Drs. Paul Herscu and Amy Rothenberg, a husband and wife team, are homeopaths and naturopathic physicians. Together, they founded the New England School of Homeopathy in 1987 and he and Amy are the directors. Dr. Herscu’s is author of The Homeopathic Treatment of Children: Pediatric Constitutional Types and Stramonium: With an Introduction to Analysis using Cycles and Segments. That book was the foundation for a unique and creative new approach which Paul and Amy teach at NESH and all over the world. Paul is also author of Provings, with a Proving of Alcoholus, which is a comprehensive guide to the philosophy and methodology of conducting a proving. Dr. Rothenberg, also a writer and teacher, was the long time editor of the New England Journal of Homeopathy and is the author of The A Cappella Singer Who Lost Her Voice and Other Stories from Natural Medicine.
AS: We recently published a case quiz and forty nine people responded with around fifteen different remedies, none of which were correct. Is this difference of opinion something we just have to accept in homeopathy?
AR : Thank you for this terrific question Alan. The answer is a resounding NO!! Paul has written extensively on this topic in the Herscu Letter, Letter #134 where he has done some of the statistical analysis on this topic and underscoring how, as a profession, we MUST do better and that in fact, with those we have trained, we are! The questions comes right after two recent weekends where we had the pleasure of bringing together students and practitioners who have studied with us for at least a two year course which we teach with an emphasis on using Cycles & Segments (C&S). C&S allows us to group symptoms that are similar and helps us to streamline both case taking and case analysis. The aim of these clinical weekends is to see patient after patient for several days. Paul or I take the case and then, with the participants, work to analyze the case & come up with the remedy prescription. We take the case to model all the different aspects of case taking: understanding the narrative, seeing how the main symptoms are contextualized in the person’s life, doing a thorough review of symptoms including physical generals and how to get to the most important aspect of the patient’s story. We know the most important aspect because we see examples of it throughout the case. In the articles associated with this interview, you can find more complete and detailed descriptions of C&S as well case examples.
We have repeatedly been impressed by our students/colleagues in this regard, in their ability to zero in on what needs to be helped, to figure out what aspect of the patient’s story is the part(s) to pay attention to! With Cycles and Segments, we are grouping similar symptoms together, we are building an understanding of what drives the imbalance or pathology. We train people to be better at focusing on the right thing! That is a huge issue in homeopathy and always has been. Any patient at any given time can have a myriad of symptoms and it can be overwhelming for the homeopath and challenging to know what to pay attention to. But if you know you are supposed to pay attention to those things that are most limiting to the patient and occur over & again in a case, it becomes more manageable.
We use other tools to help as well. Paul’s development of the Map of Hierarchy is invaluable. Not all remedies are created equal. If we understand that a patient is further to the right on the Map of Hierarchy, ie further disturbed with deeper pathology, then we know not to consider more basic polychrests. To get a fuller understanding of Cycles and Segments and the Map of Hierarchy and how we use them in practice, see the first 40 pages of Paul’s Stramonium with an Introduction to Analysis Using Cycles and Segments. To read more about a case where the Map of Hierarchy was relevant and essential to understanding a patient over time, see the case of Autism attached.
When we have a group doing cases together it is common for the group, whether 20 people or 100 people or more, to come down to 4-5 remedy choices. This is closer to an acceptable rate. And with that number, often several of the remedies are close, say Belladonna & Veratrum album or in another case, Carsinosin and Silica, as opposed to what might seem like a random list of unrelated remedies.
Regarding the experiment you described, this seems to be a common experience in our profession, as at conferences one can often see what you describe . We think we know at least some of the reasons it occurs. Those reading or watching the case are not focused on the correct things, and/or they are only focusing on one particular aspect of the case, not the whole person. Seeing our students time and again get right into the ballpark is heartening for us. That they may have 4-5 remedies to think about, gives the practitioner a good back up remedy, should the first one chosen, fall short. I am edified as a teacher, knowing my students come down to the same small handful of relevant remedies, one of which most often does help, when we see patients together.
