Integrating complementary and alternative therapies into psychological practice: A qualitative analysis

Abstract

Although complementary and alternative therapies (CATs) are utilised widely for treating psychological disorders, little research has examined psychologists' beliefs about integrating CAT into psychological practice. Six practicing psychologists and six psychology students were interviewed about their CAT integration beliefs, in particular integrating CAT into clinical practice via recommending CATs, offering referrals to CAT practitioners, or undertaking training to utilise CATs within psychological practice. Guided broadly from a theory of planned behaviour perspective, participants raised a number of costs and benefits, discussed referent groups who would influence their decisions, and suggested motivators and barriers for integration. A number of additional themes were raised, including risks, such as the possibility of litigation and the need for clear Society guidelines, as most participants were unclear about what constitutes appropriate practice. Identifying these themes serves as an important initial step to informing discussion and policy for this emerging practice issue within psychology.

Key words:

• attitudes—beliefs and values
• clinical/counselling psychology
• discipline issues
• ethical issues
• health attitudes and behavior
• health psychology

Many Australians are using complementary and alternative therapies (CAT) for the treatment of psychological disorders (Page, Jones, & Wilson, 2004) yet little is known about how psychologists are broaching this usage. Questions remain about the extent to which psychologists are aware of their clients' CAT usage, psychologists' beliefs about integration, and whether some psychologists are already integrating therapies (including offering alternative therapies) within their own practice. The aim of the present study was to undertake a preliminary exploration of current and future psychologists' beliefs about integrating CAT into psychological practice.

It is important to note that there are many and varied definitions of CAT. For instance, some, but not all definitions of CAT do not include chiropractic, vitamins, massage, or meditation. The definition employed in this research was intentionally broad so that participants would think about those practices which they themselves consider to be complementary and/or alternative. According to the website of the United States National Centre for Complementary and Alternative Medicines (NCCAM, 2007):

CAM (or CAT) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine . . . While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well‐designed scientific studies—questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.

Within Australia, naturopathy, acupuncture, traditional Chinese medicine, aromatherapy, homeopathy, iridology, and kinesiology are all considered complementary therapies (Australian Bureau of Statistics (ABS), 2005). The terms complementary and alternative medicine (CAM) and complementary and alternative therapy (CAT) have been used interchangeably within the research literature (Bassman & Uellendahl, 2003; Kruszkowski, Malti, & Modestin, 2003). However, ‘medicine’ most often refers to treating, alleviating, or preventing disease, while ‘therapy’ tends to relate to treatment alone (Cohen, Hrbek, Davis, Schachter, & Eisenberg, 2005; Kruszkowski et al., 2003). This qualitative enquiry will focus on CAT for the treatment of psychological disorders given that most people who are seeing a psychologist do so for an existing condition rather than for maintenance of well‐being.

Use of CAT

The ‘fuzzy boundaries’ that exist around the definition of CAT mean that usage estimates can be difficult to establish clearly (MacLennan, Myers, & Taylor, 2006). In Australia, estimates of people's usage are are currently approximately 68.9% (Xue, Zhang, Lin, Da Costa, & Story, 2007) but reports are higher for some groups of people. For example, in a West Australian anxiety support group, usage was reported at 88% (Gollschewski, Anderson, Skerman, & Lyons‐Wall, 2004; Page et al., 2004). Australians are much more likely to use CAT for the management of anxiety and depression (the two most common psychological disorders) than they are to seek psychological services (ABS, 2005). It can be argued that when individuals do seek the advice of a qualified psychologist, it is important for their mental health provider to be able to respond or refer appropriately to queries about CAT.

Despite the high incidence of CAT usage, clients of traditional medical services seldom divulge their use of CAT to their service provider (MacLennan et al., 2006; MacLennan, Wilson, & Taylor, 2002). Fifty‐seven percent of South Australians surveyed by MacLennan et al. indicated that their practitioner was unaware of their CAT usage, and, in a recent national population‐based survey, only 44.9% of Australian CAM users always informed their doctors about their usage (Xue et al., 2007). Failure of clients to report CAT usage and failure of practitioners to enquire properly about clients' use of CAT can leave clients vulnerable to medical complications (Komesaroff, 1998).

