THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume 9, Number 1, 2003, pp. 39–50© Mary Ann Liebert, Inc.

Homeopathic Practitioner Views of Changes in Patients Undergoing Constitutional Treatment for

Chronic Disease

IRIS R. BELL, M.D., M.D.(H.), Ph.D.,1–9 MARY KOITHAN, R.N., Ph.D., A.P.R.N., B.C.,10

MARGARET M. GORMAN, B.A. P.A.-C.,1 and CAROL M. BALDWIN, R.N., Ph.D., H.N.C.11

ABSTRACTObjectives: To identify areas that classical homeopathic practitioners would want to see eval-

uated in a patient self-report questionnaire sensitive to change during constitutional treatment.Design: Open-ended, written practitioner questionnaire, analyzed using inductive content

analysis.Settings/Location: Two classical homeopathic meetings held in the western United States.Subjects: Homeopathic practitioners attending the above professional meetings and volun-

teering to complete the questionnaire in response to announcements prior to sessions.Data collection methods: Practitioners completed a demographic questionnaire and answered

an open-ended question inquiring for changes about which to ask people undergoing classicalhomeopathic constitutional treatment.

Results: The categories that the 38 homeopaths identified included changes in: (1) emo-tions; (2) mentation; (3) specific physical functioning; (4) general physical changes; (5) per-ception of self; (6) relationships; (7) spirituality; (8) lifestyle; (9) energy; (10) dream contentand tone; (11) well-being; (12) perceptions by others; (13) life relationships; (14) a sense offreedom or feeling less “stuck”; (15) sleep; (16) coping; (17) ability to adapt; (18) creativity;and (19) recall of past experiences. Sixteen percent (16%) of participants added more in-depthdescription of the nature of changes across categories (i.e., a rhythmical process of innova-tion and flux).

Conclusions: The findings are consistent with the systemic orientation of classical homeo-pathic philosophy to evaluate and treat the patient as a whole. Taken together, the results sup-port the need for development of new, multidimensional outcome measures for clinical researchin homeopathy beyond the disease-specific and health-related quality-of-life scales available fromconventional medical research.

39

1Program in Integrative Medicine, University of Arizona, Tucson, AZ.2Center for Frontier Medicine in Biofield Science, University of Arizona, Tucson, AZ.3Bioenergetics Core, Pediatric Center for Complementary and Alternative Medicine, University of Arizona, Tuc-

son, AZ.4Department of Psychiatry, University of Arizona, Tucson, AZ.5Department of Psychology, University of Arizona, Tucson, AZ.6Department of Medicine, University of Arizona, Tucson, AZ.7Department of Surgery, University of Arizona, Tucson, AZ.8College of Public Health, University of Arizona, Tucson, AZ.9Research Service, Southern Arizona Veterans Affairs Health Care System, Tucson, AZ.10College of Nursing, University of Arizona, Tucson, AZ.11Arizona Respiratory Center, University of Arizona, Tucson, AZ.

INTRODUCTION

Complementary and alternative medicine(CAM) therapies differ markedly not only

in the nature of their underlying philosophiesand interventions, but also in the scope andpatterning of their reported effects (Jonas andLevin, 1999). A number of CAM therapies, including Traditional Chinese Medicine, Ayur-veda, and homeopathy, distinguish themselvesfrom allopathy by using their intervention pro-gram to address chronic disease as a manifes-tation of disturbance in the whole person ratherthan in a specific organ system. However, CAMresearchers have relied largely on allopathictools developed for disease-specific outcomesor health-related quality-of-life outcomes. Re-searchers currently lack satisfactory tools forassessing the broad, individualized clinicaloutcomes claimed for various person-centeredCAM interventions (Bell et al., 2002a). Gouldand MacPherson (2001), for example, pointedout the need for CAM outcome measures ofbroad scope, especially for Traditional ChineseMedicine and acupuncture. They concluded ina qualitative/quantitative acupuncture studythat patients place greater value on changes ex-perienced in their emotions and lifestyles, eventhough they acknowledge alleviation of thephysical symptoms with which they had pre-sented.

One leading system of CAM for which prac-titioners claim multidimensional, system-wideeffects is homeopathy. Homeopathy is a 200-year old system of energy medicine developedby the German physician Samuel Hahnemann,M.D. Most classically trained homeopathicpractitioners take comprehensive bio-psycho-social-spiritual histories focused on under-standing the unique pattern of symptoms/lifeexperience that characterizes a given individ-ual in toto (Rowe, 1998; Vithoulkas, 1980). Theytreat the patient with the single remedy derivedof animal, mineral, or plant origin that best cap-tures the full picture of the patient. The rem-edy symptom pictures derive from “provings,”(i.e., tests of remedy effects on relativelyhealthy persons) (Sherr, 1994). Hahnemann(1843) claimed that “like cures like”; that is, asubstance that can cause a given symptom pat-tern in a healthy person can cure the same pat-tern in a sick individual.

Despite much scientific skepticism and de-bate over the years, homeopathy has survivedand even flourished in many different coun-tries. A small but growing body of clinical andbasic science evidence with allopathic, disease-focused outcome measures indicates thathomeopathy exerts more than simple placeboeffects (Bellavite and Signorini, 2002; Linde etal., 1994, 1997). However, many studies sufferfrom methodological flaws as well as lack ofreproducibility (Walach and Jonas, 2002). Also,it is logistically and financially easier to designbrief studies on acute illnesses or short-termstudies of chronic illnesses than to deal withthe complexities of longitudinal studies onchronic conditions. Most clinical research inhomeopathy evaluates short-term effects oftreatment, rather than long-term comprehen-sive effects on chronic diseases. Thus, much ofthe scientific data fails to address the postu-lated phenomenology of chronic disease froma homeopathic perspective or the long-termchanges that most homeopathic practitionersemphasize in their training programs, publica-tions, conferences, and clinical practices.

