiana Center for Evidence Based Practice: A Joanna Briggs Institute Collaborating Centre Hammond, IN

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Dot E. Baker, Ed.D., MSN., BSN.

Professor Wilmington University Georgetown, DE

Debra Rose Wilson, PhD, RN, IBCLC, AHN-BC, CHT

Professor Middle Tennessee State University Murfreesboro, TN Walden University Minneapolis, MN

Lynn Rew, Ed.D, RN, AHN- BC, FAAN

Professor The University of Texas at Austin Austin, TX

Sheila Stroman, PhD, RN Assistant Professor University of Central Arkansas Conway, AR

Susan Cohen, DSN, APRN, FAAN

Associate Professor University of Pittsburgh Pittsburgh, PA

Kimberly Arcoleo, PhD, MPH Professor

Ohio State University Columbus, OH

Lori Edwards, DrPH, RN, APRN, BC

Instructor Johns Hopkins University School of Nursing Baltimore, MD

Rose Mary Gee, PhD, RN Assistant Professor Georgia Southern University Statesboro, GA

Sue Hritz, MEd, PC, RN, CHT, PHN

Lecturer Kent State University Kent, OH

Gretchen Ezaki, MSN, RN Instructor Fresno City College Fresno, CA

Kathleen Murphy, PhD, MMT Assistant Professor University of Evansville Evansville, IN

Vicki Moran, MSN/MPH, RN Instructor Saint Louis University St. Louis, MO

REVIEWERS

Healing Practices: Complementary and Alternative

Therapies for Nurses

Happiness, grief, gaiety, sadness are by nature contagious. Bring your health and your strength to the weak and sickly,

and so you will be of use to them. Give them, not your weakness, but your energy, so you will revive

and lift them up.

Henri-Frederic Amiel

1 U N I T

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1 Integrative Healing

Time is generally the best doctor.

Ovid

Most of nursing education in the United States, Canada, the United Kingdom, Europe, and Australia—often referred to as Western countries—has been under the umbrella of biomedicine, and thus Western nurses are familiar and comfortable with its beliefs, theories, practices, strengths, and limitations. Fewer nurses have studied alternative medical theories and practices and as a result may lack information or even harbor misinformation about these healing practices. Unlike the profession of medicine in general, however, the profession of nursing has traditionally embraced two basic concepts embodied by alternative therapies—holism and humanism—in its approach with clients. Nurses have long believed that healing and caring must be approached holistically and that biological, psychologi- cal, emotional, spiritual, and environmental aspects of health and illness are equally important. This humanistic perspective includes propositions such as the mind and body are indivisible, people have the power to solve their own problems, people are responsible for the patterns of their lives, and well-being is a com- bination of personal satisfaction and contributions to the larger community. This theoretical basis gives nurses a solid foot in each camp and places them in the unique position to help create a bridge between biomedicine and alternative medicine ( Buchan, Shakeel, Trinidade, Buchan, & Al-See, 2012 ; Halcon, Chlan, Kreitzer, & Leonard, 2003 ; Peplau, 1952 ; Quinn, 2000 ; Shreffler- Grant, Hill, Weinert, Nichols, & Ide, 2007 ).

BACKGROUND

Many interesting exchanges around the world have debated the appropriate terminology of various healing practices. Some people

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4 Unit 1 • Healing Practices

become vested in the use of particular terms and have difficulty getting past the language limitations. For example, many people view the term alternative medi- cine as being too narrow or misleading and are concerned that the term lacks a full understanding of traditional healing practices. It would be helpful for a common language to be developed without these constraints. As language evolves, the terms used today may be quite different from those used 20 years from now. For consistency, the terms chosen for this text are conventional med- icine or biomedicine to describe Western medical practices, and the terms alternative medicine or complementary medicine to describe other healing practices. Traditional medicine refers to indigenous medical systems such as Traditional Chinese Medicine (TCM). There are no universally accepted terms. The following list presents commonly used words and their counterparts:

Mainstream Complementary/Alternative Modern Ancient Western Eastern Allopathic Homeopathic; holistic Conventional Unconventional Orthodox Traditional Biomedicine Natural medicine Scientific Indigenous healing methods

The line between conventional and complementary and alternative medicine is imprecise and frequently changing. For example, is the use of megavitamins or diet regimens to treat disease considered medicine, a life- style change, or both? Can having one’s pain lessened by massage be consid- ered a medical therapy? How should spiritual healing and prayer—some of the oldest, most widely used, and least studied traditional approaches—be classified? Although the terms alternative and complementary are frequently used, in some instances they represent the primary treatment modality for an individual. Thus, conventional medicine sometimes assumes a secondary role and becomes a complement to the primary treatment modality.

Conventional Medicine

Biomedical or Western medicine is only about 200 years old. It was founded on the philosophical beliefs of René Descartes (1596–1650)—that the mind and body are separate—and on Sir Isaac Newton’s (1642–1727) principles of physics—that the universe is like a large mechanical clock in which every- thing operates in a linear, sequential form. This mechanistic perspective of medicine views the human body as a series of body parts. It is a reductionist approach that converts the person into increasingly smaller components: sys- tems, organs, cells, and biochemicals. People are reduced to patients, patients are reduced to bodies, and bodies are reduced to machines. Health is viewed as the absence of disease or, in other words, nothing is broken at present, and sick care is focused on the symptoms of dysfunction. Physicians are trained to

Chapter 1 • Integrative Healing 5

fix or repair broken parts through the use of drugs, radiation, surgery, or replacement of body parts. The approach is aggressive and militant— physicians are in a war against disease, with a take-no-prisoners attitude. Both consumers and practitioners of biomedicine believe it is better to

• do something rather than wait and see whether the body’s natural pro- cesses resolve the problem.

• attack the disease directly by medication or surgery rather than try to build up the person’s resistance and ability to overcome the disease.

Biomedicine views the person primarily as a physical body, with the mind and spirit being separate and secondary or, at times, even irrelevant. It is powerful medicine in that it has virtually eliminated some infectious dis- eases, such as smallpox and polio. It is based on science and technology, per- sonifying a highly industrialized society. As a “rescue” medicine, the biomedical approach is appropriate. It is highly effective in emergencies, trau- matic injuries, bacterial infections, and some highly sophisticated surgeries. In these cases, treatment is fast, aggressive, and goal oriented, with the responsi- bility for cure falling on the practitioner.

The priority of intervention is on opposing and suppressing the symp- toms of illness. This approach is evidenced in many medications with prefixes such as an or anti , as in analgesics, anesthetics, anti-inflammatories, and anti- pyretics. Biomedicine characterizes each disease in terms of its mechanisms of action, based on the belief that most individuals are affected in the same way. Thus, treatment is basically the same for most people. Because conventional medicine is preoccupied with parts and symptoms and not with whole work- ing systems of matter, energy, thoughts, and feelings, it does not do well with long-term systemic illnesses such as arthritis, heart disease, and hypertension. Despite higher per capita spending on health care in the United States than in all other nations, in 2013, U.S. life expectancy ranked only 37th, and the infant mortality rate ranked 33rd among the nations studied ( World Health Rankings, 2013 ). The United States has failed to be a world leader in providing a healthier quality of life.

Complementary and Alternative Medicine

Complementary and alternative medicine (CAM) is an umbrella term for as many as 1,800 therapies practiced worldwide. Many forms have been handed down over thousands of years, both orally and in written records. These ther- apies are based on the medical systems of ancient peoples, including Egyp- tians, Chinese, Asian Indians, Greeks, and Native Americans. Others, such as osteopathy and naturopathy, evolved in the United States during the past two centuries. Still others, such as some of the mind–body and bioelectromagnetic approaches, are on the frontier of scientific knowledge and understanding. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) defines CAM therapies as a broad range of healing philosophies, approaches, and therapies that conventional

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medicine does not commonly use, accept, study, understand, or make avail- able. NCCAM also defines complementary therapies as those used with con- ventional medicine and alternative therapies as those used instead of conventional medicine (National Center for Complementary and Alternative Medicine, 2012).

Although they represent diverse approaches, CAM therapies share cer- tain attributes. They are based on the paradigm of whole systems and the belief that people are more than physical bodies with fixable and replaceable parts. Rather, mental, emotional, spiritual, and environmental components of well- being are considered to play crucial and equal roles in a person’s state of health. Interventions are individualized within the entire context of a person’s life ( Duncan, Liechty, Miller, Chinoy, & Ricciardi, 2011 ). Even Hippocrates, the father of Western medicine, espoused a holistic orientation when he taught physicians to observe their patients’ life circumstances, emotional state, stresses, environment, inherited constitution, and their subjective experience of an ill- ness. Socrates agreed, declaring, “Curing the soul; that is the first thing.” In alternative medicine, symptoms are believed to be an expression of the body’s wisdom as it reacts to cure its own imbalance or disease. Other threads or con- cepts common to most forms of alternative medicine include the following:

• An internal self-healing process exists within each person. • People are responsible for making their own decisions regarding their

health care. • Nature, time, and patience are the great healers.

When Albert Einstein (1879–1955) introduced his theory of relativity in 1905, our way of viewing the universe changed dramatically. Einstein said that mass and energy are equivalent and interconvertible, and all matter is connected at the subatomic level. No single entity could be affected without all its connecting parts being affected. In this view, the universe is not a giant clock but a living web. The human body is animated by an integrated energy called the life force . The life force sustains the physical body but is also a spiritual entity that is linked to a higher being or infinite source of energy. When the life force flows freely throughout the body, a person experiences optimal health and vitality. When the life force is blocked or weakened, organs, tissues, and cells are deprived of the energy they need to function at their full potential, and illness or disease results.

Alternative medicine is especially effective for people with chronic, debilitating illnesses for which conventional medicine has few, if any, answers. It has much to offer in the arena of health promotion and disease prevention. As costs of conventional medicine increase and people continue to suffer from chronic illnesses and degenerative diseases, alternative medicine is moving closer to the mainstream. A growing number of complementary and alterna- tive therapies are eligible for reimbursement by third-party payers in the United States. The most commonly reimbursed treatments are chiropractic, biofeedback, acupuncture, hypnotherapy, and naturopathy. Box 1.1 provides an overview of the paradigms of conventional and alternative medicine.

Chapter 1 • Integrative Healing 7

Integrative Medicine

Integrative medicine embodies both conventional and complementary and alternative medicine, making use of the best available evidence of all three approaches to healing. It is a multidisciplinary, collaborative, holistic approach that encompasses mind, body, and spirit. It stresses the relationship between the client and the practitioner as well as the human capacity for healing. Inte- grative practitioners believe that clients have the right to make informed choices about their health care options. The focus is on “using the least inva- sive, least toxic, and least costly methods to help facilitate health” ( Willison, 2006 , p. 255 ). The goal of integrative medicine is to find new solutions to pre- vention and treatment of health care problems.

Dr. Andrew Weil has been the driving force for integrative medicine in the United States and hopes to reform the entire medical delivery system by changing the way we look at health and disease and by modifying the educa- tion of physicians. His program at the Arizona Center for Integrative Medi- cine at the University of Arizona College of Medicine was the first to adopt this new curriculum. Nursing must also be open to change to meet the goal of true integrative care. In 2008, the World Health Organization (WHO) stressed the importance of integrative medicine and advocated the inclusion of com- plementary and alternative therapies in biomedical health care education ( Quartey, Ma, Chung, & Griffiths, 2012 ).

BOX 1.1

Paradigms of Medicine

View Conventional Medicine Alternative Medicine

Mind/body/spirit are separate are one The body is a machine a living microcosm of the universe Disease results parts break energy/life force becomes unbalanced when Symptoms dysfunctional and need communicators about the state of the to be fixed whole person Role of medicine to combat disease to restore mind/body/spirit harmony Approach treat and suppress search for patterns of symptoms disharmony or imbalance Focuses on parts/matter whole/energy Treatments attempt to “fix” broken support self-healing; personalized for parts; specific to disease the individual Primary drugs, surgery, diet, exercise, herbs, stress interventions radiation management, social support System sick care health care

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ASSUMPTIONS

In understanding conventional and alternative medicine, it is helpful to study the assumptions basic to their theories, practices, and research. These assump- tions include the origin of disease, the meaning of health, the curative process, and health promotion.

Origin of Disease

Biomedicine and alternative medicine have widely divergent assumptions regarding the origin of disease. Biomedicine was shaped by the observations that bacteria were responsible for producing disease and pathologic damage and that antitoxins and vaccines could improve a person’s ability to ward off the effects of pathogens. Armed with this knowledge, physicians began to conquer a large number of devastating infectious diseases. As the science developed, physicians came to believe that germs and genes caused disease, and once the offending pathogen, metabolic error, or chemical imbalance was found, all diseases would eventually yield to the appropriate vaccine, antibiotic, or chemical compound.

Conventional medicine has also been influenced by Darwin’s concept of survival of the fittest; that is, all life is a constant struggle, and only the most successful competitors survive. Applied to medicine, this notion means that humans live under constant attack by the thousands of microorganisms that, in the Western view, cause most diseases. People must defend themselves and counterattack with treatments that kill the enemy. Based on this assumption, symptoms are regarded as harmful manifestations and should be suppressed. For example, a headache is an annoyance that should be eliminated, and a fever should be reduced with the use of medications.

Complementary and alternative medicine is based on the belief of a life force or energy that flows through each person and sustains life. Balance refers to harmony among organs in the body and among body systems, and in rela- tionships to other individuals, society, and the environment. A balanced organ- ism presents a strong defense against external insults such as bacteria, viruses, and trauma. When the life force or energy is blocked or weakened, the vitality of organs and tissues is reduced, oxygen is diminished, waste products accu- mulate, and organs and tissues degenerate. Symptoms are the body’s way of communicating that the life force has been blocked or weakened, resulting in a compromised immune system. Disease is not necessarily a surprise encounter with a bacterium or a virus, since these are ever present, but rather the end result of a series of events that began with a disruption of the life force. Based on this assumption, symptoms are not suppressed unless they endanger life, such as a headache from an aneurysm or a body temperature above 105°F. Rather, symptoms are cooperated with because they express the body’s wis- dom as it reacts to cure its own disease. For example, a headache is a signal that one’s whole system needs realignment, and a fever may be the result of the breakdown of bacterial proteins or toxins. When symptoms are suppressed, they are not resolved but merely held in abeyance, gathering energy for renewed expression as soon as the outside, counteractive force is removed.

Chapter 1 • Integrative Healing 9

Meaning of Health

If you were to ask a healer from the Chinese, Indian, or Native American tra- ditions about the meaning of health, you would receive answers very differ- ent from those given by a Western physician. The biomedical view of health, in the past, was often described as the absence of disease or other abnormal conditions. That definition has been expanded to include the view that health is not a static condition; the body constantly changes and adapts to both inter- nal and external environmental challenges. The majority of conventional medical practitioners would define health as a state of well-being. They may disagree, however, about who determines well-being—the health profes- sional or the individual. With some exceptions, wellness and health promo- tion have, for the most part, been left to the initiative of the individual.

Those practicing complementary and alternative medicine (CAM) describe health as a condition of wholeness, balance, and harmony of the body, mind, emotions, and spirit. Health is not a concrete goal to be achieved; rather, it is a lifelong process that represents growth toward potential, an inner feeling of aliveness. Physical aspects include optimal functioning of all body systems. Emotional aspects include the ability to feel and express the entire range of human emotions. Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. Environmental aspects include physical, biologic, economic, social, and political conditions. Spiritual aspects involve self, others, and society. Self-components are the development of moral values and finding a meaningful purpose in life. Spiritual factors relating to others include the search for meaning through relationships and the feeling of connectedness with others and with an external power often identified as God or the divine source. Societal aspects of spiritual health can be understood as a common humanity and a belief in the fundamental sacredness and unity of all life. These beliefs motivate people toward truth and a sense of fairness and justice to all members of society.

