mind-body cam interventions: current status and considerations for integration into clinical health...

Mind-Body CAM Interventions: Current Status and Considerationsfor Integration Into Clinical Health Psychology

Crystal Park

University of Connecticut

Objective: Complementary and alternative medicine (CAM) is increasingly used for treating myriadhealth conditions and for maintaining general health. The present article provides an overview of cur-rent CAM use with a specific focus on mind-body CAM and its efficacy in treating health conditions.Method: Characteristics of CAM users are presented, and then evidence regarding the efficacy ofmind-body treatments (biofeedback, meditation, guided imagery, progressive muscle relaxation, deepbreathing, hypnosis, yoga, tai chi, and qi gong) is reviewed. Results: Demographics associatedwith CAM use are fairly well-established, but less is known about their psychological characteristics.Although the efficacy of mind-body CAM modalities for health conditions is receiving a great deal ofresearch attention, studies have thus far produced a weak base of evidence. Methodological limitationsof current research are reviewed. Suggestions are made for future research that will provide moreconclusive knowledge regarding efficacy and, ultimately, effectiveness of mind-body CAM. Considera-tions for clinical applications, including training and competence, ethics, treatment tailoring, preventionefforts, and diversity, conclude the article. Conclusions: Integration of CAM modalities into clinicalhealth psychology can be useful for researchers taking a broader perspective on stress and coping pro-cesses, illness behaviors, and culture; for practitioners seeking to incorporate CAM perspectives intotheir work; and for policy makers in directing healthcare resources wisely. C© 2012 Wiley Periodicals,Inc. J. Clin. Psychol. 00:1–19, 2012.

Keywords: complementary and alternative medicine (CAM); mind-body CAM; integrative medicine

Complementary and alternative medicine (CAM) is commonly and increasingly used to treatmyriad health conditions (Barnes, Bloom, & Nahin, 2008) and for maintaining general health(e.g., stress management; Stoney, Wallerstedt, Stagl, & Mansky, 2009). The National HealthInformation Survey (NHIS), a nationally representative survey of the U.S. population conductedcontinuously since 1957 and sponsored by the Center for Disease Control and Prevention, firstassessed CAM use in 2002. That survey showed that 62% of adults had used CAM in the past12 months (Barnes, Powell-Griner, McFann, & Nahin, 2004). A subsequent (2007) NHIS survey,using a different definition of CAM, indicated that 38.3% of American adults had used sometype of CAM in the past 12 months.1 High rates of CAM use have been reported around theworld. For example, 46% of the U.K. population is estimated to use one or more CAM therapiesin their lifetime (Bishop & Lewith, 2008), while a national study of South Koreans estimatedthat in the past 12 months, 74.8% had used CAM (Ock et al., 2009), and a large survey ofAustralians in metropolitan and rural areas found that 52% currently use CAM and 85% hadused CAM in their lifetimes (Robinson, Chesters, & Cooper, 2007). CAM use is multifaceted:In the United States in 2007, the most commonly used CAM modalities were nonvitamin,nonmineral, natural products (17.7%), deep breathing exercises (12.7%), meditation (9.4%),chiropractic or osteopathic manipulation (8.6%), massage (8.3%), and yoga (6.1%; Barnes et al.,2008).

According to the 2007 NHIS, adults in the United States spent an estimated $33.9 billionout-of-pocket on CAM treatments during the past 12 months, including $22 billion on self-carecosts (e.g., CAM products and classes) and $11.9 billion on visits to CAM practitioners. These

Please address correspondence to: Dr. Crystal Park, Box 1020, Storrs, CT 06269. E-mail: [email protected] apparent plunge in CAM use over a 5-year period in the United States is explained below.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 00(00), 1–19 (2012) C© 2012 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21910

2 Journal of Clinical Psychology, xxxx 2012

costs comprised approximately 1.5% of total health care expenditures and 11.2% of total out-of-pocket health care expenditures in the United States (Nahin, Barnes, Stussman, & Bloom,2009).

CAM modalities are gaining increasing acceptance in Western medicine and have been in-creasingly researched, particularly in the last 30 years (Arias et al., 2006). This rising interestmay be because of greater awareness of the critical role that psychological distress plays inmany medical conditions and health outcomes along with increased acceptance of the biopsy-chosocial model (Arias et al., 2006). Even the U.S. government has officially recognized CAMin recent years. In 1991, the U.S. Congress passed legislation to fund the establishment anoffice within the National Institutes of Health (NIH) to investigate and evaluate promisingunconventional medical practices, which became an official NIH Center (NCCAM) in 1998(http://www.nih.gov/about/almanac/organization/NCCAM.htm#events). A number of allo-pathic medical schools in the United States and around the world now offer training in CAMtechniques (Arias et al., 2006).

Knowledge about CAM modalities and their integration into clinical health psychologycan be useful for researchers interested in taking a broader perspective on stress and copingprocesses, health maintenance and illness behaviors, and culture, and for practitioners seekingto incorporate CAM perspectives and techniques into their work. The increasingly expandingand officially recognized use of CAM warrants greater attention by conventional health carepractitioners, decision makers, and researchers. The present article provides an overview ofcurrent CAM use with a specific focus on mind-body CAM.2

Complementary and Alternative Medicine Use

Defining CAM

Because CAM covers a broad and heterogeneous set of practices that purport to pre-vent or treat disease, a precise definition is hard to come by. NCCAM defines CAM as“a group of diverse medical and health care systems, practices, and products that are notgenerally considered part of conventional medicine” (i.e., Western allopathic medicine) be-cause there is insufficient proof of their safety and efficacy (http://nccam.nih.gov). The dis-tinction between alternative and conventional medicine is complicated in that, over time,specific CAM practices may become widely accepted, at which point they may be con-sidered to no longer be CAM but rather conventional medicine (Willison, Williams, &Andrews, 2007).

“Complementary medicine” refers to the use of CAM together with conventional medicine,while “alternative medicine” refers to use of CAM instead of conventional medicine. Mostpatients using CAM do so to complement conventional care rather than as an alterna-tive to conventional care. CAM practices tend to promote a holistic view of health andrelations between the mind and body, with many types of CAM treating nutritional, emo-tional, social, and spiritual aspects as well as physical manifestations of illness (Barnes et al.,2008).

CAM modalities vary on myriad dimensions. For example, some types of CAM requirea provider to implement treatment (e.g., acupuncture, traditional healers), while other CAMtherapies are or can be self-administered (e.g., meditation, yoga). Mind-body practitioners oftenprovide training rather than treatment per se (Frank, Khorshid, Kiffer, Moravec, & McKee,2010). In addition, CAM modalities differ in historical precedent, cultural acceptability, cost,safety, extent to which they are systematic and rooted in traditional or new-age approaches,and purported mechanism of effect and the plausibility of that mechanism (Willison et al.,2007).

