A BRIEF HISTORY OF NATUROPATHIC MEDICINE
In 1900 Benedict Lust “invented” naturopathy, a practice that combined many
natural therapies and therapeutic systems under the umbrella of a comprehensive
philosophy based upon the European nature cure movement that ourished in the
1800s, the vis medicatrix naturae (healing power of nature) and other vitalistic
principles. As such, naturopathic medicine has deep historical roots and represents
a lineage of Western natural medicine that can be traced back to the Roman, Greek,
Egyptian, and Mesopotamian cultures, and conceptually, to many traditional and
indigenous world medicines.
e modern naturopathic profession originated with Lust, and it grew under his
tireless eorts. He crisscrossed the United States lecturing and lobbying for legisla-
tion to license naturopathy, testifying for naturopaths indicted for practicing med-
icine without a license, and traveling to many events and conferences to help build
the profession. He also wrote extensively to foster and popularize the profession,
and through his eorts, the naturopathic profession grew rapidly.1-3 By the 1940s,
naturopathic medicine had developed a number of 4-year medical schools and had
achieved licensure in about one third of the United States, the District of Colum-
bia, four Canadian provinces, and a number of other countries.2,4
e profession went through a period of decline, marked with internal disunity
and paralleled by the rise of biomedicine and the promise of wonder drugs. By
1957, there was only one naturopathic college left. By 1975, only eight states still
licensed naturopathic physicians, and by 1979, there were only six. A survey con-
ducted in 1980 revealed that there were only about 175 naturopathic practitioners
still licensed and practicing in the United States and Canada.5 In contrast, in 1951,
the number was approximately 3000.6
e decline of naturopathic medicine after a rapid rise was due to several factors.
By the 1930s, a signicant tension developed within the profession regarding natu-
ropathic practice, as did the development of unied standards and the role of exper-
imental, reductionist science as an element of professional development.7,8 is
tension split the profession of naturopathic physicians from within after the death
of Lust in the late 1940s, at a time when the profession was subject to both signi-
cant external forces and internal leadership challenges. Many naturopathic doctors
questioned the capacity for the reductionist scientic paradigm to research naturo-
pathic medicine objectively in its full scope.7,9,10
is perception created mistrust of science and research. Science was also fre-
quently used as a bludgeon against naturopathic medicine, and the biases inherent in
what became the dominant paradigm of scientic reductionism made a culture of
scientic progress in the profession challenging. e discovery of eective antibiotics
elevated the standard medical profession to dominant and unquestioned stature by a
culture that turned to mechanistic science as an unquestioned authority. e dawn-
ing of the atomic age reinforced a fundamental place for science in a society increas-
ingly dominated by scientic discovery. In this culture, standard medicine, with its
growing political and economic strength, was able to force the near elimination of
naturopathic medicine through the repeal or “sunsetting” of licensure acts.1,2,11
In 1956, as the last doctor of naturopathy (ND) program ended (at the Western
States College of Chiropractic), several doctors, including Drs. Charles Stone,
W. Martin Bleything, and Frank Spaulding, created the National College of Natu-
ropathic Medicine in Portland, OR, to keep the profession alive. However, that
school was nearly invisible as the last vestige of a dying profession and rarely
CHAPTER 3 A Hierarchy of Healing: The Therapeutic Order
A Unifying Theory of Naturopathic Medicine
Jared L. Zeff, ND, LAc, Pamela Snider, ND, Stephen P. Myers, ND, BMed PhD,
and Zora DeGrandpre, MS, ND
A Brief History of Naturopathic Medicine, 18
Original Philosophy and Theory, 19
Modern Naturopathic Clinical Theory: The Process of
A Theory of Naturopathic Medicine, 22
Illness and Healing as Process, 22
The Naturopathic Model in Acute Illness, 23
The Naturopathic Model in Chronic Illness, 24
The Determinants of Health, 25
Therapeutic Order, 25
Acute and Chronic Concerns, 26
Establish the Conditions for Health, 26
Stimulate the Self-Healing Mechanisms, 27
Support Weakened or Damaged Systems or Organs, 28
Address Structural Integrity, 28
Address Pathology: Use Speciﬁc Natural Substances,
Modalities, or Interventions, 28
Address Pathology: Use Speciﬁc Pharmacologic
or Synthetic Substances, 29
Suppress Pathology, 29
Theory in Naturopathic Medicine, 29
A Hierarchy of Healing: The Therapeutic Order
attracted as many as 10 new students a year. e profession was
considered dead by its historic adversaries.
e culture of America, dominated by standard medicine since
the 1940s, however, began to change by the late 1960s. e prom-
ise of science and antibiotics was beginning to seem less than per-
fect. Chronic disease was increasing in prevalence as acute infection
was less predominant, and standard medicine had no “penicillin”
for chronic diseases. In the late 1970s, scholars in family medicine
proposed a biopsychosocial model of care in response to a prevailing
perception of a growing crisis in standard medicine.12 e publica-
tion of Engel’s “e Need for a New Medical Model” in April 1977
signaled the founding of the eld of family medicine based on a
holistic philosophy and paralleled a broader social movement in
support of alternative health practices and environmental aware-
ness. Elements of the culture were rebelling against plastics and
cheap synthetics, seeking more natural solutions. e publication
of Rachael Carson’s Silent Spring in 1962, an indictment of chemi-
cal pesticides and environmental damage, marked a turning point
in cultural thinking. In Silent Spring, Carson challenged the prac-
tices of agricultural scientists and the government and called for a
change in the way humankind viewed the natural world.13 New
evidence of the dangers of radiation, synthetic pesticides, and her-
bicides, as well as environmental degradation from industrial pollu-
tion, were creating a new ethic. Organic farming, natural bers, and
other similar possibilities were starting to capture attention. A few
began seeking natural alternatives in medicine. By the late 1960s
and early 1970s, enrollments at the National College of Naturo-
pathic Medicine began to reach into the 20s. e 1974 class num-
bered 23 students. In 1975, the National College enrolled a class of
63 students.14 e profession was experiencing a resurgence.
In 1978, with a desire to create a college based on science-based
natural medicine, Joseph E. Pizzorno, ND, LM, and his colleagues,
Les Grith, ND, LM; Bill Mitchell, ND; and Sheila Quinn cre-
ated the John Bastyr College of Naturopathic Medicine in Seattle,
WA. With the creation of Bastyr, named after the eminent naturo-
pathic physician, Dr. John Bartholomew Bastyr (1912–1995), the
profession entered a new phase. Not only did this new college dou-
ble the profession’s capacity to produce new doctors, it also rmly
placed the profession on the ground of scientic research and vali-
dation. “Science-based natural medicine,” coined by Dr. Pizzorno,
was a major driving force behind the creation and mission of Bastyr.
Both Drs. Bastyr and Pizzorno had signicant inuence and leader-
ship in achieving this focus.
One of Dr. Bastyr’s important legacies was to establish a foun-
dation and a model for reconciling the perceived conict between
science and the deeply established healing practices and principles
of naturopathic medicine. Kirchfeld and Boyle3 described his
landmark contribution as follows:
“Although naturopathic colleges in the early 1900s did include
basic sciences training, it was not until Dr. John Bastyr (1912-
1995) and his rm, ecient and professional leadership that
science and research-based training in natural medicine was
inspired to reach its fullest potential. Dr. Bastyr, whose vision was
one of ‘naturopathy’s empirical successes documented and proven
by scientic methods,’ was himself the prototype of the modern
naturopathic doctor, who culls the latest ndings from the scien-
tic literature, applies them in ways consistent with naturopathic
principles and veries the results with appropriate studies.”
