CANADIAN NATUROPATHIC PRACTITIONERS: HOLISTIC

AND SCIENTIFIC WORLD VIEWS

HEATHER BOON

Faculty of Pharmacy, University of Toronto, 19 Russell Street, Toronto, Ontario, M5S 2S2, Canada

AbstractÐThis paper describes naturopathic practitioners with two di�erent world views Ð holisticand scienti®c, and explores the relationship of practitioners' socialization experiences and practice pat-terns with these two world views. Data were gathered by a variety of methods including: (1) a 14-pagequestionnaire mailed to all 296 naturopathic practitioners licensed in Canada; (2) a participant obser-vation study at the Canadian College of Naturopathic Medicine (CCNM); and (3) open-ended inter-views with 16 students attending CCNM and 41 naturopathic practitioners which were audio-taped andtranscribed verbatim. Individuals with both holistic and scienti®c world views entered naturopathictraining and none of the practitioners who were interviewed reported a change in world view while atnaturopathic college. However, practitioners reported a new-found appreciation of the ``other'' worldview on completion of their training, indicating the occurrence of a socialization e�ect. Many decisionsinvolved in setting up a practice and seeing patients were a�ected by the practitioners' world views. Forexample, there were distinct di�erences in the way the practitioners with di�erent world views whowere interviewed chose treatment modalities. Practitioners with scienti®c world views reported choosingtreatments based on the available ``scienti®c evidence'', while practitioners with holistic world viewsincluded a careful exploration of the patient's spirituality and their own intuition in their treatment de-cisions. In addition, practitioners with holistic world views reported signi®cantly longer patient visitsthan practitioners with scienti®c world views. The data presented here suggest that one's world view in-¯uences one's perceptions of socialization experiences and social situations, and modulates the e�ects ofboth on practice patterns. # 1998 Elsevier Science Ltd. All rights reserved

Key wordsÐnaturopathic medicine, world views

INTRODUCTION

Although recent studies indicate that approximately

one-third of North Americans (Eisenberg et al.,1993; Northcott and Bachynsky, 1993) and one-

third to one-half of Europeans (Vincent andFurnham, 1996; Lewith and Aldridge, 1991) have

used some form of alternative medical care, alterna-tive practitioners have received relatively little atten-

tion from academic researchers. Naturopathictherapy is often classi®ed with many other therapiesas a form of ``alternative'' medicine; however, many

naturopathic practitioners would argue that theyprovide services complementary to allopathic medi-

cine as opposed to alternative to it. This argumentarises because the term ``alternative'' medicine,

although commonly used, is at best loosely de®nedand can have many di�erent connotations.

According to one source, alternative therapies rep-resent activities which are in some way related to

human health, but are not o�cially recognized bythe dominant political system (The Hague, 1981).The current status of naturopathic medicine in

Canada is explored elsewhere (Boon, 1996b).

This paper describes Canadian naturopathic prac-titioners as individuals with two distinct worldviews, which I have identi®ed as ``holistic'' and

``scienti®c''. The development of these categorieshas been described previously (Boon, 1996a).

Practitioners with primarily scienti®c world views

appear to be more objective, reductionistic, practi-

cal, concrete, and are more likely to emphasize

treatment on a physical and structural level when

compared to practitioners with more holistic world

views. Practitioners with primarily holistic world

views can be described as more subjective, spiritual,

abstract, intuitive and more often emphasize treat-

ment on a mental or emotional level. These two

``ideal types'' (Schutz, 1953; Weber, 1949) may be

conceptualized as two poles of a continuum. This

paper explores the suggestion that one's position

along this continuum provides a key to explaining

one's socialization experiences, and one's practice

patterns. There is no analysis of the clinical e�ec-

tiveness of naturopathic medicine in this paper, but

rather an exploration of the interaction between

world view and both the perception of the naturo-

pathic paradigm and the practice of naturopathic

medicine.

Naturopathic medicine is based on a belief in ``vis

medicatrix naturae'', the body's own inherent heal-

ing force. The aim of the naturopathic practitioner,

therefore, is to create the most suitable conditions

for the body to heal itself. These conditions are

achieved by using a combination of natural treat-

ment modalities including: clinical nutrition; botani-

cal medicine; counselling; homeopathic medicine;

Soc. Sci. Med. Vol. 46, No. 9, pp. 1213±1225, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98 $19.00+0.00

PII: S0277-9536(97)10050-8

1213

mechanotherapy; naturopathic hygienic principles

and lifestyle modi®cation; oriental medicine andacupuncture; and physical therapeutic procedures(The Board of Directors of Drugless Therapy Ð

Naturopathy and The Ontario NaturopathicAssociation, 1994; Aakster, 1986; Bloom®eld, 1983;British Medical Association, 1986; Frank, 1981;

Rosengren, 1980; van Dam, 1986; Wiesner, 1989).Naturopathic medicine is unique among alternative

therapies in North America because naturopathicpractitioners are trained to integrate this wide var-iety of therapeutic modalities. The eclectic nature of

naturopathic medicine in Canada is compoundedby the fact that although graduates of NorthAmerican naturopathic colleges receive basic train-

ing in each of the treatment modalities listed above,the way in which these modalities are combined inthe treatment of patients appears to vary greatly

between practitioners.Much discussion in sociology has focused on the

relative importance of three competing modelswhich explain such di�erences in practice patterns:(1) the social origins of those recruited; (2) second-

ary socialization during professional training; and(3) the importance of immediate work situation.

The e�ects of social origins on career choice andpractice patterns have been conceptualized in termsof social class or gender. However, it can be argued

that one's world view, de®ned as ``a particular setof constructs that make one's world meaningful'' or``a ``®lter'' through which phenomena are perceived

and comprehended'', (p. 3) constitutes social originson a di�erent level (Miller and West, 1993). Thisway of conceiving of social origins is less prone to

biological essentialist reductionism than othertheoretical dichotomies such as the di�erences in

the way men and women perceive the world asdescribed in the feminist literature (Witz, 1991;Cayle�, 1987). Although adoption of a world view

is necessarily socially-mediated, it is not possible toassume an individual's world view from any singlevariable such as gender, social class, or ethnicity;

rather world view appears to be an aggregate ofprevious social experiences.