2Because the volume of literature on CAM use and efficacy is vast and rapidly proliferating, no attempt ismade here to provide an exhaustive or systematic review; rather, this article includes representative currentliterature and reviews of the various CAM modalities.

Mind-Body Cam 3

Major Types of CAM

As described by NCCAM (http://nccam.nih.gov), three major types of CAM are currentlyused in the United States: (a) natural products, including herbal medicines, vitamins (exclud-ing standard multivitamins), minerals, and other “natural products” with the most commonlyused among adults being fish oil/omega 3; (b) manipulative/body-based practices (e.g., spinalmanipulation and massage therapy), which focus primarily on the structures and systems ofthe body (e.g., bones, joints); and (c) mind-body CAM (e.g., deep breathing exercises and med-itation), which focuses on interactions among the brain, mind, body, and behavior, with theintent to use the mind to affect physical functioning and promote health. In addition to thesethree major types of CAM, there are others, including movement therapies, traditional healerpractices, energy field manipulation, and whole medicine systems (Barnes et al., 2008).

This article distinguishes between studies addressing CAM use (e.g., what characterizes peoplewho use CAM?) and those addressing CAM efficacy. The following section presents descriptiveresearch on CAM use. Subsequent sections review efficacy and present research considerationsregarding mind-body CAM interventions.

Characteristics of CAM Users

Many community-based studies have focused on associations of CAM use with demographicfactors and medical conditions, producing a snapshot of CAM consumers. A great deal ofinformation on sociodemographic indicators of CAM use in the United States is available, muchof it derived from the NHIS, described above (Barnes et al., 2008). However, few studies haveexplored psychological factors related to CAM use (Bishop & Lewith, 2008).

Socioeconomic status. CAM use increases with education. In their exhaustive review of110 studies, Bishop and Lewith (2008) found that although a positive association is also generallyfound between income and CAM use, this relationship is less consistent than that between CAMuse and education, suggesting income does not account for the education-CAM use link. Theysuggested that awareness of and ability to seek out information about CAM, associated withhigher levels of education, probably underlies this relationship. Both the 2002 and 2007 NHISfound positive relations between income and education and CAM use (Barnes et al., 2004, 2008).

Race/Ethnicity. The evidence concerning ethnicity and CAM use is complex and generaltrends are difficult to discern. In their comprehensive review of the literature, Bishop and Lewith(2008) reported many contradictory results and noted that the different definitions of CAM usedas well as the different ways that race and ethnicity were assessed curtail interpretation acrossstudies. They did not draw any conclusions regarding race or ethnicity.

Age. Many studies indicate that middle-aged people are more likely to use CAM (comparedwith either older or younger adults; e.g., Barnes et al., 2004, 2008), although others suggest linearassociations between CAM use and age (see Bishop & Lewith, 2008).

Gender. Studies of CAM use consistently show that women are more likely to use mostCAM modalities than are men (Barnes et al., 2008; Honda & Jacobson, 2005). Bishop and Lewith(2008) noted that even though women also have higher rates of seeking help from conventionalhealth care professionals, this tendency appears to be amplified for CAM use.

Physical and mental health status. Self-reported health status is often inversely related toCAM use (Barnes et al., 2008; Bishop & Lewith, 2008). Further, studies considering the numberof illnesses people report tend to find that CAM use increases as people report more chronichealth conditions (Barnes et al., 2008; Bishop & Lewith, 2008). Indeed, chronically ill peoplereport using CAM two to five times more often than do nonchronically ill people (Willison et al.,2007). Poorer psychological health is often, but inconsistently, associated with CAM use (Bishop& Lewith, 2008; Honda & Jacobson, 2005). Inconsistent findings regarding health status and


CAM use may be at least partly due to the cross-sectional designs employed in these studies; asdescribed below, prospective studies are essential in order to understand whether poor health(diagnosed or self-perceived) actually triggers CAM use.

Motivation for CAM Use

People use CAM to treat a wide range of physical and psychological conditions as well as forgeneral improvement of health and well-being. Some seek relief of symptoms associated withchronic or life-limiting illnesses, often because they are dissatisfied with conventional treatment(Bishop & Lewith, 2008; Willison et al., 2007). Others use CAM because they want greater controlover their health (Barnes et al., 2008). In the 2007 NHIS, adults who used CAM reported usingit most often to treat musculoskeletal problems (back pain or problems, 17.1%; neck pain orproblems, 5.9%; joint pain or stiffness or other joint condition, 5.2%; arthritis, 3.5%), and othermusculoskeletal conditions (1.8%; Barnes et al., 2008).

The motivations for which people turn to CAM may differ from those for which they continueusing it. One study found that medical patients who turned to CAM had a greater awareness andpractice of healthy behaviors as well as more dissatisfaction with orthodox medicine. Further,CAM users were more open to new experiences in general and therefore more willing to exploreother treatment options (Sirois & Gick, 2002). Continued CAM use appears to be motivatedby medical need, given that established CAM users tend to have more health problems, such aschronic pain. Health-awareness behaviors also predicted continued CAM use, perhaps becausemore experience with CAM reinforces awareness and practice of healthy behaviors. CAM alsorelates to lifestyle choices and the search for alternative experiences that CAM offers (Willisonet al., 2007).

Reasons for CAM use may vary across the world. For example, among a nationally repre-sentative sample of Koreans, disease prevention and health promotion was the primary reasonfor CAM use (78.8%); specifically, for increase in energy (45.8%), disease prevention (9.1%),antiaging (7.3%), beauty (5.4%), weight reduction (3.2%), stress management (2.9%), stamina(2.8%), and longevity (2.3%). Treatment of medical problems was a distant secondary reason(reported by 20.3% of the sample) (Ock et al., 2009).

Cautions in Interpreting Descriptive Research on CAM Use

Definitions of CAM are highly fluid and variable across studies and over time. Thus, the specificdefinition of CAM used in any particular study strongly shapes the results of its prevalencestatistics. For example, NCCAM made major changes in its definition of CAM from its 2002summary to its 2007 summary of CAM use in the United States drawn from the NHIS, addinga number of specific modalities, including specific types of traditional healers (shaman, etc.) butremoving prayer as a CAM modality. This radically reshaped official CAM use statistics forthe United States. Based on the 2002 NHIS, NCCAM reported that prayer for oneself, prayerfor others, and prayer groups were the first, fourth, and seventh highest used CAM modalities,respectively, in the United States. Prayer for oneself was by far the CAM modality most used byAmericans: 45% of adults reported using some method of prayer for health reasons within thepast 12 months (Barnes, 2004).

