New Options in Primary Care: Anthroposophic Medicine
Research Summary

Anthroposophic medicine is an extension of conventional medicine that aims to provide a means by which people can develop their own latent capacities to address physical, psychological and spiritual aspects of illness.  It involves the use of a variety of therapies, including art, music, eurythmy (movement therapy), massage, and counselling as well as anthroposophic medicines.  Opportunities for social rehabilitation and work may also be offered as part of the therapeutic process.  Anthroposophic medicine is most widely developed in Germany, the Netherlands and Switzerland although there is now growing interest in many other countries, both in Europe and elsewhere.

Within the UK, there are six general practices (five NHS and one Primary Care Group based charity) and a 16 bedded residential unit offering anthroposophic treatments as an integrated part of the care they provide.  In 1996, the practices wanted systematic answers to questions about the impact, effectiveness and durability of different treatments across a range of medical conditions.  They also wanted to understand how the process of delivering anthroposophic medicine might be unified or enhanced, through collating learning from each of the practices. 

Aims of the research

The research addressed three questions:

• What is anthroposophic medicine as understood and interpreted by doctors, nurses and therapists working within general practice?
• How is anthroposophic medicine organised and delivered within primary care settings in the UK?
• What impact does anthroposophic medicine have on patients, both in terms of clinical outcomes and patient responses?

The central issues explored by the study are ones which lie at the heart of much contemporary socio-medical research.  There has been increasing interest in attempting to define different forms of general practice and the nature of the roles that GPs play within it.  Similarly, there is now widespread interest in how to provide ‘evidence’ about plural and more delicate interventions.   

The  study also takes place against a background of extensive change in the organisation, delivery and governance of primary care services. 

Study design

The study was largely qualitative in design in order to understand the nature of anthroposophic medicine in general practice and the outcomes that result from anthroposophic treatments.  The research undertaken had three main components:

• A medical record analysis in which 492 records were analysed to provide a profile of patients receiving anthroposophic medicine in the study practices;

• In depth interviews with patients (30) and various professionals (40) involved in the delivery of anthroposophic medicine to provide documentary evidence of the approach;

• Case studies of patients currently undergoing treatment (20) in which patients and their GPs and therapists were interviewed to explore the impact and effects of the treatments received.  Two patient centred outcome measures were also completed which use self generated symptom indices or effects of illness as the basis of assessment. 

The study practices

The seven practices in which the research took place are:

• Blackthorn Medical Centre (4 GPs) situated at the north-western edge of Maidstone, within a largely middle income community. 
• Wallis Avenue Surgery (Single handed) also in Maidstone, sited on a council estate. 
• Helios Surgery and Therapy Centre (3 GPs) located in a residential, high income area in the north west of Bristol. 
• St Luke’s Medical and Therapy Centre (3 GPs) situated in Stroud in Gloucestershire, with a branch surgery in Gloucester. 
• Mytton Oak Foundation (1 GP) a charitable Foundation sited on the Western edge of Shrewsbury adjacent to a six-partner NHS general practice where the Foundation doctor is also a GP. 
• Camphill Medical Practice (1 GP) sited within one of the Camphill communities on the edge of the City of Aberdeen. 
• Park Attwood Clinic  a 16-bedded  residential unit situated on the outskirts of Bewdley in Worcestershire.  Four doctors work at the clinic, two of whom are GPs. 

All of the practices, except Wallis Avenue, accept referrals from outside of their lists for anthroposophic treatments. 

The organisational structure of the centres is such that, technically, five of the six primary care practices are NHS general practices and one, Mytton Oak, is a charitable trust.  All but one of the NHS practices also provide most of their anthroposophic treatments through a linked charitable trust.  The residential clinic is a charitable company limited by guarantee attached to a ‘general practice’ with a small temporary list. 