Miller and West categorized the world views ofmembers of ®ve professional groups Ð social scien-tists, physical scientists, lawyers, military personnel

(both o�cers and noncommissioned o�cers) andministers or priests, and discovered that their worldview categorizations were largely compatible with

the participants' career choices (Miller and West,1993). They argued that ``one's choice of career

must, to some extent, re¯ect one's philosophicalorientation and one's fundamental assumptionsregarding the sources of basic truths and the proper

goals of life'' (p. 3). In addition, a Canadian studydiscovered that students entering di�erent medicalschools had di�erent socio-political attitudes which

tended to correspond with the atmosphere of themedical school they chose to attend (Maheux and

Beland, 1987). The authors concluded that ``the po-tential for socialization within medical school is

therefore less considerable than one might expect''(p. 623). This suggests the argument that naturo-pathic students select naturopathic training because

they perceive it to be consistent with their worldview. If the training is consistent with their worldview, then one would expect to see fewer socializa-

tion e�ects than if the training experience di�erssigni®cantly from their world view.Schools that train health care practitioners have

been extensively studied as agents of socialization(Becker et al., 1961; Brown, 1991; Merton et al.,1957; Chappell and Colwill, 1981; Olesen andWhittaker, 1968; Simpson et al., 1979). Generally,

the goal of professional training is assumed to bethe establishment and/or perpetuation of the valuesand attitudes of a profession (Clausen, 1968; Gecas,

1990). However, the possibility that incoming stu-dents may have di�erent world views which a�ectboth their perception of the values and attitudes of

the profession and their experience of the socializa-tion process does not appear to have beenaddressed.

Other theorists have suggested that, the social en-vironment can cause changes in the values held byindividual practitioners if it does not reinforce theirsocialization experiences. For example, Freidson's

``structural approach to medical care'' is based onthe assumptions that the values internalized duringa socialization experience such as professional edu-

cation only endure if they are continually reinforcedby the social environment (Friedson, 1970). Hemaintains that:

the average behavior of an aggregate of individuals can bepredicted more successfully by reference to the pressuresof the environment than by reference to the motives,values, and knowledge they had before entering the socialenvironment (p. 66).

In contrast, Chappell and Colwell's Canadian

study of medical socialization reveals only slightsupport for the e�ect of immediate work environ-ment on career attitudes (Chappell and Colwill,

1981). In their study, they conclude that ``previousattitudes (both attitude upon entrance to andchange in attitude during medical school) were themost important predictors of attitudes when work-

ing'' (p. 74) for all but one of the attitudesmeasured. Cantor's integration of socialization andsituational factors for understanding behavior

emphasizes the dynamic character of personalityand suggests that one's world view will a�ect one'sinterpretation of a given situation and thus it may

be key to understanding one's behavior (Cantor,1981). Cantor argues that ``to the extent that socialbehavior is cognitively mediated, one must pay

increasing attention to the cognitive generalizationsabout the world that the lay perceiver maintains''(p. 230). This paper explores the existence of worldviews prior to entering naturopathic training; inves-

H. Boon1214

tigates the relationship between world views andsocialization; and compares how practitioners with

di�erent world views perceive the naturopathicparadigm and practice naturopathic medicine.

METHOD

Phase I: survey of licensed naturopathic practitioners

in Canada

A 15-page questionnaire was mailed to all indi-

viduals licensed to practice naturopathic medicinein Canada, irrespective of current residence oremployment status. Failure to respond to the surveyand one follow-up telephone call constituted refusal

to participate. The total response rate was 63.2%(187 useable surveys of the 296 mailed out)*.Response patterns were similar across the provinces;

however, the majority of respondents were fromOntario (61.1%) and British Columbia (31.9%). Itis important to note that licensure was one of the

inclusion criteria for the study and that currentlynaturopathic practitioners are licensed only in theprovinces of British Columbia, Saskatchewan,

Manitoba and Ontario. Practitioners licensed in oneof these provinces, but practicing elsewhere wereincluded in the study, which accounts for the smallnumber of participants from the other Canadian

provinces. The response rate for female prac-titioners was signi®cantly higher (84.5%) than formales (53.3%).

The respondents ranged in age from 27 to 86years, with a mean of 43 years. The majority of therespondents were married (64.6%). There were

more male (61.6%) than female practitioners(38.4%), and 25.9% of the respondents had com-pleted chiropractic training before entering naturo-pathic college. Naturopathic medicine was the ®rst

career for over half (55.7%) of the respondents,while the remaining practitioners (who were not®rst chiropractors) reported a range of careers

including: allopathic medicine, nursing, dentistry,veterinary medicine, pharmacy, massage therapy,law, accounting and business.

Although three-quarters of the respondents wereborn in North America, a wide range of ethnicbackgrounds was apparent (based on place of birth)

in the remaining quarter. Most were from Europe(17.2%) and the rest were born in Africa, theOrient, the Middle East or India. English was theprimary language used in the treatment of patients

by all practitioners; however, respondents alsoreported treating patients in many other languagesincluding: French, German, Russian, Chinese,

Spanish, Arabic, Hindi and Punjabi (listed in orderof descending frequency of reports).

