Biofeedback
Stress-related anxiety is the common element of disorders relating to mental illness. It is known that the direct effects of sustained stress can be devastating (see Chapter 7, Coping and Defense Mechanisms). In a critical moment or progressively over time, the biological response to stress can impair the cognitive function of
the mind and cloud a person’s thinking. Pro- longed stress can lead to emotional anguish that is experienced as fear, anxiety, anger, and depression. Prolonged stress can also lead to exhaustion and possible death. Anxiety con- tributes to physical symptoms—many of which can be reduced or controlled by biofeedback techniques. Biofeedbackis a training program designed to develop one’s ability to control the autonomic nervous system. While biofeedback only recently has become a complementary medical therapy, it has been widely accepted by traditionalists in the West because of its use of scientific measuring devices and proven techniques.
The primary purpose of biofeedback train- ing is to teach patients to recognize tension within the body and to respond with relax- ation (Fig. 9-1). Typically, training for patients takes place in a series of one-hour ses- sions, sometimes spaced a week apart. The patient is taught to obtain a deep level of relaxation as a means to control a light, buzzer, image, or a video game, to which he or she is attached by electrodes and cables.
The machine is then gradually adjusted to greater sensitivity, and the patient learns improved control. When training is com- pleted, all that is needed to obtain relaxation and symptom resolution at any time or place is recall of the particular thought and feeling that worked in the clinic.
Biofeedback is being used with good results for conditions including insomnia, some types of seizures, functional nausea and vomiting, tinnitus, and phantom limb pain.
As with other forms of therapy, biofeedback practitioners must be aware of functional or even psychological symptoms that are actually caused by organic problems and require dif- ferent treatment. It may not be appropriate to use biofeedback to treat extreme or acute states of mental illness, like severe depression, mania, agitation, schizophrenia, paranoia, obsessive-compulsive disorder (OCD), delir- ium, and identity or dissociative disorders.
Critics have pointed out that the major effects from biofeedback can be more economical and easily obtained through relaxation training.
Patients with strong faith they can influ- ence their own health are the most likely to be successful at mastering biofeedback. The experience of gaining control of one’s physical reactions can have a tremendous effect on how the person will view stressful situations in the future. As an educational tool for more skeptical patients, learning biofeedback can demonstrate that they have a great deal more control over their responses and symptoms than they first expected.
Aromatherapy
Aromatherapymay well be one of the oldest methods used to treat illness in human beings. Related to herbal therapy, aromather- apy provides treatment by both the direct pharmacological effects of aromatic plant sub- stances and the indirect effects of certain smells on mood and affect. Throughout human history and in many cultures, there are accounts of the use of aromatics to treat varying forms of illness. Applied in salves or ointments, used in incense, reduced to essential oils for topical application, or even ingested, these substances often appeal to patients who are seeking a “natural” approach to healing
People’s response to the sense of smell has strong significance in their lives. People asso- ciate certain aromas with certain situations, conditions, and emotional states. Many indi- viduals are able to relive particularly strong memories when exposed to an aroma that was present when the remembered event occurred.
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Figure 9-1 Biofeedback training teaches patients to recognize tension and respond with relaxation. (Courtesy of Santé Rehabilitation Group, Euless, TX)
For example, the fragrance of baking cookies or apple pie reminds some people of being at home and even experiencing some of the emo- tions connected to that memory. The ability for a particular smell to create positive alter- ations in mood makes aromatherapy attractive to many people and has created a large market in everyday products designed to evoke calm and well-being. Scented candles and personal care products like bath oils, shampoos, and body lotions are especially popular.
Treatment for anxiety-based mental illness and depression using aromatics like lavender, thyme, gardenia, and other botanicals is be- coming a more acceptable adjunct to conven- tional methods. It is important to be aware that the oils and plant matter used in aro- matherapy can be toxic if improperly admin- istered and should be kept out of the reach of children and the cognitively impaired.
Applied to skin, many plant oils are caustic or can trigger an allergic reaction. The nurse should observe and assess to determine if the products used are effective and if there are any side effects noted. As with all alternative treat- ment, it is advisable to find a competent and knowledgeable practitioner to benefit fully from the potential of aromatherapy.
also perceived by the public to be better, or safer, because they can be purchased over the counter and do not require a trip to the doc- tor’s office. There are literally hundreds of products available to consumers seeking relief through herbal and nutritional means.
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• Bring several different aromatic herbs into class, pass them around, and have each student sniff the plant or a form of the plant. Students should discuss their immediate feelings after inhaling the aromas.