Curative Process

The curative process is another area of divergent viewpoints. Conventional medicine promotes the view that external treatments—drugs, surgery, radia- tion—cure people, and practitioners are trained to fix or repair broken parts. The focus is on the disease process or abnormal condition. Alternative practi- tioners look at conditions that block the life force and keep it from flowing freely through the body. Healing occurs when balance and harmony are restored. The focus is on the health potential of the person rather than the dis- ease problem. The cure model and the healing model are presented with greater detail in Chapter 2 .

Health Promotion

Conventional and complementary and alternative medical systems have somewhat different foci on promotion of health. The thrust of conventional

10 Unit 1 • Healing Practices

medicine is disease prevention. Consumers are taught how to decrease their risk of cancer, cardiac disorders, obesity, and other life-threatening diseases that kill most people prematurely in Western society. Although these behav- iors are important, disease prevention is only one piece of health promotion. From the complementary and alternative perspective, health promotion is a lifelong process that focuses on optimal development of people’s physical, emotional, mental, spiritual, and environmental selves. An individual’s worldviews, values, lifestyles, and health beliefs are considered to be of criti- cal importance. Consumers are encouraged to adopt healthier lifestyles, to accept increased responsibility for their own well-being, and through greater self-reliance, to learn how to handle common health problems on their own. As the Healthy People 2020 report illustrates ( U.S. Department of Health and Human Services, 2010a ), the health care delivery system of the future must make use of all approaches that effectively promote optimal health using best available evidence and knowledge. Box 1.2 describes the strategic plan 2011– 2015 of NCCAM. In the United States, the Patient Protection and Affordable Care Act, a federal statute, was signed into law by President Barack Obama in 2010. One goal of this act is to provide affordable health care for every American. ( U.S. Department of Health and Human Services, 2010b .)

RESEARCH

Scientific beliefs rest not just on facts but on paradigms (broad views of how these facts are related and organized). Differences in views among groups of nursing and medical researchers are a reflection of the different scientific paradigms—quantitative and qualitative research. Although each method results in a different type of knowledge, both provide information to research- ers and consumers. Evidence-based practice is covered in Chapter 3 .

Quantitative research represents the principles of the Western scientific method, which include formulating and testing hypotheses and then rejecting

BOX 1.2

NCCAM Strategic Plan 2011–2015

• Advance the science and practice of symptom management of CAM approaches. • Develop effective, practical, personalized strategies for promoting health and

well-being. • Enable better evidence-based decision making regarding CAM use and its integra-

tion into health care and health promotion.

Source: National Center for Complementary and Alternative Medicine ( 2011 ).

Chapter 1 • Integrative Healing 11

or accepting the hypotheses. Every question is reduced to the smallest possi- ble part. Results can be replicated and generalized, and outcomes can be pre- dicted and controlled. Quantitative research is said to be objective in that the observer is separate from what is being observed. Another part of this objec- tive paradigm is that all information can be derived from physically measur- able data. This type of research has been extremely effective for isolating causative factors of disease and developing cures. However, it cannot explain the whole person as an integrated unit.

Qualitative research seeks to understand events in context-specific set- tings. It studies the context and meaning of interactive variables as they form patterns reflective of the whole. Researchers observe, document, analyze, and qualify the interactive relationship of variables. In the science of physics, it is believed that objectivity is ultimately not possible. The Heisenberg uncer- tainty principle states that the act of observing phenomena necessarily influ- ences the behavior of the phenomena being observed. Another part of the paradigm relates to the belief that interactions between living organisms and environments are transactional, multidirectional, and synergistic in ways that cannot be reduced. This holistic approach (the whole is greater than the sum of the parts) is basic to qualitative research.

Practitioners of conventional medicine believe that procedures and sub- stances must pass blinded randomized controlled trials (RCTs) to be proven effective. As a testing method, an RCT examines a single procedure or sub- stance in isolated, controlled conditions and measures results against another existing therapy or the best available treatment. This approach is based on the assumption that single factors cause and reverse illness, and these factors can be studied alone and out of context. In contrast, practitioners of complemen- tary and alternative medicine (CAM) believe that no single factor causes any- thing, nor can a magic substance single-handedly reverse illness. Multiple factors contribute to illness, and multiple interventions work together to pro- mote healing. RCTs are incapable of reconciling this degree of complexity and variation.

Although major complementary and alternative medical systems may not have been subjected to a great deal of quantitative research, they are gen- erally not experimental therapies. They rely on well-developed clinical obser- vational skills and experience that is guided by their explanatory models. Likewise, many biomedical practices are guided by observation and experi- ence and have not been tested quantitatively. New medicines must have rigor- ous proof of efficacy and safety before clinical use. Tests, procedures, and treatments, however, are not similarly constrained. Western physicians, like alternative practitioners, use the same well-developed clinical observational skills and experience, guided by their explanatory biomedical model. Some of these discrepancies are disappearing, and the emphasis is now on evidence- based practice and the rapid growth of CAM research.

This text does not offer meticulous documentation for all claims that are made by the various therapies. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) has

12 Unit 1 • Healing Practices

been mandated to explore complementary and alternative healing practices in the context of rigorous science, to train researchers, and to provide the public with authoritative information. NCCAM has established 16 research centers to explore the safety and efficacy of a wide range of therapies. In addition, NCCAM funds hundreds of research projects and grants every year. The NIH Office of Dietary Supplements is conducting scientific studies regarding the role of dietary supplements in the improvement of health care. As a result of these and other international efforts, the evidence base for alternative thera- pies has grown significantly.

The results of scientific studies can be accessed at two websites. NCCAM and the National Library of Medicine (NLM) have partnered to create CAM on PubMed ( nccam.nih.gov/research/camonpubmed/ ). This site provides access to citations from the MEDLINE database and links to many full-text articles at journal websites. The Cochrane Library ( www.update-software. com/cochrane/ ), an international effort, consists of a regularly updated col- lection of evidence-based medicine databases, including the Cochrane Data- base of Systematic Reviews. This site lists thousands of randomized trials for various alternative therapies. This information is extremely helpful for both consumers and providers of health care. The reader is advised to access these sites for information regarding the latest research results. Chapter 3 covers evidence-based nursing practice in more detail.

CONSUMERS

Many Americans are looking beyond conventional medicine for relief from illness and improvement of health. According to a number of random sur- veys, two thirds of adults in the United States use one or more types of alter- native medicine, often to treat a chronic medical condition such as one of those listed in Box 1.3 . Most of these consumers fail to discuss the use of alter- native therapies with their primary conventional practitioner, even though the vast majority of people use both approaches simultaneously. In general, alternative therapies are more commonly used by women than by men, as well as by people with higher levels of education. Latinos have a higher rate of use (50%–90%) compared with European Americans ( Buchan et al., 2012 ; Lachance et al., 2009 ; Ortiz, Shields, Clauson, & Clay, 2007 ; Sirois, 2008 ). A random study of 1,261 adults in Australia found that 61.7% of the individuals had used self-prescribed CAM or visited a CAM practitioner. A significant proportion of the sample did not seek advice from their primary care physi- cian before using CAM ( Thomson, Jones, Evans, & Leslie, 2012 ).

The mainstream medical community can no longer ignore alternative therapies. The public interest is extensive and growing. One has only to look at the proliferation of popular health books, health food stores, and clinics offering healing therapies to realize that this interest cannot be dismissed. In March 2000, President Clinton ordered the establishment of the White House Commission on Complementary and Alternative Medicine Policy in an attempt to integrate conventional and alternative medicine. The mission of

Chapter 1 • Integrative Healing 13

the advisory committee was to make legislative and administrative recom- mendations for the education and training of health care professionals and to make suggestions for access and delivery of health care.

What are consumers seeking from alternative medicine? Some have the same goal for both types of medicine, such as control of chronic pain with pain medications and acupuncture. Other consumers may have a different expectation for each approach, such as seeing a conventional practitioner for antibiotics to eradicate an infection and using an alternative practitioner to improve natural immunity through a healthy lifestyle. A person receiving chemotherapy may use meditation and visualization to control the side effects of the chemotherapeutic agents. People who combine conventional and alter- native therapies are making therapeutic choices on their own and assuming responsibility for their own health.

It is important for nurses to understand the reasons consumers choose alternative practitioners. Some utilize alternative healers because of financial, geographic, and cultural barriers to biomedical care. Many turn to alternative healers for a sense of hope, control, personal attention, physical contact, and regard for the whole person that seems to be overlooked in conventional med- icine. Some of the common reasons for seeking alternative practitioners are listed in Box 1.4 .

It may be difficult for consumers to figure out how and where to get the best health care. At times it may be problematic to find reliable information to

BOX 1.3

Frequently Reported Conditions of Those Seeking Alternative Therapies

Back pain Head cold Neck pain Joint pain Arthritis Anxiety/depression Stomach upset Headache Chronic pain Insomnia

Source: National Center for Complementary and Alternative Medicine. 2007 Statistics on CAM Use in the United States. Retrieved from http://nccam.nih.gov/news/camstats/2007/index.htm

14 Unit 1 • Healing Practices

help separate the healers from those who pretend to have medical knowledge. Consumers should be wary of healers who

• say they have all the answers. • maintain that theirs is the only effective therapy. • promise overnight success. • refuse to include other practitioners as part of the healing team. • seem more interested in money than in people’s well-being. ( Tiedje, 1998 )

Some alternative specialties are more regulated and licensed than oth- ers, but none come with guarantees any more than conventional medicine comes with guarantees. Consumers may want to research the background, qualifications, and competence of any health care provider—alternative, con- ventional, or integrative. Most types of alternative practices have national organizations of practitioners that are familiar with legislation, state licensing, certification, or registration laws. Many of these organizations are found in the resource section at the back of each chapter in this text.

INTEGRATED NURSING PRACTICE

Nursing has been moving away from a biomedical orientation that has largely defined and directed it toward a nursing-caring-healing model. Watson (1997) described it as a shift from a nursing qua medicine paradigm (nurses helping

BOX 1.4

Reasons for Choosing Alternative Therapies

Pursue therapeutic benefit Seek a degree of wellness not supported in biomedicine Attend to quality-of-life issues Prefer high personal involvement in decision making Practitioners spend more time with clients Believe conventional medicine treats symptoms, not the underlying cause Find conventional medical treatments to be lacking or ineffective Avoid toxicities and/or invasiveness of conventional interventions Decrease use of prescribed or over-the-counter medications Identify with a particular healing system as a part of cultural background

Sources: Clement, Chen, Burke, Clement, & Zazzali, 2006 ; National Center for Complementary and Alternative Medicine, 2012. 2007 Statistics on CAM Use in the United States. Retrieved from http:// www.nccam.nih.gov/news/camstats/2007/index/.htm ; Saydah & Eberhardt, 2006 .

Chapter 1 • Integrative Healing 15

physicians practice medicine) to a nursing qua nursing paradigm (practicing the distinct art and science of nursing). This movement has reconnected nurses with the finest tradition of Florence Nightingale in using their hands, heart, and head in creating healing environments. The modern nurse–healer draws on biomedical and caring–healing models by utilizing technology and focusing on caring relationships and healing processes. Dossey, Keegan, and Guzzetta ( 2005 ) have described the modern nurse–healer as having a hybrid of scientific skills and spiritual commitment. Nurses need scientific principles, methods, and skills, but they also need to teach people ways to become more self-reliant as they shift from caregivers to healers.

In 1979, Watson published her text Nursing: The Philosophy and Science of Caring, which evolved from her experiences of nursing within the limitations of traditional biomedical models. She sought to bring new meaning to the nursing paradigm of caring-healing and health. Her caritas process was devel- oped to balance the “cure” stance of Western medicine. Watson’s theory has since evolved into “clinical caritas processes.” This perspective describes nurse–client relationships based on spirituality, love, caring, healing environ- ments, wholeness, and unity of being ( Watson, 2007 ).

The art of nursing is in being there, with another person or persons, in an atmosphere of caring. Caring involves compassion and sensitivity to each person within the context of her or his entire life. In the past, the biomedical model urged nurses not to care too much or get too involved. Caring, success- ful nurses, however, do get involved with clients as they practice nursing as an art instead of nursing as just a day-to-day job. Caring is a philosophy or context within which nurses practice nursing. Their practice is made caring not by the tools they use but by the attitude or perspective they bring. It is possible, of course, to use the tools of alternative therapies in the same reduc- tionist way of biomedicine. For example, if one knows the pressure point for headaches and simply uses this pressure point for pain relief without any fur- ther assessment, it can hardly be considered holistic or healing. The symptom of headache has been addressed, but the meaning of the headache and the person’s experience of the pain has been totally ignored.

The plurality of the sick care, health care system may be one of its great- est strengths. It enables us to meet the diverse needs of diverse populations. The question is, How can we combine the best ideas of conventional nursing practice and complementary and alternative healing practices? First, we must have education. At the basic level, our nursing curricula must include courses in caring and alternative therapies. All nurses could learn Therapeutic Touch (TT), healthy dietary plans, the use of basic herbs, as well as the use of visual- ization in the healing process. Since 2004, basic alternative therapies content is included in the NCLEX-RN examination. Because state boards of nursing vary in their detail of criteria for alternative therapies and nursing practice, it is critical that you check the Nurse Practice Act of your state.

The White House Commission on Complementary and Alternative Medicine states that “since the public utilizes both conventional health care and complementary and alternative medicine (CAM), the Commission

16 Unit 1 • Healing Practices

believes that this reality should be reflected in the education and training of all health practitioners” ( National Institutes of Health, 2002 , p. 51 ). The Com- mission goes on to say that “although there has been notable progress in introducing CAM into medical, nursing, and other fields of conventional health care education in recent years, more needs to be done” (p. 51 ). We must also participate in continuing education courses to expand our knowledge beyond the basic level. With additional education, we can learn such thera- pies as basic massage and reflexology, meditation, and yoga. Some nurses will choose to continue their education through master of science in nursing degrees with a holistic nursing concentration or through certificate programs for nurse practitioners. Other nurses will choose to complete formal programs in alternative medicine such as naturopathy, Ayurveda, homeopathy, chiro- practic medicine, or hypnotherapy. Advanced practice nurses should provide leadership in research and education in alternative therapies ( Denner, 2007 ).

Next, we must provide community education. We must provide people with information, tools, skills, and support to enable them to make healthy decisions about life and negotiate their way through the health care systems. As nurses, we have the opportunity to initiate conversations about alternative therapies. Growing immigrant populations call for more attention to a variety of health expectations, needs, and preferences. We must also become familiar with the alternative practices immigrants bring with them. An important con- sideration in evidence-based practice is patient preference. We must also attempt to keep ourselves healthy and to exemplify good health because teaching by example is a powerful influence. We can teach wherever our prac- tice is located: acute care, long-term care, community nurse-managed centers, and in areas of advanced practice nursing. And, finally, we must document our  findings, utilize and participate in nursing research, keep current with evidence-based practice, and design new studies to measure the effectiveness of various healing practices.

Self-Care

Before we nurses can care for clients, we must first learn to value and care for ourselves. One of your goals in reading this text might be to discover how to care for yourself more effectively, because only then will you have the energy to care for your clients. Caring for yourself means reducing unnecessary stress, managing conflict effectively, communicating clearly with family and friends, and taking time out for yourself. Caring for yourself may include developing a daily routine in practices such as relaxation, meditation, prayer, yoga, communion with nature, and other such forms of contemplation. In Watson’s words, “If one is to work from a caring-healing paradigm, one must live it out in daily life” ( Watson, 1997 , p. 51 ). The following guidelines will help you maintain your self-care practices ( Jahnke, 1997 ):

• Choose self-care activities that appeal to you and fit into your lifestyle. • Do one or more of these practices every day. Consider them as impor-

tant as food and sleep.

Chapter 1 • Integrative Healing 17

• Seek guidance and support from teachers/practitioners if appropriate. • Find a good spot for your practice that is physically and mentally com-

fortable. • Build up your practice slowly. Success is not gained by aggressive or

compulsive practice. • Look for opportunities to practice with others. • Focus on relaxing. The foundation of all self-healing, health enhance-

ment, stress mastery, and personal empowerment is deep relaxation.