I have one example of this. Some years ago, Paul was teaching an international group of students, in Greece. He showed a video case that a prominent homeopath had taken, and the 130 participants came to 3 remedies, by analyzing it in the Cycle and Segment fashion, one of which was given and cured the complaint. A similar sized group who had watched the same original case came up with 49 remedies, though none came up with the prescriber’s choice, which was one of the 3 that we came up with in our analysis. To highlight the point even more, the knowledge level of prescribing was very high in both groups, the same exact symptoms were captured in both groups, and finally the correct remedy was a commonly prescribed remedy. The main difference was that in one group, we had a clear method of analysis which allowed the practitioners a pathway to analyze the case appropriately.
AS: That’s encouraging, because if homeopaths are arriving at wildly different remedies for the same case, it means there are more wrong answers. In Cycles and Segments, where do deficient cases fit in, where there might be few symptoms to go on?
PH: Without digressing into a long discussion on both Hahnemann and Boeninghausen’s concepts of full cases and what was considered a “complete” symptom, there are numerous writers through the generations who have tackled this issue. For us it seems that the application of Cycles & Segments helps to eliminate many of these so-called deficient cases.
First, those cases that might be considered deficient but actually are not, include:
1. Patients who are incurable with homeopathy in their current situation. This is not to say they are incurable with say, surgery, but with homeopathy alone, their disease may well be incurable;
2. The second grouping would be those who for one reason or another, want to decline homeopathic treatment, who then “present” as a deficient case, i.e. they have a bad attitude and will purposely not give correct and full responses etc.
3. The third group could be considered deficient because they are medicated enough so they are no longer able to present with a complete case.
If you look at each of these instances, it is not that they are truly deficient, as much as, for one reason or another, either the patient is unwilling or unable to present symptoms. There are ways around these kinds of cases, but these are not what we are really talking about when we discuss deficient cases.
That said, the majority of deficient cases, or the focused writing on this subject historically, has been corrected for through the philosophy & application of Cycles & Segments. For example, Boenninghausen’s complete symptom included seven qualities, and an incomplete or deficient case will have one or more of these pieces missing. The concept of a Segment inherently takes care of this problem. We may see a modality represented in a different symptom altogether, or we may find that we arrive at a more complete symptom by something that comes out in the observation part of case taking, where we see or feel or observe certain aspects of a patient. We can funnel that information through the lens of looking for a particular Segment and when we train for those observation skills, we find much of the case reinforced by just such an ability to group like symptoms. (See case examples.) For us, this continues to be one of the most compelling reasons to use Cycles and Segments; it solves many of the problems we as homeopaths have had to wade through in the past.
A perfect example of what used to be considered a deficient case was in the treatment of people suffering with autism, as they exhibited so few general symptoms. However, what can be evidenced by our writing from the early 90’s is that we have solved that issue, in fact showing that those with autism do not present as deficient cases as much as the homeopath is not understanding what and how to perceive the case. With Cycles and Segments we have a tool that allows us to categorize symptoms, those articulated as well as those observed, those diagnosed alongside those understood.
AS: Quite a few homeopathy students cross over from non-medical fields and have not studied pathology. How important is that knowledge when practicing?
AR: We should start this answer by saying we teach extensively on the importance of understanding pathology, and Paul has written expansively on this subject in the Herscu Letter (http://www.nesh.com/the-herscu-letter/). Pathology is very important and has been so since the beginning of homeopathy. Without a clear understanding of pathology, it becomes challenging to know what it is that is being treated. It also becomes nearly impossible to make an accurate and appropriate prognosis without a working diagnosis. As far back as Boenninghausen’s writing entitled, A Contribution to the Judgment Concerning the Characteristic Value of Symptoms”, we have understood the importance of this question as one of the seven attributes that make up his complete symptom, this one being the second characteristic mentioned, i.e., “quid” or what is the thing. The third attribute is ubi or the seat of the disease. In other words, what is the nature of the disease and where does it lie. The way it is played out now in our medical training, when a patient’s history is being taken, we want to know everything about the symptoms. Every practitioner must be well enough versed in the understanding of pathology, in our most developed, modern sense of the word and if that is not an area of understanding or expertise, that person should practice in a setting where they can take advantage of the knowledge of colleagues. Pathology does not belong to any one school of medicine. Anatomy, physiology and pathology along with physical and clinical diagnosis, laboratory diagnosis and diagnostic imaging are in the purview of many kinds of practitioners and ultimately all homeopaths, should have such training as well.
