Chapter 2 The principles and practice of CAM
Principles of CAM
Within the field of complementary medicine there are many different modalities; however, all these modalities have a similar understanding of the importance of addressing the root cause of disease and supporting the body’s inherent mechanisms of repair and recovery. Complementary medicine can be defined as a group of therapeutic and diagnostic disciplines that do not have the same theories and methods of teaching and provision as conventional biomedical healthcare [9, 15]. Commonly known CAM systems include Western herbal medicine, naturopathy, Chinese medicine, Ayurveda and homeopathy [15]. Other forms of therapy that come under the umbrella of CAM can include kinesiology, reflexology, reiki, flower essence therapy and aromatherapy [15]. Examples of complementary therapies commonly used in conjunction with conventional medicine include massage and nutritional therapy [15].
Holism is a fundamental principle in all CAM modalities. The term holism can have several meanings and, in the realm of healthcare, it refers to therapy that takes into account the understanding that illness is a manifestation of imbalance or disharmony in body, mind, emotion and often spirit [9]. The term ‘integrative medicine’ implies that complementary therapies are integrated into the structure of mainstream medicine [6], combining science, art, philosophy and medicine [8]. All aspects of lifestyle, including environment, diet, physical fitness, emotional stability, emotional awareness, sense of faith, belonging and meaning and purpose in life, are taken into consideration when forming an understanding about a person’s health from a CAM perspective [9]; the notion of ‘energy’ is a shared understanding [9]. Integrative medicine can also be practised by CAM practitioners when they combine two or more CAM treatment modalities to form an individualised holistic treatment program. The term ‘integrative medicine’ therefore refers to more than just combining mainstream medicine with CAM therapies that have a biomedical science evidence base [15, 20].
The principles listed below are the foundational principles of naturopathy. These principles, however, are relevant to all CAM modalities as the fundamental concepts of holism, addressing the root cause of illness and supporting the body’s natural healing forces, are common to all. We have chosen to use the term CAM rather than naturopathy because it is more inclusive of a wide range of disciplines, and the target readership of this book includes practitioners from a range of disciplines in both CAM and conventional medicine.
Foundation principles
• The healing power of nature and identify and treat the causes [8, 10, 12, 17]. This principle acknowledges the body’s innate ability to heal and self-repair and, therefore, the aim of treatment is to encourage the body’s own capacity to heal by identifying and removing obstacles to optimal health [8, 9, 12, 15]. Treatment focuses on removing the causes of ill health rather than suppressing or eliminating symptoms to maintain health [7, 9, 12, 15]. Illness is considered a process of growth and, wherever possible, not to be suppressed. The aim of treatment is to establish optimal conditions for healing by supporting and mobilising the action of the body’s innate self-healing abilities [10, 12, 69].
• First do no harm. This concept is inherent within the history of natural therapies and relates to the use (wherever possible) of restorative therapies that do not interrupt the self-adapting capacity of the body [7, 15, 72]. This principle also encompasses the importance of immediately attending to acute or emergency situations and, where necessary, repairing weakened tissues requiring more complex intervention by healthcare professionals from a range of disciplines [8, 10, 12, 69]. Doing ‘no harm’ therefore may include identifying situations requiring referral to other health professionals and following up on these in collaborative management. Additionally, ‘doing no harm’ includes practitioners becoming aware of personal agendas that may influence their decisions or hinder a therapeutic relationship with the client, and ensuring they always keep the best interests of their client clearly in mind [33].
• The therapist as teacher. The therapist teaches and guides through the process of healing [8, 10, 12, 69]. Illness is not to be feared but embraced as a learning process that can lead to growth for both the client and the practitioner [33, 69]. As a teacher, the therapist helps the client become self-regulating in maintaining their health, rather than just directing specific treatment without providing an understanding of why their health came to be compromised in the first place. This form of education focuses on the personal growth of the client [22] and recognises the life experiences that have shaped the client’s learning goals and health outcomes [23, 24]. Helping clients understand the concept of growth through illness requires good rapport and communication between client and practitioner [69].