Herbal and Nutritional Therapy
Growing steadily in the United States today is the use of herbal compounds and nutri- tional supplements to treat illness. The pop- ularity of self-treatment with herbs is in large part due to the desire of many people to return to a simpler lifestyle and as a means to avoid costly prescription medications. Most herbal products are considered nutritional supplements rather than medications, so these products avoid regulation by the Food and Drug Administration (FDA). They are
Belief plays a considerable role in the acceptance and use of these products.
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With rapid changes in society since World War II has come people’s awareness that their lives are no longer as pastoral, calm, and idyl- lic as they would like to remember them to be. This awareness became more evident after the events of September 11, 2001. In a world full of processed food, the quality of modern nutrition has come into question, and there is growing conviction that artificial additives lack the ability to provide the basics needed for good health.
Daily, people are assured in the popular press and the news media that the solution to many of their problems can be found in nutritional and herbal supplements. Lack of cortisol has been blamed for weight gain, and taking compounds rich in HGH (human growth hormone) has been credited with reversing aging. Infomercials tout the benefits of taking coral calcium and even improving sexual performance with herb-based prepara- tions. The Internet is flooded with supple- ments that promise to improve people’s lives by making them healthier and stronger.
Some herbs have been researched and proven in their effectiveness in treating disease conditions. This should not be surprising, for many modern medications were developed from herbal and other botanical origins.
Native Americans knew the value of the inner bark of the willow tree, gathered and used for its ability to reduce fever and ease pain. They also used foxglove in their sweat lodges to energize the frail and restore vitality to the elderly. Little did they know that the salicylate in willow bark and digitalis in foxglove were the reasons for their effectiveness.
There is a tradition in Europe of using herbal medications and nutritional supple- ments to treat disease. For example, people in
Germany routinely plant and harvest herbs in their garden plots to create remedies for com- mon ailments. Some herbal preparations are available there only by a doctor’s prescription, and others can only be obtained through a licensed pharmacist. In the United States, the use of fresh or garden-grown herbs is discour- aged because of the difficulty in determining the strength of the active compounds pro- duced by plants under different growing con- ditions. Europeans are guided by generations of experience and practice to safely use avail- able botanicals.
Unfortunately, the belief in the relative safety of herbs is a misunderstanding that has caused much concern among health-care providers. Deciding on an appropriate dose is difficult, because herbal preparations do not have to conform to any specific guidelines regulating strength or purity. People tend to think that if a small amount of the product is effective, more is better still. Some herbs are very toxic, particularly in pure form. Many herbs interact negatively with prescription medications. This point demonstrates the need for the nurse to include direct questions to the patient about the use of any CAMs.
Nurses need to be able to teach their patients the importance of consulting with a physician before beginning any sort of herbal therapy.
Table 9-1 describes the five most often used herbal medications and nutritional supple- ments in the treatment of mental illness in this country.
Massage, Energy, and Touch
Widespread among complementary and alternative treatment methods are modalities centered on manipulating the body’s energy fields. Massage in one form or another has probably been known to man since before the dawn of history. Touch and movement are es- sential to life and well-being in both physical and psychological ways. Massage is the manipulation of the body using methodical pressure, friction, and kneading. People are shaped, almost literally, by their childhood experiences of touching. An infant has limited sensory discrimination but will react posi- tively to being cuddled and held, and even to the feel of a snugly wrapped blanket.
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During the admission interview, ask the patient if he or she is taking any alternative or complementary products. Some of these may be contraindicated with medications ordered by the physician.
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Tool Box|The National Institutes of Health division called the National Center for Comple- mentary and Alternative Medicine (NCCAM) is an excellent resource for obtaining informa- tion on a specific CAM, including scientific data if available. This is available at
www.nccam.nih.gov/
Tool Box|Types of Massage Therapy www.massagetherapy.com/glossary/index .php
Massage has evolved into many variations as a result of its success (Fig. 9-2). Use of touch is common to many different treatment approaches, but there can be great variation in philosophical, theoretical, and practical ideas about how touch is applied. Western variations of massage include Swedish, which was developed in the early nineteenth century and is the type most people are familiar with.
It is characterized by long, smooth strokes that go toward the direction of the heart.
The manipulation of specific body sites to relax muscle groups is known as trigger point massage. Conventional medical science has generated a similar trigger point therapy in which injections of steroids are applied at these key areas in place of massage to both relax the muscle group and reduce local in- flammation.
Of course, there are also other means of massage available. Rolfing is a therapy de- signed to realign the body with gravity through fascial manipulation, a vigorous form of bodywork that is finding increasing accept- ance. Eastern massage traditions have fol- lowed a different path. It is widely believed among Eastern practitioners that the body is governed by energy paths, called meridians.
