The Dutch Complementary and Alternative
Medicine (CAM) Protocol:
To Ensure the Safe and Effective Use
of Complementary and Alternative Medicine Within
Dutch Mental Health Care
H.J. Rogier Hoenders, MD,
Martin T. Appelo, PhD,
Erik H. van den Brink, MD,
Bregje M.A. Hartogs, MSc,
and Joop T.V.M de Jong, PhD, MPH
Background: Complementary and alternative medicine (CAM) is subject to heated debates and prejudices.
Studies show that CAM is widely used by psychiatric patients, usually without the guidance of a therapist and
without the use of a solid working method, leading to potential health risks.
Aim: The purpose of this study is to facilitate the judicious use of CAM alongside conventional psychiatry in an
outpatient psychiatric clinic.
Methods: A search was made through scientiﬁc and legal articles and discussion in focus groups.
Results: In the Centre for Integrative Psychiatry (CIP) of Lentis in the Netherlands, some carefully selected CAM
are offered under strict conditions, alongside conventional treatments. Because of the controversy and the
potential health risks, Lentis designed a protocol that is presented.
Conclusions: The CIP hopes, by using this protocol, to better serve and respect the individual needs and
preferences of the diversity of psychiatric patients in our Dutch multicultural society, and better protect them
In2002, Silvia Millecam, a famous Dutch actress, died of
breast cancer after refusing conventional medical treatment
while trusting herself to practitioners treating her with com-
plementary and alternative medicine (CAM). The Dutch
Healthcare Inspection did an extensive inquiry into the mat-
ter. Three doctors were put on trial for malpractice and were
convicted by the Medical Disciplinary Tribunal. Two of them
lost their medical license. In the years that followed, there
were heated debates on the use of alternative medicine in the
Supporters of CAM claim that conventional treatments
have too many side-effects, lack effectiveness and room for
patients’ wishes and needs. On the other hand, opponents
state that CAM is quackery and that the effects are based on
placebo and ‘‘ridiculous principles.’’
This reaction reminds
us of earlier resistance to change in medicine; for instance, in
1911 Herrick was almost laughed out of medicine for stating
that atherosclerosis causes myocardial infarction.
Previous and current bias against new developments is
undesirable because both patients and doctors are uncertain
about safety and effectiveness of CAM. This is all the more
important because about half of the population in a variety
of Western countries
and almost half of Dutch psychiatric
outpatients use CAM annually.
A majority of patients get information on CAM via the
Internet, friends, or family. The quality of this information
varies greatly, leading to potentially harmful and dangerous
In the Netherlands, many doctors do not inform their
patients about CAM and they certainly avoid prescribing or
referring to CAM. Recently the Dutch Minister of Health has
announced more severe punishment for practitioners who
harm their patients either by applying unsafe therapies or by
delaying the start of conventional treatment.
The Centre for Integrative Psychiatry, Lentis, Groningen, The Netherlands.
The Psycho-oncology Therapy Centre ‘‘Het Behouden Huys,’’ Haren, The Netherlands.
The Open University of Amsterdam, Amsterdam, The Netherlands.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 17, Number 12, 2011, pp. 1–5
ªMary Ann Liebert, Inc.
the Netherlands patients and doctors are informed about
what cannot be done concerning CAM, while it remains un-
clear what could or should be done. Despite calls from the
World Health Organization (WHO)
and the European
until now the Dutch government did not for-
mulate a policy on this matter.
In an effort to ﬁll this gap and inspired by the North
American consortium of 44 academic health centers for in-
tegrative medicine (CAHCIM)
, Lentis (a community mental
health facility in the North of the Netherlands) founded a
Centre for Integrative Psychiatry (CIP) in 2006. It consists of
an outpatient clinic, a research department, an educational
department, and organizes an annual conference (with ap-
proximately 1000 attendees).
Its main purpose is to provide
safe and effective integrative mental health care.
What Is Integrative Psychiatry?
Integrative psychiatry is based on the principles of ‘‘inte-
grative medicine’’: reafﬁrming the importance of the rela-
tionship between practitioner and patient; focusing on the
whole person; using all therapeutic approaches (conven-
tional and CAM) based on the principles of evidence-based
medicine (EBM); and achieving optimal health and healing.
