For occ-med, alternative medicine is becoming more mainstream every day

Some say unfamiliarity with alternative therapies hampers acceptance

They still are referred to in many circles as complementary and alternative medicine (CAM), which sets them apart from the more traditional modes of medicine that you would expect to see in a typical occupational health program. Yet some of these modalities that at one time might have been considered alternative have long since been incorporated into employee health programs — especially in the area of stress management. So while acceptance is far from universal, it is becoming a little more difficult in some cases to say exactly what is mainstream and what is alternative.

"In some cases, I would do away with the term," says Joan Cantwell, RN, BSN, MA, COHN-S, CJEA (expressive arts therapy), a consultant and health and wellness coach. "Enough research has been done to be able to integrate them within the mainstream of occupational health."

Cantwell, who for years directed the wellness program at the Quaker Oats Co., now runs her own company, Mindful Living Productions in Chicago, providing creative health promotion and wellness programs, wellness teaching, and coaching to companies and individuals to reduce stress and enhance mind/body wellness.

During her time at Quaker Oats, Cantwell had the opportunity to incorporate what were considered CAM modalities into her wellness programming, with a good deal of success. "If we’re looking to treat the whole person, we’d be negligent to not acknowledge that there are therapies and approaches out there that should be used more and more," she says.

Still, many occupational health professionals remain reluctant to either incorporate such modalities into their programming or to refer patients for treatment by alternative therapists, such as chiropractors and acupuncture practitioners, though these practices may have gained some acceptance among the general public.

"The majority of my patients are referred from other patients," says Brian C. Baker, DC, of REEF Chiropractic Care in Fairfield, CT. "I get referrals from some of the MDs in town, but no referrals from occupational MDs or nurses."

Still, well-respected organizations have recognized the validity of these therapies. For example, the National Center for Complementary and Alternative Medicine (NCCAM), is a component of the National Institutes of Health "dedicated to exploring complementary and alternative health practices in the context of rigorous science; educating and training CAM researchers; and disseminating authoritative information."

As part of its congressional mandate, NCCAM maintains an information clearinghouse, which was established in 1996. The purpose of the NCCAM clearinghouse is to collect, develop, and disseminate information to the public on CAM practices and on NCCAM. The database includes references to fact sheets, journal articles, newsletters and newsletter articles, directories, brochures and pamphlets, bibliographies, monographs, and reports.

In late 2002, NCCAM underscored its commitment to serious research about CAM with an initiative consisting of three companion programs:

  • Centers of Excellence for Research on CAM;
  • Developmental Centers for Research on CAM;
  • Planning Grants for International Centers for Research on CAM.

"These programs are designed to enlist researchers from multiple disciplines — in both conventional medicine and complementary and alternative medicine — to apply their expertise to advance complementary and alternative medicine research," says Stephen E. Straus, MD, NCAAM director, in making the announcement.

But Baker sees contradictions wherever he turns. On the one hand, he notes, the nearby University of Bridgeport (CT) has schools of naturopathic medicine, chiropractic, and acupuncture. "But in my opinion, we are in the netherworld — not established, but not alternative medicine, either. I have the same problem here as acupuncturists do — health care professionals don’t know whether to refer to us."

A rose by any other name . . .

Cantwell asserts that CAM is being used far more extensively in occupational health — especially in wellness programming — than one would suspect, but that "people hesitate to call it what it really is."

Anything involved with the mind/body connection, such as meditation, yoga, or progressive body relaxation, might justifiably have been called CAM at one time, she continues. "Five years ago, people were hesitant to use them, but now they are more accepted," she asserts.

Alternative modalities that have gone mainstream, in her opinion, include acupressure/ acupuncture, chiropractic and other skeletal adjustments, and massage therapy.

On what basis should decisions be made as to whether to incorporate a specific alternative therapy? "If you’re going to bring anything in, look at the health risks," Cantwell advises. "Then, you might want to do an employee survey to find out what kinds of things employees are interested in. For example, the AAOHN [American Association of Occupational Health Nurses] just did a national survey that showed stress management is the No. 1 program employees look for."

Then, she suggests, you can introduce the modality discreetly. "You can include something like a chair massage in your health fair," she suggests.

What about those professionals who are reluctant to accept CAM modalities? Is that reluctance based on a lack of science to support their efficacy? In some cases, this is no doubt true, but as Cantwell points out, there is a body of evidence to support at least some of these modalities.

Baker says the problem goes deeper than that. One group doesn’t know what the other does, he asserts. "I understand the occ-health perspective; they’re not even brought up with exposure to spinal manipulation, though some osteopaths and physical therapists use it."

Cantwell agrees — to a point. "In general, in our traditional educational curricula there isn’t that level of knowledge," she says. "But it’s starting to infiltrate some wellness organizations and hospital integrated health departments. Still, I agree that when we try to get some of the more obscure professions in the door, the docs don’t know the benefits they offer."

For example, the workers’ comp cases Baker handles are either existing patients or employees from local corporations who are referred by human resources. "They will bypass occ-health," he notes.

Despite the prevalence of lower back pain and injury in the American workplace and the experience chiropractors have in that area, Baker says that certain perceptions — some of them justified — continue to limit acceptance. "The knock on chiropractic has been that once you go, you never get released," he notes. "In some cases, there’s no question that’s true; but in workers’ comp, you need to establish maximum medical improvement. I use the same outcome measures everyone else does, such as pain treatment questionnaires. The end treatment has to be the same."