AS : As you teach around the world, what misconceptions or mistakes do you find most often in the way students practice?
The million dollar question. We’d like to take this from the other angle first. The positive trends we see among students inspire us. There is the openness to learning, there is the desire to be of help to those suffering in this world, there is the commitment to long hours of study, to coming along on this journey of learning, to suspending judgment and allowing grace and understanding to happen. We are energized by the students we teach and it inspires us to keep refining our craft, keep making it more palatable and doable, keeping ourselves on task, being consistent in our clinic and then teaching , being transparent in our work and of course, being encouraging. Nothing makes either of our days better than when we receive a letter or email from a current or past student, see an article written by someone we taught, or hearing from a colleague about a patient success, or perhaps an insight or a thought that reflects deep understanding. Sometimes when teaching we are struck by on-target questions students ask, and on observations and connections they make. These are moments, when strung together, that make us know our work is work of the mind and the heart, and that it matters. When we see our work magnified by others and spreading out into practices near and far, helping people from all walks of life, this elegant and effective medicine comes alive and evolves, as it should.
As to misconceptions or mistakes, there are many and we all make them, hopefully less and less, the more experience we gain. We often forget to figure out what it is that needs to be helped, what is it that is most limiting to the patient. We hyper-focus on small details instead seeing the whole person. We do not understand the pace of healing. We aim too high and have unrealistic expectations of the remedy. We fail to understand obstacles to cure in term of the stressors in our patients’ lives. We change remedies too fast & repeat remedies too often. We do not connect with the patient, and due to that are unable to get their real story. We forget about the tried and true remedies and seek obscure prescriptions. We lose hope in patients and give up.
The best antidote to these kinds of mistakes is to work with a good model. Model making is a relatively new approach being utilized across the disciplines. The Cycles and Segments model grew out of Paul’s appreciation of the essential importance of using models to help with both understanding of homeopathic philosophy as well as practical applications. A good model creates scaffolding on which to hang all knowledge, things known from life experience as well as from new didactic learning and individual reading and study. A good model supports the proper posture toward all patients and gives a map on how to take a case, analyze a case, study materia medica and take a patient over time. We have found Cycles and Segments to be helpful and elegant and internally consistent over the course of many years of both practice and teaching. (You can read what some our students say about Cycles and Segments here: http://www.nesh.com/course-seminar-offerings/course-and-seminar-reviews/what-nesh-students-and-alumni-are-saying/ A good model helps explain past understanding. It can help to explain things that seemed contradictory before and can also help to predict new phenomenon and observations. In an installment of the Herscu Letter Paul has also written this:
While reading one of my chess books, as my sons have been playing in local tournaments, I came across the following quote that reflects my feelings about why I presented these first 11 Letters (which focus on the model of Cycles and Segments) and most especially, why I wrote this and the last Letter. In 1943, International Grandmaster Reuben Fine in his book, The Ideas Behind Chess Openings wrote the following:
“In every field the man who can merely do things without knowing why is at a disadvantage to the one who can not only build, but also tell you why he is building in that way. This is especially noticeable when the prescribed cycle does not obey the laws it is supposed to: then the laborer must sit by with folded hands while the mechanic or engineer comes in and adjusts the delicate mechanism….All this holds true in chess just as it holds true in every field which is a combination of theory and action.”