Phase II: participant observation at the CanadianCollege of Naturopathic Medicine (CCNM)

The second component of the study was a partici-pant observation period which lasted fromSeptember 1993 until April 1994. During this time

the investigator, a doctoral student with a phar-macy background, attended classes, student meet-ings, and social events at CCNM (spending a

minimum of one day per week at the school andoften more). Sixteen students were also formallyinterviewed during this time period (four from each

year of the program) to discuss their experiences atthe College in an open-ended format (Berg, 1989;Strauss and Corbin, 1990). A wide variety of stu-

dents were selected to provide insight into the ex-periences of the diverse student population: menand women; young students and mature students;students with previous training as health pro-

fessionals and those with no previous health-relatedtraining; students with previous training in another``alternative'' health care technique; and students

from several ethnic backgrounds. This samplingtechnique has been called ``theoretical sampling''(Berg, 1989; Strauss and Corbin, 1990; Glaser and

Strauss, 1967) or ``purposeful sampling'' (Patton,1990) in which each member of the sample is pur-posefully selected to provide richness and variety ofinformation on the research question. The ongoing

inclusion of participants also allowed the freedomto explore issues raised in the previous interviews.Sampling continued until a point of ``saturation''

was reached (Strauss and Corbin, 1990; Glaser andStrauss, 1967). Saturation has been de®ned as thepoint at which additional data does not appear to

provide further insight into the developing theory(Glaser and Strauss, 1967). All the interviews wereaudio-taped and transcribed.

Phase III: interviews with practitioners

The ®nal phase of study involved the interviewing

of naturopathic practitioners, using the methodo-logical techniques described above. The 41 inter-views (21 men and 20 women; 11 from Vancouver,British Columbia and 30 from Toronto, Ontario)

were staggered from April 1994 until October 1995to allow for ongoing analysis to guide subsequenttheoretical sampling. The criteria for selecting inter-

view candidates is detailed elsewhere (Boon, 1996a),but will be summarized here. An equal number menand women were interviewed to explore the possi-

bility that any ®ndings may be in¯uenced by gen-der, as has been found in other health careprofessions (Hornosty and Coulas, 1988; Muzzin et

al., 1994; Reskin and Roos, 1990; Witz, 1991). Inaddition, the results of the survey in Phase I indi-cated that approximately 25% of the naturopathicpractitioners in Canada were also trained as chiro-

*The survey was mailed in January 1993, at which timethere were 296 licensed naturopathic practitioners inCanada. By 1996, when this paper was completed, theCanadian Naturopathic Association reported the num-ber of licensed practitioners to have grown to 360.

Canadian naturopathic practitioners 1215

practic practitioners. According to folklore withinthe naturopathic community, this group of prac-

titioners (mostly men who had been practicing nat-uropathic medicine for more than 10 years) haddistinct practice patterns. Practitioners were selected

to explore the relationship of these factors to socia-lization experiences and practice patterns.Practitioners from the two provinces in which the

majority of naturopaths were practicing (Ontarioand British Columbia) were selected to explore thepossibility of regional di�erences. In total, 65 prac-

titioners (all of those practicing in the greaterVancouver area and 80% of those practicing inMetropolitan Toronto, who responded to the sur-vey in Phase I and indicated a willingness to be

interviewed) were contacted to arrange follow upinterviews. Two practitioners refused; four agreedto be interviewed but were unavailable during the

time period that I was interviewing in Vancouver;and 18 indicated that they were not interested bynot returning my telephone calls. Each interview

was approximately one hour in length and when-ever possible took place at the individual's place ofpractice. Observations about the setting, any inter-

actions with patients or support sta� and personalfeelings were recorded in ®eld notes for each inter-view. Each interview was tape-recorded (with per-mission) and later transcribed verbatim.

Although it must be emphasized that these prac-titioners were selected using grounded theoreticalsampling techniques, subsequent analysis (reported

in detail elsewhere) (Boon, 1996a) revealed that thepractitioners who were interviewed had been inpractice, on average, for the same length of time

(mean = 11 years) as had the total set of surveyresponders and there was no di�erence in the meanage (43 years) of individuals who were interviewedand those who were not. However, women were

over-sampled in the selection of practitioners whowere interviewed.

ANALYSIS

Analysis in a qualitative framework occurs simul-taneously with ongoing data collection, directing

the selection of new participants who will provideinformation about emerging themes. Qualitativeanalysis of the type undertaken here follows the

method of ``constant comparisons'' (Glaser andStrauss, 1967) in which each incident is categorizedand compared with all previous incidents coded in

the same category. The process begins with a largenumber of coding categories derived directly fromthe interviews and as relationships between cat-

egories are discovered, they are merged to producea coherent theory (Huberman and Miles, 1994).The analysis in this study was completed withoutthe aid of qualitative computer software programs.

Phase I: identifying scienti®c and holistic world views

The development of world view ideal types fromthe interview data is described in detail elsewhere(Boon, 1996a) and will only be summarized brie¯y

here. Schutz describes a method for fabricating acomposite ideal type from the phenomenologicaldata collected from many individuals (Schutz,

1953). He argues that the ideal type should berecognizable by any individual who is part of thephenomenon being described, even though it may

not accurately describe any single individual in thesample. Using this strategy it was possible to derivetwo ideal types from the interview data collected Ðpractitioners with holistic and scienti®c world views.

Practitioners with primarily holistic world views donot perceive the spiritual and physical worlds asseparate entities, but rather manifestations of a

single life force. Thus they give emotional, psycho-logical and spiritual symptoms the same weight asphysical symptoms, and emphasize the importance

of maintaining a balance in all aspects of one's life.Illness, in general terms, is conceived as the conse-quence of some disharmony in the cosmic orderand the restoration of harmony or balance (within

nature and human relationship) is the goal of alltherapy. Practitioners with holistic world viewsbelieve disease to be intimately associated with the

cultural and social environment of the patient andoften emphasize the psychosomatic component oftherapies. They value intuition (both their own and

that of their patients).In contrast, practitioners with primarily scienti®c

world views perceive health and health care in

terms of the biomedical model which is based onthe belief that disease is the result of the malfunc-tioning of the biological mechanism at the cellularor molecular level and that the doctor's role is to

intervene to correct the speci®c malfunctioningmechanism. They see the scienti®c method as theprimary source of all knowledge and believe that

naturopathic modalities which are currently basedon empirical data will ultimately be explained byscienti®c investigation. This emphasis on the pri-

macy of the scienti®c method is accompanied bythe high value placed on objectivity, reproducibility,and rationality. Although environment is acknowl-

edged to a�ect an individual's health, it is the physi-cal and biochemical e�ects of the environmentwhich are emphasized by practitioners with scienti-®c world views.