This energy is perceived as the life force, or
l
Table 9-1Common Herbal and Dietary Therapies Specific Therapy Ginkgo Biloba Kava KavaActive Ingredients Ginkgentin, Ginkolic acid Kavapyrones, Piper methys- ticum, Kava pepper
Usual Dose 120–140 mg PO daily, depending on what is treated; divide into 2–3 equal doses 10–110 mg PO dried kava extract three times daily, or freshly prepared kava beverages, 400–900 g weekly
Uses Short-term memory loss though research is conflicting as to benefits Antidepressant, antianxiety, antipsychotic, to use as sleep aide
Side Effect Bleeding, contact dermatitis, nausea, vomiting, diarrhea, headache; rarely, subdural hematoma, seizures (especially in children) Drowsiness, changes in reflex and judgment, nausea, muscle weakness, blurred vision, decreased platelet counts, decreased urea and bilirubin levels,
Contra- Indications Pregnant or breast- feeding, children; use cautiously for patient taking anti- coagulants, MAOI med- ications because Ginkgo Biloba can act as an MAOI Pregnancy, breastfeeding Skin yellow- ing from accumula- tion of plant pigment can occur in chronic use. Liver disease Drug/Food Inter- actions May increase the ef- fects of anticoagulant and antiplatelet drugs. Avoid foods contain- ing large amounts of tyramine: aged meat and cheese, red wine, pickled herring, yogurt, raisins, sour cream, and other foods high in tyra- mine; also OTC cold and flu preparations. Do not use with: Alcohol: increases risk of kava toxicity. Alprazolam: risk for coma exists. CNS depressants: kava potentiates these. Levodopa: can in- crease Parkinson-like symptoms. Phenobar- bital: can increase effects.
Patient Teaching Do not use if on Coumadin or aspirin. Works well for people over 50 as well as younger adults. May take 6–8 weeks to experience benefits. Use with some fruits and nuts can cause a poison ivy-like reaction. Symptom relief may occur in as little as 1 week. Potential for significant ad- verse reactions when using kava. Alcohol and CNS medications are enhanced with kava.
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St. John’s Wort Omega 3 Fatty Acids (Dietary Supplement) Sam-E (Supple- ment for Natur
ally Produced
Body Substanc
e
Hypericum perforatum Alpha- linolenic acid (ALA), docosa- hexaenoic acid (DHA), and eicosa- pentaenoic acid (EPA) 3:2 EPA to DHA (fish oil) s-adenosyl-L- methionine
300 mg PO three times daily for 4–6 weeks 1–2 g PO daily for health, cognitive enhancement See manufac- turer’s specifications and use as directed by a physician
Antidepressant Depression, postpartum depression, bipolar disorder, anxiety, dementia Depression
dry skin, is a dopamine antagonist Severe photosensi- tivity, dry mouth, constipa- tion, GI upset, sleep distur- bances, restlessness Loose stools with higher doses; “fishy” reflux Mild and transient anxiety, insomnia, heartburn, loose bowels
Pregnant or breastfeed- ing, children; use cau- tiously for patient taking anti- coagulants, MAOI medication Use cau- tiously for patients taking anti- coagulants Can cause mania in patients with bipolar disorder; rule out before beginning treatment.
MAOIs, antidepres- sants, digoxin, birth control pills May increase effects of anticoagulants
Avoid prolonged exposure to sunlight. May increase the effects of MAOIs, OTC flu and cold medications, alcohol; do not use with these types of chemicals. If taking anti- coagulant drugs or high doses of aspirin, practice good safety. The oils may increase clotting time. Patients with bipolar disorder should not use except under supervision of physician. Enteric coated prepara- tions may reduce gastric upset. Source: Spidle, R.A. (2006). Alternative and Complementary Treatment Modalities. In Neeb, K. (2006). Fundamentals of Mental Health Nursing. Philadelphia, F.A. Davis, pp. 164–166. National Center for Complementary & Alternative Medicine at http://nccam.nih.gov
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chi, ki, or prana. When the life force is obstructed, emotional and physical illnesses result. Various types of pressure, massage, and other techniques are employed along these meridians to release the flow of chi, restore balance, and improve health. Shiatsu is a
Japanese form of acupressure that uses pres- sure from the fingers to free energy flow.
Reflexologyis also based upon the belief that energy pathways and zones cross the body, connecting vital organs and body parts (Fig. 9-3). Reflexologists use massage of the feet to act upon these pathways, unblocking and renewing the energy flow.
