Naturopathic case taking

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Chapter 1 Naturopathic case taking

Greg Connolly, BA, ND

NATUROPATHIC PHILOSOPHY AND PRINCIPLES

For naturopaths, the patient-centred approach to case taking with its emphasis on rapport, empathy and authenticity is a vital part of the healing process. It is based not just on current accepted health practices but on the philosophy and principles that have underpinned naturopathy since its beginnings. This chapter examines how to establish and maintain a therapeutic relationship with patients through the process of a holistic consultation in the light of these values and practices. This chapter also presents a model of the structure and process of holistic case taking that will facilitate this consultation and provide both patient and naturopath with the knowledge and insight needed for healing and wellness.

Historical precursors

Having a philosophy by which to practice gives a clearer understanding of what constitutes good health, how illness is caused, what the role of the practitioner should be, and the type of treatments that should be given.¹ Naturopathy has a loosely defined set of principles that have arisen from three interrelated philosophical sources. The first main source is the historical precursors of eclectic health-care practices that formed naturopathy in the 19th and 20th centuries.² Allied to this are two other essential philosophical concepts intertwined with the historical development of naturopathy: vitalism^3,⁴ and holism⁵.

The tenets of naturopathic philosophy have developed from its chequered historical background, which includes the traditions of Hippocratic health, herbal medicine, homoeopathy, nature cure, hydrotherapy, dietetics and manipulative therapies.⁶ In modern times naturopathic philosophy has borrowed from the social movements of the 1960s and 1970s that fostered independence from authoritative structures and challenged the dependency upon technology and drugs for health care. These social movements emphasised a holistic approach to the environment and ecology with a yearning for health care that was natural and promoted self-reliance harking back to late 19th-century principles of nature care philosophy.⁷ Naturopathy also borrowed from other counterculture movements and began to be suffused with New Age themes of transpersonal and humanistic psychology, spirituality, metaphysics and new science paradigms.⁸ Since the 1980s naturopathy has increasingly used scientific research to increase understanding of body systems and validate treatments.^9,¹⁰

From this variety of sources, naturopathy has consolidated a number of core principles. These principles have had many diverse adherents and an eclectic variety of blended philosophies. Notwithstanding this, there are key concepts within naturopathy that are agreed upon and are flexible enough to accommodate a broad range of styles in naturopathic practice.¹¹

The historical precursors of naturopathy emphasise the responsibility of the patient in following a healthy lifestyle with a balance of work, recreation, exercise, meditation and rest; eating healthily, and having fresh air, water and sunshine; regular detoxification and cleansing; healthy emotions within healthy relationships; an ethical life; and a healthy environment. These views highlight the fact that each patient is unique and, in light of this, naturopathic treatments for each patient are tailored to addressing the individual factors that cause their ill health. An essential part of a holistic consultation is the education of the patient to promote healthy living, self-care, preventive medicine and the unique factors affecting their vitality.¹²

Vitalism

A fundamental belief of naturopathy is that ill health begins with a loss of vitality. Health is positive vitality and not just an absence of medical findings of disease. Health is restored by raising the vitality of the patient, initiating the regenerative capacity for self-healing. The vital force is diminished by a range of physical, mental, emotional, spiritual and environmental factors.¹³

Vitalism is the belief that living things depend on the action of a special energy or force that guides the processes of metabolism, growth, reproduction, adaptation and interaction.¹⁴ This vital force is capable of interactions with material matter, such as a person’s biochemistry, and these interactions of the vital force are necessary for life to exist. The vital force is non-material and occurs only in living things. It is the guiding force that accounts not only for the maintenance of life, but for the development and activities of living organisms such as the progression from seed to plant, or the development of an embryo to a living being.¹⁵

The vital force is seen to be different from all the other forces recognised by physics and chemistry. And, most importantly, living organisms are more than just the effects of physics and chemistry. Vitalists agree with the value of biochemistry and physics in physiology but claim that such sciences will never fully comprehend the nature of life. Conversely, vitalism is not the same as a traditional religious view of life. Vitalists do not necessarily attribute the vital force to a creator, a god or a supernatural being, although vitalism can be compatible with such views. This is considered a ‘strong’ interpretation of vitalism. Naturopaths use a ‘moderate’ form of vitalism: vis medicatrix naturae, or the healing power of nature.¹

