Complementary Health Approaches and Integrative Health in Occupational Therapy

Abstract

This AOTA Position Statement describes the use of complementary and integrative health approaches in occupational therapy practice and presents ethical and pragmatic matters, including diversity, equity, inclusion, cultural humility, continuing competence, standards of practice, and supporting evidence.

The American Occupational Therapy Association (AOTA) asserts that numerous complementary health approaches may be used in occupational therapy practice by competent occupational therapy practitioners for the purpose of enabling and enhancing participation and engagement in everyday life occupations (AOTA, 2020d). Occupational therapy practice enhances engagement, participation, performance, and function in meaningful roles, habits, and routines in various life situations for persons, groups, and populations through the therapeutic use of occupations (AOTA, 2020d, 2021a).

The occupational therapy profession’s philosophical base; client-centered approach; and commitment to diversity, equity, and inclusion align with and support the use of many complementary health approaches in occupational therapy practice, including those that use these services and products as part of health management (AOTA, 2017, 2020c). This Position Statement describes the use of complementary and integrative health approaches in occupational therapy practice and presents ethical and pragmatic matters, including diversity, equity, inclusion, cultural humility, continuing competence, standards of practice, and supporting evidence.

Definitions

Complementary health approaches and integrative health are nonpharmacological options commonly used for preventing or managing chronic conditions; managing symptoms such as pain; and improving or enhancing one’s personal emotional wellness, mental health, and well-being (Farmer et al., 2021; Russell et al., 2020; World Health Organization [WHO], 2019). Nomenclature continues to reflect evolving paradigms for a broad range of products and services that historically existed outside of typical allopathic approaches to health care in the United States.

Definitions of complementary health approaches have used language of exclusion in nonmainstream approaches to health with a “history of use or origins outside of conventional Western medicine” (Clarke et al., 2015, p. 1). Using a more inclusive lens, complementary health approaches are those “that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system” (WHO, 2019, p. 8).

Integrative health refers to health care that incorporates both complementary health approaches and allopathic medicine in a coordinated way (National Center for Complementary and Integrative Health [NCCIH], 2021). NCCIH (2022) recently expanded their concept of integrative health to include whole-person health, placing their focus on the interconnectedness of biological, behavioral, social, and environmental domains for empowering individuals, families, communities, and populations to improve and restore their health.

Integrative health occupational therapy (IHOT) is the practice area where complementary health approaches are incorporated into an occupation-focused and client-centered occupational therapy plan of care by competent, ethical, and culturally humble occupational therapy practitioners.

The terms complementary health approaches and integrative health are used in this Position Statement despite varied nomenclature in the published literature that is often based on the publication date and the respective discipline the literature represents.

Use Within the Scope of Occupational Therapy Practice

The scope of practice of occupational therapy is broad and varied. At the core of the occupational therapy profession is the belief that engagement in meaningful occupations positively affects one’s health, and all humans are occupational beings (AOTA, 2020d, 2021a). Occupations are meaningful, everyday life activities and events that people, families, and communities engage in (AOTA, 2020d). Occupations include activities that people want, need, and are expected to do and that have an impact on their health, identities, and sense of meaning (AOTA, 2020d).

Occupations are vital to the health and well-being of persons, groups, and populations and occur within contexts on the basis of the interaction between the client’s unique personal and environmental factors, performance skills, and performance patterns. Cultural and sociopolitical determinants impact the value placed on and ways clients engage in occupations in intricate and transactional ways (AOTA, 2020d; Wilcock & Townsend, 2019). Occupations include activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2020d).

Occupational therapy practitioners are required to obtain training, credentials, or licensure to establish competence in any complementary health approaches that they intend to use prior to incorporating them into an occupational therapy plan of care (AOTA, 2020b). IHOT practitioners must commit to continued competence in all practice areas by engaging in learning opportunities that expand clinical reasoning skills and ensure evidence-informed care.

Evaluation

Establishing a client’s occupational profile, and identifying facilitators and barriers to their health, well-being, and occupational participation, is the start of the collaborative occupational therapy process (AOTA 2020d). Information from the occupational profile ensures a client-centered approach and informs the process of selecting complementary health approaches to incorporate, determining the theoretical framework, writing goals, developing an intervention plan, and planning for discharge (AOTA, 2020d). Including a general inquiry to all clients about the current use of integrative health practices ensures that each client’s unique identities, values, and needs are centered throughout the occupational therapy process, thereby upholding the profession’s commitment to diversity, equity, and the inclusion of every individual (AOTA, 2020c).