Bastyr also saw a tremendous expansion in both allopathic and
naturopathic medical knowledge, and he played a major role in
making sure the best of both were integrated into naturopathic
Bastyr met Lust on two occasions and was closely tied to the
nature cure tradition of Kneipp through two inuential women:
his mother and his mentor, Dr. Elizabeth Peters, who studied
with Father Kneipp. He eortlessly integrated the clinical the-
ories and practices of naturopathy with the latest scientic studies
and helped create a new and truly original form of modern pri-
mary clinical care within naturopathic medicine. He spent the
twentieth century preparing the nature cure of the nineteenth
century for entry into the twenty-rst century.1,15 Today’s philo-
sophical debates within the profession are no longer about sci-
ence. ey tend to center on challenges to the Nature Cure
tradition. A current debate, for instance, is about the role of
“green allopathy” within the profession: the tendency to use
botanical medicine or nutritional supplements as a simple “green
drug” or pharmaceutical replacement versus the importance of
implementing the full range of healing practices derived from
Nature Cure to stimulate health restoration alongside, or instead
of, botanical medicine or nutritional supplements. Professional
consensus appears strong that the full range of naturopathic heal-
ing practices must be retained, strengthened, and engaged in the
process of education and scientic research and discovery in the
ORIGINAL PHILOSOPHY AND THEORY
rough the initial 50-year period of professional growth and
development (1896–1945), naturopathic medicine had no clear
and concise statement of identity. e profession was whatever
Lust said it was. He dened “naturopathy” or “nature cure” as both
a way of life and a concept of healing that used various natural
means of treating human inrmities and disease states. e “nat-
ural means” were integrated into naturopathic medicine by Lust
and others based on the emerging naturopathic theory of healing
and disease etiology. e earliest therapies associated with the
term involved a combination of American hygienics and Austro-
Germanic nature cure and hydrotherapy. Leaders in this eld in-
cluded Kuhne, Lindlahr, Trall, Kellogg, Holbrook, Tilden,
Graham, McFadden, Rikli, omson, and others who wrote foun-
dational naturopathic medical treatises or developed naturopathic
clinical theory, philosophy, and texts to enhance, agree with, and
diverge from Lust’s original work.19-27
e bulk of professional theory was found in Lust’s magazines,
Herald of Health and e Naturopath. ese publications displayed
the prodigious writings of Lust, but did not contain a comprehen-
sive and denitive statement of either philosophy or clinical
theory. Lust often stated that all natural therapies fell under the
purview of naturopathy. Several texts were considered as some-
what denitive by various aspects of the profession at dierent
times. ese texts included the seven-volume Natural erapeutics
by Henry Lindlahr, MD, which was published in the early 1900s.
Lindlahr’s Nature Cure (1913) was considered a seminal work in
naturopathic theory, laying the groundwork for a systematic ap-
proach to naturopathic treatment and diagnosis. Lindlahr ulti-
mately presented the most coherent naturopathic theory extant,
summarized in his Catechism of Naturopathy, which presented a
ve-part therapeutic progression:
1. “Return to Nature”—attend to the basics of diet, dress, exer-
cise, rest, etc.
2. Elementary remedies—water, air, light, electricity
3. Chemical remedies—botanicals, homeopathy, etc.
4. Mechanical remedies—manipulations, massage, etc.
5. Mental/spiritual remedies—prayer, positive thinking, doing
good works, etc.28
20 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
In the 1950s Spitler wrote Basic Naturopathy, a Textbook,9 and
Wendel wrote Standardized Naturopathy.10 ese texts presented
somewhat dierent approaches; Spitler’s text emphasized theory
and philosophy, whereas Wendel’s text was written, as evidenced
by the title, to emphasize the standard naturopathic practices of
the day, with an eye toward regulatory practice. In contrast,
Kuts-Cheraux’s Naturopathic Materia Medica, written in the
1950s, was produced to satisfy a statutory demand by the Ari-
zona legislature, but persisted as one of the few extant guides of
that era. Practitioners relied on a number of earlier texts, many of
which arose from the German hydrotherapy practitioners29-34
or the Eclectic school of medicine (a renement and expansion of
the earlier “omsonian” system of medicine)35-39 and predated
the formal American naturopathic profession (1900). However,
by the late 1950s, publications diminished. e profession was
generally considered on its last gasp, an anachronism of the pre-
During the process of winning licensure, naturopathic medicine
was dened formally by the various licensure statutes, but these
denitions were legal and scope-of-practice denitions, often in
conict with each other, reecting dierent standards of practice
in dierent jurisdictions. In 1965, the U.S. Department of Labor’s
Dictionary of Occupational Titles40 presented the most formal and
widespread denition. e denition was not without contro-
versy. as it reected one of the internally competing views of the
profession, primarily, the nature cure perspective:
“Diagnoses, treats and cares for patients using a system of practice
that bases treatment of physiological function and abnormal con-
ditions on natural laws governing the human body. Utilizes
physiological, psychological and mechanical methods such as air,
water, light, heat, earth, phytotherapy, food and herbs therapy,
psychotherapy, electrotherapy, physiotherapy, minor and oricial
therapy, mechanotherapy, naturopathic corrections and manipu-
lations, and natural methods or modalities together with natural
medicines, natural processed food and herbs and natural rem-
edies. Excludes major surgery, therapeutic use of x-ray and
radium, and the use of drugs, except those assimilable substances
containing elements or compounds which are components of body
tissues and physiologically compatible to body processes for the
maintenance of life.”40
is denition did not list drugs or surgery within the scope of
modalities available to the profession. It dened the profession by
therapeutic modality and was more limited than most of the stat-
utes under which naturopathic physicians practiced,41 even in
1975, when there were only eight licensing authorities still active.
MODERN NATUROPATHIC CLINICAL THEORY:
THE PROCESS OF DEVELOPMENT
“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 under-
standing of health and disease evolve in an orderly and truth-
—Randall Bradley, ND42
After the profession’s decline in the 1950s and 1960s, a rebirth was
experienced, more grounded in medical sciences and fueled by a
young generation with few teachers. e profession’s roots were
neglected out of ignorance, for the most part, along with a youthful
arrogance. By the early 1980s, it was apparent that attempts to
regenerate the progress made by Lust would require the creation of
a unied professional organization and all which that entailed: ac-
creditation for schools, national standards in education and licen-
sure, clinical research, and the articulation of a coherent denition
of the profession for legislative purposes, as well as for its own
internal development. ese accomplishments would be necessary
to be able to demonstrate the uniqueness and validity of the pro-
fession, guide its educational process, and justify its status as a
separate and distinct medical profession.
In 1987, the newly formed (1985) American Association of
Naturopathic Physicians (AANP) began this task under the leader-
ship of James Sensenig, ND (president) and Cathy Rogers, ND
(vice president), appointing a committee to head the creation of a
new denition of naturopathic medicine. e “Select Committee
on the Denition of Naturopathic Medicine” succeeded in a
3-year project that culminated in the unanimous adoption by
AANP’s House of Delegates (HOD) of a comprehensive, consen-
sus denition of naturopathic medicine in 1989 at the annual
convention held at Rippling River, OR.43-45 e unique aspect of
this denition was its basis in denitive principles, rather than
therapeutic modalities, as the dening characteristics of the pro-
fession. In passing this resolution, the HOD also asserted that the
principles would continue to evolve with the progress of knowl-
edge and should be formally reexamined by the profession as
needed, perhaps every 5 years.43-48
In September 1996, the AANP HOD passed a resolution to
review three proposed principles of practice that had been recom-
mended as additions to the AANP denition of naturopathic
medicine originally passed by the HOD in 1989. ese three new
proposed principles were rejected, and the AANP HOD recon-
rmed the 1989 AANP denition unanimously in 2000. e
results of a profession-wide survey conducted from 1996 to 1998
on these three new proposed principles demonstrated that
although there was lively input, the profession agreed strongly that
the original denition was accurate and should remain intact. e
HOD recommended that the discussion be moved to the aca-
demic community involved in clinical theory, research, and prac-
tice for pursuit through scholarly dialogue.49-53 is formed the
basis for further eorts to articulate a clinical theory. AANP mem-
bers stated in 1987–1989 during the denition process: “ese
principles are the skeleton, the core of naturopathic theory. ere
will be more growth from this foundation.”45 By 1997, this growth
in modern clinical theory was evident.
e rst statement of such a theory was published in the
AANP’s Journal of Naturopathic Medicine in 1997 in an article
titled “e Process of Healing, a Unifying eory of Naturo-
pathic Medicine.”54 is article contained three fundamental
concepts that were presented as an organizing theory for the many
therapeutic systems and modalities used within the profession
and were based on the principles articulated in the consensus
AANP denition of naturopathic medicine. e rst of these was
the characterization of disease as a process rather than a patho-
logic entity. e second was the focus on the determinants of
health rather than on pathology. e third was the concept of a
is article also signaled the emergence of a growing dialogue
among physicians, faculty, leaders, and scholars of naturopathic
philosophy concerning theory in naturopathic medicine. e
hope and dialogue sparked by this article was the natural next step
of a profession redening itself both in the light of today’s ad-
vances in health care and with respect to the foundations of phi-
losophy at the traditional heart of naturopathic medicine. is
dialogue naturally followed the discussions of the denition
A Hierarchy of Healing: The Therapeutic Order
process and created a vehicle for emerging models and concepts to
be built on the bones of the principles. e essence and inherent
concepts of traditional naturopathic philosophy were carried in
the hearts and minds of a new generation of naturopathic physi-
cians into the twenty-rst century—these modern naturopathic
students and naturopathic physicians began to gather to articu-
late, redene, and reunify the heart of the medicine.