Vis medicatrix naturae defines health as good vitality where the vital force flows energetically through a person’s being, sustaining and replenishing us, whereas ill health is a disturbance of vital energy.³ While naturopaths agree with modern pathology about the concepts of disease (cellular dysfunction, genetics, accidents, toxins and microbes), naturopathic philosophy further believes that a person’s vital force determines their susceptibility to illness, the amount of treatment necessary, the vigour of treatment and the speed of recovery.¹⁶ Those with poor vitality will succumb more quickly, require more treatment, need gentler treatments and take longer to recover.¹⁷

Vis medicatrix naturae sees the role of the practitioner as finding the cause (tolle causum) of the disturbance of vital force. The practitioner must then use treatments that are gentle, safe, non-invasive techniques from nature to restore the vital force; and to use preventative medicine by teaching (docere—doctor as teacher) the principles of good health.¹⁸

Vitality and disease

Vitalistic theory merges with naturopathy in the understanding of how disease progresses (see Table 1.1). The acute stages of disease have active, heightened responses to challenges within the body systems. When the vital force is strong it reacts to an acute crisis by mobilising forces within the body to ‘throw off’ the disease.¹⁷ The effect on vitality is usually only temporary as the body reacts with pain, redness, heat and swelling. If this stage is not dealt with appropriately where suppressive medicines are used the vital force is weakened and acute illnesses begin to become subacute. This is where there are less activity, less pain and less reaction within the body, accompanied by a lingering loss of vitality, mild toxicity and sluggishness. The patient begins to feel more persistently ‘not quite right’ but nothing will show up on medical tests and, in the absence of disease, the patient will be declared ‘healthy’ in biomedical terms. If the patient continues without addressing their health and lifestyle in a holistic way they can begin to

Table 1.1 Stages of disease

experience chronic diseases where there are long-term, persistent health problems. This is highlighted by weakened vitality, poor immune responses, toxicity, metabolic sluggishness, and the relationships between systems both within and outside the patient becomes dysfunctional. The final stage of disease is destructive where there are tissue breakdown, cellular dysfunction, low vitality and high toxicity.¹⁹

In traditional naturopathic theory the above concepts emphasise the connections between lowered vitality and ill health. Traditional naturopathic philosophy also emphasises that the return of vitality through naturopathic treatment will bring about healing. The stages of this healing are succinctly summarised by Dr Constantine Hering, a 19th-century physician, and these principles of healing are known as Hering’s Law of Cure.^19,²⁰

HERING’S LAW OF CURE

• Healing begins on the inside in the vital organs first, from the most important organs to the least important organs. The outer surfaces are healed last.

• Healing begins from the middle of the body out to the extremities.

• Healing begins from the top and goes down the body.

• Retracing—healing begins on the most recent problems back to the original problems.

• Healing crisis—as retracing and healing take place the body will re-experience any prior illness where the vital force was inappropriately treated. In re-experiencing the symptoms the patient will awaken their vitality and have an inner sense that the cleansing ‘is doing them good’. A healing crisis is usually of a brief duration.

Holism

Another essential principle of naturopathy developed from its eclectic history is the importance of a holistic perspective to explore, understand and treat the patient. Holism comes from the Greek word holos, meaning whole.^21,²² The concept of holism has a more formal description in general philosophy and has three main beliefs.²³ First, it is important to consider an organism as a whole. The best way to study the behaviour of a complex system is to treat it as a whole and not merely to analyse the structure and behaviour of its component parts. It is the principles governing the behaviour of the whole system rather than its parts that best elucidate an understanding of the system.