References

Buchan, S., Shakeel, M., Trinidade, A., Buchan, D., & Ah-See, K. (2012). The use of complementary and alternative medicine by nurses. British Journal of Nursing, 21(11): 672–675.

Clement, J. P., Chen, H. F., Burke, D., Clement, D. G., & Zazzali, J. L. (2006). Are consumers reshaping hospitals? Complementary and alternative medi- cine in U.S. hospitals, 1999–2003. Health Care Management Review, 131(2): 109–118.

Denner, S. S. (2007). The advanced prac- tice nurse and integration of comple- mentary and alternative medicine. Holistic Nursing Practice , 21(3): 152–159.

Dossey, B. M., Keegan, L. G., & Guzzetta, C. E. (2005). Holistic Nursing: A Hand- book for Practice (4th ed.). Sudbury, MA: Jones & Bartlett.

Duncan, A. D., Liechty, J. M., Miller, C.,  Chinoy, G., & Ricciardi, R. (2011). Employee use and perceived benefit of a complementary and alternative med- icine wellness clinic at a major military hospital. Journal of Alternative and Com- plementary Medicine, 9(17): 809–815.

Halcon, L. L., Chlan, L. L., Kreitzer, M. J., & Leonard, B. J. (2003). Complementary therapies and healing practices: Faculty/student beliefs and attitudes and the implications for nursing edu- cation. Journal of Professional Nursing , 19(6): 387–397.

Jahnke, R. (1997). The Healer Within . San Francisco, CA: Harper.

Lachance, L. L., Hawthorne, V., Brien, S., Hyland, M. E., Lewith, G. T., Verhoef, M. J., . . . Zick, S. (2009). Delphi-derived development of a common core for mea- suring complementary and alternative medicine prevalence. Journal of Alterna- tive and Complementary Medicine, 15(5): 489–494. doi: 10.1089/acm.2008.0430

National Center for Complementary and Alternative Medicine. (2011). Third strategic plan: 2011–2015. Retrieved from www.nccam.nih.gov/about/ plans/2011?nav=gsa

National Institutes of Health. (2002). White House Commission on Complemen- tary and Alternative Medicine Policy, Final Report . Washington, DC: U.S. Government Printing Office. Retrieved from www.whccamp.hhs.gov

Ortiz, B. I., Shields, K. M., Clauson, K. A., & Clay, P. G. (2007). Complementary and alternative medicine use among Hispanics in the United States. Annals of Pharmacotherapy , 41(6): 994–1004.

Peplau, H. E. (1952). Interpersonal Relations in Nursing. New York, NY: Putnam.

Quartey, N. K., Ma, P. H. X., Chung, V. C. H., & Griffiths, S. M. (2012). Comple- mentary and alternative medical edu- c a t i o n f o r m e d i c a l p r o f e s s i o n : Systematic review. Evidence Based Complementary and Alternative Medi- cine. doi: 10.1155/2012/656812

Quinn, J. F. (2000). The self as healer: Reflections from a nurse’s journey. AACN Clinical Issues , 11(1): 17–26.

18 Unit 1 • Healing Practices

Saydah, S. H., & Eberhardt, M. S. (2006). Use of complementary and alternative medicine among adults with chronic diseases. Journal of Alternative and Com- plementary Medicine , 12(8): 805–812.

Shreffler-Grant, J., Hill, W., Weinert, C., Nichols, E., & Ide, B. (2007). Com- plementary therapy and older rural w o m e n : W h o u s e s i t a n d w h o does not? Nursing Research , 56(1): 28–33.

Sirois, F. M. (2008). Provider-based com- plementary and alternative medicine use among three chronic illness groups. Complementary Therapies in Medicine , 16: 73–80.

Thomson, P., Jones, J., Evans, J. M., & Leslie, S. J. (2012). Factors influencing the use of complementary and alterna- tive medicine and whether patients inform their primary care physician. Complementary Therapies in Medicine, 20: 45–53. doi: 10.1016/j.ctim.2011.10.001

Tiedje, L. B. (1998). Alternative health care: An overview. Journal of Obstetric, Gynecologic, and Neonatal Nursing , 27(5): 557–562.

U.S. Department of Health and Human Services. (2010a). Healthy People 2020. Washington, DC: U.S. Government Printing Office.

U.S. Department of Health and Human Services. (2010b). Patient Protection and Affordable Care Act. Retrieved from http://www.hhs.gov/healthcare/ rights/law/index.html

Watson, J. (1979). Nursing: The Philosophy and Science of Caring . New York, NY: Little, Brown.

Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly , 10(1): 49–52.

Watson, J. (2007). Caring theory defined. University of Colorado Denver, Col- lege of Nursing. Retrieved from www. n u r s i n g . u c d e n v e r . e d u / f a c u l t y / theory_caring.htm

Willison, K. D. (2006). Integrating Swedish massage therapy with primary health care initiatives as part of a holistic nurs- ing approach. Complementary Therapies in Medicine , 14: 254–260.

World Health Rankings. (2013). Retrieved from www.worldlifeexpectancy.com

Resources

American Holistic Health Association

P.O. Box 17400

Anaheim, CA 92817–7400

714.779.6152

www.ahha.org

American Association of Integrative Medicine

2750 E. Sunshine St.

Springfield, MO 65804

877.718.3053

www.aaimedicine.com

Australian National Institute of Complementary Medicine

www.nicm.edu.au

National Center for Complementary and Alternative Medicine

National Institutes of Health

9000 Rockville Pike

Bethesda, MD 20892

888.644.6226

www.nccam.nih.gov

2 Basic Concepts Guiding Alternative Therapies

For breath is life, and if you breathe well, you will live long on earth.

Sanskrit Proverb

In this book, separate chapters are devoted to each of the most widely used methods in complementary and alternative med-icine. Because the methods share many principles, there is overlap in the various types of complementary and alternative practices. Although practices are grouped in units, many of the practices could be placed in several units. Thus, before examining the specifics of each practice, it may be helpful to introduce sev- eral concepts common to most healing practices, namely, balance, spirituality, energy, and breath.

BALANCE

An expression in the Native American culture, “walking in bal- ance,” describes the philosophy of a peaceful coexistence and har- mony with all aspects of life. This concept of balance is found in all cultures throughout time. Balance is viewed as a path rather than a steady state, and it is believed that each of us has a unique path as we move through life. In terms of optimal wellness, the concept of balance consists of mental, physical, emotional, spiritual, and environmental components. Not only does each component have to be balanced, but equilibrium is necessary among the compo- nents. Physical aspects include optimal functioning of all body sys- tems. Emotional aspects include the ability to feel and express the

19

20 Unit 1 • Healing Practices

entire range of human emotions. Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. Spiritual aspects involve moral values, a meaningful purpose in life, and a feeling of connectedness to others and to a divine source. Environmental aspects include physical, biologic, economic, social, and political conditions. Walking in balance is a learned skill and one that must be practiced regularly to engage in the process of healthy living. This concept of balance appears repeatedly throughout the various alternative healing practices.

Cyclic Rhythms

The daily lives of all living things are filled with various changes that take place in cyclic patterns. Circadian rhythms are regular fluctuations of a vari- ety of physiologic factors over 24 hours. Most familiar is the 24-hour tempera- ture and sleep patterns. These include adrenal, thyroid, and growth hormone-secreting patterns, as well as temperature, sleep, arousal, energy, appetite, and motor activity patterns. Ultradian rhythms are regular fluctua- tions repeated throughout a 24-hour day. An example of an ultradian rhythm is the 90-minute REM/non-REM sleep cycle. Infradian rhythms are regular fluctuations over periods longer than 24 hours, such as the menstrual cycle. The constant rhythmic processes bring about a dynamic, healthy balance in the body.

Rhythms may be desynchronized by external or internal factors. An example of external desynchronization is jet lag, in which rapid time zone changes result in a decreased energy level and ability to concentrate, as well as mood variations. In some individuals, internal desynchronization may result in depression. The tendency toward internal desynchronization is prob- ably inherited, but stress, lifestyle, and normal aging influence it. Attention to the rhythmic nature of one’s own being reveals an intimate relationship with the rhythms of the surrounding natural world.

Musical Rhythms

Health is about balance or harmony of body, mind, and spirit. In a state of optimal health, all frequencies are in harmony, like a finely tuned piano. In fact, music is often employed in healing, from the ancient use of the drum, rattle, bone flute, and other primitive instruments to the current use of music as a prescription for health. Several nursing research studies have demon- strated the effectiveness of music therapy for persons with mental disorders, autism, dementia, cancer, cognition disorders, and neurological problems. Chapter 21 covers music and its research in greater detail.

Dr. Andrew Weil, the leader in the field of integrative medicine, has cre- ated the Mindbody Tool Kit ( 2005 ) to help people utilize self-healing techniques. Sound therapy consists of classical music combined with healing sound fre- quencies. The combination of sounds entrains the brain to theta and delta brain waves, the state of deep relaxation in which the body and mind can heal

Chapter 2 • Basic Concepts Guiding Alternative Therapies 21

themselves. The benefits of sound therapy are far reaching. People who may benefit from sound therapy include those

• experiencing an illness. • who are having or have had surgical procedures. • who are having or have had chemotherapy infusions. • in intensive care. • in labor and delivery. • experiencing anxiety, depression, or insomnia. • who wish to maintain a high level of wellness.

Drumming and chanting are powerful ways to bring oneself in balance with self, others, and the world. The drumbeat serves as a focus for concentra- tion and quiets the chattering mind. The pace of the drumbeat enhances theta brain wave production. In one study, group drumming improved the social- emotional behavior of preteens experiencing the effects of chronic stress ( Ho, Tsao, Bloch, & Zeltzer, 2011 ).

SPIRITUALITY

Spiritual healing techniques and spiritually based health care systems are among the most ancient healing practices. Spirit is the liveliness, richness, and beauty of one’s life. It is who one is and how one exists in the world. Spirituality is the drive to become all that one can be, and it is bound to intuition, creativity, and motivation. It is the dimension that involves relationship with oneself, with others, and with a higher power. Spirituality is that which gives people mean- ing and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death ( Jampolsky, 2005 ; Taylor, 2002 ).

Many people are searching for wholeness in their lives and a way to allow their innermost selves to grow and expand. Spiritual healing practices guide individuals to places within themselves they did not know existed, through techniques as ancient as prayer, contemplation, meditation, drumming, story- telling, and mythology. In consciously awakening the energies of the spirit, peo- ple are able to move toward healing places and sacred moments in their lives.

During periods of stress, illness, or crisis, people search for meaning and purpose in their pain and suffering. They ask questions such as Why am I sick? or Why did this bad thing happen? This spiritual quest for meaning can lead to insight and healing or to fear and isolation. In the words of Ken Wilber:

A person who is beginning to sense the suffering of life is, at the same time, beginning to awaken to deeper realities, truer realities. For suffering smashes to pieces the complacency of our normal fictions about reality, and forces us to become alive in a special sense—to see carefully, to feel deeply, to touch ourselves and our world in ways we have heretofore avoided. It has been said, and truly I think, that suffering is the first grace. (quoted in Borysenko & Borysenko, 1994 , p. 191 )

22 Unit 1 • Healing Practices

Spirituality is often confused with religiosity, which is not surprising, because the two constructs are closely related. Religion involves a search for the sacred, a group identity, and a sense of belonging. Spirituality , a much broader concept, is the search for wholeness and purpose that underlies the world’s religions. Removing the dogma, the politics, and cultural influence from any of the world’s religions uncovers the same questions, the same seek- ing, and the same answers. The concept of spirituality does not undermine any religion but rather enhances all religions by illuminating their common- alities and the unity of all people. Spirituality reveals far more similarities than differences among individuals. Chapter 23 covers faith and prayer as it relates to health and well-being.

Many traditions also speak of spiritual guides. Some individuals think of them as guardian angels, and others, as Beings of Light who guide people through near-death experiences. Buddhists think of them as devas . Cherokees call them Adawees , the great protectors of the Four Directions. Malakh , or “messenger,” is the Hebrew word for angel. There are the cherubim and the seraphim and the four great archangels: Uriel, Raphael, Michael, and Gabriel. The Iranian angel Vohu Manah is believed to have revealed the message of God to Zoroaster some twenty-five hundred years ago. Similarly, the archangel Gabriel is credited for revealing the Quran to Muhammad a thousand years later. Gabriel, honored by Jews, Christians, and Muslims, has a special role as a mediator between human consciousness and the higher realms from which spirit descends into the body. Although no Western scientific evidence supports the existence of angels, one can find phenomenological evidence. Many first-person accounts of near-death occurrences involve angels and similar experiences from people of different ages, from diverse cultures, and with different personal and religious beliefs ( Borysenko & Dveirin, 2007 ).

ENERGY

The concept of energy has been recognized for centuries and in most cultures. Many ancient and current cultures have great respect for the subtle and unseen forces in life. Most spiritual traditions share the belief that energy is the bridge between spirit and physical being. Meditation and prayer are believed to be subtle energy phenomena that represent contact with the spiritual dimension.

Chinese Taoist scholars believed that energy, not matter, was the basic building material of the universe. Albert Einstein and other physicists proved that matter and energy are equivalent and that energy is not only the raw material of the cosmos but the glue that holds it together. Modern scientists now view the universe in terms of forces instead of tiny particles of matter. Their experimental findings are similar to the intuitive observations of China’s ancient scholars. Everything in the world—animate and inanimate—is made of energy. People are beings of energy, living in a universe composed of energy.

Chapter 2 • Basic Concepts Guiding Alternative Therapies 23

Although Western scientists agree on this theory, they do not yet fully agree that a distinct energy system exists within the human body. For energy to be “real,” it must be measurable by scientific instruments. By this logic, of course, brain waves did not exist prior to the invention of electroencephalo- graphs! Because technology is not yet capable of measuring all the energy fields in the body, references to energy are not often found in conventional medicine.

For more than 2,000 years, various practitioners worldwide have insisted that a person is more than the physical body. According to these healers, a “life force” of subtle energy surrounds and permeates every person. Energy is viewed as the force that integrates the body, mind, and spirit; it is that which connects everything. The Japanese call this energy ki (pronounced “key”); the Tibetans refer to it as lung (pronounced “loong”); the Polynesians call it mana ; Native Americans call it oki, orenda , or ton ; Americans call it subtle energy or bioenergy; the Greeks call it pneuma ; and the Hindus give it the name prana . Prana is sometimes translated from the Sanskrit as “primary energy,” “breath,” or “vital force.” The Chinese refer to this energy as qi or chi ( pronounced “chee”) and believe that it takes the form of two opposite but complementary phases, yin and yang. Yin is the earth, moon, night, fall and winter, cold, wetness, darkness, the feet, the left side, the female gender, and passivity. Yin is involved in tissue growth. Yang is the sun, day, spring and summer, heat, dryness, light, the head, the right side, the male gender, and aggressiveness. Yang is involved in tissue breakdown. It is believed that each person is a unique combination of the complementary energies yin and yang. This union of opposites constitutes wholeness. Figure 2.1 shows the t’ai chi symbol, which illustrates the yin and yang of Chinese thought. The white dot on the black portion of the symbol and the black dot on the white section are reminders that each quality contains some of its opposite. Further descriptions of yin and yang are found in Chapter 4 .