is new dialogue was formally launched in 1996, when the
AANP Convention opened with the plenary session: “Towards a
Unifying eory of Naturopathic Medicine” with four naturo-
pathic physicians presenting facets of emerging modern naturo-
pathic theory. e session closed with an open microphone. e
impassioned and powerful comments of the naturopathic profes-
sion throughout the United States and Canada engaged in the vital
process of deepening and clarifying its unifying theory. Dr. Ze
presented “e Process of Healing: e Hierarchy of erapeutics”;
Dr. Mitchell presented “e Physics of Adjacency, Intention, Natu-
ropathic Medicine, and Gaia”; Dr. Sensenig presented “Back to the
Future: Reintroducing Vitalism as a New Paradigm”; and Dr. Snider
announced the Integration Project, inviting the profession to engage
in it by “sharing a beautiful and inspiring anguish—the labor pains
of naturopathic theory in the twenty-rst century. We know what
we have done, and we know there is much more…e foundation
is laid. We are ready now for development and integration.”55
Days later, in September 1996, the Consortium of Naturo-
pathic Medical Colleges (now the American Association of Natu-
ropathic Medical Colleges [AANMC]) formally adopted and
launched the Integration Project, an initiative to integrate naturo-
pathic theory and philosophy throughout all divisions of all natu-
ropathic college curricula, from basic sciences to clinical training.
A key element of the project engaged the further development and
renement of naturopathic theory. e project was co-chaired by
Drs. Snider and Ze from 1996 to 2003. Steering members from
all North American naturopathic colleges participated and con-
tributed.45 Methods included professional and scholarly research,
expert teams, symposiums, and training. e result was the fos-
tering of systematic inquiry among academicians, clinicians, and
researchers concerning the underlying theory of naturopathic
medicine, bringing the fruits of this work and inquiry into the
classroom and into scientic discussion.56
e Integration Project sustained both formal and informal di-
alogue since its inception in 1996, which continues today. e
work has engaged faculty and scholars of naturopathic philosophy
in the United States, Canada, and Australia. It has also engaged
institutional leaders and practicing doctors and faculty in all areas
of the profession. Why? Naturopathic philosophy is deeply felt as
the “commons” of naturopathic medicine: a place where the pro-
fession meets—one that is owned by all naturopathic physicians—
that reects, holds, and deepens the heart of naturopathic
medicine. Naturopathic philosophy is the foundation and heart of
naturopathic medicine. It remains valid by evolving with the pro-
gress of knowledge, the progress of science, and the progress of the
human spirit. It is for this reason medicine is seen as an art as well
as a science. Because naturopathic philosophy engages the intui-
tively felt mission of nature doctors, it is vital that the profession
periodically gathers to renew and revitalize progress regarding its
e Integration Project sparked a wide range of activities in all
six ND colleges, resulting in all-college retreats to share tools,
retreats for training of non-ND faculty in naturopathic philosophy,
integration of a basic sciences curriculum, expert teams revision of
core competencies across departments ranging from nutrition to
case management and counseling, development of clinical tools
and seminars for clinic faculty, creation of new courses, and the
integration of important research questions derived from naturo-
pathic philosophy into research studies and initiatives.57 e latest
eort is the Foundations of Naturopathic Medicine Project (text-
book and symposia series, www.foundationsproject.com) and its
development and presentation of the educational module on
Emunctorology, an essentially naturopathic science, during 2009
and 2010. is is a joint eort of faculty from several of our
schools, led by Drs. om Kruzel and Stephen Myers.
North American core competencies for naturopathic philos-
ophy and clinical theory were developed by faculty representing
all accredited ND colleges in a landmark AANMC retreat in
2000. e AANMC’s Dean’s Council formally adopted these
competencies in 2000 and recommended that they be integrated
throughout curricula in all ND colleges. ese national core com-
petencies included the process of healing theory, Lindlahr’s model,
and the hierarchy of therapeutics (the therapeutic order).58,59
Finally, many meetings with scholars and teachers of naturo-
pathic theory and other faculty and leaders—formal and infor-
mal—resulted in the further development and renement of the
hierarchy of therapeutics developed by Dr. Ze in 1997.
Drs. Snider and Ze and naturopathic theory faculty worked
closely with other naturopathic faculty from AANMC colleges in a
series of revisions. Drs. Snider and Ze collaborated in 1998 to
develop the hierarchy of therapeutics into the therapeutic order.
e therapeutic order was subsequently explored and rened
through a series of faculty retreats and meetings, as well as through
experience with students and through student feedback. A key
nding of the clinical faculty at Bastyr University was the emphasis
on the principle “holism: treat the whole person” and respect for the
patient’s own unique healing order and his or her values as a context
for applying the therapeutic order to clinical decision making.60
e therapeutic order, or hierarchy of healing, is now incorporated
into ND college curricula throughout the United States, Canada,
Australia, and New Zealand. For example, an important interna-
tional outgrowth of the profession’s development of theory is the
adoption of the unied “Working Denition of Naturopathic Nutri-
tion” in June 2003 by the Australian naturopathic profession
(Box 3-1). e 3-year project, fostered by Dr. Stephen Myers,
brought together nutrition faculty from naturopathic medicine col-
leges throughout Australia. e project was co-hosted by the Natu-
ropathy and Nutrition panel, an independent group of naturopaths
and nutrition educators whose mission is to foster and support the
development of the science, teaching, and practice of naturopathic
nutrition, and the School of Natural and Complementary Medi-
cine at Southern Cross University. e denition evolved over two
retreats attended by more than 40 faculty members involved in
teaching nutrition as part of a naturopathic medicine education. It
commenced as a general agreement within the group that there was
a real and distinct dierence between conventional nutritional con-
cepts and naturopathic nutritional theory. General agreement was
that the distinction between the two had to date been poorly
dened and had been the source of dissonance between the naturo-
pathic and science faculty within the colleges. e obvious next step
was to dene that dierence to ensure that nutrition curriculum
within naturopathic medicine colleges reected the core elements
of naturopathic nutrition. At the second retreat held in June 2003,
the working denition was adopted with a recommendation that it
be widely circulated within the naturopathic medicine profession to
commence a dialogue aimed at both appropriate revision and broad
adoption. is process created a much-needed consensus denition
on naturopathic nutrition. is denition is based on the AANP
dening principles and incorporates the therapeutic order theory.
22 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
A THEORY OF NATUROPATHIC MEDICINE
Standard medicine, or biomedicine, has a simple and elegant
paradigm. Simply stated, it is “the diagnosis and treatment of
disease.” In practice, this statement contains several assump-
tions. One assumption is that illness can be understood in terms
of discrete diseases (i.e., human illnesses can be divided into
identiable entities, such as measles or specic forms of cancer,
etc.). e next assumption is that “cure” is the elimination of
the disease entity. e third assumption is that this is accom-
plished by the evidence-based application of pharmaceuticals,
surgeries, or similar treatments to eliminate, palliate, or sup-
press the entity and its symptomatic expressions. ese are so
obvious that they are not commonly considered. ey form the
background thinking in medical decision making: identify and
treat the disease.
e elegance of this model, and the science behind it, has taken
medicine to its highest point in history as a reliable vehicle to ease
human illness, and its application has saved countless lives. e
understanding of the physician, at least about the nature of
pathology, has never been as complete. However, illness has a
near-innite capacity to bae the physician. New diseases arise,
such as human immunodeciency virus/acquired immune de-
ciency syndrome, and shifts occur in disease focus, such as the
shift between 1900 and 2000 from acute infection to chronic ill-
ness as the predominant cause of death.61
Beyond these obvious changes, even with the current depth of
understanding, the standard medical world often lacks the ability
to eectively understand and cure chronic disease, and treatment
tends to become a task of the management of symptoms and the
attempt to reduce long-term damage and other consequences,
rather than actual cure of the illness. So, even representing an apex
of human achievement as it does, modern medicine is not without
its weaknesses. Its greatest weakness is probably this inability to
cure chronic illness as easily as it once cured pneumonia with pen-
icillin or tuberculosis with streptomycin. Compounding the prob-
lem is the growing prevalence of antibiotic-resistant infections.62,63
Part of the reason for the failures within modern medical science is
its mechanistic basis. Breaking the body down to its constituent
parts has led to a fundamental ignorance of and disrespect for the
wholeness of the individual, the natural laws of physiology govern-
ing health and healing, and particularly for all things spiritual (the
transpersonal domains). Inherent in the dictum—diagnose and
treat the disease—is the general neglect of the larger understanding
that disease is a process conducted by and within an intelligent
organism that is constantly attempting to heal itself, with disease
manifestations often expressions of this self-healing endeavor. As
noted by Pizzorno etal,64 this intelligent organism strives for opti-
mal function and health. Human beings “…are natural organisms,
our genomes developed and expressed in the natural world. e
patterns and processes inherent in nature are inherent in us. We
exist as a part of complex patterns of matter, energy, and spirit.
