Empowerment in naturopathy: A qualitative analysis of practitioner perspectives

Chronic pain (lasting more than 3 months) is frequently associated with emotional distress, impaired functional ability, decreased work and lower social interaction [1]. It is a growing burden on society, estimated to affect up to 20% of the world's population and accounting for up to 20% of medical visits. The growing incidence of chronic pain is associated with increasing ageing populations and a lack of conventional pain treatment options [1]. Individuals with chronic pain often find themselves managing their condition themselves, with inadequate or no conventional pain treatment [2].

The impact of chronic pain extends well beyond local physical pain [[2], [3], [4]]. For people living with chronic pain, independence and quality of life are often compromised [5]. For these individuals, self-medication and medical non-compliance is common [6]. According to Pain Australia [3], many people with chronic pain seek multi-disciplinary support with varying levels of success, despite enormous cost. In 2018, Australian tax payers spent $139 billion with a further $2.7 billion in out-of-pocket expenses on chronic pain management [3]. Causal factors of chronic pain are complex, including modifiable (i.e. smoking, diet and physical activity) and non-modifiable (age, gender, and socio-economic background) factors that may interact with beliefs and histories of injury and abuse [7]. In a survey of 379 Australian consumers of complementary therapies, the majority (95%) viewed themselves as primary managers of their own healthcare [8]. This suggests there is a large population of people with chronic pain who may benefit from greater education about pain management strategies and treatment options. According to Grady and Gough [5], self-management involves education to facilitate problem solving and decision making and the formation of therapeutic partnerships.

Naturopathy has been described as an example of person-centred care [9,10]. As a whole medical system, naturopathy has a complete theoretical and practical framework that has evolved independent of conventional medicine [11]. It is based on the concept that health arises when the mind, body and spirit are in harmony [12]. According to the World Naturopathic Federation [13], there are seven core principles that underpin naturopathic practice: (i) first, do no harm (primum non nocere), (ii) healing power of nature (vis medicatrix naturae), (iii) treat the cause (tolle causam), (iv) treat the whole person (tolle totum), (v) doctor as teacher (docere), (vi) health promotion and disease prevention and (vii) wellness and wellbeing. The last principle has only recently been formally recognised [13] and highlights naturopaths' regard for the importance of individuals as agents of self-care.

Naturopaths traditionally utilise various therapeutic modalities, such as herbal medicine or nutritional supplementation, either individually or in combination. Interventions are generally prescribed in a therapeutic order that begins with identifying and removing obstacles to health before progressing towards more invasive therapies [14]. For example, nutritional imbalances may be addressed by first attempting to correct dietary imbalances. If further intervention is required, a regime of nutritional supplements may be prescribed. Interventions are employed to address specific health conditions as well as provide symptomatic relief. With a shifting focus towards more active health promotion, disease prevention and wellness, practitioners are simultaneously required to foster increased patient self-awareness and self-agency. Through this process, it is hoped that increased self-awareness will deepen the therapeutic dialogue which may further guide the use of interventions and modality choices.

The naturopathic interpretation of docere is therefore a key principle of naturopathic practice. Patients are guided to increase their self-awareness and personal responsibility. Docere also facilitates the sharing of knowledge of health conditions, treatment options and wellness in a bid to increase patient health literacy. Health literacy is “the degree to which individuals can obtain, process and understand the health information and services they need to make appropriate health decisions” [15]. By increasing health literacy, patients have greater opportunities to make decisions affecting their health.

The naturopathic principles of tolle totum and docere promote an individualised, person-centred approach to healthcare which aligns with definitions of patient empowerment [16,17]. An empowered patient is defined as one who has control over their daily life, is able to participate in decisions related to their condition and be co-managers of their condition in partnership with health professionals [17]. To manage the daily impacts of chronic pain, it is suggested that individuals need to develop “self-confidence, self-esteem and coping skills” [17]. A qualitative study by Thomas [18] found patient empowerment was fostered through person-centred care that increased patient literacy and their sense of being respected. It has also been suggested that person-centred care is perceived as safer and associated with perceived improvements in patient health outcomes [19].

Within the growing evidence supporting naturopathic practice, there have been studies investigating the benefits of naturopathy as a whole medical system for chronic pain [13]. In one randomised trial, postal workers who experienced low back pain for more than six weeks received either physiotherapy or naturopathic care [20]. Those who saw a naturopath reported significantly lower back pain as measured by the Oswestry questionnaire (−6.89, 95% CI. −9.23 to −3.54, P = .0001) as well as improved quality of life (measured by Short Form 36), improved spinal flexion and decreased weight compared to the control group [20]. In another randomised trial involving warehouse workers with chronic low back pain, the efficacy and cost-effectiveness of naturopathic care was investigated [21]. Participants were randomised to receive either naturopathic care or standard physiotherapy education for six months. Participants who underwent naturopathic care were given acupuncture, relaxation exercises, dietary counselling, exercise advice and a booklet on back care. Only participants receiving naturopathic care experienced a statistically significant (P = .006) increase in quality adjusted life years. The difference in quality adjusted life years between the two groups was statistically significant (P = .036) with the average mental health gain equivalent to 9.4 “perfect health” days [21]. Participants in the naturopathic group also had reduced adjunctive care and absenteeism that resulted in a saving to society of $1212 per participant. These studies demonstrate the potentially positive impact that naturopathy may offer patients with chronic pain.

It has been suggested that some of the positive impacts of naturopathy on health have been the result of “social, comforting interaction”(22), however the establishment of a therapeutic relationship in naturopathic practice may go beyond social comforting interaction to patient empowerment. So far, there has been little research into what constitutes therapeutic clinical interactions, how they are established, how they may be used to benefit patients or the impact that such interactions have on practitioners. The aim of this research was to explore naturopaths' perspectives on the role of empowerment in their consultations with patients with chronic pain.

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