Chapter 1 Introduction
The purpose of this book is to help students and practitioners of complementary therapies extend their skills in clinical diagnosis and integrative case management. As complementary and alternative medicine (CAM) educators, we recognised our students’ need for specific guidance in diagnosis and treatment prioritisation, along with the effective integration of a range of modalities into individualised holistic treatment programs. This style of case analysis was developed to provide students, teachers and practitioners with a framework within which they could effectively analyse and classify the extensive amount of information gathered in a CAM consultation [1]. We expect this book will be of particular benefit to CAM students and recent graduates who are seeking tools to enhance practice, particularly those who are learning or practising in countries in which CAM practitioners are not primary healthcare providers.
Detailed explanations for specific treatment protocols and modalities are not included in each case because we have assumed our target readership has an understanding of basic CAM principles, herbal therapy and actions, along with nutritional and dietary protocols. Readers who are unfamiliar with these concepts are directed to the outline of the fundamental principles and practice of CAM in Chapter 2, and subsequently listed reference materials; these recommend some excellent resources.
The process of case analysis and decision making outlined in this book can help the user develop effective and appropriate treatment protocols within the time constraints of a busy clinic [1]. The case analysis format, together with the case studies in this book, have been used with great success in quite different CAM training institutions. Students found the decision-making framework extremely helpful, despite training within differing models of CAM. The inspiration to develop this book came from seeing how this method allowed student practitioners to collate facts and relate the information collected into an understanding of how the underlying issues connected to the presenting symptoms [5]. The case analysis framework is deliberately simplistic so it can be adapted for all models of CAM, and the analysis method presented can be used as a scaffolding on which varying levels of complexity can be formed into a holistic understanding of the general and specific needs of the individual client.
How to use this book
The first section focuses on diagnostic analysis from a holistic perspective, taking into account both individual and common themes for specific disease conditions. The questioning protocols are focused on initial consultations; however, they can be adapted for use in subsequent consultations. It concludes with a decision table for referral, outlining referral flags, issues of significance and referral options with suggestions for further medical investigations. Additionally, a table of investigations for integrated holistic analysis is presented in Appendix B.
The three C’s case analysis formula
Clinical questions
Clinical questioning has been divided into three main sections called the three C’s:
• Complaint – questions to define the client’s presenting complaint. The aim is to understand the complaint.
• Context – questions to put the presenting complaint into context. The aim is to understand the disease. Questions on common contributing physical, dietary and lifestyle factors that may trigger the presenting complaint and lead to differential diagnosis considerations.
• Core – questions for holistic assessment to understand the client. Questions to reveal unique contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors for the individual client.
Although these categories have been set out in three chronological sections, it may be necessary to interweave the three lines of questioning throughout the consultation. How the questioning unfolds will depend upon the discretion of the practitioner, information-gathering priorities and rapport building with the client. The client may dictate which areas of information they wish to share, which will influence how the practitioner approaches questioning and information gathering. The examples of open and closed questions presented in this book have been designed to encourage confidence in the practitioner. Specific question examples may seem to extend beyond the level of qualification and jurisdiction of a non-primary practitioner. These questions have been included to help practitioners recognise symptoms and situations where referral to other healthcare providers is necessary. It is not our intention to encourage CAM practitioners to take over the role of primary healthcare professionals when that is beyond the scope of their training and professional boundaries. The purpose of these questions is to suggest ways in which CAM practitioners can elicit information that link the language of orthodox differential diagnosis into the observations and understandings acquired during the consultation process [7].
The ‘apple’ analogy
The three C’s formula is woven into the clinical questions, case analysis, referral suggestions and treatment options for all cases studies presented in this book. To more
clearly illustrate this concept, we have likened the framework to the analogy of an apple, which consists of three distinct and purposeful layers.
1. The skin of the apple can be likened to the ‘complaint’, providing a first impression and surface information about why the client has come for help. This section shows us the cover that has developed as the underlying issues progress and manifest outwardly. For example, a feeling of fatigue is a ‘complaint’ symptom for which several reasons may need to be considered in order for it to be put into context.
2. The layers of physiological, environmental and lifestyle triggers of illness that are commonly shared or implicated in the development of conditions is the flesh of the apple, corresponding to the ‘context’. This flesh is usually significant and helps identify the cause of complaint symptoms, which may be common to a number of different individuals. For example, if a group of people with low thyroid function experience fatigue, then the shared complaint symptom of fatigue can be understood within a common context for that disease process.
3. The underlying issues at the heart of the apple make up the core emotional and lifestyle triggers that are unique to each individual. The ‘core’ of an apple houses the seed in the same way that we house the seed of our illness. This is where an understanding of the metaphysical/spiritual/emotional influences on illness plays an important role, with consideration that physical manifestations of disease have an underlying energetic or emotional beginning [13, 18, 19]. If unique stressors for individuals are recognised as the seeds that can develop into illness, the core section can be the gateway to understanding how to let go of the cycle of ill health and move towards wellness. The reasons an individual is vulnerable to compromised health are unique to that person and understanding those reasons is the key to holistic healing.
By using the framework of the three C’s formula it is possible to consider a case from a holistic perspective. If an individual is experiencing extreme stress due to their struggle to make life decisions based on their own values and beliefs rather than those of others (core), this stress may contribute to thyroid imbalance (context), thus causing the surface symptom of fatigue (complaint). In using this example we recognise the medical fact that hypothyroidism may cause fatigue and there is no biomedical evidence that hypothyroidism can result from the inability to make life decisions; however, chronic stress has been linked to the development and progression of a range of medical conditions including immune dysregulation [19]. It is therefore possible to see how chronic stress caused by an emotional conflict could trigger or worsen underlying immune-related thyroid dysfunction [19, 21]. We hope readers will be open to the concept of individual beginnings to common themes of illness. In offering this analogy as a suggested means of exploring individual cases, we are by no means suggesting this is the only way to perceive the causes of health imbalance in individuals with specific health conditions but rather suggesting that the three C’s formula framework is useful in holistically analysing cases.
