Developing Homeopathic Practice: Towards a Framework of Working with Multiple Interventions

Abstract

In the current health care environment there is the constant need to examine existing situations and initiate developments to move practice forward in positive and effective ways.  This need necessitates practitioners to embark on local projects, which analyse specific issues, develop proposals for change and implement these proposals in practice.  This paper aims to support, facilitate and evaluate the practice development process and synthesise strategies in practice and benefit patient experience. In this reflective piece, the area I have chosen from my working environment to focus on is patient compliance in 21^st century Homeopathy. In the main, homeopathic medicine has remained unchanged since its inception. But are our patients the same? Biologically, of course, but what about their behaviour and their expectations? Integrating other medical interventions into the working paradigm of homeopathy is a fundamental issue of practice that needs developing. Our patients are behaving badly, if you take some of the principle attitudes and philosophies of the founders. In the West it seems that patients do what they want. They grab at techniques and treatments and modalities in a way not done in the past. Treatment plans become clouded and results hard to determine.  There are clear reasons why this aspect of homeopathy needs developing, the least being poor communication with other modalities, poor communication with our patients, and poor perception of homeopaths as being ‘precious’ by practitioners of other modalities. Most importantly, there are cases with unsuccessful outcomes. An examination of multiple interventions in homeopathy throws up a number of questions, most notably how we market ourselves in the 21st century, how we treat complicated cases of people living 21st century lifestyles, how we teach our students, how we possibly need a reorientation of our attitudes to the simillimum as an aspiration as opposed to a close similar, how we maintain our relationships with our clients, how we measure the result of our prescriptions and gauge efficacy, how we evaluate the second prescription, how we conceive of the notion of success, how we publish our cured cases.

Keywords

Homeopathy, Clinical audit, Integrative Medicine, Research, Treatment plans, Direction of cure, Second prescription, Hahnemann.

Establishing the Issue

It is a normal day in the clinic. A mother turned with her two children. One is four months old, being breast-fed, the other is four years old and is a tornado. Usual story. My room gets destroyed. He hits me, punches his mother and decides that it’s very important to start drumming on every conceivable service.  In amongst all of din I was able to discern that he has daily explosions over trifles,  like whether the aerial is up in the car or not, how his father mows the lawn, if the baby is fed properly or not.  He also pumps out 40° fevers, has a history of ear infections, and is badly affected by artificial additives and colours etc. Prescription; Belladonna 200.  The mother sends me a text message two hours later.  ‘Okay what’s in that mixture?  The only word he said between Drummoyne and the M4 was ‘octagon’ when he saw a stop sign.  Then he fell asleep.  He has woken now but is very quiet.  Have we drugged him?  This could be great!  Ha ha ha ha laugh out loud.’

It’s was nice result. He has remained well these last 6 weeks. Almost a good enough result to present a paper about it. All except for this part. She also said, ‘shall I keep going with the antibiotics and the stuff I got from the health food store?’

Just when do we say, ‘that patient is better?’ When do we publish our cases? Just what is cure?  Many homoeopaths don’t use this term at all anymore. They prefer to use the term ‘improvement,’ or something else.

My personal state of professional schizophrenia grew and was heightened by an experience in 2007. At the Links Heidelberg conference I heard two things which made me stop and reflect. The first was in Sankaran’s presentation when he played a case, worked the evaluation with the audience, come to a conclusion and then finished with, ‘and the patient did beautifully.’ He must said that 10 times during his presentation. And I am sure they did. Soon afterwards it was the turn of Mangliavori to present. He says in a recent book (Mangliavori  2004) that his criteria for a published case or a ‘cure’ is, ‘only one remedy used over a period of two years which works in all chronic and acute situations.’ From conducting a recent and exhaustive audit of my practice, if I used his criteria I could publish or speak about 3% of my clients. But if I used Sankaran’s criteria I think I could present 70% of my cases as cured cases. Having spent the last two years in the world of clinical research I can no longer agree with either. One is too loose. One is too tight and does not reflect reality.