Although questions on prayer were asked again in the 2007 NHIS, NCCAM no longerconsidered them as CAM in their summary report (Barnes et al., 2008). Thus, as citedearlier, it appears that nearly 24% fewer adults in the United States used CAM in 2007than in 2002. Only a few remnants of spirituality remain on the NCCAM website (e.g.,http://nccam.nih.gov/training/videolectures/spirituality.htm), although spirituality is com-monly considered by other researchers as a form of CAM (Tippens, Marsman, & Zwickey,2009). For example, MIDUS, the nationally representative study of midlife, found that the mostcommonly used CAM modality was prayer/spiritual practice, which was used by about 28%of all respondents (Honda & Jacobson, 2005). More recently, without public notice, NCCAMchanged its categorical scheme, reducing the number of major categories of CAM from five

Mind-Body Cam 5

to three, demoting two formerly major categories (energy therapies and alternative systems ofmedicine) to residual status.3

Descriptive studies of CAM have, to date, been primarily conducted using cross-sectionaldesigns (Bishop & Lewith, 2008), although some efforts to track CAM use longitudinally inspecific populations have been made (e.g., in breast cancer treatment; Greenlee et al., 2009).Bishop and Lewith (2008) found that 97% of the 110 studies in their comprehensive review werecross-sectional. This means that little is known about the timelines involved in CAM use. Cross-sectional designs may not necessarily pose a problem for studies of associations of demographicfactors and CAM use, but are problematic for examining associations between health or illnessand CAM use (Bishop & Lewith, 2008).

Another limitation is that much of the literature reports on CAM use as a whole ratherthan on specific types of CAM (Bishop & Lewith, 2008). Thus, there are many gaps in ourknowledge regarding correlates or effects of specific types of CAM. In addition, it is importantto consider the sample of any given study. Many studies have used convenience samples drawnfrom treatment settings or other places, limiting generalizability (Bishop & Lewith, 2008). Ingeneral, studies have been forced to compromise, choosing between having large, representativesamples and collecting rich, detailed information.

Mind-Body CAM

The descriptive studies of CAM use reviewed above provide a valuable overview. However,because CAM comprises many different treatment modalities, and because each study defines“CAM” somewhat differently, drawing comparisons across studies is difficult. For example, theMIDUS study included 14 CAM modalities but did not assess some essential ones (e.g., yoga,deep breathing). Further, different modalities may have very different patterns and predictorsof use (e.g., Honda & Jacobson, 2005) and the likelihood of using any particular type of CAMis only slightly related to the use of another (Bishop, Yardley, & Lewith, 2006). Thus, broadsurveys of “CAM use” are less helpful in understanding people’s CAM use than are studiesfocused on specific modalities.

The remainder of this article focuses specifically on the mind-body CAM therapies, those thatare most relevant to clinical psychologists engaged with behavioral medicine. Although mind–body medicine comprises a range of healing practices, all share a common effort to enhance thecapacity of the mind to improve bodily function and reduce symptoms (Bertisch et al., 2009).Mind–body therapies focus on relations among the brain, mind, body, and behavior and ontheir collective effect on health and disease. Because these techniques are generally associatedwith relaxation (Bertisch et al., 2009), they may be particularly helpful for mental and physicalhealth issues in which psychological stress plays an important role.

Mind-body interventions appear to be the CAM modalities most commonly used. Reportingon the 2007 NHIS, Barnes and colleagues (2008) concluded that, overall, 16.6% of U.S. adults,representing 34.1 million Americans, used at least one mind-body CAM in the past year. Deepbreathing exercises were most commonly used (12.7%), followed by meditation (9.4%), yoga(6.1%), progressive muscle relaxation (2.9%), and guided imagery (2.2%), while tai chi and qigong were used by 1% and 0.3%, respectively. Use of hypnosis and biofeedback remain relativelyuncommon (each 0.2%; Barnes et al., 2008)

In the 2007 NHIS, mind-body CAM use was positively associated with younger age, femalegender, higher education and income levels, possession of private insurance, and greater physicalactivity compared with the general population. Users of mind-body CAM also had a higherprevalence of most medical conditions, except for hypertension, for which mind-body CAMusers had an equal or lower prevalence. Similarly, in the MIDUS study, female gender, highereducation, and presence of mental disorders were associated with mind–body CAM use (Honda& Jacobson, 2005).

3This change from five to three major categories, which was unannounced and made without remark,occurred the week of July 1, 2011.


Psychological characteristics associated with higher mind-body CAM use include higherlevels of openness, extraversion, social support, and goal persistence (Honda & Jacobson, 2005).In addition, considering one’s illness as having more severe consequences and beliefs that onehas control over one’s health are related to greater use of mind-body CAM (Bishop et al., 2006).In the NHIS, only 30% of mind-body CAM users reported using it to treat a specific condition(particularly anxiety/depression, musculoskeletal pain, and insomnia).

Specific Mind-body CAM Modalities

Within the category of mind-body CAM, there are many different modalities; these modalitieshave a common focus but are also quite distinct. The following description of mind-body CAMmodalities illustrates the breadth of mind-body CAM interventions.

Biofeedback. Biofeedback involves using technology to provide the user with information(feedback) on physiologic states such as muscle tension, galvanic skin temperature, and brainwaves, so that the user can manipulate these states through conscious mental control. Biofeed-back requires equipment and a trainer to teach the method (Greenhalgh et al., 2010) and istypically used to help patients learn to regulate their physiologic responses by providing directand immediate feedback on the effectiveness of their attempts. Observing that biofeedback isbased on a mainstream understanding of human physiology and that most of the literature onbiofeedback is published in mainstream medical journals rather than in CAM journals, Hughes(2008) questioned whether it was actually a CAM modality at all, or whether it was time tocategorize it as conventional medicine.

Meditation. Because of its wide range of traditions and techniques, developing a cleardefinition of meditation is quite difficult. One recent effort was a five-round Delphi study witha panel of seven meditation research experts who aimed to reach agreement on a set of criteriafor a working definition of “meditation” (Bond et al., 2009). These experts agreed that essentialto meditation practice is “its use of (a) a defined technique, (b) logic relaxation, and (c) aself-induced state. Participants also agreed that a meditation practice may (d) involve a stateof psychophysical relaxation somewhere in the process; (e) use a self-focus skill or anchor; (f)involve an altered state/mode of consciousness, mystic experience, enlightenment or suspensionof logical thought processes; (g) be embedded in a religious/spiritual/philosophical context; or(h) involve an experience of mental silence” (Bond et al., 2009, p. 129).

