Vithoulkas (1993) describes case taking as integrated to the Homeopathic system based upon sound and verifiable laws, principles and techniques. He continues to state that in its application to the individual patient, however, it is also an art and it is through case taking that the artistic aspect of Homeopathy is clearly seen.
Case taking, as one can see is a key aspect of Homeopathy as it is through this, the Homeopath, is able to identify the best course of treatment to enable the healing process that realises Hahnemann’s vision of the highest ideal of cure. That being ‘rapid, gentle and permanent restoration of health, in the shortest most reliable and most harmless way.’
Through the application of three key elements of effective case taking, the Homeopath can facilitate a high quality, time effective period of assessment and treatment for the patient. Through pre, during and post case taking planning, implementation and evaluation, the Homeopath can truly give the patient the service they deserve and stay true to the Homeopathic ideals of cure Hahnemann laid down in the Organon of Medicine and illustrate the art of healing Vithoulkas describes.
Prior to taking the case, time should be spent in ensuring that the Homeopath is prepared in order to create a sense of organisation within the practice. The environment preparation is valuable with regard to temperature balance, for example, not too cold or warm and lighting balanced to support the patient’s comfort and maintain an environment conducive to talking and reflection.
The Homeopath themselves, needs to ensure they are in a good place prior to taking the case and take all reasonable precautions to maintain their health and wellbeing, so they are fully able to take on board the consultation and the issues the patient may bring to the session, so that a cure can be facilitated through the correct remedy selection.
Should the practitioner have current ‘issues’ themselves for example, emotional imbalance, or a physical complaint such as pain or discomfort, their focus during the session could be diverted away from the patient to themselves and the current issue they themselves are facing. Another risk here is the issue of over relation with the patient’s personal circumstances and the practitioner’s state of mind being in a similar place. To minimise these situations occurring it is considered good practice for a Homeopath to regularly consult another practitioner for ‘treatment’ and also seek support through a supervision system on a regular basis, either on a one to one or peer supervision format to support health and wellbeing or mind and body.
It is also good practice to ensure all ‘equipment’ is at hand and prepared prior to taking the case. Items such as note paper, any proformas to be used including case taking templates, pens and if appropriate the Repertory to confirm symptom rubrics and a Materia Medica for cross referencing for remedy prescribing. If the patient is attending a follow up appointment, then a revision of previous case notes and having their personal file to hand is an important part of preparation.
Interruptions should be minimised such as telephone ringers being turned off and precautions to reduce back ground noise should be taken. Should the practice be within a family home, the Homeopath should ensure all people are aware of the appointment and the need for privacy and minimal disturbance. It is personal preference as to whether pre-case taking/ consultation information is gathered about the patient by using pre visit questionnaires or telephone discussions, including why they are wishing to consult a Homeopath. Should this be the case, then time prior to the consultation should be dedicated to familiarising themselves with the information and outline reasons for the patient attending the consultation, thus supporting the formulation of further questions to elicit more information than previous received from the patient to date.
Importantly, considering the Homeopathic system is focussed on the human elements of disease and not exclusively symptom and suppression focussed as embedded in the allopathic medical world, the Homeopath should ensure that they remain true to themselves and simply be themselves in the moment during the case taking process. This will enable the patient to feel at ease and have a further sense of freedom to share their story honestly, thus enabling the practitioner to take the case effectively.
During the Case
Faubister (1989) stated that ‘the golden rule of case taking is to allow the patient to express himself in his own way without interruption. This will enable the correct remedy to be discovered. He should be allowed to paint his own clinical picture. If the patient is allowed freedom to speak, it is surprising how often the characteristic features of a remedy are presented.’ Kent (1990) also echoes this theory by stating that the ‘simplicity of what the patient tells in his own way is preserved, unless he digresses from the important issues and confines his information to his own suffering.’