Conducting an audit can be exhaustive, but has transformed the way I think in practice and what I say about it and how I teach. I realize that in addition to not having a criteria for what constitutes ‘cure’ in our profession we also don’t have an active dialogue about what we do about those patients who get better but are also seeking and receiving other medical interventions. Given the working reality of the coal face of practice; that few if any, or NO clients are only ever getting just homeopathy for their chronic diseases, do we need to reframe, adjust or discard any aspects of our homeopathic behaviours and principles? Said one homeopath,

‘It has been years since I had a client come into my clinic and say, I am just getting homeopathy, I am doing no other form of medicine, just homeopathy. All of my clients are doing herbs, Feldenkrais, naturopathy, supplements, epilepsy drugs, osteopathy or something as well as seeing me, especially the clients with serious pathologies.’ Interview H10-17.

In 2007 three practicing homeopaths and lecturers in three countries turned their attention to this important issue. Working as a group with problem based learning templates they asked some fundamental questions. How does the reality that our clients are getting multiple medical interventions from various modalities

• effect the principles of similars in our clinics?
• effect the principles of totality when we are selecting symptoms, and which totality?
• effect the basis of the prescriptions?
• effect how we look at Hering’s direction of cure and gauge how our remedies are truly working?
• effect working with obstacles to cure?
• effect research, the writing up and reporting of results?
• matter at all?

Moreover, how does this impact on our perceived efficacy given that practitioners in these other disciplines usually have no idea about our concepts of minimum dose, the direction of cure and homeopathic treatment plans and therefore, it is argued, intervene inappropriately.

There is very little knowledge base underpinning these questions. When interviewing practicing homeopaths everybody seems to ‘do their best’.  They muddle on through. ‘On critical reflection the best I could say about my method in these cases is, I am making it up as I go. Is this good enough? For a profession that has aspirations? Not at all (Interview H10-17)?’ This seems ludicrous for a profession that is wanting and demanding the respect of it medical peers. It seems clear that some literature needs to be created, and some clinical guidelines, some clinical principles, some structures and some sort of a common language that is multi modality. This is doubly crucial because in every other branch of the practice of homeopathic medicine there is clarity. Got this? Do this. When does this happens? Do that. But if the estimation from one exhaustive clinical audit of four years of practice is correct and around 90% of the time patients are seeing other practitioners and getting other treatments and doing other medicinal things, perhaps we do need to begin a discussion and reframe this aspect of homeopathic medical practice and the teaching of it.

We have all had this experience. Patient shows up in the clinic. She presents with irritable bowel syndrome, and after questioning it is clear that there is a massive component of anxiety that goes along with it.  She is struggling, and soon after six months of treatment, so am I. Arsenicum, Nux, Sil, Cina, all the suggestions from Jon Gamble’s book have been tried. Some improvement but nothing startling. After this amount of time we have established a good therapeutic relationship of some depth. She wants to stay with my treatment and trusts that the small improvements we have had will continue. Like so many others she’s down the health food shop. She found a homeopathic combination. Amongst the few ingredients that I actually recognized was Ferr, Hyper, Berberis, Sepia, Ars, Nicotiana, Merc viv, Arg nit, Mocsh, E-coli and something called Ovary co. There were a number of other ingredients which I didn’t recognize.

This scenario is surely familiar to you.  What is your reaction?  Punch, yell, counsel, anger, sack the patient? What do you do when a patient says I am getting osteopathy? I am getting herbs.  I am getting an MRI.  I am getting fish oils. We work as if our remedies will act on the parts of the case that are not being affected by the other treatments. We say to the remedy, ‘hey remedy I just want you to work on the knees and the throat okay.’ What I previously did in my practice of the patients who had this was to do my best. Is this good enough?

Research is about determining the action of one factor; to eliminate everything else to just one thing. ‘In this double-blind trial I have shown that prednisone does this in people with this thing. I can show how this homeopathic medicine did this in this person.’ But what I am suggesting is that this is massively difficult if what is happening in my practice is being mirrored elsewhere in the profession.

