Psychology Students’ Beliefs about Integrating Complementary and Alternative Therapy (CAT) into Their Future Psychology Practice

doi:10.4236/psych.2012.32029

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Psychology

2012. Vol.3, No.2, 208-212

Published Online February 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.32029

208

Psychology Students’ Beliefs about Integrating Complementary

and Alternative Therapy (CAT) into Their Future

Psychology Practice

Lee-Ann M. Wilson1, Kyra Hamilton2, Katherine M. White2

1School of Public Health, Queensland University o f Technology, Brisbane, Australia

2School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia

Email: [email protected]

Received November 22nd, 2011; revised December 23rd, 2011; accepted January 27th, 2012

We investigated whether belief-based differences exist between students who have strong and weak in-

tentions to integrate complementary and alternative therapy (CAT) into future psychology practice by

recommending CAT or specific CAT practitioners to clients. A cross-sectional methodology was used.

Psychology undergraduate students (N = 106) participated in a paper-based questionnaire design to ex-

plore their underlying beliefs related to CAT integration. The study was undertaken at a major university

in Queensland, Australia. The theory of planned behaviour belief-based framework guided the study.

Multivariate analyses of variance examined the influence of behavioural, normative, and control beliefs

on the strong and weak intention groups. A multiple regression analysis investigated the relative impor-

tance of these belief sets for predicting intentions. We found that clear differences emerged between

strong and weak intenders on behavioural and normative beliefs, but not control beliefs. Strong intenders

perceived the positive outcomes of integrating CAT, such as being able to offer clients a more holistic

practice and having confidence in the practitioners/practices, as more likely to occur than weak intenders,

and perceived the negative outcome of compromising my professional practice as less likely. Strong in-

tenders were more likely than weak intenders to perceive that a range of important referents (e.g., clients)

would think they should integrate CAT. Results of the regression analysis revealed the same pattern of

results in that behavioural and normative beliefs, but not control beliefs, significantly predicted intentions.

The findings from this study can be used to inform policy and educational initiatives that aim to encour-

age CAT use in psychology practice.

Keywords: Integrating Complementary Therapy; Psychology Practice; Psychology Student; Theory of

Planned Behaviour; Beliefs

Introduction

Recent research sugge sts that many individuals with mental

health disorders seek the advice of naturopaths, or combine

yoga, meditation, or herbal therapies with their traditional

psychotherapy (Page, Jones, & Wilson, 2004; Australian Bu-

reau of Statistics, 2004-2005). While significant research has

been conducted exploring medical practitioners’ attitudes and

perceptions toward complementary and alternative therapies

(CAT) (Halcon, Chlan, Kreitzer, & Leonard, 2003; Hyland,

Lewith, & Westoby, 2003; Lewith, Hyland, & Shaw, 2002),

there is an absence of similar investigati ons within the field of

psychology. Although some previous research has attempted

to explore differences between medical and social science

students’ (predominately psychology students) attitudes to-

ward complementary medical practitioners and medical

treatment preferences (Yardley, Fahmy, Jamie, & Furnham,

1999), no previous study has tried to demonstrate the key

perceptions underlying psychology students’ decisions re-

garding integrating CAT into their future professional prac-

tice.

Current research suggests that psychologists are integrating

CAT into psychological practice via recommending CAT to

clients, offering clients referrals to CAT practitioners, or ac-

cessing training in CAT therapies to integrate these therapies

into practice (Bassman & Uellendahl, 2003). Previous research,

although somewhat limited, has found that psychologists are

recommending CAT generally at relatively high rates and at

significantly higher rates than they are offering specific refer-

rals to CAT practitioners (Bassman & Uellendahl, 2003).

However, little is known about how psychology students, who

are the next cohort of health professionals and who will be in a

position to direct future initiatives in the field, perceive inte-

grating CAT into psychology practice. A qualitative pilot study

examining psychology students’ and practicing psychologists’

attitudes and beliefs about CAT integration revealed that stu-

dents are generally positive about CAT integration but indi-

cated that they were largely unaware of the professional impli-

cations of the various integration choices, and their responses

did not vary much between the different integration scenarios

(i.e., they saw much the same implications between training

themselves in CAT, recommending CAT to clients, and refer-

ring clients to CAT practitioners) (Wilson & White, 2011).