Additions to the occupational therapy evaluation process are based on the occupational therapist’s knowledge of specific complementary and integrative health practices, available evidence, and their level of competence in those areas. For example, an occupational therapist trained in yoga may add yoga-specific structural assessments, and an occupational therapist trained in Reiki may follow up with energy-related questions. The evaluation process may reveal the need to refer to or collaborate with a complementary health or integrative health provider when the client would benefit from services that fall outside the occupational therapy scope of practice or the occupational therapy practitioner’s area or level of expertise.

Intervention

Complementary health approaches in occupational therapy may be used as interventions to support occupations (e.g., deep breathing or Reiki for self-regulation or pain reduction prior to performing ADLs), as occupations (e.g., meditation or yoga asanas as spiritual practices), and as activities (e.g., tai chi for standing balance during occupations) when incorporated into an overall occupational therapy plan of care that aims to enhance or enable participation in meaningful, everyday activities (AOTA, 2020d). The selected interventions must align with the client’s health values, be safe to use, be offered by a competent practitioner, and fall within the scope of occupational therapy practice (AOTA, 2021a).

The appropriateness of using specific integrative health interventions is established through the evaluation process, and outcomes are assessed by measuring progress toward occupation-centered goals that positively affect the client’s health, well-being, and participation in valued occupations. IHOT practices serve persons, groups, and populations that are experiencing or are at risk for developing health challenges across the lifespan.

Outcomes

Consistent with all other occupational therapy practice areas, outcome assessments in IHOT are selected on the basis of the client’s belief systems, the client’s stated occupational performance needs or desires, and the theoretical framework used to guide the occupational therapy process (AOTA, 2020d). IHOT assessment and interventions vary widely, leading to diverse outcomes across many domains. For example, using IHOT to improve or enhance a client’s ability to manage their own health could lead to the prevention of clinical conditions, alleviation of barriers or perceived barriers to participation, empowerment to advocate for their own needs, enhanced occupational performance, or increased participation in life and quality of life.

Roles, Responsibilities, and Supervision of Occupational Therapy Assistants

Occupational therapy assistants are valued collaborators in IHOT practice and are expected to establish competence in any complementary health approaches being integrated into occupational therapy interventions. Occupational therapy assistants practice under the supervision and mentorship of occupational therapists who are competent in the integrative health approaches being used.

After the occupational therapist establishes a client-centered and customized occupational therapy plan of care with the client and caregivers, occupational therapy assistants can implement the plan of care (AOTA, 2020b). If the intervention plan requires integrative health interventions outside the skill set of the occupational therapy assistant, the occupational therapist will provide the intervention or supervise the occupational therapy assistant until competence is established. Clear and regular communication between the occupational therapist and occupational therapy assistant regarding interventions, adjusting goals, changes in client condition, and outcomes is essential in this practice area. Communication between the occupational therapy practitioners, the client, and caregivers supports effective and client-centered care.

Evidence

Evidence supporting the use of various complementary health approaches and integrative health with occupational therapy practice continues to expand. Complementary health approaches are often used individually or in combination with conventional occupational therapy interventions to address the occupational needs of the client and for self-care by occupational therapy practitioners and educators. For example, yoga and mindfulness are commonly used together.

Evidence indicates that various complementary health approaches offer benefits in areas typically addressed in conventional occupational therapy for clients living with a wide range of physical and psychosocial conditions occurring across the lifespan and in various practice settings. For example, yoga influences positive outcomes for individuals with pain, neurological conditions, anxiety, difficulty with emotion regulation, risk for falling, and trauma-related conditions, among others (Field, 2016; Harris et al., 2019; Macy et al., 2018; O’Shea et al., 2022; Rashedi et al., 2019; Schmid et al., 2016; Tibbitts et al., 2021; Van Puymbroeck et al., 2014; Wiese et al., 2019).