So even if you never study Cycles and Segments, try to find a model around which to wrap your study and practice of homeopathy!
Colleagues also help. The best way to avoid making the same mistakes over and again is to find a mentor whose work you respect and spend time together. Don’t forget to take time off, model the essential life ingredients of both rest and reflection for your patients. This medicine is good and this medicine works. A recent patient of Amy’s who’d been chronically depressed and suffering with ulcerative colitis, took the remedy Natrum sulphuricum, and over the course of three months became symptom free and on follow-up told Amy, “I feel like I have my life back.” Keep a little folder of those kinds of comments, or other kind words you receive in thank you cards or emails. Pull them out on the tough days. Keep the faith. Keep at it and it will get easier.
AS: In recent years the concept of Kingdom has become more popular. How reliable is it as a means of narrowing down the choice of remedy? What do you consider the right way and wrong way to use it?
We do not use kingdom concepts, never have. The approach to homeopathy that we practice is based on classical tenets, refined through the Cycles and Segments approach. We use the word refined, specifically. We are not trying to replace any of the tenets of homeopathic theory, that being matching a homeopathic remedy to the pathology of the patient. Through the history of homeopathy there have been different theories proposed which supplant the symptoms of a proving with other a priori theories. We are not placing judgment or saying one way is better, but some other approaches would not be what we would consider classical homeopathy and therefore we do not use.
AS: If someone has a friend or relative in the hospital, what advice would you give for intervening with homeopathy?
AR: In many new models of health care, the patient will not be hospitalized for things they now are, so this question in the coming years will be less and less relevant. The purpose of the hospital was to concentrate expensive equipment and operating rooms. As we move toward powerful pharmaceuticals and in-office equipment and procedures, traditional uses of the overnight hospital stay will become less and less common.
That said, happy to answer the question as posed! First off, we would not use the word intervene. Homeopathy is a helpful tool to use alongside other approaches whether allopathic or integrative. There are many reasons why a patient would be in the hospital and those reasons would inform the role that homeopathy plays. We have had numerous opportunities to treat those in life or death situations in hospital, whether at the first breath of life or the last, during acute ailments and when the ravages of chronic disease are taking their toll; we have worked with head trauma patients and those who have been the recipients of donor organs, those recovering from joint replacement and those getting tonsils out. There is no difference as to how you take the case with someone who is hospitalized. You look at the specific symptoms they have, you look at physical general symptoms, you take into account temperamental aspects and you prescribe the best remedy you can, to match the presenting symptoms. We do not worry about other drugs or diagnostic tests or IVs. We use the best potency you might think of, sometimes lower and repeated, at other times the highest available.
One of the main goals of all physicians is to keep people out of the hospital, but there is a time and a place for hospital care and homeopathy can be used in so many situations. The general list of what kind of patients might benefit from homeopathy while hospitalized includes:
1. Patients in for diagnostic work-ups. In some of these, a patient may experience an adverse event, such as from a toxic exposure or an allergy. There can also be trauma involved or an emotional response to a procedure or news revealed from a diagnostic work-up. In each of these cases, homeopathy can help support the patient, so that essential findings are gleaned but the patient has not suffered unnecessarily.
2. Severe acute ailments. Trauma or acute illness can bring patients to the hospital setting as we all know. Very often we’re dealing with species susceptibility (vs. individual susceptibility) so that the overall number of possible remedies to choose from is often MUCH less and therefore the possibility of getting it right is much greater, i.e., there is a smaller number of remedy presentations in trauma cases. Likewise, severe acute illnesses are also responsive to homeopathic remedies. In many of these ailments, time is one of the most important variables; the quicker help can be found, the better. The correct homeopathic remedy during an acute illness or event can be extremely helpful and though there is more variability than in a first aid or trauma situation, the overall number of remedy possibilities is also lower than say compared to treating someone with chronic disease.
3. We also use homeopathy post surgery for elective or planned procedures in order to support and promote healing. Remedies can speed up the healing time and help with the emotional aspects often involved.