Furthermore, despite the whole-person em-phasis of homeopathic philosophy, most pastresearch studies examine disease-specific out-comes of particular allopathic diagnoses suchas allergies or arthritis. In contrast, homeo-pathic theory predicts a certain pattern of sys-temic changes throughout the individual in re-sponse to long-term homeopathic treatmentthat may or may not lead to change in long-standing disease symptoms before the end of ashort-term study. In homeopathy, Hering’s lawstates that change occurs from higher to lowerparts of the body, from inside out (from moreimportant organs such as the heart to less im-portant organs for immediate survival, such asthe skin), and in reverse order of the symptoms’appearance in time. Although consensus pan-els on CAM research have emphasized theneed to honor the conceptual framework of agiven modality in designing studies (Levin etal., 1997), no currently available outcome mea-sures address this patterning of nonspecificchanges that homeopathic theory predicts forpersons with chronic diseases over periods ofmonths to years (see also Walach, 2001).

The resulting irony is that the field of CAMresearch offers only minimal data on the phe-

BELL ET AL.40

nomena that homeopaths claim to see regularlyin their practices. Clinical researchers know lit-tle about the experience as lived, let alone lon-gitudinal outcomes, of persons who undergopractitioner-delivered homeopathic care overyears for long-standing, chronic conditions(Goldstein and Glik, 1998). A useful first steptoward developing appropriate outcome toolsthat are sensitive to change during homeopathictreatment of individuals with chronic disease isto apply qualitative research methods (Pope andMays, 2000). Qualitative approaches can estab-lish a foundation for understanding the phe-nomena that require consideration.

METHODOLOGY

The purpose of this study was to identify anddescribe the expected symptom and life patternchanges that occur during classical long-term,homeopathic, constitutional treatment from theperspective of the provider, many of whomalso have experience as homeopathic patients.Because there is little research literature thataccounts for providers’ expectations of care, therecipients’ responses or the patients’ experi-ences while undergoing homeopathic treat-ment, it was appropriate to use a triangulated,qualitative/quantitative approach to elicit amore holistic view of this complex phenome-non (Morse, 1994). Triangulation consists of us-ing two or more data sources and researchmethodologies to ensure the comprehensive-ness in a set of findings (Pope and Mays, 2000).In these study data, investigator and method-ological triangulation was applied to answerthe research questions:

1. What are the expected changes in symptomswhen using classical homeopathic, constitu-tional treatment?

2. What are the expected changes in life pat-terns that result from classical homeopathic,constitutional treatment?

3. Are there differences in expected patientchanges between more experienced and lessexperienced homeopathic providers?

We focused first on homeopathic providersrather than patients because of the homeopathicclaims that many patients manifest improve-

ments in broad aspects of their health and lifethat the treating practitioner perceives long be-fore the person undergoing the changes does(Vithoulkas, 1980). Such a claim has a precedentin psychiatric outcomes research on major de-pression, for instance, in which it is well estab-lished that observers often note behavioral im-provements much earlier than patients reportpositive mood changes during antidepressanttreatment. Moreover, even in the United King-dom, where homeopathy has achieved widerpublic acknowledgment as a CAM modalitythan in the United States (Furnham, 2000), con-sumer knowledge about homeopathy is limited(Furnham, 1999). Finally, anecdotally, a largepercentage of homeopathic practitioners havethemselves undergone, or continue to undergo,homeopathic treatment.

Setting and sample (or participants)

Participants were recruited by announce-ments during two different U.S. homeopathiceducational meetings in 2000–2001, either theAnnual Southwest Regional Classical Homeo-pathy Conference in Phoenix, AZ (sponsoredby the National Center for Homeopathy-affili-ated Phoenix Homeopathy Study Group) or thefirst year of a 2-year Homeopathic Master Clin-ician Course in the San Francisco Bay area (SanFrancisco, CA; organized by Luminos Homeo-pathic Courses, Ltd., Vancouver, B.C.).

Instruments

All participants completed a demographicquestionnaire with items on conventional andhomeopathic education and clinical experience.One item asked whether or not the respondenthad undergone classic homeopathic treatment.A 10-cm long visual analogue scale was usedto ask participants’ perspectives on the relativeusefulness that they believed should be ex-pected from conventional medicine (left an-chor) versus homeopathy (right anchor) in thecare of patients with chronic diseases. Formswere number coded to protect confidentialityand anonymity.

A second questionnaire was used to gener-ate the qualitative data. The purpose of thisquestionnaire was to elicit critical expectedsymptom and life change outcomes thathomeopathic providers would expect to see

CONSTITUTIONAL HOMEOPATHY 41

over the course of long-term classical constitu-tional treatment. A statement that framed theresearch question and intent of the study wasprovided for the participants: We are develop-ing a questionnaire for people who are under-going classical homeopathic, constitutionaltreatment. The goal is to evaluate the full rangeof symptom and life changes that people reportin the course of their long-term treatment.Please generate as many statements as you canconcerning what you believe we should ask onthis type of questionnaire. Formulate your re-sponses as if you were finishing the followingsentence: “One thing we should ask in a ques-tionnaire looking for changes in people under-going classical homeopathic, constitutionaltreatment is. . . “

Because there is little systematic researchabout the nature of change with homeopathiccare, the statement and language used in thisquestionnaire were intentionally broad andnonleading. We did not provide any biasing in-formation or suggestions on changes or typesof changes. Instead, we wanted the participantsto generate responses based on their profes-sional experiences, their own knowledge base,and their personal expectations of homeopathiccare. In doing so, we hoped to gain a better un-derstanding of homeopathic treatment as livedand experienced by homeopaths.