Mindfulness and meditation-based interventions have been shown to positively impact perceptions of stress; executive functioning; attention; chronic pain; adaptation to disability; mental health, including stress and anxiety; body awareness; and self-compassion among various age groups and clinical conditions (Luiggi-Hernandez et al., 2018; Parkinson et al., 2019). Tai chi has been shown to improve balance and reduce fear of falling in older adults (Wingert et al., 2020; Wu et al., 2020). Reiki can improve pain, symptoms of anxiety and depression, and overall well-being for those experiencing acute symptoms outside the hospital setting (Dyer et al., 2019). Many complementary health approaches promote health and wellness of the mind, body, and spirit, which ultimately enable or enhance greater occupational engagement and participation.

Although a full summary of the evidence for IHOT practices and products is beyond the scope of this Position Statement, a growing body of evidence shows the value of incorporating complementary health approaches into an occupational therapy plan of care. For example, yoga has influenced relaxation and psychological well-being during inpatient rehabilitation (Schmid et al., 2015), enhanced balance in adults with neurological conditions (Candray et al., 2023; Green et al., 2019); significantly decreased maladaptive behavior of autistic students in school (Koenig et al., 2012); and reduced anxiety among children and adolescents (Weaver & Darragh, 2015). Mindfulness has improved pain, social function, and stress in adults with fibromyalgia (Siegel et al., 2018); improved self-regulation among occupational therapy students (Mattila et al., 2020; Szucs et al., 2020); and improved attention in elementary students, preadolescents, and adolescents (Rutta et al., 2021; Swanson, 2021). Tai chi has been used to manage fear of falling psychosocial responses among older adults (Wu et al., 2020) and can enhance mood, leading to a better quality of life for older adults in assisted-living facilities (Ghai et al., 2021).

The available evidence describes occupational therapy interventions with a variety of populations and practice settings and across the lifespan (see Case Studies 1–4 ). As a result, it is the responsibility of IHOT practitioners to use the most current and relevant evidence available to inform the occupational therapy process for any complementary health approaches being used. Each of the case studies provides research evidence and related resources guiding practice as examples of using evidence in occupational therapy interventions that include integrative health practices.

Case Study 1: Child in a School Setting

Occupational Therapy Process	Clinician’s Findings
Client description	Malak (they/them) is a 10-yr-old child with moderate cerebral palsy who is seeking occupational therapy services in a school setting to enhance their self-regulation, social participation, and academic success. The occupational therapist noticed that Malak has been experiencing greater challenges in the student role after their parents split up. In addition to declining grades, Malak is experiencing sleep disturbances, decreased motivation, and increased anxiety about learning because it is hard for them to pay attention in school. They intermittently display maladaptive behaviors and outbursts of frustration, which further alienates their peers.
