America’s use of natural supplements continues to rise, especially in those patients experiencing chronic mental illness. In fact, about 70% of children diagnosed with autism or attention-deficit/hyperactivity disorder use natural supplements or other complementary and alternative medicine (CAM) to augment their care. This is rarely the result of physician advice, though. Many parents simply seek out supplements on their own, rarely discussing them with their child’s psychiatrist. And the psychiatrists seldom think to ask. When it comes to talking about CAM, Dr. David M. Eisenberg and others have documented a "don’t ask, don’t tell" policy between medical professionals and patients (JAMA 1998;280:1569-75).
Outside of mental health, about 38% of Americans use natural supplements on a regular basis. They are typically female, over 30, well educated, and affluent. Children whose parents use CAM treatments are much more likely to use them, both now and in the future. Why do these individuals select CAM options? And why has this utilization continued to grow among families, especially those with chronic illness?
In 1998, John A. Astin, Ph.D., published a landmark article in JAMA asking this very question (1998;279:1548-53). He found that patients were drawn to CAM not by dissatisfaction with conventional medicine or a desire for more control, but rather because CAM better fit their value system. This is perhaps the best explanation for why research continues to document the hesitation of most Americans to take psychiatric drugs. "Americans believe that psychiatric medications are effective at relieving symptoms associated with mental disorders," wrote Dr. Ramin Mojtabai, "yet they are relatively unwilling to use them in most situations" (Psychiatr. Serv. 2009;60:1015-23) As you might expect, that unwillingness is high among parents of psychiatrically ill children, the same group that’s flocking to natural supplements.
It’s values, not empiricism or a physician’s advice, that inform many patients’ and parents’ treatment choices. And that phenomenon sees more and more people turning away from conventional medicine and toward the use of natural supplements. As a practitioner, think of it in terms of cross-cultural psychiatry. By virtue of their choice, CAM users reflect a different worldview, one that shares many of the underlying premises of holistic medicine.
Holistic medicine believes the body has innate healing power and that treatment works best when done with this force. Rather than impose hasty treatments or introduce new, untested agents, the CAM culture prefers to adjust the environmental milieu and lifestyle of the patient in order to gently foster a more positive, innate healing effect. Because of this, and in light of the fact that correctly prescribed medications cause more than 100,000 American deaths a year, safety is often more important than efficacy in the view of these patients.
Both critics and supporters are often quick to assume this safety vs. efficacy dichotomy separates conventional medicine from CAM in the United States. But the characterization is not totally accurate. CAM is not an alternative to conventional care, but a complement to it. This is has long been clear to patients, even if practitioners are slow on the uptick. More than 90% of patients diagnosed with a malignancy, for example, embrace the tools of CAM with their ongoing conventional treatments. Patients and parents appreciate our expertise with diagnosis, experience with significant mental illness, and extensive training. But they often want more.
Sadly, at-home CAM research can often be misguided or lead patients astray through hype and illegitimate claims. Research has consistently demonstrated that patients and parents do not ask their practitioners for advice or information about CAM out of a fear of condemnation, as well as a sense of practitioner bias and ignorance. In the era of Internet self-diagnosis, it’s up to practitioners to understand the mind-set of values-driven patients and create an environment where they feel comfortable bringing all options to the table. If we take the time to do this, we can more effectively reach them and build a strong therapeutic alliance based on common goals, open communication, and shared values.
A few questions can assist the practitioner in better understanding their patient’s worldview. Do you prefer to use natural supplements? What else do you do to support your health (or your child’s health)? Do you believe that the body has the ability to heal itself? Do you believe in holistic or natural medicine? Only after you have a basic grasp of the patient’s perspective can you start a real dialogue about healing. A few dismissive words or a roll of your eyes will shut communication down for good.
Remember, CAM is not only a treatment option but also represents a wide-ranging belief system. And like those who ascribe to any belief system, CAM users range from skeptical to unwavering. The challenge here, just as in cross-cultural psychiatry, is feeling out the individual features of that belief system, and then navigating it with respect and candor.