Research Plan

Suspecting that this was an area of clinical significance in practice that needed developing, in 2007 a small research team was established to investigate this issue.[1] The research plan consisted of;

1 Completing clinical audits to confirm that this is in fact as big an issue as assumed.[2]

2 Researching the traditional homeopathic literature for guidelines.

3 Research the modern academic literature for guidelines.

4 Interviewing and auditing practitioners of other modalities, researching and delving into their curriculums and directives.

Research Results; Deconstruction

In order to determine if this was an area of genuine concern a Clinical Audit was conducted  from one practitioner’s last 550 cases. [3]

The message from this piece of research in one practice is unequivocal.  93% of patients are doing what they want.  Here’s another surprising statistic. From the audit, male patients are using other medicinal interventions far less than female patients. The conclusion from this particular audit was overwhelmingly that this is an area of practice in need of developing.[5] Further evidence gathered anecdotally confirms the finding.

“In my own experience at the cancer charity, patients have often chosen to use a number of complementary therapies alongside their conventional treatment.  It is exceedingly rare for patients to choose only to use homeopathy without exploring other therapies, and of course conventional medical intervention.  However, I feel that in such an acute situation, the homeopath cannot expect a patient to choose to use only homeopathy, in order that we are able to ascertain the remedy’s effect, and whether the Law of Cure is progressing in the correct manner.  Patients need to be able to use whatever they feel is important, in this situation, in maintaining a good level of health. In my own practice, I always ask patients whether they are currently taking other medication, whether complementary or conventional.  This can help me ascertain whether the patient’s Vital Force is being suppressed by conventional medication, and therefore often has an effect on the potency I choose for the patient.  It also allows an indication of the patient’s reaction to complementary therapies and which ones they choose to use.”  Interview H15-7

Traditional Homeopathic Guidelines

In researching the traditional homeopathic literature it is clear that Hahnemann (1842) gave us no instructions when it comes to how to interact with, or integrate ongoing or new treatments from other modalities into our treatment plans. Of course he does mention things to avoid in his aphorisms on Obstacles to Cure in 259 and 260. The advice was in essence, to take away everything which can have any medical action.

§ 259 “Considering the minuteness of the doses necessary and proper in homeopathic treatment, we can easily understand that during the treatment everything must be removed from the diet and regimen which can have any medicinal action, in order that the small dose may not be overwhelmed and extinguished or disturbed by any foreign medicinal irritant” § 260 “Hence the careful investigation into such obstacles to cure is so much the more necessary in the case of patients affected by chronic diseases, as their diseases are usually aggravated by such noxious influences and other disease-causing errors in the diet and regimen, which often pass unnoticed.” And in the footnote to § 260: Coffee; fine Chinese and other herb teas; beer prepared with medicinal vegetable substances unsuitable for the patient’s state; so-called fine liquors made with medicinal spices; all kinds of punch; spiced chocolate; odorous waters and perfumes of many kinds; strong-scented flowers in the apartment; tooth powders and essences and perfumed sachets compounded of drugs; highly spiced dishes and sauces; spiced cakes and ices; crude medicinal vegetables for soups; dishes of herbs, roots and stalks of plants possessing medicinal qualities; asparagus with long green tips, hops, and all vegetables possessing medicinal properties, celery, onions; old cheese, and meats that are in a state of decomposition, or that passes medicinal properties (as the flesh and fat of pork, ducks and geese, or veal that is too young and sour viands), ought just as certainly to be kept from patients as they should avoid all excesses in food, and in the use of sugar and salt, as also spirituous drinks, undiluted with water, heated rooms, woollen clothing next the skin, a sedentary life in close apartments, or the frequent indulgence in mere passive exercise (such as riding, driving or swinging), prolonged suckling, taking a long siesta in a recumbent posture in bed, sitting up long at night, uncleanliness, unnatural debauchery, enervation by reading obscene books, reading while lying down, Onanism or imperfect or suppressed intercourse in order to prevent conception, subjects of anger, grief or vexation, a passion for play, over-exertion of the mind or body, especially after meals, dwelling in marshy districts, damp rooms, penurious living, etc. All these things must be as far as possible avoided or removed, in order that the cure may not be obstructed or rendered impossible. Some of my disciples seem needlessly to increase the difficulties of the patient’s dietary by forbidding the use of many more, tolerably indifferent things, which is not to be commended. Also in some aphorisms at the end of the Organon he mentions the use of magnets and water.