Nature doctors have observed the natural processes of these pat-
terns in health and disease and determined that there is an in-
herent drive toward health that lives within the patterns and
processes of nature.”
e uniqueness of naturopathic medicine is not in its therapeutic
modalities or the “natural” alternatives to the drugs and surgeries of
standard medicine. It is in the clinical theory that governs the selec-
tion and application of these modalities, captured in the unifying
denition adopted in 1989 and expressed more specically in the
continuing articulation of clinical theory. at is, it is the way the
naturopathic physician thinks about illness and healing.
e rst element of this theory is based upon the rst dening
principle: vis medicatrix naturae. It is based on the understanding
that disease can be seen as a process, as well as an entity. One can
analyze the process of illness and derive some understanding. How-
ever, to do this, one needs to examine the assumptions underlying
this concept. e governing assumptions of standard medicine are
principally that diseases are entities, and that drugs and surgery can
eliminate these entities from the suering person. ese are not the
governing assumptions of naturopathic medicine.
ILLNESS AND HEALING AS PROCESS
Naturopathic medicine can be characterized by a dierent model
than “identify and treat the disease.” “e restoration of health”
would be a better characterization. Naturopathic physicians
adopted the following elegantly brief denition of naturopathic
Naturopathic medicine is a distinct system of primary health care—an
art, science, philosophy and practice of diagnosis, as well as treatment
and prevention of illness. Naturopathic medicine is distinguished by the
principles that underlie and determine its practice. These principles
include the healing power of nature (vis medicatrix naturae), identiﬁcation
and treatment of the causes (tolle causam), the promise to ﬁrst do no
harm (primum non nocere), doctor as teacher (docere), treatment of the
whole person, and emphasis on prevention. These principles give rise to a
practice that emphasizes the individual and empowers him or her to
greater responsibility in personal health care and maintenance.
Naturopathic nutrition is the practice of nutrition in the context of naturo-
Naturopathic nutrition integrates both scientiﬁc nutrition and the prin-
ciples of naturopathic medicine into a distinct approach to nutritional
Core components of naturopathic nutrition are:
• A respect for the traditional and empirical naturopathic approach to
• The value of food as medicine
• An understanding that whole foods are greater than the sum of their
parts and recognition that they have vitality (properties beyond physio-
• Individuals have unique interactions with their nutritional environments
In the context of the deﬁnition, and with respect to the therapeutic order,
the practice of naturopathic nutrition may include the appropriate use of
• Behavioral and lifestyle counseling
• Diet therapy (including health maintenance, therapeutic diets, and di-
• Food selection, preparation, and medicinal cooking
• Therapeutic application of foods with speciﬁc functions
• Traditional approaches to detoxiﬁcation
• Therapeutic fasting strategies
• Nutritional supplementation
BOX 3-1 Working Deﬁnition of Naturopathic Nutrition
Data from Snider P, Payne S. Making naturopathic curriculum more naturopathic:
agendas, minutes, 1999-2001. Clinic faculty task force on integration. Faculty
development retreat, Bastyr University, 1999.
A Hierarchy of Healing: The Therapeutic Order
medicine in 1989 in an AANP position paper: “Naturopathic
physicians treat disease by restoring health.”44 Immediately a
signicant dierence is made clear: standard medicine is disease
based; naturopathic medicine is health based. Although naturo-
pathic medical students study pathology with the same intensity
and depth as standard medical students, as well as its concomi-
tant diagnoses, the naturopathic medical student learns to apply
that information in a dierent context. In standard medicine,
pathology and diagnosis are the basis for the discernment of the
disease “entity” that aicts the patient, the rst of the two steps
of identifying and destroying the entity of aiction. In naturo-
pathic medicine, however, disease is seen much more as a process
than as an entity. Rather than viewing the ill patient as experi-
encing a “disease,” the naturopathic physician views the ill per-
son as functioning within a process of disturbance and recovery,
in the context of nature and natural systems. Various factors dis-
turb normal health. If the physician can identify these distur-
bances and moderate them (or at least some of them), the illness
and its eects abate, at least to some extent, if not totally. As
disturbances are removed, the body can improve in function,
and in doing so, health naturally improves. e natural tendency
of the body is to maintain itself in as normal a state of health as
is possible—this is the basis of homeostatic principles.65 e role
of the physician facilitates this self-healing process.
e obvious rst task of the naturopathic physician, there-
fore, is to determine what is disturbing the health so that these
causative elements may be ameliorated. Disease is the process
whereby the intelligent body reacts to disturbing elements. It
employs such processes as inammation and fever to help
restore its health. In general, one can graph this process simply,
as in Figure 3-1.
The Naturopathic Model in Acute Illness
One can see “illness-as-process” most easily in the common cold.
Within standard medical understanding, the common cold is
caused by a virus, from among a family of pathologic viruses,
which can infect a person. e immune system responds, devel-
oping appropriate antibodies, which eventually neutralize the
virus. ere is no “cure” yet discovered, except time. Medications
are used to ameliorate the symptomatic experience: aspirin or
acetaminophen for fever, antihistamines to dry the mucus dis-
charge, etc. ese measures are not cures; they reduce the symp-
tomatic expression of the “cold” but often lengthen the process. In
naturopathic medicine, the cold is seen not as a disease entity, but
as part of a fundamental process whereby the body restores itself
If the virus were the sole cause of the common cold, then every-
one who came into contact with sucient dose of the virus would
get the cold. Obviously, this does not happen. Susceptibility fac-
tors include immune competence, fatigue, vitality, genetics, and
other host factors.66 e virus enters a milieu in which all these
factors aect the process. Once the virus enters the system, and if
it overcomes resistance factors (Box 3-2), one begins to see distur-
bance of function, as illustrated in Figure 3-1. One does not feel
quite right. One may begin to get a sore throat, the rst inamma-
tory reaction, occurring at the point of entry of the virus into the
body. e immune factors described may overcome the virus at
this point, may be insucient, or may be suppressed. All of this is
mutable to some extent and is aected by host factors, such as
nutritional status and fatigue, and can be inuenced by taking
immune tonics, vitamin C, and other supplements.
To the individual with the condition, the “cold” may proceed
into a general state of fatigue and inammation, possibly fever
followed by mucus discharge, cough, and other symptoms, as the
body processes and responds to the virus and its eects; eventually
the body overcomes it and eliminates the results.
In the naturopathic model, the virus is not understood so much
to be a separate disease entity, but a general and fundamental
process of disturbance and recovery within the living body. It is a
method whereby the body restores itself after a sucient amount
of disturbance accumulates within the system. is is why the cold
has no “cure.” It is the cure for what ails the body. In the naturo-
pathic model of health, it is the support of this “adaptive
response”—the restoration of balance that is the central point—
through which the process is the “cure” (Box 3-3).
The Process of Healing
(inflammation, fever, etc.)
(ulceration, atrophy, scar, paralysis, tumor, etc.)
FIGURE 3-1 The process of healing (used by permission Jared L. Zeff, ND).
Once inside the body, the rhinovirus binds to cellular receptors (primarily
the intercellular adhesion molecule-1 [ICAM-1]) or to the low-density lipo-
protein (LDL) receptor. The viral particles are then internalized and begin to
take over the cellular machinery to produce intact virions.66,67 At this stage,
the body can sometimes mount an adequate defense via cell-mediated
immunity to overcome the viral incursion. If we have been previously
exposed to the virus, the body’s humoral immune response will rapidly pro-
duce antibodies to the viral protein, which can also lead to eradication of
the microbe. These two immune responses explain why some individuals
may develop the full condition, whereas others will shake off the exposure
within a few hours. If the viral load overcomes the body’s innate defenses,
the virus replicates unabated. In the process of replication, the virus not
only disrupts the cellular mechanisms, but damages them as well by
infecting the surface epithelium, as well as the macrophages68 and ﬁbro-
blasts.69 Naturopathic physicians are interested in the factors that lead to
greater immune competence and health restoration through the process of
healing and the health practices that support it. French physiologist
Claude Bernard (1813–1878) said that the inner terrain or “milieu inter-
ieur” was the cause of disease, and not the microbes; this concept under-
pins the naturopathic approach.