Phase II: categorizing respondents' world views

Each interview transcript was compared with thetwo ideal types described above. This process isdescribed in detail elsewhere (Boon, 1996a).

Generally, a given individual was described as hav-ing a holistic or scienti®c world view based uponhis or her entire interview, ®eld notes writtendirectly after the interview, and any supplementary

H. Boon1216

documentation available (e.g., pamphlets, ¯iers,business cards, or pictures obtained during the

visit). It is important to emphasize that thegrounded theory researcher does not enter the ®eldintending to test speci®c hypotheses. These cat-

egories (practitioners with scienti®c and holisticworld views) emerged at the end of the data collec-tion process. Thus this phase of analysis was a re-

organization of previously collected qualitativedata. It was not possible to infer practitioners'orientations or world views from demographic cor-

relations.

Phase III: comparison

The ®nal phase of the analysis involved the com-

parison of individuals with holistic and scienti®cworld views in terms of: (1) how they chose naturo-pathic medicine as a career; (2) their socialization

experiences; and (3) their practice of naturopathicmedicine.

RESULTS

It was possible to categorize all 41 practitioners

and 16 students that were interviewed. In total, 27individuals were classi®ed as having primarily scien-ti®c world views (16 men and 11 women); and 30

individuals were classi®ed as having primarily holis-tic world views (12 men and 18 women). Althoughit must be emphasized that this was not a represen-

tative sample, there was no di�erence in mean age,mean number of years in practice, or ethnicitybetween the two groups.

Choosing naturopathic medicine

Practitioners with primarily holistic world viewswere more likely to list compatibility with personal

philosophy and their perception of the holisticnature of naturopathic medicine as reasons forchoosing naturopathic medicine as a career than

practitioners with scienti®c world views. All thepractitioners with primarily holistic world viewsbelieved that entering naturopathic medicine wouldallow them to practice in a tradition which was con-

sistent with their personal goals and values. One``holistic'' practitioner explains:

I always knew there was another way. I just had this feel-ing that there was another way and that I had a talent forit. I seriously considered becoming a vet, but it felt too sti-¯ing or too limiting. Naturopathic medicine was a way tostudy something that I was naturally doing in my life Ðtreating people naturally. Wow! I could get credentials fordoing what I had always done!

In contrast, practitioners with primarily scienti®cworld views described the decision to enter naturo-

pathic medicine in more practical, objective terms.They weighed the pros and cons and decided in ananalytical fashion to move along this career path,

as is exempli®ed by this practitioner:

I somehow got the idea that this [naturopathic medicine]was viable: it was covered somewhat by the medical plan,so it had a certain amount of credibility; it was licensed;and yet it was alternative. So it sort of ®t my needs. Ididn't really want to go completely outside the pro-fessional realm. I wanted to be part of a legal profession.

Practitioners in this category described a wish tolearn a speci®c modality in a scienti®c manner. The

naturopathic program o�ered a unique chance forthem to do this. Often the other therapies weresimply ``part of the package'' rather than the reason

they entered the naturopathic medicine. As onethird-year student at CCNM observed:

Naturopathic medicine really o�ered me the only bona ®decourse in North America to study botanicals. There wereno Ph.D. [programs] in botanical studies for pharmacistsor doctors or dentists. And the other colleges Ð many ofthem don't teach to a technical level that is suitable. Youknow, being a herbalist is all very good, but there is noth-ing in the biochemistry.

Socialization experiences

Students were seen to enter naturopathic medi-

cine with either a predominantly holistic or a scien-ti®c world view. Practitioners described a ``rift'' intheir ®rst and second year classes, which indicates

the distance between students with di�erent worldviews when they commence naturopathic training.As one practitioner recalled:

There were some major con¯icts in our ®rst year class.There was a real major division that occurred within theclass itself: those of us who were very hard-core scienti®cand didn't quite get some of the airy±fairy stu�, andothers of us who really knew what this airy±fairy stu� wasabout and really embraced it. There were a couple ofclasses that were kind of psychosocial or something andthere were some real hard-core science-types who justdidn't get it. It was very uncomfortable and it caused asort of rift in our class initially.

The curriculum at CCNM explicitly emphasizes

the scienti®c world view, as is evidenced by thenumber of class hours devoted to classes taughtwithin the scienti®c paradigm* and thus the experi-

ences of students with primarily scienti®c worldviews meshed with their expectations. Theyexpressed little surprise at the emphasis on the basic

sciences and even though they complained that thiscould be ``boring'', students with primarily scienti®cworld views did not distinguish the basic sciences asseparate from naturopathic medicine. A ®rst-year

student explained:

With respect to the scienti®c and naturopathic models, Ithink it's just a lack of education Ð this is not orthodox,but if more people get into it, it will become moreaccepted. I don't think this school is out to abolish the old

*In the ®rst year curriculum, 700 h of class time weredevoted to the Basic Sciences, 166 h were devoted toClinical Sciences and 126 h were devoted toNaturopathic modalities. The ``scienti®c emphasis'' inthe CCNM curriculum is discussed in detail in Boon,H., ``The Making of a Naturopathic Practitioner''Health and Canadian Society, 3(1±2), 15±41, 1996.

Canadian naturopathic practitioners 1217

[scienti®c] ways because a lot of great discoveries havebeen made through scienti®c discovery and I think that'sgreat. This is just another ®eld that needs to be opened upmore.

And a practitioner added:

[Naturopathic medicine] seemed just like a spin-o� frombio-chem[istry, my ®rst degree], it was just using it clini-cally. Bio-chem[istry] is like the basics, like genetics orsomething like that. Its all very very ``biochem'' to me Ðlike I'm still in the same ®eld.