The debate in the Netherlands focuses mainly on the
principle of EBM (i.e., the use of CAM within conventional
treatment centers, and the correct deﬁnition of EBM). In this
regard, it is noteworthy that Sackett et al.
deﬁned EBM as
(1) the best available evidence for effective and safe treat-
ment options, (2) the preferences and needs of the patient,
and (3) the clinical expertise of the professional. These three
together should be decisive in making treatment choices.
This deﬁnition is in contrast with the present-day more re-
ductionist explanation of EBM in which the ﬁrst and third
principles are emphasized without paying much attention to
the patient’s preference.
The original deﬁnition therefore
accommodates therapies that still lack (sufﬁcient) evidence-
Table 1. Prejudices Against Complementary and Alternative Medicine (CAM)
1. Only few people use CAM 1. 30%–70% of the population uses CAM
and 43% of Dutch psychiatric
2. My patients do not use CAM because
they never ask or tell me about it
2. 60%–75% of patients using CAM do not tell their doctor out of fear
of a negative response
3. CAM users are less educated and
3. CAM users are typically female, highly educated, high income
with chronic disease
4. They use CAM instead of conventional
4. 80%–95% combines
5. They use CAM because of negative
reasons (against conventional medicine)
5. Besides disappointment about side effects and limited results, also
positive reasons play a part: good relationship with therapist and a
shared belief about health and disease (holism)
6. CAM effects are due to placebo 6. Several CAM are more effective then placebo
7. CAM and EBM are incompatible 7. CAM can be offered based on the principles of EBM
8. CAM are not endorsed by inﬂuential
8. The CAHCIM,
and the EP
endorse the integration
of effective CAM in conventional clinics
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EBM, evidence-based medicine; CAHCIM, academic health centers for integrative medicine; WHO, World Health Organization; EP,
Table 2. Prejudices for Complementary
and Alternative Medicine (CAM)
1. If it does not work,
at least it will not harm
1. Some supplements or herbs
can cause severe side-effect
2. Natural substances are
more healthy then
2. Nature contains severe
toxins, besides natural
3. CAM does not need to
be researched; I know
it works from experience
3. Experience is not enough;
research is needed to
distinguish from placebo
4. CAM are not suitable
for research because of
their speciﬁc nature
4. Science can be applied to
all phenomena; it is essential
to choose the right design
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2 HOENDERS ET AL.
based proof. It is also important to realize that according to
some researchers, only about one third of culturally and
professionally accepted interventions in Western medicine
are proven effective by randomized controlled trials.
Some reasons why opponents feel doctors should not use
CAM seem to be based on prejudices. Table 1 compares the
most common prejudices against CAM with information
from scientiﬁc studies.
Similarly, those in favor of CAM also seem to have
prejudices. Those are mentioned in Table 2. We therefore
argue that CAM needs serious attention, both within
conventional treatment centers and in the alternative ﬁeld
The CAM Protocol
One of the primary tasks of our center was to formulate a
scientiﬁc model based on the requirements that it would (1)
answer patients’ needs and wishes; (2) respect their freedom
FIG. 1. Complementary and alternative medicine (CAM) protocol for the Center for Integrative Psychiatry (CIP). CBT,
cognitive behavioral therapy; EBAM, evidence-based alternative medicine; ROA, routine outcome assessment.
DUTCH CAM PROTOCOL 3
of choice; (3) would offer Western medicine and CAM that
are safe and effective; (4) would protect against quackery
and abuse; (5) should be based on Dutch law, the jurispru-
dence of the Medical Disciplinary Tribunal, and the rules of
the Dutch Association of Medical Practitioners; and (6) be
based on scientiﬁc evidence.
The authors reviewed documents, the scientiﬁc literature,
and collected information with the help of focus groups.
This resulted in the CAM protocol.
In this protocol, we
distinguish (between) complementary and alternative medi-
cine. The ﬁrst is deﬁned as ‘‘approaches based on main-
stream biomedical theory and supported by research
evidence but not part of mainstream practice because of so-
cial, political or ideological reasons.’’ Examples are St. John’s
wort and massage. Alternative medicine is deﬁned as ‘‘ap-
proaches that are based on concepts that are outside main-
stream Western medicine.’’ Examples include homeopathy
Based on an analysis of the results, we pro-
duced the algorithm shown in Figure 1.
This is the working method of the CIP. The ﬁrst step of the
algorithm clariﬁes that CAM can only be used after an ex-
tensive and precise stepwise process. CAM can only be
started if conventional treatments have been applied before
or at least advised as suggested by guidelines and protocols.