BOX 3-2 Scientiﬁc Considerations: The Immune
Response and Resistance Factors
24 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
The Naturopathic Model in Chronic Illness
Chronic illness arises, in general, when any or all of three factors
1. e disturbing factors persist, such as a chronically improper
diet, which continues to burden the body cumulatively, as the
digestive processes slowly weaken under the stress of the im-
proper or inadequate diet.
2. e reactive potential is blocked or suppressed, usually by
drugs, which interfere with the capacity of the body to process
and remove its disturbances.
3. e vitality of the system is insucient, or has become too
overwhelmed, to mount a signicant and sucient reaction.
As these three factors prevent a sucient reactive purge of dis-
turbances, the body slides into a chronic, weakened reactive state
with possible episodes of intermittent reaction, and is perceived to
be in a persistent chronic illness. Ultimately, as function is su-
ciently disturbed, structures or functions are damaged, and
chronic inammation becomes ulceration or scar tissue forma-
tion. In terms of the allostatic model, the balance has been dis-
rupted, and there is no more adaptive potential. Atrophy, paralysis,
or even tumor formation76–78 may occur. All of this is the body
manifestly doing the best it can for itself in the presence of persis-
tent disturbing factors and with respect to the limitations and
range of vitality inuenced by the constitution, psycho-emotional/
spiritual state, genotype of the person, and his or her surrounding
environment (Boxes 3-4 and 3-5).
Reversal of this overwhelmed condition is rarely accomplished
by medicating the pathologic state. is often results in the con-
trol of symptoms but with the persistence of the illness, while ide-
ally controlling its more dangerous aspects using higher force
interventions such as pharmaceutical drugs and surgical interven-
tion. Reversal is more likely accomplished by identifying and ame-
liorating the disturbance, and as necessary, strengthening or
Environmental and lifestyle disturbances are a profound driver in the
naturopathic model of health. The scientiﬁc evidence is now irrefutable
that the national and global burden of chronic disease is highly dependent
on modiﬁable behavioral factors. In a recent study of the causes of death,
it was found that tobacco, poor diet and lack of physical activity, alcohol
and drug use, toxic agents, and vehicular and ﬁrearm incidents were the
leading actual causes of death.79 Other factors included frank malnutrition
(as opposed to poor nutrition), unsafe sexual practices, and poor sanita-
tion.80,81 It has been deﬁnitively shown, for example, that diet and lifestyle
changes can prevent some forms of diabetes82,83 and other chronic
diseases84,85 that are leading causes of death in the United States.79,82,83
BOX 3-4 Scientiﬁc Considerations: The Role
of Environment in Chronic Illness
Current research shows that future pathologies may be linked to “suppres-
sion” of early rhinovirus infection. These include childhood asthma, adult
asthma, and chronic obstructive pulmonary disease (COPD).70,71 Individ-
uals with asthma are known to have subtle deﬁciencies in production of
type I and type III interferon (IFN),72,73 indicating that for some asthma
patients, early exposure to the rhinovirus predisposes them to asthma, and
that the suppression of the normal response may be critical in the future
development of asthma. With these effects in mind, the naturopathic phy-
sician does not look solely at the virus as a pathogenic entity, but also
seeks to determine how the patient responds to the virus, thereby deter-
mining the most reasonable approach to aiding the patient’s natural re-
sponses and moderating the patient’s long-term health strategies.
Suppression of the body’s natural responses is avoided. The long-term use
of corticosteroids is a prime example of suppression and its conse-
BOX 3-3 Scientiﬁc Considerations: Consequences
of Suppressing the Body’s Response
Regarding the responses of an overwhelmed or chronically disturbed
organism, it has been argued recently that the anemia of chronic disease
is an adaptive biological response rather than a harmful disorder and is
associated with a number of chronic states.86 Citing a number of studies,
it was also argued that it was the treatment of the anemia of chronic
disease among critically ill patients and those with renal failure and can-
cer (e.g., breast cancer and head and neck cancers) that was associated
with the greater mortality. The U.S. Food and Drug Administration issued a
warning against the use of erythropoiesis-stimulating agents in those can-
cer patients not undergoing chemotherapy or radiation therapy.87
States where the normal compensatory mechanisms become over-
whelmed or suppressed (reducing the reactive potential of the body) include
states of chronic oxidative stress88 and inﬂammatory processes.89,90 It is
not, however, solely a matter of an overwhelmed or chronically disturbed
organism that is critical to the process of disease progression. Adaptive
responses are also of vital importance to the development of chronic
disease. Research has shown that these evolutionarily preserved adaptive
mechanisms of physical activity, insulin sensitivity, and fat storage are
essential in the prevention of chronic disease states.84,85 In the develop-
ment of type 2 diabetes, for example, there is increasing evidence that it is
the individual’s maladaptation to lack of physical activity that appears to
lead to decreased insulin sensitivity and increased fat storage, which can
then lead to a plethora of chronic diseases, many characterized by states of
chronic inﬂammation91 and oxidative stress. Continuing basic and clinical
studies indicate that many of the processes currently regarded in main-
stream medicine as harmful have been evolutionarily retained to provide an
adaptive advantage.92,93 The Harvard Health Letter recently published an
article describing inﬂammation as part of the “Unifying Theory of Disease”94
giving support to the argument that inﬂammation is crucial in both health
and disease and that chronic diseases arise when the inﬂammatory process
occurs without appropriate control. The allostatic model also provides a
theoretical basis for naturopathic clinical theory. The allostatic model
describes the process of achieving stability (homeostasis) through changes
in the homeostatic “set points” or control boundaries.95-98 Homeostasis, the
maintenance of stability in biochemical and physiologic processes, is
essential for life—and allostasis, the “re-setting” of the homeostatic “set
points”, is essential for the maintenance of homeostasis. As it develops
through the various iterations of researchers and clinicians, the model em-
phasizes the need to look beyond the current linear-reductionist model of
disease and toward a more wholistic and balanced approach to disease
The adaptive response of the organism to insult or frank structural
damage is a concept that also has support outside naturopathic medicine.
For example, Schnaper etal99 described a conceptual framework for pro-
gressive kidney disease where the initial disease develops through an
injury of some nature that provokes a cellular response as an adaptation
to the original injury. Where this cellular response is effective, no progres-
sive kidney disease may ensue. If, however, there is a maladaptation,
these attempts at self-repair may lead to progressive loss of nephrons and
chronic kidney disease.
BOX 3-5 Scientiﬁc Considerations: Chronic Illness
and the Adaptive Response
A Hierarchy of Healing: The Therapeutic Order
supporting the reactive potential. e rst step in this process is to
identify and reduce disturbing factors.
THE DETERMINANTS OF HEALTH
To reduce the disturbance, one must identify the disturbance. In
standard medicine, the rst step is to identify the pathology, which
is then treated. In naturopathic medicine, one must come to
understand what is disturbing the health. To do this, the physician
needs to understand what determines health in the rst place. e
physician can then evaluate the patient in these terms and come to
understand what is disturbing the natural state of health. Such a
list could be created by any doctor, certainly any naturopathic
physician. e authors propose using the list in Box 3-6.
Some of these determinants have been discussed—those modi-
able behavioral factors such as drug and alcohol use, poor diet or
frank malnutrition, lack of physical exercise, environmental and so-
cioeconomic factors, and unsafe sexual practices.79-81,100 (Box 3-7).
Many of these behavioral factors have major psychological and spir-
itual components, and the eect can be increased stress on both the
individual and the family, with all its attendant consequences.100-102
e naturopathic physician evaluates the patient with these areas in
mind, looking for aspects of disturbance, rst in the spirit, and
most generally in diet, digestion, and stress in its various aspects. In
this evaluation, the naturopathic physician brings to bear a body of
knowledge somewhat unique to naturopathic medicine to evaluate
not solely in terms of pathologic entity, but in terms of normal
function and subclinical functional disturbance (Box 3-8). By lo-
cating areas of abnormal function or disturbance, the naturopathic
physician acts or recommends ways to ameliorate the disturbance.
As disturbing factors or insults to the system are reduced, the
natural tendency of the system is to improve and optimize its
function, directing the system back toward normalcy, or homeo-
stasis. In more conventional medical terms, this is one of the fun-
damental concepts of the allostatic model.95-98,101 In naturopathic
thinking, this is the removal of the obstacles to cure, which allows
the emerging action of the vis medicatrix naturae, the vital force,
the healing power of nature. is is the rst step in the hierarchy
of healing and what naturopathic physicians may call the over-
arching model in the clinical theory (the process of healing) of
naturopathic medicine: the therapeutic order. is process can be
seen in the naturopathic model of healing in Figure 3-1.
e therapeutic order is a natural hierarchy of therapeutic interven-
tion based on, or dictated by, observations of the nature of the heal-
ing process from ancient times through the present.112 “erapeutic
orders” also exist in traditional Chinese, Tibetan, Ayurvedic, and
Unani medicine theories. It is a natural ordering of the modalities of
naturopathic medicine and their application. e concept is some-
what plastic, in that one must evaluate the unique needs, and even
the unique healing requirements, of the specic patient or situa-
tion.113 However, in general, the nature of healing dictates a general
approach to treatment. In general, this order is listed in Box 3-9.
