THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 11, Number 3, 2005, pp. 569–574

© Mary Ann Liebert, Inc.

EDUCATION, INITIATIVES AND INFORMATION RESOURCES

Integrating Complementary Therapies into Community

Mental Health Practice: An Exploration

WILLIAM COLLINGE, Ph.D.,1 ROBERTA WENTWORTH, L.C.S.W., L.M.T.,2

and SHERRY SABO, Ph.D.2

ABSTRACT

Objectives: To (1) describe the integration of massage and energy-based therapies with psychotherapy in a
community mental health center, (2) to present qualitative feedback on the service, and (3) to present pilot data
from a sample of long-term clients with persistent mental health concerns.
Design: A noncontrolled pilot study was conducted using interview data before and self-report instruments
after completing a brief program of complementary therapy accompanying ongoing psychotherapy.
Settings/Location: The program took place at a comprehensive community mental health center in south-
ern Maine and in the private offices of massage therapists and energy healing practitioners who contracted with
the program.
Subjects: Subjects were 20 women and 5 men, with mean age of 42 years and a mean history of 7.4 years
of mental health treatment. All had histories that included trauma, 10 of which involved sexual abuse. The Di-
agnostic and Statistical Manual of Mental Disorders IV Axis I diagnoses were PTSD (10), major depression
(nine), anxiety disorder (three), and dual diagnosis (three).
Interventions: Clients receiving ongoing psychotherapy were assigned to one modality of complementary
therapy based on clinical judgment, availability of practitioners, and client interest. Modalities used were mas-
sage, acupuncture, Reiki, and Healing Touch. The mean number of sessions was five.
Outcome measures: Clients completed an investigator-generated instrument with Likert-scaled ratings of
satisfaction and perceived changes in four dimensions of trauma recovery: perceived interpersonal safety, in-
terpersonal boundary setting, bodily sensation, and bodily shame.
Results: Clients reported high levels of satisfaction with the service and significant levels of perceived (self-
rated) change on each outcome measure. Qualitative results included enhanced psychotherapeutic outcomes re-
ported by mental health clinicians.
Conclusions: The integration of complementary therapies into community mental health practice may hold
promise of enhancing mental health outcomes and improving quality of life for long-term users of mental health
services.

INTRODUCTION tical medication. By combining these two distinct modali-

ties it has, in a limited sense, used an integrative approach

C ommunity mental health practice in the United States

has historically been based on a combination of psy-
chosocial interventions and, when appropriate, pharmaceu-
to patient care. There are, however, many other modalities
that can complement each other in an integrative approach
to mental health. The repertoire of interventions used in

1Collinge and Associates, Kittery Point, ME.

2Counseling Services, Inc., Saco, ME.