Anthroposophic treatments and therapies available

The practices had been providing anthroposophic treatments for between five and fifty years and, in all cases, key developments had taken place during that time.  At least one GP in all the practices prescribes anthroposophic medicines for their patients.  Massage is also available at every practice, largely because it is used for diagnostic as well as therapeutic purposes. 

Most of the practices had widened the range of treatments available since anthroposophic medicine was first introduced.  As a general pattern, art therapy, massage and counselling had been introduced at earlier stages than, for example, eurythmy, hydrotherapy, music or garden therapy, partly because the latter required special accommodation or equipment. 

Some of the practices are developing specialist services or clinics for specific conditions, based on anthroposophic principles.  All of the practices had experienced a significant growth in the demand for anthroposophic treatments, particularly in recent years. 

Funding

In all the general practices other than Wallis Avenue, charitable Trusts have been established to manage and administer the anthroposophic work and to co-ordinate fund raising activities.  Funding for patients either comes through Health Authorities, through the charitable foundations, or through patients themselves paying privately, or paying according to their resources. 

Those with purpose-built premises have undertaken major fund-raising for this purpose.  In these instances, the land and buildings are owned by the charitable foundations, and the NHS practice, where this is linked, rents space in the building, thus generating additional NHS funded income for the Trust. 

Defining anthroposophic medical practice

All the practitioners were firmly committed to working within mainstream general practice.  There was an equally universal view about the limitations of orthodox clinical practice and a desire to push the boundaries to include both psychological and spiritual dimensions.  Most crucially there was felt to be value in ‘having a foot in both camps’, both for patient care and for professional development.

There are important philosophies and principles that define an anthroposophic approach.  These are summarised very briefly in the report. 

Referrals

A distinction is made between patients who are members of one of the anthroposophic general practice lists through local residency and are treated by an anthroposophically trained GP (local list patients); and patients who come to the practices specifically for anthroposophic treatments (referrals).  List patients are treated anthroposophically by their GPs as a list patient at the practice although they will need to be referred for other therapies and treatments.  Other patients need some mechanism of referral to begin their anthroposophic consultations and treatments with GPs. The majority of the latter referrals are made either by another GP in the practice or one belonging to the same Primary Care Groups.

Some basic reasons were identified as to why anthroposophic treatments may be more suitable for some patients on medical grounds than conventional treatments:

• avoidance of adverse side-effects associated with conventional treatment;

• conventional treatment alone cannot address the range of factors contributing to the condition;

• all orthodox treatment options have been exhausted without success;

• no conventional treatment options exist.

Medical Care

Patients are generally seen by one GP throughout their whole treatment programme and a key role played by the doctor is as ‘overseer’ of the treatment package.  Being involved throughout, and having an overall sense of each stage of the treatment, allows both development and continuity of care.

Length and frequency of consultations

The length of the initial consultation with new patients averages between 45 minutes to one hour.  Slightly less time is usually needed for in-depth consultations with patients known to the doctor where information has been built up over time.  Subsequent follow up appointments are generally shorter than initial sessions, but also vary in length of time depending on knowledge of the patient, the condition(s) they have and the treatment programme they are following.

Medication

As all anthroposophic doctors are trained in conventional medicine, full use is made of the same spectrum of allopathic medicines as used by more orthodox colleagues.  The degree and style of prescribing anthroposophic medicines varies amongst doctors according to the degree of experience and training. 

There are a wide variety of anthroposophic medicines available which provide practitioners with a range of prescribing options in illness management.  They may prescribe anthroposophic medicines before, or along side, allopathic medicines, or as an alternative.  For some conditions (e.g. established diabetes, severe hypertension), often only allopathic medicines are used. 

Three key benefits were felt to be gained through the use of anthroposophic medicines:

• Lowered prescribing rates for allopathic medicines and, hence, reduced prescription costs;
• Increased self medication for minor illnesses thus reducing GP time;
• Reduced referrals to secondary care.

 Anthroposophic nursing

The roles of anthroposophic nurses are similar to those of orthodox nurses.  All must have completed conventional training prior to learning an anthroposophic approach.