4. The other place we use homeopathy in the hospital setting is to help care for the caregivers, certainly to support family members who are often there around the clock and can easily succumb to worry and the stress of the setting.
AS: A question that often comes up is, how is treating cancer similar to and different from treating other illnesses?
AR: In some respects, this question has various levels of complexity. Let me start with the very basic answer. We don’t treat cancer, we treat people who have cancer. We don’t treat bronchitis, we treat people who have bronchitis. And I have to be very particular here, as the difference between the question and the answer is the difference that leads to many misconceptions both for homeopaths and for those looking at homeopathy. If the question is how do you treat cancer, then what you’re saying is, you see disease as an externalizing force, as something outside ourselves that attacks us. In the latter, disease is a manifestation or an internalized force or disequilibrium. I know, at this time, in the homeopathic community there is a host of writing and beliefs that lead to a ‘modified’ version of homeopathy, where at times more than one remedy is give, etc. and that these people fit into a unique set. However, I have always seen this ‘set’ creations in homeopathy as both transitory to our professional history, and missing the overarching grandness of homeopathic practice.
Ok, so from this point of view, treating people who are presenting with cancer is similar to treating other people. For example, when the person is strong, has a clear presentation, has had few disturbances to their constitution, they often present and need a polychrest, and when they have been in poor health for many years, have had many disturbances, they may need a more rare remedy. The rules around repetition are the same as other patients. Follow-up considerations are the same. For example, if they are having concurrent chemotherapy, then that treatment may alter the presentation, and the way one deciphers that situation is similar to how one deciphers a change that occurs if someone just went on a drug for Hepatitis C, or for Rheumatoid arthritis, or in another case for someone who did not go on a drug and has these complaints, but just was in a car accident and broke bones, or was just robbed at gunpoint and is dealing with PTSD. The rules of how we contend with new symptoms that arise during treatment we described nearly 30 years ago, rules based on case after case, and they still fit perfectly today. This is the case whether someone has an acute disease or a disease that is currently considered incurable by our medical colleagues.
To sum up, I believe that a better way to think about the question asked is to focus less about the disease in question and more about the patient in question. I believe in doing so, we will discover why it is that some people who have a particular cancer, for example, can live 30 years with it, where others only live 30 months. The way to understand the heterogeneity found in these diseases has little to do with the disease itself, and most to do with the patient in question. The more we can remember that, the less confounding factors enter into the clinician’s practice, which is better both for the physician and the patient.
The difficulty for the prescriber is to understand how to use the full current understanding of pathology, and yet not lose the patient in the storyline. Making believe that the disease does not exist is not helpful. Making believe that the patient does not exist, and it is all disease, is likewise not helpful. I can give you an example of this as well. If you look at any therapeutics book, and there are many, of them, you find one common error. You find the symptoms of the disease, stated as if the disease walked in to your office. For example, in hay fever, if you look at any book, what you read is about the nose symptoms, and the eye symptoms and the mouth/throat symptoms. However, most often the correct prescription is decided upon, not just by these symptoms, but as importantly and often more importantly, by how the patient is responding to those symptoms. For example, the most consistent feature of Nux vomica hay fever is the irritation of these symptoms getting in the way of the patient functioning, whereas the most consistent feature of the Natrum muriaticum hay fever is the absolute embarrassment around the sneezing and the puffy eyes, and having everyone looking at them. Ultimately, the rest of the local symptoms may be similar or somewhat different, but the nexus of those local symptoms with the rest of the functioning of the patient is where homeopathy is unique. In 200 years, no therapeutics book has been written with this in mind. All have been written as if the disease existed by itself, outside the patient. It is such discordant messages our profession sometimes manifests that confuses the homeopath.
AS: Amy and Paul, it’s been wonderful chatting with you. Thank you for handling these questions with such depth and clarity. I hope our readers will explore your work and especially Cycles and Segments.
Visit Drs. Paul Herscu and Amy Rothenberg at: