Complementary and Alternative Medicine: If You Don’t Ask, They Won’t Tell

The use of traditional medicine along with complementary and alternative medicine (CAM) is widespread. CAM is defined by the National Center for Complementary and Integrative Health as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (1). CAM therapy is used by almost 40% of adults in the United States, with American Indians using these approaches most commonly (around 50%), followed by white adults (approximately 43%). Around 12% of children and adolescents use CAM, primarily those whose parents also use these treatments. Generally, individuals who choose CAM approaches are seeking ways to improve their health and well-being or to relieve symptoms of chronic illness—especially chronic pain (2). Others may choose CAM as a component of a holistic health philosophy. In the United States, most users of CAM also receive conventional allopathic care (3).

Studies suggest that many conventional health and mental health care settings are unaware of the CAM practices of their patients (4). This may be particularly problematic when herbs or other biologically active CAM treatments may result in adverse interactions with some prescribed allopathic medications (5–7). Physicians are often poorly trained in homeopathic, naturopathic, herbal, massage, chiropractic manipulation, and diet therapies, as well as other CAM treatments, and thus may not consider these when taking a medication history (3, 6, 8). For example, in one study of oncology patients (5), it was estimated that between 11% and 95% of the patients receiving cancer treatment also used CAM treatments, yet between 20% and 77% did not disclose their CAM use to their oncologist. It has been estimated that less than 40% of all patients disclose their use of CAM to their primary care physicians (8). The most common reasons endorsed for nondisclosure were the doctor’s lack of inquiry; the patient’s anticipation of the doctor’s disapproval, disinterest, or inability to help; and the patient’s perception that disclosure of CAM use is irrelevant to their conventional care (5). Another study of cancer patients (9) suggested that CAM users have a higher desire for control and are more desirous of being actively involved in their health care decisions than those who have not used CAM.

Patients may choose CAMs for a combination of social, cultural, philosophic, and personal factors that often differ among ethnic groups and disease types (2, 3, 8–10). Interestingly, physicians tend to utilize these modalities about as often as the rest of the public (3). CAM therapies have been noted to offer patients “a participatory experience of empowerment, authenticity, and enlarged self-identity when illness threatens their sense of intactness and connection to the world” (10, p. 1061). The treating physician will be most helpful when she/he opens a dialogue aimed at understanding the broad range of personal, cultural, spiritual, and philosophical motivators for CAM use (11). In this regard, a multicultural orientation accentuating cultural humility is essential. Cultural humility has been defined as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (12, p. 354). A culturally humble physician makes a lifelong commitment to self-examination, has a greater awareness of personal limitations, and is dedicated to understanding and addressing power imbalances in the doctor–patient relationship that interfere with optimal care (12, 13). Cultural humility of the psychotherapist has been found to relate significantly to the patients’ ability to develop a strong therapeutic alliance and their ultimate clinical improvement (12). The attitude of cultural humility and genuine interest in the full variety of health practices of one’s patients is the most potent antidote for patients’ lack of disclosure of CAM.

The most effective method of learning about a patient’s CAM use was for the physician to directly inquire about it (11). Physicians often underestimate the prevalence of CAM use in their patients and may forget to inquire. In addition, lack of sufficient understanding to discuss the CAM practices therapeutically may disincentivize a clinician from asking. Physicians may assume that asking a patient what they are currently taking includes herbs or other nonprescription medications. Patients may not have that same interpretation. Clinicians who communicated support of the patient’s efforts toward self-care, without directly supporting a CAM that has not been proven to have efficacy and safety, formed a stronger alliance. Advising against the use of CAM or a chastising attitude tended to decrease the likelihood of the patient informing their doctor of their CAM use—although it often did not alter it (4).

Clinical Vignette

Olivia Bushbanks is a 42-year-old woman of mixed ethnicity (American Indian, Hispanic, and European ancestry). She is employed full-time as a preschool teacher and has two children in high school. Ms. Bushbanks arrived for her first visit to the psychiatrist’s office, appearing somewhat uncomfortable and anxious, with a slow, stooped walk.

When she met Ms. Bushbanks, Dr. Marks smiled warmly, and Ms. Bushbanks reciprocated with a muted smile. “What brings you to see me today?” Dr. Marks queried.

“I’ve never seen a psychiatrist before,” Ms. Bushbanks murmured. “I typically can pull myself out of this darkness. But the usual cures just aren’t working this time.”

Dr. Marks cocked her head quizzically, nodded, and waited. When further explanation was not forthcoming, she asked, “Can you tell me more about what you mean—by the darkness?”

Ms. Bushbanks continued, “I guess it is probably depression and anxiety. But if feels like spiritual darkness.” This time, Ms. Bushbanks continued when Dr. Marks nodded and waited. “Well, when I wake up in the morning, I don’t hear the birds chirping. I just feel a lump in my stomach and dread. And I don’t know why. I mean, nothing specific happened. I worry that I am losing touch with my spirit. You know, getting too concerned about material things and all.”

Dr. Marks considered the cultural issues that may be affecting Ms. Bushbanks and then asked thoughtfully, “It seems that your spiritual life is important to you. Can you tell me more about your beliefs?” Ms. Bushbanks went on to describe her American Indian roots and how spiritual oneness with nature was integral to a feeling of well-being. Dr. Marks continued, “Thank you for sharing this. It seems that you are a very deep and thoughtful person. You mentioned that the usual cures aren’t working. What cures have you tried so far?”

