The Path Between

Every Medicine Is a Construct

Thomas Easley — Fri, 31 Jul 2026 18:56:24 GMT

All systems of medicine are a construct, in the very literal sense that at decisive moments we can often name the people who decided what would and would not count as part of their system of medicine (and often why). Medicine is constructed because people select, combine, exclude, standardize, and transmit particular practices. Constructed does not mean arbitrary, ineffective, or unreal. It means the system could have been assembled differently, and that its present form has a history.

Historians of every major medical system have written about this. A lot of people practicing those systems don’t know it. Our systems train us in what to ignore, and what to pay attention to, and what counts as an answer. I want to talk about what the construction of medicine looks like at the level of patient interaction, but for that conversation I need you to read your own system’s history and understand how heterogeneous practices get chosen, organized, institutionally defended, and eventually narrated as a coherent tradition.

Modern Western Medicine

When the American Medical Association was founded, its ethics code forbade its members from consulting with anyone whose practice was considered exclusive dogma, including the eclectics and homeopaths. That line, that boundary, kept the irregulars out, but other than that it really settled nothing about what medicine was (Starr 1982; Burrow 1963).

Regular physicians differed wildly in how they practiced, depending on the region they lived in, the season, the patient’s constitution, and they all defended these very distinct variations as doctrine (Warner 1986). An even deeper split, between measuring outcomes and reasoning from known mechanisms, crystallized among the Paris-trained physicians of the 1830s and 40s (Warner 1998) and resurfaces almost unchanged in the evidence-based medicine debates of the 1990s.

Also, germ theory wasn’t a clean revolution but a thirty-year negotiation among multiple competing germ theories (Worboys 2000). There was a strong holistic medicine movement that ran inside Harvard and Johns Hopkins from the 1920s to the 50s (Lawrence and Weisz 1998). And, intentional or not, specialization made the pluralism a permanent thing: a cardiologist and a psychiatrist reason differently about the nature of disease (Stevens 1998; Weisz 2006).

Evidence-based medicine began as an internal revolt against the authority of eminence and immediately got pushback (Timmermans and Berg 2003). And then, almost as quickly, prominent EBM advocates were arguing that its authority had been appropriated by the vested interests of big pharma (Greenhalgh et al. 2014). And Annemarie Mol spent years documenting that, at least in one Dutch hospital, atherosclerosis was a different disease depending on whether you were in the clinic, the vascular lab, or the pathology department, and what really held these different atheroscleroses together was the referrals, case conferences, scheduling, and a lot of paperwork (Mol 2002).

Traditional Chinese Medicine

The first official use of "Traditional Chinese Medicine" seems to be 1955, in material written for foreign readers. Mao had been wishy-washy about traditional practices before this, but in 1954 the state strongly embraced them for both political and practical reasons. Then colleges opened, and in the 1960s the first unified national textbooks were written. Historian Kim Taylor argues that regularization of Chinese medical knowledge is itself a twentieth-century phenomenon, and that the very idea of a unified basic theory of TCM is “strictly a PRC China phenomenon” (Taylor 2005, 145).

Before the ‘60s there wasn’t a single standardized system of Chinese medicine that looks like what “TCM” does today. Demonic medicine, systematic correspondence, and pragmatic drug therapies had coexisted with folk practices and countless family lineage-based practices (Unschuld 1985). Modern acupuncture descends from big changes in the 1930s, when points were re-described against nerve anatomy and the needles themselves changed (Andrews 2014). And even after standardization, the practice in China stayed plural (Scheid 2002). What we know of as TCM is, according to historians of Chinese medicine, a mid-century product, and the actual traditions underneath are older and stranger and contradictory. Decisions were made about what constitutes Traditional Chinese Medicine by people whose names we know.

Ayurvedic Medicine

A different version of the same process happened in India, twice. Kenneth Zysk argues the empirical medicine at Ayurveda's core came out of heterodox ascetic communities, Buddhist and Jain renunciants, and was later assimilated by Brahmans into an orthodox frame, with the story of divine transmission added afterward (Zysk 1991). The second version came with the British orientalists splitting a multitude of cultural practices into a “great tradition” written in Sanskrit texts and a “little tradition” of actual practices.

Indian revivalists then turned that split into a program, and in 1938, the Bombay Medical Practitioners Act was passed, which started the shift towards college and board examinations (Langford 2002). The current central focus on the tridosha system is modern: classical disease causation often ran on misplacement, not imbalance, and Mukharji traces chakras' popularity to modern Ayurveda’s early interaction with protoplasmic cell theories. As early as the 1920s, the doshas were being equated with hormones by the tradition’s own reformers, a handful of families, mostly upper-caste, mostly Western-qualified (Mukharji 2016).

The actual classical texts are massive (D. Wujastyk 1998), and lineages that diverge from institutional Ayurveda are still being practiced and documented, like in Todd Caldecott's collection of the teachings of Vaidya Mana Bajra Bajracharya, a Newar vaidya in Kathmandu (Caldecott 2011). The divergences are fun to explore.

Modern Western Herbal Medicine

North American herbalism split from domestic medicine and medical practice with Samuel Thomson, who codified the New England folk medicine he learned from Widow Benton. Alison Denham suspects he was also influenced by the seven years of evenings with Dr. Bliss, a medical student who had studied with a root doctor and rented a house on the farm (Denham, in Tobyn, Denham, and Whitelegg 2011). Thomson systematized a simple qualitative binary into a patented system of six remedies, where the rights to use the system and the training material were provided to families for twenty dollars (Berman 1951). Buying in also gave you access to exclusive pharmacy sources for those formulas. I’ve pondered whether this medicine-of-the-people/commercial-pharmacy marriage isn’t the foundation of the herbal multi-level marketing companies that came out of the 1960s Utah Mormon Neo-Thomsonian herbal revival.

The physiomedicalists and eclectics, among my primary early influences, wanted a more formal system, using the new physiology as their explanatory and conceptual models, intentionally moving away from the explicit qualities Thomson used because those were too reminiscent of the Greek qualities (Cook 1869; Haller 1994, 1997). They built colleges, built pharmacies, built legacies, and then, through a combination of mismanagement, changing cultural perspectives about health, and poor adaptation to new scientific discoveries, both distinct schools of medicine collapsed into ineffective skeletons of their former selves. They crumbled completely once the Flexner Report held medical schools to newly constructed standards (which were reasonable and which they legitimately failed to meet).