569
570
community mental health could be expanded, making it even
more integrative and perhaps improving patient outcomes.
This paper describes rationale for and the implementation
of a complementary therapies program at a conventional
community mental health center. It then presents exploratory
findings from a sample of long-term clients who have ex-
perienced trauma.
USE OF COMPLEMENTARY THERAPIES
FOR MENTAL HEALTH
Recent findings indicate that complementary and alterna-
tive therapies are used by two thirds of Americans, three of
10 pre–Baby Boomers, five of 10 Baby-Boomers, and seven
of 10 post–Baby Boomers, with increasing use across all ma-
jor sociodemographic groups.1 Large surveys and clinical ob-
servation consistently indicate that mental health–related is-
sues are among the most common reasons that people seek
complementary therapies. These reasons include anxiety, af-
fective disorders, substance abuse, fatigue, insomnia, chronic
pain, depression, and stress-related problems.2–4
Unutzer et al.5 conducted a national survey with more
than 9000 respondents and found that of individuals report-
ing use of complementary and alternative medicine during
the past year, 21.3% met diagnostic criteria for one or more
mental disorders compared to 12.8% of respondents who did
not report use of alternative medicine. Furthermore these in-
vestigators found that people with panic disorder and major
depression were significantly more likely to use alternative
medicine than those without those disorders.
Because anxiety and depression predominate in clients
presenting for mental health services, it is useful to consider
how the general public regard complementary therapies for
these symptoms. Kessler et al.1 reported that complemen-
tary therapies were used by 57% of people reporting anxi-
ety attacks, 66% of those who were seeing a physician for
treatment of anxiety, 54% of those reporting severe depres-
sion, and 67% of those seeing a physician for treatment of
depression. Respondents in this study perceived the help-
fulness of complementary therapies for anxiety and depres-
sion to be comparable to that of conventional drug thera-
pies. The authors concluded that complementary and
alternative therapies are used more than conventional ther-
apies by people with self-defined anxiety attacks and severe
depression, and most patients visiting conventional mental
health providers for these problems also use complementary
and alternative therapies.
Based on the above studies, it would not be surprising if
clients in community mental health services would be re-
ceptive to treatment regimens integrating such therapies. Un-
fortunately, although complementary therapies are being
widely used by the general population and aggressively stud-
ied as to their efficacy in various medical conditions, little
is known about their potential role or efficacy in treating
COLLINGE ET AL.
mental health concerns. For example, in the case of diag-
nosed depression a review of the literature by Ernst et al.6
concluded that data supporting complementary therapies are
“extremely limited” and that the modalities with the best ev-
idence are exercise, herbal therapy (specifically, Hypericum
perforatum) and, to a lesser extent, acupuncture and relax-
ation therapies.
A health services perspective
Controlled clinical trials of the efficacy of complemen-
tary therapies for specific mental disorders are needed. How-
ever, from the perspective of health services research,
popular demand, use rates, and consumer satisfaction are
important drivers in the development of innovative service
approaches that often later prove efficacious. From this per-
spective, certain complementary therapies may have partic-
ular relevance to community mental health practice. We
selected massage and four forms of energy medicine (Ther-
apeutic Touch [TT], Healing Touch [HT], Reiki, and
acupuncture) were selected. These modalities bear close at-
tention for several reasons.
First, a growing body of empirical evidence indicates that
these modalities support some outcomes that are sought in
mental health services (discussed in more detail below).
Second, there is ready availability of trained and creden-
tialed practitioners of these therapies in many communities.
Licensing laws (massage, acupuncture) or certification lev-
els (TT, HT, Reiki) provide reasonable means of quality as-
surance and knowing what can be expected from practi-
tioners.
Third, manipulative and energy-based modalities are rel-
atively low risk and noncontroversial compared to some
other complementary therapies such as herbs or nutrition,
which may require closer medical oversight. Interaction ef-
