INTRODUCTION
The half-century-long pandemic of non-communicable conditions is by far the leading cause of premature disability, morbidity, and mortality world-wide.1 While social determinants2 are major influences on health at the level of populations,3 long-term unhealthy lifestyle choices form the key risk factors for individuals.4,5 As such conditions are the expected results of these lifestyles,6,7 in this article the term “non-communicable lifestyle-related conditions” (NCLRCs) is used to refer to what have been called non-communicable diseases. Individuals experiencing such conditions or wishing to prevent them may be guided by their philosophies of life and health to consult with practitioners of different types, including chiropractors.8,9
NCLRCs are chronic conditions of gradual onset and slow progression and as such are not amenable to quick fixes.10 They involve widespread individual and family suffering and expense.11 On the societal level, they involve high and ongoing costs of treatment while they reduce national economic productivity and the ability to fund those costs.12 This situation may exist, at least in part, because of inappropriate thinking and behaviours about life, health, and disease.7
Biomedical Approaches to NCLRCs
NCLRCs are commonly addressed using approaches based on the biomedical model.10,13 This model emerged with the germ theory of disease and pharmacological developments aimed at treating acute infectious diseases.14 Biomedicine focuses on the physical aspects, causes, and treatments of diseases.15 Comprehended through molecular biology, diseases are seen as measured variations from accepted standards of body biology.7,16 Diseases are classified into separate entities so separate causes and treatments are pursued for each disease. Treatments are sought in biomedical research and therapeutic technologies, usually allopathic drugs and surgeries, and are mainly used to manage existing disease.17 Biomedicine remains the dominant approach in the health/disease field.13,14 It has been useful in addressing infectious conditions and body biological faults, but less successful in addressing NCLRCs.10 Furthermore, its philosophical basis in mechanism and mind/body dualism may not give sufficient attention to the individual’s state of mind and life context.7,15
Biopsychosocial Medicine
The biopsychosocial medical model adds the patient’s psychological and social contexts to biomedicine,18 and has been applied in areas such as theory19 and research.20 However, it appears to have had less influence in dominant areas of medicine such as acute medicine, surgery, and funding.13,21 Some consider it to be too complicated and impractical for everyday practice.22,23
In general, most approaches to NCLRCs retain biomedicine’s focus on treatment and management of existing conditions10 or on prevention via reduction of risk factors.24,25 Such approaches have met with limited success17,26 in improving patient results and reducing costs, perhaps because these approaches focus on treating the effects of NCLRCs rather than on effectively addressing their causes.13 The need for other approaches to productively address NCLRCs has long been evident.27,28 Health cannot be maintained or regained simply by purchasing the products and services of the medical industry.3 Reduction of the growing prevalence of NCLRCs will likely require thinking and actions in addition to biomedical and biopsychosocial approaches, such as aligning individual and societal behaviours away from disease and towards health.17
Salutogenesis
Rather than disease, the salutogenic model focuses on the origins and causes of health.29 At any time, an individual is considered not just healthy/well (referred to as “ease”) or sick/diseased (“dis-ease”), but is somewhere on a continuum between them.30 While they are exposed to the natural breakdown forces of entrophy, which may involve loss of health,31 salutary factors actively resist breakdown and generate health. In addition, resistance resources are attributes that help individuals to deal with life stressors. When experienced repeatedly, these attributes can lead to a “sense of coherence”,30 with which the individual optimistically perceives their external and internal environments as predictable. The world appears as comprehensible, manageable, and meaningful.32 The belief that life has positive meaning motivates these individuals to comprehend stressors on the basis of their experiences and to find and use resistance resources to manage them. These salutary actions then create movement towards health and life.
