Characteristics of experienced natural therapists.
Sutherland and Ritenbaugh, (1) in a convincing editorial, proposed to conduct research into the effects of practitioner factors on therapeutic outcomes in complementary and alternative medicine (CAM). The authors suggested research into several aspects of the practitioner including spiritual development, understanding of disease, healing intent, and other personality characteristics. DiMateo et al. (2) reported that research into practitioner personality characteristics is generally rare in medicine, because of the complexity involved in collecting information about physicians and their practices, and linking such data to treatment outcomes. Some research examined motives and personal characteristics that health care professionals themselves value. Vaglum, Wiers-Jenssen, and Ekeberg (3) identified empathy and person-oriented motives to be the most important motivations of medical students. Similarly, Engebretson (4) reported that patient-centred care was at the core of the nursing profession, expressed in the desire to unite head and heart with intent to heal. Chiropractic students were found to also place a high value on work fulfilment and successful interpersonal relations with patients. (5) Professional self-confidence was another personal trait characterizing final year medical students. Beagan, (6) in interviews with 25 third-year students and 23 medical school faculty members, described a process where medical students begin playing a role that becomes more real as responses from others confirm their new identity.
By comparison, the psychotherapy literature has explored practitioner characteristics to a greater depth: typically a positive correlation between practitioner characteristics and treatment outcomes has been reported. For example, in a comprehensive review of 25 studies examining psychotherapist's personal characteristics Ackerman and Hilsenroth (7) found the following attributes to have significant positive effects on the therapeutic alliance: flexible, experienced, honest, respectful, confident, interested, alert, friendly, warm, and open. In another study of the effects of psychotherapists' characteristics, Hatcher (8) found that therapists' confidence had the highest correlations with therapist and patient estimates of improvement. Other therapist factors that enhanced outcomes in psychotherapy included the degree of the therapist's self-disclosure, (9) the therapist's commitment to the work, (10) and therapist's warmth, understanding, competence, and respect for the patient. (11)
In comparison to the psychotherapy literature there is a paucity of research on personality characteristics in CAM. As studies quantifying the effects of CAM practitioner characteristics on health outcomes could not be located, characteristics that practitioners value themselves were examined. Therefore this study aims to examine values, motivators and personality traits that natural therapists believe enhance the therapeutic relationship and the medical outcomes of their clients.
Participants and sampling: The sampling strategy was based on the principle of purposeful sampling according to predetermined criteria. (12) The initial and minimum criteria for the selection were natural therapists, including naturopaths, nutritional medicine practitioners, herbalists and homoeopaths, who were registered with a Therapeutic Goods Act-recognized professional association, with at least three years of professional experience. For gender balance five male and five female practitioners were chosen. Preference was given to more experienced over less experienced practitioners, as it was thought that they have a richer story to tell. Interviewees had spent between eight and 29 years in professional practice (mean 15.4 years). The first author, a natural therapist himself, contacted ten experienced natural therapists in South Australia who fulfilled the selection criteria. Sample size was not predetermined but interviews were conducted to the point of redundancy. (13) The tenth natural therapist provided very little new information. A 22 question semi-structured questionnaire was based on the findings from a previously conducted literature review. (14) Face-to-face interviews lasting between 45-90 minutes were conducted in the clinic of each natural therapist.
Open coding (15) was used by examining every line of the transcripts, thus defining actions and events in it. After thoroughly reading through the first interview tentative codes were discussed between the first and the second author. In this phase memos were written to make sense of each meaning unit. The Qualitative Data Analysis program WEFT (16) was used for coding. In Grounded Theory the second step of analysis is called axial coding, in which relationships among categories are organized and further explicated. (17) In this study each category was analysed again for sub-categories by grouping codes with similar meaning together. The next step in the development of an overarching grounded theory is theoretical sampling. (18) According to the principles of the constant comparative method, each interview in this study was summarized on the basis of identified sub-categories and then sent back by email to each interviewee for verification, or refinement. The final stage of analysis in Grounded Theory involved the creation of substantive theory or "core" category.18 This substantive theory will be published in a future paper.
Therapist characteristics were not asked for in the interviews, as the questionnaire mostly focused on the clinical skills that improved the therapeutic relationship. However, during the interviews it emerged that the therapists believed that 'personal characteristics', enduring personality traits, motivators and values, also affected therapeutic outcomes. Analysis of the transcripts revealed seven practitioner characteristics: authenticity, altruism, intention, self-confidence, intuition, conscientiousness, and fulfilment of the practitioner.
