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It is very refreshing that an entire article in the April Monitor was dedicated to pointing out the possible use of complementary and alternative medicine (CAM) in psychology ("Alternative techniques"). Among other things, the article provided a good foundation of clinical information touting the benefits of various practices. It also pointed out how various forms of CAM are being integrated at an ever-growing pace in the treatment of clients.
However, one aspect of the use of CAM that continues to be an interesting point is that it is only after these techniques received heavy research attention that they have been "proven" to be effective. This is surprising, and a bit unfortunate, in that many of these practices have been pursued for hundreds, if not thousands, of years by individuals who have touted their "benefits."
Also of note is that, although there has been a great deal of attention paid to numerous CAM practices as they may directly assist clients dealing with a wide variety of emotional and psychological challenges, little attention is being given to the fact that by engaging in these practices themselves, therapists enhance many of the same qualities that research has been shown to be effective in producing positive therapeutic outcomes. That is, not only can the practice of CAM be beneficial to clients, it can also be seen to be very "beneficial" to therapists themselves and therapy in general.
Bill Fitzgerald, PhD
Since I received my April Monitor on April 1, I thought, "How amusing" when I read the article suggesting psychologists learn CAM techniques and integrate them into their practices. Then, I realized that this was not an April Fool's joke and that the authors were disturbingly serious. If their recommendations are adopted, it would be a giant leap backward for behavioral science and clinical psychology. Given that much of science already holds clinical psychology in low esteem (and justifiably so, see recovered memories, EMDR, facilitated communication, and the Rorschach test to name a few pseudo-scientific concepts that psychology has embraced in the past), imagine what partnering with fringe, non-empirically based approaches would do. Barnett and Shale (2013) offer support of the 14 CAM techniques by citing selected articles that hardly can replace systematic literature reviews and randomized clinical trials. They also suggest that validity is associated with being "in use for thousands of years and … widely accepted by the public." Accommodating CAM techniques simply because they are popular amplifies Walter Mischel's (2009) observation that "the disconnect between much of clinical practice and the advances in psychological science is an unconscionable embarrassment for many reasons, and a case of professional cognitive dissonance with heavy costs." The authors further suggest that psychologists advocate for research funding for CAM techniques. Given the extremely fragile scientific frameworks of many CAM techniques, I for one hope precious behavioral science resources are not expended on CAM research programs.
John S. Searles, PhD
In the April Monitor, I was surprised to find that the authors of the article on "alternative techniques" felt that some of the techniques could be inherently unethical if administered by psychologists to their patients. Specifically, they state that a psychologist who is also licensed in another field, such as chiropractic medicine or massage therapy, cannot offer both treatments to patients due to the "multiple relationships" and "boundary violations" that would result from physical touch.
I fully disagree. As a primary-care psychologist, I cannot imagine one of my physician colleagues not offering treatment or brief counseling for depression because they have done a physical exam. In fact, a psychologist who offers other forms of treatment (that they are competent/licensed to provide) would not even constitute a multiple relationship. The ethics code specifies that a multiple relationship occurs when a psychologist is "in a professional role with a person" and "another role." If a psychologist offers both therapy and chiropractic intervention, both constitute professional roles. Additionally, these relationships are unethical only if there is possible impairment or exploitation. Chiropractic medicine and massage therapy are not inherently harmful or exploitative, and the vast majority of professionals offering physical treatments do so without exploiting their patients.
Patients love integrated care and often prefer to receive multiple treatments from the same provider. If a patient has been fully informed and consented to a combined treatment, the boundaries have been set to include the alternative treatment, and thus providers are not violating boundaries.
Adrienne A. Williams, PhD
University of Maryland School of Medicine
Currently, 45 states require licensure for the independent practice of acupuncture. Licensed acupuncturists have typically graduated from a four-year college of acupuncture and/or Asian medicine, and in most states must obtain board certification for licensure. To the assertion that a psychologist should not serve as both a client's acupuncturist and psychotherapist, I offer the following:
- Training in acupuncture is inherently grounded in respect for patients, their bodies and boundaries, and clinical technique reflects this vital concern. Exposure and treatment of an area of the body are boundary violations only if provided by an untrained, unlicensed, unqualified practitioner, unpermitted by the patient and/or exceeding what is required for a given treatment.
