Therapeutic Order

What is Naturopathic Medicine?

The Therapeutic Order is the second cornerstone to Naturopathic Practice.  It provides the framework with which to determine appropriate interventions for maximum effectiveness and minimum harm.  The therapeutic order is a stepwise model that directs the naturopathic practitioner’s treatment.  It always starts with the least invasive intervention effecting the most foundational cause of disease and moves towards more invasive and symptomatic treatments only if the initial treatments fail or if the client is presenting with a state of a highly progressed or aggressive disease.  While there is a good deal of overlap and the boundaries between two or more levels can be blurry, in general the order follows a gradient from the least risk and cost to increasing risk and cost.  The levels of intervention of the Therapeutic Order are as follows:

Establish the Foundations for Health

This includes discussing the health goals of the individual client which can vary greatly between healthy individuals and even more so between patients presenting with various health concerns.  What is important here is that you establish each individual client’s health goals and work with them on clear ways to achieve them.  At this level of intervention, the most common treatment is removing obstacles to optimal health.  In other words, after understanding what their health goals are, understanding what is keeping them from achieving those goals and helping them remove or get around those obstacles.  Removing obstacles to health often goes a long way towards achieving health.  This level of intervention is mostly counseling and support.

Stimulate the body’s innate healing systems

The goal of this level of intervention is to optimize the body’s wellness mechanisms.  Some examples of common interventions would be hydrotherapy to increase circulation, fiber to improve bowel and liver function, herbal support for adrenal function, meditation and breathing exercises to show appreciation for your body’s innate healing systems, or increased sweating through sauna treatments or exercise.  These first two levels of intervention should be addressed at every visit, no matter how healthy the patient already is.  They are the cornerstone of preventative medicine.

Support and restore weakened systems

This represents the first level of intervention that may be needed as treatment of a pathological process.  All the same measures of the previous levels may be used but they are targeted at specific organs or systems (but not a pathological process).  As an example, fasting may be used to restore blood sugar stability and insulin sensitivity.  While intermittent fasting is a reasonable maintenance or preventative measure for lifelong health, in this example we are targeting the endocrine system and specifically insulin receptor sensitivity which we may have determined to be “weakened” from an elevated HbA1C test, fasting blood glucose test or simply from patient presentation of fatigue or lethargy.

Correct structural integrity

This could include naturopathic manipulation, therapeutic massage, visceral manipulation, MES, and so on.  It may be clear at this point that with each step up in the therapeutic order the clinician becomes more directly involved in the treatment.  This is the first point as we go up the therapeutic that it has become truly necessary for the clinician to touch or even actually intervene in the patient’s health (although it is highly likely that the clinician has provided some interventions at the previous levels).  While these treatments may still be quite gentle, in general the risk is slightly greater.

Targeted Natural therapies

This is referring to herbs and nutritional supplements.  Here the risk has increased more, as we are telling the patient to put some type of substance in their body.  This requires care and awareness of appropriate dosing, possible side effects, interactions and potential allergic reactions.  While we may use herbs for previous levels of interventions, now we are directing this at a specific diagnosis, not as a preventative measure or even support for a specific organ or system, but to treat a disorder.  For example passion flower tea is a reasonable recommendation for relaxation and improved sleep which can prevent hypertension, but at this level we are prescribing (not recommending) Passiflora incarnata to treat hypertension (for instance) and it must be accompanied with a specific dose and frequency.

Pharmaceuticals

This is not unlike the previous level but because the risk is usually (not always) greater and the side effects are often (not always) more severe, drug therapies gets its own category here.  In addition, pharmaceuticals are targeted at more specific cell receptors or enzymes or pathways and so are considered a more precision, higher force intervention.  I consider hormone replacement within this level of the Therapeutic Order, although some argue it deserves its own ranking just below pharmaceuticals.

Surgery or other high force interventions

This is the highest level of risk, the most invasive, and the highest force of intervention and is associated with very advanced pathologies or emergencies.  Other high force interventions can include chemotherapy and radiation therapy.

All of these are legitimate and necessary interventions at times and naturopaths are trained to engage in each one of these interventions as needed. It is the goal and hope of naturopathic doctors to never the higher-level interventions and to only ever need to intervene at the lowest levels to maintain optimal health for life. One of the main differences between naturopathic training and allopathic training is that naturopaths learn to intervene at the lowest levels in order to avoid the higher-level interventions while allopathic doctors do not usually intervene until the patient already requires higher force interventions.