• Treat the whole person. Disease is a manifestation of imbalance in the body–mind state that can arise in the physical body from a range of causes including genetic, nutritional, environmental, emotional and trauma factors [9, 12, 66]. CAM treatment protocols aim to be client centred rather than disease oriented. This often requires therapy that holistically addresses all areas of imbalance in the whole person, not merely dealing with a single aspect of the symptom picture [15, 19].
• Prevention. Healthy lifestyle, good nutrition, clean air, spiritual wellbeing, light, rest, exercise, a sense of community, meaningful service or work and family are all part of promoting positive health [8, 10, 12, 15]. Prevention also includes identifying and removing factors that disturb health and wellbeing on all of these levels [10, 12, 18, 69]. This may involve removing sources of toxicity, such as poor lifestyle or dietary habits, allergies/intolerances/sensitivities, chemical or heavy metal toxicity or emotional toxicity, or enhancing neuro-muscular and skeletal integrity and enhancing emotional and mental health [10]. Prevention is about inspiring clients to choose a healthier lifestyle and helping them establish a beneficial way of living [10, 69].
The practice and role of CAM professionals
The role of CAM professionals and the legal and professional boundaries for primary diagnosis and healthcare by CAM practitioners varies between countries [68, 69]. In Australia and the United Kingdom (UK) CAM practitioners do not practise as primary healthcare providers and therefore need to work alongside medical practitioners to ensure appropriate medical diagnosis and management occurs within the framework of a holistic healthcare program [8, 13, 15]. In Canada and the United States (US), naturopaths practise as primary healthcare providers and therefore have a greater degree of autonomy and responsibility in diagnostic and treatment procedures [8, 15, 69, 71]. The modalities used by Australian naturopaths can be different from those used by British naturopaths. In the UK herbalists prescribe herbal liquid and tablet formulations, and naturopaths focus primarily on physical therapies and dietary treatment. In Australia naturopaths are likely to prescribe herbal and nutritional supplements along with physical therapies and dietary treatment [15].
The consultation process
Accurate information gathering is essential for a meaningful holistic diagnosis and treatment program. Integral to this process is the ability to ask questions in a way that elicits relevant information from the client. Effective information-gathering techniques are both an art and a skill, informed by an understanding of the when, what and why of clinical questioning [5]. Knowing when and how to question clients is influenced by the type of questions asked, consultation time, the individual needs of the client and the development of client–practitioner rapport [2, 5, 37]. Knowing what questions to ask ensures practitioners gain a relevant and thorough understanding of the client as they work towards a diagnosis; understanding why particular questions should be asked ensures practitioners have sufficient perspective for holistic case analysis and treatment recommendations. Integration of different questioning skills provides opportunities to recognise and understand potential physical, mental and emotional imbalances along with referral flags within each case. Skilful case taking therefore allows practitioners to holistically consider underlying reasons for the manifestation of disease, as well as negotiating treatment options and identifying where cross-referral to allied health professionals is necessary [2]. Ideally, a consultation is a journey in which both practitioner and client participate, understanding that the process is far more than just coming to an understanding of presenting symptoms [39]. It is in fact a process in which information is gathered in a professional, ethical and empathetic manner [2, 5] giving the client freedom to communicate their unique story and current problem in order for the practitioner to guide them towards meaningful treatment options and space for healing [5].
Building rapport
To ensure the consultation process is thorough and meaningful it is essential for rapport to occur between practitioner and client. The process of building rapport begins the moment the client enters the consultation room. It is therefore important for the practitioner to ensure they have let go of previous activities and are fully ‘present’ before commencing the consultation process [1]. Warmly introducing yourself and showing the client where to sit can help ease apprehension and help the client to feel more relaxed and secure [1, 49, 51]. Advising the client at the start of the consultation how much time it will take is also recommended so they are aware of how long they have to share their story [1].