An analogy for the therapeutic order in Australian standard
medicine is what is called the “softer option” model of patient
care.118 is model recognizes that, given a choice, the patient will
generally choose the softer option, provided that this does not
limit a harder option, if the softer option fails. By way of example,
given a choice between an antibiotic and amputation for a minor
cut nger, most people would choose the softer option. Expand-
ing this range of choice to an herbal cream, antiseptic (herbal or
nonherbal) and a Band-Aid, an antibiotic, or amputation, we
develop a therapeutic order ranging from the softest option (the
least force) to the hardest option (the higher force intervention).
e therapeutic order can be seen as a progression of therapeutic
interventions that begin with this “softer option.”
Genetic make-up (genotype)
Intrauterine inﬂuences: maternal nutrition, health, & lifestyle
Maternal exposures: drugs, toxins, illnesses, viruses, psycho-emotional
Constitution: determines susceptibility
Medical Interventions (or lack of)
Physical and emotional exposures, stresses and trauma
Toxic and harmful substances
Environmental disturbances, stress: environmental, physical, emotional
How We Live - Hygienic, Lifestyle, Psycho-emotional,
Spiritual, Socioeconomic & Environmental Factors
Relationship to larger universe (trust, consciousness, compassion)
Exposure to Nature/ Environment
Geography and ecosystem
Exposure to natural systems, wild places, cycles
Diet, Nutrition, and Digestion
Rest and Exercise
Rest and sleep
Exercise and movement
Vital Force, vital reserve, energy
Loving and being loved
Income and economic
Health care (quality and access)
BOX 3-6 Naturopathic Medicine Determinants of Health
Factors That Inﬂuence Health
From Snider P, Zeff J, Myers S, DeGrandpre Z, etal. Course syllabus: NM5114,
Naturopathic Clinical Theory. Seattle: Bastyr University, 1997-2012.
26 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
Acute and Chronic Concerns
As discussed previously, there is an inherent drive toward health that
is observable within the patterns and processes of nature. e drive
is not perfect. ere are times when unguided, unassisted, or
unstopped, the drive goes astray, causing preventable harm or even
death in patients; the constructive healing intention119 becomes de-
structive pathology. e ND is trained to know, respect, and work
with this drive in both acute and chronic illness, using the thera-
peutic order, and to know when to wait or do nothing, act preven-
tively, assist, amplify, palliate, intervene, manipulate, control, or
even suppress using the principle of the least force.120 Acute and
chronic concerns are both addressed and managed using the thera-
peutic order.121 Acute concerns are addressed rst to avoid further
damage, risk, or harm to the patient. e point of entry for assess-
ment and therapy is dependent on each patient’s need for eective,
safe care, healing, and prevention of suering and degeneration.64,121
Naturopathic physicians avoid suppression of symptoms in acute
circumstances unless necessary for patients’ well-being and safety.
Instead, wherever possible, therapies for acute concerns use the least
force (minimizing toxic side eects, suppression of natural functions,
and physiologic burdens) available to intervene eectively, healing or
palliating as needed. e full range of modalities from nutrition to
homeopathy, botanical and physical medicine, hydrotherapy, coun-
seling, prescriptive medication, and surgery are available to the
patient as the naturopathic physician works to apply the least force
in providing eective preventive, acute, and chronic care.121
Establish the Conditions for Health
Identify and Remove Disturbing Factors
If one understands health to be the natural state and “disturbance”
the original culprit, then identifying and reducing disturbance is
the obvious rst step, unless there is immediate danger to life or
limb, in which case acting to reduce suering and preserve life or
limb is paramount. In most chronic disease, neither is immedi-
ately threatened. is understanding dictates the primary
treatment goal the physician must attend to: the identication
and amelioration of those factors disturbing health, especially fac-
tors that most disturb health (inappropriate diet, excessive stress,
and spiritual disharmony). To understand what disturbs health,
one must understand what determines health. e naturopathic
physician evaluates a patient with reference to the determinants of
health to discover wherein the patient’s health is disturbed. In this
step, the physician is essentially removing the obstacles to cure
andallowing the vis medicatrix naturae to do its work.
Among these many possibilities, in general, the most signicant
are attitude diet, digestion, psychological and other stressers, and
what might be called “spiritual integrity.” Humans have a transper-
sonal dimension and can be seen as spiritual beings. Spirit here is
not dened by religion or belief in a deity or deities; it is that com-
ponent of the individual that gives rise to their inner compass, their
“joie de vivre” and their internal meaning of life, their core beliefs,
and their values. Perceived in this way, it can be seen that many
people in society are experiencing “spiritual crises.”86 Although the
general purview of the physician is the body, that instrument cannot
be separated from the spirit that animates it. If the spirit is disturbed,
the body cannot be fundamentally healthy. Hahnemann, the bril-
liant and insightful founder of homeopathy, instructed physicians to
attend to the spirit.122 Disturbance in the spirit permeates the body
and eventuates in physical manifestation. Physicians are responsible
There exists increasing consensus that Crohn’s disease and ulcerative
colitis result from the combined effects of four important factors, none of
which are individually sufﬁcient to cause the disease. These four factors
are the global changes in the environment, alterations in the microbiome
of the intestine, multiple genetic factors, and aberrations or maladapta-
tions in both the innate and adaptive immune systems.114-117 These four
factors, considered to be vital to the development and the increased rates
of irritable bowel disease, are quite similar to the Determinant of Health
described in Box 3-6. This serves as a further example of the growing
appreciation for the similarities (with important differences) between
naturopathic medicine and public and community health.
BOX 3-8 Scientiﬁc Considerations: Determinants
of Health within Public and Community Health
1. Establish the conditions for health
• Identify and remove disturbing factors
• Institute a more healthful regimen
2. Stimulate the healing power of nature
(vis medicatrix naturae): the self-healing processes
3. Address weakened or damaged systems or organs
• Strengthen the immune system
• Decrease toxicity
• Normalize inﬂammatory function
• Optimize metabolic function
• Balance regulatory systems
• Enhance regeneration
• Harmonize with your life force1
4. Correct structural integrity
5. Address pathology: Use speciﬁc natural substances,
modalities, or interventions
6. Address pathology: Use speciﬁc pharmacologic or
7. Suppress or surgically remove pathology
The actual therapeutic order may change, depending on the individual
patient’s needs for safe and effective care. The needs of the patient are
primary in determining the appropriate approach to therapy.
Acute and chronic concerns are both addressed using the therapeutic
order.121 Acute concerns are addressed ﬁrst to avoid further damage, risk,
or harm to the patient. The point of entry for assessment and therapy is
dependent on each patient’s need for effective, safe care, healing, and
prevention of suffering or degeneration.1,121
BOX 3-9 The Therapeutic Order: Hierarchy of Healing
From Zeff J, Snider P. Course syllabus: NM5131, Naturopathic clinical theory.
Seattle: Bastyr University, 1997-2005.
It is becoming increasingly evident that many chronic diseases may have
a long subclinical phase, most involving the inﬂammatory process. As
mentioned, a chronic, subclinical inﬂammatory state has been linked to a
number of disorders, including insulin resistance,104 obesity,105 vascular
disease,106-109 hypertension,110 and aging.111
BOX 3-7 Scientiﬁc Considerations: Subclinical
Inﬂammation and Chronic Illness
A Hierarchy of Healing: The Therapeutic Order
for perceiving such disturbances and addressing them. At colleges of
naturopathic medicine in Australia, the United Kingdom, and
North America, faculty work with naturopathic medicine students
to develop their ability to perceive the spiritual nature of an indi-
vidual as a foundational skill in addressing the spiritual crises or
fundamental needs that have a profound eect on health and
well-being. Using this denition, both atheists and agnostics can be
seen to have a spiritual aspect. is denition also removes spiritu-
ality from religiosity in a way that does not denigrate any individual
religious belief a patient may hold, allowing the naturopathic clini-
cian to explore this aspect of the individual.
