Nutritional and Integrative Medicine & Ethics

Transcription

1 Ethics Leslie Korn, PhD, MPH LMHC, ACS, RPP, NTP, NCBTMB Copyright Dr. Leslie Korn, 2018 Nutritional and Integrative Medicine & Ethics

2 Ethics and Your Practice of Nutrition & CAM Scope of Practice Defined by your license or certification State Laws that Govern Practice Federal Laws (FDA) (e.g Cranial Electrical Stimulation) Differentiate between Laws and clinical practice Regulation of particular substances or materials Clinical Competency 3 State Laws Govern Nutritional Practice 4

3 State Laws Govern Touch Therapies Touch/Massage Therapies Acupuncture Therapies Naturopathic Therapies There is currently no licensing or certification for herbalists in any state that precludes the rights of anyone to use, dispense, or recommend herbs 5 Your Competency Levels Primary/autonomous when a combination of competency, credentials, & state laws allows the clinician to fully integrate nutritional & CAM into mental health counseling Collaborative/Referrals working with or referring to a more advanced nutritional professional or a professional who is licensed to design nutritional programs or to prescribe Ethical Self Review of Competency Am I competent to discuss or demonstrate? Do I need additional training? Do I need certification or a license Do I refer or reach out to a colleague? 6

4 CAM & Nutritional Self-Care is Psychoeducation Nutrition as Psychoeducation Make linkages between what clients eat & drink & how it affects their cognitive & emotional well being The effects of nutrition behaviors on mental and emotional well being Helps clients assess their self care nutrition routines Links to mental distress behaviors like substance abuse Self care behaviors Social connection behaviors Know the literature & clinical practice to provide options, even if you do not prescribe / recommend protocols Make the link between emotional nourishment & nutritional nourishment 7 Differentiating Your Competency Levels Administering The Korn Food-Mood diary vs. reading a urinary Neurotransmitter lab test Assessing caffeine intake, sleep & motivation vs replace with 500 mg of tyrosine BID Provide a recipe to prepare a mocha smoothie to enhance focus Serve green tea in the waiting area & discuss theanine & caffeine Share the latest research on how eggs help memory YOU will assess your competency & choose to enhance your competency 8

5 Ethics & Traditional Medicine Cultural Practices in the USA All present different ethical issues Curanderismo Mexican American healing art that combines the physical, spiritual & supernatural Hmong Shamanic practice Spirit Catches you & You Fall Down Anne Fadiman Ibogaine for substance abuse An entheogen currently used outside the USA for Tx of opiate addiction Native Sweat Lodge Ceremony Is it cultural appropriation? 9 Demographics, Culture & Ethics 34%-42% of U.S. adults use CAM Age 50 and older (51% women and 43% men) 41% of w/ liver disease: anxiety or depression, fatigue, & substance use 88.8% Hispanic and 81.3% non-hispanic white in herbal medicine But Hispanic women share this info with providers less CAM 26.6% of children with pain conditions use CAM 57.3% of lesbians versus 40.8% of heterosexual women use CAM 85% of women w/ RA av. age 54, used some form of CAM Nearly 1/3 of therapies were not reported to health care providers, mostly because the provider did not to ask 10

6 It is Ethical to Ask about CAM Use First: Reveal your acceptance/knowledge of these approaches. Consider adding this to your intake & self disclosure Ask: What is your use of CAM, or other practices? Have you shared your use with other practitioners? If not why not? If so was their response acceptable to you? Tell me about your CAM support team support State: I think it is important to collaborate with other practitioners Explore Drug-Herbal-Nutrient-pharmaceutical interactions to ensure appropriate combinations Results: Enhances efficacy, Rapport and Decreases compartmentalization & triangulation 11 It is Ethical to ask about Medications & Self-Care practices Let s identify your prescribed medicines. Lets identify medicines you are taking that others have suggested you take or that you read about Dietary habits (Use of nutrition & herbs) Individuals concept of the illness The meaning of the illness in context of culture Medication characteristics, side effects etc. which may be important to the patient Symbolic power & value of the medication in the patient s culture 12

7 Ethics: The Practice of CAM & Culture Our codes mandate cultural competency & cultural awareness Awareness of Transnational health practices & provider networks Awareness of how culture informs & often defines our diagnostic & treatment categories 13 Traditional Medicine The sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness World Health Organization 14

8 Cultural Concepts of Distress Ways that cultural groups experience, understand, & communicate suffering, behavioral problems, or troubling thoughts & emotions Consider what you believe about & why You caught a cold, a headache, are depressed, can t sleep? These reasons vary across cultures & religions All forms of distress are locally shaped Cultural Formulation Interview: The DSM5 interview 15 Cultural Formulation Interview DSM 5 Semi-structured interview Assess cultural factors Focuses on the individual's experience, social contexts of the clinical problem Person-centered approach to cultural assessment Designed to avoid stereotyping 16