During the case-taking process there will be times of active questioning, and perhaps also times of silence or reflective listening to allow the client time and space to fully explain their circumstances or consider suggestions. The practitioner may need to summarise or paraphrase the client’s explanation in order to clarify information and they may also need to offer non-verbal cues and encouragement to help the client explain their story [1–3, 5, 38, 40–44, 51]. Non-verbal communication skills include knowing how to face a client, to make eye contact (where culturally and individually appropriate), to maintain an open posture and to use an appropriate tone of voice to sustain a relaxed atmosphere conducive to good communication [1, 5, 11, 45]. In this manner practitioners are not merely ‘taking’ information from the client but are actually ‘receiving’ a history from the client through both verbal and non-verbal communication, resulting from a positive rapport with the client [1, 70]. This process requires flexibility and openness on the part of the practitioner, along with professional honesty and confidence [1–3, 5, 38, 40–44, 51, 70].
An Australian survey conducted in 2005 revealed that one major aspect of satisfaction consumers have with CAM is that there is time for discussion and being listened to, along with a positive quality to the therapeutic relationship that develops [15]. Building rapport and offering empathy can often improve client adherence to treatment regimens for the long-term benefit of the client and the client–practitioner relationship [41, 70]. During a consultation it may be appropriate for the practitioner and client to alternate between asking and answering questions to promote a dialogue based on trust [5, 70]. This interplay and ‘therapeutic conversation’ can encourage empathy to develop, which inevitably gives the practitioner insight into the client’s unique perspective and therefore helps them to better understand the client [5, 39, 70].
Building rapport also requires an awareness of cultural sensitivities. While the underlying principles of CAM practice require practitioners to consider each client as an individual, it is important to understand the individual needs of a client within their cultural or social context [1, 5]. When building rapport with clients, it is important for practitioners to understand that clients from cultures different from their own may respond differently to situations or questions from clients from their own background. The practitioner therefore needs to understand both the cultural background of each client and the personal culture of each individual.
If a client has hearing, speech or cognitive difficulties it is important that the practitioner does not make assumptions about what the client is trying to convey [1]. Alternative methods of communication, such as sign language, pointing to written words or symbols or using an interpreter, can be very helpful to ensure good communication and rapport [1, 49, 50]. It may be necessary to repeatedly confirm that the client understands questions and treatment options to ensure their consent is informed [1]. To help clients with hearing difficulties more easily lip read, the practitioner should sit in good light so their face can be clearly seen, remain still, not put objects in their mouth while talking, have minimal facial hair around the mouth and maintain good eye contact and an open facial expression [51]. If a client doesn’t communicate in a language the practitioner can understand it may be necessary to seek assistance from an interpreter. It is wise for practitioners to be aware of the availability of interpreter services in their local area.
Open and closed questioning
During the initial stages of taking a case history, open-ended questions often allow practitioners to gain an overall impression of the client and begin to establish rapport [1, 2, 4, 45, 71]. Once this rapport has been initiated, the client is more likely to accept more challenging and probing questions [11, 39]. As the practitioner thoroughly investigates the client’s condition, they will need to ask both open and closed questions in order to gain both the wider perspective and the specific detail required [2, 11, 71].
Specific or ‘closed’ questions are often required to obtain the information necessary to arrive at a specific working diagnosis or to determine whether there are red flags that warrant referral to other health practitioners [1, 2, 4]. These specific questions allow the practitioner to gain information not easily elicited from the client’s own description [2, 6]. This line of questioning often concentrates on matching symptom pictures to common themes of organic disease [4, 11, 39]. However, relying solely on closed questioning will not elicit all necessary information, and it is the practitioner’s responsibility to know what questions to ask to obtain all relevant information [2]. Diagnostic summaries that rely solely on closed questioning inevitably miss relevant holistic information and result in a case history that is too narrow [2]. Practitioners may need to explain to the client why closed questions are necessary so the client is able to place them in the context of their particular health issues [1, 11, 39]. Clients with speech impairments may have difficulty in easily answering open questions and in such situations the practitioner will need to direct the questioning in such a way that short answers are all that is necessary. Some clients may find speaking freely disconcerting or uncomfortable and prefer the practitioner to take the major role in the questioning process [1]. On the other hand, incorporating client-centred open questions into the consultation can result in spontaneous sharing of important information from the client. By expressing themselves in this manner, clients may experience an improvement in their overall emotional health and reduced manifestation of disease, lessening the need for diagnostic tests and cross-referral [1, 2, 46]. Open questions help practitioners to gain a broad perspective of how the client’s state of imbalance developed [1, 2, 39]; opening up conversation in this way can be extremely useful to the practitioner allowing them time to listen while they consider what other information-gathering tools may be required [2].