Parts of these schools lived on in books, regional practices, families, and scattered practitioner lineages. From the 60s-80s, Rosemary Gladstar, Michael Moore, David Winston, Christopher Hobbs, and others selectively recovered pieces of these schools and synthesized them into the North American Herbal Revival.

I come from this North American revival lineage, both the Utah Mormon Neo-Thomsonian revival (thanks, Steven) and the energetic lineage (thanks, Matthew, David, and Phyllis). The North American energetic system is maybe the best-documented construction of all of our examples, because its builders were explicit about how they constructed their practices and systems. Matthew Wood acknowledges that the six tissue states derive from Thurston (1900) and the taste-to-action model largely from David Winston, and then credits LeSassier and Moore and Light and Gladstar (Wood 2004). Winston names his own sources as Chinese medicine, Cherokee and Southeastern traditions, the eclectics, the physiomedicalists, Ayurveda, and Unani-tibb (Winston 2022). Tierra put the East-West synthesis in his book’s subtitle (Tierra 1988).

There are many, many concepts from the North American Herbal Revival that aren’t Western or traditional at all (which neither detracts from nor establishes clinical effectiveness, but does give us a lot of juicy explorations for the future).

And I should nod towards my U.K. friends who have their own well-documented history of ongoing construction. Around 1978 the National Institute of Medical Herbalists removed physiomedicalism from its training course, wanting to modernize, prescribe more European herbs, and lean less on American ones (Denham, in Tobyn, Denham, and Whitelegg 2011). Folks made decisions about what was and wasn’t part of their system, and we know when and why.

Why am I telling you all of this?

There were choices made in your system’s construction that you don’t realize were choices because they have been there so long they seem to be part of the foundation. Choices that you don’t know the alternatives to, or the original arguments for or against.

Construction is not bad, wrong, or a falsehood. It is simply what it is, out of necessity and human nature. So is a house. It’s constructed, and you can live in it.

To talk about how to build constructs better, we need to be able to separate ourselves from the story, and our system’s structure from its literalized legitimacy narrative.

Almost every claim of unbroken, unchanged ancient transmission you have ever heard, of any system, is at best a stretch, and if you practice, the actual history of your own system is the one you’re responsible for.

Our system supplies the patterns we are trained to notice, the questions we think to ask, and the names we give what happens next. But construction is ongoing at the practitioner level, and it happens again in the room, between practitioner and patient.

When you’ve sat with this a while, we’ll talk about what construction looks like in the room with a person (and maybe a plant).

-Thomas Easley, Registered Herbalist (AHG)

P.S. This is a doorway, not a complete history. Follow the references and the historians working from within traditions I have only touched here.

P.P.S. Literalized legitimacy narrative, a legitimizing story mistaken for literal history is Forrest Chalmers’ phrase, and it's excellent, and I’d have credited him above where I used it, except it would have broken the reading experience I wanted.

References

Modern Western Medicine

Burrow, James G. AMA: Voice of American Medicine. Baltimore: Johns Hopkins Press, 1963.

Greenhalgh, Trisha, Jeremy Howick, and Neal Maskrey. “Evidence Based Medicine: A Movement in Crisis?” BMJ 348 (2014): g3725. https://doi.org/10.1136/bmj.g3725.

Lawrence, Christopher, and George Weisz, eds. Greater Than the Parts: Holism in Biomedicine, 1920–1950. New York: Oxford University Press, 1998.

Mol, Annemarie. The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press, 2002.

Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.

Stevens, Rosemary. American Medicine and the Public Interest. Berkeley: University of California Press, 1998 (orig. 1971).

Timmermans, Stefan, and Marc Berg. The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press, 2003.

Warner, John Harley. The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820–1885. Cambridge, MA: Harvard University Press, 1986.

Warner, John Harley. Against the Spirit of System: The French Impulse in Nineteenth-Century American Medicine. Princeton: Princeton University Press, 1998.

Weisz, George. Divide and Conquer: A Comparative History of Medical Specialization. New York: Oxford University Press, 2006.

Worboys, Michael. Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900. Cambridge: Cambridge University Press, 2000.

Traditional Chinese Medicine

Andrews, Bridie. The Making of Modern Chinese Medicine, 1850–1960. Vancouver: UBC Press, 2014.

Scheid, Volker. Chinese Medicine in Contemporary China: Plurality and Synthesis. Durham, NC: Duke University Press, 2002.

Taylor, Kim. Chinese Medicine in Early Communist China, 1945–63: A Medicine of Revolution. London: Routledge, 2005.

Unschuld, Paul U. Medicine in China: A History of Ideas. Berkeley: University of California Press, 1985.

Ayurvedic Medicine

Caldecott, Todd, ed. Ayurveda in Nepal: The Teachings of Vaidya Mana Bajra Bajracharya. PhytoAlchemy, 2011.

Langford, Jean M. Fluent Bodies: Ayurvedic Remedies for Postcolonial Imbalance. Durham, NC: Duke University Press, 2002.

Mukharji, Projit Bihari. Doctoring Traditions: Ayurveda, Small Technologies, and Braided Sciences. Chicago: University of Chicago Press, 2016.

Wujastyk, Dominik. The Roots of Ayurveda: Selections from Sanskrit Medical Writings. London: Penguin, 1998.

Zysk, Kenneth G. Asceticism and Healing in Ancient India: Medicine in the Buddhist Monastery. New York: Oxford University Press, 1991.

Modern Western Herbal Medicine

Berman, Alex. “The Thomsonian Movement and Its Relation to American Pharmacy and Medicine.” Bulletin of the History of Medicine 25 (1951): 405–428, 519–538.

Cook, William H. The Physio-Medical Dispensatory. Cincinnati, 1869.

Denham, Alison. “Origins and Proponents of the Revival of Herbal Medicine in Nineteenth-Century Britain.” In Graeme Tobyn, Alison Denham, and Margaret Whitelegg, The Western Herbal Tradition: 2000 Years of Medicinal Plant Knowledge. Edinburgh: Churchill Livingstone, 2011.

Haller, John S. Medical Protestants: The Eclectics in American Medicine, 1825–1939. Carbondale: Southern Illinois University Press, 1994.