Try it . . . you might like it

One way for occupational health professionals to become more familiar with CAM is to experience it firsthand, Cantwell suggests.

"For example, I took a seven-day program on mindfulness," she notes. "You could take a program in your community, attend a workshop or a conference, or just read about CAM. There are many wonderful web resources. Dr. Andy Weil [] has a lot of information; many docs are being trained by him in integrative medicine."

Integrative medicine, according to Weil’s web site, "combines the best ideas and practices of alternative and conventional medicine in order to maximize the body’s natural healing mechanisms." Weil, a Harvard-trained physician, has founded the Program in Integrative Medicine at the University of Arizona’s Health Sciences Center in Tucson, where he says he is training a new generation of physicians.

Cantwell turned her experience with mindfulness into a successful wellness program at Quaker Oats. "It’s an eight-week program using meditation, gentle yoga, and body awareness exercises for stress management," she explains. "We had a lot of good self-reported information each year, which allowed us to support the program for four or five years."

Another reason to learn about these therapies is that many employees will be using alternative therapies, even if they are not formally offered as part of the occ-health program. "Depending on the situation, you might want to make CAM part of taking a case history," Cantwell suggests. "There might be good questions to ask, especially if the employee is on herbs or supplements. This would be important information to have and perhaps integrate into the program for better health or recovery."

Learning something you didn’t know about the employee’s health practices is always important. If the employee is already seeing an alternative practitioner as part of their return-to-work program, you might consider integrating their services with your own program, Cantwell suggests. "Or, you may discover the worker is on an herb that would interfere with other medications," she notes. "It’s just a matter of asking — put it on a standard questionnaire when they come in."

Is integration the key?

Baker says that, at least when it comes to chiropractic, integration with other services would be beneficial for patients.

"Part of the climate in workers’ comp involves the establishment of a lot of occupational health clinics," he notes. "They are getting a larger piece of the workers’ comp pie, and in a free market that’s all well and good. But they should be on the lookout for getting a chiropractor on staff — not for referral, but to have someone work with them side by side.

"In many cases, a chiropractor can be the first one people see if they have a musculoskeletal problem." Baker cites the Texas Back Institute, which includes neurosurgeons, orthopedists, and chiropractors, as an example of this type of integration.

Meanwhile, Cantwell continues to work with different modalities to help workers deal with stress and improve self-esteem. One of those modalities is expressive art. "Art therapy helps with creativity and stress management, allowing people to get at pre-verbal wellness issues," she asserts, adding that she uses drawing, painting, sculpting, music, and writing in a supportive setting to facilitate healing.

"It’s based on the principle that all people have the innate ability for self-growth and awareness, which makes art therapy very good in stress management," Cantwell explains. "The creative process is a great process for helping people delve into and show their emotions."

Cantwell notes that the whole field of psychoneuroimmunology has demonstrated that the central nervous system is linked to the immune system. "We know the immune system is compromised when we are stressed," she says. "So when people chronically suppress their emotions, they can get sick."

Cantwell says she has used journaling quite a bit in the hospital setting, to help patients get their emotions out on the page. "You can use it in an occ-health setting to deal with chronic pain," she says. "It’s not necessarily meant as a quick fix, but rather to alleviate stress and improve quality of life. For example, working with clay is great for anger. It may seem a bit off to bring this to the occ-health setting; but at Quaker Oats, we effectively used a scribbling-your-stress-away program to help employees get what was bothering them out of their systems."

Noting once again that there is ample evidence, both scientific and anecdotal, that much of what has been called alternative medicine can be helpful in the occupational health setting, Cantwell suggests that interested occ-health professionals do a bit of benchmarking. "Have other companies benefited from these therapies? Do some benchmarking to find out," she suggests. "Then see if your employees benefit."

[For more information contact:

Joan Cantwell, RN, BSN, MA, COHN-S, CJEA, Mindful Living Productions, 4856 N. Oakley Ave., No. 2, Chicago, IL 60625. Telephone (773) 561-1314. E-mail: Web:

Brian C. Baker, DC, REEF Chiropractic Care, 133 Reef Road, Fairfield, CT 06824. Telephone: (203) 259-4939. Fax: (203) 259-3793. E-mail:

NCCAM: National Institutes of Health, National Center for Complementary and Alter-native Medicine, 6707 Democracy Blvd., Suite 401, Bethesda, MD 20892-5475. Project Officer: Chris Thomsen. Clearinghouse Staff, toll-free: (888) 644-6226. E-mail: International calls: (301) 519-3153. Fax toll-free: (866) 464-3616. TTY toll-free: (866) 464-3615.]

Additional reading

• Capacchione L. Living with Feeling, The Art of Emotional Expression. New York City: Jeremy P. Tarcher/Putham; 2001.

• Pennebake J W. Confession, inhibition, and disease, Advances in Experimental Psychology 1989; 22:211-244.

• Pert CB. The wisdom of the receptors: Neuropeptides, the emotions, and bodymind. Advances 1986; 3(3):8-16.

• Rogers N. The Creative Connection: Expressive Arts as Healing. Palo Alto, CA: Science and Behavior Books; 1993.

• Wadeson H. Art Psychotherapy. New York City: John Wiley & Sons; 1980.