Allowing time for a question to be answered thoroughly is necessary to gain an accurate history [1], and practitioners may find this challenging as they try to keep within the consultation time while still ensuring they arrive at a working diagnosis, develop a treatment program and identify situations requiring cross-referral [1, 51]. Because people take different amounts of time to answer questions it is important to allow the client sufficient time to frame their response. One of the aims of using open questions is for the client to feel they have conveyed their whole story [71]. Following open questions with closed questions to elicit specific information helps the practitioner to gather all relevant information [49]; concluding a consultation with specific questions and then summarising the information helps ensure accurate information has been gathered while maintaining consistency with the client’s story [49]. General examples outlined in this chapter offer examples of how specific (closed) and open questions can complement each other in a clinical situation.
CAM diagnosis
There are two main factors in clinical diagnosis from a CAM perspective. The first is the understanding that each client is an individual and the reasons why physical or emotional imbalance manifests in the way it does must be understood from a unique perspective [2, 3]. The second factor is that physiological and mental manifestations of organic disease have common and specific symptomatic themes, which can be identified with effective case analysis [2, 4]. These symptomatic themes are recognised through effective questioning, thorough physical examination and utilisation of appropriate diagnostic tools. The aim of CAM diagnosis is to develop an individualised treatment program that is formulated with an understanding of the individual within the context of a disease process rather than by the disease diagnosis alone [5, 70, 72].
Using the three C’s formula
Complaint
The first line of questioning in clinical case taking has the specific purpose of gathering information about the presenting complaint(s). This information reveals the location, timing, pattern, aggravating and ameliorating factors and provides a clear description, rating and the overall character of the complaint [1, 2, 49]. Because the client may have more than one presenting complaint it may be necessary to go through this process more than once [2]. The presenting complaint that is most important to the client may not be the one the practitioner wants to explore later in the consultation [1], and the client may disclose additional complaints during the consultation process. By organising information in this way it is easier to come up with an overall working diagnosis and links to symptoms requiring referral are easier to identify. This first stage of a consultation is often when factual information is gathered, which can provide an opportunity for the client to relax and become accustomed to the consultation environment [45]. The way in which subsequent dealings and rapport with a client progresses is often influenced by the first consultation [1, 2, 50], so inappropriately worded comments or questions in an initial consultation may prevent the client from communicating core issues later on [2, 5, 45]. Attentive listening by the practitioner allows the client to offer all necessary information without hesitation. Such information may be critical in correctly determining a working diagnosis and identifying situations requiring referral and it will be difficult to achieve full therapeutic benefit for the client without it [1, 72].
Context
The second line of questioning focuses on investigating the range of symptoms that place the presenting complaint into context to understand the disease process. This line of questioning involves considering what is influencing the presenting complaint and draws upon knowledge of generic body systems and common lifestyle factors that may be causing or aggravating the presenting complaint [2]. For example, a client may present with abdominal pain that has several possible causes or reasons for development. Questions at this stage may be very specific to place the symptom of abdominal pain into context such as: ‘Is your abdominal pain better for taking antacids or from sitting up?’ (peptic conditions).