Meditation was among the first mind-body interventions to be widely accepted by mainstreamhealthcare providers in the United States and abroad (Ospina et al., 2007). The most studiedconditions treated by meditation are hypertension, other cardiovascular diseases, and substanceabuse. Commonly used forms of meditation include mindfulness, Vipassana, TM, Sahaja yoga,Kundalini yoga, and meditative prayer. Many of the traditions and religions from which medi-tative forms originated use meditation as a method to achieve a state of enlightenment or higherconsciousness (Ospina et al., 2007; Wachholtz & Pargament, 2005).

Much of the research on meditation has been conducted on a specific type: mindfulness-basedstress reduction (MBSR). MBSR, a standardized meditation program based on Buddhist prin-ciples, was developed as a group-based program for chronic pain patients, but it has increasinglybeen used as a treatment for many other health conditions. MBSR emphasizes the cultivationof mindfulness, a particular kind of attention characterized by a nonjudgmental awareness,openness, curiosity, and acceptance of present experience. MBSR involves multiple techniques,including body scans (sweeping attention through the body while focusing on sensations withoutjudgment), seated meditation, and Hatha yoga (Ospina et al., 2007).

Guided imagery. Guided imagery involves “the generation of different mental images(either sensory or affective) using the capacities of visualization and imagination” (Posadzki &Ernst, 2011a, p. 648). These images are quite detailed and can involve not only vision but alsoother senses including hearing, smell, touch, and taste. Images are typically conjured to evoke astate of relaxation and often have a targeted outcome such as pain relief.

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Progressive muscle relaxation. Introduced by Jacobson in 1938, progressive muscle re-laxation (PMR) teaches patients to relax their muscles through a training procedure that involvesfirst tensing certain muscle groups and then releasing that tension. With practice, patients canquickly learn PMR and obtain mental calmness along with sustained muscle relaxation. PMRis based on the notions that psychological distress involves elicitation of a generalized stressactivation response and that learning to deactivate the muscular system reduces activation inmany other body systems (Conrad & Roth, 2006). Although PMR can be used as a completetreatment, it is often part of a multimodal intervention (Conrad & Roth, 2006).

Deep breathing exercises. Deliberately altering or deepening breathing patterns is acommon treatment for anxiety disorders as well as a technique to help people deal with stressand tension (Conrad et al., 2007). A common goal of breathing exercises is to counteract the fast,deep, and irregular breathing of stressed or anxious individuals and to avoid hyperventilation.Deep breathing exercises are often paired with cognitive-behavioral, meditative, or somatictherapies (Wilhelm, Gevirtz, & Roth, 2001). It is important to note that breathing exercises area part of many mind-body modalities, especially yoga and meditation, but breathing exercisesare often also explicitly considered a separate CAM modality (www.nccam.gov).

Hypnosis. Hypnosis involves attention and focused concentration with a relative sus-pension of peripheral awareness. Hypnosis involves absorption (becoming fully involved in aperceptual, imaginative, or ideational experience), dissociation (mental separation of experien-tial components that would ordinarily be processed together), and suggestibility (heightenedresponsiveness to social cues leading to an enhanced compliance with hypnotic instructions;Bernardy, Fuber, Klose, & Hauser, 2011).

Yoga. Although yoga is often characterized as simply stretching, the poses or postures(asanas) are only one of eight limbs of a larger philosophy of complete health and balanceoutlined in the Yoga Sutras. The other seven limbs, or disciplines, of yoga are as follows: yamas(ethical disciplines), niyamas (individual observances), pranayama (breath control), pratya-hara (withdrawal of senses), dharana (concentration), dhyana (meditation), and samadhi (self-realization, enlightenment). Most yoga currently practiced in the West can be considered Hathayoga and typically includes elements of poses and energetic breathing exercises, often combinedwith mindfulness/meditation and concentration (Bower, 2005). Thus, modern yoga practicetypically comprises an instructor leading a group through a series of specific postures whileperforming deep breathing exercises. Teachers typically demonstrate correct asanas and helpstudents focus their attention or concentrate on their alignment, breathing, or bodily sensationsthat arise.

The many different types of Hatha yoga vary on many dimensions: the rate at which practi-tioners cycle through poses; the extent of emphasis on deep or rhythmic breathing, alignment,and attention; the focus to which attention is directed; and overall intensity and difficulty ofposes (Groessl et al., 2008). Mindfulness is often, but not always, a central aspect. Some typesof yoga may be gentle and meditative (e.g., Integral, Svaroopa), vigorous (e.g., Ashtanga, poweryoga), or both (e.g., Iyengar, Kundalini). Some forms involve environmental changes, usingheaters and humidifiers (e.g., Baptiste, Bikram). Other yoga styles (e.g., Sudarshan Kriya yoga)focus almost exclusively on breathing (Bower et al., 2005).

Tai chi. Also known as Tai Chi Chuan or Taiji, tai chi comprises a series of movementsand forms that can be practiced in group settings or individually. Tai chi, widely practicedby older adults in China, has become increasingly popular in Western countries. It originatedas a martial art form in China during the 12th century and has five main schools, or styles,each named for the style’s founding family (Yang, Chen, Sun, Wu [Jian Qian], and Wu [HeQin]). Each style is distinct in the forms included, the order in which the forms appear, thepace of movement, and the level of difficulty. However, all styles include a series of gentle fluidmovements, mental concentration, and controlled breathing. Tai chi is characterized by slownessof movement, absolute continuity without break or pause, and total focusing of awareness on


the moment. The active concentration of the mind is instrumental in guiding the flow of thebody’s movements (Ospina et al., 2007; Stoney et al., 2009). Traditionally, tai chi is thought tobenefit health through its ability to resolve imbalance, blockage, or interruption of ‘‘qi’ (vitalenergy) and restore its flow to maximize health and relieve pain (Mansky et al., 2006).

Qi gong. Qi gong, like tai chi, is a traditional Chinese practice that involves concentrationand slow, controlled motions and is performed to enhance the circulation of qi in the body.Tai chi and qi gong are nearly identical in practical application in the health enhancementcontext and share what traditional Chinese medicine describes as the “three regulations”: bodyfocus (posture and movement), breath focus, and mind focus (meditative components; Jahnke,2002; Larkey et al., 2009). The main difference between them is that tai chi is a martial art; themovements, if performed quickly, can provide self-defense and are externally focused. Qi gong,in distinction, is not a martial art and is internally focused (Wahbeh, Elsas, & Oken, 2008). As aresult, the visualization that accompanies a particular form differs: In tai chi, the visualizationaccompanying a particular movement might involve its external consequences (e.g., disabling anadversary), the same movement in qi gong might involve visualization of an internal consequenceof qi flow (e.g., qi flowing down the arm, healing arthritis; Ospina et al., 2007, p. 59).