Haller, John S. Kindly Medicine: Physio-Medicalism in America, 1836–1911. Kent, OH: Kent State University Press, 1997.

Thurston, Joseph M. The Philosophy of Physiomedicalism. Richmond, IN, 1900.

Tierra, Michael. Planetary Herbology: An Integration of Western Herbs into the Traditional Chinese and Ayurvedic Systems. Lotus Press, 1988.

Winston, David. Interview, “Herbal Elders” series. Everything Herbal, September 29, 2022. https://everythingherbal.ca/an-interview-with-david-winston/.

Wood, Matthew. The Practice of Traditional Western Herbalism: Basic Doctrine, Energetics, and Classification. Berkeley: North Atlantic Books, 2004.

Other traditions, same pattern

Flint, Karen. Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948. Athens: Ohio University Press, 2008.

Pormann, Peter E., and Emilie Savage-Smith. Medieval Islamic Medicine. Washington, DC: Georgetown University Press, 2007.

The general case

Pickstone, John V. Ways of Knowing: A New History of Science, Technology and Medicine. Manchester: Manchester University Press, 2000.

Rosenberg, Charles E. “The Tyranny of Diagnosis: Specific Entities and Individual Experience.” Milbank Quarterly 80, no. 2 (2002): 237–260.

Solomon, Miriam. Making Medical Knowledge. Oxford: Oxford University Press, 2015.

In Defense of Ouija Boards as Clinical Assessment Tools

Thomas Easley — Tue, 14 Jul 2026 13:28:47 GMT

The Ouija board is the most unfairly dismissed instrument in clinical practice. Its association with slumber parties and basement séances has kept it out of serious use for over a century, which is a shame, because, on the merits, it outperforms most assessments we currently rely on.

It treats the whole person

Modern medicine fragments the patient. Cardiology takes the heart, gastroenterology takes the gut, and no one is left holding the human being who walked in carrying all of it at once. The board makes no such error. It has no interest in your lipid panel. It responds to the whole patient, present in the room, hands on the planchette, history and fears and family patterns all feeding into where it drifts. It individualizes completely. Two patients with the same diagnosis receive entirely different sessions because they are different people, which is more than a standardized reference range has ever managed to notice.

It has an established history of use

The board predates most of the pharmaceuticals in your cabinet. It predates the randomized controlled trial and the double-blind by a comfortable margin. Generations of operators have laid hands on it and reported meaningful results. The accumulated body of individualized clinical experience is vast. To discard a century of hands-on encounter because a skeptic with a clipboard could not reproduce it under fluorescent lighting would be, frankly, arrogant.

Absence of evidence is not evidence of absence

Have you wondered why “people of science” won’t use their science to test it? You heard me right, no one has run a proper trial on board-guided assessment. No one has funded one, because the funding bodies decided in advance what counts as a real question. An empty shelf in the literature tells you about the politics of research money. It does not tell you the instrument fails. You cannot point at a gap and call it a refutation.

The method resists standardization, which is a point in its favor

Even a well-designed trial would miss what matters. You cannot randomize an encounter of this kind. Blind the operator, script the questions, strip out the relationship, and you have destroyed the thing you set out to measure and are now measuring its corpse. The board works because it sits inside a particular human moment that no protocol can hold. That reductionism cannot see the effect is a limitation of reductionism.

It is safe

The board is noninvasive. It has no side effects, no contraindications, no interactions. It cannot perforate anything. It puts the patient back at the center of their own care rather than leaving them a passive recipient of expert pronouncement. Weighed against the harm profile of nearly everything else on the ward, this alone should have earned it a place in the standard workup years ago.

It works

I have sat in those rooms. I have watched people arrive at something true about their own lives with their hands resting on that small plastic pointer. I am not in the habit of ignoring what I have seen with my own eyes across many years of practice. The board delivers. The profession’s refusal to say so is a failure of nerve, not of evidence.

The therapeutic relationship carries the work

No serious person believes the cardboard is doing anything. That was never the claim. The board is a focusing device for what passes between two people who have agreed to take a shared question seriously in a quiet room. The patient feels attended to. Someone is finally giving their suffering full and unhurried attention, inside a ritual that says this matters, we will sit here until something emerges. That attention is therapeutic. It is the best-documented effect in all of medicine, and it has never required the mechanism to be real. It requires only that the encounter be real, and the encounter is real.

-Thomas Easley, Registered Herbalist (AHG)

P.S. — A note on what an assessment is for. An assessment earns the name by producing a finding that can contradict you. The pulse comes back faster than you predicted. The tongue is a color you did not expect. The patient mentions a detail that wrecks your working theory. The instrument pushes back, which is the whole reason it can tell you anything. The board cannot do this. It can surprise you (ideomotor movement draws on more than conscious expectation, which is why the answers feel like they arrive from somewhere else), but surprise is not correction. Its answer cannot be separated from the hands producing it, and there is no signal from the patient’s condition in there that can be separated out. It cannot adjudicate between the operator’s belief and the patient’s reality. Applied kinesiology has the same property. So does the pendulum, and on a bad day even the pulse, when someone has already decided what they will find. The pulse has a real signal, but a real signal validates only itself. A dry tongue is a dry tongue; whether that dryness means what my syndrome map says it means is a question that still has to be earned.

And harmless isn’t quite right either. There is no iatrogenic harm during the session. It arrives later, in the regimen, the expense, the diagnosis that waited. The encounter can still help and it often does. The comfort belongs to the relationship, though, not the instrument, and the assessment claim has to be earned separately. So before you defend any assessment you use, ask two questions. What could it hand you that you did not already believe? Could it correct you without your cooperation? If the answers are "nothing" and "no," you do not have an assessment instrument. You have a courteous way of talking to yourself, and the board, to its credit, is at least sold as a game.

To Feel Different, You Have to Live Different

Thomas Easley — Wed, 24 Jun 2026 16:14:26 GMT

Most folks don’t come to an herbalist to change their life. They come hoping the tincture will do the changing for them.

They’ll tell you they want to feel better, and they mean it. But sit with someone long enough and the deeper request comes into focus. Often, they want to keep the same hours, the same food, the same low simmer of stress they stopped noticing years ago, and they want to feel good anyway. The herb is meant to stand in for the life they aren’t going to change.