9 CFI Modules Explanatory Model Level of Functioning Social Network Psychosocial Stressors Spirituality, Religion, & Moral Traditions Cultural Identity Coping & Help-Seeking Patient-Clinician Relationship School-Age Children & Adolescents Older Adults Immigrants & Refugees Caregivers 17 CFI Interview Designed to explore culturally based issues with flexible language Concerns and beliefs about the course of the illness Provides a language to explore Cultural & Religious questions Explore Traditional Medicine Practices 18

10 Culture, Stigma and Mental Health Stigma across cultures about obtaining mental health support CAM/Traditional Medicine use is high across cultures & ethnic groups Framing the physical as a doorway to the mental and emotional is very effective Questions about stress, digestion sleep & pain are universally accepted as acceptable terms of reference that allow for entrée to emotional well being 19 CAM is Cross disciplinary & Cross Cultural Mental health providers: Integrate physical health history Physical health providers: integrate mental health history (ACE score) Identify and treat the intersections: Trauma, Pain, chronic illnesses substance abuse, surgeries, poor sleep Minority Discrimination Stress Inflammation Depression Poor sleep Diabetes type 2 20

11 CAM Intersects Culture & Perceived Racism Accumulation of physiological wear and tear effects as a result of chronic stressors in daily life Racism: stressor to chronic autonomic arousal Depression Hypertension Diabetes 2 Self medication behaviors African Americans early mortality compared to whites Clinical Action: Screen for Allostatic Load 21 Integrative Medicine for Mental Health Allostatic Load Screening Physiological and Psychological Indicators Perceived discrimination Poverty ACE score 24 hr. Cortisol stress and 24 hr. circadian rhythm HBa1C av. blood glucose over time Heart Rate Variability autonomic dysfunction C-Reactive Protein inflammation 22

12 References: Emotional Stress, Discrimination and Health Beatty DL, Hall MH, Kamarck TA, Buysse DJ, Owens JF, Reis SE, Mezick EJ, Strollo PJ, Matthews KA.Unfair treatment is associated with poor sleep in African American and Caucasian adults: Pittsburgh Sleep SCORE project. Health Psychol May;30(3): doi: /a Hicken, M.T., Lee, H., Ailshire, J. et al. Every shut eye, ain t sleep : The role of racismrelated vigilance in racial/ethnic disparities in sleep difficulty Race Soc Probl (2013) 5: 100. doi: /s Korn, L., Ryser, R., Preventing and treating Diabetes Naturally, The Native Way, Daykeeper Press, 2009 Tomfohra,L., Pung,M, Edwards, KM., Dimsdalea, JE.,Racial differences in sleep architecture: The role of ethnic discrimination. Biological Psychology., Volume 89, Issue 1, January 2012, p Ethnicity, CAM + Sleep Sleep health supported by CAM and CBT to modify a range of physical and emotional health challenges American Indians and African Americans get less sleep than White people 4+ ACE score = poor quality sleep Less slow wave, restorative sleep; sensitive to stress Results in fatigue, insulin resistance Theorized due to the stress of vigilance in response to discrimination 24

13 Integrative Assessment & Clinical Intervention Screen for sleep; identify the types of sleep disruption Insomnia Severity Index; Pittsburgh Sleep Quality Index Brief Hypervigilance scale: 25 Our Own Meaning-Making The Consensus Trance Together, human groups agree on which of their perceptions should be admitted to awareness (hence, consensus), then they train each other to see the world in that way and only in that way (hence trance) Howard Rheingold writing about Dr. Charles Tart s research Culture informs how we make meaning Our beliefs about diagnosis and treatment 26

14 Hysteria in Ancient Greece Sigmund Freud & the Oedipal Theory

15 World War 1 & Shellshock Homosexuality as a pejorative Frontal Lobe Transorbital Lobotomy Procedure Orbitoclast

16 Refrigerator Mother Homosexuality & the DSM DSM I "paraphilia," DSM II "sexual orientation disturbance." DSM III "ego-dystonic homosexuality

17 Today? What are our Cultural Controversies Gulf War syndrome ADHD Fibromyalgia Serotonin theory of Depression Borderline Personality or Complex Trauma Vaccines and Autism How do our beliefs about diagnosis affect our approaches to treatment? How do we expand our options to address the diverse & changing need of our clients 33 Ethics and Practice Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice #_appendixes_app5_s2_ 34

18 Summary Ethics of CAM practice includes awareness of federal & state laws Ethics of CAM practice includes awareness of scope of practice in licensure & certification & clinical competency Nutrition for mental health is psychoeducation as the basic level of competency. Open to everyone Ethics of CAM practices asks us to explore our own belief systems in cultural context Ethics of CAM practice asks that we explore with our clients their own practices without judgement Use the Cultural Formulation Interview to explore questions of Traditional Medicine & CAM use Ethics asks us to understand the complex interplay with physical health mental health & ethnic identity Thank you! drlesliekorn.com