It is believed that qi creates qi. In other words, physical activities such as eating, work, and rest, as well as nonphysical aspects of life such as will, moti- vation, feelings, desires, and a sense of purpose in life, are all made possible

Yang Yin

FIGURE 2.1 T’ai Chi Symbol

24 Unit 1 • Healing Practices

by qi. Those same activities and aspects also create more qi. Most schools of thought basically agree on the following points regarding energy:

• Energy comes from one universal source. • Movement of energy is the basis of all life. • Matter is an expression of energy and vice versa. • All things are manifestations of energy. • The entire earth has energetic and metabolic qualities. • People are composed of multiple, interacting energy fields that extend

out into the environment. • People’s relationships with one another are shaped by the interactions of

their energies. • Qi, ki, and prana have no exact counterpart in conventional medicine,

though the concept of a physical bioenergy system is under research. It is described as a weak but complex electromagnetic field that is hypothesized to involve electromagnetic bioinformation for regulating homeodynamics. ( Newman & Miller, 2006 ; Warber, Cornelio, Straughn, & Kile, 2004 )

Chakras

The Hindu concept of chakras (a Sanskrit word for “spinning wheel”) describes seven major energy centers within the physical body. Chakras have been described by most Eastern cultures and several South American cultures (such as Mayan) for thousands of years. Chakras are major centers of both electromagnetic activity and circulation of vital energy. They are usually thought of as funnels of perpetually rotating energy and are considered the gateways through which energy enters and leaves the body. Each chakra in the body is recognized as a focal point of the life force relating to physical, emotional, mental, and spiritual aspects of people and is the network through which the body, mind, and spirit interact as one holistic system. Figure 2.2 illustrates the sites of the chakras in the body.

The concept of chakras may be foreign to the Western scientific mind, but chakras are not completely unknown to those familiar with Judeo- Christian culture, particularly in the artwork and sculptures passed down through the ages. For centuries, the crown chakra, which signifies a conscious awareness of the divine, has been painted as a halo over those who are con- sciously aware of a divine presence in their lives.

The seven main chakras are vertically aligned up the center of the body from the base of the pelvis to the top of the head. Each has its own individual characteristics and functions, and each has a corresponding relationship to various organs and structures of the body, to one of the endocrine glands, as well as to one of the seven spectral colors of the rainbow. The characteristics of the seven major chakras are described in Box 2.1 . Of the many smaller chakras throughout the body, the most significant are in the palms of the hands. The hand chakras are considered extensions of the heart chakra and, as such, radiate healing and soothing energies. Spiritual healers who practice the

Chapter 2 • Basic Concepts Guiding Alternative Therapies 25

(continued)

BOX 2.1

The Chakras

1. Root chakra Location: base of the spine Center of: physical vitality, urge to survive Gland: adrenal glands Organs/Structures: kidneys, bladder, spine Color: red

2. Sexual or navel chakra Location: slightly below the navel, in front of the sacrum Center of: sexual energy, ego, extrasensory perception Gland: gonads Organs/Structures: reproductive organs, legs Color: orange

FIGURE 2.2 The Chakras and the Auric Field

26 Unit 1 • Healing Practices

laying on of hands concentrate energy in their hand chakras. Each chakra has a purpose and a function that

• regulates the human energy system and maintains an equilibrium of health (purpose); and

• links body, mind, and spirit and exchanges energy (function).

Each chakra also operates at its own optimum frequency; generally, the lower the chakra on the body, the lower its frequency. If one frequency is out of sync, all others will be also.

The main purpose in working with and understanding the chakras is to create integration and wholeness within people. The chakras are the “door- ways” through which the energy from within and without is distributed to cells, tissues, and organs. If chakras stop functioning properly, the intake of energy will be disturbed, and the body organs served by that chakra will not

3. Solar plexus chakra Location: slightly above the navel Center of: unrefined emotions, urge for power Gland: pancreas Organs/Structures: stomach, liver, gallbladder Color: yellow

4. Heart chakra Location: middle of the chest at the height of the heart Center of: unconditional affection, compassion, devotion, love, spiritual growth Gland: thymus Organs/Structures: heart, liver, lungs, circulatory system Color: emerald

5. Throat chakra Location: throat area Center of: communication, self-expression, creativity Gland: thyroid Organs/Structures: throat, upper lungs, digestive tract, arms Color: blue

6. Third-eye chakra Location: middle of the forehead, a little higher than the eyebrows Center of: the will, intellect, spirit, spiritual awakening, visualization Gland: pituitary Organs/Structures: spine, lower brain, left eye, nose Color: purple

7. Crown chakra Location: at the top of the head at the fontanel Center of: highest level of consciousness or enlightenment, intuition, direct spiritual vision Gland: pineal Organs/Structures: upper brain, right eye Color: golden white

Chapter 2 • Basic Concepts Guiding Alternative Therapies 27

get their needed supply of energy. Eventually, organ functioning will be dis- rupted, leading to weakened organs with a diminished immune defense. If this process continues, the end result will be dysfunction and disease ( McGuinness, 2012 ). Dr. Dean Ornish ( 1999 ), well known for his program to reverse coronary artery disease through diet, exercise, support groups, and meditation without surgery or drugs, believes that a closed heart chakra (unresolved anger and fear) is related to blocked coronary arteries. Conse- quently, the meditation technique he incorporates into his program involves opening the heart chakra. His holistic approach has now become a recognized program practiced nationwide.

Aura

Closely related to the notion of chakras is the concept of aura. The aura is the energy field surrounding each person as far as the outstretched arms and from head to toe. This energy field is both an information center and a highly sensitive perceptual system that transmits and receives messages from the internal and external environments. Each of the seven layers of the auric field is associated with a chakra; the first layer is related to the first chakra, and so on. Each layer has physical, mental, emotional, and spiritual dimensions and purposes, and the lay- ers function together through the transmission of energy. Box 2.2 lists

BOX 2.2

Seven Layers of the Auric Field

Level 1. Etheric Body Location: 1/4 inch to 2 inches beyond the physical body Center of: physical functioning and physical sensation Color: light blue to gray Level 2. Emotional Body Location: 1 to 3 inches beyond the physical body; roughly follows the outline of the physical body Center of: emotional aspects of person Color: all colors of the rainbow Level 3. Mental Body Location: 3 to 8 inches beyond the physical body Center of: instinct, intellect, intuition Color: bright yellow with additional colors superimposed Level 4. Astral Body Location: 6 to 16 inches beyond the physical body Center of: love Color: same colors as in level 3 but infused with the rose light of love Level 5. Etheric Template Body Location: 18 to 24 inches beyond the physical body

(continued)

28 Unit 1 • Healing Practices

characteristics of the auric field, and Figure 2.2 shows a diagrammatic view of the auric field. Virtually every alternative healing therapy has a way of interpreting the body’s subtle energy , which will be discussed throughout this text .

Meridians

A person’s vital energy is not simply radiated outward but has patterns of cir- culation within the body, referred to as the meridian system. Meridians are a network of energy circuits or lines of force that run vertically through the body, connecting all parts. Meridians may be understood more clearly if they are com- pared to a major city’s highway system with entrance and exit ramps, merging roads, and connecting surface streets. If a flood blocks an exit ramp, the streets served by this ramp become inaccessible, which, in turn, affects the people who live and work on those streets. Also, the traffic may back up on the highway, as cars wait for the ramp to reopen, creating a traffic jam. Meridians operate simi- larly in a person’s body. If some type of blockage affects one’s hip, for example, the pathways of energy leading to that hip get “backed up.” Pain or discomfort restricts the motion of the hip, which may affect the position of the foot, which creates a strain on other sets of muscles. These changes in the body’s general posture affect the positions of the internal organs, which, in turn, restrict the nutrition to the organs, alter organ function, and thereby change the body’s bal- ance. As the body and mind are affected, the person will think and feel differ- ently, leading to more tension and more changes ( Zhu, 2012 ).

Each meridian passes close to the skin’s surface at places called hsueh , which means “cave” or “hollow” and is translated as point or acupuncture point. Because each meridian is associated with an internal organ, the acu- puncture points offer surface access to the internal organ systems. The flow of qi can be strengthened or weakened by manipulating specific points. Keeping the flow of energy open and regular contributes to a state of balance and health.

The California Institute for Human Science ( www.cihs.edu ) is the U.S. center for research on a device called the Apparatus for Meridian Identifica- tion (AMI). The AMI measures the flow of ions through the body and in 10 minutes can completely evaluate the condition of a person’s meridian system

Center of: higher will connected with divine will, speaking, listening, working, tak- ing responsibility for our actions Color: clear lines on cobalt blue background Level 6. Celestial Body Location: 24 to 33 inches beyond the physical body Center of: celestial love, spiritual ecstasy, protection and nurturance of all life Color: shimmering pastel colors Level 7. Causal Body Location: 30 to 42 inches, forming an egg shape around the body Center of: higher mind; integration of spiritual and physical body Color: shimmering gold threads

Chapter 2 • Basic Concepts Guiding Alternative Therapies 29

and the corresponding internal organs related to those meridians. This stream of ions is not vital energy or qi itself. Rather, it is a secondary electromagnetic effect of qi—in a sense, its imprint in the physical domain. The AMI is now available for distribution as a diagnostic tool in complementary and alterna- tive therapies and in conventional medicine ( Ahn & Martinsen, 2007 ).

Energy Concentration

The mind’s energy, or willpower, can be developed by individuals to control  their body’s energy system to an extraordinary degree. Healers can concentrate and manipulate energy in remarkable ways using their energy to align and balance the electromagnetic field of the patient. In attempting to trace the source of healers’ energy, studies demonstrate that it seems to come from the central body in the area between the solar plexus and the lower abdomen. The Chinese refer to this spot as the tan dien or the home of qi, and the Hindus refer to it as the solar plexus chakra or the seat of prana ( Zhu, 2012 ).

Grounding and Centering

Two terms common in various healing practices and related to energy and bal- ance are grounding and centering . Grounding , as its name suggests, relates to one’s connection with the ground and, in a broader sense, to one’s whole con- tact with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present rather than escaping into dreams. It means having a mature sense of responsibility for oneself. Much of the sense of grounding comes from identification with the lower half of one’s body—the parts of being that are less conscious and have more instinctive functions of movement. Learning to breathe into the belly, for example, is vital for grounding, for if the breath is shallow, contact with feelings and reality is limited. Many of the practices in this text , such as biofield therapies, mind– body techniques, and spiritual therapies, help increase one’s groundedness.

Centering refers to the process of bringing oneself to the center or mid- dle. When people are centered, they are fully connected to the part of their body where all their energies meet. Centering is the process of focusing one’s mind on the center of energy, usually in the navel or solar plexus chakra. All movement in the body originates from this center, providing the meeting point for body and mind. It is commonly considered the “earth” center, for it gathers energy from the earth rising up through the legs. Centering can be done through movement, as in t’ai chi, or can be found in stillness, as in med- itation. Being centered allows one to operate intuitively, with awareness, and to channel energy throughout the body.

BREATH

Breath is at the center of all spiritual and religious traditions. In many languages, the words for spirit and breath are one and the same—Sanskrit prana , Hebrew ruach , Greek pneuma , and Latin spiritus . In Christianity, the Holy Spirit

30 Unit 1 • Healing Practices

is referred to as “the breath of life.” To inspire, or take in spirit, means not only to inhale but to encourage, motivate, and give hope. To expire, or lose spirit, means not only to exhale but to die, cease to exist, to end, or be destroyed.

In Eastern cultures, when air is inhaled, so is vital energy, which flows into the body to nourish and enliven. In traditional Chinese medicine, the exhalation is considered the yin part of the breath, and the inhalation is yang. It is impossible only to breathe in without breathing out or to breathe out without breathing in. It is the continuous dynamic balance of yin and yang that contributes to health and well-being. Most of the healing traditions worldwide believe breath is the most important function of life, and restric- tions in breathing lead to dysfunction and disease.

In Western culture, the breath has been considered simply a mechanical, metabolic function of the body. Scientists are now beginning to recognize that breath can be used for healing, improving the body’s self-repair processes, and reducing vulnerability to illness. Oxygen is toxic to viruses, bacteria, yeasts, and parasites in the body, and cancer cells find it more difficult to survive in an oxygen-rich environment. Andrew Weil ( 1995a ) believes that “breath is the master key to health and wellness, a function we can learn to regulate and develop in order to improve our physical, mental, and spiritual well-being” (p. 86 ).

The breath is constantly adapting to accommodate the needs of the situa- tion at hand. When people eat heavy meals or exercise rapidly, when their noses are congested or dry, or when their environment is filled with pleasant or unpleasant smells, their breathing changes. Every change in posture has an effect on the combination of muscles used to breathe. Breath does not feel the same standing or sitting as when one is lying down. Breathing also changes under stress. For example, anxious people take shallow “chest” breaths, using only their chest muscles to inhale rather than their diaphragm. As a result, only the top part of their lungs fills with air, depriving the body of the optimal amount of oxygen.

Many people, even when feeling relaxed, breathe in a shallow way that keeps them in a constant state of underoxygenation that contributes to a decreased level of energy and increased vulnerability to illness. The typical shallow chest breath moves about half a pint of air, whereas a full abdominal breath can move eight to ten times that amount. Forming healthy breathing habits can produce dramatic results. Probably no other single step that people can take will so profoundly and positively affect body, mind, and spirit. Deep breathing can counter stress. Just three deep, full belly breaths can move indi- viduals from panic to calmness by increasing their oxygen intake. Much of perceived stress is worrying about the future or the past, and deep breathing is a great way to return to the present. Twenty minutes of deep breathing exercises a day can lower blood pressure by increasing oxygen intake, which decreases workload on the cardiovascular system ( Anselmo, 2013 ; Ody, 2011 ).

INTEGRATED NURSING PRACTICE

In complementary and alternative medicine, the focus of restoring health is within each person and cannot be “given” to a client by any health care practitioner. Drugs, herbs, procedures, surgeries, or mind–body techniques

Chapter 2 • Basic Concepts Guiding Alternative Therapies 31

may be helpful or necessary but by themselves do not cure disease. People must, and do, rebalance and repair themselves. The profession of nursing was founded on this philosophy and view of life as noted by Florence Nightingale’s ( 1860 ) basic premise that healing is a function of nature that comes from within the individual. She saw the role of the nurse as putting the “patient in the best condition for nature to act on him.”

In contrast, biomedicine has taught people to listen to external authori- ties and to view themselves as helpless victims of disease. Conventional medi- cine is based on the idea of cure, which usually refers to the elimination of the signs and symptoms of disease. “Curing,” however, is effective for only about 15% to 20% of the sick population. In 80% to 85% of acute disruptions of health, one of three things happens with or without medical intervention: The person gets well, develops a chronic disorder for which there is no cure, or dies. When the focus is on cure, death is seen as a failure. Certainly, the curative aspects of Western medicine have allowed many people to live healthy, productive lives. But for many others, fixing the body is not enough. As individuals search for meaning in their illness and their life, as well as a sense of connectedness with others, they begin the healing process. Box 2.3 compares the philosophy and beliefs of the medical-curing model with the nursing-healing model.

Many sick people eventually get better no matter what treatment is given or even if no treatment is given. If the person is given “something,” recovery is even more likely because of the placebo effect . The concept of the placebo effect follows directly from biomedicine’s denial of the power of self-healing.

(continued)

BOX 2.3

The Cure Versus Heal Models

Medical-Curing Model Nursing-Healing Model

Diseases are cured People are healed Focus on diagnosis Focus on meaning Patient is dependent Person is autonomous Effective for 15%–20% of Effective for everyone; healing is always

population; cure may or may not possible be possible

Body is viewed as a machine; Body is a living microcosm of the disease results when parts break universe; disease results through imbalance

Role of medicine is to combat Role of medicine is to restore harmony; disease; practitioners are soldiers practitioners are the Peace Corps, in a war fostering learning and growth

Body is passive recipient of Body is capable of self-healing treatments to fix it

32 Unit 1 • Healing Practices

In Western research studies, the placebo is a simulated biomedical treatment with no inherent medical value. The placebo response complicates researchers’ experiments. In study after study, the placebo has been found effective in at least 30% to 35% of the cases. In fact, the rate is as high as 70%; typically, 40% of individuals report excellent results, and another 30% report good results ( Benson, 1997 ; Bishop, Adams, Kaptchuk, & Lewith, 2012 ; Harrington, 2008) . Norman Cousins, author of Anatomy of an Illness ( 1991 ) and The Healing Heart ( 1985 ), described the placebo as the “doctor who resides within.” In fact, the placebo response in Western scientific literature demonstrates the unity of mind–body and provides great evidence of humans’ self-curing capacity. Janet Quinn ( 1989 ), a leader in holistic nursing, believes that because the site of all curing is within the individual, “there are no longer any ‘real’ or ‘placebo’ treatments and effects. There are only stimuli for healing processes” (p. 554 ). Andrew Weil ( 1995b ) regards the placebo response as a “pure example of healing elicited by the mind; far from being a nuisance, it is, potentially, the greatest therapeutic ally doctors can find in their efforts to mitigate disease” (p. 52 ).

Beliefs can also work against people. The nocebo is the placebo’s negative counterpart. It is destructive thinking that contributes to sickness and even death. The body is good at healing, but at times individuals inhibit this pro- cess by worrying or doubting their ability to overcome the illness. Nurses must routinely assess clients’ beliefs and expectations for health and use them systematically in the healing process. The goal is not to deny reality but to help people project healthy images. When a person acts “as if” the preferred reality were true, the body responds, and improved health can emerge ( Hauser, Hansen, & Enck, 2012 ).

The word heal comes from the Greek word halos and the Anglo-Saxon word haelan , which mean “to be or to become whole.” (Interestingly, the word holy is derived from the same source.) Thus “healing” means “making whole”—that is, restoring balance and harmony. It is a movement toward a sense of wholeness and completion. Healing comes from surrendering to life as it is, including all feelings, from anger and despair through joy and peace- fulness. The irony is that in the process of accepting life as it is, most people feel more alive and live more fully, even when facing death. When the focus is on healing, success does not depend on whether the person lives. Healing can take place even as the body weakens. Through healing, people allow them- selves to be everything they already are and move toward a greater sense of

Primary treatments are drugs, Primary treatments are diet, herbs, stress surgery, radiation management, social support Focus on pain Focus on the human experience of pain, which is suffering Caring is seen as a means to an end Caring is the end in itself

Sources: Dossey & Keegan, 2013 , 2005; Quinn, 1989 ; Watson, 2007 .

Chapter 2 • Basic Concepts Guiding Alternative Therapies 33

the meaning of their experiences. Even when nothing can be done physically to alter the course of disease, still much can be done in a caring sense to make the human experience more meaningful and understandable ( Dossey & Keegan, 2013 ; Quinn, 1997 ). As Joellen Goertz Koerner ( 2011 ) stated: “The ‘being’ dimension of the role of the nurse is less about what nurses do and more about the how. . . . ‘Being’ is what slows down the nurse so that space is created for an authentic, deep connection with the patient and healing” (p. xiv).

Nursing has always focused on creating healing environments for those who have been entrusted to our care. We create healing environments when we use our hands, heart, and mind to provide holistic nursing care. We create heal- ing environments when we empower others by providing the knowledge, skills, and support that allow them to tap into their inner wisdom and make healthy decisions for themselves. Healing environments are a synthesis of the medical- curing approach and nursing-healing approach. We need a healthy balance between technology and compassion. We create healing environments when we take the time to be with clients in deeply caring ways. It is when we stop, become still, and enter the other’s subjective world that we are able to be wholly present for that person. This moment of spiritual connection is uplifting for both client and nurse. Karilee Shames ( 1993 ) described sacred healing moments that occurred when her “goal became to inspire, to share tenderness, and to help instill a will to live, or to surrender to the call of death peacefully, if that was most appropriate. In my highest vision, this is what nursing was all about” ( Shames, 1993 , p. 131 ).

Patients come to us at the most vulnerable times of their lives. Many suf- fer deeply as they try to make sense of serious illness, huge losses, and unan- swerable questions. Healing of spiritual suffering is as important as technical treatment of physical illness. Spirituality is also very important to the dying person’s ability to complete the end-of-life task of transcending the self. Until recently, many of us gave the spiritual health of our patients very little atten- tion. In the area of spiritual assessment, we nurses often simply wrote in the patient’s religious affiliation. We must ask our patients about their spiritual beliefs if we are to know who they are and how they cope with their illnesses. There are a number of tools for assessing spirituality, such as the following. Howden’s Spirituality Assessment Scale ( SAS ; Burkhardt and Nagai-Jacobson, 2002 ), the JAREL Spiritual Well-Being Scale ( Hunglemann, Kenkel-Rossi , Klassen, & Strollenwerk, 1997 ), the Spiritual Involvement and Beliefs Scale ( SIBS ; Hatch, Burg, Naberhaus, & Hellmich, 1998 ), and the Spiritual Assessment Tool ( Dossey & Keegan, 2013 ) are available to help us gain proficiency in the area of spiritual assessment. The tools ask questions regarding relationships, sense of balance and peace, sense of meaning and purpose in life, strengths and limitations, God or a higher power, and meditation or prayer.

We must also create healing environments for ourselves. Working with people can be draining work. As nurses, we need to learn how to restore our energy and replenish ourselves. We might compare our ability to care for others to a well of fresh, healing water. If the well is never dipped into, the water becomes stagnant and brackish. If the water is constantly drawn out and given away, with no source of replenishment, the well will soon run dry. What happens to nurses

34 Unit 1 • Healing Practices

who don’t sincerely care for others or take the time to replenish themselves? It soon becomes obvious by their behavior that they are stagnant or depleted; they are less patient, less tolerant, more irritable, and unhappy. Their state of “burn- out” contaminates all aspects of their professional and personal lives.

When we care for others, care for ourselves, and allow others to care for us, the well of healing is constantly replenished. There are many techniques in this book that can be incorporated into daily life. It is important that we take time for ourselves, even if for only 10 minutes a day. Learning to take care of ourselves means letting go of self-defeating behaviors and attitudes. We must teach ourselves to relax without feeling guilty or selfish for taking time out. Self-renewal is a continuous process. To be there for others and care for them in their times of need, we must first look after our own well-being. It is only when we walk in balance that we can help others learn how to balance their lives.

TRY THIS

Energy

See the Aura

Find a room with a plain white background that has natural lighting or lights other than fluorescent. The lights should not be too bright and should not be shining directly on the person/subject. If you wear glasses, try the experiment with glasses on and glasses off. Ask the person to stand 18 inches in front of the white background and relax and breathe deeply. Stand 10 feet away from the person and focus on the wall, past the person’s head and shoulders. You may notice a fuzzy white or gray field around the body, looking almost like a light behind the person. Continue to stare at the wall—DO NOT focus on the per- son. You may begin to see colors or sharp rays. This may take some time. Try different people as subjects.

You may want to try using your own hands. With the same background, hold your hands out at arm’s length, in front of your face, with your palms facing each other. Point the fingertips of each hand until they are 1 inch apart. Soften your gaze and look past your fingers. Look for a gray, white, or other-colored aura.

Energizing the Hands

Lightly oil your hands and sit in a chair with your back comfortably straight. Cup your hands slightly and bend your arms at the elbows and hold your hands up at the level of your heart. Feel the warmth or tingle as the energy enters your hands. Let the energy flow through your arms into your heart. Then, bring your hands together with the right hand on top of the left hand and rapidly rub the back of the left hand. Reverse the hands and rub the back of the right hand. Then, rub your palms together rapidly until they feel hot. Return your hands to the original position—cupped and at the level of your heart.

Source: Tulku ( 2007 ).

Chapter 2 • Basic Concepts Guiding Alternative Therapies 35

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Q uinn , J. F. (1989). On healing, whole- ness, and the haelan effect. Nursing and Health Care , 10(10): 553–556.

Quinn, J . F. (1997). Healing: A model for an integrative health care system. Advanced Practice Nursing Quarterly , 3(1): 1–7.

Shames, K. H. (1993). The Nightingale Con- spiracy . Montclair, NJ: Enlightenment Press.

Taylor, E. J. (2002). Spiritual Care: Nursing Theory, Research, and Practice . Upper Saddle River, NJ: Prentice Hall.

Tulku, T. (2007). Tibetan Relaxation . London, UK: Thorsons.

Warber, S. L., Cornelio, M. A., Straughn, J., & Kile, G. (2004). Biofield energy healing from the inside. Journal of

36 Unit 1 • Healing Practices

Alternative and Complementary Medi- cine , 10(6): 1107–1113.

Watson, J. (2007). Theoretical questions and concerns: Response from a caring science framework. Nursing Science Quarterly , 20(1): 13–15.

Weil, A. (1995a). Natural Health, Natural Medicine . Boston, MA: Houghton Mifflin.

Resources

Weil, A. (1995b). Spontaneous Healing . New York, NY: Knopf.

Weil, A. (2005). Mindbody Tool Kit . Boulder, CO: Sounds True.

Zhu, J. W. (2012). Chinese Medicine: Acupuncture, Herbal Medicine, and Therapies. Hauppauge, NY: Nova Science.

American Holistic Medical Association

27629 Chagrin Blvd, Suite 213

Woodmore, OH 44122

www.holisticmedicine.org

American Holistic Nurses Association

323 N. San Francisco St., Suite 201

Flagstaff, AZ 86001

800.278.2462

www.ahna.org

British Complementary Medical Association

P.O. Box 5122

Bournemouth BH8 OWG

0845.345.5977

www.bcma.co.uk

Canadian Holistic Nurses Association

www.chna.ca

3 The Role of Evidence-Based Health Care in Complementary and Alternative Therapies

Leslie Rittenmeyer PsyD, CNS, RN

Science is nothing but perception.

Plato

BACKGROUND

Evidence-based health care encompasses all the health profes- sions, including medicine, nursing, and allied health (Joanna Briggs Institute, n.d.). Evidence-based medicine was influenced by scholars such as David Sackett and A. L. Cochrane, and pre- ceded evidence-based nursing. The Cochrane Collaboration, which has played a leading role in promoting evidence-based practice, arose from a concern by its founder, A. L. Cochrane, that there was little information about the outcomes of health care practices. The emphasis of the Cochrane Collaboration was, and for the most part continues to be, the systematic review of randomized clinical trials (RCTs). Later in the chapter the rela- tionship of complementary and alternative medicine (CAM) to the Cochrane Collaboration will be discussed. Over the years

37

38 Unit 1 • Healing Practices

additional systematic review methodologies beyond RCTs have been devel- oped to take a more pluralistic approach. Philosophically, evidence-based practice means doing what works and doing it the right way to achieve the best possible patient outcomes ( Muir-Gray, 1997 , 18).

Definitions

Sackett, Rosenberg, Gray, Haynes, and Richardson ( 1996 ) provided the classic definition of evidence-based medicine. They described it as an explicit use of the best evidence available in making decisions about the care delivered to individual clients. Evidence-based medicine involves integrating individual clinical exper- tise with the best available external clinical evidence from systematic review.

A number of definitions of evidence-based nursing can be found in the literature. Generally, they all emphasize that evidence-based nursing is a set of tools, resources, and procedures for finding current best available evidence from various sources and applying this evidence to make clinical decisions that promote positive health outcomes or to inform policy. This process takes into account the situation, cultural context, resources, preferences of patients, clinical expertise and judgment, and common sense. The Honor Society of Nursing, Sigma Theta Tau International ( n.d. ), defines evidence-based nurs- ing as the integration of the best available evidence, nursing expertise, and the values and preferences of individuals, families, and communities who are served. DiCenso, Guyatt, and Ciliska ( 2005 ) defined evidence-based nursing as “the integration of best evidence with clinical expertise, and patient values to facilitate clinical decision making” (DiCenso et al., 2005 , p. 4 ).

The Joanna Briggs Institute (JBI), an interdisciplinary, not-for-profit, inter- national research and development agency, provides a comprehensive descrip- tion of evidence-based practice and its relationship to evidence-based nursing:

Simply defined, evidence-based practice is the melding of individ- ual clinical judgment and expertise with the best available external evidence to generate the kind of practice that is most likely to lead to a positive outcome for a client or patient. Evidence-based nurs- ing is nursing practice that is characterized by these attributes. Evidence-based clinical practice takes into account the context in which care takes place; the preferences of the client; and the clinical judgment of the health professional, as well as the best available evidence. ( Joanna Briggs Institute, n.d. )

As you can see all these definitions share some similarities, namely, best available evidence, clinical expertise, patient preference, and context of the situation. All parts of the definition are equally important, although discuss- ing them in depth is beyond the scope of this chapter. For a closer analysis refer to Hopp and Rittenmeyer ( 2012 ).

Several authors ( DiCenso et al., 2005 ; Ingersoll, 2000 ; Melnyk & Fineout- Overholt, 2005 ; Rycroft-Malone, 2004 ) differentiate evidence-based practice from research utilization. Research utilization focuses on the application of

Chapter 3 • The Role of Evidence-Based Health Care 39

individual research findings to planning and implementing patient care, whereas evidence-based practice is an integration of factors such as clinical expertise, clini- cal context, and patient preferences with the best available international evidence identified by a transparent, systematic research process called systematic review.

Systematic Review

A systematic review is the use of explicit, scientifically rigorous, and trans- parent research methods to critically appraise and synthesize the data from more than one research study. A systematic review protocol provides a plan to ensure scientific rigor and to minimize potential bias in the review. See Box 3.1 for the JBI steps in a systematic review protocol.

BOX 3.1

JBI Steps to a Systematic Review Protocol

1. Background: Provide a rationale for the systematic review through initial explora- tion of the research literature.

2. Review Questions/Objectives; Statement of PICO or PICo Questions; In quan- titative reviews, questions should be specific regarding the patient problem or pop- ulation (P), intervention (I), comparison intervention (C), and outcomes (O) (PICO questions) to be investigated. For instance, how effective is vitamin C compared with vitamin D in reducing pain in patients with osteoarthritis? Other types of ques- tions for systematic reviews focus on the meaning of an experience, as opposed to the effectiveness of an intervention. The focus is on the phenomena of interest (PI) and the context (Co) (PICo questions). These types of questions are sometimes called meaningful questions, and this research is usually qualitative in design. For example, what is the experience of receiving a massage after a chemotherapy treatment?

3. Inclusion Criteria: Include types of participants, interventions in quantitative reviews of phenomena of interest, outcomes or context in qualitative reviews.

4. Types of Studies: Choose RCTs or other quantitative designs, or the array of qual- itative designs in qualitative reviews.

5. Search Strategies: Strategies must be transparent; identify a search strategy and the databases to be searched.

6. Assessment of Methodological Quality: Identify the appraisal instruments to be employed for judging the quality of the included studies.

7. Data Collection: Identify the extraction tools that will be used to extract data from the studies.

8. Data Synthesis: State how the data will be synthesized, for example, by meta- analysis or meta-aggregation.

9. Statement of Conflict of Interest

Source: Joanna Briggs Institute.

40 Unit 1 • Healing Practices

Evidence-based nursing, although closely aligned with evidence-based medicine, has differentiated itself by the value the former places on holistic paradigms. This difference is partly reflected in the recognition that in addi- tion to meta-analysis of quantitative studies, evidence-based nursing requires meta-aggregation of qualitative studies ( Jensen & Allen, 1996 ; Sandelowski & Barroso, 2003 ; Walsh & Downe, 2005 ). The latter are particularly important to the discipline of nursing because it is a human science, and a large amount of qualitative research informs its practice.

Controversies Related to Evidence-Based Practice

Evidence-based nursing has not escaped controversy in the nursing literature. Fawcett, Watson, Neuman, Walker, and Fitzpatrick ( 2001 ) and Upton ( 1999 ) expressed concern that the practice of evidence-based nursing is more focused on the science of nursing than the art of nursing. They feared that this would compromise nursing’s holistic roots. Melnyk and Fineout-Overholt ( 2005 ) and Mitchell ( 1999 ) cautioned that the practice of evidence-based nursing could lead to a kind of cookbook nursing with emphasis on only the tech- nical side of practice. Ingersoll ( 2000 ) suggested that ethical concerns are raised when the reimbursement of health care is connected exclusively to a documented body of evidence.