The practitioners reported that being a natural therapist was a reflection of their life values. Authenticity was seen as a core value which meant several things: to be genuine in clinic rather than playing a professional role, an awareness that the practitioner's personality had an impact on the therapeutic relationship, and a desire to live one's private life according to the holistic and health promoting principles that they promoted to their clients. The practitioners believed that if they were genuine the client would be genuine too and would not simply say things to please the practitioner.
I'm just myself. If you come from your true self then the other person will read you and will be more likely to come from their true self. If you come from your adapted self, the professional self, then that person will be a pleaser, say the right things and do the right things, but they will manipulate the whole thing.
(Naturopathic practitioner 3)
However, one practitioner disagreed, believing that in order to give clients hope practitioners had to be enthusiastic and motivating, especially when feeling low themselves.
I think we put on an act. The therapeutic relationship does impart putting a performance on. It's an up-beat performance. We say, here is another reality, do you want to buy it? All communication is like a play acting game. It is a necessary game, otherwise we would be catatonic schizophrenics banging our heads against the wall. (Naturopathic practitioner 2)
In spite of disagreements about levels of authenticity, most practitioners thought that their personality contributed to their identity as a healer which affected thetherapeutic relationship.
Some things are inherent in the practitioner's personality type, their temperament which is partially genetically acquired. (Naturopathic practitioner 2)
Bringing one's personality into the consultation meant different things for different practitioners. The practitioners described aspects of their personality, such as being a jester (Naturopathic practitioner 3, motherly (Naturopathic practitioner 5), or an optimist (Naturopathic practitioner 10). One practitioner raised the concept of the wounded healer. He thought that if the healer and client had a similar emotional pathology the healer would have a better understanding of the patient's suffering, and perhaps get better outcomes.
I think there is a certain truism that a lot of patients see practitioners because the practitioner and the patient reverberate at a similar level of emotional damage. (Naturopathic practitioner 2)
Authenticity was not seen by the practitioners as confined to the clinic room but extended into their private lives as well. Four practitioners thought that it was imperative to live their personal lives in accordance with the values they expressed to their clients, that is, living a holistic life. This meant eating the diet that they recommend for their clients, and adopting an exemplary, salutogenic personal lifestyle
Every day I have time to dedicate to studies, or work on my property and spend time with my children. So the balance has to be there. (Naturopathic practitioner 4)
Two practitioners spoke at length about what being a healer meant for them. They wanted to live a value-driven life and therefore considered healing people as an integral part of their life mission, which was to make the world a better place.
Being a homoeopath or any healthcare practitioner is not a career, it is a vocation. I can't imagine how people live without homoeopathy. It's the way I think, it's the way I live, it's who I am, including being a mother, a wife, and a homoeopath. But I think it is also really important to have a life outside of our practice. I am very much part of the world and my community, trying to make a difference, and trying to take some small action that might change things. So homeopathy is a part of a bigger picture making the world a better place. (Naturopathic practitioner 9)
Healing people was seen as actualization of altruism.
The therapists reported being driven by altruistic values such as love, empathy or compassion, rather than monetary values.
You need to love your work and you need to love your patients, and tolerate your patients, and accept them. I don't see patients for money. I see patients to help them. (Naturopathic practitioner 5)
The best thing one can do with one's life is to help others. (Naturopathic practitioner 2)
One therapist, who was involved in martial arts and Eastern spiritual practices, reported being motivated by compassion married with strong discipline and a sharp mind.
I am almost a compassionate warrior; that tends to be the mind frame that I bring into the clinic. It is a loving, caring, heartfelt approach to people and situations. (Naturopathic practitioner 10)
Four practitioners indicated that intention was an extension of their altruism. Intention was generally defined as an internal wish for clients to get better.
I am sincerely wishing them to get better. (Naturopathic practitioner 2)
My intention is automatically I want the best, fastest, most positive outcome out of every consultation. (Naturopathic practitioner 5)
These practitioners talked about putting energy into healing by consciously visualizing a positive outcome. They believed that having an intention can help to achieve the intended outcome.