Mind-Body CAM Intervention Efficacy Research

So much research on therapeutic efficacy has already been conducted on mind-body modalitiesthat many systematic reviews (with explicit and repeatable methods sections) and even reviewsof reviews are available for each modality. Most reviews are organized by disease or conditionand focus on a specific modality for a specific health condition or a set of modalities for a specificcondition (e.g., qi gong for pain; Lee, Pittler, & Ernst, 2009). Included here is merely an overviewof the most recent and comprehensive reviews for each mind-body CAM modality. Much moredetail on specific studies on the effects of each mind-body modality can be found in the citedreviews.

Biofeedback. A thorough review of the efficacy of biofeedback on a variety of conditionsconcluded that the evidence was strong for positive effects on many of them (female urinary in-continence, anxiety, attention deficit/hyperactivity disorder, chronic pain, constipation, epilepsy,headache, hypertension, motion sickness, Raynaud’s disease, and temporomandibular joint dis-order; Yucha & Montgomery, 2008). However, an extensive review sponsored by the U.K. HealthTechnology Assessment Programme, part of the National Institute for Health Research, focusingspecifically on evidence for the long-term effectiveness of biofeedback for the treatment of es-sential hypertension in adults, examined 36 randomized controlled trials (RCTs) and concludedthat there was “no convincing evidence” for the efficacy of biofeedback treatment in the controlof essential hypertension when compared with other active treatments or even with no inter-vention. The review noted that meta-analysis was precluded because of poor methodologicalquality and heterogeneity in interventions (Greenhalgh, Dickson, Rumona, & Dundar, 2010).Similar conclusions regarding biofeedback for hypertension have been drawn by others (e.g.,Rainforth et al., 2007).

Reviews of studies of biofeedback for other conditions have generally found support forthe efficacy of biofeedback, but conclusions are tentative because evidence is based largely onmethodologically weak studies (e.g., Nestoriuc, Martin, Rief, & Andrasik, 2008). For example,a meta-analysis of biofeedback for tension headache found biofeedback helpful in reducingheadache frequency, but the effects were modest when compared with active controls (Nestoriuc,Rief, & Martin, 2008).

Meditation. Meditation has received a large amount of research attention. Not surpris-ingly, given the many ways meditation has been operationally defined, many reviews of medita-tion have defined it very broadly, limiting their ability to determine the effects of specific typesof meditation. For example, Ospina and colleagues (2008) conducted an extremely thoroughand detailed review of the effects of meditation, focusing specifically on hypertension, other

Mind-Body Cam 9

cardiovascular disorders, and substance abuse. Their review included studies of tai chi, qi gong,and yoga as well as transcendental meditation (TM), mindfulness, mantra, Rosary prayer, andother types of meditation, and their report describes the difficulties of summarizing dimensionsof meditation across studies. Overall, they found convincing evidence only for TM and Zen Bud-dhist meditation for reducing blood pressure. They noted that the poor quality of most studiesreviewed prevented more definitive conclusions. Arias et al. (2006) reviewed RCTs of meditationfor medical illnesses, including meditative prayer and Kundalini and hatha yoga, concluding thatfairly strong efficacy was demonstrated for epilepsy, symptoms of premenstrual syndrome andmenopausal symptoms as well as mood and anxiety disorders and autoimmune illness. A recentsystematic review concluded that meditation-based interventions (including dialectical behaviortherapy, acceptance and commitment therapy, and spiritual self schema therapy) appeared ef-ficacious in treating substance abuse, but conclusions were tentative due to the poor quality ofthe extant body of research (Zgierska et al., 2009).

As noted above, a great deal of research has focused specifically on mindfulness and MBSR.A meta-analysis of MBSR for a variety of health conditions found a robust, moderately-largepositive effect on both physical and mental health (Grossman, Niemann, Schmidt, & Walach,2004), although a systematic review of MBSR for chronic pain concluded that MBSR appearedto have nonspecific effects on pain reduction and improvement of depressive symptoms, thereis little evidence of specific effects of such interventions due to the poor quality of the studies(Chiesa & Serretti, 2011). A review of MBSR for nonclinical samples indicated that MBSRwas efficacious in reducing stress relative to an inactive control but equally efficacious relativeto standard relaxation training; however, relative to relaxation, MBSR also led to reductionsin ruminative thinking and increases in spirituality, empathy, and self-compassion (Chiesa &Serretti, 2009). Although one review of mindfulness meditation efficacy for depression andanxiety found positive effects, but no better than other active controls (Toneatto & Nguyen,2007), a more recent review based on a larger number of studies found robust reductions in bothdepression and anxiety, particularly for people who had clinical levels of symptomatology; theseeffects were smaller but remained when compared with active controls (Hofman, Sawyer, Witt,& Oh, 2010).

Guided imagery. Relatively few studies of the efficacy of guided imagery (GI) have beenconducted. One review of GI as a treatment for fatigue identified eight studies. Due to the poorquality of the studies and inconsistent findings, the authors concluded that GI is a promisingintervention, warranting further research, but no strong evidence supports its efficacy at thispoint (Menzies & Jallo, 2011). Similarly, in a systematic review of the effectiveness of GI asa treatment option for musculoskeletal pain, eight of the nine identified RCTs found that GIled to a significant reduction of pain (Posadzki & Ernst, 2011a). However, the generally poorquality of the studies led the authors to conclude that although the evidence was “encouraging,”it remained “inconclusive” (Posadzki & Ernst, 2011a, p. 652).

Progressive muscle relaxation. Progressive muscle relaxation has been shown to be effi-cacious for a range of conditions including anxiety, pain, and treatment-related nausea (Carlson& Hoyle, 1993; Manzoni et al., 2008); however, the effects demonstrated in most studies aremodest and the studies have typically been of poor quality, failing to include many elementsof RCTs (e.g., rigorous randomization, sensible control groups). When evidence is examinedmore rigorously, many of the effects are reduced. For example, the effect of progressive musclerelaxation on blood pressure appears to be small (Rainforth et al., 2007), and for anxiety, issmaller than meditation’s effects (Manzoni et al., 2008).