These and other concerns were addressed by DiCenso et al. ( 2005 ), who pointed out that evidence-based practice not only is informed by research studies but also is determined by context, available resources, patient preferences, expert opinion, and feasibility. Rycroft-Malone ( 2004 ) supported this view in her contention that evidence-based practice involves both quantitative and qualitative evidence, clinical expertise, patient experiences, and consideration of local and organizational influences.

The scholarly debate pertaining to evidence-based nursing practice is healthy for the profession, and owing to the expansion of the definition to include patient preference, clinical expertise, and context of care, there appears to be less fear that the practice will diminish the holistic values of the disci- pline of nursing. Rittenmeyer ( 2012 ) contends that as long as one adheres to the expanded definition of evidence-based practice, it is hard to see the con- flict between the aims and structures of theory-guided practice and evidence- based practice.

EVIDENCE-BASED PRACTICE MODELS

The primary rationale for the use of evidence-based practice (EBP) is that it increases nurses’ confidence that medical care and nursing care will lead to better patient outcomes. Another reason is the long lag time between knowl- edge generation and the use of that knowledge in the planning and provision of care by clinicians. The summaries of systematic reviews, such as best prac- tice sheets, provide a more expedient way for clinicians to access knowledge.

Chapter 3 • The Role of Evidence-Based Health Care 41

It is difficult for busy clinicians to keep up when approximately 1,500 articles, 55 new clinical trials, 1,500 books, and more than 7,000 systematic reviews are produced annually.

Models of Practice

Numerous models of evidence-based practice can be found in the litera- ture. The ACE Star Model ( Academic Center for Evidence-Based Nursing, n.d. ) from the University of Texas, and the Iowa Model from the Univer- sity of Iowa ( Iowa Model of Evidence-Based Practice, n.d. ) are examples of these. A discussion of all models of evidence-based practice is beyond the scope of this chapter but can readily be found on their websites. This chap- ter focuses on the Joanna Briggs Institute (JBI) model of evidence-based practice.

The JBI model of evidence-based health care conceptualizes evidence- based practice as “clinical decision-making that considers the best available evidence, in the context in which the care is delivered, client preference and the professional judgment of the health professional” ( Pearson, Wiechula, Court, & Lockwood, 2007 , p. 85 ). Included in the model are four major compo- nents of the evidence-based health care process, namely, health care evidence generation, evidence synthesis, evidence (knowledge) transfer, and evidence utilization ( Pearson et al., 2007 ).

The JBI model depicts health care as a cyclical process that derives its foci from the identification of global health care needs by clinicians and patients or consumers and addresses those needs by generating knowledge and evidence to effectively and appropriately meet those needs “in ways that are feasible and meaningful to specific populations, cultures and set- tings” ( Pearson et al., 2007 , p. 86 ). Lastly, the evidence is then appraised and synthesized and transferred to health care delivery systems and clinicians who utilize and evaluate its impact on health outcomes ( Pearson et al., 2007 ). Figure 3.1 depicts the JBI model.

Barriers to Evidence-Based Practice

Grol and Grimshaw ( 2003 ) and Grol and Wensing ( 2004 ) contended that one of the most consistent findings in health services research is the gap between best practice and actual clinical care. A review of studies in countries such as the United States and the Netherlands indicated that 30% to 40% of patients do not receive care based on the best available scientific evidence. A study by Hannes, Vandersmissen, De Blaesar, Peeters, Goedhuys, & Aertgeerts ( 2007 ) of 53 Flemish nurses identified some of the following barriers to EBP: lack of time and resources, resistance to change, lack of responsibility in the uptake of evidence, and unequal power structures for decision making. Melnyk and Fineout-Overholt ( 2005 ) likewise identified such barriers to EBP in nursing as lack of knowledge, lack of time or resources, and overwhelming clinical responsibilities.

42 Unit 1 • Healing Practices

EVIDENCE-BASED PRACTICE AND COMPLEMENTARY AND ALTERNATIVE THERAPIES

The use of complementary and alternative therapies is becoming increasingly prevalent. Persons choose to pursue complementary treatment for myriad reasons, such as quality-of-life issues, holistic beliefs, unresolved pain, cultural

Dis cou

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implementation F A M E *

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change

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Evidence Synthesis

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nPractice Change

Evaluation ofimpact onsystem/processoutcome

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Global Health

* F A M E

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A p p r o p r i a t e n e s s

M e a n i n g f u l n e s s

E ff e c t i v e n e s s

FIGURE 3.1 Joanna Briggs Institute of Evidence-Based Practice

Source: From The JBI Model of Evidence-Based Healthcare, by A. Pearson, R. Wiechula, A. Court, and C. Lockwood, 2005, International Journal of Evidence Based Healthcare, 3(8): 209.

Chapter 3 • The Role of Evidence-Based Health Care 43

values, or simply to avoid the invasiveness of biomedical treatments. Some have contended that the use of complementary and alternative therapies has increased because patients are dissatisfied with traditional Western health care. This may be true for some, but data from a U.S. national survey do not support this view. Adults often use and seem to value both. Of 831 respon- dents who saw a medical doctor and used complementary therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone ( Eisenberg et al., 2001 ).

In an update of the work of Eisenberg et al., the National Center for Complementary and Alternative Medicine (NCCAM), a part of the National Institutes of Health (NIH), released the 2007 National Health Interview Sur- vey (NHIS) titled Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007 ( Nahin, Barnes, Stussman, & Bloom, 2009 ). The results of this study are found in Box 3.2 . Com- pared with the results of the earlier survey by Eisenberg et al., the data sug- gest that visits to CAM providers decreased (except for acupuncture), but the use of self-care CAM strategies increased.

To relate evidence-based health care to complementary and alternative health care may seem at first glance an uncomfortable fit, but it appears this is no longer true. It is significant that the Cochrane Collaboration has a working group called the Complementary Alternative Medicine Field. The mission of this group is to facilitate the systematic review of existing randomized con- trolled trials (RCTs) to provide information to benefit clinical decision making and the planning of future research in the field of complementary health care. The group also maintains a database of RCTs pertaining to CAM. Manheimer and Berman ( 2008 ) reported that as of 2007, there were 313 completed Cochrane complementary medicine systematic reviews in the Cochrane

BOX 3.2

• In 2007, adults spent $33.09 billion out of pocket on visits to CAM practitioners and purchase of CAM products.

• Nearly two thirds of the total out-of-pocket costs were for self-care purchases of CAM products.

• Approximately one third was spent on visits to CAM practitioners. • Approximately 38.1 million adults made an estimated 354.2 million visits to practi-

tioners of CAM. • About three quarters of both visits to CAM practitioners and total out-of-pocket

costs spent on CAM practitioners were associated with manipulative and body- based therapies.

• About $14.8 billion was spent on the purchase of nonvitamin, nonmineral natural products.

44 Unit 1 • Healing Practices

Collaborative Library and 180 complementary protocols. As of 2013, there were 568 documents relating to complementary and alternative therapies on the Cochrane Collaboration website. An increasing number of systematic reviews in the field of complementary interventions can be found in other sources as well, suggesting an increasing demand by health care practitio- ners for knowledge generated by systematic reviews of complementary and alternative therapies.

Web-Based Resources in Evidence-Based Practice

The following are valuable resources for practitioners seeking information on evidence-based practice:

• About the Cochrane Library www.cochrane.org • Evidence-Based Practice Centers www.ahrq.gov/professionals/clinicians-

providers/ • The Joanna Briggs Institute for Evidence Based Nursing and Midwifery

www.joannabriggs.edu.au/ • The NICHD Cochrane Neonatal Collaborative Review Group (alpha-

betic listing of systematic reviews) www.nichd.nih.gov/cochrane /Pages/cochrane.aspx

• Clinical Evidence (subscription required): clinicalevidence.com

Guidelines

• National Guideline Clearinghouse www.guideline.gov • CDC Recommends: The Prevention Guidelines System www.cdc.gov

/wonder/prevguid.html • Society of Critical Care Medicine www.sccm.org • Institute for Clinical Systems Improvement www.icsi.org/ • National Kidney Foundation Clinical Practice Guidelines www.kidney.

org/professionals/kdoqi/guidelines_commentaries.cfm • NIH Consensus Statements—Index by Date consensus.nih.gov • PDQ (Physician Data Query): NCI’s Comprehensive Cancer Database

www.cancer.gov/ncicancerbulletin/011012/page6 • Registered Nurses Association of Ontario (RNAO) www.rnao.org/ (see

Best Practice Guidelines)

Implementation and Links

• The Hartford Institute for Geriatric Nursing http://hartfordign.org/ • Getting Research into Practice (how to make a change in practice) www

.shef.ac.uk/scharr/ir/units/resprac/index.htm

Chapter 3 • The Role of Evidence-Based Health Care 45

References

Academic Center for Evidence Based Nurs- ing. (n.d.). Explanation of the ACE Star Model of Knowledge Transformation. Retrieved from www.acestar.uthscsa .edu/Learn_model.htm

DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Introduction to evidence based nursing. In A. DiCenso, D. Ciliska, & G. Guyatt (Eds.), Evidence-Based Nursing: A Guide to Clinical Practice (pp. 3 – 19 ). St. Louis, MO: Elsevier.

Fawcett, J., Watson, J., Neuman, B., Walker, P. H., & Fitzpatrick, J. J. (2001). On nursing theories and evidence. Journal of Nursing Scholarship , 33(2): 115–119.

Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change. Lancet , 362: 1225–1230.

Grol, R., & Wensing, M. (2004). What drives change? Barriers to and incen- tives for achieving evidence-based practice. Medical Journal of Australia , 180: 57–60.

Hannes, K., Vandersmissen, J., De Blaeser, L., Peeters, G., Goedhuys, J., & Aertgeerts, B. (2007). Barriers to evidence based nurs- ing: A focus group study. Journal of Advanced Nursing, 60(2): 162–171.

Hopp, L., & Rittenmeyer. L. (2012). Intro- duction to Evidence-Based Practice: A Practical Guide for Nursing . Philadelphia, PA: F.A. Davis.

Ingersoll, G. L. (2000). Evidence-based nursing: What it is and what it isn’t. Nursing Outlook , 48: 151–152.

Iowa Model of Evidence Based Practice. (n.d.). Explanation of the model. Retrieved from www.uihealthcare.com/depts /nursing/rqom/evidencebasedpractice /iowamodel.html

Jensen, L., & Allen, M. (1996). Metasyn- thesis of qualitative findings. Qualita- tive Health Research , 6(4): 553–560.

Joanna Briggs Institute. (n.d.). Definition of evidence based practice and nursing. Retrieved from www.joannabriggs .edu.au/

Manheimer, E., & Berman, B. (2008). Cochrane complementary medicine field: About the Cochrane Collabora- tion (fields). Cochrane Collaboration (2): CE000052.

Melnyk, B. M., & Fineout-Overholt, E. (2005). Making the case for evidence- based practice. In B. M. Melnyk & E. Fineout-Overhold (Eds.), Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice (pp. 3 – 24 ). Philadelphia, PA: Lippincott Williams & Wilkins.

Mitchell, G. J. (1999). Evidence-based prac- tice: Critique and alternative view. Nurs- ing Science Quarterly , 12(1): 30–35.

Muir-Gray, J. A. (1997). Evidence Based Health Care: How to Make Health Policy and Management Decisions. New York, NY: Churchill Livingstone.

Nahin, R., Barnes, P., Stussman, B., & Bloom, B. (2009). Costs of complementary and alterna- tive medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. National Health Statistics Report; no. 18. Hyattsville, MD: National Center for Health Statistics.

Pearson, A., Wiechula, R., Court, A., & Lockwood, C. (2007). A re-construction of what constitutes “evidence” in the healthcare professions. Nursing Science Quarterly , 20(1): 85–88.

Rittenmeyer, L. (2012). Why bother with theory. In L. Hopp & L. Rittenmeyer, I n t r o d u c t i o n t o E v i d e n c e – B a s e d

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Practice: A Practical Guide for Nursing. Philadelphia, PA: F. A. Davis.

Rycroft-Malone, J. (2004). The PARIHS framework: A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quar- terly , 19(4): 297–304.

Sackett, L., Rosenberg, C., Gray, M., Haynes, B., & Richardson, S. (1996). Evidence-based medicine: What it is and what it is not. British Medical Journal , 312: 71–72.

Sandelowski, M., & Barroso, J. (2003). Creating metasummaries of qualitative

findings. Nursing Research , 52(4): 226–233.

Sigma Theta Tau International. (n.d.). Position statement on evidence based nursing. Retrieved from www .nursingsocieity.org/research/main.html

Upton, D. J. (1999). How can we achieve evidence-based practice if we have a the- ory-practice gap in nursing today? Jour- nal of Advanced Nursing , 29(3): 549–555.

Walsh, D., & Downe, S. (2005). Meta- synthesis method for qualitative research: A literature review. Journal of Advanced Nursing , 50(2): 204–211.

Systematized Health Care

Practices Everything on earth has a purpose, every disease an herb to

cure it, and every person a mission. This is the Indian theory of existence.

Mourning Dove

2 U N I T

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4 Traditional Chinese Medicine

A cheerful heart is good medicine, but a downcast spirit dries up the bones.

Proverbs 17:22

Traditional Chinese Medicine (TCM) originated in Chinese culture more than 3,000 years ago and has spread, with variations, throughout other Asian countries, particularly Japan, Korea, Tibet, and Vietnam. As a comprehensive health sys- tem, it has a range of applications, from preventive health care and maintenance to diagnosis and treatment of acute and chronic disorders.

BACKGROUND

Traditional Chinese Medicine has a long and extensive history. Shen Nong, the Fire Emperor, said to have lived from 2698 to 2598 b.c. , is considered the founder of herbal medicine in China. The written history itself is more than 2,500 years old, dating to the text on internal medicine of Huang Di, the Yellow Emperor. Written long before the birth of Hippocrates, the father of Western medicine, Yellow Emperor’s Classic of Medicine covers such princi- ples as yin and yang, the five phases, the effects of the season, and treatments such as acupuncture and moxibustion.

TCM is associated with early Taoists and Buddhists, who observed energy within themselves, in plants and animals, and throughout the cosmos. Based on a belief in the natural order of the universe and the direct correlation between the human body and the cosmos, TCM philosophy stresses the constant search for harmony and balance in an environment of constant change. By the close of the Han era ( a.d. 220), the Chinese had a clear grasp

49

50 Unit 2 • Systematized Health Care Practices

of pathology, preventive medicine, first aid, and dietetics and had devised breathing practices to promote longevity. During the fourth and fifth centuries a.d. , China’s influence spread throughout Asia, and both Taoism and Buddhism had a marked impact on ideas about health. Sun Si Mian ( a.d. 581– 682), a famous physician, established himself as China’s first medical ethicist. He advocated the need for rigorous scholarship, compassion toward patients, and high moral standards in physicians. In the 11th century, TCM began to focus more on social phenomena, especially human relations and ethical behavior. Initially, this orientation resulted in increased scientific medical study and publications. As TCM developed further, people began to take for granted that a breakthrough in one realm of knowledge would eventually solve all problems of human existence. (As in the West, some assume that advances in technology will solve all problems.) Eventually, sociological methods were used to solve medical problems, and clinical and empirical research reached a low point. Fortunately, the core of the scientific system was never obliterated, and the past 50 years have seen a worldwide revival of TCM ( McNamara & Ke, 2012 ; Zhu, 2012 ). In China today, TCM is practiced in hospitals along with Western medicine. Physicians study not only principles of anatomy, histology, biochemistry, bacteriology, and surgery but also acupuncture, acupressure, and herbal medicine. Patients can choose TCM or Western approaches or a combination of these for their particular problem. Inpatient and outpatient care is provided in large, well-equipped hospitals, as well as in private clinics and pharmacies.

