A Hierarchy of Healing: Origins of the Therapeutic Order and Implications for Research

Abstract

The philosophy, principles, and theories of naturopathic medicine include the six Principles of Naturopathic Medicine and the Therapeutic Order. Together these constructs, describe the core principles of the practice of naturopathic medicine, as established by thought leaders throughout the formation and development of the profession. The naturopathic medicine research agenda (NMRA) set forth recommendations for the codification of the foundational theories of naturopathic medical practice. The “Therapeutic Order, Whole-systems, Evidence-based Research Standards” (TOWERS) initiative is proposed with the primary objective to conduct the rigorous evaluation of the Principles of Naturopathic Medicine and the Therapeutic Order constructs. It is envisioned that this initiative will result in the development of an evidence-base concerning the clinical theory, philosophy and principles of whole-systems naturopathic medicine. After over one hundred years of professional organization and formal practice, there is a need to translate these empirically derived constructs into an evidence-informed theory of naturopathic medicine.

Introduction

There is a need for a system of global health that codifies a way of living that promotes individual, public and environmental health that is in ecological alignment with life on Earth. Naturopathic medicine is a system of medicine that holds tenets of health and healing aligned with sustainable living and planetary well-being. The goal, in part, is to adopt a global culture of health that is consistent with health promotion, disease prevention, and ecological sustainability. Given the current state of bio-medicine, with its limitations in both expense and approach to chronic illness, now is the time for naturopathic medicine to flourish.

The Naturopathic Medical Research Agenda (NMRA) funded by a grant from the National Institutes of Health National Center for Complementary and Integrative Health (NCCIH, formerly NCCAM; R21 AT833) recommended that the naturopathic medical profession codify its knowledge, operationalize its core concepts and principles, and develop rigorous standards for research in naturopathic medicine.¹ The NRMA hypothesized that: “The scientific exploration of naturopathic medical practices and principles will yield important, perhaps even revolutionary, insights into the nature of health and the biology of healing.”² Over the last decade there has been a significant increase in naturopathic scholarship around the globe, and especially in North America. A recent global systematic scoping review found 33 papers (n = 9859) on whole-system multi-modality naturopathic medicine that showed evidence for efficacy across a range of chronic health conditions.³ This paper validated and expanded upon a 2015 systematic review of 15 North American papers, which concluded that naturopathic medicine has potentially positive public health implications for a wide variety of chronic health conditions.⁴

The core philosophical principle of naturopathic medicine is the vis medicatrix naturae–‘Healing Power of Nature.’ The American Association of Naturopathic Physicians (AANP) defines the vis medicatrix naturae as “the inherent self-organizing and healing process of living systems which establishes, maintains and restores health. Naturopathic medicine recognizes this healing process to be ordered and intelligent.”^5-7 This core philosophical principle of naturopathic medicine describes the biological, bioenergetic and physiological healing process within natural systems.^8,9 The Therapeutic Order is a central concept in naturopathic medicine constructs and expands upon the ordered process of healing of the vis medicatrix naturae by emphasizing the determinants of health as the basis for the maintenance and restoration of vitality and health and healing.

History of Development and Definitions

Naturopathy was founded in the United States by Benedict Lust in 1901 through establishing the American Naturopathic Society and the American School of Naturopathy. Lust purchased the name Naturopathy (meaning Nature Cure and Homeopathy) from Sophie and John Scheel in 1900.¹⁰ The ontological framework of naturopathic medicine, influenced by the Austro-Germanic naturheil kunde and homeopathic practitioners and the natural hygienists in the United States, was developed via contributions of multiple schools of thought and natural medicine thought leaders.^11-21 Henry Lindlahr, ND, codified the medical philosophy and clinical theory of naturopathic medicine in his seminal work: “Nature Cure: Philosophy and Practice Based on the Unity of Disease and Cure,” drawing from numerous scholars and schools of thought.²²

Lindlahr described the determinants of health in his Unity of Disease Theory, predicated on primary and secondary causes of disease. The primary causes of disease were defined as (1) lowered vitality, (2) abnormal composition of blood and lymph and (3) accumulation of waste matter, morbid matter, and poisons; and the three secondary causes were defined as (1) hereditary and constitutional taints; (2) infectious diseases; and (3) anatomical, physiological and psychological pathologies.²² Lindlahr also set forth the five-part therapeutic progression of the (1) return to nature, (2) elemental therapies, (3) chemical remedies, (4) mechanical remedies, and (5) mental and spiritual remedies, describing a state in which not following the natural determinants of health in living systems results in a state of disease.²²

“Medical philosophy comprises the underlying premises on which a health care system is based. Once a system is acknowledged, it is subject to debate. In naturopathic medicine, the philosophical debates are a valuable ongoing process which helps the understanding of health and disease evolve in an orderly and truth revealing fashion.” Rachelle Bradley, ND^23-26

In 1948, Harry Spitler, ND, at the behest of the American Naturopathic Association (ANA), published Basic Naturopathy.²⁷ There he discusses a similar step order to engage the healing response or crisis, beginning with the return to a natural environment, removing disturbances and establishing nourishing factors.