The context section focuses on a general body systems review that will enable a concise differential diagnosis to be considered. In the case-questioning and analysis we are most interested at this point with what common themes could trigger the complaint for anyone who may present with the complaint symptoms. The common disease processes are considered and focused upon. This allows relevant information to be elicited that may point towards potential referral situations, and ensures the client is properly informed about their health concern and is appropriately referred if necessary [1]. It is helpful to summarise to the client what information has been gathered through context questioning to ensure the line of enquiry and information gathered is relevant [1, 2].
Core
The third line of questioning relates to the core and holistic information concerning the individual client. It is equally important to focus on underlying emotional issues that may be contributing to the symptoms the client is experiencing. Questioning at this level may involve exploring information about family, friends, support networks, bereavements, shock or trauma, as well as specific behaviour integral to the development of the health imbalance [2, 50, 71].
People may experience disease symptoms without the presence of underlying pathology when symptoms have arisen from a bereavement, shock or trauma [2]. Likewise, individuals with the same disease diagnosis can experience quite different symptoms or ‘illness’ [2]. While CAM practitioners may not be qualified counsellors, the task of gathering a perspective of illness from each client is important [2, 6, 72]. A client may engage in a therapeutic consultation during a ‘crossroads’ in their life, hoping to find ways to change their future direction. This process may result in an aggravation of symptoms initially, such as the return of symptoms previously experienced, or even the development of new symptoms [8]. In these situations practitioners can facilitate time and space for their client to reconnect with the possibilities of a new beginning and the potential for personal growth [5]. Moods and emotions pervade all aspects of human behaviour and it is therefore necessary to understand the influence of mental and emotional conditions on the development and progression of the client’s present state of health. This understanding also allows the practitioner to know how to help foster a healthier outcome for the future [5, 6]. For this reason it is essential to understand the wider context of the client’s life.
The core section of questioning provided in this book is intended to acknowledge that all clients are unique and individual people and not merely a collection of symptoms [5, 6]. Practitioners who are sensitive to and understand the relevance of this line of questioning may choose to follow the client’s agenda during the consultation, not assuming or reading information into the core section that is not true for the client [5]. The openness, trust and empathy that can develop between practitioner and client during the exploration of the core line of questioning creates an environment in which key information can be revealed [69, 72]. This area of questioning may reveal one or more emotional or mental health issues that practitioners would be wise to recognise and refer to appropriately qualified allied health professionals. This encourages integration and the possibility of working collaboratively for the optimal healthcare management of the client.
CAM treatment
Treatment or helping is not something ‘done to’ clients by CAM practitioners but is a collaborative effort between the practitioner and client [5, 6]. The CAM practitioner’s aim is to ensure the client is asked clearly what they want, what they need and what they are willing to change [5]. The intrinsic motivation of the client is ‘found’ rather than ‘created’ and the client is encouraged to make choices for themselves [25–27]. Some clients are self-motivated and well informed while others may require structure, boundaries and direction so they can establish self-regulating preventative strategies that lead them towards long-term good health [25–27].
The goals of a CAM treatment program are therefore far more than simply achieving an improvement or elimination of troublesome physical symptoms [5, 15, 69]. While addressing the presenting complaint is important, programs should also help clients understand how and why the complaint developed in the first place and help them discover their personal potential, helping them work towards their desired lifestyle and optimum health both in the present and into the future [5, 72]. Individualised treatment programs also take into account the client’s lifestyle as well as their financial, emotional and physical circumstances [5]. They are presented in a time and manner that is appropriate to the individual, ensuring they are not overwhelmed or disempowered [6]. The basis of treatment recommendations and expected outcomes are discussed [6] and if more than one treatment solution is available it may be appropriate to give clients an informed choice of their preferred option [6, 67]. At other times practitioners will need to direct clients towards important treatment recommendations, particularly in situations that require immediate medical collaboration [6]. This approach therefore requires flexibility and ongoing evaluation [5].