PREPARATION

As of 2013, the Council of Colleges of Acupuncture and Oriental Medicine consisted of 53 schools of acupuncture in the United States that had been fully accredited or were candidates for accreditation with the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). An accredited graduate-level program consists of 2,625 hours or 146 credits covering Oriental medicine, acupuncture theory, Chinese herbs, and biomedicine theory. Additionally, 1,330 hours of clinical practice are required. Practitioners who already have a master’s degree in acupuncture are eligible for an herb certificate program of 450 hours of didactic instruction and 210 hours of clinical training in the use of Chinese herbs. Forty-three states plus the District of Columbia require passing a national board exam as a prerequisite for licensure. In addition, each state has its own eligibility requirements.

CONCEPTS

The focus of Traditional Chinese Medicine is on the patient rather than on disease, with the goal to promote health and improve the quality of life. A basic understanding of TCM requires recognition of its long-lived tradition, multiple philosophies, and varied practices. It is impossible to separate the individual concepts and the specific treatment approaches from the context of

Chapter 4 • Traditional Chinese Medicine 51

a complete theoretical system. Prevention, diagnosis, and treatment of dis- eases are based on the concepts of qi, yin and yang, the five phases, the five seasons, and the three treasures. Often only isolated fragments of TCM emerge in the West.

Qi

The concept most central to TCM is qi or chi (pronounced “chee”), which is translated as energy. Qi represents an invisible flow of energy that circulates through plants, animals, and people, as well as through the earth and sky. It is what maintains physiologic functions and the health and well-being of the individual. In TCM theory, energy is distributed throughout the body along a network of energy circuits or meridians connecting all parts of the body. The many different types of qi in the body are described according to their source, location, and function. Yin qi supports and nourishes the body, wei qi protects and warms the body, jing qi flows in the meridians, zang qi flows in the organs, and zong qi is responsible for respiration and circulation. Obstructed qi flow in the human body can cause problems ranging from social difficulties to illness. Its effects are specific to each individual—a person gets sick, has problems at work, or fights with family—and depend on each individual’s unique qi. Cer- tain TCM treatments such as meditation, exercise, and acupuncture are ways of enhancing or correcting the flow of qi ( Ody, 2011 ).

Yin and Yang

In Taoist philosophy, wholeness comprises the union of opposites—dark and light, soft and hard, female and male, slow and fast, and so on. These opposite but complementary aspects are called yin and yang . Originally, the terms desig- nated geographic aspects such as the shady and sunny side of a mountain or the southern and northern bank of a river. Currently, the terms are used to character- ize the polar opposites that exist in everything and make up the physical world.

From the health perspective, the basis of well-being is the appropriate balance of yin and yang as they interact in the body. Imbalance of yin and yang is considered to be the cause of illness. Yin is the general category for passivity and is like water, with a tendency to be cold and heavy. Yin uses fluids to moisten and cool the body. It provides for restfulness as people slow down and sleep. Yin is associated more with substance than with energy. Things that are close to the ground are yin or more earthy. Yin is associated with the symptoms of coldness, paleness, low blood pressure, and chronic conditions. People with excess yin tend to catch colds easily and are sedentary and sleepy. Yang is the general category for activity and aggressiveness. It is like fire, with its heating and circulating characteristics. Associated with things higher up or more heavenly, yang is the energy that directs movement and supports its substance. Symptoms such as redness in the face, fever, high blood pressure, and acute conditions are associated with yang. People with excess yang tend to be nervous and agitated and cannot tolerate much heat ( McNamara & Ke, 2012 ). It must be understood that yin and yang cannot exist

52 Unit 2 • Systematized Health Care Practices

independently of each other. Figure 2.1 in Chapter 2 showed the t’ai chi sym- bol of yin and yang. Nothing is either all yin or all yang. They are complemen- tary and depend on each other for their very existence—without night there can be no day, without moisture there can be no dryness, and without cold there can be no heat. It is the interaction of yin and yang that creates the changes that keep the world in motion; summer leads to winter, and night becomes day. Yin and yang are used in both the diagnosis and the treatment of illness. For example, if a person is experiencing too much stress—usually understood as an excess of yang—more yin activities, such as meditation and relaxation, constitute the appropriate treatment.

Five Phases

As they studied the world around them, the Chinese perceived connections between major forces in nature and particular internal organ systems. Seeing similarities between natural elements and the body, early practitioners developed a concept of health care that encompassed both natural elements and body organs. This theory is known as the five phases theory ( wu-hsing ). Five elements—fire, earth, metal, water, and wood—represent movement or energies that succeed one another in a dynamic relationship and in a continuous cycle of birth, life, and death. These elements do not represent static objects, since even mountains and rivers change constantly with time. In the five phases theory, it is not the substances themselves that are important but their interactions in making up the essential life force or qi ( McNamara & Ke, 2012 ; Zhu, 2012 ).

The rhythm of events resembles a circle known as the creation cycle. In this cycle, burning wood feeds fire; from its ashes, fire produces earth; earth in turn gives up its ore, creating metal; from condensation on its surface, metal brings forth water; and water nourishes and creates plants and trees, creating wood. Each element is related to a pair of internal organs. The yin organ is solid and dense, like the liver, while its yang partner is hollow or forms a pocket, like the gallbladder. The proper interaction of the organ partners influences how well the entire body functions. Fire is linked to the circulation of blood, hor- mones, and food. Its partner organs are the heart (yin) and small intestine (yang). Earth is linked to digestion and comprises the spleen/pancreas (yin) and the stomach (yang). Metal is linked to respiration and elimination and is made up of the lungs (yin) and large intestine (yang). Water is linked to elimination and comprises the kidneys (yin) and urinary bladder (yang). Wood is linked to toxic processing and is made up of the liver (yin) and gallbladder (yang). In addition, each organ is related to a time of day of optimal functioning. If a problem occurs during those hours when an organ is most vulnerable, the timing may alert a TCM practitioner of an imbalance in that organ system ( Zhu, 2012 ).

Five Seasons

The four cardinal compass directions—south, west, north, and east—are affiliated with four of the five elements: fire, metal, water, and wood. The fifth element, earth, is depicted in the center. The Chinese place so much

Chapter 4 • Traditional Chinese Medicine 53

importance on the direction south that they put it at the top of their maps and navigate from it in the same way that Westerners use north. Just as south rules the top of the compass, it also represents summer, the “high noon” of the year, and is linked to fire. West, the direction of the setting sun, is associ- ated with autumn and metal, which is used to make tools for harvesting. North is linked to winter and water, the opposite of the element fire, and is seen as a period of dormancy. East, the direction of the rising sun, is associ- ated with spring and with wood, which represents all growing things. The fifth and central element, earth, is related to the late summer season and a time of maturity. Figure 4.1 illustrates the five directions as they correlate to the five seasons and the five elements.

The etiology of disease in TCM is linked to the five phases, five seasons, and five directions. It is believed that if one component is overbearing and excessive, then another becomes weak and debilitated. It is a complex system of checks and balances that is often not easily grasped by those with a West- ern perspective. Diagnosis and treatment of illness depends on understanding the five elements, seasons, and directions and how they interact.

Three Treasures

The Chinese believe that a combination of life force elements makes up the substance and functions of the body, mind, and spirit, and that these three are all one and the same. One way to understand this connection is to think of water and its wet, fluid nature. Compare liquid water with ice, which not only appears different but feels hard and cold. And then consider steam and its hot, gaseous nature. Despite the differences in appearance, the three different

SOUTH

Summer Fire Peak

CENTER

Late summer Earth Maturity

EAST

Spring Wood Growth

WEST

Autumn Metal Tools

NORTH

Winter Water Dormancy

FIGURE 4.1 Five Directions/Seasons/Elements

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forms are the same substance. In the same way, body, mind, and spirit can be seen as different expressions of the same individual ( Ody, 2011 ).

The Taoists call body, mind, and spirit the three “vital treasures.” They are jing , meaning basic essence; qi , meaning energy or life force; and shen , mean- ing spirit and mind. The balance of their abundance or deficiency influences the state of health. Jing is the essence with which people are born. It is similar to Western concepts of genes, DNA, and heredity. Essence is the gift from one’s parents; it is the basic cellular material that allows that cell to function. It is the bodily reserve that supports life and must be restored by food and rest.

There are several types of qi: the hereditary qi, which is from the jing; the nutritive qi derived from food; and the cosmic qi from the breathed air. Wei qi is a specialized qi associated with the immune system. Wei qi circulates near the surface of the body and is the first level of protection when a bacterium or virus tries to enter the body. If the circulating wei qi is weak, it can allow a pathogen to enter the body, and illness ensues.

The vital treasure known as shen is the gift from heaven and represents spiritual and mental aspects of life. Shen comprises one’s emotional well- being, thoughts, and beliefs. It is the radiance, or inner glow, that can be per- ceived by others. For people to be healthy, their physical, emotional, mental, and spiritual aspects must be balanced ( Ody, 2011 ).

VIEW OF HEALTH AND ILLNESS

The Chinese regard the body as a system that requires a balance of yin and yang energy to enjoy good health. Each part of the body is also thought of as an individual system that requires its own balance of yin and yang to function properly. A headache is not just an event in the head, and it is more than just a pain. In Traditional Chinese Medicine, a headache is the obstruction of energy related to the overall energy patterns in the body as well as the circum- stances and lifestyle of the sufferer. TCM assumes that a balanced body has a natural ability to resist or cope with agents of disease. Symptoms are caused by an imbalance of yin and yang in some part of the body, and illness can develop if the balance is disturbed for any length of time. Therefore, health is maintained by recognizing an imbalance before it becomes a disease. It is believed that everything needed to restore health already exists in nature, and it is up to the individual, with or without the aid of a health practitioner, to free up energy and restore balance using diet, herbs, acupuncture, and other yin/yang treatments ( Ody, 2011 ; Zhu, 2012 ).

The Chinese believe that all living things—people, the earth, the universe—are connected by cosmic energy. Thus, the balance of qi in an indi- vidual is connected to the balance in the environment; the forces active within the world are the same forces active within the individual body. Simply put, nothing happens without consequence to something else. The concern for bal- ance and harmony is reflected not only in the TCM approach to the individ- ual but also in the view that the balance and well-being of the resources of the

Chapter 4 • Traditional Chinese Medicine 55

natural world and society are vital to the overall health of all who live on the earth. Practitioners never lose sight of the multifaceted relationship between individuals, communities, societies, and nature.

Because the human body is a microcosm of the universe, extremes of climate in the body can create problems, just as extreme environmental condi- tions can wreak havoc on the environment. Sometimes, people experience a “cold” or yin illness caused by too much coldness in the body. For example, the symptoms of a “cold” influenza include a low-grade fever, no sweating, headache, muscle aches, stuffy nose, and a cough with clear white phlegm. Some influenzas are “hot” or yang influenzas caused by too much heat in the body. Symptoms include high fever, sweating, headache, dry or sore throat, thirst, and nasal congestion with sticky or yellow mucus. Too much cold in the body requires “warming” remedies, and too much heat in the body requires “cooling” remedies ( Ody, 2011 ).

DIAGNOSTIC METHODS

The Traditional Chinese Medicine practitioner has four diagnostic methods ( szu-chen ): inspection, auscultation and olfaction, inquiry, and palpation. These methods gather information about the five phases and their related body systems. The practitioner examines how the person eats, sleeps, thinks, works, relaxes, dreams, and imagines. No part of the self is considered a neu- tral bystander when the body is in a state of imbalance.

Inspection

Inspection refers to the visual assessment of the spirit and physical body of patients. Spirit inspection or observation is an assessment of the person’s overall appearance, especially the eyes, the complexion, and the quality of voice. Good spirit, even in the presence of serious illness, indicates a more positive prognosis. Tongue diagnosis is a highly developed system of inspection of the physical body. The tongue is considered to be the visual gateway to the interior of the body. The whole body “lives” on the tongue, rather like a hologram. Different areas of the tongue correspond to the five phases and related organ systems, as depicted in Figure 4.2 . The central area of the tongue is related to the spleen/pancreas and stomach. The very back of the tongue reflects the kidneys and urinary bladder. The sides of the tongue are related to the liver and gallbladder. The very tip of the tongue corresponds to the heart, and surrounding the heart are the lungs in the front third of the tongue. The practitioner inspects the color, shape, markings, and coating of the tongue to gather information about the state of balance in the person’s body. For example, a moist tongue with a thin white coating may signal the presence of a “cold” or yin illness, whereas a dry, yellow, or dark tongue may signal a “hot” or yang illness ( McNamara & Ke, 2012 ).

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Auscultation/Olfaction

The second part of diagnosis, auscultation and olfaction, refers to listening to the quality of speech, breath, and other sounds, as well as being aware of the odors of breath, body, and excreta. Types of sound are associated with the five phases and organ systems. How the person is breathing is a good indication of the status of the organs. Phases and organ systems are associated with specific odors such as sickly sweet, rotten, putrid, rancid, and scorched. Odors can arise from the skin itself or from the ears, nose, genitals, urine, stool, or bodily discharges. The breath may also have a distinctive odor. Usually, the stronger the odor, the more serious the imbalance has become.

Inquiry

The third part of diagnosis, inquiry, is the process of taking a comprehensive health, social, emotional, and spiritual history. The practitioner questions the person not only about the presenting complaint but also about many other factors, including sensations of hot and cold, perspiration, excreta, hearing, thirst, sleep, digestion, emotions, sexual drive, and energy level.

Kidneys/urinary bladder

Spleen/pancreas stomach

Lungs

Heart

Liver/gallbladder

FIGURE 4.2 Tongue Map

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Palpation

Palpation is the fourth diagnostic method and includes pulse examination, general palpation of the body, and palpation of the acupuncture points. Read- ing the pulses, or pulse diagnosis , can provide key information about the person’s condition. For example, a fast pulse might indicate a problem with an overactive heart or liver; a slow pulse might indicate a sluggish digestive system; pulses described as wide, flat, and soft might indicate a spleen prob- lem; and narrow, forceful pulses might indicate a liver dysfunction. The radial pulse is felt in three positions and two layers on both the right and the left arm. The more superficial, or surface layer, belongs to the yang organs; the deeper layer belongs to the yin organs. The locations of major points used in pulse diagnosis are illustrated in Figure 4.3 . The pulse allows the practitioner to feel the quality of qi and blood at the different locations in the body. Twenty-nine pulse qualities are described according to size, rate, depth, force, and volume. Examples of qualities are surging, scattered, vacuous, slippery, stringlike, and flat ( Ody, 2011 ).

All this diagnostic information is compiled to arrive at a “pattern of dis- harmony,” or bian zheng . A single biomedical disease can be associated with a large number of Chinese diagnostic patterns. A lower urinary tract infection,

(s) Small intestine (d) Heart

(s) Gallbladder (d) Liver

(s) Urinary bladder (d) Kidney yin

(s) Large intestine (d) Lung

(s) Stomach (d) Spleen/pancreas

(s) Kidney yang (d) Pericardium

(s) = Superficial (d) = Deep

Left hand Right hand

FIGURE 4.3 Location of Major Points Used in Pulse Diagnosis

58 Unit 2 • Systematized Health Care Practices

for example, might be related to one of four distinct diagnostic patterns. Each of these patterns would be treated in different ways, as it is said, “one disease, different treatments.” Also, many different biomedical diseases may fall into one pattern, thus the saying, “different diseases, one treatment.”

TREATMENT

Because an individual’s combinations of yin and yang are unique, Traditional Chinese Medicine practitioners must tailor their treatment to each client. The goal of treatment is to reestablish a balanced flow of energy in the person through diet, herbs, massage, acupuncture, qigong, and gua sha. Feng shui, although not considered an actual treatment, is employed to improve health and well-being.