Evaluation and goal setting	Malak is experiencing greater challenges with self-regulation, social participation, and academic success given a change in their routine at home. The occupational therapist met with Malak, their parents, and their teacher to review the occupational profile during the individualized education program (IEP) review (American Occupational Therapy Association [AOTA], 2020). Malak was also asked questions exploring openness to, or use of, integrative health practices. Malak was open to trying new strategies to make themselves feel better. The School Function Assessment (SFA; Coster et al., 1998) was completed by Malak’s classroom teacher to assess participation, task performance, and activity performance. Compared with the most recent occupational therapy evaluation, Malak’s scores for participation in the classroom, at recess, transition to and from class, and at mealtime were notably lower. They required more adaptations to participate in their educational program and to interact with others and communicate their needs, especially when they needed assistance in the presence of their peers. The Child Occupational Self-Assessment (COSA; Kramer et al., 2010) was administered to Malak to assess how they feel about engaging in and completing activities as well as how much they value the activities. The results indicated new challenges with important school-related tasks in the areas of communicating with teachers and friends, getting motivated to complete schoolwork, and calming themselves down when they are upset. Finally, a checklist of classroom behavior (authentic structured observation) was completed by the occupational therapist; the observations corroborated data from the SFA and COSA. Goals Prioritized in the Annual IEP Review Promote academic success and satisfaction with their own performance (e.g., Malak will complete their work independently and ask for supports when needed). Promote and enhance mental wellness through emotion regulation (e.g., Malak will consistently eat lunch with peers in the cafeteria, demonstrating adaptive behaviors). Restore social participation by cultivating meaningful peer and adult relationships (e.g., Malak will communicate with peers and offer ideas during group work in the classroom and during recess).
Occupational therapy intervention	With a focus on their role of student, and within the parameters set by the school, the occupational therapist worked with Malak to address their goals using the following interventions: ▪ Establish a daily self-care routine that promotes academic success by fostering self-efficacy, self-esteem, and motivation. For Malak, organizational strategies; reminders on their computer; and self-regulation tools, such as breathing techniques and mantras (yoga), meditation, mindfulness, and use of scents (clinical aromatherapy) were used. ▪ Incorporate self-care breaks into Malak’s school routine to support school-based occupations. Malak found using fidget toys, using self-care strategies in a quiet corner, and using recess to regain their optimal level of arousal helped prevent unwanted maladaptive behaviors in social situations. ▪ Develop strategies for enhancing social participation by creating opportunities for successful interactions and reflecting on what they could do differently next time if things did not go as planned. Malak identified a classmate with whom they felt safe to try new strategies. Positive experiences with this peer led to Malak taking risks with other classmates and the teacher individually and within groups.
Occupational therapy outcomes	Malak established important routines and habits that slowly affected their self-efficacy (i.e., their sense that they could complete their work successfully and on time and experience positive social interactions with peers and adults). Malak expanded their toolbox of strategies to focus on. Engaging in school-based occupations and feeling part of their social groups reduced their fears of failure or embarrassment, leading to academic success. They even began taking the lead in some group learning activities and initiated positive peer interactions at recess. Malak’s teacher and parents noted slow, steady progress toward the level of participation and sense of satisfaction that Malak experienced prior to their parents split up.

Case Study 2: Young Adults in an Occupational Therapy Program

Occupational Therapy Process	Clinician’s Findings
Client description	A cohort of occupational therapy students are entering their last 2 years of the program, a time when all the courses comprise occupational therapy content. Although the students have been excited about getting to this point in their education, they also express concerns about their personal academic success with such a challenging course load, especially because there are grade requirements to move forward in the program.
Evaluation and goal setting	▪ Ongoing feedback from occupational therapy students was solicited over time and across cohorts related to student achievement and professional growth at a programmatic level. Survey results showed a steady increase in stress and anxiety over the past few years, especially during and after the coronavirus disease 2019 pandemic. ▪ A cohort-specific survey was administered to establish cohort perceptions of perceived stress, as well as barriers to and facilitators of their learning and success. Students were also asked general questions exploring their openness to and use of integrative health practices or products in the classroom. Students reported high levels of stress, a limited sense of mastery over learning material, varying levels of motivation, and challenges with self-regulation in a competitive environment. Reported facilitators for learning included organized course materials and flexible and compassionate instructors who set clear expectations. Students welcomed information about potentially helpful integrative health practices, with the majority of students using them already. Students were asked to complete at least three of the following assessments on the basis of what was most individually relevant: Occupational Balance Questionnaire (Wagman & Håkansson, 2014) Activity Configuration Worksheet, to assess occupational balance and gain awareness of daily routines, habits, and occupations (Dunn, 2011) Anxiety Inventory Questionnaire, to assess student stress individually (Beck & Steer, 1993) Occupational Self-Assessment (Baron, 2006) General Self-Efficacy Assessment (Schwarzer & Jerusalem, 1995) Students were asked to score their own assessments and establish action steps on their own or with their faculty academic adviser. When meeting individually, an occupational profile was established (AOTA, 2021). Although results varied by student, there was generally high anxiety, limited self-efficacy, highly variable self-regulation, and minimal occupational balance within the group. A desire for occupational balance was great, but actual occupational balance was limited because of the students’ emphasis on achieving desired grades. Goals ▪ Student achievement and professional growth in the occupational therapy program will be facilitated using evidence-informed approaches to teaching and learning (AOTA, 2020a; McGuire, 2015; Super et al., 2020). ▪ At the cohort level, faculty members will offer organized course content and solicit student feedback throughout the course and modify plans as needed. This will provide students an opportunity to use and expand self-care strategies in the classroom. ▪ At the student level, faculty may support students by customizing self-care and self- regulation suggestions and strategies based on the needs of the individual student and the particular course content. Areas may include promoting student engagement, mental wellness, strategies for occupational balance, routines for self-care, coping strategies for self-regulation and self-efficacy, and overall health promotion (AOTA, 2020b).
Occupational therapy intervention	In a program that is committed to responding to student input, the following steps were taken: Program level ▪ A student achievement/success goal was added to the program’s strategic plan. ▪ All faculty added personal and professional development goals to expand strategies and supports for student learning across cohorts. Cohort level ▪ Faculty members consistently solicited cohort-specific feedback and made modifications when possible (e.g., leveraged technology, used universal design for learning strategies, modified policies to allow for more flexibility). ▪ Faculty members included reflective assignments and asked students to make action steps to change their learning plans. ▪ Faculty members also offered suggestions for and opportunities to practice self-regulating strategies in the classroom (e.g., using deep breathing and guided imagery prior to a test, taking stretch breaks when individually needed, and building awareness of one’s internal climate after performance-based learning activities). Individual Level Students were encouraged to use available resources on campus to promote academic success (e.g., office hours with course instructors, academic advising, student accessibility services, counseling services, tutoring, peer groups). Common topics discussed between the instructor and student included ▪ incorporating strategies for self-regulation in stressful times; ▪ using time management and organizational strategies to promote occupational balance; ▪ establishing daily health routines incorporating mind, body, and spiritual components (e.g., nutrition, exercise, mindfulness, sleep, self-Reiki, yoga [AOTA, 2020b; Bukowski, 2015; Erb & Schmid, 2021]); ▪ establishing and practicing a growth mindset and motivation for learning (McGuire, 2015); ▪ creating self-care strategies for different amounts of time and situations (e.g., deep breathing, grounding activities, aromatherapy, meditation, mantras, connecting to nature); ▪ developing advocacy skills to ask for what they need; and ▪ sharing campus and community resources that support student health and wellness.
Occupational therapy outcome	After actions at the program, cohort, and individual levels were taken, student satisfaction and success increased. On the basis of interactions with students in the classroom, faculty members reported improved participation and engagement in the classroom, students adopting a growth mindset, and greater personal satisfaction in their role as academic faculty. Upon reassessment with the tools the students self-selected during the evaluation process, students reported varying levels of growth in self-awareness, self-efficacy, and self-regulation in the student role. Gaining more experience through the various learning activities in the classroom led to greater academic success and student reports of enhanced mental wellness because they had tools for self-care and the ability to advocate for themselves. As a result, occupational balance and greater social participation were achieved.

Case Study 3: Adult in an Outpatient Setting

Occupational Therapy Process	Clinician’s Findings
Client description	Mary (she/her/hers) is a 48-yr-old adult who sustained multiple injuries during a domestic dispute 3 months ago. She sustained a T11 complete spinal cord injury (SCI) and is working toward living at her home with her daughter and two small grandchildren. Mary is challenged by feeling safe, and although she receives intermittent support from her daughter, she avoids asking for help because she is fiercely independent. Currently, Mary wants to make her morning routine more efficient and gain access to an emergency call system because she panics when home alone. She wants to work on tub, toilet, and bed-to-wheelchair transfers, making her morning routine more efficient, and reestablishing her spirituality-based health management practices.
Evaluation and goal setting	Mary met her outpatient occupational therapist about 3 mo after sustaining a T11 SCI during a domestic dispute. Knowing the traumatic mechanism of Mary’s injury, the occupational therapist used a trauma-informed approach to assessment, putting Mary in control of the information she wanted to share during the assessment process. The occupational therapist and occupational therapy assistant met with Mary to establish her occupational profile (American Occupational Therapy Association [AOTA], 2021), current health management practices, values, beliefs, spirituality, and openness to or use of integrative health practices (AOTA, 2017, 2020). Mary was thrilled that this came up in conversation because she had been hesitant to share her spiritual practices with her medical team. The Upstream Risks Screening Tool (Manchanda & Gottlieb, 2015) was administered to learn more about macro-level factors affecting Mary’s health. Mary noted financial strain, poor access to food, limited transportation, and exposure to violence as being barriers in her life. The Barthel Index for Activities of Daily Living (Collin et al., 1988) was used to assess Mary’s activities of daily living (ADLs) functioning, and the Perceived Stress Questionnaire (Cohen et al., 1983) was used to identify Mary’s current level of stress. Last, an informal interview was conducted to learn more about Mary’s spiritual practices. Mary wanted to return to and incorporate her spiritual practices into her daily routine and have the necessary resources to support these practices. Mary said her spiritual practices just “make me feel better and boost my motivation” to engage in life. Goals Establish a daily routine for ADLs and instrumental ADLs (IADLs). Master transfers required for daily ADLs routine. Establish a safety plan for leaving the home on her own. Establish a process for answering the door (to know who is outside before opening it). Foster communication skills to establish positive relationships with family and peers. Reestablish spiritual practices as part of her health management routine.
Occupational therapy interventions	Using a trauma-informed approach, the occupational therapist worked with Mary to establish a plan of care to address her goals. The following interventions were implemented, primarily by the occupational therapy assistant: ▪ Establish a morning ADL and IADL routine that works for Mary and her family. ▪ Train for mastery in transfers using a tub transfer bench, slide board, drop arm commode, and handheld shower. ▪ Establish a safety plan for times when Mary is home alone, and secure resources for enhancing home security. ▪ Explore options and encourage Mary to participate in community-based support groups for people who have experienced domestic violence. ▪ Provide family education and psychosocial supports, including discussing risks while living at home. ▪ Reestablish spiritual practices to support health management. Mary restored her daily routine of starting the day with a short meditation to give thanks and using mantras to keep her mind focused on the positive. She also began seated yoga classes at her local community center. Mary’s self-efficacy, self-confidence, and a greater sense of safety in her home environment are growing. This promoted a positive shift in the relationship with her daughter, largely because now Mary will ask for what she needs and offers possible solutions that work for the whole family.
Occupational therapy outcomes	Mary felt a renewed sense of hope toward life and getting back to how she was before the domestic dispute. She has returned to her daily prayer and meditation practice upon waking to start her day. Focusing on gratitude and staying in the present moment have cleared her mind, and she is able to stay more positive as a result. Attending her community yoga class is something she looks forward to each week. Mary’s occupational performance improved; she is now successful and independent with toilet and tub transfers with adaptive equipment that works with the routines of the whole family. She also improved the speed of the bed-to-wheelchair transfer. Mary stated, “I can get out of bed fast enough to keep myself safe now, and I have a camera that helps me see the door,” which leads to feelings of safety in her home. Mary has been able to return to the role of mother with her daughter, which has reduced the strain between them and the grandchildren. Mary joined two community-based groups, and she is glad to “get out and connect with people again.” She reports feeling empowered to advocate for herself in many areas and is just finding more joy. Mary acknowledges that it is a long road to get through the trauma of domestic violence, but she now feels like she has the tools to move toward a better quality of life. She can even see herself being an agent of change to help reduce this type of violence in her community.