Integration pathways

There are a number of complementary and alternative therapies with increasing levels of acceptance within the medical community, with the majority of Australian doctors considering non‐medicinal complementary therapies, such as yoga, meditation, and acupuncture, to be both mainstream and effective (Cohen, Penman, Pirotta, and Da Costa, 2005). Many clients of psychologists will have already sourced alternative therapies for themselves and their psychologists will usually only be aware of this use if they ask. In many cases, traditional therapy could be augmented successfully by CAT, such as a client with a social anxiety disorder attending a yoga class once a week, as well as attending therapy sessions. The yoga classes would serve the dual purpose of exposing the client to social situations while also facilitating relaxation (Brown & Gerbarg, 2005). Indeed, in a report comparing the beliefs of general practitioners, psychiatrists, and clinical psychologists regarding the helpfulness of various interventions for mental disorders (N = 454), 15% believed that a naturopath or herbalist could be helpful for the treatment of depression and 21%reported a belief that vitamins and minerals, tonics, or herbal medicines be helpful for the treatment of depression. In both of these cases, more psychologists than general practitioners or psychiatrists indicated a belief in the efficacy of CAT (Jorm et al., 1997).

Little is known about the ways in which psychologists are integrating CAT; however, the types of integration that have been reported by health professionals, including psychologists, fall into three broad categories: recommending CAT to clients, offering referrals to CAT practitioners, and accessing training and integrating CAT into one's own psychological practice. In the United States, Bassman and Uellendahl (2003) mailed surveys to 1000 members of the American Psychological Association to assess knowledge, attitudes, practices, and patterns of referral in relation to CAT. The response rate was low (N = 202); however, the findings indicated that most psychologists believed CAT could aid in treatment. Respondents reported recommending CAT at relatively high rates and significantly higher rates than they were offering specific practitioner referrals. A few of the psychologists surveyed reported that they were using CATs, including chiropractic, herbalism, sharmanism, acupuncture, and massage directly in their practice, in conjunction with traditional psychotherapy methods.

In an Australian survey administered to 69 natural therapists, it was reported that 75.4% of natural therapists had referred their clients to a mental health professional; however, only 46.4% had actually received a referral from a mental health professional (Morgan & Francis, 2008). In an effort to provide guidelines for health professionals, Hirschkorn and Bourgeault (2005) suggested that practitioners should consider the client, the practice in which they work, and the pros and cons of available complementary and traditional allopathic therapies. They also suggested that once a decision has been made to pursue a complementary approach to therapy, an appropriate referral to a trained/registered practitioner should be made to ensure client welfare and maintenance of clear and open communication between practitioners.

Within Australia, guidelines for psychological practice are developed by the Australian Psychological Society (APS) (APS, 2003). These guidelines are general, can be open to interpretation, and do not directly address CAT. Certainly, the practice of psychology has been grounded in the scientific/medical model and, therefore, psychologists may be hesitant to embrace alternative therapies that have little empirical evidence to support their use. However, there is an active APS interest group ‘Psychology and Complementary and Alternative Medicine’ (PsyCAM) whose stated goal is to promote collaboration between psychologists and CAT providers (Durbock, 2007). Clearly, even if this option is adopted by only a small number of psychologists, it would be advantageous for them to know under which circumstances they may safely and appropriately refer to CAT should they wish to (Bassman & Uellendahl, 2003).

Some of the challenges of integrating CAT have been highlighted by the experiences of general practitioners. With increased patient use of CAT and increased integration has come a greater demand on practitioner time and resources, as well as an increase in litigation (Cohen & Eisenberg, 2002). A review by Hirschkorn and Bouregault (2005) proposed a conceptual framework for interpreting health‐care providers' behaviours in relation to CAT integration. They found that practitioners' decisions to integrate are influenced by a number of multi‐level factors, including individual attitudes and experience, type of practice worked in and the views of their colleagues, potential risks (e.g., litigation and client health), and the needs of clientele.

Risks associated with integration

In a similar vein to integrating CAT into medical care, there are a number of risks associated with CAT usage itself and its integration into psychological care. One serious risk is possible dangerous side effects. Kava, for instance, is effective for the treatment of anxiety. However, people experiencing alcohol dependency and individuals with hepatitis must be advised to avoid the use of kava due to its toxic effect on the liver (Pittler & Edzard, 2000). St John's Wort is an effective treatment for depression, and, while it has few side effects on its own, it has been shown to interact with a number of medications (in particular, commonly used antidepressants). Side effects due to drug interactions can include serotonin syndrome, a life‐threatening condition, and Jorm, Christensen, Griffiths, and Rodgers (2002) recommend that St. John's Wort only be used under medical supervision.