Students focused on the potential benefits to clients, such as

being able to offer a broader range of treatment options. Given

that previous research has found examining attitudes and beliefs

useful in understanding CAT practices in general (Chua &

Furnham, 2008), having an understanding of the ways in which

LEE-A. M. WILSON ET AL.

underlying beliefs guide psychology students’ decisions about

whether to integrate CAT into future practice might also be

useful to inform both clinical practice policy and educational

initiatives.

The Theory of Planned Behaviour (TPB; Ajzen, 1991) is a

well validated decision-making model that allows for an ex-

amination of people’s underlying beliefs and has much support

in the social and health domains (see Armitage & Christian,

2003). According to the TPB, intention to perform a given be-

haviour and the individual’s actual control over performing the

behaviour predict behavioural performance. Intention, in turn,

is influenced by 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 norms), and the degree to which a person feels they

have control over performing the behaviour (perceived behav-

ioural control) (Ajzen, 1991). Underlying the TPB is the as-

sumption that the antecedents of attitude, subjective norms, and

perceived behavioural control are corresponding behavioural

(costs and benefits), normative (pressure to comply with im-

portant others’ approval/disapproval), and control beliefs (mo-

tivating or inhibiting factors), respectively, that reflect an indi-

vidual’s intention and subsequent behaviour (Ajzen, 1991).

Assessing the belief-based determinants of attitude, subjective

norms, and perceived behavioural control allows researchers to

establish the beliefs that differentiate those who perform a

given behaviour from those who do not. A number of studies

have explored these underlying beliefs in order to increase un-

derstanding of health behaviours, including CAT practices

(O’Conner & White, 2009; Pawlak et al., 2008; Wilson &

White, 2008).

Using the TPB as a theoretical framework, this study aims to

investigate the beliefs that differentiate those psychology stu-

dents who have strong and weak intentions to integrate CAT

into future psychology practice by either recommending CAT

to clients or referring clients to specific CAT practitioners.

Specifically, the study assessed psychology students’ beliefs

relating to the costs and benefits associated with recommending

or referring CAT to clients (behavioural beliefs), beliefs about

which important referents would approve or disapprove of their

recommending or referring CAT (normative beliefs), and be-

liefs about inhibiting factors (control beliefs) for recommending

or referring CAT to clients.

Method

Participants

Participants (N = 106) were psychology undergraduate stu-

dents from a major Australian university. The majority of the

students was enrolled in first year psychology units (89%) and

indicated a preference of clinical (42%) or counseling (32%)

psychology as their future area of professional interest. The

study comprised of 77 females and 29 males and the mean age

of participants was 24.55 years (SD = 10.46 years).

Measures

The target behaviour assessed students’ beliefs about inte-

grating CAT into future psychology practice by either rec-

ommending CAT to clients or referring clients to specific

CAT practitioners. The two behaviours, recommending and

referring, were combined as pilot research utilising semi-

structured interviews indicated that students did not differen-

tiate between the professional implications or clients out-

comes associated with these two practices (Wilson & White,

2011). CAT was operationalised as: “A group of diverse

medical and health care systems, practices, and products that

are not presently considered to be part of conventional medi-

cine”. This definition is consistent with the National Centre

for Complementary and Alternative Medicines (2006). The

pilot study which involved both practicing psychologists and

psychology students was conducted (N = 12; 6 psychologists

and 6 students) to elicit the salient behavioural, normative,

and control beliefs (8) as recommended by Fishbein and

Ajzen (1975). Using content analysis, the most commonly

reported advantages (e.g., being able to offer clients a more

holistic practice) and disadvantages (e.g., not being able to

follow up client progress with CAT), referents approving or

disapproving (e.g., employers), and factors preventing inte-

grating CAT into future psychology practice by recommend-

ing or referring CAT (e.g., lack of knowledge about relevant

CATs) reported by students were used to assess the behav-

ioural, normative, and control belief-based measures, respec-

tively, in the present study.