Data analysis

Descriptive data were entered via Teleformsscannable software forms (Cardiff Software,Vista, CA) into a database file and analyzed us-ing SPSS for Windows (version 10.0, SPSS Inc.,Chicago, IL). Responses to the qualitative ques-tionnaire were transcribed verbatim into Mi-crosoft® Word (Bellevue, WA) for contentanalysis.

Qualitative analysis. Inductive content analy-sis was used to analyze the narrative responsesto the qualitative questionnaire. Content analy-sis provides systematic means of making validinferences from written, visual or verbal data(Krippendorff, 1980; Weber, 1990). The purposeof content analysis is to identify and describecharacteristics or domains of phenomena usingboth qualitative (textual/thematic concepts)

and quantitative (frequency data) methods(Downe-Wamboldt, 1992; Polit and Hungler,1995). Therefore, this type of analysis was par-ticularly helpful as we developed an under-standing of the complexities of changes associ-ated with homeopathic treatment.

Inductive content analysis, as developedwithin the social sciences and linguistics, in-volves the process of inductive data reductionto distill out the most important or essential do-mains of homeopathic outcomes from thewords of the participants (Krippendorff, 1980).Rather than try to fit the responses into pre-conceived categories developed by the disci-pline (homeopathy), content analysis allowscategories to emerge from the perspective ofthe participants. Words and word phrases thatdescribe the expected changes during homeo-pathic treatment were identified from the tran-scribed data. These data units were first iden-tified using participant’s phrases, thensubsequently reduced to abstract-theoreticalcodes by combining similarly stated coded cat-egories. Once these abstract coding units wereidentified, data were again reduced and cate-gories were developed to reflect broad types ofchanges during homeopathic constitutionaltreatment and to generate an organizing frame-work.

Several methods were used to assure scien-tific rigor or trustworthiness during the quali-tative data analysis process. The use of a re-search team, periodic team conferences duringdata analysis and interpretation, triangulationacross data sources and types of homeopathicproviders, and the confirmation of the emer-gent theory with participants from a study-naïve homeopathic provider population, allstrengthened the credibility of the study results(Sandelowski, 1986). The use of a research teamand retrievable Excel documents, memos anddecisional matrices created an audit or decisiontrail that augmented the dependability of thestudy results (Lincoln and Guba, 1985). Con-firmability was ensured through extensive dis-cussions by the research team during dataanalysis and examination of the findings withfour representatives from the provider popu-lation (with different conventional and CAMtraining backgrounds) during the confirmatorystage of data analysis.

BELL ET AL.42

Quantitative analysis. The x2 statistic was usedto analyze categorical variables, including de-mographics, current and/or past classic home-opathic treatment, differences in proportions ofproviders from the two groups with differinglevels of classic homeopathic training (top ter-cile versus the rest of the providers) identify-ing the various categories, and the differencesin proportions of providers from the Arizonaand California meetings that identified the var-ious categories. Frequency data provided thenumber of statements per category. Analysis ofvariance (ANOVA) was used to determine dif-ferences in mean number of years of formal andinformal training in and practice of homeopa-thy, conventional education, and perceivedlevel of usefulness of conventional medicineversus classic homeopathic treatment on the vi-sual analogue rating scale (in centimeters fromleft anchor [conventional medicine], where ahigher score indicates greater emphasis onhomeopathy). SPSS (version 10.0) was used fordata analysis with significance set at p , 0.05(Fisher’s exact two-tailed) where relevant.

RESULTS

The respondents with completed forms (n 538) included 28 persons from the Phoenix con-ference (approximately 35% of total attendees)and 10 persons from the San Francisco course(approximately 33% of total attendees). Over-all, women comprised 86.8% of the sample,and 76.3% were non-Hispanic white. Averageconventional education (nonhomeopathic)was 18.3 6 4.6 years. Mean homeopathic for-mal training (e.g., schools, courses) was 3.3 63.5 years; homeopathic informal training (e.g.,self-study) was 7.3 6 6.9 years. Mean time inhomeopathic practice was 7.8 6 6.9 years.More than half of the sample (65.8%) reportedcurrent classical homeopathic constitutionaltreatment as patients, and more than one quar-ter (28.9%) reported having undergone classichomeopathic, constitutional treatment them-selves as patients in the past. The sample over-all rated the usefulness of classic homeopathictreatment for chronic diseases at 8.4 6 1.1 ona scale of 0 to 10 cm.

The sample fell into two subgroups with dif-

ferent levels of training and practice experi-ence. Table 1 provides the characteristics of thesubgroups (level of background/experience inclassical homeopathy). Between groups, Level1 had significantly more years of formal (5.29versus 2.17 years) and informal training (13.61versus 3.34 years), as well as years of practicein classical homeopathic, constitutional treat-ment (13.8 versus 3.5 years) compared to Level2. There were no significant differences for gen-der, ethnicity, years of conventional education,current/past treatment with homeopathy, orhomeopathy usefulness ratings between groups.

Results of content analysis

Participants identified a total of 395 state-ments related to change. These data units werethen reduced to a total of 19 distinct abstractcategories (n 5 386). To clarify these categoriesfurther, definitions were created using the par-ticipants’ language and descriptions of ex-pected phenomena rather than using extant the-ory of the discipline or a standard linguisticinterpretation/definition of the label devel-oped. Definitions reflective of the participants’descriptions of expected changes related to clas-sical homeopathic treatment were confirmedand validated by the research team and fourhomeopathic experts as noted above (two hadattended the Phoenix conference from whichthe data derived and two had not attended ei-ther meeting). In order to describe these emer-gent categories more fully, statements from theparticipants were selected as exemplars for eachof the definitions. Table 2 outlines categories,their definitions, and statement examples.