Ms. Bushbanks looked away for a long while. “I don’t think you are going to agree with this,” she finally admitted.

“Have you seen a tribal healer?” Dr. Marks inquired empathically.

“Yes,” Ms. Bushbanks said, appearing somewhat sheepish. My GP told me not to do that anymore. But I still did.”

“Hmm,” Dr. Marks mused, appearing interested. “Healers can be very wise. What advice did yours give you?”

“Well,” Ms. Bushbanks began cautiously, “I did a sweat. That usually helps. You know, in a sweat lodge? It’s a tribal ceremony to bring spiritual balance and cleansing. He also gave me an herbal tea that I have been drinking twice daily. At first, I thought I was feeling better, but this weekend, I couldn’t even make myself get out of bed. My GP said there is nothing wrong with me—physically, at least. He told me to see a psychiatrist. So, here I am,” Ms. Bushbanks ended with a defeated smile.

Dr. Marks smiled reassuringly. “I’m glad you’re here. And thank you for being honest. I’m sorry the usual cures didn’t work this time.” Ms. Bushbanks didn’t know the component herbs in the tea, but she did sign a release to allow Dr. Marks to talk with the tribal healer. They also reviewed any other complementary, alternative, or over-the-counter treatments Ms. Bushbanks had used. Dr. Marks finished up the history, mental status exam, and review of systems. “Well,” Dr. Marks concluded, nodding thoughtfully, “It does seem that you are suffering from a serious depression.” They spent time reviewing the tribal explanation and the medical explanation for depression. “So, I agree with your tribal healer,” concluded Dr. Marks. “You are out of balance. What we think is out of balance may be a bit different, but we probably agree on more than you might think. Since some herbs can interact negatively with antidepressant medications, I don’t recommend taking both. Are you comfortable stopping the herbal tea and beginning an antidepressant medication? Sweats are OK, as long as you don’t get dehydrated.”

They made a plan for psychotherapy, an SSRI medication, exercise (a daily walk in the woods and bird watching), and to return in one week. When Ms. Bushbanks left the office, she stood tall, appearing as if a great weight had been taken off her shoulders.

Physician–Patient Communication Around CAM Use

The following are communication tips to enhance the psychiatrists’ assessment and understanding of the types of CAM treatments that their patients are using, the purpose they serve, and therapeutic engagement (4, 6, 11):

1. Always inquire about the use of complementary, alternative, or traditional medicine practices.

   1. Most patients will only disclose the use of CAMs if asked directly. Initiate the question matter-of-factly. Begin by assuming that your patient is using some type of complementary or alternative therapy, thus minimizing the suggestion of stigma regarding CAM use. For example: “Which vitamins, supplements, herbal treatments, naturopathic, or over-the-counter medications do you take?” “How about acupuncture, therapeutic massage, chiropractic treatments or other nonmedication healing practices—which of these do you use?” “Do you use alternative health practices as part of cultural or religious practices?”

   2. Inquire about reasons for using these CAMS—be sensitive to cultural traditions and listen carefully to motivations as a guide to what is most important to the patient.

   3. Acknowledge the patient’s efforts toward self-care, wellness, and autonomy in choosing CAMs.

   4. Remain curious: Does the CAM help? If so, in what way? How does the patient understand the healing properties? Is the patient seeing a naturopathic or other CAM specialist? What has the patient learned from this person?

2. Maintain a nonjudgmental and open attitude toward the topic of CAM use.

   1. Assume that patients will naturally be reluctant to disclose a treatment option that they know conventional physicians don’t promote. Set the stage for acceptance toward these practices.

   2. Cultivate an attitude of cultural humility. Self-observe your reactions to patients and their health care practices. Reflect regularly on your automatic reactions and potential unconscious biases toward patients to improve your CHQ (cultural humility quotient).

   3. Be sure your patient knows that you appreciate honesty and candor in the disclosure of healing practices.

   4. Be prepared to discuss what you know and don’t know about CAMs.

   5. Look up any interactions between prescribed medications and the CAM use of your patient, and discuss.

3. Openly discuss any safety concerns about CAM use.

   1. If a CAM practice is contraindicated or there may be adverse drug interactions (such as with St. John’s wort and SSRIs, which may increase the risk of serotonin syndrome), be clear about this. Discuss the treatment options frankly (e.g., a patient who chooses to either stay on St. John’s wort or taper off and start an SSRI).

   2. For patients who are interested in nonconventional treatments, review those that may have benefit; for example, exercise, yoga, mindfulness meditation, or vitamin D supplementation (after labwork, if the level is low).

   3. Directly address the potential that the patient may feel skeptical about the physician’s diagnoses, medications, or conventional treatments. Media, friends and family, other sources, and/or philosophical or religious beliefs may legitimately frighten patients about seeing a psychiatrist, taking medications, or embracing conventional mental health treatments.

4. Begin to educate yourself about CAMs.

   1. There is a growing database about herbal remedies and other CAMs and potential interactions with prescribed medications. Make a habit of looking up these interactions for each patient who discloses a CAM.

   2. A review article by Werneke et al. (7) provides a synopsis of herbal remedies that may have evidence for effectiveness or adverse effects in psychiatric practice.