Secondly, every system within the organism loses some of its characteristics when any of its components undergo change. The component parts of a system will lose their nature, function, significance and even their existence when removed from their interconnection with the rest of the systems that support them. An organism is said to differ from a mere mechanism by reason of its interdependence with nature and its parts in the whole. For instance, any changes that occur in the nervous system can cause changes in other systems such as musculoskeletal, cognition and mood, and digestion. Or, more widely, any changes that occur in social relationships have an effect on the nervous system and vice versa.

Thirdly, the important characteristics of an organism do not occur at the physical and chemical levels but at a higher level where there is a holistic integration of systems within the whole being. There are important interrelations that define the systems and these may be completely missed in a ‘parts-only perspective’. These interrelations are completely independent of the parts. For instance, the digestive tract is functional only when its blood supply, nerve supply, enzymes and hormones are integrated and unified by complex interrelationships.

In naturopathic health care, holism is the understanding that a person’s health functions as a whole, unified, complex system in balance. When any one part of their human experience suffers, a person’s entire sense of being may suffer.

PATIENT-CENTRED APPROACH TO HOLISTIC CONSULTATION

One of the most difficult duties as a human being is to listen to the voices of those who suffer … listening is hard but fundamentally a moral act.²⁴

The holistic consultation and treatment of the whole person includes emotional, mental, spiritual, physical and environmental factors, and it aims to promote wellbeing through the whole person rather than just the symptomatic relief of a disease. To best enhance this holistic consultative process a ‘patient-centred’ approach is used. This is where the emphasis is on patient autonomy; the patient and practitioner are in an equal relationship that values and respects the wants and needs of the patient.²⁵ The role of the practitioner is to develop a therapeutic relationship of rapport, empathy and authenticity to serve the patient’s choices and engender the healing process.

An essential component of developing a therapeutic relationship with the patient is the ability to listen.²⁶ Naturopaths must never forget that each patient is an individual with their own unique story of illness and treatment. The patient needs to be allowed to tell that story and in turn the naturopathic practitioner needs to listen with sensitive, authentic attention and empathy. This disciplined type of therapeutic listening bonds the patient and practitioner and enhances the effectiveness of treatment.²⁷

When patients feel listened to, they open up and declare hidden information that can be clinically significant to the type of treatment given and to how well that treatment works. A clinical example is where a stressed final year secondary student wanted ‘something natural’ to help her sleep. As she spoke about her situation, another deeper narrative slowly unfolded in which she divulged that she had been sexually assaulted by an ex-boyfriend and her current anxiety centred upon thoughts of self-harm. The act of listening not only deepened rapport and established trust and empathy but also led to better clinical support for her with a referral to a psychologist.

If a naturopath does not holistically enquire into the causes of a patient’s presenting complaint and merely follows a protocol—in this case, an insomnia prescription—they may be, at the very least, clinically ineffective in treating insomnia or, worse, prolonging the patient’s suffering and increasing her risk of self-harm.

A practitioner needs to be aware that a holistic consultation is not a routine event for the patient. It is dense with meaning and can represent a turning point for them.²⁸ Fully listening to a patient’s concerns in a patient-centred holistic consultation helps the naturopath to explore and understand what is at stake and why it matters so much.²⁹ With this knowledge it is then possible to provide appropriate and effective treatment. Establishing rapport, empathy and authenticity in a patient-centred holistic consultation also enhances the practitioner’s ongoing ability to assess recovery and to achieve the patient-centred aim of independent self-care.³⁰

This therapeutic relationship depends upon the practitioner being proficient in consulting skills, communication skills and counselling skills. This chapter now focuses on consulting skills and the reader is recommended to the ‘Further reading’ section at the end of this chapter for texts discussing communication skills and counselling skills.

It should also be noted that some patients present to clinic with little or no prior understanding of what the naturopathic consultation involves. Some preliminary steps can be taken to facilitate a better understanding for the patient. Initially, a practitioner’s website can provide explanatory details of naturopathic philosophy, treatment modalities and the consulting process. This can be reinforced with clinic brochures in the reception area of the clinic. As the holistic consultation begins the practitioner can sensitively enquire as to the patient’s level of understanding of naturopathy and what their expectations about the consultation are.