To make this a reality and as highlighted in the previous section, the Homeopath should have pre-prepared the ‘tools’ they are going to utilise during the case taking process. These will differ somewhat from practitioner to practitioner and will largely be a matter of preference. However, certain key elements of case taking will remain. To be effective in taking the case, the patient needs to feel comfortable, have space and an element of trust in order to start the process of talking, and offering the Homeopath an insight into their world as it currently stands. Vithoulkas (1993) continues to state that the case ‘is not merely a collection of data but it is a living expression drawn on the most intimate and meaningful regions of a patient’s life, so the Homeopath must gently and sensitively encourage the externalised expression of this inner state.’
During this process the Homeopath must ensure that their own body language is conducive to supporting and eliciting an open, trust worthy environment to ensure the patient feels as though they are being fully supported, feel safe and effectively listened to. This can be achieved by the application of certain techniques, the use of specific tools and utilising a framework by which to conduct a consultation. Currently, as a personal preference, should I personally being taking a case I would focus on five key areas:-
To find out whether the patient’s current issue is within an acute or chronic state in its presentation. It is worth noting here that to find out what the patient actually wants from a Homeopathic treatment is a priority. This enables the relationship power to be handed back to the patient and a future benchmark to assess whether or not the treatment has been successful.
Utilise a pre designed case taking proforma in order to ensure that symptoms that are affecting the patient and impacting on their health and wellbeing are received and a full picture of the patient is gathered.
Ensure that my own case taking techniques and questioning avoids using leading questions, thus putting words into the patient’s mouth, direct closed questions requiring only a yes or no answer from the patient’s part and enabling space within the questioning to allow the patient to fully answer in their own way. Time should be given before changing focus and keeping the patient on ‘point’, thus reducing the risk of them straying away from the matter in question. Such techniques reduce the patient’s answers being what they think the Homeopath wants to hear and allows a true reflection of their current position. The case taking process should also avoid prejudicial reactions and comments to minimise judgement on the practitioner’s part and support the patient to maintain a level of independence and ownership in their healing journey. By avoiding the patient becoming dependent on the practitioner or indeed the homeopathic process, the true calling of Homeopathy as described by Hahnemann in relation to cure remains at the heart of the case taking and treatment process.
Vithoulkas (1989) highlights the fact that the information gathered during a case is only half of the process for leading to an eventual cure. He adds that a ‘well-taken case which provides living images of the patient and, which is thorough can be fruitfully studied for hours on end, not only for the purpose of arriving at a remedy, but also from the learning about fundamental interactions between health and disease.’ This is a valuable statement and by ensuring a case is well-taken in Vithoulkas’s words will facilitate the Homeopath to have a complete picture of the symptoms and patient picture to be treated.
Important and pivotal to the case taking process is the unspoken patient sitting in the consultation room in front of the Homeopath. The body language, eye contact, physical appearance, skin, hair and general demeanour need to be observed as key indicators of the patient’s true picture. This may sound a simple technique; however, the art of this process is to gain an insight into the totality of symptoms presented to the practitioner with regard to all elements of the patient’s life story.
As preceding points illustrate the case taking process can result in the Homeopath being faced with a large amount of notes that require interpretation during the consultation in order to arrive at a remedy to support the vital force with the ‘similimum’ of what is presented to them to facilitate the cure. This can appear somewhat daunting; however, the CLAMS framework can support the Homeopath to confirm the symptamology picture in an organised and easily interpreted format.
Concomitant symptoms for example are those symptoms identified that are occurring at the same time for the patient. For example pain in the left leg as well as watering eyes and headaches. Such symptoms can indicate specific remedies and enhance the totality of symptoms methodology. The patient should be supported to freely describe the location of their symptoms and encouraged to identify where possible the point at which such symptoms began and any life events that may have precipitated their current physical and psychological ‘state’. In case taking terms this is known as the aetiology. A key note to take into consideration is in relation to the aggravating and ameliorating conditions of the patient’s symptoms. Modalities as they are termed are an essential case note which can support the identification of the ideal remedy, especially when more than one remedy could be indicated as result of the patient’s symptomatic picture. The sensation of such symptoms can also confirm or rule out specific Homeopathic treatment paths and provide an excellent foundation to assess the success of the treatment or the need to revisit the remedy prescription during future consultations should sensations change, disappear or worsen. As one can see by the implementation of the CLAMS framework the Homeopath can begin to formulate a full picture of the patient sitting in the consultation.