Vitalism
Vitalism is a philosophical school of thought with ancient origins.33,34 Its premise is that living organisms and non-living things differ fundamentally in that living organisms possess a life principle, force, or energy which non-living things do not have. Multiple strands of vitalism35 permeate philosophy36,37 and its boundaries with science and medicine,38,39 culture and media,40,41 and disconnection from nature.42 Vitalism’s enduring nature suggests that it offers value of some sort.43,44
Palmer,45 the founder of chiropractic, referred to vitalism’s life principle as the body’s “Innate Intelligence”. He described it as part of an intelligence which pervades and gives order to the universe. He then argued that this intelligence is channelled over the nervous system from the brain to the body to organise its functions. According to Palmer, its ability to do that depended on 2 factors. One required the nervous system to be free of any interference to that channel. The other was the quality and quantity of material (air, food, and water) ingested for Innate Intelligence to work with. Together, he believed, these factors determined health.
Some chiropractors perceive vitalism as a fundamental feature which distinguishes chiropractic from mechanistic biomedicine.46 In an urbanised world focused on technology, vitalism symbolises a coherent relationship with the natural universal order.47 The potential of chiropractic as a salutogenic system for the preservation of health48,49 should be therefore explored outside of biomedicine and via thinking, research, and practice congruent with vitalism.50
In contrast, other chiropractors regard the concept of innate intelligence as untestable by positivist science and therefore unacceptable.51 According to these chiropractors, vitalism endangers the profession by excluding it from acceptance by science and medicine.51,52 It should therefore be replaced by science53,54 so that chiropractic might earn acceptance into the mainstream.55 These arguments for and against vitalism in chiropractic are, however, based on opinions, which may involve bias.56
Some empirical data exists on what chiropractors actually mean when they speak about vitalism. Fox57 found that, to most lecturers at the New Zealand College of Chiropractic, vitalism meant the self-healing, self-organising, and self-regulating properties of the human body. Richards49 established that, to the majority of a group of chiropractors in Australia and New Zealand, vitalism meant innate intelligence and a guide to a good life. To a minority, vitalism meant a “neo-vitalism” focused on the self-healing, self-organising, and self-regulating properties of the human body; or healthy lifestyle; or an unscientific doctrine which hinders the progress of the profession. Nevertheless, there is a lack of empirical data on what practical value the profession believes vitalism might offer in dealing with any major problem in the health/disease field, such as global prevalence of NCLRCs.
Concepts such as salutogenesis, sense of coherence, healthy lifestyle, wellness, vitalism, and innate intelligence resonate with many chiropractors.49,58–60 Indeed, Palmer45 proposed vitalistic chiropractic as a system for the preservation of health, rather than as a treatment of disease or pain. Chiropractors may be able to offer approaches related to vitalism that are useful in addressing wellness and the growing prevalence of NCLRCs.50,61,62 Little is known about what value chiropractors attribute to vitalism. This present article reports on research on the following question: what value do chiropractors believe that chiropractic thinking and practices based on vitalism might offer in addressing global prevalence of NCLRCs?
METHODS
Design
A constructivist research paradigm63 was combined with a research stance64 of descriptive phenomenology.65 To minimise possible over-intrusion of the researchers’ opinions into the research, this stance required them to describe rather than to interpret the gathered data66 and to seek to put aside (bracket) their own opinions.67 The first author is an experienced chiropractor and researcher who has a keen interest in linking chiropractic philosophy and healthy lifestyles. He holds BS, Doctor of Chiropractic, and PhD degrees. The other authors are university researchers and academics trained and experienced in chiropractic, osteopathy, nursing, midwifery, and qualitative research.
The semi-structured interview was selected for data gathering as it could offer flexible and productive interactions between the interviewer and the interviewee participants.68 The interview schedule was composed of 2 questions: Do you think vitalistic thinking and practices add value to the services chiropractors offer? And: Do you think vitalistic thinking and practices used by chiropractors could help address the current global prevalence of non-communicable conditions, which are mainly caused by unhealthy lifestyles?
Twenty-one chiropractors from 9 countries were selected as potential participants using Patton’s68 approach to purposive key informant sampling. This intentionally non-random, non-probability type of sampling was utilized to select people who, based on their levels of expertise and contributions to the profession, were judged as potentially able to contribute deep and rich data towards answering the research question. As generalizability to the broader profession was appraised in subsequent research, no attempt was made to select a representative sample of the profession beyond inviting a majority of chiropractors believed to be knowledgeable and supportive of vitalism and a minority of disconfirming non-supporters.
Email invitations which included details of the study and the researchers were issued to potential participants. Two failed to respond for reasons not known and another declined to install the Skype program necessary for participation. The final sample composed 18 people from 8 countries, and included chiropractic practitioners, educational administrators, lecturers, researchers, and politicians. Their ages ranged from 37 to 74 years. A university Human Research Ethics Committee provided ethics approval for the study and all participants provided written informed consent prior to enrolment in the study.
Data collection
The interview questions were pilot tested before collection of data was carried out between January and July 2017. All interviews were carried out by the first author via Skype web technology except for 4, which were carried out in person in participants’ offices. The first author made extensive field notes, and no observers were present during interviews, which were between 38 and 100 minutes in length and recorded on a smartphone before being professionally transcribed. One participant was interviewed twice due to the difficulty in getting him to answer questions. After 15 interviews data saturation69 was reached. However, an additional 3 participants were available and so were interviewed to confirm saturation.
Data Analysis
Braun and Clarke’s70,71 system of reflexive thematic analysis was used to analyse the data, as this system was congruent with the qualitative and constructivist approaches of the research. In addition, Neuman’s72 procedure of open, axial, and sequential coding was inserted into this system to clarify and strengthen the coding process. The complete analysis system used can be seen in Table 1 and an example of coding in Figure 1. The data were managed using Microsoft Excel (Redmond, WA). Initial coding was carried out by the first author and then discussed and refined into themes during in-person conferences with the other authors. The consolidated criteria for reporting qualitative research (COREQ) appraisal tool73 guided the reporting of the study findings (see Supplementary Material).
RESULTS
Two themes were identified from the data, as presented below. The contributions of multiple participants are represented in each theme and the interview quotes which best exemplify each theme or part thereof most succinctly are used to illustrate the themes. Contributions from disconfirming cases are included when informative.
Theme 1: Individuals’ lack of connection with the order of the universe and the innate intelligence of their bodies
All participants were aware of the prevalence of NCLRCs and acknowledged unhealthy lifestyles as the major causes of them. Participant 3 summarized:
I think the major health concerns facing the world today … it’s the chronic lifestyle choices – the obesity rates, the smoking rates, the processed foods …
Some participants pointed out that most people were aware of the causes of NCLRCs. According to Participant 4: “Most people know how much they should drink. Most people know that they should exercise”. Similarly, for Participant 12: “The major problem is not the fact that we do not know what’s good for us.”
In addition, some participants offered what they believed were deeper reasons for the prevalence of NCLRCs. For example, Participant 5 felt that many people believed that their health was determined by factors over which they had no control. Their belief that they were victims of genes or bad luck had a “disempowering and dehumanising” effect, so they exercised little agency and control over their health. This situation, he believed, contributed to attitudes often seen in relation to NCLRCs.
Other participants posited that this situation arose in part because many people saw health simply as the absence of disease. They believed that many people were lazy, could not be bothered to make the effort to live healthfully, and were careless about their health:
They just don’t care. They just want to go through the day, and it doesn’t matter how. But if the body starts to fall apart, then they want to have a solution … with no extra effort than just going [to a doctor]. And they stop immediately at that moment when it feels better. And that’s not health. Participant 4
Participant 12 posed that the underlying cause of poor lifestyle choices lies deep in human nature:
The human being wants to reward itself. It’s as simple as that. And when the society around it wants to offer it everything and not to deny it … you are under a constant pressure to say no. On the other hand, there’s still a centre in your brain that says, “Okay. You deserve it. It’s okay. It makes you feel good for a short while.”