To be super duper clear. I often want this too. This is not patient blaming. It’s a very human thing to wish for. If there were a plant/drug/magic that let me skip some of the parts of my life that are hard and still come out rested and clear, I would take it, and so would you. The wish isn’t the problem. The problem is that almost nothing about the body actually works the way the wish needs it to work.

Underneath the request for a sleep remedy or an energy remedy or a something-for-my-nerves remedy is an older and deeper wish. People want health to be something done to them. A repair. You bring the broken thing in, a competent person applies the fix, you carry it back out, and you were not required to be present for any of it except to hand over the broken thing and receive it mended. That is a completely reasonable expectation for a dishwasher. It is the wrong model for most of what goes wrong with a human being, and we have known it was the wrong model for about two and a half thousand years. We didn’t just know it. We named the alternative, built it into the structure of medicine, and taught it as the core of the physician’s job. Then we mostly forgot we had it.

The model was called the non-naturals, which is a terrible name that held back solid interventions. It’s basically the entire thing we now repackage and sell back to ourselves as wellness, except the people who built it were more honest about what it was and what it asks of you.

Two ways to want to be well

There are two fundamentally different things that can be wrong with a person, and they call for two fundamentally different relationships between the sick person and the cure.

In the first kind, something has gotten into you, or something has run out in you, and the fix is a discrete act performed on your body. A thorn is in your foot; the thorn comes out; you are fine. A specific bacterium is colonizing your throat; the right drug kills it; you are fine. A specific molecule your body needs has gone missing from your diet; you supply the molecule; you are fine. In all of these, you really can be a passive recipient. The cure is a thing that happens to you. You can be asleep for it. The relationship is the relationship you have with a mechanic, and there is nothing degrading about it, because for that class of problem it is exactly right.

In the second kind, nothing got in and nothing ran out. Instead, the way you are living has, over months or years or decades, produced the state you’re now in, and the state is not a part that can be swapped but a pattern that has to be lived differently to come out differently. Your sleep is wrecked because of how your days are built. Your gut is a mess because of what goes into it and the speed at which you live around it. Your nervous system runs hot because the life around it runs hot. For this kind of problem there is no part to replace and no invader to kill, because the trouble is not a thing lodged in you. It’s a shape your living has taken. And a shape can only be changed by the thing that’s making the shape, which is you. Here you cannot be a passive recipient, because there is nothing to receive. There is only something to do, repeatedly, until the pattern bends.

Two people come to clinic on the same day, both worn down to nothing, both with exhaustion seeping from every pore. The first turns out to have a B12 level in the pits, the kind of thing a simple test catches and a simple correction fixes. A couple of months later, she has her energy back, and nothing about her life had to change, because nothing about her life was the problem. The second has every test come back unremarkable and is exhausted anyway, because he sleeps five to six hours a night, eats standing up at his desk, hasn’t moved his body for joy in a year, and carries a job and a marriage he doesn’t have the energy to talk about. There is no supplement for the second man that does what the supplement did for the first woman. And the worst thing I could do is treat him as if there were, run him through a hopeful parade of vitamins/minerals/adaptogens and let him believe each time that this one will be the one that hands him back his life while the life itself stays exactly as it is. They both came in with the same word. They did not have the same kind of problem, and most of the art of clinical practice is in knowing that before you reach for anything.

If you look at these two together, you might notice that the entire history of medicine is, in a sense, an argument about which one is more fundamental, and a long series of attempts to apply the tools of one to the problems of the other. We are living right now at the far end of a period where the first model won so completely that most people can no longer quite believe in the second. The pill that cures the infection was so spectacular a success that we came to expect a pill for everything, including for the conditions that are not infections at all but are patterns in how a person lives. Most of what fills a clinic is the second kind wearing the costume of the first. Often, someone arrives absolutely certain they have a deficiency of some compound, or an invasion of some scary critter, when what they have is a life that no compound is going to fix.

The old physicians, by which I mean a specific and traceable line of people I’m about to nerd out on for 15 pages, were not confused about this. They had a precise vocabulary for the second kind of problem and a precise practice for it. We threw the vocabulary away around the time we got the magic bullet, and we are only now, slowly, and under newer and clumsier names, reinventing it.

So let me take you back to where the vocabulary came from. It is one of the most carefully built and longest-lasting intellectual structures in the Western tradition, and it was the mainstream for longer than germ theory has existed by an order of magnitude.

The ancient root: a way of life

Begin in the world that produced Hippocratic medicine, roughly the fifth and fourth centuries before the common era, and begin by stripping away everything you know about how the body works.

The Hippocratic writers had no concept of bacteria. No microscope, no cell, no germ, no notion that a specific external organism could cause a specific disease. They had no chemistry worth the name. What they had was the human eye, the human hand, and time. They watched sick people, carefully, over days and weeks, and they wrote down what they saw with a patience that is humbling to read. They noticed that illnesses had courses. That fevers broke on particular days. That the body did things on its own, without any help from the physician, that often tended toward recovery. It sweated, it coughed, it vomited, it formed pus and expelled it, and wounds closed over. They built a medicine around watching those processes and trying not to wreck them.

Out of this came a word that matters more than any other for our purposes. The Greeks called the management of how a person lived their diaita. We have inherited the word, shrunken almost beyond recognition, as diet. But diaita did not mean what you ate, or not only that. It meant your whole way of living, the entirety of your days. What you ate and drank, yes, but also how you exercised and rested, when you slept and when you woke, the air and climate you lived in, how much you let your body fill and how regularly you let it empty, the state of your mind. A Hippocratic text titled Regimen lays this out: health is something you produce and maintain through the ordering of these things, and illness often comes from their disorder. The physician’s job was in large part to be an expert in diaita, a person who could look at how you were living and tell you where the disorder was.

Sounds radically different from a modern doctor’s visit. You did not go to the Hippocratic physician to receive a substance. You went to have your life examined and adjusted. The substance, when there was one, was a minor character. The major character was the conduct of your days, and you were the one who conducted them.

Now move forward about six hundred years, to Rome in the second century, and meet the man who gathered all of this into a system so complete it governed European medicine for the next fifteen hundred years.

Galen arrived in Rome around 162, a provincial physician from Pergamon in Asia Minor, learned, combative, and absolutely certain that most of the physicians then dominating Roman medicine were fools. He had trained partly by patching up gladiators, which is to say he had seen the inside of more human bodies than almost anyone alive, and he had read everything. What Galen did, across an output so vast that it makes up a substantial fraction of all surviving ancient Greek literature, was weld Hippocratic observation to a philosophical physiology, and within that system he gave the factors of diaita a formal place.

Galen sorted the things a physician had to think about into groups. There were the things that made you up, your constituent nature: the elements, the qualities, the humors, the parts of the body, the faculties. There were the things that could go wrong, the diseases and their causes. And there was a third group in between, the things that were neither your nature nor your disease but that acted on you constantly and determined which way your nature tended. The air around you, your food and drink, your sleeping and waking, your activity and rest, what your body took in and let go, and the motions of your mind. Galen taught the physician to monitor all of these like a hawk, reading the signs of the body for evidence that one of them had tipped out of proportion, and to correct illness in the first instance by adjusting them. He had a whole science of signs for it, a way of reading skin color and pulse and the look of a person for the story those factors were telling.

Galen’s non-naturals were a diagnostic instrument. The physician was trained to look at a patient and read backward from the body to the life. This pulse, this color, this heaviness, this restlessness, and to ask which of the six had gone wrong to produce it, then to adjust that one. A complaint was a clue to a disordered factor, and the factor was the thing you treated. This is a medicine that takes the conduct of a person’s living as the primary object of clinical attention, and reads the body as the record of that conduct. It is a long way from handing someone a bottle. It is closer to what a good clinician still does when they stop treating the complaint and start asking how the person actually lives, except Galen had it built into the formal structure of the art rather than smuggled in as the thing experienced practitioners learn to do despite their training.

What he was pointing at when he pointed at air and food and sleep and motion and evacuation and the passions was real. Those things do govern health. How he pictured the body, to organize the looking, is a separate question for a separate article (a much longer story I’m writing with Forrest Chalmers).

What Galen did not yet have was the name. He had the factors and he had the practice. The name and the fixed list of six, came later, from further away.

How the doctrine got its strange name

To understand why we call them the non-naturals, you have to leave Rome and go to Baghdad, where the doctrine as a named, numbered, teachable thing was assembled in the medical culture of the medieval Islamic world and handed to Europe more or less finished.

In ninth-century Baghdad, there lived a physician and translator named Hunayn ibn Ishaq, a Nestorian Christian who ran a translation bureau, rigorously transcribing Greek medical and philosophical works into Arabic. Hunayn wrote a short introduction to Galen’s medical art, a primer for students, that in its Latin form came to be called the Isagoge. In that little primer, the threefold division gets stated cleanly and didactically: the naturals, the things that constitute the body; the non-naturals, the things that are not the body’s own nature but bear on it from the conditions of living; and the contra-naturals, the things against nature, meaning disease and its causes.

To a modern ear “non-natural” sounds like “artificial” or “unhealthy,” as if these were the bad inputs. That is the reverse of what it means. These factors are called non-natural precisely because they are not part of your nature, not built into you the way your humors and organs supposedly were. They are the things that come at your nature from the conditions of life. Air is not you. Food is not you. Your grief is not, in this scheme, a constituent of your body the way your blood is. They are the surrounding conditions you live within and act upon, and the whole point is that they are the part you can adjust. Your nature you were more or less stuck with. The non-naturals were the levers. Calling them non-natural was a way of saying: these are the handles, the part of the system that is open to deliberate management.

I really wonder if the doctrine had come down to us called “the six conditions of living” or “the six things you tend,” or “the six pillars of health,” it might never have fallen out of view the way it did.

The doctrine traveled with the rest of Greek medicine into Arabic and got elaborated by the giants of that tradition. In the system that later became known in South Asia as Unani medicine, which simply means “Greek” medicine, the Yunani inheritance of Galen carried forward and is still practiced today, the doctrine appears as the asbab sitta daruriyya, the six necessary causes. And the division is subtly, interestingly different from the Latin one. The Unani six are the air and environment; food and drink; the movement and rest of the body, the movement and rest of the soul; sleep and waking; and retention and evacuation.

Notice what happened to the emotions. In the Latin list the passions of the soul are their own separate sixth item. In the Unani list there is no separate slot for the emotions, because they have been folded into motion and rest, and split off into a second kind. There is movement and rest of the body, and there is movement and rest of the soul. Your anger, your joy, your grief, your fear, these are understood as the soul in motion or at rest, exactly parallel to the body walking or sitting still. I find that a beautiful concept. It treats an emotional life as something with the same basic dynamics as a physical life, something that can be too agitated or too stagnant, that needs both exertion and repose, that you participate in rather than simply suffer. The same idea reaches the Latin West and the Islamic world and gets carved differently. But both are telling you that emotions are a thing you do, not only a thing that happens.

In the eleventh century a man known as Constantine the African, a merchant from North Africa who ended his life as a monk at the great monastery of Monte Cassino in southern Italy, translated a shelf of Arabic medical works into Latin, including Hunayn’s Isagoge and a large medical encyclopedia he rendered as the Pantegni. It is in these Latin translations, coming out of Monte Cassino and feeding directly into the nearby medical school at Salerno, that the threefold division of naturals, non-naturals, and contra-naturals enters European medicine as a fixed teaching structure. The Isagoge became the seed of a standard medical textbook anthology, the Articella, the thing medieval students actually learned from. For roughly five hundred years, if you trained as a physician in Europe, you learned this scheme early and you never stopped using it.

For two thousand years, this ancient Greek practice of diaita, systematized by Galen in imperial Rome, named and numbered in the medical Arabic of Baghdad, and carried into Latin by a monk at Monte Cassino, was a central teaching structure across learned European medicine from the high Middle Ages to the edge of the modern era.

The six, one at a time

Air

In the old framework, air was the most constant and inescapable of the non-naturals, the one you are bathed in every second and cannot stop taking into yourself. They thought about it in terms of qualities, the air being hot or cold, moist or dry, and they also thought a corrupted or miasmatic air could sicken whole cities, a guess about how disease travels that germ theory would later replace. Managing air meant choosing where you lived if you could, the situation of your house, its exposure, its dampness or dryness. It meant ventilation, the airing of rooms, the avoidance of stagnant and enclosed and fouled spaces. It meant getting out into good air, and seeking different air when your own had gone bad, which is the deep root of the whole later European institution of the convalescent who is sent to the mountains or the seaside for the air.