In keeping with the understanding of the innate intelligence of the vital force and vis medicatrix naturae, there may be times when the decision is made to not actively treat [7] but rather to respect the body’s innate ability to self-heal without intervention. In some situations the consultation process may be healing enough [8]. Readers may be more familiar with the terms ‘homeostasis’ or ‘general adaptation syndrome’ to describe the body’s innate self-healing force [8].
Negotiating treatment
Arriving at a mutually acceptable treatment program is essential for optimal client compliance. In order to gain insight into the client’s expectations practitioners can ask questions such as ‘What were you hoping I could do for your symptoms?’ [1, 2, 50, 72], ‘How do you hope I can help you with this?, ‘What type of treatment were you expecting?’ or ‘What type of treatment approach were you hoping for?’ [1, 2, 5, 6, 72].
If the client is uncertain or unclear about their expectations it will be necessary for the practitioner to give their opinion regarding their treatment options and the most appropriate course of action, clearly explaining the reasons for these recommendations [1, 6, 71]. Ways of suggesting treatment can include statements and/or questions such as ‘Perhaps we could try this type of treatment plan first’, ‘One possibility is…’, ‘Sometimes I find that…’ or ‘How would you advise a friend in your situation?’ [6]. This allows the client to participate in treatment decisions while the practitioner negotiates a specific therapeutic contract or treatment plan with them [6, 50]. It is also important to be honest about any uncertainties you may have as a practitioner about cultural sensitivities. ‘I’m not always sure about cultural factors I need to be aware of so would you let me know if there is anything you don’t understand or if there is anything specific I can do to help you be more confident about your treatment program?’ [1]. Providing well-written and easily understandable information on the treatment program [1, 11, 71], explaining potential unexpected outcomes, outlining clearly how many visits may be required, summarising treatment priorities and asking the client if they understand the treatment plan all helps to ensure the highest potential of compliance can be reached [1, 71]. If the practitioner is clear about the intent and direction of therapy and/or prescribed treatments, it is more likely the client will understand and participate in the process [6].
Ending consultations
The closing phase of a consultation is the time to summarise the client’s story and check for accuracy [11]. Ideally practitioner and client should feel they have both participated in the process of information gathering and arriving at a holistic understanding of the client’s condition [11, 45, 72]. Phrases that can be used to finalise a consultation include:
• ‘I would like to make sure I have understood you correctly. Today you shared that …’[1]
• ‘Do you feel you have told me enough or is there anything specific you would like to let me know before we finish?’
• ‘Now that I understand more about your physical symptoms and how you are feeling, let’s talk about the practical ways we can work together to help you.’ [2]
• ‘Thank you for sharing information with me because it has helped me understand your situation much better. Our time is up for today.’
Referral
At times it is necessary for practitioners to refer their clients to other healthcare professionals, particularly when situations requiring immediate cross-referral have been identified. Firm opening statements may be necessary to ensure the client understands the importance of the referral. At times the student or practitioner may find it difficult to confidently communicate their recommendation for referral. Examples of how to suggest to clients that they would benefit from a referral may include ‘I have known cases where a counsellor has been very helpful’ [6], ‘I strongly advise…’, ‘My advice to you is…’ or ‘There is no doubt in my mind…’ [6]. It is important the client understands the need for the referral and that the CAM practitioner and CAM therapies may still form part of their overall healthcare in conjunction with other health professionals [70]. One way to recommend referral could be ‘I will write a referral letter to your GP/allied health professional explaining the symptoms you described today and ask them for a copy of the results of any investigations. Would you call me after your appointment and let me know what was discussed?’ [2].
It is equally important to explain the importance of referral to a child, especially after they have developed a positive therapeutic rapport with the CAM practitioner. It may be appropriate to use wording such as ‘I was just telling your parents about someone I would like you to meet and who I think would be very keen to meet you. She knows all about bad dreams and how to get rid of them. Would you like to meet her tomorrow?’ [1].