In addition, CAM is considered if there is no danger when a
patient refused treatment (for instance: a patient with mania
or psychosis with severe symptoms will be strongly advised
ﬁrst to accept conventional medication even when asking for
After deciding to start CAM, the second step is based on
the principles of EBM (i.e., alternative treatments with a
lower level of evidence can be provided on a patient’s re-
quest when there is no contraindication). However, these
treatments will not be offered within the CIP. Patients will be
referred to an external network that provides these treat-
ments in conjunction with proven treatments provided by
CIP and not instead of them. In addition, there are the fol-
lowing required conditions:
The therapists are members of a (para)professional or-
ganization with a formal procedure for complaints and
The therapists base their treatments and way of working
on the professional guidelines of the organization.
The therapists conform themselves to legal demands
concerning patient ﬁles.
The clinic or ofﬁce where patients are being treated meet
privacy and hygiene demands, as common in conven-
The therapists have malpractice insurance.
There has to be at least monthly contact between the CIP
and the alternative practitioner.
After ﬁnishing the alternative treatment, there will be at
least one contact with the CIP to evaluate.
The alternative therapists agree to be included in sci-
entiﬁc evaluation by routine outcome measurement
(ROM) of the effect of the treatments and agrees with
publication, regardless the results.
Center for Integrative Psychiatry
In the CIP of Lentis, only conventional and complemen-
tary medicines that have been proven effective and safe are
being practiced. That means that they have to be based on
(reviews of ) several well-designed scientiﬁc studies. Ex-
amples are St. John’s wort for depression,
valerian for in-
relaxation for anxiety,
and mindfulness-based cognitive therapy for
massage for stress, anxiety, and depression,
exercise for depression, anxiety, and sleep disorders,
rate variability training for anxiety and stress-related and
single vitamins as a supplement
to medication for depression (such as folic acid),
supplements like such as S-adenosyl-l-methionine 1,4-buta-
nedisulfonate for depression,
melatonin for sleep disor-
inositol for depression, panic, and obsessive–
and dietary changes for depression.
These treatments, integrated with conventional psychia-
try, have been offered for 3 years to psychiatric outpatients in
Alternative medicine such as homeopathy, Reiki, or heal-
ing are not being offered. However, patients can be referred
to these treatments under strict conditions, which are ex-
plained above. All treatments are evaluated by ROM. In
addition, we study the outcome of innovative treatments
with individual outcome measurements (IOM) such as ‘‘Nof
1 design,’’ ‘‘single-subject experimental design,’’ and ‘‘time
serial analysis.’’ ROM consists of six questionnaires: psy-
chopathology, quality of life, resiliency, costs, satisfaction,
and one self-report personalized outcome indicator, chosen
by the patient. Patients ﬁll out these forms before treatment
starts, every half year, at the end of treatment, and half a year
after their discharge. Patients with IOM ﬁll out diaries con-
cerning items that are most relevant to their treatment and
symptoms to assess subjective improvement on core symp-
toms and complaints.
Because of the increasing demand of patients for alterna-
tive medicine and integrative treatments and because of so-
cial, political, scientiﬁc, and ethical reasons, and inspired by
the CAHCIM, Lentis has founded a CIP. Here it offers se-
lected complementary treatments alongside conventional
ones under strict conditions. By doing so, the CIP responds
to a call from the WHO and European Parliament, even
though the Dutch government still has not made a policy on
this subject. Because of the controversy surrounding CAM,
because of the lack of clear information, and because we
need not only an open attitude but also a critical one, the CIP
has formulated the CAM protocol. It believes that in this way
CAM can be offered in a safe and effective way within
conventional treatment centers. The CIP hopes in this way to
better serve and respect the individual needs and preferences
of the diversity of patients who need mental health care in
our Dutch multicultural society. It believes the protocol also
protects against quackery, abuse, and false hope.
The authors thank E.C. Waarsenburg for valuable sug-
gestions, S.D.E. Broekema for designing Figure 1, and K.M.
van der Ploeg for general assistance.
No competing ﬁnancial interests exist.
4 HOENDERS ET AL.
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Address correspondence to:
H.J. Rogier Hoenders, MD
The Centre for Integrative Psychiatry, Lentis
P.O. Box 86
AB Groningen 9700
DUTCH CAM PROTOCOL 5