Another potential risk related to CAT integration into psychological practice is the question of what constitutes ethical integration practice. Bassman and Uellendahl (2003) noted that, because of the lack of guidelines, American psychologists are recommending various holistic healing modalities, but are not offering referrals to specific practitioners to avoid potentially placing clients at risk from unqualified CAT therapists. While the complexities of CAT integration are not specifically addressed by the ethics statement of the Australian Psychological Society (APS), it is, nevertheless, expected that psychologists will act in the best interests of their clients (APS, 2003). Also of concern is the fact that the majority of Australians surveyed by MacLennan et al. (2002, 2006) expressed the belief that some or all alternative therapies are safe when, in fact, both the efficacy and the relative safety of many individual therapies remain in question. Thus, it would appear that Australian psychologists face the ethical, and perhaps legal, responsibility to advise clients appropriately about CAT but without adequate training or resources.

Proposed framework

While a number of previous studies have examined psychologists' attitudes towards CAT and integration behaviours (Bassman & Uellendahl, 2003; Jorm et al., 1997; Wilson & White, 2007), there is a need for more comprehensive and current Australian research. In addition, there are advantages to conducting theoretically informed qualitative research so that the dialogue will be rich in terms of eliciting people's underlying attitudes and beliefs. By adopting a theory‐based approach, the beliefs elicited can more readily inform future quantitative research, enabling the formal testing of belief‐based theories in larger cohorts.

One well‐validated decision‐making model that may provide an appropriate framework to understanding the beliefs underlying psychologists' decision‐making in relation to CAT integration is the theory of planned behaviour (TPB; Ajzen, 1991). According to the TPB, the degree to which a person is in favour of performing a particular behaviour (attitude), the degree to which a person feels social pressure to perform a behaviour (subjective norm), and the degree to which a person feels they have control over performing the behaviour (perceived behavioural control) influence people's intention to perform specified behaviours and thereby increase performance itself. In addition, perceived behavioural control is said to impact directly on behaviour. Importantly, underlying the TPB is the assumption that the antecedents of attitude, subjective norms, and perceived behavioural control are corresponding salient beliefs. Attitudes are determined by the individual's beliefs about the likely outcomes of performing the behaviour and the evaluations, either positive or negative, of these outcomes (behavioural beliefs). Subjective norms relate to the individual's beliefs about important referents either approving or disapproving of a given behaviour (normative beliefs). Perceived behavioural control is based on the individual's beliefs concerning the extent to which internal and external factors may inhibit or facilitate performance of a given behaviour (control beliefs) (Ajzen, 2006). Ajzen (2006) states that the TPB is appropriate as an heuristic framework to guide questions to be raised in qualitative research specifically for the elicitation of salient behavioral, normative, and control beliefs and this method has been used previously to explore people's underlying beliefs in contexts such as adolescent sun safety (Wilson & White, 2008) and adults' organ donation choices (Hyde & White, 2010).

The aim of the present study, then, was to adopt a broad TPB framework to explore the underlying beliefs of psychologists and future psychologists (psychology students) to CAT integration for the specific behaviours of (1) integration by seeking training for a specific CAT therapy and then employing that therapy into practice, (2) integration through specific referral to a trained practitioner, and (3) integration through offering general recommendations for CAT therapies. A deeper understanding of the factors that influence psychologists' choices in integrating CAT can be used to inform both clinical practice policy and educational initiatives.

METHOD

Participants

Before potential participants were contacted for participation in this study, ethical clearance was awarded by the Queensland University of Technology Human Research Ethics Committee. To elicit beliefs about CAT integration, semi‐structured interviews were conducted with six clinical psychologists and six undergraduate psychology students from South‐East Queensland, Australia. Students were two males and four females, and all were in their third or fourth year of full‐time equivalent study and were close to completion of their undergraduate or fourth‐year psychology degree. The students ranged in age from 20 to 50 years. The practising psychologists were represented also by two males and four females from both the private and public sector. The psychologists ranged in age from 25 to 63 years. Both psychologists and students were recruited via a snowballing technique through friends or associates of the researchers. Psychologists were each given a $50 Coles/Myer gift voucher as a gratuity, and students were entered into a draw for one $50 Coles/Myer gift voucher. In most cases, participants were unaware of the gratuity when they agreed to participate.