All students who arrived at the naturopathic col-lege with a holistic perception of the naturopathicphilosophy reported a di�cult ®rst year. Their pri-

mary complaint was about a lack of emphasis onthe philosophy of naturopathic medicine, which canalso be interpreted as a lack of emphasis on their

holistic perceptions of the naturopathic philosophy:

I wish there were more naturopathic courses... It's all thebasic sciences Ð the naturopathic things are kind of onthe side... I mean I can understand how they need to dothat, but it gets kind of boring after a while. I mean, we'rehere for a reason, and this term all we have is hydro-therapy and naturopathic history to balance it out. Thenine other courses are ``ologies''. It can get to be a bitheavy. Last term was better because we had stress man-agement, soft tissue and it was almost a balance of ®veand ®ve. Now it's nine and two. It's just dry (CCNM stu-dent, ®rst-year).

These students seem to equate the holistic naturo-pathic philosophy with the naturopathic modalitieswhich they have not yet studied. There was a per-

ception that the sciences are useful in a peripheralsense, but certainly not as a core component of thenaturopathic philosophy. The same student

explained:

I think what they do is try to teach us a well-roundedview so that we can relate with other medical pro-fessionals. But I guess it is really in third year and fourthyear where you put it all together and make yourself anaturopath. Like ®rst and second year you just get all theinformation and in third and fourth year you put in a nat-uropathic perspective. I ®gure that will come. Now thingsseem more allopathic or whatever you want to call it.

But not all of the ®rst year experience is incom-

patible with the holistic interpretation of the nat-uropathic philosophy. For example, the CCNMstudent quoted above identi®es naturopathic his-

tory, hydrotherapy, stress management and soft tis-sue manipulation (156 out of 992 or 16% of theclass hours in ®rst year) as ``real naturopathic medi-

cine'' from his primarily holistic point of view. Inaddition, some individuals reported experiences inwhich their scienti®c beliefs were challenged early intheir training. One practitioner recalled:

I can remember a real hardship in one of the psychologycourses that was o�ered by a couple professors from York[University]. They were trying to introduce us to what Icall energy. Some people had a bent in one direction;some people had a bent in another direction. I was reallyuncomfortable with it. I can remember having a confron-tation with the instructor and him telling me that I wastrying to rede®ne naturopathy. And I can remember say-ing to him, ``I don't like this. I feel really uncomfortable

with this course''. As a matter of fact, it was so far out Ðto put it in scienti®c terms it was more than two standarddeviations away from what I thought was appropriate.

Students also have the opportunity to receive sev-eral free consultations for treatments given by the

fourth year students. For many, this is their ®rstpersonal experience with the treatment modalitiesthat they are starting to learn in the classroom.

Occasionally a student with a primarily scienti®cworld view ®nds that a therapy with ``no scienti®cproof'' actually produces positive clinical e�ects in

himself or a patient. Several practitioners with pri-marily holistic world views described this as an``aha'' experience:

There's usually an ``aha'' experience while they are atschool when suddenly they ``get it'' And if they don't getit, then they will not get it when they are out in practiceeither. I think we see most of the students, by the timethey are in fourth year, have had that kind of experienceÐ either for themselves or by watching their patients. [Doyou think everyone has an ``aha'' experience?] If theydon't have it themselves, then... a lot of things that we doand talk about are hard to see in the material and objec-tive ®ndings. And I think that's true in medical practice.Experience is the great teacher.

Second year is generally recognized as the mostrigorous year academically. Students are required to

take a full course load of sciences, as well as intro-ductions to most of the naturopathic treatmentmodalities. In addition to their heavy course load,

second year students spend three months of theyear giving hydrotherapy and massage treatmentsin the public clinic attached to the school. Although

the ®rst and second year curriculum formally tea-ches primarily the science of naturopathic medicine,the students may have personal experience or dis-cover clinical mentors which rea�rm a holistic in-

terpretation of the naturopathic philosophy. Thirdyear courses focus primarily on the naturopathictreatment modalities and the students spend signi®-

cant amounts of time in the clinic as observers. Thecontent of these courses appears to be largely in¯u-enced by the world view of the instructor as is

described in detail elsewhere (Boon, 1996a,b).Fourth year students spend the majority of theirtime seeing patients under the supervision oflicensed naturopathic practitioners in the school's

clinic.There is evidence that practitioners with both

scienti®c and holistic world views begin to appreci-

ate the world view of the other as they near thecompletion of their training. For example, as onefourth-year student observed:

Some things you just have to believe in. Now I know that,even if I still sometimes have trouble doing it. Somepeople are just like that and I really admire it. I wouldn'thave said that before. I mean I need science, but if youcan just know things then that can be OK. It's a gift Iguess. I don't have it so I rely on science.

And a practitioner recalled:

H. Boon1218

Learning the science has strengthened my intuition. I stilllook for things that ``resonate'' with both me and thepatient when I start a treatment Ð you know, some thingsjust don't feel right for some patients. But the science thatI learned is a part of my decision. Let's say it informs myintuition (Practitioner #299).

This respect for the di�erent world views ofothers was evident only in fourth year students and

naturopathic practitioners. However, there was noevidence that the socialization process fundamen-tally changed the world views with which studentsentered the College. Practitioners with holistic

world views say that they remained holistic:

I had really idealistic expectations. I really thought,because of what I thought the profession stood for, that Iwould be walking into an environment that was really sup-portive and encouraging and nonsexist, noncompetitive Ðall of that. And it shocked me again and again and againbecause I refused to let go of my idealistic image of whatthe college should have been. [Q: Where did that imagecome from?] Well, it probably came largely from withinme. I mean, I saw naturopathic medicine as o�ering some-thing so wonderful and so balanced that I thought itwould be balanced there [at CCNM] too. And I think itcan be and personally I am Ð have been and will continueto work towards creating that kind of atmosphere at thecollege. Because I think it really can be (emphasis on orig-inal).