Cast Study 4: Older Adult in a Community Setting

Occupational Therapy Process	Clinician’s Findings
Client description	Thomas (he/him/his) is an older adult who experiences chronic low back pain of insidious origin. He has a long history of agriculture work, with many hours picking crops and driving machinery. Thomas lives alone in a small dwelling in the same rural community he grew up in. He is grateful for the generosity of his church community because they provide financial assistance for utilities, food from the food pantry, and transportation to the community-based health care clinic. He has taken advantage of all prescribed interventions that his allopathic medical team has to offer, but he states that “Nothing is helping, and the pain is ruining my life. What else could help my pain?”
Evaluation and goal setting	Thomas was eager to explore services with occupational therapy because he was motivated to find ways to relieve his chronic pain. He described the relief that chiropractic care and acupuncture provide when he does get to the treatment sessions. The occupational therapist met with Thomas to establish his occupational profile (AOTA, 2021a), current health management practices, values, beliefs, spirituality, and openness to or use of integrative health practices (AOTA, 2020, 2021b). The Pain Self-Efficacy Questionnaire (Nicholas, 2007) was administered to assess how Thomas’ pain was affecting his life. Although the pain varied, his ability to engage in his meaningful activities was consistently limited even when he was feeling his best. The Lower Extremity Functional Scale (LEFS; Binkley et al., 1999) was administered to identify how difficult Thomas thought it was to do everyday tasks. Thomas admitted that because of the pain in his back he was challenged to complete lower body dressing tasks, lift objects (e.g., groceries), and engage in leisure activities. The Perceived Stress Questionnaire (Cohen et al., 1983) was administered to further explore any stressful life events and circumstances that may exacerbate Thomas’ symptoms. Thomas admitted to being worried about his finances and food security and his feelings of isolation. The General Self-Efficacy Scale (Schwarzer & Jerusalem, 1995) was administered to assess Thomas’ self-efficacy with his health management. He admitted finding it difficult to overcome challenges because it seemed like his efforts had not made significant changes in his chronic pain. The Upstream Risks Screening Tool (Manchanda & Gottlieb, 2015) was administered to learn more about macro-level factors affecting Thomas’ health. Thomas confirmed that financial strain, inconsistent access to reliable transportation, and food insecurity contributed to his uneasiness about the future. Last, an informal interview was conducted to explore Thomas’ personal values, meaning-making, and sense of purpose. Thomas highlighted the importance of his church community and culture. He values his role as an elder in the community and loves reading books to the children, especially related to cultural practices or when the book is written in Spanish. Goals ▪ Restore occupational engagement and participation in occupations he needs and wants to do, such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), social participation, health management, and community mobility ▪ Enhance his health management toolbox with strategies to manage chronic pain and to promote meaning and purpose ▪ Introduce additional community resources to support participation in occupations he finds meaningful, including referral to or collaboration with complementary health providers who work with chronic pain and holistic self-care, for evaluation.
Occupational therapy intervention	Using a culturally humble approach, the occupational therapist or occupational therapy assistant worked with Thomas to address his goals using the following interventions: ▪ Long-handled dressing equipment, shower bench, and grabber were introduced to reduce physical challenges that contributed to physical pain with occupations such as meal prep, lower body dressing, and activities with the children in Thomas’ church. ▪ Energy conservation strategies were implemented to enhance Thomas’ energy level to participate in self-care, home management, meal prep, and keeping up with the kids at the church. ▪ A daily pain management routine was established using a variety of tools, such as stretching, strengthening, self-administered modalities (e.g., hot packs or transcutaneous electrical nerve stimulation [TENs]), mindfulness, mediation, self-massage, and energy conservation strategies. A tracking sheet was used to record pain levels with associated occupations to determine whether there were any patterns in the pain. ▪ They established collaboration with Thomas’ chiropractor and acupuncturist to promote integrated care around his chronic pain. Thomas was introduced to additional community services that could support his overall well-being, such as a community cooking group, yoga, and Reiki. ▪ Thomas was connected with a county case worker to explore additional community resources to minimize the impact of upstream factors, or the economic, social, and physical environmental factors that indirectly affect health outcomes (Distelhorst et al., 2021).
Occupational therapy outcomes	Thomas was grateful to learn ways to reduce his pain in his own home. Making small adjustments in his apartment to improve accessibility made a big difference. When reassessed, Thomas also reported greater self-efficacy with health management, stating he felt empowered to know how to help himself when feeling pain instead of letting the pain consume him. He noted that having a set of strategies to choose from was hugely helpful, especially because he gained awareness of how and when to use home-based modalities and the other integrative health tools in his toolbox. He now feels like he has a health care team that supports him to move beyond the pain and start living again. Although the chronic pain persists at varying levels of intensity, Thomas describes less pain, improved perceived quality of life, and overall well-being. His success with ADLs, IADLs, and other meaningful occupations is more consistent, and he now enjoys a renewed motivation to take good care of himself, ask for help when needed, and participate more in his community. He is thrilled to be able to attend weekly church services and volunteer as a helper in the Sunday school program at his church.

Ethical Considerations, Continuing Competence, and Standards of Practice

Occupational therapy practitioners have a professional and ethical responsibility to provide services only within their level of competence and scope of practice. The AOTA 2020 Occupational Therapy Code of Ethics (Code of Ethics) establishes principles that guide safe and competent occupational therapy practice and that must be applied when integrating complementary and integrative health approaches into an occupational therapy plan of care (AOTA, 2020a).