All of the statements were further examinedin terms of total number of times that partici-pants identified each change category. A per-cent total was then determined for each cate-gory. Categories of change were then rankedfrom most frequently to least frequently iden-tified. This information is provided in Table 3.

In addition to the categories that describedspecific areas associated with homeopathictreatment, 16% (n 5 6) of the participants choseto elaborate on the quality or nature of thosechanges. They provided a total of nine explicit“descriptor” statements, indicating that thesequalities could be applied across all of the pre-

CONSTITUTIONAL HOMEOPATHY 43

viously identified changes and could not be iso-lated to only one or two particular categories.Participant phrases describing the quality ofchanges included “lasted over time,” “dramatic,”“impact,” “peak,” “most difficult,” “planes,” “ag-gravation,” “worse before better,” and “persis-tently resolved or significantly improved.” Theseterms communicate the rhythmic patterns offlux inherent in changes that occur with home-opathic treatment and care. Specifically, home-opathic changes entail a rhythmic process of in-novation and change that occurs within humanlife processes with particular designs, arrange-ments, or distributions. These descriptions cap-ture the process and quality of the changes,above and beyond the states within which pa-tients might stabilize during treatment. Theyindicate that patients who receive homeopathictreatment do not simply “return to a healthy

state” but instead experience “different planesof change.”

In addition to identifying and quantifyingemergent change categories, participants wereidentified by years of training, and divided intotwo levels (top tercile versus remainder ofproviders). This analysis was done in order todetermine differences in the response cate-gories with respect to the amount of back-ground in classical homeopathy. There were nosignificant proportional differences betweenproviders with the different levels of trainingfor any category, or for the overarching de-scriptor for the nature of the changes. Com-parisons between Arizona and California con-ference homeopaths as to number of providersidentifying the different categories also did notreveal any significant differences by any cate-gory, including the descriptor of change pat-

BELL ET AL.44

TABLE 1. CHARACTERISTICS OF THE STUDIED SAMPLE

Level 1 Level 2n 5 13 homeopaths n 5 25 homeopaths

Characteristics (%) (%)

GenderMale 3 (23.1) 2 (8)Female 10 (76.9) 23 (92.0)

EthnicityNon-Hispanic white 12 (92.3) 17 (70.8)Other 1 (7.7) 7 (29.2)

Conventional educationYears (mean 6 SD) 18.7 6 4.1 18.2 6 4.9

Homeopathic education (mean years 6 SD)Formal training 5.29 6 4.8 2.17 6 1.6*Independent study 13.61 6 7.3 3.34 6 2.1**

Homeopathic practiceYears (mean 6 SD) 13.8 6 3.5 3.5 6 1.8**

Currently undergoing homeopathic therapyYes 9 (69.2) 16 (64.0)No 4 (30.8) 9 (36.0)

Past history of homeopathic therapyYes 4 (40) 7 (33.3)No 6 (60) 14 (66.7)

Visual analogue rating of the usefulness ofclassic homeopathic treatment for chronicdiseases—mean 6 SD (possible range 0–10 cm)a 8.5 6 1.3 8.4 6 1.1

Level 1 homeopaths $5 years formal training and .13 years of independent study; level 2 homeopaths, #5 yearsformal training and ,13 years of independent study.

*p 5 0.10; **p , 0.0001aHigher score indicates a greater perceived usefulness of homeopathy over conventional medicine in the treatment

of patients with chronic diseases.SD, standard deviation.

CONSTITUTIONAL HOMEOPATHY 45TABLE2.

CATEGORIE

S , D

EFIN

ITIO

NS , A

NDSA

MPLEST

ATEMENTSRELATED

TOCHANGE

WIT

HC

LASS

ICH

OM

EOPATHIC

TREATM

ENT

Categories

Definitions

Sample statements from transcripts

Ada

ptive

ness

The

cap

acity of a perso

n to adjust or be

come acclim

ated

to a situation

Hav

e yo

u been ab

le to integrate yo

ur cha

nges into yo

ur presen

t life?

that is ch

aracterize

d by op

enne

ss and

recep

tivity

Cop

ing

A situation-sp

ecific respo

nse, the

pur

pose of w

hich

is to con

tend

with

Greater ability to cop

e with ev

eryd

ay hassles?

and suc

cessfully

man

age a problem

Hav

e there be

en cha

nges in ho

w you

han

dle stress?

Creativity

Origina

lity an

d resou

rcefulness reflective

of on

e’s capa

city or poten

tial

Is creativity flow

ing?

for hu

man

becom

ing

Dream

sSeries of complex men

tal im

ages, thou

ghts, o

r story-lik

e experienc

esDream

con

tent m

irrors issues. A

ny cha

nges in recu

rring dream

s?during

sleep

tha

t are thou

ght to serve

som

e restorative or

Do yo

u remem

ber an

y dr

eams from

childho

od?

corrective

func

tion

Wha

t ch

ange

s em

otiona

lly hav

e yo

u no

ticed?

Emotiona

lA com

plex su

bjective

respo

nse that inv

olve

s feeling or sen

sibility;

Cha

nge in emotiona

l toleranc

e?often referred

to as human

passion

sCha

nges in vitality?

Ene

rgy

A vital cap

acity or life vigo

r that is resp

onsible for hu

man

pow

erHow

is yo

ur en

ergy

and

stamina?

in action

Are the

y ab

le to mov

e through

life more easily?

Freedom

The

ease or facility of men

tal, em

otiona

l, sp

iritual, or phy

sical

Do yo

u feel stuck in an

y area

s? A

bility to m

ove on

—no

t stuc

k.mov

emen

t, progress, or grow

thHav

e yo

u m

ade ch

ange

s in you

r life (left relation

ship, e

tc.)?