fects with psychiatric medication are not an issue.
Finally, it is feasible for case collaboration to take place
between mental health clinicians and community-based
practitioners of these therapies. Mutual referral relationships
often exist. Mental health clinicians and complementary
practitioners can, with client permission, exchange infor-
mation about client progress and can give each other im-
portant insights from their respective paradigms about the
client.
Together this rationale formed the basis for considering
use of massage and energy medicine to complement con-
ventional mental health treatment.
Evidence of benefits related to mental health
While it is not a systematic review, the following
overview provides the rationale for our choice of therapies.
In the course of research into the medical effects of mas-
sage, many researchers have used psychosocial outcome
measures as a routine part of data collection protocols. For
example, The Touch Research Institutes (TRI), based at the
COMPLEMENTARY THERAPIES IN MENTAL HEALTH
University of Miami Medical School and directed by Tiffany
Field, Ph.D., use standardized indices of anxiety and de-
pression regardless of the presenting problem being stud-
ied.7 More than 83 clinical outcome studies of massage for
a wide range of conditions have been conducted at TRI. Fol-
lowing is a partial listing of conditions or populations for
which reductions in anxiety or depression have been docu-
mented by standardized measures: anorexia, asthma, atten-
tion-deficit hyperactivity disorder, back pain, cancer, bu-
limia, burn trauma, chronic fatigue syndrome, depressed
mothers, dermatitis in children, diabetes in children, elderly
volunteers, fibromyalgia syndrome, human immunodefi-
ciency virus–positive adults, hypertension, infants of de-
pressed mothers, job performance, juvenile rheumatoid
arthritis, multiple sclerosis, post-traumatic stress disorder
(PTSD) in children, pregnancy and labor pain, premenstrual
syndrome, psychiatric patients (both adults and adolescents),
and sexual abuse.*
The evidence favoring massage for anxiety and depres-
sion suggests a clear rationale for considering massage in
community mental health practice. Of particular interest to
the clinic staff at this institution, however, is evidence that
survivors of sexual abuse may benefit from massage ther-
apy. Indeed the high prevalence of sexual abuse histories
among our clinic population and their slow pace of thera-
peutic progress were factors leading to this investigation of
treatment alternatives. Although using a manipulative ther-
apy for sex abuse survivors may seem counter-intuitive at
first, the experience of the current authors is that, at the right
time in the course of their treatment, many sexual abuse sur-
vivors can benefit a great deal from massage as a part of
their healing process alongside psychotherapy.
This observation is supported by findings by Field et al.8
in a study in which 20 sexually abused women were ran-
domized to a Swedish massage group or a progressive re-
laxation group. Each group received twice-weekly sessions
for 1 month. The massage group had significant improve-
ments related to depression, anxiety, and life event stress.
Although there was no significant change in their aversion
to touch, those in the progressive relaxation group had a sig-
nificant increase in aversion to touch over the 4 weeks. The
researchers concluded that “The greater improvement of the
massage group could . . . relate to the special significance
of a positive touch experience following one of abusive
touch.”
Therapeutic Touch is a specific technique in which the
practitioner works to restore balance and harmony in the en-
ergy field surrounding the body a few inches above the sur-
face of the skin. Many community-based and hospital-based
nurses are trained in TT, as are many massage therapists,
making this modality widely accessible. TT is also part of
*Online document at: www.miami.edu/touch-research/index.
html
571
a repertoire of related techniques taught together under the
name Healing Touch.
Of the energy therapies most easily accessible to clients
in most communities, TT is the best documented in terms
of clinical trials. As with the massage research, many TT
studies have used outcome indices of anxiety or depression
when studying other medical conditions. A meta-analysis of
11 clinical trials of TT9 suggested that TT improves mood.
Outcomes observed in this meta-analysis included reduc-
tions in tension, confusion, anxiety, and pain and increases
in vigor and quality of life or general well-being. All of these
are relevant mental health outcomes.
In Reiki, the practitioner intervenes through the energy
field surrounding the body, although the focus is on chan-
neling the flow of universal or spiritual energy into the per-
son. There may at times be direct hands-on touch. Reiki is
also a popular and commonly available modality in many
communities, with many trained lay practitioners.
Reiki does not have a history of clinical trials compara-
ble to that TT. However, a study of the biological correlates
of Reiki treatment was conducted at the University of Texas
School of Nursing with 23 healthy subjects. Results included
reductions in anxiety, systolic blood pressure, and muscle
tension and increased salivary IgA and skin temperature.10
All of these changes are consistent with the relaxation re-
sponse,11 a hallmark of stress reduction with clear implica-
tions for mental health.
Acupuncture is a form of energy medicine by virtue of
its efforts to stimulate the flow and circulation of energy by
inserting needles along energetic pathways. Acupuncture is
a less widely available form of energy medicine, although
the number of practitioners accessible to individuals in
smaller communities is growing.
The World Health Organization12 lists anxiety and de-
pression among conditions successfully treated by acupunc-
ture. However, there is little in the way of preliminary data
in Western journals suggesting clinical benefits for anxiety
and depression. One study of note is that of Eich et al.,13
who randomized 28 patients with minor depression or gen-
eralized anxiety to either authentic acupuncture or sham
acupuncture (insertion of needles away from acupuncture
points). There were significant improvements in patients in
the treatment group compared to the sham control group as
measured by standardized instruments.
EXPERIENCE OF A COMMUNITY
MENTAL HEALTH PROGRAM
Counseling Services, Inc., is the comprehensive commu-
nity mental health center for the southernmost county in
Maine, York County, with a population of 193,000 in a 991
square mile area. The service area consists of communities,
small inland towns, and large rural areas. The center’s clien-
tele are primarily low income, with a majority receiving
572
Medicaid benefits. The center has outpatient clinics in three
towns and support services at several locations.
The Complementary Therapies Program began in spring
2000 as a result of a convergence of several factors, pri-
marily the recognition of a high prevalence of cases with
trauma among the agency’s client population (estimated at
approximately 70%) and the slow pace of therapeutic
progress observed by the clinical staff. Other factors in-
cluded spontaneous inquiries by several clients as to whether
complementary therapies would help them, exploration of
complementary therapies by several clients on their own ini-
tiative, and encouragement from clinical staff who had
sought outside training in complementary therapies.
One clinical social worker who had been on the staff for
17 years (R.W.) had received training in massage and Heal-
ing Touch on her own to pursue alternative sources of pro-
fessional satisfaction. In the course of her part-time practice
she observed unexpected benefits for clients with anxiety,
depression, dissociation, bodily shame, and other symptoms
associated with trauma. She then initiated discussion with
the executive director (S.S.) who agreed that it was time to
explore making complementary therapies available to the
agency’s clients alongside their ongoing mental health ser-
vices.
Funding
Because these therapies are not ordinarily supported by
Medicaid or third-party reimbursement for mental health
services, the question of funding had to be creatively ad-
dressed. Funding was ultimately achieved with the follow-
ing strategies. (1) One donor to the center made a contribu-
tion earmarked specifically to provide complementary
therapies to a small number of clients. (2) A second donor
agreed to allow a contribution that had been given to the
general fund to be diverted to provide complementary ther-
apies. (3) Management of the center earmarked an additional
small amount of annual fund money for the program. (4)
Complementary therapy providers in the community agreed
to lower their rates for this exploratory program. (5) Based
on early indications of benefit to long-term clients, small
grants were eventually received from the Maine Department
of Behavioral and Developmental Services and the United
Way to fund further provision of complementary therapies.
At no time have clients paid for these services. Third-
party reimbursement has not been sought, and fund-raising
efforts are ongoing. The modalities available to clients in-
clude Swedish massage, Healing Touch, Reiki, and Five El-
ement acupuncture.
Motives expressed by clients
Through the course of the program clients have expressed
a variety of reasons for wanting to experience complemen-
tary therapies. These reasons generally have fallen into two
major categories: psycho-emotional, and somatic-related.
COLLINGE ET AL.
Psycho-emotional reasons that have been given include the
desire to relax and feel peaceful; to feel less depressed, anx-
ious, or fearful; to have more energy; to be able to cry again
or feel sad feelings; to enjoy the moment; “to have a greater
sense of control over my life”; and “to feel better about my-
self.”
Somatic-related reasons expressed by clients have in-
cluded “to be able to feel my physical body,” “to feel less
pain in my body,” “to experience nonhurtful touch,” “to like
my body better,” “to have more control over my body,” and
“to lose weight by being in control over my body.”
It is the perception of the present authors that clients have
expressed these two types of motivations with approxi-
mately equal frequency. One or the other motivation has
been primary for some individuals, but many have simulta-
neously expressed both types of motivations. In our experi-
ence clients often show a clear intuitive understanding that
psyche and soma are intertwined, and that intervention with
the massage or energy therapies available can help them to
overcome emotional issues associated with physical trauma
or feelings about their bodies.
Treatment protocols
Intervention consists of up to ten sessions of Swedish
massage, Healing Touch, or Reiki; or up to five sessions of
Five Element acupuncture. Assignment is determined by
client interest and willingness to receive a certain modality,
the intuitive and clinical judgment of the client’s individual
therapist and the director of the program (R.W.), and the
availability of practitioners. All clients are given printed in-
formation about what could be expected during the course
of receiving the assigned complementary therapy.
The client’s psychotherapist attends the first meeting with
the complementary therapy provider so that the three par-
ties can discuss the client’s needs and provide an environ-
ment of safety. On an as-needed basis, the psychotherapist
attends other complementary therapy sessions to support the
client further. Between sessions the psychotherapist and
complementary therapy provider communicate with each
other about client progress and needs.
Complementary therapy providers for the program con-
sist of one Reiki practitioner (level II), one Healing Touch
practitioner (level III), one licensed massage therapist who
is also trained in Healing Touch (level III), two other li-
censed massage therapists, and one licensed acupuncturist
(nonphysician).
Referrals and use
During the first 2 years of the program there were 55 re-
ferrals to the program by the agency’s psychotherapy clin-
icians. Of these, five clients chose not to proceed; eight were
in process with services at this writing; and 12 started ser-
vices but dropped out because of transportation issues (two),
loss of interest (three), moving (two), leaving the agency
COMPLEMENTARY THERAPIES IN MENTAL HEALTH
(two), or believing that the complementary therapy made
them feel worse (two). A total of 30 clients completed at
least two complementary therapy sessions; 25 of these pro-
vided follow-up data, which are reported below.
PILOT DATA
Method
A brief survey of client satisfaction was conducted with
a sample of 25 clients. After completing a series of com-
plementary therapy treatments all clients completed feed-
back forms about their experience. This included a rating of
their satisfaction with the service on a 10-point Likert scale
in response to the question, “How helpful was complemen-
tary therapy?” and open-ended questions inviting their ob-
servations.
Sample
The pilot sample included 20 women and five men with
a mean age of 42.1 years (range 26–60, SD 9.2), a mean ed-
ucation level of 12.1 years (range 8–18, SD 2.3), and a mean
treatment history of 7.4 years at the agency (range 1–20, SD
4.9). All reported histories of trauma, including 10 with sex-
ual abuse. Ten clients were diagnosed with PTSD, nine with
major depression, three with anxiety disorders, and three
with dual diagnosis.
Results
Nineteen clients received massage, three received
acupuncture, two received Reiki, and one received Healing
Touch. The mean number of sessions across modalities was
five (range 2–10, SD 1.8).
The question, “How helpful was complementary ther-
apy?” yielded a mean rating of 8.6 (range 2–10, SD 2.3).
Perceived helpfulness was significantly correlated with
number of complementary therapy sessions (r
0.46, p

0.02 two-tailed). There were nonsignificant trends for higher
perceived helpfulness for higher education level, sexual
abuse history, and substance abuse history. Recognizing the
small sample size, there were no indications of perceived
helpfulness being significantly associated with the specific
modality used, age, gender, or diagnosis.
TABLE 1. CLIENTS’ PERCEPTIONS
Question
How safe did you feel during the session?
How much sensation did you have of your physical self?
How comfortable were you with telling your therapist
where to work and where not to work on your body?
How ashamed of your body did you feel?
573
Supplemental findings
Based on clinical and client observations during the pro-
gram, four investigator-generated, Likert-scaled questions
were added to assess clients’ perceptions of change during
the treatments. These items were added because it became
clear that for many clients this was the first time in years
that they had allowed a significant level of intimate contact
and vulnerability with another person.
Ten clients provided supplemental data on their percep-
tions of change in four clinically relevant areas that were of
particular interest. These were sense of interpersonal safety
in the presence of the complementary therapy provider, bod-
ily sensation (as opposed to dissociation) during the course
of the complementary treatments, interpersonal boundary-
setting relative to how comfortable the client felt in telling
the provider where to touch and where not to touch (e.g.,
allowing only hands or feet to be massaged at first), and
sense of bodily shame during the course of the treatment.
Upon completion of the last session, the clients were
asked to rate retrospectively how they felt about the above
four dimensions during the first session and how they felt
during the last session. Data on perceived change are shown
in Table 1.
DISCUSSION
Experience with this program indicates that it is feasible
to apply an integrative approach in community mental health
with creative program planning and collaborative relation-
ships with community-based practitioners. It has been
instructive for mental health clinicians to learn from com-
plementary practitioners about somatic and energetic para-
digms of intervention. Complementary practitioners have
benefited from the insights of mental health practitioners
about the psychological and emotional aspects of trauma.
Both groups have become more expansive in their thinking
and their understanding of what kinds of interventions can
benefit persons with mental health concerns. It has also been
found that many complementary practitioners feel a sense
of commitment to community well-being and are eager to
participate in cross-disciplinary collaboration.
Anecdotal reports from clients, psychotherapists, and
complementary therapists during the course of the program
OF CHANGE (N
10)
First session Last session
Mean (range, SD) Mean (range, SD) p
5.9 (0–10, 3.4) 9.3 (8–10, 8.2) 0.004
3.8 (0–10, 3.5) 7.9 (5–10, 1.9) 0.001
6.2 (1–10, 2.8) 8.6 (3–10, 2.2) 0.005
8.5 (5–10, 1.8) 5.0 (0–10, 3.5) 0.012
574
have consistently been favorable. Clients have reported
breakthroughs in their sense of self-confidence in interper-
sonal relations and in their ability to receive healthy and
noninvasive touch from others. In some cases psychothera-
pists have reported great strides in resolution of trauma-re-
lated issues in clients who had shown little prior progress.
Complementary therapists have reported that most clients
progress rapidly in their ability to relax and receive the treat-
ments.
The observations of the present authors and those reported
by clients seem consistent with the views of Bessel van der
Kolk, M.D., medical director of the Trauma Center in
Boston, who writes: “Current research concludes that trau-
matic experiences involve the whole person’s emotions and
feelings (mind, body and spirit). It is believed that traumatic
experience is evidenced at the biochemical/neuromuscular
levels and that treatment must integrate cognitive-based
narrative therapy (psychotherapy/counseling) with somatic
body memory treatment” (italics added).14
From a health services perspective, evidence of consumer
satisfaction and interest in new approaches often precedes doc-
umentation of clinical benefits, and this is particularly true in
the area of complementary therapies. The observation pre-
sented here are from a small pilot sample, are exploratory only,
and are best viewed from a health services research perspec-
tive. They suggest that clients who completed a regimen of
complementary therapies alongside their ongoing psychother-
apy generally had favorable experiences. Some of their per-
ceptions are consistent with progress toward important goals
in psychotherapy for persons with trauma.
Formal studies are needed to determine the extent to
which these exploratory findings presage documentation of
clinical efficacy. This program is ongoing and a data col-
lection protocol has been started that uses standardized mea-
sures of psychiatric symptomatology and PTSD symptoms
and severity at baseline and follow-up, with a more tightly
controlled research design. Further research will need to
compare outcomes with a usual-care control group. A future
report of clinical findings from a larger sample is anticipated.
ACKNOWLEDGMENTS
The authors thank Patrick Maidman, M.D., medical di-
rector, Counseling Services, Inc., and James Sims, M.S.W.,
and Pamela Arnsberger, Ph.D., University of New England
School of Social Work, for their assistance on this project.
COLLINGE ET AL.
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Address reprint requests to:
William Collinge, Ph.D.
Collinge and Associates
P.O. Box 263
Kittery Point, ME 03905
E-mail: wcollinge@comcast.net