I think it [healing] is achieved by using the positive energy, use your energy, your mind, your thoughts. (Naturopathic practitioner 9) But I have a strong belief that our intentions are leading us to where we want to go. I use a lot of intention, a lot of vision; how I want to be and how I want to help people. (Naturopathic practitioner 5)
The homoeopaths in particular talked about putting healing intention into the medicines when preparing them. They reported visualizing a positive outcome for clients when they were succussing (i.e. shaking) homeopathic remedies.
When I make up remedies for clients I will actually put intention into the remedies. I will be thinking about that client and of the outcome, what I am hoping the remedy will do for them. (Naturopathic practitioner 1)
Practitioners actively fostered the belief that they can help clients to overcome their diseases. Therefore it was important for the therapists to feel confident in their diagnostic and prescribing skills.
I really feel that clients can get on top of this [their illness]. (Naturopathic practitioner 1)
According to the participants this confidence was based upon the traditional and evidence-based knowledge of effective treatment for the client's condition gained in professional training. Seven practitioners emphasised that the medical and naturopathic knowledge was indispensable in the understanding of the causes of any patient's disease and consequently finding the most appropriate treatment.
I have a bachelor of medical science, which is a research degree, sometimes in America called the premed degree. So I understand the pathology, the biochemistry, the drugs, how they work. (Naturopathic practitioner 2)
One naturopath acknowledged that practitioners can be either focused on the medical analysis and decision-making or be emotionally attuned to the client. This naturopath described how she is constantly moving between these two worlds.
When I test them I might go out of the patient and go into my world. I think about the illness, where does it start, what causes it, what is the chain reaction? So I am going into my own world for a moment. I test them, and explain to them, whilst I am doing it, on a very physical level. (Naturopathic practitioner 5)
Self-confidence was also based on their personal skills and ability to apply this knowledge to individual clients.
One is having confidence in one's skills and knowledge, the ability to work with the client, all that comes through to the client, that's again part of the placebo effect. (Naturopathic practitioner 8)
While medical and naturopathic training and knowledge were seen as the foundation of the practitioner's confidence, an exclusive focus on medical factors was seen to be insufficient in their work with clients.
Four practitioners remarked that intuition played an essential role in their understanding of the client's subtle non-verbal behaviours and the practitioner's corresponding choice of treatment.
So there are a lot of subtleties to stuff, but it is still real and definite, and if it isn't there the treatment is compromised by 70%. (Naturopathic practitioner 2)
Intuition was seen as the ability to perceive subtle clues beyond an intellectual understanding of clients, and beyond 'mere' empathy for the client. Particularly for homoeopaths this intuitive understanding was essential for the choice of the correct medicine. Practitioners reported that intuition developed with experience.
Intuition is just acute awareness and intelligence. It's like 'this is going on with their body, this is going on with their mind and this is what happened when they were a child' and when I put all of these things together I really try to experience that, and then I can come into contact with the substance [homeopathic medicine]. (Naturopathic practitioner 1)
My experience is of5000patients. Intuition has come in with that too. I use my intuition to work, but my intuition is also linked to my experience. (Naturopathic practitioner 5)
In order to enhance their intuitive skills meditation was utilized by four therapists. Meditation was seen to serve two purposes: firstly as an activity that practitioners used to put themselves into a frame of mind that enabled them to intuitively see a larger picture, and secondly to intuitively understand information that the patient presented during the interview, but whose importance was missed by the therapist at the time of the interview.
I will actually meditate on people for three days and then I have another conversation with them just about my impression. I meditate on them so that all the different fragmented parts of the picture that they might have given to me start to form a whole picture and sometimes also there are aspects of their biography that I may not have picked up on in the interview. (Naturopathic practitioner 1)
Another practitioner reported using meditation before seeing clients to put himself into a frame of mind that enabled him to perceive the subtle messages that clients might disclose.
There is a certain mindset that you have to have, a certain meditative frame of mind when you go into a situation, that enables me to be objective, also to be sharp, alert, and focused, and also to be able to pick up on what people are saying, to be really present with people. (Naturopathic practitioner 10)
Thus, some practitioners saw intuition as an important basis for diagnosis and treatment and some used meditation as a tool for sharpening their intuitive abilities.