Therapeutic touch also deserves mention.
Reikiis representative of methods of touch healing that are often associated with mas- sage. Reiki is a term that means “universal life energy” and refers to the process whereby this energy is drawn along the body’s meridians.
Unlike methods that use physical movement, pressure, or massage to unblock these chan- nels, Reiki uses the flow of life energy itself to accomplish the task. Practitioners are
“attuned” to the energy channels and can manipulate them hands-on, hands just above the body, or even at a distance. Reiki tech- niques can even be employed as part of a more traditional massage session to enhance the physical benefits of the massage. Reiki has been demonstrated to increase warmth in the areas being treated and also to produce relax- ation in the subject.
Figure 9-2 Massage can be an effective tool for relieving tension. (Courtesy of everything- jersey.com)
Brain
Glands Nose Throat
Thalamus Lungs
Heart Liver Adrenal glands
Spine Bladder Small intestine
Pelvis Sciatic nerve Sinuses
Shoulder Shoulder
Spleen Stomach Pancreas Diaphragm
Gallbladder Kidneys
Colon Colon
Appendix Pelvis/buttock
Eye Ear
Figure 9-3 Reflexology foot diagram.
Hypnotherapy
Hypnotherapyis one of the most controver- sial complementary and alternative modali- ties. Hypnosis is a means for entering an altered state of consciousness, and in this state, using visualization and suggestion to bring about desired changes in behavior and thinking. Called trance, people enter this state of focused attention every day. The Eng- lish language even contains references to this common experience of “zoning out.” Trance is not sleep but rather describes a state of mind wherein a person is less aware of what is going on around him or her and instead is very focused on an internal experience, like a memory or an imagined event.
Everyone responds to suggestion to some extent. A person who is watching television and wants a snack after seeing commercials for a favorite fast-food restaurant has responded to suggestion. Fortunately, people’s minds fil- ter out suggestions that are unacceptably dan- gerous so they are not persuaded to imitate some of the more unsafe things seen on TV.
hypnosis. In some states a therapist must be certified or licensed, but in others no one but a psychologist, psychiatrist, medical doc- tor, or other professional may practice the techniques.
Milton H. Erickson, M.D. (1901–1980), was one of the best-known figures in the development of hypnosis for modern therapeu- tic purposes. Dr. Erickson was a victim of polio, which left him partially paralyzed. He had little strength in his arms and upper body and was confined to a wheelchair. As if that were not enough, he was dyslexic, tone-deaf, color-blind, and had heart problems. Left alone during long periods of illness, Erickson became a master of observation and learned that subtle changes in facial expression, skin color, nuance of voice, and physical posture could tell him much about a person’s inner state.
Dr. Erickson structured his therapeutic approach to patients in a new way. He refused to allow his own past disabilities ruin his living of life to its fullest and therefore refused to let old problems get in the way of his patients’
enjoyment of living. Erickson ignored the past history of presenting patients, preferring instead to focus on present and future out- comes. In one classic case, Erickson gave the task of tending violets to a woman with depres- sion. Combined with other therapeutic sugges- tions, she was kept too busy and involved in her community to remain depressed.
Traditional hypnotherapy and psychother- apy center on diagnosing problems and treat- ing symptoms. Erickson promoted well-being, and study of his methods has challenged a whole new generation of hypnotherapists to do the same. Later, John Grinder and Richard Bandler would develop the field of neurolin- guistic programming (NLP), based in large part upon their study of the extraordinary sensory acuity of Milton Erickson.
Neurolinguistic Programming
Investigating the techniques and methods of many successful therapists, Bandler and Grinder searched for ways to make psy- chotherapy more consistently effective. It was through these explorations that they realized that language cues could be used to under- stand how an individual experiences his or her
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A hypnotherapist uses suggestion, both direct and indirect, to help the patient create change.
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The general public has been subjected to an enormous amount of misinformation about hypnosis by stage hypnotists, movies, and books. As a result, hypnotherapy is widely misunderstood and wrongly feared by many people. Watching a stage hypnotist appear to make a volunteer cluck like a chicken or dance on a table certainly does not inspire confi- dence in hypnosis as a therapeutic tool. It is very hard for some people to overcome these fears, especially the stubborn belief in the myth that hypnosis is somehow “mind con- trol” exercised for evil (or entertainment) pur- poses by the therapist.
Whereas some researchers and practition- ers contend that hypnosis cannot stand on its own as a treatment modality, others are equally convinced that even lay practitioners can deliver effective therapy with a mini- mum of training and practice. No doubt this controversy will continue, as there are at present few regulations governing the use of