Anthroposophic general practice nurses, like other NHS practice nurses, run clinics, for example for blood tests, vaccinations, dressings etc.  Where the nursing role differs is in the application of compresses, footbaths and massage.  In some practices, anthroposophic principles are applied to antenatal care and midwifery. 

Specialist medicinal treatments

Another key respect in which anthroposophic medicine differs from orthodox practice is in the use of oils, ointments, lotions, and infusions.  These are administered in various forms such as teas, compresses, baths and water massage.  They may be prescribed and applied both by nurses and by massage therapists.  The substances used are made from mineral and plant extracts and, like the medicines already described, are applied using anthroposophic principles. 

Massage

Rhythmical massage practised by anthroposophic massage therapists is a body massage where the focus is on generating a general balance to the ‘system’ as a whole, but also addresses specific problems through working with particular systems and areas of the body.  Massage is often the first treatment prescribed for patients because it also provides valuable diagnostic information for the doctor. 

Massage plays a key role in enhancing physical processes, such as circulation and muscle function.  The skin, as one of the major sensory organs, is the obvious point of contact but the therapist is able to reach much deeper into the organism itself and affect other processes, such as liver, spleen and kidney functions.  The physiological processes that may be facilitated by massage include increased mobility, lymph drainage, improved circulation, enhanced adrenal function, pain reduction, muscle tone, reduced tension, increased energy and general up-building of the system. 

Eurythmy

Eurythmy is a form of movement unique to anthroposophy and has various therapeutic applications.  Rhythm is key to this form of movement which also makes use of physical and symbolic space.  Therapeutically, work begins with very simple exercises that facilitate assessment and diagnosis but which also begin to address imbalances in the physical body.  An important role of the movements is to increase awareness of the body, the self and ultimately the surrounding environment.  As the diagnostic picture develops, therapy progresses with the use of various exercises which mostly centre around gestures.  These are connected to sounds related to the letters of the alphabet, each of which has its own effects (e.g. calming or energising).

The combination of movements has a variety of roles, as well as being a gentle form of exercise.  The functions of eurythmy include increasing mobility, promoting healthier breathing patterns, loosening and releasing tension, improving posture, strengthening muscle tone, stretching and relaxing of muscles, reducing pain, promoting more balanced forms of movement and generally enhancing physical vitality.

Eurythmy therapy is mostly done on a one-to-one basis but groups are run for specific conditions (e.g. asthma, back problems).  It is available at four of the study centres.

Counselling

Counselling was available at four of the study practices.  Other centres have access to statutory services.  All of the counsellors operate, to a greater or lesser degree, within anthroposophic principles although only one had training in biographical counselling, which is specific to anthroposophy.  Most work is done on a one-to-one basis but some group work is undertaken.

In biographical work, the phases of development are primarily explored within the principles of seven-year cycles. These stages allow insight not only into personal development but also provide a context for processes likely to occur at different stages in a person’s life.  The approach is described as being eclectic, humanistic and ‘very much person centred’. 

Therapists have an integrative approach to their work and use ‘working hypotheses’.  These relate strongly to an anthroposophic approach.  The role of the counsellor is seen as working alongside patients in helping them to ‘manifest who they really are’. 

To further this, each counsellor has developed techniques drawn from varied disciplines, as well as anthroposophy.  A common approach is the use of visual imagery in developing more positive pictures of situations and responses to events. 

In some circumstances, patients may be encouraged to extend this visual element artistically through painting or drawing.

The number of counselling sessions given varies with conditions but also across the practices.  Sessions last between 50 minutes to an hour and are run on a weekly or fortnightly basis.

Art and sculpture therapy

The key activities in art therapy are drawing, painting (with both wet and dry mediums), and sculpting.  Techniques and exercises, which are specific to anthroposophic art therapy, are tailored to the individual and the mediums used are watercolours, pigments made from natural plant colours, pastels, charcoals, pencils and clay.  Sculpture therapy, which has developed as a separate therapy in recent years, works primarily with the medium of clay.  Although a diagnostic element of art therapy exists, it is used primarily to inform treatment.