He does suggest value of the use of magnets, minerals, massage and basic hygiene, but nowhere is there an implication of how to use these with homeopathy.

§ 286 (Sixth Edition) The dynamic force of minerals magnets, electricity and galvanism act no less powerfully upon our life principle and they are not less homeopathic than the properly so-called medicines which neutralize disease by taking them through the mouth, or by rubbing them on the skin or by olfaction. There may be diseases, especially diseases of sensibility and irritability, abnormal sensations, and involuntary muscular movements which may be cured by those means. But the more certain way of applying the last two as well as that of the so-called electromagnetic lies still very much in the dark to make homeopathic use of them. So far both electricity and Galvanism have been used only for palliation to the great damage of the sick. The positive, pure action of both upon the healthy human body have until the present time been but little tested. § 287 (Sixth Edition) The powers of the magnet for healing purposes can be employed with more certainty according to the positive effects detailed in the Materia Medica Pura under north and south pole of a powerful magnetic bar. Though both poles are alike powerful, they nevertheless oppose each other in the manner of their respective action. The doses may be modified by the length of time of contact with one or the other pole, according as the symptoms of either north or south pole are indicated. As antidote to a too violent action the application of a plate of polished zinc will suffice.

Beyond this there are few directives. Close (1990) says, ‘It is taken for granted that the physician, acting in another capacity than that of a prescriber of homeopathic medicine, will remove the causes of the disease and the obstacles to cure as far as possible before he addresses himself to the task of selecting and administering the remedy which is homeopathic to the symptoms of the case, by which the cure is to be performed.’

Other homeopaths have stated stronger opinions. Vithoulkas (1986) says other treatment will interfere with homeopathy: dental treatment, essential oils, acupuncture, herbs etc. “This occurs by interferences with the action of the defence mechanism itself.” Johnston (2007) is tougher still with her opinions.

CONSTITUTIONAL HOMEOPATHIC TREATMENT ANTIDOTE LIST Homeopathic remedies are very powerful medicinal substances. Their action and effectiveness, however, can be disturbed by some of the chemicals and medicines commonly used in our lives.  The following is a list of things that should be completely avoided for maximum benefit from your Homeopathic treatment. If you ever have any questions about a particular medicine, it is better to call to inquire than take the chance of disrupting your treatment program. MOST MEDICATIONS Antihistamines,  antibiotics,  or cortisone  ointments, sprays, creams or pills, cold formulas, antibiotic ointments such as Neosporin, pain medications. Each medication needs to be evaluated individually , so please check your current medications and inquire about  any you may take in the future. All `over the counter’, non- prescription medicines must be avoided. RECREATIONAL DRUGS  Marijuana, hashish, cocaine, LSD, mescaline and all others. DENTAL WORK, CHIROPRACTIC or ACUPUNCTURE. Contact the office if dental work is planned, preferably have it done before homeopathic treatment. Routine teeth cleaning is not a problem. Chiropractic or Acupuncture treatments should be avoided.  ELECTRIC BLANKETS You may use the electric blanket to warm your bed, but it is inadvisable sleep with the blanket on.

Bill Gray (2007) presents a long list of interfering issues including such an array of common aspects of western lifestyle that it is bewildering to think how our medicines can possibly act at all.