And practitioners with scienti®c world viewsremained scienti®c:

I had a lot of learning to do in terms of naturopathic phil-osophy Ð working with the psychological or emotionalaspect of the patient. Those were really foreign to me.Those were things I really had to work on and to be ableto adapt. Psychoneuroimmunology really helped methrough Ð there is science behind this. Your mind reallya�ects your body. [Q: How did you deal with those thingswhich seemed to be at odds with your scienti®c perspective?]Denial (laughter). I just ignored those people for the long-est time. I thought they were weird. I thought I could gothrough the whole school without ever having to deal withthat side of naturopathic medicine. Well, it was imposs-ible. When you start doing case studies, and reading abouthow people get through a cancer diagnosis and psycho-neuroimmunology. You start to read more and moreabout neuropeptides that actually cross the blood±brainbarrier, which was thought to be impossible. Then youstart to broaden your spectrum and think that there are alot of things that we can't answer. I just started to be lessrestrictive in my thinking.

Although students gained insight into the factthat there is another world view and described

increasing acceptance of diversity, there were nocases among any of the 41 practitioners (that wereinterviewed) reporting changing world views during

the training process. Students were most critical ofcomponents of the curriculum which embodied oremphasized a world view which di�ered from their

own interpretation of the naturopathic philosophy.However, most were able to incorporate some el-ements of both perspectives into their practices. For

example, practitioners with primarily holistic worldviews learned to support their intuition with thera-peutic interventions which are scienti®cally provento be e�ective; and practitioners with primarily

scienti®c world views learned to appreciate thepowerful e�ects of the mind on the body.

Practicing naturopathic medicine

Seeing patients. Naturopathic practitionersresponding to the survey reported seeing an average

of 12.8 patients per day; however, there were di�er-ences between the practices of those with primarilyholistic or scienti®c world views. Practitioners

classi®ed as having primarily scienti®c world viewsreported seeing almost twice as many patients perday (15.3) on average as practitioners classi®ed ashaving primarily holistic world views (8.2). There

was no di�erence in the gender of patients seen bypractitioners with either world view.However, practitioners with primarily holistic

world views generally reported seeing a greater pro-portion of patients 40 years of age or younger,while practitioners with primarily scienti®c world

views reported seeing a greater proportion ofpatients older than 40 years of age. These agegroupings may be related to the types of presentingcomplaints that holistic and scienti®c practitioners

reported seeing most. For example, ``holistic'' prac-titioners reported treating more asthma, allergies,skin problems, stress and providing more health

maintenance and pre-natal care. In contrast, ``scien-ti®c'' practitioners reported treating more patientswith cardiac problems, hypertension, musculoskele-

tal and gastrointestinal problems. In general, this isconsistent with the fact that they reported treatinga slightly older population (see Fig. 1). As Fig. 1

shows, individual practitioners, regardless of worldview, see a wide range of patients both in terms ofage and chief complaints.Using treatment modalities. Naturopathic medi-

cine is unique because its practitioners are trainedto employ a wide variety of complete therapeutictechniques. Thus, if an individual presents to a nat-

uropathic practitioner with a complaint of fatigueand headaches, the practitioner selects a treatmentprotocol from a wide range of possible alternatives.

It appears that practitioners with primarily holisticand scienti®c world views select di�erent treatmentmodalities with di�ering frequencies.Practitioners with primarily holistic world views

reported using clinical nutrition, library or edu-cational resources and counselling more often thanpractitioners with primarily scienti®c world views

(see Fig. 2). These treatment modalities requireextensive patient contact and minimal technology.They are also easily used in any practice setting,

including home practices. Thus this appears consist-ent with holistic practitioners' long patient visits. Incontrast, practitioners with primarily scienti®c

world views reported using more acupuncture ascompared to ``holistic'' practitioners (see Fig. 2).Acupuncture treatments tend to require short butfrequent visits by patients, which may partially

Canadian naturopathic practitioners 1219

explain the shorter visit times of scienti®c prac-

titioners.Some treatment modalities are used relatively

equally by practitioners with both world views (see

Fig. 2). However, these therapies appear to be per-ceived di�erently by practitioners with di�erentworld views. For example, homeopathy can beexplained in the scienti®c terms of ``chaos theory''

and medications can be chosen with the aid ofVega* testing as one ``scienti®c'' practitionerexplained:

I only use homeopathy acutely. Often I use combinationremedies for things like allergies, colds or ¯us and I ®nd

Fig. 1. Reported presenting complaints: holistic (n = 23) vs. scienti®c (n= 17) practitioners.

*The Vega test or Vegetative Re¯ex Test (VRT) wasdeveloped by Dr. Helmut Schimmel and is an elector-diagnostic procedure which relies on the measurementof evoked electrical conductivity over acupuncturepoints. A direct current voltage of 0.87 V is applied viaa hand-held measuring stylus over an acupuncturepoint, generally one of the points on the end of the ®n-gers or toes. The patient holds an electrode in order tocomplete the circuit. By placing a test ampoule into thecircuitry, the response on the galvanometer can registerthe skin electrical resistance thought to represent thebody's resistance to that particular ampoule. The testis commonly used to test possible homeopathic reme-dies to ®nd the most suitable one for a particularpatient. It may also be used to test for food sensi-tivities (Practitioner #80).

H. Boon1220

they work quite well. [Q: But homeopathy doesn't seem tohave a scienti®c basis like the nutritional products you weredescribing earlier. How do you deal with that?] We justdon't understand how it works Ð yet. Personally, I'm nottoo sure about some of the philosophy behind it. I thinkthat some of that is a bit of ``mumbo jumbo'' becausescientists haven't ®gured out what's going on. But acutelyit works wonderfully.