One of the oldest concepts in naturopathic medicine is the con-
cept of toxemia. Toxemia is the generation and accumulation of
metabolic wastes and exogenous toxins within the body. ese
toxins may be the results of maldigestive processes, intermediate
metabolites, environmental xenobiotics, colon bacterial metabo-
lites, etc. ese toxins become irritants within the body, resulting
in the inammation of tissues and the ultimate interference with
normal biochemical processes.123 e maldigestive and dysbi-
otic124,125 origin of these internally and externally derived toxins is
the result of an inappropriate diet, broad spectrum antibiotics,
and the eects of excessive stress on digestion.126 Eating a diet that
cannot be easily digested or that is out of appropriate nutrient
balance for the individual results in the creation of metabolic
toxins in the intestines.124,125-127 Stress, causing the excessive se-
cretion of cortisol and adrenalin, results in the decrease of blood
ow to the digestive process, among other eects,95-98,101 which
decreases the ecient functioning of digestion and increases the
tendency toward maldigestion, dysbiosis, and toxemia. Physicians
can now easily measure the degree of toxemia in various ways (uri-
nary indican or phenol127). e older concept of toxemia,129,130
with scientic advances in its understanding121,129 (Box 3-10),
may now be productively combined with understanding of the
newer concept of allostasis95-98 and the historical119,130 and re-
emerging discussion on the inammatory component of many, if
not most, chronic diseases.* Spiritual disharmony, inappropriate
diet, digestive disturbance, stress, and toxemia (leading to inam-
mation) are considered primary causes of chronic illness and must
be addressed if healing is to occur. Beyond these, other disturbing
factors must be discerned and addressed, whichever pertain to the
Institute a Healthier Regimen
As a corollary of the rst, once physicians have determined major
contributing factors to illness, they construct a healthier regimen
for the patient. Some disturbing factors can be eliminated, like
inappropriate dietary elements.82,83 Others are a matter of dif-
ferent choices or living dierently.† e basics to consider are ap-
propriate diet, appropriate rest and exercise, stress moderation, a
healthy environment, and a good spiritual connection.
If this model is correct, these measures alone should result in
enhanced health. e problem arises in knowing how to do these
things. What is an appropriate diet? is is an area of considerable
controversy. Physicians think about diet in many dierent ways.
e goal of dietary improvement is to reduce the symptomatic
consequences of the patient’s diet and provide optimal nutrition
to the patient. e point here, regardless of how this is done, is
that it is central and essential for fundamental health improve-
ment. If the diet is not correct, if digestion is not appropriate, if
nutrition is not adequate, the patient cannot maximally improve,
*References 104-106, 110, 111, 131-138.
†References 84, 85, 89, 90, 92, 94.
and the scene is potentially set for chronic inammatory condi-
tions and the re-setting of the adaptive allostatic and homeostatic
set points. If the diet and digestion are appropriate, the basis for
improvement in other areas is enhanced.
e same is true with these other fundamental elements, to
which Lindlahr referred in the rst element of his catechism, “return
to nature”: exercise, rest, dress, etc.28 ese have been expanded in
the “determinants of health.” ey create the basis for improve-
ment. What this really means is to change the “terrain,” the condi-
tions in which the disease has formed—not only to change but to
improve the conditions so that there is less basis for the disease.
Hahnemann addresses this on the rst page of his Organon of
Medicine.122 He identied four tasks for the physician: to under-
stand the true nature of illness, “what is to be cured”; to understand
the healing potential of medicines; to understand obstacles to
recovery and how to remove them; and to understand the elements
that derange health and how to correct them so that recovery may
be permanent.122 Changing and improving the terrain in which the
disease developed is the obvious rst step in bringing about im-
provement. is sets up the basis for the following elements to have
the most benecial eects.
Stimulate the Self-Healing Mechanisms
A certain percentage of patients improve suciently simply by
removing disturbing factors and establishing a healthier regimen.
Most require more work. Once the patient is prepared, once the
terrain is beginning to clear of disturbing factors, then one begins
to apply stimulation to the self-healing mechanisms. e basis of
this approach is the underlying recognition of the vis medicatrix
naturae, the tendency of the body 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.). e body heals
itself. e physician can help create the circumstances to promote
this. en, as necessary, the physician stimulates the system. is
also requires that attention be given to the patient’s emotional
state of mind, because the psychological condition of the patient
is often of major importance.140,141
One of the best ways to do this is through constitutional hydro-
therapy, as developed by Otis G. Carroll, ND, early in the past
century. is procedure is simple, involving the placement of hot
and then cold towels on the trunk and back, in specic sequence
(depending on the patient), usually accompanied by a sine wave
stimulation of the digestive tract. is is a dynamic treatment,
simple, inexpensive, and universally applicable. It helps recover
digestive function, stimulates toxin elimination, “cleans the
blood,” enhances immune function, and has several other eects.
It moves the system along toward a healthier state.142 Exercise
Using conventional medical terminology, environmental, dietary, and life-
style derived disorders are termed idiopathic environmental intolerances,
multiple chemical sensitivities,127,128,132,133 or sometimes oxidative stress
disorders.134-138 The terminology may be different, but it describes the
same symptomatology. Environmental toxins accumulate, and chronic
inﬂammation increases. These exogenous and endogenous toxins and the
lack of exercise stress the system further. The ketogenic diet to control
epilepsy may be considered one example of the successful application of
diet to control symptoms.103
BOX 3-10 Scientiﬁc Considerations: Toxemia Today
28 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
often achieves similar results. Many naturopathic modalities can
be used to stimulate the overall vital force.
More specic approaches to stimulation, although general in
eect, are applied dierently to each patient and have a less gen-
eral eect than those previously mentioned. Homeopathy and
acupuncture143-145 are often the primary methods of such stimu-
lation. ey add little to the system; they are not gross chemical
treatments. ey work with what is there, stimulating a reaction,
stimulating function, and correcting disturbed patterns.
Each method helps move the system out of its disturbed state and,
with the reduction of encumbrance, helps move it toward health.
Finally, exposure to the patterns, rhythms, and forces of nature
is a traditional part of naturopathic medicine and the tradition of
nature doctors throughout the world. As previously noted, “We
exist as part of complex patterns of matter, energy, and spirit,”1
and the natural progression of these patterns and the drive toward
health inherent in them, is a natural ally for the physician. Expo-
sure to appropriate rhythms, patterns, and forces of nature
strengthens vitality and stimulates the healing power of nature.
Support Weakened or Damaged Systems or Organs
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., the hepatic detoxication pathways) and require
extra help. is is where naturopathic physicians use their vast
natural medicinary. Botanical medicines can aect any system or
organ, enhancing its function, improving its circulation, pro-
viding specic nutrition, and stimulating repair. Glandular sub-
stances can be applied to a similar purpose. Plus, there are the
growing number of evidence-based “nutraceuticals”—biological
compounds that enhance metabolic pathways and provide sub-
stance for metabolic function.146-157
Naturopathic physicians can also apply specic homeopathic
medications, usually in the lower potencies, which act nutritively
and can stimulate specic organs or functions. is method, gener-
ally referred to as drainage, can be used to stimulate detoxication
of specic substances from the body in general or of specic organ
systems or tissues. Dr. Pizzorno’s work in Total Wellness,158 the work
of “functional medicine” leader Jerey Bland, PhD, and the Text-
book of Functional Medicine by Jones120 exemplify the clinical strat-
egies applied at this level of the therapeutic order. ese strategies
are used to restore optimal function to an entire physiologic system
(immune, cardiovascular, detoxication, life force, endocrine).158
One can also use specic exercises to stimulate or enhance organ
health. Some systems of Yoga and Qi Gong are organ specic.
Specic applications of hydrotherapy and other physiotherapy
systems can be applied to enhance the function of organs or
It has been the clinical experience of many naturopathic physi-
cians that these methods, combined with an appropriate diet and
a healthier regimen, along with constitutional hydrotherapy,
appropriate homeopathy, and acupuncture, bring most health
problems back to normal, without negative consequence, rapidly,
eciently, and permanently.