Throughout the process of conducting the interviews, responses were scrutinised to check for theoretical saturation (Morgan, 1998). It was decided after 12 interviews (six each of psychologists and students) that further data collection would be unlikely to add to the obtained information in regards to the beliefs of psychologists and future psychologists (psychology students) about CAT integration.

Concepts/measures

The aim of this study was to explore participants' beliefs about the integration of CAT in the treatment of psychological disorders. At the commencement of the interview, as an ice‐breaker and to orient participants to the nature of the topic under investigation, participants were asked about their knowledge of CAT for the treatment of psychological disorder. They were also asked about the extent to which they believe other psychologists were integrating CAT or were willing to integrate CAT. Three specific integration pathways were then discussed: (1) integration by seeking training for a specific CAT therapy and then employing that therapy into practice, (2) integration through specific referral to a trained practitioner, and (3) integration through offering general recommendations for CAT therapies. A copy of the interview protocol is included in Appendix-A. Questions exploring the behavioural, normative, and control beliefs in relation to CAT integration were identical for each scenario and were designed to elicit an in‐depth understanding of participants' beliefs about CAT integration in psychological care. For each scenario, the researcher described to participants the scenario; for example, ‘A psychologist chooses to recommend specific complementary or alternative therapies to their clients without direct referral to a practitioner’. Participants then were asked questions to elicit the behavioural, normative, and control beliefs, such as ‘What are the advantages that come to mind about this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?’; ‘Who are the individuals or groups that would approve of this use of Complementary and Alternative Medicine/Therapies for the treatment of Psychological Disorder?’; ‘What are the factors that would motivate or encourage you to integrate Complementary and Alternative Medicines/Therapies into your clinical practice in this way?’, respectively.

The facilitator adopted a semi‐structured interview schedule in that it allowed the researcher the freedom to follow up on any new and unexpected issues (beyond the theoretical framework being drawn upon). Questions were framed generally around the belief basis of the TPB variables of attitude, norms, and perceived behavioural control, as well as further inquiries about participants' knowledge of CAT. Knowledge was included, as it may be an important predictor of people's attitudes (Wilson & White, 2007) and behavioural intentions (Brubaker & Wickersham, 1990), and degree of CAT knowledge would undoubtedly be an important consideration in the appropriateness of any integrative practice. In addition, any new or emergent themes beyond those consistent with the TPB framework were noted.

Data collection

Individual interviews were conducted to minimise any burden on participants (i.e., to ensure ease of participation at a convenient time and place), and to ensure confidentiality in a one‐to‐one context as opposed to the use of focus groups. Interviews with psychologists were conducted at their place of work at a time that they nominated. Interviews with students were conducted in private rooms on their university campus. In all cases, interviews began with the interviewer explaining the project and giving the participant time to read and sign the informed consent sheet. The interviewer then read aloud the definition of CAT used in the present study. With permission from participants, all interviews were digitally audio‐recorded and later transcribed verbatim by the first author for analysis.

Analysis

Transcripts from student and psychologists interviews were content analysed using NVivo 7. Coding rules were partially pre‐determined, with concepts drawn from the semi‐structured questionnaire that was designed to elicit responses according to the TPB belief basis (Francis et al., 2004); however, there were also a number of emergent constructs. When conducting the analysis, there was no limit to the identification of themes; rather, this aspect was data driven, not researcher or theory driven. Themes were identified both by the frequency of ideas and by the number of individuals who mentioned particular topics. Initial broad constructs included behavioural, normative, and control beliefs relating to each type of CAT integration. Each of these broad constructs was separated according to positive or negative valence. Other constructs that emerged included the role of knowledge (from a specific prompt) and perceived risks (unprompted).

RESULTS

To gain an appreciation of the level of the awareness of CAT among students and psychologists, participants were asked to mention some complementary or alternative therapies that they know of that are used for the treatment of psychological disorder. While two of the students were unable to suggest any therapies, the other four students mentioned herbs and homeopathic remedies, mindfulness meditation, aromatherapy, reflexology, yoga, and fish oil for attention deficit disorders. All of the psychologists were able to mention at least a couple of therapies, including most of those mentioned above. Meditation was the most commonly mentioned complementary therapy for the treatment of psychological disorder.