Alternatively, homeopathy can be explained inspiritual or mystical terms and medications chosen

only after extensive explorations of the patients'physical, emotional and spiritual state as a ``holis-tic'' practitioner explained:

[Q: Why did you specialize in homeopathy?] I think it cameinitially from acute prescribing Ð that's always incrediblydramatic and very e�ective. And then seeing patients whowere profoundly changed, whose lives were radicallyaltered because of homeopathic treatment. And I alsothink it was in the belief system Ð it made sense to me. Itresonated from a very deep place. Early on it resonated in

me very deeply. I believe in it. Like now I can say I believein it because I've had training in the philosophy, but Ithink early on it was just an intuitive sense that I believedin it.

In a similar manner, botanical medicine can be

prescribed based on a purely biochemical rationaleor based on what one ``holistic'' practitionerdescribed as the ``personality'' of the herb. Thus

although these therapies may both be used by thosewith primarily holistic or scienti®c world views,they appear to be used within di�erent paradigms.

How did practitioners decide which treatmentmodality to use with a given patient? As might beexpected, practitioners with primarily holistic world

views and practitioners with primarily scienti®cworld views described di�erent methods of makingthis decision. Practitioners with scienti®c worldviews turned to science to guide their choice of mo-

Fig. 2. Use of modalities: holistic (n = 23) vs. scienti®c (n= 18) practitioners.

Canadian naturopathic practitioners 1221

dality. They tried to use modalities that had been``proven'' to work for speci®c conditions, as one

practitioner explained:

In the beginning I used to try to remember which herb westudied was good for what, and then I would go and usethat herb. I used to go home and research everybody'scase before I would treat. Now I ®nd that I can kind ofgo by experience Ð with what I ®nd has worked andgiven consistent results for me in the past.

``Scienti®c'' practitioners often consulted proto-cols for the treatment of speci®c diseases or syn-dromes. One said:

I like working with my partners because we all have thesame philosophy: if a protocol tells you to treat saychronic fatigue syndrome for example, with a list ofthings, we narrow it down to three things that we are con-®dent will work. That's what shapes our practice.

Practitioners with primarily holistic world viewsfocused on the individual human being rather than

a scienti®c rationale as the key to selecting the besttreatment modality:

My thing in practice has been understanding as much aspossible the whole picture. Who's the person and what'sthe person? You know, what are the forces and energiesor qualities that make up the person and how do thesethings interact and produce behavior, physical symptomsand so on. I guess I'm trying to understand the nature ofhuman reality.

They took the selection of treatment modalities

on an individual basis to its extreme:

You try to select the thing which you feel will support thehealing powers in that person, whatever it is. I mean it hasto be ethical obviously, and within the scope of naturo-pathic medicine. What you have to do is ®nd out whatappeals to that person, either on a conscious or subcon-scious level. It's a complicated thing because it deals withthe nature of the person Ð a combination of physiology,mental, emotional and spiritual. I think it's bewilderingand it's threatening because it doesn't seem precise. WhatI do is I test it against my heart.

Practitioners with primarily holistic world viewsoften described treatment selection as a kind of

intuition. For example, one found it hard to explainhow she decides on a therapy for a given patient.Finally she said, ``I just seem to know once I take

everything into account''. This kind of ``just know-ing'' was described by many ``holistic'' practitioners.For example, one tried to explain:

I have a value for letting myself not know through a lotof the session what I am going to do. I like to let it comefrom a place beyond just mechanics, if that makes anysense.

SUMMARY AND DISCUSSION

Previous studies of the socialization of healthcare practitioners have not investigated the possi-

bility that incoming students may have di�erentworld views. Thus when di�erent practice patternswere identi®ed it was assumed that they could beattributed to ``socialization'' or ``situational fac-

tors''. The rich and varied data collection in this

study suggests that a more complete understandingof the socialization process can be generated by pla-cing it within the context of each practitioner's life

history. In summary, this study argues that naturo-pathic students enter professional training with apre-formed world view which acts as a ®lter for

their perceptions of the socialization experience.The evidence presented in this paper suggests that

although secondary socialization in naturopathicmedicine has a homogenizing e�ect, students withdi�erent world views actually experience the train-

ing di�erently. Although the majority of the sta� atthe naturopathic college during this study appearedto have primarily scienti®c world views, role models

with holistic world views were accessible to studentsthroughout the program. Given the eclectic natureof the socialization experience, it is not surprising

that students retained the fundamental world viewwith which they enter the program.

The identi®cation of two types of practitionerswith distinct world views appears to be supportedby the work of Richenda Power, who describes two

di�erent philosophies of British naturopathic prac-titioners which also appear to be independent of

training (Power, 1994). She analyzes the division interms of di�erent practice patterns Ð treatment/modality-inclined practitioners (eclectics or mixers)

and those who practice ``straight'' nature cure(straights) and thus do not prescribe ``remedies''.From her detailed description of the practice of

``straight'' nature cure, it is possible to hypothesizethat these practitioners may be similar to Canadiannaturopathic practitioners with primarily holistic

world views. Further comparison may yield insightinto the cultural in¯uences on world view.

This type of philosophical ``split'' in a seeminglyhomogeneous health care group is not unique toalternative or complementary practitioners.

Research with medical students and practicingphysicians has yielded similar results. For example,Good and Good (p. 81) identify two themes in

``learning medicine'': the juxtaposition of ``caring''and ``competence'' (Good and Good, 1993). They

argue that these two themes represent a culturaltension running through medical education. Goodand Good's caring theme is ``expressed (by the

medical students) in the language of values, re-lationships, attitudes, compassion, and empathy,the nontechnical or as one student called it the

``personal'' aspects of medicine'' (p. 91). This isanalogous to the holistic interpretation of the nat-

uropathic philosophy that has emerged from thisresearch. In contrast, the theme of competence is``associated with the language of the basic sciences,

with ``value-free'' facts and knowledge, skills, tech-niques, and ``doing'' or action'' (p. 91) and it paral-lels what I have termed the scienti®c interpretation

of the naturopathic philosophy (Good and Good,1993).

