I sometimes refer to my 1983-1993 years with the re-emergence of the naturopathic profession – amidst the broader social-medical movement that birthed integrative health – as my boot-camp. Given the decade duration of the commitment, it was more of an extended Marine Corps stint. The work was hard, ground won celebrated, compensation scarce, friendships fierce, and mission central.
The pole star was the naturopathic profession’s commitment to “treat disease by restoring health.” The constellations that guided the voyage were a set of principles and something educators Jared Zeff, ND and Pamela Snider, ND would articulate as the “naturopathic therapeutic order.” So when the Association of Accredited Naturopathic Medical Colleges (AANMC) recently posted an updated version of the profession’s therapeutic order, I thought it a good time to re-visit the engine room of that field’s transformational work.
The idea of such an order is attached to regular medicine. All healthcare professions pay homage to primum non nocere (above all do no harm) – if sometimes seemingly only lip-service. The principle suggests that if there is a less invasive method, then using such a method first would be best.
Yet a biomedical practitioner without the array of natural therapeutics and mind-body practices used by naturopathic doctors and other integrative health practitioners is poorly prepare to climb the ladder of the order. He or she has little but watchful waiting and an 18-second stop-smoking and eat your vegetables pitched on the less-invasive “low-force” end of the therapeutic spectrum. Thus the biomedical therapeutic order tends to leap-frog from passive monitoring to prescription of pharmaceutical drugs. This phase is characterized in the naturopathic order as “synthetic symptom relief”. From there, the conventional practitioner zips on up the therapeutic ladder into suppression of pathology via “high-force interventions.”
For most clinical practice in the dominant school of medicine, at least 4 realms in the naturopathic order simply don’t exist. They are as pre-Colombian, undiscovered continents of therapeutic activity. Additionally, the ground levels in the naturopathic order, with their focus on social and behavioral determinants – while gaining more attention recently – are also typically relegated to public health by clinicians. They still figure little into conventional clinical practice.
In the last two decades, multiple forces have been driving biomedical practice toward discovering and exploring these missing steps in the therapeutic order:
- The move to value-based medicine with its team-oriented “patient-centered medical home” concept includes services of nutritionists, behavioral medicine practitioners, health coaches and others.
- The popular movement for more whole person approaches that stimulated the uptake of integrative practices and practitioners.
- The internet’s powerful boost to self-care.
- Most specific relative to the therapeutic order is the crisis in chronic pain management. Morbidity and mortality tied to opioids are elevating the importance of non-pharmacologic approaches, explicitly pointing to the adverse consequences of mere symptom relied, and promoting less invasive “lower force” means to diminish negative consequences of pharma such as are advocated in the naturopathic order.
Evidence of medical industry short-comings promoted the exploration of substantive changes that are pushing these new tiers of therapeutic possibility into biomedical practice. A different sort of evidence provoked the “update” from the AANMC on the therapeutic order. The new graphic and text changes — which were approved by Zeff and Snider – was provoked by the social media connectivity of AANMC’s target online audience: prospective students. I asked AANMC executive director JoAnn Yanez, ND, MPH about the update. She sent this electronic note:
“We decided to refresh the Therapeutic Order graphic this year. Since initially posting it from an adaption of work by Drs. Snider and Zeff, numerous NDs and clinics have requested its use in their practices and have shared it on social media. As such, we felt streamlining the text a bit and brightening the colors would translate better in these instances. We hope the community finds it useful and that this image helps spread the word about how naturopathic doctors work with patients to facilitate the healing process.”
Thus the AANMC update supports the AANMC’s core work in serving its member colleges reach their potential customers. The AANMC posting describes six prior iterations of the therapeutic order in various writings of Zeff, Snider and other co-authors. Most recent was a publication in Integrative Medicine: A Clinician’s Journal.
The distinguishing influence of the healing power of nature
Notably, those curious enough to click through to the AANMC’s Aug 6, 2019 page on the therapeutic order will immediately encounter text that, while not embedded in the graphic, further differentiates the naturopathic therapeutic order from a biomedical model that is learning to graft on a new step or two. This is the lens of what the naturopathic doctors declare for first in their six principles: the healing power of nature (vis medicatrix naturae).
I was first struck by this distinguishing feature of naturopathic practice when, through a series of interview for an unpublished book project in the mid-1990s, I sought to understand how the holism of a bio-psycho-social-enviro model in conventional primary care was, in practice, so different than the whole system of naturopathic medicine that embraced those same elements.
The AANMC’s updated text on the therapeutic order reads:
“One of the basic assumptions in science is that nature is organized, ordered and inherently has recognizable regularity. Since naturopathic therapies respect nature and all it has to offer patient healing, it follows that this same regularity and order should be reflected in the way naturopathic principles are applied. The therapeutic order is based on the idea that the human form possesses an inherent drive to heal itself.”
This respect for nature in the naturopathic profession – expressed as the charge to remove the obstacles to cure and aid and abet the healing power of nature – thoroughly animates the application of their therapeutic order’s seemingly more linear decision tree.
The AANMC’s re-tweaked introduction to the therapeutic order ends with a restatement of the field’s core proposition – a proposition that will be increasingly meaningful to a medical industry that is learning to distinguish between managing disease and salutogenesis: “Central to the therapeutic order is that the order is not rigid, it is adapted to each patient, yet follows this pattern overall, most efficiently to ‘treat disease by restoring health.’” The merits of this approach to the therapeutic order resonate deeply for a human kind seeking to right its relationship to nature.