All belief-based items we re scored on 7-point Likert scale s,

scored extremely unlikely (1) to extremely likely (7). To assess

behavioural beliefs, participants were asked to rate how likely

two costs and two benefits would result if they integrated

CAT into a future psychology practice by recommending

CAT or specific CAT practitioners to clients. For normative

beliefs, participants were asked to rate how likely four refer-

ents would think they should integrate CAT into a future

psychology practice by recommending CAT or specific CAT

practitioners to clients. Participants indicating how likely

internal and external factors would prevent them from inte-

grating CAT into a future psychology practice by recom-

mending CAT or specific CAT practitioners to clients as-

sessed control beliefs. It should be noted that internal consis-

tency is not a necessary feature of belief composites as no

assumption is made that the salient beliefs are internally con-

sistent (Ajzen, 1991); thus, alpha coefficients were not com-

puted for the behavioural , normative, a nd control bel ief-based

measures. For a full listing of the belief-based items, see Ta-

ble 1. The outcome measure of intention was measured on a

single item scale. Students were asked to respond to the ques-

tion: “I intend (1), do not intend (7) to integrate CAT into a

future p sychology practice by recomme nding CAT or specifi c

CAT practitioners to clients?” For analyses, intention scores

were recoded such that higher scores were associated with

stronger intentions. Furthermore, for belief-based analyses,

responses were recoded to indicate those who had weak

(scores 1.0 to 4.0) and strong intentions (scores 4.0 to 7.0) to

perform the target behaviour.

Procedure

Prior to any data collection, the university human research

ethics committee approved the study. Students were informed

about the opportunity to participate in the study during one of

their regularly scheduled classes. At the end of the class, stu-

dents who were willing to participate were able to complete and

return their survey before leaving. The student participants

were offered a small number of credit points towards a research

participation mark in their psychology class as a thank you for

LEE-A. M. WILSON ET AL.

their involvement.

Results

Belief-B ased Analyses

Behavioural, normative, and control beliefs were examined

to identify those beliefs differentiating between students who

had strong and weak intentions to integrate CAT into a future

psychology practice by recommending CAT or specific CAT

practitioners to clients. Three one-way multivariate analyses of

variance (MANOVAs) were conducted with intentions to per-

form the target behaviour as the independent variable and the

belief-based items as the dependent variables. Overall, Wilks’

Lambdas were significant for behavioural (F(4, 101) = 7.59, p

< .001, η² = .23) and normative beliefs (F(4, 101) = 4.80, p

= .001, η² = .16), but not for control beliefs (F(4, 101) = .28, p

= .891). To explore further where differences existed between the

groups for behavioural beliefs and normative beliefs, dependent

variables were examined at the univariate level. Bonferonni

adjustments were used to control for familywise type 1 error

(refer to Table 1). For behavioural beliefs, univariate analyses

revealed that strong intenders perceived the positive outcomes

of integrating CAT, such as be able to offer clients a more ho-

listic practice and having confidence in the practitioners/prac-

Table 1.

Mean differences in behavioural, norm ative, and control beliefs.

Intentions Weak

Intenders Strong

Intenders

Behavioural be liefs N = 58 N = 48

Being able t o o ffer a more holistic practice 4.67 5.73***

Not being able to follow up client p rogress

with CAT 3.97 3.56

Having confidence in the practitioners/

practices that are being recommended 4.40 5.44***

Compromising my professional re putation 3.86 3.08***

***p < .012

Normative bel iefs n = 57 n = 48

Your clients 4.40 5.19***

Complementary or alternative p ractitioners 5.44 5.77

Your employers 3.98 4.83***

Professional organisations 3.84 4.56***

***p < .012

Control beliefs n = 58 n = 48

Lack of knowledge about appropri ate

practitioners 5.31 5.04

Lack of knowledge about relevant CATs 5.34 5.17

Lack of scienti fi c evidence i n support

of CAT 4.91 4.71

Absence of clear legal and professional

bodies guidelines 5.00 4.83

***p < .012

tices, as more likely to occur than weak intenders, and were less

likely to perceive that integrating CAT would compromise their

professional practice. For normative beliefs, univa riate analy ses

indicated that strong intenders were more likely than weak

intenders to report the important referents of “your clients”,

“your employers”, and “professional organisations” would

think they should integrate CAT into a future psychology prac-

tice by recommending CAT or specific CAT practitioners to

clients.