Strip off the humoral theory and ask what survives on observation alone. A startling amount does. The room you sleep in, its temperature and its darkness and whether the air in it is fresh or stale, has more to do with how you actually sleep than any herb I could hand you. Whether you ever get outside, whether you move through real weather and real daylight, shapes your physiology in ways we are still cataloguing, from the circadian signal that morning light sends to a clock that runs the whole body, to the simple fact that a person who never leaves a sealed box of recirculated office air is breathing a different medium than the one we evolved in. The quality of the air where you spend your waking hours is a determinant of your health, and it is partly, often substantially, within your control. The Hippocratic physician already understood the half of this that didn’t need a microscope, that place and air and exposure make people well or sick. The instinct was sound, and the practice it produced is still sound, whatever picture of the body it once came wrapped in.

You cannot be handed good air. You can choose what you can of it, open what you can open, get yourself out into the better of it, and keep the worst of it out of the rooms where you sleep and work, and all of that is action, repeated daily, that no one can perform on your behalf.

Food and drink

This is the one that survived in name, which is exactly why it’s the most misunderstood. Diaita shrank down to diet, the whole became the part, and a word that once meant your entire way of living now means a temporary regimen of restriction you go on and off of.

The tradition’s handling of food was relentlessly practical and individualized. Foods had qualities, were warming or cooling, moistening or drying, heavy or light, and the art was matching what you ate to your own constitution, your age, the season, your condition. The same food was not right for everyone, or right for the same person in winter and in summer, or right for the hot-tempered young man and the cold, dry old one. Notice the stance, and notice how strange it looks next to our own moment, in which a single eating plan is marketed to millions of different bodies at once as the answer for all of them. The old approach assumed the opposite, that the right regimen was a fitting, particular to the person and revisable as the person changed. And notice the ranking. Food was the first instrument of treatment, ahead of drugs, not behind them. The Unani tradition states this outright. Dietotherapy, the adjustment of what a person eats, was the first line of approach, and drugs came after, when food was not enough. There is a line that runs through this whole literature, attributed in the Avicennan tradition, that the stomach is the house of disease and that diet is the head of healing. Food was not the soft preliminary before the real medicine. Food was the real medicine, and the drug was the backup.

And here, more than anywhere, the thing cannot be done for you. I can tell you what to eat until I’m hoarse. I cannot eat it for you. There is no version of nutrition where you lie still and receive it (the rare clinical exception of an actual feeding tube aside, and even that is a thing done because the doing-it-yourself has failed). Every day, several times a day, you decide what goes into you, and those decisions accumulate into a body. The accumulation is the medicine or the disease. You are the one accumulating.

Sleep and waking

The old physicians treated sleep and its absence as a paired non-natural, a rhythm to be kept in proportion, and they worried as much about too much sleep as too little, about the heavy daytime nap that left a person dull and congested as much as about the sleepless night that frayed them.

We have rediscovered, in the last few decades and with great fanfare, that sleep is not optional and not a luxury but a load-bearing pillar of nearly everything, that wrecking it wrecks mood and metabolism and immunity and cognition, that it is arguably the single most important thing most people are getting wrong. The Salernitan physicians would have found the fanfare a little quaint. Of course it is a pillar. It is one of the six.

What I want from you here is to notice the structure of the problem, because sleep is the cleanest case in the whole list. When someone comes to me unable to sleep, the thing they almost always want is a substance that will produce sleep while everything that is preventing sleep stays in place. And there are substances that may move the needle. But they are working against a current, and the current is the life. The phone in the bed, the coffee at four in the afternoon, the habit of running at full speed right up until the body is supposed to drop into stillness on command, the bedroom that’s too warm and too bright, the complete absence of any wind-down. Some of that a person can change tonight. But sometimes it’s a night shift that can’t be refused or a second job standing between someone and the sleep they know they need. A life with no slack in it is a different and harder problem. No herb in my apothecary can carry a life that is organized against rest. You cannot be handed sleep. You can only build the conditions that allow it and then get out of its way, and the building is a set of actions, performed by you, every single night.

Motion and rest

Movement and its counterpart, deliberate rest, made the fourth pair, and the inclusion of rest as an active item, not just the absence of motion but a thing you do on purpose, is one of the most important parts of the regime.

We have, characteristically, turned the movement half into “exercise,” a discrete activity you schedule and often dread, a thing with its own industry. The older idea was that a body is meant to be in motion through the ordinary course of a day, and that prolonged stillness is itself a derangement to be corrected. The Salernitan verse tells you to rise from the table and to move and stretch your limbs in the morning before anything else. The point was not a workout. The point was that a living body kept in motion stays well and a body kept still goes wrong, and that this is daily, not weekly.

You already know where I’m going. Nobody can do your walking for you. This is the most literal case in the list. The benefit of movement is conferred only by moving, and there is no substance, no supplement, no procedure, that delivers the effect of having moved to a body that did not move. We keep looking for one, and the looking is itself a symptom of the wish I started with, the wish to receive the result without performing the act. The result is not separable from the act. The motion is the medicine, and only you can be in motion.

Retention and evacuation

The fifth non-natural concerned the body’s taking in and, especially, its letting go. The regular and adequate emptying of the body of its wastes, and the dangers of both retention and excess. In the old framework this ranged across everything the body expels, and it loomed large, because a medicine without our tools placed enormous weight on the visible evidence of the body’s own processes working or failing.

This is also where the tradition did harm. The conviction that corrupt matter had literally to be drawn off the body is the root of centuries of overzealous purging and bloodletting. Some of the worst things done to patients in the name of this tradition were done under this heading. But underneath the harm sits an observation that we have, if anything, become too polite to take seriously: that whether and how the body eliminates is a real and daily determinant of how a person feels and functions, and that it tracks closely with the other non-naturals, with what you eat and how you move and how much water you take and how you sleep. The digestive tradition in herbalism, the bitters and the carminatives and the gentle supports for a sluggish gut, lives here. And once again the herb’s role is to assist a process, not to install one. You support evacuation; you do not receive it. The body does the work. The most a remedy does is help the body do its own work a little better, which is a different thing entirely from doing the work in the body’s place.