Conscientiousness is the character trait of being painstaking and careful. It includes self-discipline, carefulness, thoroughness, organization, deliberation (the tendency to think carefully before acting), and need for achievement. In this study two practitioners emphasised that 'doing my best' with every client was the basis for getting good outcomes.
One thing that I always promise is doing my best, I do my very best. (Naturopathic practitioner 9)
Doing one's best involved persisting until the practitioner had found the true cause of the disease and an appropriate treatment. They were not satisfied unless they were certain that they had found the right treatment to help the client.
I give everything, I have to find out why they are not well. (Naturopathic practitioner 5)
I work hard. I don't prescribe unless I am absolutely certain, which sounds like a small thing, but it is not, it is a big thing. I go back to people if I am not certain. I say, there is something missing. I have not got the full story, I need some more. And I do that by following up with a phone conversation. (Naturopathic practitioner 9)
All practitioners mentioned that doing one's best entailed being fully present for the client. However, the two practitioners mentioned above strove for absolute excellence with every client. For one homoeopath, doing her best was almost a spiritual duty.
I do my very best I have honoured my gift, my knowledge, my connection with people. (Naturopathic practitioner 9)
Three practitioners spoke about the reciprocal nature of being a natural therapist. A close therapeutic relationship clearly benefited clients, but it benefited the practitioner too.
The practitioner-client relationship gives a lot of fulfilment to the practitioner.(Naturopathic practitioner 8)
Two practitioners felt that it was a privilege to be invited into a very vulnerable and precious part of their clients and to be part of their struggle to overcome disease.
I am here to care for them. I am here to help them, and I am honoured to be part of their journey. It's not just this illness, I am honoured. (Naturopathic practitioner 5)
One homoeopath spoke in depth about the almost spiritual experience of being a therapist accompanying clients on their journey from life to death. In poetic terms she described the healing effects on herself while being with her clients.
What a privilege, people bring me their treasure, their life story, their journey. Often people are telling me things that they have never told anyone else. I feel that this just washes over you just like a balm, an anointing, if you like. I find it very peaceful, calming. I do a lot of work with people who are dying. We are all going to die and often the therapeutic relationship is about allowing for this to happen in the best way possible; we don't always save people. I often say, I love sitting with people these last days and months. You get it in birthing too, a real sense that you are empty of yourself and you are part of it. It is like my food. I draw great strength from this emptiness. For me it is not a stressful thing at all. To me it feels very healing. You might have your own concerns and worries, and your own a private life, and that just dissipates, it just comes into some context. It enables you to live more fully. (Naturopathic practitioner 9)
The natural therapists in our study aimed at living a value-driven life, mostly based upon authenticity and altruism. They generally desired to live authentically both in their private and their professional life. This meant that they aimed to be authentic in clinic, not to hide behind a professional role: a theme reflected by Risdon and Eddy (19) who demanded integration between the professional role and person of physician, which in practice was not always achieved. Authenticity was also put forward by Rogers (20) as one of three necessary and sufficient conditions for therapeutic change in psychotherapy. Perhaps authenticity is necessary in natural therapies as well, but by no means sufficient to cure disease.
Another value that motivated the work of the therapists in our study was altruism, which included empathy and a desire to help their fellow human beings. These values are similar to those of medical students and beginning doctors. Therapist empathy has shown to improve patient satisfaction and outcomes. Price, Mercer, and MacPherson (21) in a study of 51 patients of acupuncture, found that patients' perception of practitioner empathy was associated with patient enablement at initial consultation and predicted changes in health outcome at eight weeks. Koss-Chioino (22), in an historical review of medicine, contends that altruism in medicine emerged out of spiritual traditions of healing and is seen as an integral part of CAM as well as folk and indigenous religious healing traditions.
Some practitioners in our study extended their empathy by consciously setting an intention to heal which they believed led to improve health outcomes. The belief that setting an intention will help to achieve one's goals has been made popular by the bestselling DVD "The Secret" (23) which is based upon ancient religious ideas, in line with a historical associations between religious beliefs and health. (24) More research is needed to find out if intention can affect health outcomes in natural therapies.