Perceived current integration practices

Participants were asked to what extent psychologists might already be integrating CAT into psychological practice or might be willing to integrate for the three stated integration pathways. Responses varied widely between participants, from ‘not at all’ to ‘quite a lot’, and depended upon participants' own CAT usage and integration experiences. Students largely indicated that any figure that they stated would be an estimate only, while psychologists indicated that they were forced to rely on their own experience as they did not talk about CAT integration with other psychologists. One participant summed up what others indicated was the general feeling among psychologists.

I know a couple of psychologists who are a bit ‘out there’ and who are a bit ‘alternative’ and when we've been together and we've been with my more conservative colleagues, we've looked at each other and kinda gone ‘ooh ooh, which planet have they come down from?’ You know . . . psychologists who are very keen to use alternative practices probably aren't that concerned with the evidence.

Interestingly, the psychologist who made the above comment had integrated CAT on occasion but did not feel that this practice would be accepted by their peers and was not prepared to talk about it openly with them.

Advantages and disadvantages of integrating CAT (behavioural beliefs)

Accessing CAT training and integrating into practice

Participants were asked about the advantages and disadvantages of the three different types of integration. When asked about a psychologist receiving specific training in one or more modes of complementary or alternative therapy and then integrating these therapy options into their practice, students tended to suggest that this practice would provide some benefit to clients.

Well, you could offer your client a much broader service

Students also noted that some psychologists who also practice complementary or alternative therapies might unwittingly be doing a disservice to their clients.

They [the psychologist] may become very biased in their way of thinking and not be effective to people who have extreme disorders, like schizophrenia or bipolar, that do need a chemical intervention.

Several of the psychologists were able to suggest some advantages to training and then integrating CAT into their practices.

Some people are far more sensory, somatic in their orientation, so if I had the choice of training, I would probably choose relaxation massage, something like that,

However, all of the psychologists expressed vehement concern about the ethical implications of a psychologist practicing any type of complementary or alternative therapy with their clients. One psychologist expressed this concern by saying:

One of my dreams at one stage of my career was to integrate my psych practice and my dojo . . . but it opens a tin of worms ethically because the role of a martial arts teacher is one of a mentor, friend, teacher. There are a whole lot of roles there that, certainly, the APS would disagree with a psychologist getting that involved with their clients.

Another psychologist reported that: ‘The disadvantages are that we shouldn't be touching our clients . . . I wouldn't add complementary medicine to my practice coz I'm kind of a double blind cross over trial kind of girl and I suppose im very uncomfortable with being seen to be alternative’.

And another psychologist stated:

They might see a sense of quackery about this psychologist once they mention something alternative.

Offering referrals to a trained alternative practitioner

When asked about a psychologist making a direct referral to a trained practitioner of a specific complementary or alternative therapy, students and psychologists suggested similar advantages.

. . . you would know the quality of the person you are referring to.

They also suggested similar disadvantages.

The patient may feel they are being railroaded from one professional to another.

Recommending CAT to clients

When asked about a psychologist choosing to recommend specific complementary or alternative therapies to their clients without direct referral to a practitioner, both students and psychologists were quick to point out the advantage of client autonomy.

An advantage would be that the client would have freedom to pick and choose who they wanted to see and to see someone who they thought would fit into their lifestyle and that fits with them.

However, concerns were also expressed, particularly about not being able to follow‐up client progress and about professional practice.

I think there's some charlatans out there . . . I don't think I'd be willing to just let them go out there. It's a bit airy fairy.

Perceptions of others' approval or disapproval (normative beliefs)

Accessing CAT training and integrating into practice

To establish the perceived norms surrounding CAT usage, participants were asked to identify the individuals or groups that might approve or disapprove of each type of integration. In relation to receiving training and then integrating CAT into practice, students suggested that younger people, some patients, many mental health professionals, and those who have used CAT in the past would approve and that women would be more likely to approve than men. They suggested that medical professionals, academics, and religious groups would disapprove. Psychologists suggested that some patients, CAT practitioners, and some individual psychologists who have an interest in CAT would approve. They suggested that psychologists with conservative beliefs, medical professionals, the Psychology Board, the Australian Psychological Society (APS), and some workplaces, particularly government workplaces, would disapprove.