This said, the CLAMS process may still not provide the Homeopath with the final picture to identify the remedy prescription that can facilitate the cure. At this present stage in my development as a Homeopath, I would personally utilise a final model in order to identify the key aspect of the patient’s dis-ease. The Hierarchy symptom classification framework effectively supports the identification of priority rubrics, thus enabling the cross referencing of the Repertory and Materia Medica in prescribing. By assessing the CLAMS notes and other supporting information during the consultation, the patient’s symptoms can be arranged into five main categories and graded accordingly as to their importance to the patient and current life situation. Strange, rare and peculiar symptoms can instantly provide the Homeopath with a possible remedy starting point as a well described and interpreted symptom within this definition can indicate a narrower field of choice for prescribing. Following with Mental and Emotional symptoms, the homeopath can support the individual patient to begin the process of understanding that such psychological states can have a major impact on the body’s wellness and can be considered as a key element in any healing process. Physical symptoms can be arranged into two main categories those being physical general and physical particular and an example of each could be a ‘feeling of tiredness’ (physical general) with ‘heat in the right leg each time I try to sleep’ being a physical particular symptom. A Common Symptom in relation to the feeling of tiredness could be described as a difficulty in concentration during the day as a result of lack of rest.
In summary, it is possible to conclude that by utilising the discussed methods, frameworks and tools available to the Homeopath the full case taking process can be conducted and arranged in a format that is both conducive to the patient having the ability to talk about their present circumstances affecting their health and wellbeing and, for the Homeopath to arrange the notes recorded into a meaningful reference document to prescribe, monitor and evaluate the treatment path.
Post Case Taking
Prior to the patient leaving the practice, the Homeopath, as result of identifying the totality of symptoms and a priority area for treatment, can prescribe the remedy to be taken and dispense it, in accordance with good practice guidance. The patient should have the remedy and treatment explained in particular how to take the medicine in order to get the best results and key reasons for the prescription type. This way the Homeopath can ensure that consent to treatment has been obtained by the patient taking the remedy on an informed basis. A note of the prescription and potency should be made to maintain a record of the treatment pathway and key results of each remedy taken.
Follow up treatment recommendations can also be discussed and if appropriate a further appointment offered and booked.
Once the patient has left the consultation, it is important that certain housekeeping and professional standards are maintained. The Homeopathic practitioner can take time to reflect on the process just implemented and possibly identify areas for development in their skills, techniques and tools used, and make some relevant footnotes to discuss during the next appointment as an aide memoire, so they do not get forgotten.
Notes should be arranged in the patient’s personal record file in chronological order, for ease of future reference and secured in a locked cabinet to maintain the good practice recommendations under data protection and professional standards.
The practitioner themselves if possible should take time to rest and this can be a personal choice dependant on the case just taken and the information exchanged during it. The case taking process may have involved distressing experiences for the patient and involving a high amount of energy on the Homeopaths part. Back to back bookings would not be considered best practice but by giving time between appointments for reflections and rest, the Homeopath can offer equal quality to all patients in their practice and maintain their own health and wellbeing.
As this paper illustrates, the case taking process is more than just a method for talking and note taking and careful consideration needs to be taken with regard to pre, during and post case taking through preparation. To use Vithoulkas’ reference and metaphorical description, the Homeopath through organisational skills can prepare the canvas for the patient to have the freedom to paint their life’s picture within the consultation, thus enabling the Homeopath to interpret what is laid out before them to facilitate the cure. That is the true art of Homeopathy!
David F. 2011
References and Bibliography
Foubister, D, Dr (1989). Tutorials on Homeopathy
Hahnemann, S (1982) Organon of Medicine. Translated by Kunzli, J et al.
Kent, J (1990) Lectures on Homeopathic Philosophy.
Vithoulkas, G (1993) The Science of Homeopathy.
A gentle miracle post by David.