After the hiatus that affected the profession in the United States during the 1940s and 1950s, the profession had a renaissance in the 1970s. In 1989, the six principles of naturopathic medicine were formally developed and adopted unanimously by the AANP: (1) the vis medicatrix naturae; (2) identify and treat the cause; (3) first do no harm; (4) doctor as teacher, (5) treat the whole person, and (6) prevention.⁵

In the mid-nineties, Jared Zeff, ND, LAc, published “The Process of Healing: A unifying theory of naturopathic medicine.”²⁸ The theory presented the origin of chronic disease including toxemia; and proposed a system of applied clinical theory: (1) the determinants of health, (2) the process of disease and a model of healing, and (3) the four-level hierarchy of therapeutics which began to formalize the therapeutic progression of healing.²⁸

The addition of three levels to the hierarchy, renaming it as the seven-level ‘Therapeutic Order,’ was proposed by Pamela Snider, ND, and Jared Zeff, ND, LAc.²⁹ The therapeutic order was subsequently explored, refined and codified through a series of publications, faculty retreats, discussion, and meetings, as well as through experience with students and student feedback; the resulting seven-level Therapeutic Order is presented earlier in Figure 1.^8,9,28-32 Brief definitions of the seven-level Therapeutic Order and the role each level plays in the promotion of healing and health, the delivery of safe and effective care, the prevention of suffering and further degeneration of the condition, and the preservation of life are provided in Table 1.^8,9,29,33-35

Figure 1.

The Seven-Level Naturopathic

Table 1.

Definitions of the Seven-Level Therapeutic Order

Level One – Establish the Conditions for Health

Address Determinants of Health (DOH): inborn, behavioral, social, cultural, environmental and spiritual, as health supporting and promoting factors or as disturbing factors (obstacles to cure). DOH are the “terrain” or the soil, from which healing, health or illness arises. Strengthen inborn factors, remove disturbing factors, and establish health promoting factors. “If one understands health to be the natural state and “disturbance” the original culprit, then identifying and reducing disturbance is the obvious first step, unless there is immediate danger to life or limb, in which case acting to reduce suffering and preserve life or limb is paramount. Generally refers to actions a patient undertakes themselves (vs. any form of medication) and actions people, groups or communities can enact through system change and advocacy. At this level the individual also takes self-responsibility for their well-being.

Level Two – Stimulate the Healing Power of Nature (vis medicatrix naturae) and Self-Healing Processes

Once the terrain is cleared of disturbing factors, inborn needs are supported and health promoting factors are in place, apply general stimulation to engage the global healing response - the self-healing mechanisms. The basis of this approach is recognition of the vis medicatrix naturae as both force and process, the tendency of the body and spirit to be self-healing, the wisdom and intelligence within the system that constantly tends toward the healthiest expression of function, and the healing “forces” in the natural environment (air, water, light, etc.). The body heals itself. The physician can help create the circumstances to promote this. Then, as necessary, the physician stimulates the system. In this regard, we apply agencies such as homeopathy, needling, hydrotherapy, physical medicine approaches, meditation, even exercise, that add nothing of substance, but move or stimulate the energy of the system. When appropriate supervised fasting is encouraged.

Level Three – Support and Balance Physiologic and Bioenergetic Systems

These strategies are used to restore optimal function to an biological, bioenergetic, physiological and mind-body systems (digestion, immune, cardiovascular, detoxification & emunctories, biofield, psychospiritual, endocrine, etc.). Some systems or functions require more than stimulation to improve. Some organs are weakened or damaged (e.g., adrenal fatigue after prolonged stress), and some systems are blocked or congested (e.g., hepatic detoxification pathways) and require extra help. Some systems are overactive and require soothing, while causative factors are identified and addressed. Following assessment, therapeutics involve specific diets, or nutritional, botanical medicine, physical medicine, or homeopathic preparations and counseling, strategies directed at specific organs, tissues and system functions to strengthen and nourish, or soothe them.

Level Four – Address or Correct Structural Integrity

Structural problems originate from and create stress upon internal systems. Structural misalignment may be related to underlying functional disturbances. Simple structural dis-integrity is corrected by physical therapies including simple manipulation, therapeutic massage, acupressure, Rolfing and other forms of tactile therapeutics. Usually the problem of structure is part of the larger problem, and such intervention becomes a fourth-order therapeutic approach. Manipulation, massage, exercise are central modalities. Some systems of exercise are designed to reintegrate and maintain normal structural relationships. Any of these might be appropriate to a specific patient. By approaching the problem in the context of the therapeutic order, one can expect structural corrections to be required only occasionally and for the results to be more or less permanent, if the underlying organic disturbance is corrected.