- Separating the two modalities for a practitioner qualified to provide both equates to missing subtle changes in mood, emotional status, thought processes and physical changes that can be addressed therapeutically in the moment in which they occur, thereby depriving the therapeutic scenario of a powerful advantage.
- The acupuncturist, if not also the person's psychotherapist, is surely going to be commenting on such matters — acupuncturists also counsel their patients — and the possibility of conflicting or unhelpful messages from the two practitioners is always possible.
While we must always be attentive to risks and exercise best clinical judgment, I believe we must reassess proscriptions such as "no-touch" in the case of psychologists who have obtained a license to touch.
James C. Nourse, PhD
Response from the authors of "Alternative techniques":
We are delighted that our article has stimulated interest and welcome the opportunity to respond to the questions raised. Two letters raise very interesting points about the unique relationship that a client could potentially have with his or her acupuncturist or massage therapist. With that, we see the issues raised as highlighting a broader issue related to touch and really, treatment in general. As clinicians, we must always consider each client as an individual, assessing what is in his or her best interest and then making treatment recommendations accordingly. Individual differences and circumstances can and should be taken into consideration. Things to consider include the type of psychotherapy being offered, the client's history and presenting problems, and the client's personal preferences. In addition to psychotherapy, there exists a wide range of modalities, techniques and other psychological interventions being offered to clients, with some perhaps being more amenable to the integration of treatments that involve physical contact by the psychologist than others. With all of this in mind, we hope that, at a minimum, psychologists will engage in a thoughtful and deliberative decision-making process to help ensure that any treatment offered is in each client's best interest and not contraindicated. This will assist us to consider the potential impact of different interventions on each client and to consider viable alternatives. This pertains to the decision to integrate any CAM modality, not just those involving touch, into ongoing psychological treatment or to refer the client to a competent CAM practitioner to provide that additional treatment.
Jeffrey E. Barnett, PsyD
Allison J. Shale
University of Maryland
Commitment to the military
I was delighted to read APA President Donald Bersoff's April Monitor column, as I have been working with our wounded warriors since 2008 and spend two days a week volunteering through the Red Cross at the Walter Reed National Military Medical Center, in Bethesda, Md., helping these young warriors face a very difficult future. His call for action by our profession is timely, and I applaud his commitment to this special group of patients. I am constantly amazed at the resilience of these young people and how they deal with their multiple amputations and severe TBI. But while my medical and surgical colleagues work miracles in putting back the pieces of their shattered bodies, I fear that not enough attention is being placed on the persistent emotional and behavioral problems they will face when they return to their home communities. While they may be "damaged" physically, they are strong and will survive if they have a system of mental health support back home. The Give an Hour program founded by Dr. Van Dahlen is an exceptional example of how all practicing psychologists should get involved, to ensure that when these wounded "warriors" become wounded "veterans" and have to pick up the pieces of their lives without the "buddy" support system of the military family, we will be there to help them. It is the least we can do to thank them for their exceptional service to our country.
Inge Guen, PsyD
Recognition for DRN psychologists
I want to thank APA President Donald Bersoff for recognizing the work that Disaster Response Network psychologists do (February Monitor, "President's Column"). We are a group of psychologists who quite often go invisible among our colleagues. We put in long hours, work pro bono and take time off from our own work and personal lives. We are very dedicated and committed to our work. I appreciate your recognition of our endeavors.
Rut Gubkin, PhD
Please send letters to Sara Martin, Monitor Editor. Letters should be no more than 250 words and may be edited for space and clarity.
The May Monitor article "APA's Annual Convention in Honolulu" incorrectly described a talk by Craig Haney, PhD. He will discuss among other topics the psychological factors that influence the imposition of the death penalty and the psychological effects of incarceration.
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