Analysis Predicting Intentions

The MANOVA analyses identified how the strong and weak

intenders differed in terms of their beliefs. However, these

analyses did not allow an assessment of which beliefs are most

influential for students’ intentions to integrate CAT into a fu-

ture psychology practice by recommending CAT or specific

CAT practitioners to clients. A multiple regression analysis,

therefore, was conducted to assess the relative importance of

the behavioural, normative, and control beliefs for predicting

intentions. The dependent measure was based on a continuous

scale reflecting intentions (as described in the Method Section).

Together, the belief-based measures significantly predicted

intentions, F(3, 101) = 17.62, p < .001, accounting for 34% of

the variance of intentions to integrate CAT into a future psy-

chology practice by recommending CAT or specific CAT prac-

titioners to clients (refer to Table 2). Behavioural and norma-

tive beliefs, but not control beliefs, were significant predictors

of intentions. Thus, the more likely students perceived benefits

associated with recommending or referring CAT and the more

important referents approved of recommending or referring, the

more students were to intend to integrate CAT into a future

psychology practice by recommending CAT or specific CAT

practitioners to clients.

Discussion

The present study aimed to investigate whether belief-based

differences exist between those students who have strong and

weak intentions to integrate CAT into a future psychology

practice by recommending CAT or specific CAT practitioners

to clients. We found that the behavioural and normative beliefs,

but not control beliefs, differed significantly betwee n the inten-

tion groups. Additionally, the analysis examining the relative

importance of these belief sets in predicting intentions showed

the same pattern of results.

The findings of this study help us to understand the relation-

ship between beliefs and students’ intentions to integrate CAT

into future psychology practice. This understanding, in turn, has

important practical implications for those involved in clinical

Table 2.

Regression analysis pr ed i c ti n g i n te n t io n s .

Variable R R² F df β

Intentions .59.34 17.62 3, 101

Behavioural be liefs .42***

Normative beliefs .23**

Control belief s –.14

**p = .017, ***p < .001.

210

LEE-A. M. WILSON ET AL.

practice policy-making and educational initiatives aimed at

influencing CAT use within psychology practice. First, the

finding that behavioural beliefs differed significantly between

the groups suggests that policy and educational initiatives aimed

towards promoting CAT integration into psychology practice

should focus on increasing students’ positive attitudes. Specifi-

cally, these should highlight that recommending or referring

CAT would result in the ability to offer clients a more holistic

practice, or building their confidence in the practitioners/prac-

tices that are being recommended, and reassuring them that

compromising their professional reputation is not necessarily an

outcome. Second, the differences in normative beliefs suggest

that strong intenders were more likely than weak intenders to

report those important referents (namely, clients, employers,

and professional organizations) would think they should inte-

grate CAT into future psychology practice by recommending

CAT or specific CAT practitioners to clients. Consequently,

policy and educational initiatives should focus on strategies that

explicitly show clients, employers, and professional organiza-

tions approving of integrating CAT into psychology practice.

Finally, inspection of the control beliefs revealed that strong

and weak intenders were equally likely to perceive certain pre-

ventive factors (e.g., lack of knowledge about appropriate prac-

titioners) as inhibiting their control over future integration.

Accordingly, strategies that focus on discouraging aspects of

integrating CAT into psychological practice (e.g., compromis-

ing professional reputation) may not be useful to help students

overcome barriers that might prevent them from intending to

integrate these behaviours into their future practice.

The results of the current study are broadly consistent with

previous TPB belief-based studies investigating psychologists’

intentions to integrate CAT (see Wilson & White, 2008), where

a range of behavioural, normative, and control beliefs influ-

enced CAT decision-making. Practicing psychologists, how-

ever, have established professional training and experience and

will be strongly influenced by past behaviours and norms; thus,

psychologists’ beliefs about CAT cannot be used to fully ex-

plain the beliefs of psychology students. This argument is sup-

ported by the finding that, in contrast with literature examining

psychologists’ beliefs (Wilson & White, 2008), we did not find

support for differences between strong and weak intenders for

control beliefs. This discrepancy in findings may be attributable

to the professional practice experience of the psychologists as

students may not yet fully understand the potential barriers of

integrating CAT into clinical practice. For example, psychology

students may not have been exposed to professional codes of

conduct that might potentially constrain the use of CAT in

psychology practice.