Art and sculpture exercises are designed to allow the patient to make small steps at the point at which they are ready so that progress is tailored to each patient.  Initial exercises are designed to help patients to familiarise themselves with the medium and techniques and to build confidence in their artistic abilities. 

The key emphasis in both art and sculpture therapy is more on the process than the finished product.  The process of communication during therapy is derived from the use of colour and form and more subtle elements of light, dark, warmth, coolness, flow and movement.  These often have direct parallels to the illness itself.

Therapy is conducted both on an individual basis and in group settings. Individual sessions last approximately forty-five minutes to an hour, but group sessions tend to be longer (one to one and a half hours on average).  An average ‘term’ of therapy consists of ten or eleven sessions.  Art therapy is available at all but one of the study practices.

Music Therapy

Music therapy, developed in two study centres relates closely to ‘creative music therapy’ and specifically to the work of Paul Nordoff and Clive Robbins who initially developed their work with children with physical and learning disabilities, later extended to other patient groups.

Patients are seen on either a one-to-one basis or as part of a group.  The principal instruments used are the hand lyre (a hand-held stringed instrument), and a range of percussion instruments and small flutes.  The therapist normally accompanies patients and the key method used in individual sessions is improvisation.  This allows the patient to build up the range of musical expression and provides an immediate musical experience.  The main focus in therapy is on the ‘flow and meaning’ of the music rather than the accuracy of playing.

There are three main principles that underpin the form music therapy might take: the relationship between music and emotion, achieving balance, and developing communication and personal/social contact.  Music therapy principally relates to the development of the ‘soul life’. 

Sessions last approximately fifty minutes and are generally on a weekly basis.  The average length of therapy is around twelve sessions over a period of few months. 

Occupational and social therapies

Each organisation is at a different phase in the development of what are termed ‘social’ therapies.  The occupational project at the Blackthorn Trust has the most fully developed services, made possible through statutory as well as voluntary funding.

The activities of the project are based on anthroposophic principles and include a garden and garden centre, a café and the production of crafts, oils and other products. 

Approximately sixty patients (referred to as co-workers) were attending at the time of the research.  Half are referred through local mental health services with which the Trust has built strong relationships.  The remaining patients, who have a wide range of predominantly physical conditions, are referred to the services by GPs at the practice.

Individuals work a varying number of days within the project.  They also stay in the project differing lengths of time depending on their condition and personal development.

The patients

The analysis of patient records shows that the demography of patients getting treatments, the consultation rates and the conditions of patients being treated were similar across practices.

• 72 % of patients receiving therapy within anthroposophic practices were women, compared to 51% of general practice consultations nationally.
• The largest group of patients attending for therapy in 1998 was aged between 35 and 54 years (42%)The data on occupation are limited but indicate that there are a disproportionate number of patients with professional and associated professional occupations amongst the patient population.
• Consultation rates tended to be higher than among the general patient population.  This difference is not surprising: since patients referred to anthroposophic therapies are more likely to have chronic conditions and thus more likely to consult their general practitioner or practice nurse than other patients.
• The most frequently recorded diagnosis was connected with mental health (20% of all recorded diagnoses).  Nine per cent of recorded diagnoses were associated with musculoskeletal problems.  A variety of other medical conditions were recorded. 

The patients divide between those who had knowledge or experience of anthroposophic or other complementary medicines prior to treatment and those who came from more orthodox medical traditions.  Among the latter group, there was a degree of scepticism about the treatments prior to receiving them.  Some also had misconceptions and apprehensions about what might be delivered.

Patients’ experiences of anthroposophic medicine in general practice

Patients were overwhelmingly positive in their appraisals of the doctors, therapists and nurses who had treated them as well as other practice staff with whom they had come into contact.  Those new to anthroposophic medicine were often pleasantly surprised by the approach taken by anthroposophic doctors finding it very different from previous experiences of orthodox care. 