Offering referrals to a trained alternative practitioner

When asked about a psychologist making a direct referral to a trained practitioner of a specific complementary or alternative therapy, again students did not differ from their responses in relation to receiving training and then integrating CAT into practice. A few of the psychologists indicated that this option was the most ethical and acceptable and that it would be approved of by some clients, other psychologists and governing bodies. They indicated that religious groups and individuals who did not approve of other modes of integration would also disapprove of offering referrals. Two of the psychologists stated that they did not think that the practice of referral would be acceptable.

I'm not sure anyone would approve. I don't know any psychologists who do refer out. No, I don't know any groups who would approve of it.

Recommending CAT to clients

When asked about a psychologist choosing to recommend specific complementary or alternative therapies to their clients without direct referral to a practitioner, students offered similar suggestions to those offered in relation to receiving training and then integrating CAT into practice. Psychologists, on the other hand, were less unanimous in their assessment of which groups would or would not approve. Some psychologists still indicated that this practice would not be ‘the norm’ and would not be accepted by government institutions, the Psychologists Registration Board, or the APS. Other psychologists indicated that offering referrals would be acceptable to clients and other psychologists as it was in keeping with their duty of care and respected client autonomy.

The people who obviously have their clients' best interests as central focus (would approve)

Motivators or barriers to integration (control beliefs)

Participants were asked what factors might motivate or encourageand prevent or discourage CAT integration. Responses were similar across the three integration scenarios. Students focused on the importance of scientific evidence and knowledge and on the desires of the client. One student stated:

First I would have to have some knowledge of that particular person I'm going to refer them to and have some knowledge about what is going to take place. So yeah, lack of knowledge about the therapy [would discourage integration].

Psychologists, too, were concerned about these factors, but were also very concerned about the ethics of integration and about the potential for litigation. A number of comments related to this theme were:

Well, a lot of psychologists themselves would be quite keen but are working within strict guidelines

One psychologist stated that they would be willing to integrate ‘If it was more widely accepted by society. If it was endorsed by my employer and other regulatory bodies and if the client suggested it first; if it was accepted’.

Another suggested ‘We at some level as a profession, and all professions do this, they say we don't have all the answers, but they don't make any real active roles as a profession to encourage multidisciplinary practice I think’.

Risks associated with integration

While no questions directly asked about the risks associated with integration, this topic emerged as an important theme. Participants' concerns were expressed throughout the interviews, most of them coming from psychologists who indicated that they were unaware of where their obligations lay in relation to their duty of care. While they might believe a particular therapy to be effective for a given disorder, they would often not recommend or refer to it because:

It may not be recognized by the board, or the APS, or the person's workplace. It might be perceived as kind of hokey or without scientific basis. It could be perceived as not being evidence based. It might not be seen as ethical.

While differing widely in what they did and did not consider to be ethical and acceptable integration, most of the psychologists indicated that by using, recommending, or referring to CAT, they could be leaving themselves open to litigation, and could put themselves at risk of losing their professional registration and becoming an outcast among their peers. Interestingly, none of the psychology students who were interviewed expressed any concern about associated professional risks, most likely because they have not yet practiced psychology so have not encountered this issue personally.

The importance of being knowledgeable

Finally, participants were asked to briefly talk about their level of knowledge and skill in relation to the integration of complementary and alternative medicine/therapies for the treatment of psychological disorder. They were asked also what influence their knowledge and skill level have on whether they integrate or are willing to integrate CAT. One psychologist was interested in integration, but indicated that they had already dedicated many years of study to becoming a psychologist and still maintained professional development, and that they did not have time to familiarise themselves with a whole other field of knowledge.

. . . there's a lot of ‘Jack of all trades’ practitioners out there who might have done a weekend course or something and feel that they're fully qualified, which is probably why, personally, I would not extend my professional knowledge and practice to include complementary therapy and I'd always prefer to refer out to a trusted colleague or something like that.

Psychologists and students alike made it clear that their level of knowledge about complementary therapies would influence their willingness to integrate. When asked whether their level of knowledge would have an influence on whether they were willing to integrate, one psychologist responded: ‘I think very much so and I think there'd be a fairly direct linear relationship; not only in my own [practice] but in the whole sample of people’.