Confidentiality
Clients who convey sensitive information during a consultation need to know their information will be kept confidential. In situations where you believe a client has physical or mental health issues beyond the scope of your professional expertise, it may be necessary to refer them to another healthcare provider who can help them. If a client communicates that they have a notifiable disease, is a danger to themselves or may harm others (e.g. issues surrounding child abuse, sexual abuse, domestic abuse or suicidal tendencies) it will be necessary to explain to the client that you must not be the only healthcare provider who knows this information [1, 51]. In some circumstances practitioners have a legal and professional duty of care to report or act upon such information [11, 51], for example, where it is discovered the client has been the victim of abuse. It may be helpful to the client if the practitioner initially explores why they feel unable to share this information with other health professionals or their general practitioner [1]. After they have shared the information with a CAM therapist, the client may begin to feel more confident in sharing it with another therapist. Provided that confidential information is received respectfully by practitioners, the opportunity to open doors to successful and voluntary collaborative referral in the future is more likely to occur.
Record keeping and informed consent
Some clients share their health history in ways that are difficult to record in notes. For example, recording answers to open questions may be difficult compared with answers to closed questions [1]. Consultation sheets that help direct questioning and facilitate easy recording of case notes are helpful (see Appendix B). It is extremely important that practitioners are confident and comfortable in recording case histories because case notes are not only a summary of information elicited during a consultation but are also legal documents [1, 50]. For this reason it is vital that case notes have clear headings, are organised, are concise, are easily interpreted, provide summarised information and only convey necessary personal client identification in the event they are misplaced [1, 50]. Because clients have legal access to their case notes, it is wise to ensure nothing is written that the practitioner would not want the client to see [50]. Practitioners should be aware of the legal requirements in their state or country regarding client record keeping, mandatory reporting, privacy legislation, etc. [71].
Clients should give informed consent before undertaking any procedures, treatments or taking prescriptions [1, 15, 68]. Although it is not always possible for a client to be ‘truly informed’, there are a number of ways practitioners can help the client make informed decisions. Assessing potential literacy, language or competency barriers to informed consent is essential [1, 51], and judging whether the client has demonstrated competency to give informed consent may need to be done by more than one health professional. For informed consent to be valid the client must be able to understand information about their condition and treatment options, remember the information, weigh up treatment options and believe the information is relevant to them [51, 67, 68]. Providing clearly written information to the client (if appropriate) that explains the recommended treatments or medicines is a good start. Determining the client’s prior knowledge of any therapy from the outset is also helpful, as is offering specific information and instructions for the client to read at home. Providing a list of helpful telephone numbers and links to research literature or websites may be appreciated by the client. Ideally ‘informed consent’ is an educational process and not just an act of the client signing their name to a procedure [51]. Providing a copied treatment form for the client to sign and keep, offering suitable visual or audio information and suggesting avenues for further education on a proposed therapy may all help to ensure the client’s implicit understanding for the management of their health condition [1, 51]. One way this can be suggested is by expressing ‘First I will explain what treatment/medicines I am recommending and give you information to take home and read. Then we can discuss how I think this can help you. Finally, I will talk with you about potential effects of the treatment and try to answer any questions you may have’ [1]. Essentially the way in which information is conveyed can have a significant effect on the client’s satisfaction with and their compliance to a treatment protocol.
Interviewing children
Consultations between children and practitioners can be positive and rewarding experiences for all concerned when both the child and the parent are involved in the process. Effectively interviewing children requires specific skills and questioning techniques. Communication ability, knowledge of paediatric stages of development and appropriate questioning techniques for children at different ages are all important [1]. Checking periodically that the child understandings the meaning of questions helps ensure their answers are genuine [45].