The key aspects of care from practitioners that were favourably mentioned include: 

• Time given to consultations to discuss their concerns as well as the ‘calm’ and ‘unrushed’ nature of the practitioner, though time was related to quality rather than quantity.
• Technical care and thoroughness in exploring medical and biographical histories.  A key element in appraising this thoroughness was the connections that could be made between physiological problems and their underlying causes.  Value was consistently placed on having both an orthodox and anthroposophic approach combined.
• Communication and information Patients consistently described communication with their doctors and therapists as more of a ‘dialogue’ or ‘two way process’.  The approachable and friendly manner of the doctors was frequently noted.
• Personal care and support Patients emphasised the levels of care and concern that the doctors and therapists showed in their consultations and the degree of personal encouragement they gave to individuals. 

Key aspects of an anthroposophic approach that patients viewed very favourably included: its holistic nature; a person centred approach that was tailored to individual needs; the facilitation of personal learning and development; its ability to look at underlying causes; the use of natural treatments and remedies; and the involvement of patients in the management of their illness.

Around half the patients interviewed had paid in full or in part for their treatments and just under half were non fee-paying.  There were no apparent differences between fee or non-fee paying patients with respect to the reported degree of engagement in their treatment.  The cost of therapies to patients was, however, a significant factor in barriers to uptake of therapies for those with limited finances.  A number of patients reported that they would have been unable to receive treatments without financial assistance for therapies.  Payment plans made it easier for some patients with limited financial resources.

Clinical outcomes and their measurement

The data on outcomes were collected primarily through a series of case studies carried out with patients who were currently undergoing anthroposophic treatments.  Patients were interviewed on two occasions - the first just as they began treatment and the second usually after it was complete.  The patients were also asked to complete Measure Your Own Medical Outcome Profile (MYMOP) and Patient Generated Index of Quality of Life (PGI) questionnaires on both occasions.  There were also interviews with the therapists that carried out the treatments and with the referring GPs. 

The outcomes resulting from anthroposophic treatments that patients identify are mainly positive.  They fall broadly into physiological, psychological, behavioural and spiritual effects.  There is a general sequence to the way in which outcomes are described with movement from the physical to the psychological, the psychological to the behavioural and the behavioural to the spiritual.  Because of this sequential pattern, the longer-term effects are more open to the influence of other factors and interventions.  Nevertheless, as they are perceived, these deeper level outcomes are still attributed, at least in part, to the anthroposophic treatments received.

MYMOP and PGI were both found to be effective in identifying physical symptoms and in terms similar to the qualitative data.  Although both identify a range of psychological factors, those characterised in the PGI are more specific than in MYMOP.  The PGI identifies more behavioural features (consequences of illness) than MYMOP and, again, these are more specific to individual patients.  Neither tool captured the spiritual elements that emerged from the in depth interviews.

Problems of outcome measures

The measurement of outcomes for patients with chronic conditions participating in complex treatment programmes poses significant methodological difficulties.  These are discussed in detail in the report covering the varying nature of outcomes identified depending on the ‘instrument’ used for data collection; the time frame over which measurement should take place; and whether single treatments or clinical packages should be assessed.  It is concluded that a combination of qualitative and quantitative data may be particularly useful in the study of any medical practice which aims to address illness beyond the physical level.

Further research

The report concludes with analysis of the need for further research and the forms this could take.  In particular, it supports the widespread call for robust research into the effectiveness of complementary medicines, particularly in primary care.  It also discusses issues surrounding the assessment of ‘quality’ in primary care for the development of national frameworks and the need for research on issues such as co-morbidity, training and development for partnership working.  The final discussion surrounds the need for further evaluation of anthroposophic practice and the form that clinical trials or other research might take.

(Published here with kind permission of the authors (Gene Feder); © Authors)