H. Boon1222

The medical students studied by Good and Good

expressed concern that in attempting to increasetheir competence, they will lose their ability to carefor patients. A few felt that the medical curriculum

neglects the caring dimensions of medicine; how-ever, most felt that while science needs to be taught,caring is ``an innate human quality, to be cultivated

but not taught'' (p. 93). May and colleagues suggestthat an increasing emphasis on a ``holistic'' or biop-

sychosocial model of health care creates an ``elabor-ate structure of moral pressures, role stresses anddiscontents'' (p. 194) for physicians (May et al.,

1996). Their study of general practitioners inBritain demonstrates that, in practice, pathology-based diagnosis (which appears to be compatible

with a scienti®c world view) overwhelms the currentemphasis in medical education on the psychosocialcomponent of illness (corresponding to a more hol-

istic world view). The model of diagnosis based onpathology facilitates treatment; while exploration of

the patients' subjective experience of illness andsocially-mediated histories results in few concretetreatment options. Thus while medical theory may

be seen as increasingly compatible with a holisticworld view; general practitioners continue to prac-tice in a manner more consistent with a scienti®c

world view. May and colleagues argue that this jux-taposition of ``caring for and counselling'' patients

and the ``imperative to maintain detachment anddistance'' while employing what has recently beentermed ``evidence-based medicine'' creates a

dilemma for the medical practitioner (May et al.,1996). This incompatibility appears to parallel theincompatibility of the holistic and scienti®c world

views as they are described in this paper. Thus itappears that these tensions are not unique to the

realm of ``alternative medicine''.In this study, there is no evidence that socializa-

tion experiences change individuals' predominant

world views, which should not be interpreted to in-dicate that there were no socialization e�ects orthat world views are intransigent. Although stu-

dents enter the program with distinct perceptions of``the'' naturopathic philosophy which are consistent

with their world views, by the time students gradu-ate they appear to have developed an understandingof the dual nature of the ``o�cial'' naturopathic

philosophy. Individual practitioners do not reportchanging world views, but they do express anacknowledgment and often an appreciation for the

``other'' world view. In other words, there wasmovement from the two poles of the continuum(i.e., the ideal types described in this paper) toward

a middle ground. This broadening of perspectivedemonstrates the dialectical component of a world

view: it acts as a perceptual ®lter for experiences,but is in turn shaped by those experiences.Integrating the concept of world views into the

social origins±socialization±situation debate allowsan integrated understanding of the e�ects of these

aspects of practice, rather than conceiving of them

as discrete ``variables''. One's world view in¯uencesboth one's perceptions of socialization experiencesand social situations. Yet one's perceptions are

necessarily limited both by socialization and situ-ation. In summary, world views provide the goals,socialization provides the means and situation pro-

vides the opportunity. For example, a naturopathicpractitioner strives to provide spiritual and

emotional support to his or her patients. This goalcan only be reached if he or she has learned appro-priate strategies and internalized appropriate values

through a process of socialization. The ®nalrequirement for the attainment of the practitioner'sgoal is a setting or environment which is conducive

to providing the appropriate care (e.g., enoughtime). Thus behavioral goals are ultimately deter-mined by one's world view; however, both socializa-

tion and situation play a role in determining ifthese goals are realized.

The issues explored in this paper may also haveimplications for patient care. Many theorists haveattempted to explain why patients are attracted to

alternative health care providers. For example,Alster maintains that alternative practitioners pro-

vide answers not only to health problems but, alsofor ``philosophical problems, social dilemmas, en-vironmental concerns and spiritual issues'' (Alster,

1989), thus o�ering an alternative system that isboth comprehensive and simple. And Grossingersuggests that they may be the ``shamans'' of mod-

ern society, ful®lling a spiritual need in a culturewhich has forsaken religion (Grossinger, 1990).These arguments appear to rely on the assumption

that practitioners with a holistic world view domi-nate alternative health care occupations. In con-

trast, several theorists suggest that alternativemedicine does not o�er a real alternative to allo-pathic medical care (Berliner and Salmon, 1980;

Montbriand and Laing, 1991). The data presentedhere suggest that both positions are partially cor-rect.

Naturopathic practitioners with a primarily scien-ti®c world view may o�er di�erent treatment

options, but as Berliner and Salmon contend(Berliner and Salmon, 1980), they may not o�er anapproach to health and illness which di�ers in any

fundamental way from the allopathic medical sys-tem which has evolved in a society with a predomi-nantly scienti®c view of the world. However, it can

be argued that naturopathic practitioners with aprimarily holistic world view do in fact o�er

patients a real alternative. These practitioners are``bucking the system'' to provide health and well-ness care which is derived from a world view funda-

mentally di�erent from the dominant view. Furtherresearch is necessary to determine the extent towhich the holistic world view is expressed in prac-

tice. This requires direct observation of the prac-titioners in practice, which was beyond the scope of

Canadian naturopathic practitioners 1223

this study, but it is an important direction forfurther research.

Another question which this study raises is thepossibility that di�erent types of patients seek carefrom di�erent types of practitioners. Practitioners

with primarily holistic and primarily scienti®c worldviews reported treating patients with di�erent typesof complaints. This may be a re¯ection of the prac-

titioners' di�ering perceptions of disease and illness;it may re¯ect the world view of the patient; or itmay be an interaction of the two. Another question

to be answered with further research is whetherpatients with holistic world views preferentially seektreatment from holistic practitioners. It will also beimportant to determine what happens when the

practitioners' and patients' world views do not cor-respond. The fact that both scienti®c and holisticpractitioners stressed the necessity of becoming

``partners in health'' with their patients suggeststhat compatibility in world views may be key tounderstanding a successful patient±practitioner re-

lationship. This theoretical model could be appliedto patients' relationships with all health pro-fessionals.

AcknowledgementsÐThe author was funded by a: SocialSciences and Humanities Research Council of CanadaDoctoral Fellowship; a University of Toronto OpenDoctoral Fellowship; and a Canadian Foundation forPharmacy Support Grant for Pharmacy Administration.Special thanks for the support and guidance of Dr. LindaMuzzin throughout this project.

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