Deep breathing. Curiously, given that it is the most commonly used mind-body CAMmodality in the United States (Barnes et al., 2008), deep breathing has received relatively littleresearch attention. The few published reviews found few studies to aggregate, although manyother mind-body therapies include a focus on breathing as well (e.g., meditation, yoga, taichi). Reviews of deep breathing exercises for asthma have concluded that it is a promisingtherapy but that the research base is insufficient in quantity or quality (see Steurer-Stey, Russi, &


Steurer, 2002). A review of therapies for panic disorder noted that breathing retraining improvedmeasures of panic disorder compared with nonactive or active control (Sanchez-Meca, Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa, 2010). Another review, of mind-body therapiesfor menopausal symptoms, similarly reported that deep breathing-based relaxation therapiesalso show promise for alleviating menopausal symptoms but, in general, these studies lack rigor(Innes, Selfe, & Vishnua, 2010).

Hypnosis. Systematic reviews of hypnosis as a treatment for chronic and acute pain (Stoelbet al., 2009), headache and migraine (Hammond, 2007), asthma (Brown, 2007), and many otherconditions generally suggest that hypnosis is an efficacious treatment with good short-term andlong-term effects and no adverse outcomes. However, many of these reviews also note that thequality of much of the research is poor, preventing definitive conclusions (e.g., Bernardy et al.,2011; Dhanani, Caruso & Carinci, 2011).

Yoga. In recent years, research on yoga as a treatment for many conditions has proliferated,and many systematic reviews are available, including using yoga for stress management (Chong,Tsunaka, Tsang, Chan, & Cheung, 2011), physiologic and anthropometric risk profiles for Type2 diabetes (Innes & Vincent, 2007), arthritis (Haaz & Bartlett, 2011), asthma (Posadzki & Ernst,2011b), chronic pain (Bussing Schnepp, Ostermann, & Neugebauer, 2009; Posadzki, Ernst,Terry, & Lee, 2011), depression (Uebelacker et al., 2010), chronic disease risk factors (Yang,2007), and adverse effects of aging (Roland, Jakobi, & Jones, 2011). These studies consistentlyconclude that the preponderance of evidence suggests that yoga is helpful for these conditions,but because the research is methodologically problematic, more firm conclusions await futureresearch with more rigor, including randomization, adequate control conditions, and longerterm follow-ups.

Tai chi. Given its slow and gentle movements, tai chi has been considered a CAM inter-vention that may be particularly appropriate for older adults, and most research on its efficacyhas been with older adults. Systematic reviews of available studies in both English and Chinesereporting the effects of tai chi on blood pressure (Yeh, Wang, Wayne, & Phillips, 2008) and car-diovascular conditions and risk factors (Yeh, Wang, Wayne, & Phillips, 2009) reported positiveeffects. However, effects were, generally, no greater than those for control conditions such asexercise or relaxation. Similar findings were reported in a review of 77 RCTs of tai chi or qigong interventions for a variety of conditions including bone density, cardiopulmonary effects,physical function, falls and related risk factors, quality of life, self-efficacy, patient-reportedoutcomes, psychological symptoms, and immune function (Jahnke, Larkey, Rogers, Etnier, &Lin, 2010) and in a metaanalysis of 13 studies of tai chi for fall prevention in the elderly (Leung,Chan, Tsang, Tsang & Jones, 2011).

Two systematic reviews of tai chi as an intervention for osteoporosis in older adults foundinconsistent effects, and those effects were comparable to those of resistance training or calciumsupplements (Lee, Pittler, Shin, & Ernst, 2008; Wayne et al., 2007). A more recent systematicreview of 35 systematic reviews on the effects of tai chi in improving any medical condition notedthat although the conclusions of reviews were contradictory, relatively clear evidence emergedfor the efficacy of tai chi for fall prevention and improving psychological health and generalhealth for older people, although tai chi seems to be ineffective for treating symptoms of cancerand rheumatoid arthritis. For most conditions studied (e.g., osteoarthritis, pain, muscle strengthand flexibility, blood pressure, diabetes), results were inconclusive due to the poor quality of thestudies reviewed (Lee & Ernst, 2011). Similar inconclusive results were reported for tai chi in theexhaustive review of meditation cited earlier (Ospina et al., 2007). In general, systematic reviewsof tai chi efficacy have concluded that the literature was weak and that more rigorous futureresearch was necessary (e.g., Lee et al., 2008; Wayne et al., 2007).

Qi gong. Although its movements are even slower and gentler than those of tai chi, qigong has received relatively less research attention with regard to issues of the elderly and morewith regard to general health conditions. One systematic review of qi gong in supportive care for

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cancer patients reported evidence of improved quality of life, immune function, and survival,but the authors noted substantial methodological limitations of most studies and drew onlytentative conclusions (Oh et al., 2011). Similarly, a review on qi gong for diabetes managementfound potentially salutary effects, but the authors called for more research (Lee, Chen, Choi, &Ernst, 2009). A meta-analysis of 26 RCTs of qi gong for people with chronic health conditionsfound support for positive effects on many biomarkers, including increased white blood celland lymphocytes counts and lowered cholesterol. However, authors noted the methodologicallimitations, including inadequate control conditions (Ng & Tsang, 2009).

Systematic reviews of clinical trials have failed to demonstrate convincing evidence that qi gongis helpful for pain management (Lee, Pittler, & Ernst, 2009), but have demonstrated beneficialeffects for hypertension compared with usual treatment, exercise, or waitlist control. However,the authors concluded that rigorously designed trials are needed to confirm these results (Lee,Pittler, Guo, & Ernst, 2007). Finally, a review of 10 systematic reviews of qi gong for a varietyof health conditions found that most of the primary studies and reviews had a high risk of bias.The authors, noting the poor quality of the research, concluded, “it would be unwise to drawfirm conclusions at this stage” (Lee, Oh, & Ernst, 2011, p. 7).

Critique of Extant Research on Mind-Body CAM Interventions and Recommendationsfor Future Research

Because many systematic reviews of mind-body CAM efficacy are based on a small number ofstudies, most of which are not rigorously conducted, they nearly always point to the limitationsof the studies reviewed and conclude that more and better research is needed before firmconclusions can be drawn (Barnes et al., 2008). These limitations highlight the challenges inconducting rigorous research on mind-body therapies as treatments for a variety of conditionsand illnesses as well as general health promotion (Stoney et al., 2009). This section presents someof the major research considerations in evaluating and conducting mind-body CAM (Stoneyet al., 2009).

Study design. To date, most investigations of the effects of mind-body CAM therapieson either specific conditions or general health lack a control, are poorly controlled and are notrandomized, or lack descriptions on which to evaluate adequacy of randomization (Stoney et al.,2009). Some objections to reliance on RCTs as the gold standard for mind-body therapies havebeen raised, given their origin in and particular appropriateness for pharmaceutical interventions(e.g., Moliver, 2010), and there are instances in which RCTs may not be appropriate (e.g., fortreatments that are already generally accepted as effective or for which the therapy inherentlydepends on patients’ faith in a particular modality or provider; IOM, 2005). Yet, at this stageof knowledge, RCTs are widely viewed as essential in evaluating the efficacy of mind-bodymodalities (Ospina et al., 2007), and the fields of clinical psychology and behavioral medicineseem likely to continue to rely on RCTs.