Practitioners are responsible for acquiring specific complementary and integrative health knowledge, establishing competence by engaging in requisite trainings and certifications, and continually expanding their expertise to ensure that complementary health approaches are safely and effectively incorporated into occupational therapy practice (AOTA, 2020a, 2021b). Establishing competence in complementary and integrative health approaches depends on knowledge acquisition that is customary for the services or products being integrated into an occupational therapy plan of care. Additional educational and certification opportunities for occupational therapy practitioners who incorporate complementary health approaches into interventions are available in a variety of formats specific to the particular complementary health practice or product.

Incorporating complementary health approaches into occupational therapy interventions necessitates the additional awareness of regulatory requirements for practice, such as licensure or certification requirements for incorporating complementary health approaches and the scopes of practice for licensed complementary and integrative health professions (AOTA, 2021b). Acupuncture and Asian medicine, chiropractic, massage therapy, direct-entry (home birth) midwifery, and naturopathic medicine are the five licensed integrative health and medicine professions with established scopes of practice that are recognized by a federal accrediting agency and regulated individually by state (Academic Collaborative for Integrative Health [ACIH], 2017).

Education and Training

Occupational therapy practitioners are responsible for continuing to develop their competence with all services they provide by regularly reflecting on their current level of competence and taking actions toward advancing their knowledge, professional reasoning, interpersonal skills, performance skills, ethical practice, and interprofessional competencies needed for current and future practice (ACIH, 2017; AOTA, 2020a, 2021b). Practitioners are obligated to refer to relevant principles in the Code of Ethics, comply with state and federal regulatory requirements, and avoid incorporating products and services that fall within the scope of practice for the five licensed integrative health and medicine professions.

In alignment with occupational therapy’s commitment to diversity, equity, and inclusion, occupational therapy practitioners must honor and respect the various health practices that originate in cultures and practices from around the world (AOTA, 2020b). For example, occupational therapy practitioners are expected to learn about the history and origins of the practices or products; acknowledge all aspects of the approach, even if not fully used within the occupational therapy plan of care; develop and embrace cultural humility; avoid misappropriating interventions; and respect the knowledge and expertise of complementary and integrative health providers by referring to or collaborating with them.

Funding and Reimbursement

Funding for and reimbursement of IHOT varies according to the location of the practice, the business model of the practice, and the services provided in the practice. Obtaining reimbursement for IHOT requires knowledge of state laws, federal laws, and third-party payer guidelines when insurance is being billed, or of federal and state laws when clients are paying privately.

Summary

Mounting evidence suggests that incorporating various complementary health approaches into an occupational therapy plan of care enhances participation and engagement in meaningful occupations in valuable ways. When choosing to use complementary health approaches in practice, practitioners assume the responsibility to do the following:

▪ Obtain training, credentials, or licensure to establish competence in all complementary health approaches being used prior to using them, and to expand competence over time.

▪ Engage in a collaborative occupational therapy process in which occupation and client identities, values, and needs are centered.

▪ Select interventions that align with the client’s health values, are safe to use, are offered by a competent practitioner, and fall within the scope of occupational therapy practice. The interventions may be used to support occupations as occupations, and occupations as activities.

▪ Honor and respect the diverse health practices that originate in cultures and practices from around the world.

▪ Collaborate with and refer to complementary and integrative health providers in areas where the occupational therapy practitioner has yet to develop competence or when the intervention is outside the scope of occupational therapy.

▪ Abide by regulatory requirements for practice, such as licensure or certification requirements for certain complementary health approaches and the scopes of practice for licensed complementary and integrative health professions.

Authors

Michelle L. Bradshaw, DC, OTR/L

For the Commission on Practice

Meredith Gronski, OTD, OTR/L, CLA, FAOTA, Chairperson

Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly, 2022.

Note. This revision replaces the 2017 Occupational Therapy and Complementary Health Approaches and Integrative Health position statement previously published and copyrighted in 2017 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 71(Suppl. 2), 7112410020. https://doi.org/10.5014/ajot.2017.716S08

Citation. American Occupational Therapy Association. (2023). Complementary health approaches and integrative health in occupational therapy. American Journal of Occupational Therapy, 77(Suppl. 3), 7713410200. https://doi.org/10.5014/ajot.2023.77S3001

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