This lack of caring about health was related by another participant to his belief that many people lived their lives disconnected from lifestyle factors which would support their health:
People are disconnected and there’s a disconnect between what people are bringing into their mouths and these chronic disorders that are arising. … I think there’s a complete disconnect between people’s thinking and the actions they bring to bear in this life and then the unexpected hit of chronic disease. Participant 6
He felt that this disconnection arose because many people were focused on what was happening outside of themselves. They had little awareness of the innate intelligence of their bodies and how they should live in ways supportive of it.
Other participants extended this concept of disconnection to a universal level. Participant 5 expressed such disconnection in terms of misalignment with the universe. His understanding of vitalism included that the universe manifested “order and design”. Misalignment with these on the planetary level could be seen in widespread human-caused degradation of the natural environment. Similar misalignment on the human level was seen in the unhealthy lifestyles which led to degradation of the internal bodily environments of many individuals and the prevalence of NCLRCs. He concluded that: “The origins of illness, rather than being failures of the [human] machine, are failures of alignment with the order of the universe”. Participant 2 exemplified this in her own life. After noting that the universe demonstrated organisation, such as in the cycle of day and night, she stated that: “We’re not living in the cycle of the universe …”. Indeed, she shared her own lived experience of diminished health as a result of placing herself out of this cycle by frequently working late into the night.
Theme 2: Chiropractic approaches based on vitalism offer a conceptual gateway to self-empowering reconnection and realignment to universal order, innate intelligence, and health
Most participants firmly believed that vitalistic thinking and practices added value to the services chiropractors offered and could help address global prevalence of NCLRCs. When asked, many responded very positively, using words such as “absolutely” or “a resounding yes”. Such thinking and practices offered value because they were different from other thinking and practices commonly utilized in the health/disease field. According to Participant 7: “I really do think they add value. There’s a different point of view.” Participant 6 agreed: “[V]italism provides for and underpins a clinical model and a life of meaning … different to a life and a clinical encounter underpinned by mechanistic perspectives.”
For Participant 5, the “monumental value” of vitalistic thinking and practices lay in the completely different perspective and potential they offered. However, many people exhibited attitudes which were out-of-alignment with the vitalistic order of the universe and adopted a “victim” mentality. They then relied on the “heroic intervention of some party outside of you and apart from you” to give them back their lost health or to at least mitigate their problems. In contrast, he explained:
Vitalistic innate intelligence, an embodied part of this order and design, provided a context for the individual’s functioning and living in the world, and a capacity for reasoning which could enhance or degrade that function and life. Overall, vitalistic thinking incorporated a desire to be aligned with the function, growth, and wellbeing of the universe.
He then explained how the different perspective of and potential inherent in vitalistic thinking and practices differed from those of mechanistic medicine:
[A] physician or a surgeon looks at someone and says, “It’s my job to repair this broken down … incomplete entity that’s in front of me that is chemically lacking, biologically lacking …”. [T]he vitalistically oriented chiropractor looks at that same patient and sees a wonderful healing potential that’s been interfered with. And how can I remove that interference and allow that healing to happen? Those two reasoning points … not only are they radically different in and of themselves, but the behaviours that flow from them are night and day. [A]s one changes from one view to the other, the outflow from that changes dramatically as well … [It] takes the patient out of the role of a victim … and it places them as the prime agent of their healing …
Similarly, Participant 11 saw vitalism as:
… an empowering perspective as far as health goes because it starts to form the perspective that you have a degree of control or ability that increase your probability of good health … [I]f you contrast that with a more materialistic perspective where there’s not the same sense of reverence for the systemic design and robustness of our bodies … there’s less control over how healthy they can be.
In contrast to mechanistic surgery, Participant 14 (who had been purposely selected as a disconfirming participant) considered that vitalistic thinking:
… may have a value in terms of making people think about patients other than just machines that need to be fixed. … I’m talking about medicine where you go in with hip pain and you get a new hip put in. That’s a very mechanical fix pain approach that is completely the opposite.
Some underlying reasons for the differences between the vitalistic chiropractic and the mechanistic medical approaches were articulated by Participant 16. He first described the mechanistic medical approach as follows:
[A] mechanist is always trying to alter the body from the outside in, to drive it back into the ranges it believes that body should be in. … [to] diagnose the machine when it breaks down and treat it back to what we think it should be.
He argued that the complexity of the living body meant that its function could not be run by the conscious human mind. There must be a deeper intelligence in living things to control that function, so: “… life is intelligent … the body is smarter than the doctor”. Accordingly:
As a vitalist who believes the body is self-developing, self-healing, and self-maintaining … the whole issue in my life comes down to instead of manipulating the body with something, how do I get rid of the interferences so it could be what it’s supposed to be?
Similarly, Participant 6 pointed out that vitalistic chiropractic thinking and practices did not include drug prescription or surgery aimed at treating disease. High costs associated with the medical approach might therefore be avoided:
[T]his idea of vitalism, I think, underpins our inclination as chiropractors towards being very, very conservative in the care that we offer: not using drugs, not using surgery, but using largely our hands to not add anything but remove interference from the system to allow the body to heal itself more efficiently, more effectively …
He also believed that vitalistic thinking offered a solution to the disconnection believed to contribute to the prevalence of NCLRCs:
[V]italism provides us with a model … for better connecting people to their circumstances or encouraging people to take responsibilities for their actions … in terms of the decisions they make regarding their health …
The ability of this vitalistic model to better connect and encourage people was of a non-material form:
[V]italism suggests that there’s something more than just physical and chemical properties as a base of explanation for our reality. It opens the door to something of a non-material nature to give rise to … the fundamental order that we find around us in the universe … that underpins everything and goes beyond our material existence…. [T]hat idea … breathes life into a lot of what I do … It shapes my thinking and my actions …
This non-material value of vitalism was shared by other participants. For Participant 18, vitalism created: "… a sense of understanding and comfort that I’m just part of a bigger thing, that my existence is part of something bigger than just me as an entity wandering around on the planet." Participant 14 perceived vitalism in practice as a way to augment the health-enhancing potential of chiropractic by going beyond just the application of physical techniques to people:
[V]italism] provides a portal to allow practitioners to think about things that are not necessarily only physical … You’re not just a technician … [V]italism] does offer a context such that if you wish to optimally benefit your patient that you can draw on things that are abstract, mental, or emotional to try and enable your patient in a particular direction.
In contrast, non-confirming Participant 9 saw no connection at all between chiropractic care itself and vitalism. For him, the only possible relationship between vitalism and NCLRCs might be the need to wholistically support healthy body self-regulation by living a healthy lifestyle in a healthy environment.
DISCUSSION
Almost all participants believed that chiropractic thinking and practices based on vitalism offered value in addressing the global prevalence of NCLRCs. This is congruent with the understanding of vitalistic chiropractic as a system for the preservation of health.45,48 To our knowledge, this study is the first which provides insights into why some chiropractors believe that this system might offer such value. Overall, the majority beliefs were expressed in the 2 themes: 1) Individuals’ lack of connection with the order of the universe and the innate intelligence of their bodies; and 2) Chiropractic approaches based on vitalism offer a conceptual gateway to self-empowering reconnection and realignment to universal order, innate intelligence, and health.
While all participants demonstrated awareness of the prevalence of NCLRCs and the unhealthy lifestyle causes of them, some participants proposed deeper reasons underlying the prevalence NCLRCs, as follows. Despite common knowledge about the causes of these conditions,3–5 many people were disconnected and misaligned from the powerful natural life-supporting order of the universe. They unconsciously adopted a dehumanising mindset, became machine-like, unaware of their innate intelligence, and unwilling to control their own lives and health. They cared little about their health until it was lost, at which time they sought its restoration through mechanical biomedicine. There is little in the chiropractic literature comparing vitalistic and mechanistic approaches in this way.
In contrast, according to many participants, the value of vitalism emerged from ways of thinking and practice that were different from the orthodox ways predominant in the health/disease field. This belief that vitalism underpinned lifestyles and clinical models that were different from those of mechanically and physically based biomedicine has limited support in the literature.75 However, in this present study, vitalism as innate intelligence was seen as a gateway to self-empowerment. The individual who was re-connected to their innate intelligence could transcend victimhood and become aware of, aligned with, and supported by the order and design of the universe. Secure in this sense of coherence, they could take responsibility to live in ways which provided support for innate intelligence’s profound salutogenic influence over their life and health. According to most participants, the chiropractor’s job was to guide individuals to that source of health within themselves and to assist in the removal of interferences to it.76 Even most disconfirming participants showed some support for vitalism in this context, while one perceived value only in the possibility that such thinking might involve living healthy lifestyles.
Chiropractic vitalistic thinking has previously been linked to a coherent relationship with the natural order of the universe and health.47 This present study expands understanding of that relationship by relating participants’ lived experiences of their perception of people’s disconnection and misalignment from that order as deeper reasons for the prevalence of NCLRCs. In addition, this study explicates the experience of some participants and their vitalistic thinking as forming a conceptual gateway from that disconnection and misalignment to a reconnection and realignment of the individual to the universal order and to the associated salutogenic benefits of innate intelligence. These participants believed that such thinking and practices may underpin innovative, effective, and valuable ways to address the global challenge of prevalence of NCLRCs. The question then arises as to how such thinking could be put into practice. Given some participants’ experiences of people’s disempowering attitudes towards health, how could these attitudes be changed? What might constitute vitalistic chiropractic practices which successfully seek to generate such changes? Regardless, this study’s positive findings with respect to the value of chiropractic thinking and practices based on vitalism contrast sharply with that literature which rejects vitalism as having any legitimate role in chiropractic.51,54,55,77
Rigor and Quality
Criteria such as credibility, trustworthiness, truthfulness, and authenticity are commonly considered in judging the rigor and quality of qualitative research.78 Multiple approaches were used to address these criteria in this present study. For example, 18 participants were interviewed and each researcher carefully studied and compared interview transcripts before contributing to the development of the final themes in face-to-face meetings. These actions represented forms of triangulation.72 Additionally, purposive sample selection of disconfirming cases68 provided disconfirming evidence.78 The researchers reflected on their professional and personal frames of reference to identify any assumptions, beliefs or biases which might affect the research process.79 Interviewing of three additional participants confirmed that data saturation was reached.79
Researcher collaboration68 with participants included attentive listening to interview contributions, development of probe questions from those contributions, and the termination of interviews only when the interviewee confirmed that they had no more to add. Following data collection, repeated listening of the interview recordings and reading of the transcripts fostered deep researcher engagement with the data, contributing to authentic codes and themes. Member checking78 involved having one participant reading and commenting on his own interview transcript and the complete draft findings. During the study, a carefully curated audit trail80 enabled the researchers to document, refine, and guide the research procedure to maximise its authenticity and credibility. Finally, the Results section above contained thick, rich description78 to illustrate those results. These approaches and the COREQ Quick Checklist (see Supplementary Material) were used in this study assist the reader to consider its credibility, trustworthiness, truthfulness, and authenticity on an informed basis.
Limitations
The difficulties of attempting descriptive phenomenology and bracketing in this type of research and that the backgrounds and values of the researchers may have led to bias are acknowledged. The sampling involved was not representative as this study sought to explore deep rather than broad understandings of the value of chiropractic thinking and practices based on vitalism. Many of the participants interviewed were involved in education and administration rather than practice, and different themes may have been identified with a different sample.
CONCLUSION
This study contributes deeper understandings of the potential value of vitalistic thinking and practices in chiropractic. By informing a conceptual gateway from disconnection and misalignment to connection and coherence, such thinking and practices may underpin innovative and effective ways to address the global challenge of prevalence of NCLRCs. Future research should investigate the extent to which these understandings are shared in the wider profession and how they might be operationalized into a practical and effective vitalistic chiropractic practice model.