Life ch

ange

sAlterations

in central life ev

ents or role respo

nsibilities

Hav

e yo

u dev

elop

ed frien

dsh

ips or los

t friend

s sinc

e starting

trea

tmen

t?Lifestyle

Patterns

of life that reflect persona

l attitudes and

values

Ask

abo

ut foo

d preferenc

e an

d/o

r av

ersion

s.Wha

t are yo

u doing

in yo

ur free tim

e? C

hang

e in hob

bies?

Men

tal

Of or pertaining to the

mind or intellect; the capacity to deliberate

Hav

e there be

en cha

nges in yo

ur ability to think

, to think with clarity?

func

tion

ing

using

the

processes of an

alys

is and

syn

thesis

Wha

t do yo

u think

abo

ut? N

ew rev

elations

?Perception

sRecog

nition

of ch

ange

or alteration

by othe

rsHow

do yo

ur frien

ds an

d fam

ily feel yo

u are different?

by others

Do they

appearhe

althier, hap

pier, m

ore vibran

t?Phy

sical

Of or pertaining to the

bod

y an

d its corporea

l func

tion

s;Cha

nge in phy

sical bo

dy posture?

gene

ralities

nons

pecific cap

acity for bo

dily

func

tion

Cha

nges in ge

neral symptoms (tim

e of day

, season

s, tem

perature)?

Decreased

fatigue? N

ew sen

sation

s in you

r bo

dy?

Phy

sical

Of or pertaining to specific phy

siolog

ic sys

tems or corporea

lCha

nges in reco

very tim

es w

ith flu, h

eadache

s?func

tion

ing:

func

tion

s; specific cap

acity for pa

rticular bod

y func

tion

s or

How

are you

r phy

sical sign

s an

d sym

ptom

s?sp

ecific

presenc

e of sym

ptom

sCha

nges in men

ses, urina

tion

, bow

el m

ovem

ents?

Persona

lA sen

se of self; the

view one

has of self or self-discernmen

tInsigh

t into persona

l be

havior, b

eliefs, a

ttitud

es, va

lues?

percep

tion

How

do yo

u see yo

urself now

versu

s be

fore?

Recall

Reten

tion

and

recall of past ex

perien

ces; recollection

Recalled m

emories of past that w

ere no

t there be

fore.

Relations

hips

The

state of interpersona

l affairs or assoc

iation

sHas you

r ap

proa

ch/ab

ility to dea

l with pe

ople cha

nged

?Notab

le differenc

es in ho

w you

reson

ate with peo

ple, places, e

tc.?

Sleep

A periodically

recurring state of existen

ce cha

racterized

by

Are you

sleep

ing be

tter?

reduc

tion

of aw

aren

ess an

d voluntary phy

sical activity, an

dCha

nge in sleep

pos

itions

?reduc

ed respo

nsiven

ess to externa

l stim

uli

Spiritual

The

cap

acity of ind

ividua

ls to tran

sform con

flicts and

life’s

Hav

e there be

en any

cha

nges in yo

ur ow

n sens

e of m

eaning

in life?

func

tion

challeng

es into mea

ning

ful an

d pur

poseful experienc

es throu

ghDo yo

u feel you

hav

e a pa

rticular purp

ose or path in being

aliv

e at

a perception of self, po

werful othe

r, and

interpe

rson

althis tim

e?conn

ectedne

ssW

ell-be

ing

The

perception

of who

lene

ss or ha

rmon

y within the en

tire nature

Ove

rall feeling of w

ellness?

(phy

sical, so

cial, a

esthetic and

moral) of the

ind

ividua

l; simila

rDo yo

u feel m

ore ba

lanc

ed?

to the

con

cept of eu

daimon

ia

terning. Table 4 provides data on the numberof providers who identified at least one state-ment in each category.

After data analysis, four homeopathic ex-perts (one each: medical doctor, doctor of osteopathy, registered nurse, homeopathicmedical assistant) were queried as to theiragreement/disagreement with the change cat-egories and categorical definitions. They werespecifically asked whether the changes identi-fied in this study were representative of theirknowledge of homeopathy and their practice,and if the definitions were consistent with theirown use of the terminology. In addition, theywere asked to comment on the clarity of thecategorical definitions and the exemplar state-ments. While there was consensus that the cat-egories are representative of their practice, twoof the four commented that spirituality may becase-dependent and not applicable across allhomeopathic patients. The experts also pro-vided detailed feedback about the categoricaldefinitions. The categorical definitions of gen-eral and specific physical functioning weremodified to increase clarity and applicability toclinical practice based on feedback received

from three experts. One expert stated that cre-ativity might be more clearly identified as in-sight, while another stated that it is awarenessor “perception of creativity” that is importantrather than simply the acts associated with cre-ativity. Furthermore, two experts suggestedchanges to adaptation. One expert stated thatadaptation is more appropriately defined as“flexibility”; the other expert stated that adap-tation is associated with “harmony with theirenvironment.”

DISCUSSION

Qualitative methods were used to examinewritten responses made by homeopaths at-tending two different educational meetings toa query regarding changes that they would ex-pect to see with classical homeopathic treat-ment. From these data, 19 salient change cate-gories emerged that can be used for thedevelopment of appropriate outcomes tool thatare sensitive to change during homeopathictreatment, particularly for individuals withchronic illnesses. The categories, from most toleast frequently identified, include changes in:(1) emotions; (2) mentation; (3) specific physi-cal functioning; (4) general physical changes;(5) perception of self; (6) relationships; (7) spir-ituality; (8) lifestyle; (9) energy; (10) dream con-tent and tone; (11) well-being; (12) perceptionsby others; (13) life relationships; (14) a sense offreedom or feeling less “stuck”; (15) sleep; (16)coping; (17) the ability to adapt; (18) creativity;and (19) recall of past experiences. Addition-ally, participants provided descriptors relatedto the characteristics of the change process thathelped to describe the nature and dimension-ality of “change” itself. Finally, comparisonsbetween homeopaths with differing levels ofbackground in the field, as well as from meet-ings in two different states (Arizona and Cali-fornia) revealed no significant differences innumber of providers identifying each of thecategories.