So, while knowledge or lack of knowledge was evident also in many of the above TPB belief‐based themes, it stood out independently as an important contributor to CAT integration decisions among psychologists and students.

DISCUSSION

The purpose of this study was to explore current and future psychologists' beliefs about the integration of CAT into psychological practice. As expected, a number of themes relating to TPB beliefs were elicited. Behavioural beliefs, in the form of identified advantages and disadvantages to particular integration behaviours, included beliefs such as offering clients a much broader service and knowing the quality of the person to whom you would be willing to refer your client. For normative beliefs, comprising the perceptions of approval or disapproval of integration, participants indicated that groups such as the Registration Board and the APS would not approve of CAT integration. Participants indicated that CAT practitioners and users of CAT would approve of CAT integration. When asked about control beliefs, what factors might motivate or prevent integration, participants expressed concerns about the apparent lack of scientific evidence, and indicated that psychologists are working within strict practice guidelines.

In addition to these expected themes, psychologists, but not students, talked openly about the perceived professional risks they associated with integration, and emphasised the importance of this construct in influencing their thoughts about integration. Risks included the possibility of litigation, and, more often, the possibility of damaging their professional reputation. All participants also emphasised the importance of knowledge in the decision to integrate, suggesting that they did not have the time or resources to learn an entirely new field and that they would want to understand a complementary therapy well before they would be willing to utilise, recommend, or refer to it.

Students indicated that they were largely unaware of the professional implications of the various integration choices and their responses did not vary much between the different integration scenarios. Psychologists, on the other hand, indicated a belief that integration was not widely or openly accepted by society in general or by their peers. They also indicated that professional bodies would generally disapprove of all integration; in particular, that professional bodies would disapprove of psychologists seeking training and then integrating complementary therapies within their own practices. This option, to train in CAT and integrate directly within a practice, was generally disregarded by psychologists. Recommending therapies was dependent largely on knowledge of the therapies and acceptance by the client, while referral tended to be dependent upon the practitioner's knowledge or experience and an appropriate and trusted network of qualified practitioners to refer to. Perhaps, most importantly, all respondents indicated that more scientific evidence, more open acceptance, and clear guidelines would motivate psychologists to integrate CAT into their practices.

This study had a number of strengths, including the use of both students and practicing psychologists as participants. This sample allowed a broad overview of the degree of awareness and acceptance of CAT among current practising psychologists and an upcoming cohort. A second strength was that the psychologists who participated came from a variety of clinical and educational backgrounds, including both private and public practitioners, allowing insight into the meaning and implications of integration across different sectors. For example, a psychologist practicing in a clinic for sufferers of a specific chronic health condition was very aware of CAT options and felt that integration was expected as part of a multidisciplinary approach to health. Alternatively, a psychologist in a private practice in a high socioeconomic area expressed the belief that CAT integration would be ethically and professionally unacceptable. A final strength of this study was that, by using a semi‐structured interview technique informed by an established psychological theory, a number of beliefs that are contributing to psychologists' decisions about integration behaviours were able to be elicited. These beliefs will be able to be addressed in future quantitative research to establish the prevalence of the beliefs in larger cohorts of psychologists and psychology students, as well as in professional discourse around the topic of integration.

One limitation of this study is that it utilised a relatively small sample. However, despite the small sample size and snowballing sampling method, psychologists and students were drawn from a wide age range and from a variety of backgrounds. Further, the themes and ideas that emerged were relatively consistent. Another limitation is that the psychology students sampled had very limited knowledge about the practice of psychology and this limited knowledge restricted their ability to comment on the practice and implications of integration although the participation of students was an important aspect of the design and served to highlight the role of experience in the decision to integrate CAT into practice. Finally, using a semi‐structured approach can be very directive and it is likely that different issues and themes would have emerged if a more open structure had been adopted. Nevertheless, utilising a more directive, theory‐based approach was intentional as the results of this study can inform future research, especially quantitative, to verify the prevalence of these beliefs among a broader sample of students and psychologists, as well as, over time, to reflect any changes in perceptions that may accompany the increasing use of CAT in self‐treatment of mental health conditions.