Australian Tea Tree (Melalucca) Oil. Often used to heal skin or gums in a variety of ways, skin exposure can antidote just like camphor. Antibiotics and Steroids. It is a frequent story for someone to be doing well for a chronic disease, to catch a cold or sinus infection, go to a doctor for diagnosis, and then thoughtlessly take antibiotics. Within days, all the chronic symptoms come back full force. Whenever prescription drugs are recommended, call the office first to get our advice. If needed, I will agree and we will pick up the pieces later. But usually, I will advise waiting and to allow the remedy to work through the acute problem on its own. One interesting situation is the use of antibiotics during gum surgery or dental cleaning in people with heart valve problems. Antibiotics do not usually antidote in that setting. Also, when given for viral complaints, they tend not to antidote. Therefore, it seems the antidotive action of antibiotics arises out of interfering with the body’s ability to fight infection rather than the drug itself. If antibiotics prevent an infection from happening, the body suffers no interference and is not antidoted. Antibiotics are the most common drug antidote. Oral steroids are also risky. Other allopathic drugs vary in their potency to antidote or interfere, so the best policy is to call and ask. Over-the-counter medicines are safe. They do not antidote. People worry about aspirin or Tylenol interfering, but they do not. Dental Drilling. Drilling on teeth with medium and low-speed drills consistently antidotes remedies. High-speed drilling (with a light touch) may also antidote, but much less frequently. For this reason, we recommend avoiding drilling unless the situation warrants it. If there is pain, or if the cavity is causing other risks like structural weakening or abscess formation, then drilling may be necessary. Have it done, wait 3 weeks, and then we will re-evaluate the remedy. Routine procedures at the dentist are not a problem except when they lead to drilling. Teeth cleaning is fine, X-rays are fine, but cavities that are found are best left undrilled until they pose more of a problem. In discussions with dentists, they usually agree with me that drilling can be delayed when I point out the likelihood of an overnight flare-up of, say, multiple sclerosis or ulcerative colitis. Teeth cleaning is fine, but the ultrasonic cleaner (called a Cavitron, which is not used so often anymore) will antidote. Otherwise, using hand tools and a rubber polisher is fine. Sonicaire toothbrushes do not antidote remedies. Acupuncture. Acupuncture, whether with needles or moxa, frequently antidotes remedies. Because it is a powerfully curative system in its own right, acupuncture can be an extremely good choice for chronic disease – but a choice it must be, because both systems interfere with each other. Acupressure, however, does not antidote. Chinese herbs do not antidote in my experience. Mothballs. Brief inhalation, even for a few hours, may not be a problem. But sleeping overnight in the midst of mothball odors often antidotes. Electric blankets. Sleeping under an electric blanket covering most of the body seems to inhibit flows of electromagnetic energy in the body, preventing adjustments crucial to healing and balance. Using the blanket to warm the bed beforehand and then turning it off once in bed is no problem. Heating pads are no problem because the body’s energy flows can adjust around it. TENS units do not antidote. Geothermal Hot Springs. Water activated by minerals coming up from deep in the Earth apparently interfere with remedies. Being around the baths, sunning by the side, etc., do not antidote. But full immersion, even in the side-tubs, will likely antidote. Minerals added to the bath at home do not antidote. Safe Interactions. Cigarettes do not antidote. Alcohol Safe, except Kahlua, Irish coffee, anything with coffee beans. Tea Any amount. Recreational Drugs This is variable. Some people are hypersensitive to many chemicals and could be easily antidoted. General recreational use is not a problem for most people. Chronic habitual use, however, can eventually antidote. Allopathic Medications. Do not stop medications without advice. Most patients begin homeopathy on medication, then gradually wean off as many as possible over time. Medications are not instant antidotes, except antibiotics and steroids. Most others eventually shorten the action of remedies within 2 to 9 months, depending on the situation. The issue with allopathic drugs is their suppressive nature. Aimed to relieve symptoms, which are attempts to heal, they convert acute to chronic and delay cure in chronic disease. Thus, if nothing else, they act like a “parking break” on remedies.

The vast majority of our literature and certainly a number of authorities in our profession have all said, ‘do not integrate treatments’. An Australian homeopath in interview said, ‘It’s wrong. The patients are wrong. Don’t encourage it’ (Interview H13-25).  Three reasons are generally given. We cannot get clear symptom pictures on which to prescribe, these factors antidote our remedies, and we are less able to monitor our patient’s progress well and refine our second prescriptions when there are multi medicines and multi modalities.

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Alastair Gray

Alastair Gray MSc (UK) ADH (NZ) RSHom (UK) DSH (UK) PCH (UK) PCHom (Malay) BAHons (NZ)