Level Five – Address Pathology using Specific Natural Substances or Modalities

Use of specific natural or physiologic (found in the body as isolated substances in the same form) substances against specific pathologic states or symptoms. Having gone through the first four steps of this therapeutic hierarchy, most patients improve. The improvement is based on the sound footing of the underlying correction or removal of fundamental causative elements. It is also based on the intrinsic nature of the body to heal itself by using the least possible force. Most pathology improves or disappears under these circumstances. Sometimes it is necessary to address pathology directly with specific therapeutic agents; directed at symptoms or the pathological state, which tends to be the starting point for biomedical treatment. Biochemical or genetic individuality also can demand an emphasis at this level of intervention.

Level Six – Address Pathology using Pharmaceutical or Synthetic Medicines

Use specific pharmaceutical or synthetically created medicines to manage specific symptoms, biochemical pathways or interactions. Pharmaceuticals tend to be “mono” substances. These substances are also not associated genomically or epigenetically with the evolution of the human organism in the broader ecosystem in which plants, animals and people co-develop. Compounds in plants and glandulars work with the human organism and therefore are considered a lower force and more general intervention than prescribed pharmaceutical substances, which are more specific in their interaction and more directive of biochemical pathways. Pharmaceutical substances are associated with a higher rate of adverse events, making this level of the intervention higher force. (Botanical preparations, nutritional supplements and glandular products may also have adverse effects, and can be toxic).

Level Seven – Suppress or Surgically Remove Pathology

Sometimes it is necessary when there is risk of harm to the patient’s health or tissue, or to relieve suffering, to suppress pathology. Conventional medical doctors are especially trained in this art and have powerful and effective tools with which to do this. Unfortunately, suppression, because it does not fundamentally remove or address essential causative factors (such as dietary error) often results in the development of other, often deeper disturbance or pathology. Because much pathologic expression is the result of the actual self-healing mechanisms (e.g., inflammation), suppressive measures, in general, work in opposition to the vis medicatrix naturae. The result of suppression is that the fundamental disturbing factors are still at play within the person, still disrupting function to some extent, whereas the suppression reduces the symptomatic expression and resolution of disturbance. Evidence-based surgical interventions can cure specific pathologies; though it can also exacerbate current and create new pathological conditions.

Naturopathic Medicine Research

The NMRA brought together thought leaders in naturopathic and biomedical research and developed a roadmap for research in naturopathic medicine, which included a research strategy to address three fundamental questions surrounding naturopathic medical practice: (1) safety and efficacy; (2) cost-benefits and access to care; and (3) the rigorous study of the biology of healing related to naturopathic practices and principles.¹ The NMRA research strategy recommended research on the components of naturopathic medical theory and practice, observational outcomes research, and whole systems research.²

Over the last decade, targeted studies were conducted, in alignment with the NMRA recommendations, to assess naturopathic approaches to address conditions, including cardio-metabolic disorders.^36-43 geriatrics,^44-52 cancer,^53-69 mind-body medicine,^70-73 pain conditions,^74-76 and whole systems research.^77-80

Standards for Research in Naturopathic Medicine

There is broad agreement about the philosophies, principles, and theories of naturopathic medicine.^5-9,35,81 To-date, the Principles of Naturopathic Medicine and Therapeutic Order constructs presented in presentations, publications, and book chapters⁸¹,⁸² have not yet been rigorously evaluated and codified into a validated, evidence-informed theory.³⁴

There is a need to systematize the application and reporting of naturopathic philosophy, practice theory, and principles.² Robust methodological and reporting guidelines that outline the use of the Principles of Naturopathic Medicine and the Therapeutic Order within rigorous study design (explicitly or tacitly) are critical to the generation of structured and reproducible results. The validation of Naturopathic Medical Theory will result in a body of literature in naturopathic medicine predicated on the application of the six Principles of Naturopathic Medicine and the use of the Therapeutic Order in the provision of clinical care.

The authors recommend the “Therapeutic Order, Whole-systems, Evidence-based Research Standards” (TOWERS) project as an international initiative, with the primary objective to undertake a rigorous evaluation of the Principles of Naturopathic Medicine and the Therapeutic Order constructs. The first step in achieving this objective will be to develop reporting guidelines for whole-systems research in naturopathic medicine which make explicit and evaluate the outcomes of naturopathic clinical decision making. The first product of this project will be the development of the TOWERS Statement, a codification of standards for a systematic approach to naturopathic medical research-one that is robust, transparent, accurate, of the highest quality.

Inherent in the birth of scientific theory is the derivation of empirically derived constructs, development of hypotheses, testing of these hypotheses, and the resultant development of an evidence-based theory. Throughout the development of the naturopathic medical profession, robust theoretical constructs describing the tenets of naturopathic medicine were developed collaboratively, independently and in parallel. These constructs were both influenced by the practices of experienced naturopathic physicians and by contemporary and historical traditional health practices from around the world. It is noteworthy that multiple contributors to the philosophy and principles of naturopathic medical practice independently and similarly arrived at conclusions of the importance of the constructs that eventually formed the Principles of Naturopathic Medicine and the Therapeutic Order. The next step in the evolution of these constructs is rigorous evaluation via the TOWERS Statement and the refinement into a validated Naturopathic Medical Theory.