Control conditions. Mind-body CAM trials have often been conducted without a con-trol condition, essentially using pre-post designs, but researchers increasingly include controlconditions. Although necessary, finding adequate control conditions can be difficult. In theircomprehensive review, Ospina and colleagues (2007) noted that almost half of the clinical trialsof meditation efficacy used a waitlist or no-treatment control group “rather than a comparatorthat would more fully control for the variety of influences that may bias the results includ-ing expectancy effects, social interactions, attention given by instructors, and time spent in thepractice” (p. 200). Other aspects that must be equivalent between control and active treatmentconditions include sense of control, mindfulness, motivation, homework, and participant burdenand risk (Bussing et al., 2009). While waitlist or usual treatment conditions may control for thepassage of time, they are a particularly poor control for mind-body CAM interventions giventhe potential for many nonspecific confounds (Stoney et al., 2009). In addition, some researchershave argued that using a waitlist control may spuriously amplify the difference in treatment effect


between the intervention and the control because people assigned to the waitlist may expect tonot get better without active treatment (Ospina et al., 2007).

Blinding. Most mind-body CAM trials have not been conducted with rigorous blinding,often because blinding the instructor and participant to treatment in mind-body CAM studiesis infeasible: Instructors or healers must typically apply a particular therapeutic skill. In addi-tion, no validated sham versions of any of the mind-body interventions are currently available(Dhanani, Caruso, & Carinci, 2011). The lack of blinding introduces multiple sources of bias,and blinding should be used to the extent possible (e.g., blinding participants, providers, andoutcome assessors to the hypotheses; Ospina et al., 2007).

Standardization of treatments/heterogeneity of therapy. Many of the systematic re-views cited above reported that heterogeneity of the interventions precluded conducting meta-analyses. In actual practice, CAM modalities are typically loosely standardized in terms ofelements and procedures (Stoney et al., 2009). Although mind-body CAM researchers typicallyattempt to standardize interventions, specific elements are often poorly described, and theremay be tremendous variability in how a treatment is implemented within a single study letalone across studies (Stoney et al., 2009; Yang, 2007). For example, few efficacy studies of yogaprovide detailed descriptions of the relative emphasis placed on components such as postures,breath, mindfulness, or relaxation nor describe many other potentially important aspects of theintervention (e.g., degree of physical exertion, spiritual focus, teacher behaviors; Yang, 2007).

This variability surely contributes to the inconsistencies in reported findings. Mind-bodyCAM researchers have been urged to manualize specific treatment modalities for particularconditions, such as outlining its specific elements, how those elements might be incorporatedinto treatment, and the frequency of treatments (Stoney et al., 2009). However, while higherdegrees of homogeneity will increase internal validity, the intervention may become increasinglyremoved from its original practice (Salmon, Lush, Jablonski, & Sephton, 2008).

Adequate statistical power. Many mind-body CAM efficacy studies have used smallsamples, rendering interpretation of null findings difficult. Few studies provide calculationsof necessary sample size to determine effects and it may be that many efficacy studies areunderpowered and therefore hampered by Type II error (Ospina et al., 2007; Salmon et al.,2008).

Standards for reviews. One way in which researchers attempt to compensate for low statis-tical power in individual studies and to determine the robustness of their findings is to aggregateresults of a number of studies into a systematic review. If appropriate, statistical techniques suchas meta-analysis can be used. Most of the reviews cited earlier were systematic reviews; only afew metaanalyses of mind-body CAM have been published (e.g., Leung et al., 2011). Althoughsystematic reviews can be invaluable in discerning broader patterns, they often suffer from a lackof methodological rigor and can be incomplete and misleading (Moher et al., 2010). A set ofguidelines for conducting systematic reviews has been developed (Preferred Reporting Items forSystematic Reviews and Meta-Analyses; http://www.prisma-statement.org/) that can be usefulin determining the methodological sufficiency of reviews as well as in directing future reviews.Most of the reviews cited earlier fall short of meeting these rigorous standards (e.g., in providingreplicable search strategies), rendering their conclusions even more tentative.

Outcome criteria. Although mind-body CAM research has sometimes focused on efficacyfor objective outcomes (e.g., blood glucose, immune markers), many have focused on or foundstronger effects for subjective outcomes (i.e., those that are not directly observable by others);such subjective outcomes are often important foci of treatment (e.g., pain, sensations of nausea ordizziness, functional status, ability to perform activities of daily living, and moods or emotionalstates; IOM, 2005). These subjective states can be assessed with well-validated measures butare regarded by many researchers as lacking credibility (Hughes, 2008). Perhaps in terms ofestablishing credibility within the behavioral medicine realm, studies should include, where

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possible, objective indices. Perhaps, too, behavioral medicine researchers may need to broadentheir notion of worthwhile outcomes.

Placebo effects. As mentioned earlier, mind-body CAM efficacy studies must attend toand—to the extent possible—equalize expectancies for improvement across conditions. Re-searchers may benefit, however, from not only controlling for expectancies but also actuallystudying their potential role in mind-body CAM interventions. In recent years, the “placeboeffect” has come to be known as “nonspecific effects” in recognition that, far from being inert,these effects can be potent, complicated, and essential aspects of treatment (Walach, 2011). Manysalutary physiological effects can follow from these nonspecific psychological effects, includingdecreased physiological arousal and changes in endorphins (Stoney et al., 2009).

Dose. To determine efficacy, it is important to determine the amount or intensity of anintervention necessary to effect a particular degree of change. At this point, little informationis available regarding the optimal dose for any given mind-body CAM therapy. Instead, manyinterventions use a conventional 8-week or 12-week framework, meeting once or twice weekly.But for many mind-body CAM modalities, other dosages may be more powerful. Pharmacolog-ical interventions employ dose-ranging studies to determine optimal dosage, which may preventthe premature dismissal of a therapy tested at only one dosage as being ineffective (Stoneyet al., 2009). Problematic for the standard RCT approach is that effects of many mind-bodyCAM therapies may be greatest when used over long periods of time rather than in the relativelybrief intervention periods in which they are typically implemented.