The passions of the soul

The passions of the soul, the accidents of the soul, the affections of the mind: the old physicians put your emotional life on the list of things that determine your physical health, with the same seriousness they gave to food and air. Anger, fear, grief, excessive joy, sorrow, all of these were understood to move the body, to shift its heat and its spirits inward or outward, to sicken or to heal. The Salernitan rule opens, in the line that became its manifesto, by telling you that if your doctors fail you, three doctors will do in their place: a cheerful mind, rest, and a moderate diet. The cheerful mind comes first. Sir John Harington, translating the poem into English verse in 1607, gave those three doctors names that have stuck for four hundred years, Doctor Quiet, Doctor Merryman, and Doctor Diet. Your emotional state was a physician you carried inside you, for good or ill.

I told you the Unani tradition folded the emotions into motion and rest, treating them as the movement and rest of the soul. Put that next to the Latin list’s “passions” and you get a stereoscopic picture of what these people were after. The emotional life is something with its own dynamics, that can be too stirred or too stagnant, that needs both engagement and repose, and that you tend, the way you tend the other five. It is not, in this scheme, a private weather you simply endure. It is a thing you participate in and can order well or badly.

And of all six, this is the one where the fantasy of passive reception does the most harm, because this is the territory where the modern remedy market is most aggressive and most dishonest. The whole apparatus of substances that promise to fix your mood while your life stays exactly as miserable as it is, the supplement that will lift your spirits without your having to change one thing about the relationships and the work and the meaning that are actually producing the state of your spirits, is the oldest con in the book, and it is aimed precisely at the sixth non-natural. The herbs I reach for here, the nervines and the gentle lifters of mood, the saffron and the holy basil and the rest, help, and not one of them is a substitute for tending the actual passions of your actual life. You cannot be handed a settled mind. You can build the conditions for one and practice it, which is, again, an action, and yours.

Step back from the six and the pattern is total. Air, food, sleep, motion, evacuation, emotion. Not one of them is receivable. There is no posture in which you lie still and have any of them administered to you. Every one is a doing, a daily practice, a way of conducting yourself in relation to the world around you. The doctrine of the non-naturals is, at its foundation, a claim about what kind of thing health is. It is not a substance you can be given. It is a pattern you keep up, in how you live in your particular corner of the world, and the keeping-up is yours to do. The one caution the old physicians could mostly skip is that the room to tend the six is not handed out equally, and the realm that rations it, the world a person actually lives inside, is its own subject and the one this essay does not enter.

Salerno put it in verse

The clearest evidence for how mainstream all of this was is that it became, in the most literal sense, popular. Not popular among physicians. Popular among everyone.

Out of Salerno, the southern Italian town that held the first medical school in Western Europe, came a poem sometime in the twelfth or thirteenth century, and it did the thing almost no medical text has done before or since. It escaped the profession. The Regimen Sanitatis Salernitanum, the Salernitan Rule of Health, was a didactic poem in Latin verse, written to be understood by ordinary educated people rather than by doctors, organized around the six non-naturals, and in more than three hundred printed editions it became, by most accounts, the most widely circulated medical book in European history. From roughly the thirteenth century to the nineteenth it was the health guide a literate European was most likely to have encountered. Six hundred years. There is no health book in our own time with a fraction of that reach.

And what is this most popular of all medical books actually about? It is about how to live. It tells you to rise and wash and move your limbs before you do anything else, to shun heavy suppers and too much wine, to take the air, to skip the idle midday nap, not to put off the urgent calls of nature, and above all and first of all to keep a cheerful mind and put down your cares and your anger. Doctor Quiet, Doctor Merryman, Doctor Diet. It is, from beginning to end, a manual of the non-naturals, a set of instructions for the things you do, addressed to the person who has to do them.

The man who weighed himself for thirty years

If a practice organized around air and sleep and evacuation sounds too soft to count as real medicine, consider Santorio Santorio. A physician in Venice and Padua at the turn of the seventeenth century, he became convinced the non-naturals could be studied with instruments and numbers and not just managed by judgment. So he built a chair, an enormous balance big enough to hold a chair and a table and himself, and he lived a substantial part of his life on it. He weighed himself. He weighed his food before he ate it and his waste after. And he found, by arithmetic sustained over roughly thirty years, that the weight going in vastly exceeded the visible weight coming out, that pounds of it left him daily through the skin and the breath in a process nobody could see. He called it insensible perspiration, and in chasing it he more or less invented the quantitative study of metabolism.

This is not a soft tradition. A respected professor of medicine spent three decades on a giant scale to put the fifth non-natural, the body’s taking in and letting go, onto a rigorous footing, right at the threshold of the modern era. And notice what he was studying: the conduct of his own living, quantified. The instrument changed nothing about the claim, it only measured it. The subject and the object of the experiment were one man, because that is what health is, a thing you do to and with yourself, continuously, whether or not anyone is weighing it.

When the bullet really is magic

I have been hard on the wish to be a passive recipient of health, but now I’m going to turn around and defend it, because there is a whole class of problems where it is not a fantasy at all but the correct approach.

Sometimes a person really just has a part that needs replacing or an invader that needs killing, and for those people, the mechanic model is exactly right, and the regimen model is a dangerous distraction.

For most of recorded medicine there was a disease, pernicious anemia, that was precisely what its name says: pernicious, meaning it killed you, reliably, no matter how well you lived. People wasted and weakened and their nerves failed and they died, and no regimen on earth touched it, because the problem was not in how they lived. In the 1920s two American physicians, George Minot and William Murphy, discovered that feeding these patients enormous quantities of raw liver, half a pound a day and more, of a food most of them could barely choke down, reversed the disease. It looked like witchcraft. It earned a Nobel Prize. And it turned out that what the liver contained, isolated finally in 1948, was a single molecule, vitamin B12, that these patients could not absorb and were dying for the lack of. Today the whole death sentence collapses into an injection. You supply the missing molecule and the dying person becomes a well person, and they did not have to change one thing about how they live, because how they lived was never the problem. The problem was an absence of one specific compound, and the cure is its presence. That is a pure repair. The patient can be, in the fullest sense, a passive recipient, and to insist they become an active participant in their own healing would be obscene.