Diet

The simplest and most accessible treatment is diet. Dietary interventions are individualized on the basis of the individual’s pattern of disharmony. Foods are used to rebalance the body’s internal “climate” by bringing warmth to coldness or by cooling off too much heat. The thermal nature of food is described by the way a person feels after ingesting it. For example, after eating watermelon or asparagus, which are cooling foods, one feels physically and emotionally cooler. An internal feeling of warmth comes after eating warming foods such as salmon, lamb, or sweet potatoes. Neutral foods do not create a specific thermal quality and are thus good diet balancers. A diet to maintain health should be varied and include a minimum of seven different fruits and vegetables a day to avoid a cold or a hot imbalance. If a person is ill and the symptoms indicate a hot condition, then the diet should emphasize cooling foods, and vice versa. In addition to the overall daily diet, specific foods are used as medicines to correct hot and cold imbalances ( Zhu, 2012 ). Box 4.1 lists common foods and their thermal effects on the body.

Foods are categorized according to one of six tastes, each having a specific function in the body. Sweet foods are often used to aid digestion and qi, and influence the spleen and stomach. Salty foods affect the kidney and bladder and are often used to “soften” cysts or tumors and may be tried before surgery. Sour foods, such as lemons or tomatoes, are used to dry mucous membranes in the intestinal, urinary, reproductive, or respiratory surfaces. Pungent foods such as garlic and onion are used to aid digestion, stimulate circulation, and promote sweating. Bitter foods, such as greens or tonic water, also help in digestion and are used to regulate the bowels. Astringent foods, such as beans or potatoes, stop the flow of bodily secretions such as tears, saliva, and sweat.

Each food has both yin and yang energies, but often one predominates. Cooling foods and those with bitter and salty flavors are yin. Warming foods are yang, as are foods with pungent and sweet flavors. When people have an excess of yin they may be sluggish, laid back, calm, slightly overweight, and emotionally sensitive. To balance these overly yin tendencies, yang foods are

Chapter 4 • Traditional Chinese Medicine 59

added to the diet to help activate the metabolism and provide more energy. People experiencing an excess in yang may be tense, loud, hyperactive, and aggressive. Adding yin foods to the diet cools their internal tension.

TCM practitioners recommend certain foods for balancing and improv- ing a variety of conditions. Foods can be potent healers, especially when deal- ing with temporary illnesses, but they are never used as a lone treatment for serious or chronic conditions.

Herbs

Herbal medicine ( ahong yao ) is an integral part of TCM. In terms of the complex- ity of diagnosis and treatment, it resembles the practice of Western internal medicine. Herbs may be taken in the form of tea, or the substances may be pow- dered and made into pills, pastes, or tinctures for internal or external use. Just as with food, some herbs are warming (cinnamon) and some are cooling (mint).

With the exception of conditions that require surgery, herbs can be used to treat almost any condition in the practice of TCM. Herbs are often pre- scribed in complex mixtures and tend not to be used as isolated components, for example, as extractions from the parent plant. TCM practitioners believe that the healing benefits of herbs result from the synergistic interactions of all the components of the plant. The same herb can be used for many different disorders. Likewise, the same disorder in different people will be treated with different herbs, depending on the assessment of the individual. Herbs are used in the following ways: antiviral, antibacterial, antifungal, and anticancer. Herbs are also used to treat pain, aid digestion, lower cholesterol, treat colds and flus, increase resistance to disease, enhance immune function, improve

BOX 4.1

Thermal Food Qualities

Cooling

Pork, duck, eggs, clams, crab, millet, barley, wheat, lettuce, celery, broccoli, spinach, tomato, banana, watermelon, asparagus, ice cream, soy sauce

Neutral

Beef, beef liver, rabbit, sardines, yam, rice, corn, rye, potato, beet, turnip, carrot, lemon, apple

Warming

Tuna, turkey, salmon, lamb, venison, chicken, chicken liver, shrimp, trout, oats, cabbage, squash, kale, scallion, celery, ginger, sugar, garlic, pepper

60 Unit 2 • Systematized Health Care Practices

circulation, regulate menstruation, and increase energy ( Zhu, 2012 ). Box 4.2 lists herbs commonly used as tonics in TCM. Chapter 7 covers the use of herbs in greater detail.

Massage

Traditional Chinese massage methods were described in texts as early as 200 b.c. Tui na is the forerunner of all forms of massage therapy that exist today. It differs from other forms of massage in that it is used to treat not only muscu- loskeletal problems but also internal diseases. Tui na practitioners must know

BOX 4.2

Tonic Herbs Frequently Used in Traditional Chinese Medicine

Herb Use

Astragalus Enhances immune function by increasing activity of WBCs; increases production of antibodies and interferon

Dong quai Blood-building tonic that improves circulation, tones the uterus, balances female hormones

Garlic Lowers blood pressure, lowers cholesterol and triglycerides; antiseptic, antifungal

Ginger Warming effect; stimulates digestion, decreases nausea, relieves aches and pains

Gingko Mediates the allergic and inflammatory reaction in asthma; not to be taken with aspirin or other anticoagulants; discontinue before surgery

Ginseng Increases appetite and digestion, tones skin and muscles, restores depleted sexual energy

Siberian ginseng Enhances immune function, increases energy Green tea Lowers cholesterol; anticancer effects, antibacterial effects Ho shou wu Cleans the blood, nourishes hair and teeth, increases energy; pow-

erful sexual tonic Licorice Used as an expectorant in bronchitis and asthma;

anti-inflammatory, antitussive Ligusticum Inhibits bronchospasm through bronchodilation Ma huang Effective for mild asthma; because it contains ephedrine, in excess

it can cause hypertension, tachycardia, palpitations, headache, ner- vousness, and insomnia. Ephedrine products are banned in many countries because of their use in producing methamphetamines.

Onion (quercetin) Inhibits the platelet-activating factor in asthma

Chapter 4 • Traditional Chinese Medicine 61

Traditional Chinese Medicine to make a diagnosis before beginning treat- ment. Tui na is often combined with qigong exercises for building up general health, strength, and stamina. Both energizing and sedating techniques are used to treat and relieve many medical conditions. The following major tech- niques are in use ( Pritchard, 2010 ):

• Ma — rubbing with palm or fingertips • Pai — tapping with palm or fingertips • Tao — strong pinching with thumb and fingertip • An — rapid and rhythmical pressing with thumb, palm, or back of the

clenched hand • Nie — twisting, with both thumbs and tips of the index fingers grasping

and twisting the area being treated • Ning — pinching and lifting in a stationary position • Na — rhythmic compression along energy channels • Tui — pushing, often with slight vibratory effect

Massage increases circulation of blood and lymph to the skin and under- lying muscles, bringing added nutrients and pain relief. Massage can help restore proper movement to injured limbs and joints and help restore a sense of balance. Massage is an effective method of reducing stress and tension that usually leads to a feeling of relaxation. Massage is the treatment modality of first choice for children. Chapter 12 covers massage in greater detail.

Acupuncture

Acupuncture involves stimulating specific anatomic points called hsueh where each meridian passes close to the skin surface. Puncturing the skin with very fine needles is the usual method, but practitioners may also use pressure (shiatsu), friction, suction, heat, or electromagnetic energy to stimulate points. The primary goal of acupuncture is the manipulation of energy flow through- out the body following a thorough assessment by a TCM practitioner. Treat- ment is offered in the context of the total person and with the goal of correcting the flow of qi to restore health. Some Western health care practitioners who have learned the techniques of acupuncture miss the broader context and limit their focus to an injured or painful body part.

Acupuncture is effective in the treatment of acute and chronic pain and motion disabilities. In addition, it is used in respiratory and cardiovascular con- ditions (asthma, COPD, palpitations, hypertension); eye, ear, nose, and throat disorders (conjunctivitis, tinnitus, Ménière’s disease, rhinitis, sore throat); gas- trointestinal problems (gastritis, ulcers, colitis, constipation, irritable bowel syndrome); urogenital conditions (premenstrual syndrome, endometriosis, menopausal symptoms, prostatitis, incontinence, erectile problems); skin disor- ders (eczema, shingles, urticaria); psychiatric problems (anxiety, depression, schizophrenia); and in addictive disorders and withdrawal syndromes. Auricular acupuncture is a complete system of its own and is quite powerful for balancing the hormones and overall energy of the body. Contraindications

62 Unit 2 • Systematized Health Care Practices

to acupuncture are childhood, pregnancy, hemophilia, and acute cardiovascu- lar disorders ( Ody, 2011 ). Chapter 13 covers acupuncture in more detail.

Moxibustion is an application of heat from certain burning substances at acupuncture points on the body. A systematic review of moxibustion to correct breech birth presentation found it to be effective at 33 to 35 weeks of gestation. The Health Ministry of Spain has begun a multicenter, randomized controlled trial of moxibustion and breech birth ( Zhu, 2012 ).

Cupping is the application of suction cups on the skin. The cups create a vacuum on the skin and break up accumulated toxins. The first few applica- tions result in painless circular areas of erythema or ecchymosis. When the toxins are successfully removed from the body, cupping no longer creates these marks ( Zhu, 2012 ).

Qigong

Qigong (pronounced “chee-gong”) is the art and science of using breath, move- ment, self-massage, and meditation to cleanse, strengthen, and circulate vital life energy and blood. In India the comparable practice is called yoga. Both of these traditions of self-healing have been called “moving meditation” or “medi- tation in motion.” T’ai chi, which is familiar to many Americans, is a more phys- ical form of qigong. In China, millions of people from children, to workers, to elders, to patients in the hospital practice qigong daily. The techniques are easy to learn and simple to apply for all people, well or sick. Qigong decreases fatigue and forgetfulness and generates energy by enhancing bodily functions.

It is inevitable that taking a deep breath triggers a sense of relaxation. By adding the intention to relax with the breath, the effect is even greater. Add- ing gentle movements or self-massage to the deep breathing and relaxation generates increased self-healing abilities. The focus on deep and intentional relaxation allows for release of emotional stress, for a sense of tranquility, and for one’s natural spirituality to arise ( Ody, 2011 ).

Gua Sha

Gua sha (pronounced “gwaw saw”) is a TCM technique of smearing oil on the skin and then rubbing it with a flat jade stone, spoon, or other round- edged tool to bring out impurities in the body. Gua means “to rub or scrape.” Sha is the red rash that appears afterward, signifying that the impurities have been expelled through the skin. Most practitioners do gua sha on the arms, back, and chest, where many of the meridians are located. Gua sha is used to treat such problems as fibromyalgia, hypertension, arthritis, muscle aches, and early onset of colds and flu.

Feng Shui

Feng shui (pronounced “fung shway”) is the ancient Chinese system of arranging the environment for living in harmony with one’s surroundings. It began thousands of years ago in China and India as a process of decorating

Chapter 4 • Traditional Chinese Medicine 63

graves and has now gained popularity in many parts of the world. For mod- ern practitioners, feng shui is a design system based on the flow of energy through one’s home and environment. The primary objective is to control and balance surroundings in a way that brings happiness, prosperity, and health. Feng shui is based on the principles of qi, yin and yang, five phases, five sea- sons, and numbers and as such is an adjunct to other healing methods.

Many people are aware of the impact their surroundings have on them and use feng shui principles to improve their lives. Practitioners assess the interaction between the home’s energy field and those of the people who reside there. These combined energy forces are significant factors in why and how we develop certain diseases and can be altered to improve our health status. Feng shui practitioners help people determine placement of furniture, colors, and designs that are comfortable, healthy, and supportive. For exam- ple, the entrance to the home should draw people into its nurturing space. The front door is seen as an opening for qi, and obstructions near the door can block good qi, prosperity, and luck from entering the home. Feng shui describes stairway placement; front and back door alignment; bedroom arrangement; placement of electronic equipment; living room, dining room, kitchen, and bathroom arrangement; use of a fireplace; as well as the choice of art. Mirrors have many curative uses, such as lighting up dark corners, slow- ing down the flow of qi, and deflecting unwanted influences.

Color is a vibration to which people respond both consciously and unconsciously. Red is stimulating and dominant and is associated with warmth and prosperity. Yellow is associated with intellect, decisiveness, and optimism. Green symbolizes growth, fertility, and harmony, while blue is peaceful and soothing. Purple is dignified and spiritual, brown suggests stabil- ity and safety, pink is linked to happiness and romance, and orange encourages communication. White symbolizes new beginnings and purity. Black is myste- rious and independent. The aim of feng shui is to ensure good qi flow, bal- ance, and harmony with one’s surroundings. Feng shui music is designed to help people improve their physical and mental health through naturally bal- ancing the energy in the physical and etheric bodies ( Collins, 2008 ).

RESEARCH

Although extensive research has been done in China through the institutions of Traditional Chinese Medicine, much clinical research has been in the form of reports of observed results of various treatments. Many of these reports have been difficult to translate into Western languages and into the causal and analytic type of research modalities typical of the biomedical model. Research standards throughout the world are subject to cultural influences. Not all cul- tures require their medical practitioners to conduct randomized, double-blind clinical trials. Consequently, the research data are influenced by the location of the study. Research that is meaningful to the scientific communities of China and Japan may not have the same impact on European and North American biomedical communities.

64 Unit 2 • Systematized Health Care Practices

Extensive research has been published on the pharmacology and toxic- ity of many traditional herbs. Researchers in China and Japan have studied the therapeutic value of herbs in the following areas: chronic hepatitis, rheu- matoid arthritis, hypertension, atopic eczema, various immunologic disorders including AIDS, and certain cancers. Herbs are also given to control the side effects of chemotherapy and radiation. It would be useful to repeat these stud- ies using biomedical research criteria. Research on the medical effects of qigong has been continuing since the mid-1980s and is now focusing on qigong as a biophysical rather than a mystical force. Acupuncture is one of the most thoroughly researched and documented TCM practices. Research stud- ies are covered in more detail in the chapters devoted to these specific prac- tices. Research opportunities in the future might include studies regarding manual healing therapies, bioelectricity, magnetic physical interventions, and the use of mind–body interactions for health purposes. For the most up-to- date list of research studies available in the United States, contact the National Center for Complementary and Alternative Medicine at the National Insti- tutes of Health.

RELATED SYSTEMS

Tibet

In Tibetan Buddhism, religion and medicine are never separated from each other. The spiritual goal of Buddhism is to understand the nature of oneself and suffering and to develop compassion and compassionate action in one’s life. Tibetan medicine, a sophisticated system, is based on general medical and philosophical assumptions as well as on each individual’s emotions, atti- tudes, lifestyles, and spiritual beliefs. It is believed that one’s positive actions produce happiness, and one’s negative actions produce suffering. This belief in cause and effect is referred to as karma .

In Tibetan medicine, disease results from two causes. The first cause is spiritual, something brought from past-life karma. Spiritual diseases are mediated by a qualified teacher who uses meditation and yoga to balance body, mind, and spirit. The process of learning how to control one’s mind to function in a balanced mode with one’s body is called dharma .

The second cause of disease involves factors from this life, including sea- sonal changes, personal habits and behaviors, poisons, and negative spirits. Illness is considered to be a lack of internal harmony or balance or a lack of harmony with the larger external environment. The process of diagnosis is similar to that of Traditional Chinese Medicine. Essential components in help- ing people mobilize their resources for self-healing are caring and compas- sion. As Forde ( 2008 ) stated, “The most revered healing method in Tibetan medicine is compassion” (p. 14 ). We in the biomedical field should take care- ful note of that philosophy.

Other treatments include dietary changes, massage, exercise, yoga, med- itation, breath work, moxibustion, and acupuncture. Surgery is used only

Chapter 4 • Traditional Chinese Medicine 65

when absolutely necessary. Herbal medicines are made from a variety of herbs, minerals, fruits, twigs, roots, and animals. As in the Native American tradition, the state of the practitioner’s mind and the method of gathering are important to the medication’s therapeutic outcome. All preparation of medi- cines begins with prayer.

Korea

Chinese medicine arrived in Korea in approximately 200 b.c. The close relation- ship between China and Korea facilitated the exchange of ideas for hundreds of years. In the 10th century a.d. , Korea established its political independence from China, but cultural and medical exchange continued. A contemporary innovative system developed in Korea in 1971 involves hand and finger acu- puncture. Energy channels of the entire body are mapped onto the hands, where they are stimulated using short, fine needles and magnets. This system is rapidly gaining in popularity throughout the world ( Sing, 2012 ).


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