To our knowledge, this study is the first todescribe the categories that homeopaths use inassessing long-term changes in their patients,toward the development of a homeopathic con-stitutional tool for use in homeopathy-related

BELL ET AL.46

TABLE 3. FREQUENCY OF STATEMENTS BY CATEGORY

FOR CHANGES DURING CONSTITUTIONAL

HOMEOPATHIC TREATMENT

Percent of totalCategory Frequency statements (%)

Emotional 67 17.4Mental 51 13.3Physical: specific 38 10.0Physical generalities 38 9.8Personal perception 25 6.5Relationships 22 5.7Spiritual 17 4.4Lifestyle 17 4.4Energy 16 4.2Dreams 15 3.9Well-being 14 3.6Perception by others 14 3.6Life changes 14 3.6Freedom 13 3.4Sleep 9 2.3Coping 7 1.8Adaptiveness 4 1.0Creativity 3 1.0Recall 2 0.5

NTOTAL 5 386 statements excluding the 9 additional de-scriptor statements on the nature of the changes acrosscategories.

outcomes studies. Previous homeopathy out-comes research has emphasized more short-term, primary care issues (Riley et al., 2001). Atool for constitutional treatment would providea more comprehensive, multidimensional pic-ture of changes in homeopathic patients dur-ing long-term treatment for chronic diseasesthan would currently available conventionalmedical scales that focus on end-organ or dis-ease-specific outcomes.

Specific and general physical changes are notunlike what a conventional medical providerwould assess in a medical examination. How-ever, physical assessment is generally the mainfocus of the conventional medical assessmentprior to prescribing. Although specific and gen-eral physical changes are leading categories en-dorsed by homeopaths, emotional changes takeprecedence, and the percentage of total state-ments for this category (17.4%) nearly achievesthat of the combined physical statements(19.6%). Changes in mentation also supercedethe physical change categories. The respondents’emphasis on the first four categories may reflect,in part, the teachings of leading master classicalhomeopaths such as Vithoulkas (1980), whose in-

fluential textbook devotes much attention to thehierarchical patterning of mental, emotional, andphysical outcomes. When the remaining cate-gories are viewed in toto, it can be seen thathomeopathic assessment encompasses a com-prehensive milieu of change that is much morereflective of the client’s life experiences and qual-ity of life, from relationships, spirituality, abilityto cope and adapt, to overall well-being. More-over, homeopathic quality-of-life outcomes mayextend beyond health-related domains to a muchbroader view of the individual’s entire scope andflow of life experience.

Implicit in several of the categories, includ-ing “Freedom” (e.g., “ability to move on—notstuck”), is the notion of the patient showing anincreased capacity to make various changes,sometimes abrupt, sometimes subtle and grad-ual, as well as to recognize such shifts. In home-opathy, the medication (remedy) is specific tothe individual’s phenomenological history anddynamic pattern as a whole, not to a pre-sumptive local, biochemical mechanism un-derlying a specific conventional physical diag-nosis. Thus, changes in the homeopathicpatient may focus on a more multidimensional

CONSTITUTIONAL HOMEOPATHY 47

TABLE 4. PERCENT OF PROVIDERS IDENTIFYING EACH CATEGORY, BASED ON THEIR LEVEL OF

TRAINING IN CLASSIC HOMEOPATHY

% Level 1 [most experienced] % Level 2 [rest of sample]Category (n 5 13 homeopaths) (n 5 25 homeopaths)

Emotional 69% (9) 72% (18)Mental 69% (9) 68% (17)Physical: specific 69% (9) 48% (12)Physical generalities 31% (4) 60% (15)Personal perception 23% (3) 44% (11)Relationships 23% (3) 32% (8)Spiritual 23% (3) 36% (9)Lifestyle 23% (3) 16% (4)Energy 23% (3) 40% (10)Dreams 31% (4) 32% (8)Well-being 15% (2) 36% (9)Perception by others 15% (2) 32% (8)Life changes 31% (4) 40% (10)Freedom 15% (2) 16% (4)Sleep 23% (3) 24% (6)Coping 8% (1) 16% (4)Adaptiveness 0 12% (3)Creativity 8% (1) 8% (2)Recall 15% (2) 0Descriptor: 15% (2) 16% (4)

Nature of the changes

Level 1, top tercile, $ 5 years formal training and . 13 years of independent study; level 2, remainder of sample$ 5 years formal training and , 13 years of independent study. Percentages have been rounded.

or even global systemic process of healing thanbiomedicine addresses. Such changes requirean individual to recognize change in self andto be open to change (and thus “unstuck”). Forexample, in the “Spiritual” category, the par-ticipants indicated that they might ask a patientif there were changes in his or her “own senseof meaning in life.” Likewise, in the “Relation-ships” and “Perception by Others” categories,participants noted that clients may be queriedas to changes in their “ability to deal with peo-ple,” or “how . . . your friends and family feelyou are different,” respectively.

Interestingly, exemplars of the word“change” surfaced during the explication ofcategories. Several homeopaths qualified, en-hanced, or further defined the idea of “change”in homeopathic assessment with such terms as“dramatic,” “subtle,” “resistance,” and “res-onate.” Specifically, participants identified adynamic pattern of aggravation, peak experi-ences, and change reflective of the holistic na-ture of human health and existence and the in-evitable ebb and flow that is found in humanlife. In homeopathic theory and practice, the ef-fects of homeopathic remedies are bidirectionaland state-dependent (Bell et al., 2002b). That is,the same agent at the same dose can trigger ei-ther net worsening or improvement in a givenperson, depending on the individual’s state(sick or healthy) at the time of administration.Clinical change in a sick person also can betransiently bidirectional (Hyland and Lewith,2002), in view of the possibility of initial ag-gravations or temporary worsenings early intreatment response, prior to improvements.