The results of the regression analysis support the MANOVA

findings in that behavioural and normative beliefs, but not con-

trol beliefs, predict students’ intentions to integrate CAT into a

future psychology practice by recommending CAT or specific

CAT practitioners to clients, accounting for a reasonable

amount of variance (34%). These findings suggest that the more

students perceive that there are benefits associated with rec-

ommending or referring CAT and the more they think that im-

portant referents approve of their recommending or referring

CAT, the more students will intend to integrate CAT into a

future psychology practice by recommending CAT or specific

CAT practitioners to clients. In light of these finding, policy

and educational initiatives aimed at promoting students’ be-

havioural intentions toward CAT use in psychology practice

should place emphasis on highlighting the behavioural and

normative beliefs, and not necessarily on targeting the underly-

ing co ntrol beliefs.

Some caution should be adopted in interpreting the results of

this study. First, the sample size was small and may have been

subject to self selection bias. Second, there was an uneven rep-

resentation of female and male students. Although this imbal-

ance reflects the higher proportion of females studying under-

graduate psychology in Australia, it is important to keep in

mind that our findings are primarily reflecting the view of fe-

male students. It is possible that male students may have dif-

ferent beliefs about CAT integration, at least as can be inferred

from reported levels of personal use (MacLennan, Myers, &

Taylor, 2006; Satia-Abouta et al., 2003). Future research should

incorporate a larger sample size in order to investigate this pos-

sibility. The broad definition of CAT used in the current study

may have limited the responses toward recommending and

referring CAT. The underlying beliefs for subcategories of

CAT might show some differences to the beliefs identified in

this study. For example, students’ underlying beliefs regarding

alternative therapies that have greater scientific evidence to

support their usage (e.g., St. John’s Wort, Folate, vitamin B12,

and amino acids such as phenalalanine and S-Adenosylmetho-

nine (SAMe); Jorm, Christensen, Griffiths, & Rodgers, 2002)

might be different for beliefs held toward alternative therapies

that are less supported in the literature. Finally, we did not in-

clude a measure of the perceptions of public readiness and it

might be interesting for future research to investigate a possible

relationship between students’ perceived public readiness to

accept psychologists’ integration of CAT and both students’

own belief in CAT and their intention to use CAT in future

practice.

Overall, by adopting a TPB belief-based approach, this study

provides important practical information that can be used to

inform policy and educational initiatives which aim to influence

the integration of CAT in psychology practice. Specifically, the

findings suggest that attention to advantages and disadvantages

of integrating CAT, such as being able to offer clients a more

holistic practice and compromising professional practice, as

well as considering the social approval of clients, employers,

and professional organisations in understanding CAT deci-

sion-making, may assist in improving students’ intentions to

integrate CAT into future psychology practice by recommend-

ing CAT or specific CAT practitioners to clients. Given the rise

of CAT use for mental health disorders, this preliminary re-

search examining CAT use in psychology practice should in-

form future research efforts to continue to investigate the mo-

tives and decision-making processes for integrating CAT within

the field of psychology. This further research could include

assessing the CAT integration beliefs and actions of practising

psychologists and incorporating longitudinal designs to deter-

mine how students’ attitudes and beliefs might change over

time, especially in response to increased knowledge and profes-

sional experience.

REFERENCES

Ajzen, I. (1991). The theory of planned behavior. Organizational Be-

havior and Human Decision Processes, 50, 179-211.

doi:10.1016/0749-5978(91)90020-T

Armitage, C. J., & Christian, J. (2003). From attitudes to behaviour:

Basic and applied research on the theory of planned behaviour. Cur-

LEE-A. M. WILSON ET AL.