Positive communication between practitioners and children is integral to achieving a holistic understanding for diagnosis and treatment. Even though the accompanying adult can offer specific information and may communicate the majority of information to the practitioner, it is important to gain insight into the child’s perspective and experience of their condition [14]. Communication with children should happen in ways appropriate to their level of understanding and communication, and practitioners should ensure children feel comfortable and at ease [1, 14]. Sitting at the child’s level and arranging furniture so they feel comfortable can help achieve positive communication and rapport. Not talking down to children is important to make them comfortable and at ease [1]. Toys and activities appropriate for the child’s age and stage of development help keep them occupied and entertained, and make their experience more positive. Toys and games offered to children should be safe and appropriate for their age and hygiene must be maintained to minimise the risk of cross-infection [1]. Allowing children to handle equipment after the practitioner has used it, having spares for children to play with or by using equipment on parents, siblings or toys can help reduce their anxieties or apprehension about the consultation and examination process.
Including children in the consultation process requires sensitivity to both verbal and non-verbal cues; questions should be prioritised and kept as brief as possible. Children should be given breaks and activities throughout the session to ensure they don’t become overwhelmed or distressed by the questioning process [45]. It is also important to observe the way children and parents/caregivers relate to each other during the consultation process – this can provide valuable insights into the family dynamic and the emotional and mental state of the child.
Children may have significant anxieties or fears about medical appointments, particularly if they have seen many different healthcare practitioners. If a child is distressed or anxious it is important for the practitioner to continue to talk in a calm and reassuring voice to maintain a sense of calmness and balanced energy [1]. Allowing them to be held by their parent may also be helpful in such situations. Using terminology the child is familiar with to describe their symptoms helps the child understand what you are asking and helps them more easily explain their problem [1]. Playing games involving open and closed questions is another way to gather necessary information without making the child feel pressured or uncomfortable [14, 45]. Younger children may respond well to using a favourite toy to role play their symptoms [1], and may be more comfortable if you include their toys in the examination [1, 14]. Examples of how this can be done include ‘Let’s look at teddy’s tummy to see where it hurts’, ‘Can I look in Panda’s eyes too?’, ‘What do you think dolly needs to feel better?’, ‘Can you show piggy how wide you can open your mouth?’ [1]. Providing drawing or art material can also be very helpful because some children will be more easily able to communicate through a drawing. Asking a child to draw a picture about when they are feeling unwell and then asking them to tell you about their picture can provide significant insight into symptoms and underlying causes or concerns [14].
Challenging consultations
From time to time practitioners may experience clients showing signs of anxiety, anger, aggression or distress during consultations. It is wise to ensure your practice environment is close to other people/practitioners and your consultation space not isolated. In the event of a challenging consultation experience, there are strategies that can assist the practitioner to guide the consultation in a productive direction. In such situations it may be necessary to stay calm and spend time with the client to help calm and defuse their distress [1]. However, the safety and duty of care from a CAM practitioner does not include staying in a dangerous situation with a client and it is within professional boundaries to discontinue a consultation if necessary [1]. Overall, if a tense situation presents with a client the aim is to initially actively listen, summarise what the individual is trying to convey, be specific about your intentions as a practitioner, offer reassurance and acknowledge the emotion they are experiencing is understandable [1, 49, 50, 73]. Maintaining empathy and not interrupting the client’s flow of expression [73, 74], being non-judgemental, keeping a safe physical distance [75] and making sure there are no objects nearby that could be used as a weapon is also very important [1]. The crucial aspect to focus on in these situations is helping the client understand they have choices while remembering as a practitioner you also have a choice about how long you want the consultation process to continue. Ensuring the client feels they have been heard and understood can help to de-escalate difficult situations [73, 74], but, in doing this, practitioners should ensure they don’t make agreements or promises that can’t be kept. Maintaining a calm and composed appearance, speaking calmly and quietly, avoiding excessive eye contact and maintaining even breathing may help defuse a tense situation [1, 75]. Recognising signs of anxiety or anger, such as sweating, flushing, trembling, rapid and changing speech, loss of eye contact, impatience and dramatically changing body language, can help the practitioner to modify their questioning approach in response to the client and ensure the consultation process remains positive and productive [1, 75]. It is helpful to have a protocol in place to deal with such situations, which can include placing office furniture to allow the practitioner easy access to the door, signals to alert others that help is needed and emergency numbers on speed dial [75].