Other homeopaths in this study suggestedchange statements that reflect the notion of sys-tem-wide shifts in how symptoms remit in onesubsystem and emerge more prominently inanother (e.g., “new symptom deeper or lessdeep,” Hering’s Law of Cure: – center of grav-ity of the illness changing from more importantto less important organs, from inside out, andin reverse order of original time of appearance,over the course of long-term treatment[Vithoulkas, 1980]). The present findings sug-gest that both the breadth of change categoriesand the dynamic processes and patterns con-tained in the meaning of the term “change” are

equally important in constitutional homeo-pathic treatment.

Homeopaths are the first to acknowledgemuch diversity of viewpoints concerning opti-mal practice within their community (Rowe,2002). It is notable, therefore, in this study, thathomeopaths with differing levels and types oftraining and experience as well as homeopathsattending classical homeopathy conferences atdifferent locations agreed on the rankings ofthe categories. No differences were seen fornumber of providers identifying the variouscategories by subgroups in terms of level oftraining, or by state conference site (Arizonaand California). Concurrence between the sub-groups suggests some areas of commonality re-lated to long-term classical homeopathic carethat supercede the amount or type of trainingin classical homeopathy. Although there are nopure tests of validity in qualitative studies, tri-angulation (e.g., the use of two or more datasources, such as the Arizona and Californiahomeopaths in this study) is a means of fos-tering a more reflexive analysis of the data(Pope and Mays, 2000). Concurrence betweenthe Arizona and California homeopaths sug-gests broad coverage of salient categories andsupports the findings in this study. The feed-back of the four homeopaths who reviewed thecategories, definitions, and exemplar state-ments also largely reflected agreement with theprimary categories. Further research is neededto determine the views of other samples ofNorth American homeopaths from differenttraining backgrounds as well as the cross-cul-tural perspectives of the international homeo-pathic community.

Small sample size (i.e., number of partici-pants), the preliminary nature of this investi-gation, the noninteractive method of data col-lection, and the lack of statements of changefrom homeopathic patients who are not home-opathic providers are all potentially inherentlimitations of this study. This study constitutesthe first investigation in a line of research aboutchanges associated with homeopathic treat-ment and resultant proximal and distal out-comes of care. The sample selected for thisstudy was one of convenience and smaller thanwhat will be used in subsequent studies. Data

BELL ET AL.48

collection involved a written response formatrather than intensive individual interviews.While the procedures allowed us to beginstudy of this phenomenon, they did not allowus to investigate fully the emerging categoriesor request clarification of participant state-ments. Thus, the present data likely do not re-flect saturation in any of the categories (i.e., thepoint at which no new categories or datagroupings could emerge from the participants).

As a result, the current data analysis wasconservative in order to decrease the potentialfor premature closure, which could result inthe elimination of valid categories of homeo-pathic change and/or oversimplification ofsuggested change categories. As such, the cat-egories identified in this study constitute apreliminary list of changes associated withhomeopathic intervention that are valuablefor the development of knowledge abouthomeopathy and require further developmentand study. Some of these categories may ap-pear to have areas of redundancy in their de-finition and exemplar statements; others arederived from small numbers and percentagesof total statements collected. Yet, for ex-ploratory purposes, all emergent categoriesare reported as presented in the data to stim-ulate dialogue with others interested in simi-lar phenomena and to acknowledge accu-rately the developing basis of this work.Future studies will likely refine this initial setof change/outcomes statements and result infurther category reduction and differentiation.

Although these are significant limitations,the 38 homeopaths who participated generatednearly 400 change-related statements relevantto long-term classical homeopathic treatment.This is a respectable number of data units(statements) to which inductive analytical tech-niques, such as used in this study, can be ap-plied and interpreted (Denzin and Lincoln,2000). Furthermore, this study intentionally fo-cused on homeopaths rather than patients asbackground for a larger validation study ofhomeopaths, as well as long-term users ofhomeopathy. Notably, nearly 95% of the home-opaths who responded to this study are un-dergoing, or have undergone, long-term clas-sical homeopathic treatment as patients. Hence,

a majority of these participants were able towrite from the perspectives of both homeopathand homeopathic patient. It will be importantin future studies to determine whether or notstatements from nonhomeopath patients areconsistent with categories identified in thisstudy. Finally, the use of qualitative ap-proaches such as those used in this study arehighly appropriate to the development of toolsfor use by homeopathic researchers and clini-cians, given the current state of the science inclinical homeopathic research.

Despite any limitations, the categories thatemerged from the qualitative/quantitativeanalysis of practitioner-identified changes inlong-term, homeopathic, constitutional treat-ment overlap those reported in Gould andMacPherson’s (2001) study. They found thatclients undergoing acupuncture treatmentvalued changes in emotion and lifestyle overalleviation of their physical symptoms. Thecategories explicated in this study of home-opaths, as well as the qualitative meaningsidentified with the word “change” also sup-port the need for relevant tools for use inhomeopathic research and practice. The iden-tified categories are consistent with the philo-sophical underpinnings of homeopathy(Vithoulkas, 1980) and will facilitate develop-ment of appropriate instruments for use inhomeopathic outcomes research (Bell et al.,2002a,b). Systems of CAM such as homeopa-thy that emphasize the person as a wholerather than conventional diagnostic categoriesor disease-specific mechanisms may requiremuch more comprehensive, multidimen-sional, and individually tailored outcomemeasures than are currently available fromconventional medical research (Kane, 1997).