Address Structural Integrity
Many structural problems result from generalized stress of some
kind on internal systems. For example, mid-back misalignment or
discomfort (T1–T12) is often found associated with a history of
underlying stress on the digestive organs, the enervation of which
originates at those spinal segments. One can manipulate the verte-
bra back into proper alignment or massage contracted muscula-
ture, but until one corrects the underlying functional disturbance,
there will be a tendency to repeated structural misalignment. In
some circumstances, the singular problem may be simply struc-
tural disintegrity. One may have fallen or been hit in some fashion
and simply needs the neck manipulated back into proper align-
ment and the surrounding soft tissue relaxed. ere may be no
dietary error or other disturbance aside from the original injury,
and correction requires only simple manipulation or therapeutic
massage. is is an example of the exibility of the therapeutic
order concept. In this case, rst-order therapeutics manipulate the
cervical spine or relax chronically contracted muscles. Usually,
however, the problem of structure is part of the larger problem,
and such intervention becomes a fourth-order therapeutic.64
Reintegrating structure can occur in many ways, one of
which is the method of “bone cracking” known to the ancient
Greeks and Chinese and probably all other ancient healing cul-
tures. However, there are nonforce manipulative systems that
include many modalities of therapeutic massage. Some systems
of exercise are designed to reintegrate and maintain normal
structural relationships. Any of these might be appropriate to a
specic 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
Address Pathology: Use Speciﬁc Natural Substances,
Modalities, or Interventions
Having gone through the rst four steps of this therapeutic hierar-
chy, most patients improve. e improvement is based on the
sound footing of the underlying correction or removal of funda-
mental causative elements. It is also based on the intrinsic nature
of the body to heal itself using the least possible force. Most
pathology improves or disappears under these circumstances.
Sometimes it is necessary to address pathology. is may be the
case because the particular pathology may be threatening to life or
limb. Acting on this threat is imperative. It can be done often with
naturopathic means, directed specically against the pathology.
Biochemical or genetic individuality also can demand an emphasis
at this level of intervention.
One of the major conicts in naturopathic medicine is that some
practitioners nd it expedient to diagnose and treat pathology (the
standard medical model) rather than pursue a naturopathic model
of practice. is approach tends to be less satisfying and less pro-
ductive of the most elegant outcomes and the long-term continued
health of the patient. It also reduces the capacity of the physician to
treat, such as in cases where there is no evidence-based treatment
for the pathology in question, or where there is no clear diagnosis
(i.e., no distinct pathology to treat). is approach is increasingly
referred to as “green allopathy.” However, the vast body of knowl-
edge that naturopathic education presents in this arena makes such
an approach seductive, especially in a culture that more or less
expects, supports, reinforces, and pays for an “allopathic” approach
to diagnosis and treatment.
It is easy to do this. e culture is accustomed to this model and
often expects to encounter this in the naturopathic physician’s of-
ce. In some states, such as Oregon, Washington, and Arizona,
where the naturopathic formulary includes most antibiotics and
many pharmaceutical drugs, one can practice almost without dis-
tinction from a medical doctor. e typical naturopathic formu-
lary is often sucient to prescribe on a strictly pathologic basis.
A Hierarchy of Healing: The Therapeutic Order
e problem with this is that it is generally not as eective,
especially in the treatment of chronic disease. e value of naturo-
pathic medicine in our culture is not that naturopathic physicians
can function almost like medical doctors, with a “natural” formu-
lary instead of drugs. It is that they oer a fundamentally dierent
approach, one based on the restoration of health rather than the
treatment of disease.
Given all of this, it still may be useful to directly address the
pathologic entity or its etiology.159-163 When treating an antibiotic-
resistant infection, for example, it may be useful to apply botanical
medicines with specic antibiotic properties, along with immune
tonics and the more fundamental steps of this therapeutic hierar-
chy. In dicult cases, such as many cancers, using agents that have
specic, pathology-based therapeutics may be an essential element
of comprehensive treatment. e naturopathic formulary provides
a vast and increasing number of such options. One advantage of
such treatment is that, in general, when applied by a knowledge-
able practitioner, it rarely adds more burden or toxicity to the
system. Naturopathic pathology-based treatments still follow the
dictum “do no harm.”
Address Pathology: Use Speciﬁc Pharmacologic
or Synthetic Substances
About 800,000 medical doctors and osteopathic physicians in
the United States are trained in the science of pathologic-based
treatment, using pharmaceuticals and surgery, etc. ere are
times when such an approach is necessary to preserve life, limb,
or function. Although some naturopathic physicians, by
training and by statute, may prescribe pharmaceuticals or per-
form minor oce procedures and surgeries, naturopathic physi-
cians may also refer patients in need of such services to
appropriate medical doctors or osteopaths. In a growing number
of states, NDs can legally provide an expanding range of pre-
scription drugs. Although this is an important tool for the na-
turopathic primary caregiver, this privilege requires enhanced
responsibility for the ND to prescribe those substances only as
needed—and to thoroughly rely on applying the least force ap-
propriate to eect recovery and protect patient safety. Both Dr.
Lust (at the end of his life) and Dr. Bastyr recognized the need
for NDs to have the ability to access, as needed, prescriptive
medications and perform minor oce procedures to function as
primary caregivers. However, both admonished that the philos-
ophy and principles of the medicine guide their judicious use—
only as truly needed, based on the least force necessary to restore
the patient to health.
Naturopathic physicians are well trained in this regard and
respect the necessity and utility of standard medical practice in
appropriate situations. Some disagreement exists regarding which
situations may be appropriate. e AANP developed position
papers to resolve some of these questions.
In general, although recognizing the necessity of such treatment,
most naturopathic physicians also recognize that such treatment
often carries consequences that also must be addressed.
Sometimes it is necessary when there is risk of harm to the patient’s
health or tissue, or to relieve suering, to suppress pathology.
Medical doctors are especially trained in this art and have pow-
erful and eective tools with which to do this. Unfortunately, sup-
pression, 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., inammation), suppressive
measures are, in general, anti–vis medicatrix naturae. e 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. One simple example of this is the over
use of corticosteroidal anti-inammatory and antihistaminic
drugs in the treatment of acute asthma. is usually eectively
opens the airways. However, prolonged use weakens the patient. If
the treatment persists, the patient becomes immune compromised
and osteoporotic and can develop psychological disorders. ese
symptoms are part of the long-term eects of steroids.74 It may
necessarily maintain breathing, but the long-term cost to the
organism is high.
Suppression, although it may be life saving, often has serious
consequences. With standard medical methods of care, cure of
chronic illness is often elusive. is is the benet of the naturo-
pathic approach: by taking a nonsuppressive course of action,
based on sound physiologic principles, one can often restore
health without recourse to the potential damage of suppression.
Naturopathic physicians, although recognizing the occasional ne-
cessity of suppressive approaches, in general avoid suppression,
which is a primary way in which physicians can inict harm, even
with the best of intentions.
THEORY IN NATUROPATHIC MEDICINE
is therapeutic hierarchy is based on the observation of the
nature of healing and the inherent order of the healing process. It
is part of a unifying theory of naturopathic medicine, an out-
growth of the principles that underlie naturopathic thinking. It
provides the physician with instructions that order the many ther-
apeutic modalities used by the practice.
e consensus denition of naturopathic medicine, adopted
by the AANP in 1989, is a statement of identity, distinguishing
naturopathic medicine from other systems of medical thought.
Contained within it is a set of instructions regarding the prac-
tice of the medicine. e three concepts discussed here—
“disease as process,” “the determinants of health,” and “the
therapeutic order”—are an articulation of these instructions.
ey are presented as a clinical theory of naturopathic medi-
cine. ey have been crystallized, as is the denition, from the
observation by nature doctors throughout time and across many
traditions of the nature of health, disease, and healing. ey
provide the physician with instructions. ese instructions
include a procedure for thinking about human illness in such a
way that one can approach its cure in an ordered fashion by
understanding its process as an expression of the vis medicatrix
naturae. It provides the framework for truly evaluating the
patient as a whole being: spiritual, mental/emotional, and phys-
ical, rather than as a category of pathology. Plus, it provides the
physician a system for organizing and eciently integrating the
vast therapeutic array provided in naturopathic medicine. Ulti-
mately, it satises Hahnemann’s observation of the ideal role of
medicine, that “the highest ideal of cure is rapid, gentle and
permanent restoration of the health … in the shortest, most
reliable and most harmless way, upon easily comprehensible
principles.”122 e roots of the observations that form this
theory are traceable through the mid- and early-twentieth cen-
tury, to the traditional theory of nineteenth-century European
nature cure, and to the roots and theories of traditional world
30 SECTION 1
PHILOSOPHY OF NATURAL MEDICINE
medicines. Hippocrates’ writings on the vis medicatrix naturae
form a foundation that historically underpins the development
of this theory.164,165
Finally, it is observable across many traditional world medicines
that various healing orders are described. Such structures hold
implications for public and community health priorities and sug-
gest the reprioritization of health care priorities and nancing.
Implications for public policy and the growing national disease
debt invite exploration.
Although this presentation is not comprehensive, the attempt
has been made to demonstrate these roots, at least in some of their
major articulations. e work presented here is a continuation of
this historical process, which ultimately is driven by the true mis-
sion of the physician: to ease suering and to preserve life.
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