Most practitioners in this study identified self-confidence of the practitioner as a core characteristic to meet client's expectations of effective treatment. This confidence was based on professional training, scientific and traditional evidence of the effectiveness of one's treatment modality, and the possession of personal skills that help a client. Confidence has also been identified to be a key factor in other health care professions. In a qualitative study interviewing six chiropractors and some of their patients Langlois et al. (25) identified practitioners' confidence in the treatment as one of the three general themes characterizing chiropractic treatment. The role of CAM practitioners' confidence in treatment outcomes remains to be further examined. Confidence in one's intellectual knowledge alone was seen as insufficient to be an effective therapist. Intuition in particular was seen by the practitioners in this study to complement medical and naturopathic knowledge. Braude (26) defined intuition as a pre-conceptual element of human cognition that within medicine pertains to cognitive processes associated with practical reasoning. Thus, clinical intuition provides an empathetic means for physicians to visualize the inner essence of individual patients, and taking account of the continual flux of temporal physiological changes. (26) This was confirmed in this study, where practitioners reported that intuition enabled them to perceive subtle non-verbal cues, unspoken factors pertinent to the patient's illness that permitted practitioners to gain a more complete picture of the patient's overall life situation, which in turn increased practitioner's accuracy of diagnosis. According to Hall, (27) intuition is not just confined to the diagnosis but is also an inescapable part of decision-making in medicine and involves personal decision rules of health care professionals. This study suggested that intuition and clinical experience were linked. Both share the ability to draw connections, to see the big picture; an ability to go beyond conscious thought and pure intellectual knowledge. (27)
Three practitioners reported the use of mediation to increase their intuitive skills. They either meditated before the consult in order sharpen their clinical perception and therefore improve diagnosis, or meditated after the consult in order to improve clinical decision-making. Few studies in the medical literature have examined the role of meditation in the practice of health care professionals. Barmark (28) reported that the education of doctors of Tibetan medicine includes a 13-yearlong process of meditation training to enable them to understand the patient's mind and the individual's perception of the world. Kabat-Zinn (29) described an eight week program of Mindfulness-Based Stress Reduction for physicians that enables them to convey to patients an authentic first-hand experience of the benefits of meditation. Meditation seems to be a means of self-care for health care professionals as well as an authentic way to help clients improve clinical outcomes, which has been taken up by some natural therapists and medical practitioners.
Whether meditation by health care professionals can improve their clinical perception and decision making, or whether it can improve patients' health outcomes, remains to be examined.
In this study a few practitioners emphasised that conscientiousness was the basis for achieving optimal health outcomes for their clients. Conscientiousness has been the most consistent personality trait in the prediction of job performance in any profession.  The practitioners in this study only prescribed medicines once they felt certain that they had found the true cause of the client's disease and the most appropriate treatment. As only two practitioners volunteered this information during the interviews the role of conscientiousness in natural therapies remains to be further examined.
If conscientiousness led to improved patient outcomes perhaps these practitioners would have greater job satisfaction. A number of practitioners reported a deep personal fulfilment from their work, particularly when working with clients on very personal issues, and when supporting clients at birth and death. Professional satisfaction of health care professionals does not only benefit the professional but in turn also benefits the patient. McGlynn  found that physicians' job satisfaction was more important in predicting patient satisfaction with care than the time physicians spend with patients. Other studies of physician satisfaction demonstrated increased patients' psychosocial well-being and increased adherence to dietary and exercise advice, all critical in natural therapies. There seems to be a clear reciprocal relationship between patient and practitioner satisfaction which in turn affects health outcomes.
The methodological limitations of this study should be acknowledged. The non-randomized selection used in the recruitment of practitioners tends to attract participants sharing similar views. Furthermore, practitioner characteristics were not an a priori research question, nor asked for in the first three interviews. As practitioner characteristics emerged rather coincidentally than systematically these results may be biased. Future research should objectively assess these characteristics with validated instruments. Future analyses of practitioner characteristics could then be correlated with patient outcomes.
In spite of its limitations the present study is one of the first of its kind to define practitioner characteristics reported by naturopaths as forming the basis of their work. This study suggests that natural therapists consider their personality traits to be an integral part of the healing, but whether practitioner characteristics affect medical outcomes remains to be explored. In conclusion, outcome research in CAM should not only examine specific treatment, but in line with its holistic nature, should also examine non-specific factors such as practitioner characteristics.
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Dellman, T. and Lushington, K. Dr Thomas Dellmann is a naturopath and counsellor. Dr Kurt Lushington is Associate Professor, Head of the Discipline of Psychology at the University of South Australia