ACKNOWLEDGMENTS

The authors thank the Phoenix HomeopathyStudy Group and Luminos HomeopathicCourses Ltd. for permitting data collection inthis study as well as Lia Bello, R.N., F.N.P.,C.C.H., Bill Gray, M.D., Yolande Grill, H.M.A.,C.C.H., and Ilene M. Spector, D.O., M.D.(H.)for their review of and comments on the data.

CONSTITUTIONAL HOMEOPATHY 49

Supported in part by National Institutes ofHealth grants K24 AT00057-02, R21 AT00315-02, and P50 AT00008-03, and HL53938-08S1.

REFERENCES

Bellavite P, Signorini A. The Emerging Science of Home-opathy. Complexity, Biodynamics, and Nanopharma-cology, revised ed. Berkeley, CA: North Atlantic Books,2002.

Bell IR, Caspi O, Schwartz GE, Rychener D, Grant KL,Gaudet TW, Maizes V, Weil A. Integrative medicineand systemic outcomes research: Issues in the emer-gence of a new model for primary health care. Arch IntMed 2002a;162:133–140.

Bell IR, Baldwin CM, Schwartz GER. Translating a non-linear systems theory model for homeopathy into em-pirical tests. Altern Therap Health Med 2002b;8:58–66.

Denzin NK, Lincoln YS, eds. Handbook of Qualitative Re-search, 2nd ed. Thousand Oaks, CA: Sage, 2000.

Downe-Wamboldt B. Content analysis: Method, applica-tions, and issues. Health Care Women Int 1992;13:313–321.

Furnham A. Attitudes towards homeopathy in particularand beliefs about complementary medicines in general.Psychol Health Med 2000;5:327–342.

Furnham A. Ignorance about homeopathy. J Altern Com-plement Med 1999;5:475–478.

Goldstein MS, Glik D. Use of and satisfaction with home-opathy in a patient population. Altern Ther Health Med1998;4:60–65.

Gould A, MacPherson H. Patient perspectives on out-comes after treatment with acupuncture. J Altern Com-plement Med 2001;7:261–268.

Hahnemann S. Organon of the Medical Art, 6th ed.O’Reilly WB, trans-ed.; Decker S, trans. Redmond, WA:Birdcage Books, 1996 [first published in 1843].

Hyland ME, Lewith, GT. Oscillatory effects in a homeo-pathic clinical trial: An explanation using complexitytheory, and implications for clinical practice. Home-opathy 2002;91:145–149.

Jonas WB, Levin JS. Essentials of Complementary and Al-ternative Medicine. Philadelphia: Lippincott Williamsand Wilkins, 1999.

Kane RL. Understanding Health Care Outcomes Re-search. Gaightersburg, MD: Aspen, 1997.

Krippendorf K. Content Analysis: An Introduction to itsMethodology. Thousand Oaks, CA: Sage, 1980.

Levin JS, Glass TA, Kuski LH. Schuck JR, Steele L, Jonas WB.Quantitative methods in research on complementary andalternative medicine. Med Care 1997;35:1079–1094.

Lincoln KS, Guba EG. Naturalistic Inquiry. Beverly Hills,CA: Sage, 1985.

Linde K, Clausius N, Ramirez G, Melchart D, Eitel F,Hedges LV, Jonas WB. Are the clinical effects of home-opathy placebo effects? A meta-analysis of placebo-con-trolled trials. Lancet 1997;350:834–843.

Linde K, Jonas WB, Melchart D, Worku F, Wagner H, Ei-tel F. Critical review and meta-analysis of serial agi-tated dilutions in experimental toxicology. Hum ExpToxicol 1994;13:481–492.

Morse J. Designing funded qualitative research. In: Den-zin NK, Lincoln KS, eds. Handbook of Qualitative Re-search. Thousand Oaks, CA: Sage, 1994.

Polit D, Hungler B. Nursing Research: Principles andMethods, 5th ed. Philadelphia, PA: Lippincott. 1995.

Pope C, Mays N, eds. Qualitative Research in Health Care,2nd ed. London: BMJ Books, 2000.

Riley D, Fischer M, Singh B, Haidvogl M, Heger M.Homeopathy and conventional medicine: An outcomesstudy comparing effectiveness in a primary care set-ting. J Altern Complement Med 2001;7:149–159.

Rowe T. Homeopathic Methodology. Repertory, Case-Taking, and Case Analysis. An Introductory Homeo-pathic Workbook. Berkeley, CA: North Atlantic Books,2000.

Rowe T. Creating standards and competencies for home-opathic practice. Homeopathy Today 2002;22:2.

Sandelowski, M. The problem of rigor in qualitative re-search. Adv Nurs Sci 1986;8:27–37.

Sherr J. The Dynamics and Methodology of HomeopathicProvings, 2nd ed. Malvern, UK: Dynamis Books, 1994.

Vithoulkas G. The Science of Homeopathy. New York:Grove Press, 1980.

Walach H. The efficacy paradox in randomized controlledtrials of CAM and elsewhere: Beware of the placebotrap. J Altern Complement Med 2001;7:213–218.

Walach H, Jonas WB. Homeopathy. In: Lewith G, JonasWB, Walach B, eds. Clinical Research in Complemen-tary Therapies. Principles, Problems, and Solutions. Ed-inburgh: Churchill Livingstone, 2002:229–246.

Weber RP. Basic Content Analysis. Newbury Park, CA:Sage, 1990.

Address reprint requests to:Iris R. Bell, M.D., M.D.(H.), Ph.D.Program in Integrative Medicine

University of Arizona College of Medicine1501 North Campbell Avenue, Box 245153

Tucson, AZ 85724-5153

E-mail: ibell@u.arizona.edu

BELL ET AL.50