This research is important, as complementary and alternative therapies are increasingly being integrated into allopathic medicine, particularly for the treatment of psychological disorder. Whether psychologists integrate or not, their clients will often be utilising complementary therapies and the ways in which established and complementary therapies work together should be understood if efforts to ensure best practice. It may be beneficial for psychologists to at least be aware of such client practices if they are to understand the efficacy of their own therapy practices. If psychologists do choose to integrate CAT into their practice, the current research indicates that they would prefer to be provided with some clear information and guidelines for their own reassurance and to ensure the safety of their clients.

Future research exploring the integration of CATs into psychological practice should include both qualitative and quantitative methods. Qualitative research provides insights into underlying beliefs, motives, and behaviours, which affords a rich picture of current practice, informing quantitative research as well as professional development programs. Quantitative research can provide more thorough insight into the numbers of psychologists who hold particular beliefs and the extent to which they hold beliefs, such as the belief that the integration of CAT ‘might not be seen as ethical’. Finally, it is acknowledged that usage of CAT changes over time and it is important to periodically repeat this type of research so that ethical standard workshops and published guidelines, as well as tertiary education programs, remain current and relevant. Beliefs that are elicited and explored through such research can then be directly implemented into ethical standards workshops, professional development programs, and tertiary courses.

Overall, the purpose of this preliminary exploration has been to gauge psychologists and future psychologists' beliefs about CAT integration. To the knowledge of the authors, this is the first study to investigate qualitatively CAT integration into psychological care and this approach has provided a rich insight into the current state of integrative views and practices. This study has demonstrated that knowledge, as well as behavioural, normative, and control beliefs, plays an important role in the perceptions related to integrating CAT into psychological practice. It was clear also that there are a number of perceived risks involved, such as risks to the client's wellbeing and risks to the psychologist's professional standing. This study adds to our knowledge of the attitudes among health professionals and students of health disciplines that has been established in previous CAT studies by providing a detailed, theory‐based examination of current beliefs for practising and prospective employees within psychology practice. Future studies, both qualitative and quantitative, should monitor any changes in integration beliefs and practices over time, and examine the prevalence of the identified beliefs among a broader sample of current and future psychologists.

ACKNOWLEDGEMENTS

We wish to acknowledge the contribution of Dr Ioni Lewis who provided advice on matters relating to qualitative research methods and reporting.

Appendix APPENDIX-A

What are your general thoughts about the use of complementary or alternative therapies?

•	What are some complementary and alternative medicines/therapies you know of that are used for the treatment of psychological disorder? If you can, could you also give examples of how they are used?
•	When you think about integrating complementary and alternative therapies with the treatment of psychological disorders, what comes to mind?
•	To what extent do you think other psychologists might be integrating complementary and alternative medicine/therapies into their clinical practice?
•	To what extent do you think that other psychologists might be willing to integrate complementary and alternative medicine/therapies into their clinical practice?

The following statements precede the questions below and are read at the beginning of each set of questions, that is the statement is read before asking the questions for behavioural beliefs, again before presenting the questions for normative beliefs, and a final time before presenting the questions for control beliefs.

The following is a specific scenario which applies to a series of questions that follow:

1	In the first scenario, a psychologist receives specific training in one or more modes of complementary or alternative therapy and plans to integrate these therapy options into their practice.
2	In the second scenario, a psychologist chooses to recommend specific complementary or alternative therapies to their clients without direct referral to a practitioner.
3	In the next scenario, a psychologist makes direct referral to a trained practitioner of a specific complementary or alternative therapy.

Behavioural beliefs

•	What are the advantages that come to mind about this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?
•	What are the disadvantages that come to mind about this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?

Normative beliefs

•	Who are the individuals or groups that would approve of this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?
•	Who are the individuals or groups that would disapprove of this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?
•	Are there any other individuals or groups that come to mind when you think about this use of complementary and alternative medicine/therapies for the treatment of psychological disorder?

Control beliefs

•	What are the factors that would prevent or discourage you from integrating complementary and alternative medicines/therapies in your clinical practice in this way?
•	What are the factors that would motivate or encourage you to integrate complementary and alternative medicines/therapies into your clinical practice in this way?

The following questions are asked only once towards the end of the interview.

Knowledge

•	Can you briefly talk about your level of knowledge and skill in relation to the integration of complementary and alternative medicine/therapies for the treatment of psychological disorder?
•	What influence does your knowledge and skill level have on whether you integrate, or are willing to integrate, complementary and alternative medicine/therapies into your clinical practice?