Moderator effects. Once efficacy for a specific mind-body CAM modality is established, itis important to determine for whom that intervention may be particularly helpful and for whomit may be less helpful. That is, it is important to identify moderators of intervention effects,such as age, gender, and psychological or physical conditions, that may influence the effectsof the intervention. For example, individuals with high regard or expectancies for a particularintervention may be more open to that intervention, more likely to fully participate, and morelikely to benefit than individuals without (IOM, 2005; Walach, 2011).

Efficacy versus effectiveness. While early-stage efficacy trials focus on “proof of con-cept,” many of the very features that strengthen their internal validity (e.g., sample homogene-ity, manualized intervention) may weaken their generalizability. Well-designed efficacy studiescompare two treatment conditions to determine whether a difference exists between the groupsif a difference truly exists. In contrast, effectiveness studies examine the treatment in the real-world conditions of actual clinical practice (IOM, 2005). Effectiveness trials require carefulconsideration of external validity, feasibility of implementing interventions in community-basedsettings, and other challenges associated with translating effects of well-controlled interventionsto applied settings (Stoney et al., 2009).

Clinical Considerations and Applications

Training/Competence

Increasingly, training programs in clinical psychology and medicine include training in variousCAM modalities, including breath work, hypnosis, meditation, and guided imagery (Willisonet al., 2007). Many patients do not disclose their use of CAM to their allopathic health careprovider due to anticipated disapproval (Williston, 2007). Failing to communicate with clientsabout CAM may be considered substandard care (Prasad & Velasquez, 2007); such dialog re-quires at least some knowledge about CAM and evidence regarding its efficacy for treatingdifferent health issues, along with, perhaps, an open mind. Prasad and Velasquez (2007) sug-gested that clinicians might recommend a particular CAM modality when it has been shown tobe safe and efficacious, accept it when it has been shown to be safe but efficacy is unclear, anddissuasive when it has been shown to be dangerous.


Mind-body CAM modalities are increasingly being integrated into behavioral medicine prac-tice, creating better treatments. For example, research has demonstrated that including mind-body CAM therapies along with cognitive restructuring and behavioral modification is usefulfor treating insomnia, arthritis, and back pain (Bertisch et al., 2009). Such melding of traditionalpsychological approaches with mind-body CAM are becoming standard in treating some healthproblems, such as chronic pain (Scascighini, Toma, Dober-Spielmann, & Sprott, 2008).

Cultural Considerations

As noted above, there is tremendous variation among racial and ethnic groups in the use of vari-ous CAM modalities (Bishop & Lewith, 2008; Hsiao et al., 2006). Little attention has been paidto these issues, however, in terms of acceptability or appropriateness of particular CAM modal-ities; instead, clinical trials typically try to maximize minority participation without examiningthe impact of race or ethnicity as a moderator of efficacy. Different cultural backgrounds maylead clients to prefer different approaches to CAM as well as instill different levels of expectancyand acceptability. Clinicians must be sensitive to their clients’ specific needs and backgroundswhen introducing mind-body CAM approaches.

Another important aspect of clients’ culture is their spiritual life (Saraglou & Cohen, inpress). Spirituality is an important aspect of many individuals’ lives and worldviews, and manymind-body CAM modalities tap into wellsprings of spirituality. For example, many meditationtechniques and yogic practices include a substantial spiritual component, and other mind-bodyCAM practices are based on a set of underlying metaphysical assumptions. Some preliminaryevidence suggests that these modalities may be more effective with their explicit spiritual com-ponents intact (e.g., Wachholtz & Pargament, 2005). Although NCCAM has officially excisedspirituality from the realm of CAM, further research and clinical applications should attend tothis aspect of CAM interventions (Rogers, Larkey, & Keller, 2009).

Ethics

Professional ethics codes often emphasize evidence-based practices. For example, the code ofthe American Psychological Association (APA) requires psychologists to base their practices onempirically established knowledge (Hughes, 2008). Practitioners must decide the extent to whichthe evidence regarding mind-body CAM modalities meets this standard. Psychologists mustprovide clients with full information about treatment options, including “alternative treatmentsthat may be available” (APA, 2002, p. 15, cited in Hughes, 2008). However, the principle ofinformed consent requires psychologists to describe to clients the evidence for any therapy theyrecommend. To meet this obligation, psychologists must know the literatures pertinent to bothconventional psychological interventions and CAM alternatives.

Tailoring Treatments to Specific Clients

The clinical trials reviewed above report average intervention effects. When dealing with a specificclient, however, it is often difficult to apply those results (IOM, 2005). For example, althoughevidence for the efficacy of tai chi in treating many conditions is not yet strong, particularlyrelative to other exercise interventions, researchers have argued that it may be appropriate formany people, given its benefits, safety and low cost (Jahnke et al., 2010; Yeh et al., 2009).Patients at high risk for being diagnosed with a disease (e.g., prediabetes or prehypertension)who are reluctant to begin medication may welcome nonpharmacologic approaches. Others mayfind tai chi more appealing than conventional exercise, and it may serve as a bridge to morerigorous activity in frail or deconditioned clients. Finding an appropriate, nonthreatening, easy-to-perform activity that clients will maintain is critical to therapeutic success. Many clinical trialshave reported excellent adherence to tai chi interventions and suggest that tai chi may promoteexercise self-efficacy, social functioning, and well-being (Ng & Tsang, 2009). Similar argumentsmay be made for other mind-body CAM modalities.

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Prevention Efforts and Wellness Promotion

CAM “treatments” are often used not to treat a current problem or disease, but rather toprevent disease or promote a general state of health and well-being. This preventive use seems tobe increasing, particularly for mind-body therapies such as meditation and yoga (Barnes et al.,2008). Research demonstrating the value of CAM modalities for preventing illness or promotingwellbeing, however, lags far behind research on treating specific illnesses (IOM, 2005). Kraft(2009) identified assumptions that may underlie people’s increasing use of CAM for prevention,including the views of health as wellness and as harmony with nature, the integrated nature ofmind, body, and spirit, and the need to take personal responsibility for one’s health.

The Future of CAM

Reliance on CAM modalities is expected to rise, in large part due to the aging of the populationand the concomitant increase in people living with chronic health problems (Willison et al.,2007). This increased use is likely to be pursued both in the context of integrated health careand independent of it, as allopathic medicine becomes more open to including CAM modalitiesand as people increasingly seek out treatment information on their own. Researchers can pro-vide a more comprehensive understanding of health psychology by using CAM modalities inpursuit of wellness as well as symptom relief. Policy based on good research can direct societalresources into modalities that provide genuine help. Clinicians will be able to provide morecompetent treatment when their practices incorporate an understanding of their clients’ CAM-related beliefs and behaviors and, perhaps, begin to integrate mind-body techniques into theirrepertoires.

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