212

rent Psychology, 22, 187-195.

doi:10.1007/s12144-003-1015-5

Australian Bureau of Statistics (2004-2005). 4364.0 National Health

Survey: Summary. URL (las t ch e ck ed 1 Oc to b er 2006).

http://www.abs.gov.au/AUSSTATS/[email protected]/DetailsPage/4364.020

04-05?OpenDocument

Bassman, L. E., & Uellendahl, G. (2003). Complementary/alternative

medicine: Ethical, professional, and practical challenges for psy-

chologists. Professional Psychology: Research and Practice, 34,

264-270. doi:10.1037/0735-7028.34.3.264

Chua, S. A., & Furnham, A. (2008). Attitudes and beliefs towards com-

plementary and alternative medicine (CAM): A cross-cultural ap-

proach comparing Singapore and the United Kingdom. Complemen-

tary Therapies in Medicine, 16, 247-253.

doi:10.1016/j.ctim.2008.02.009

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behav-

ior: An introduction to theory and research. Reading, MA: Addi-

son-Wesley.

Halcon, L. L., Chlan, L. L., Kreitzer, M. J., & Leonard, B. J. (2003).

Complementary therapies and healing practices: Faculty/student be-

liefs and attitudes and the implications for nursing education. Journal

of Professional Nursing, 19, 387-397.

doi:10.1016/S8755-7223(03)00133-9

Hyland, M. E., Lewith, G. T., & Westoby, C. (2003). Developing a

measure of attitudes: The holistic complementary and alternative

medicine questionnaire. Complementary Therapies in Medicine, 11,

33-38. doi:10.1016/S0965-2299(02)00113-9

Jorm, A. F., Christensen, H., Griffiths, K. M., & Rodgers, B. (2002).

Effectiveness of complementary and self-help treatments for depres-

sion. Medical Journal of Australia, 176, S84- S95.

Lewith, G. T., Hyland, M. E., & Shaw, S. (2002). Do attitudes toward

and beliefs about complementary medicine affect treatment outcomes?

American Journal of Public Health, 92, 1064-1067.

doi:10.2105/AJPH.92.10.1604

MacLennan, A. H., Myers, S. P., & Taylor, A. W. (2006). The continu-

ing use of complementary and alternative medicine in South Austra-

lia: costs and beliefs in 2004. Medical Journal of Australia, 184,

27-32.

National Centre for Complementary and Alternative Medicine (2006).

What is complementary and alternative medicine (CAM)? URL (last

checked 15 October 2008).

http://nccam.nih.gov/health/whatiscam/index.htm

O’Connor, E. L., & White, K. M. (2009). Intentions and willingness to

use complementary and alternative medicines: What potential pa-

tients believe about CAMs. Complementary Therapy in Clinical

Practice, 15, 136-140. doi:10.1016/j.ctcp.2009.03.003

Page, A. C., Jones, R., & Wilson, F. (2004). Survey of West Australian

anxiety support group participants views on treatment processes and

outcomes. Australian Psychologist, 39, 208-211.

doi:10.1080/00050060412331295090

Pawlak, R., Brown, D., Meyer, M., Connell, C., Yadrick, K., Johnson, J.

et al. (2008). Theory of planned behavior and multivitamin supple-

ment use in caucasian college females. The Journal of Primary Pre-

vention, 29, 57-71. doi:10.1007/s10935-008-0127-y

Satia-Abouta, J., Kristal, A. R., Patterson, R. E., Littman, A. J., Stratton,

K. L., & White, E. (2003). Dietary supplement use and medical con-

ditions: The VITAL study. American Journal of Preventive Medicine,

24, 43-51. doi:10.1016/S0749-3797(02)00571-8

Wilson, L. M., & White, K. M. (2011). Integrating complementary and

alternative therapies into psychological practice: A qualitative analy-

sis. Australian Journal of Psychology, 63, 232-242.

doi:10.1111/j.1742-9536.2011.00022.x

Wilson, L. M., & White, K. M. (2008). Identifying the attitudinal, nor-

mative, and control beliefs underlying psychologists’ willingness to

integrate complementary and alternative therapies into psychological

practice. In J. Summers (Ed.), Psychology leading change 2008:

Proceedings of the 43rd APS annual conference, Hobart.

Yardley, L., Fahmy, S., Jamie, A., & Furnham, A. (1999). Health be-

liefs and preferences for medical treatment: A comparison between

medical and social science students. Complementary Therapies in

Medicine, 7, 101-109. doi:10.1016/S0965-2299(99)80088-0