Or take the other shape, the invader. A strep throat is a specific bacterium colonizing your tissue, and left alone in some people it does not stay a sore throat but goes on to inflame the heart and the joints in rheumatic fever and do permanent damage. An antibiotic kills the bacterium, and that really is the whole of what is needed. You do not treat strep throat with a better attitude and more sleep. You treat it with the drug that kills the thing, and the person who refuses the drug in favor of tending their non-naturals is not being holistic, they are possibly endangering a heart.

And the idea of the invader is not modern, even if the cure is. Two thousand years before anyone saw a microbe, the Roman scholar Varro warned farmers off building near swamps, because, he wrote, the marshes breed minute creatures too small for the eye, which rise into the air and get into the body through the mouth and the nose and cause stubborn disease. He had no microscope and no way to prove it, but he was, in the way that counts, right, and he had already reached past the vague bad-air theory of his day toward something far more specific: a living thing, invisible, that got into you and bred. What the modern era added was the lens to find the creature and the bullet to kill it.

This class of problem is real and it is large enough to have remade the world, and it is worth knowing where the wish for the magic remedy actually comes from. At the start of the twentieth century a German scientist named Paul Ehrlich imagined a kind of drug he called, borrowing from an old folk legend about a bullet that could not miss, a magic bullet. A substance that would seek out the specific organism causing a disease and destroy it while leaving the patient unharmed. In 1909 he found the first real one, an arsenic compound that killed the organism that causes syphilis, and he called it Salvarsan, and a disease that had rotted people for centuries became, more or less, curable. The age of the magic bullet had begun, and over the next half-century it delivered one miracle after another, the antibiotics above all, until infectious diseases that had slaughtered humanity for its entire history were simply, suddenly, beaten.

This was one of the few times the human race has unambiguously won. And you cannot understand the modern expectation of medicine without it. The reason everyone now believes, in their bones, that for whatever ails them there should be a pill that fixes it without their having to change, is that for a specific class of ailments, there really was. The magic bullet was real. The wish to be handed your health, mended, while you stayed exactly as you were, came true, gloriously, for the infections and the deficiencies. The trouble is what happened next.

But not normally

Ehrlich himself was sure his magic bullets would generalize, that the same approach would eventually defeat every kind of disease, cancer included. It did not, and the reason it did not is the crux of the whole thing.

The magic bullet works when a disease has a single, specific, external or absent cause: one microbe to kill, one molecule to supply. That structure, one cause and one targeted cure, is not the structure of most of what now makes people sick. The conditions that fill clinics today, the metabolic disorders, the chronic pain, the gut trouble, the anxiety and the insomnia and the grinding fatigue, the slow diseases of a long life lived a certain way, mostly do not have a single specific cause that a bullet could hit. They are not invaders and they are not simple absences. They are processes, patterns produced over years by the whole conduct of a life in a particular world, which is to say they are disorders of the non-naturals, the exact thing the old doctrine was built to address. There is no microbe in burnout. There is no missing molecule that is the cause of a life organized against rest. You cannot shoot a pattern.

And this is the category error of our moment, the thing I watch people make every week. The magic bullet was so total a victory in its own domain that we exported its logic to a domain where it doesn’t apply, and we now reach for a bullet-shaped solution, a pill or a supplement or a single heroic plant, to fix conditions that are not bullet-shaped problems at all. The entire supplement industry runs on this transposition. It takes the form of the magic bullet, a substance you swallow that works on you while you wait, and it sells it for problems that are patterns of living, problems that no substance can resolve because the substance is not addressing the cause, because the cause is not a thing in you but a shape your life has taken. People buy it because the wish is real and the historical memory of the magic bullet is real, and because being handed a fix is so much easier than changing how you live. I don’t blame anyone for wanting it. I want it too. But for the kind of problem most people actually have, it is the wrong kind of help, and selling it as the right kind is the dishonesty at the center of modern wellness.

The irony is that the content of the old doctrine is, right now, coming back. Everything currently sold under the banner of lifestyle medicine, the rediscovery that sleep and movement and food and stress and human connection are the levers of chronic disease, is the doctrine of the non-naturals returning, often in the mouths of people who have never heard the name and believe they are discovering it. In one sense that’s a vindication. The tradition got stuff right, and modern evidence keeps confirming, factor by factor, that how you live governs whether you stay well. But something got lost in the gap, and it isn’t the content. It’s the structure. The old doctrine didn’t just list the factors. It located the agency. It was built around the sick person as the one who acts and the physician as the advisor on a life that only the patient can live. What tends to come back, in a medical culture shaped by the magic bullet, is the list without the assignment. Sleep and movement and diet repackaged as more things to be optimized, more inputs to be managed, often more products to be bought, with the person still cast as the recipient of an intervention rather than the agent of a life. We are recovering the six. We have not yet recovered the thing that made them work, which was never the list itself. It was who was holding it.

The discipline, the thing a good clinician actually owes a person, is to tell the two kinds of problem apart, and to refuse to apply the logic of one to the other in either direction. If there’s a bullet-shaped problem in the mix (did I mention it’s often a mix?) identify the right magic bullet and give it, fast, and don’t make a sick person earn their cure by reforming their character. Check the B12. Give the antibiotic. Find the deficiency and fix it and be glad it was that simple. But when there’s a pattern problem, which is often, the bullet is a distraction, a way of postponing the only thing that will actually work. This is the less welcome thing to say and the harder thing to sell. It is the job.

The making and the taking

To know where a plant grows and when it is ready, to go out and gather it in its season, to clean it and dry it and make the tea or the tincture, to take it as a small daily rite with some attention paid, is to be threaded back into a world you belong to instead of one you only move through. In the oldest sense of the word, it is most of what health was.

Look at what the supplement aisle gets exactly backward. A capsule of standardized extract and a remedy you make yourself can hold the same plant and still be two entirely different objects, because your relationship to them is opposite. The capsule is the bullet-shaped relationship in its purest form: you swallow it and you wait, and the waiting is the whole of your part in it. That is passive reception, the very thing I have been arguing against. The gathering and making and taking I just described is nothing like that. It is a practice. It is a doing. It sits on the active side of every line I have drawn.

And the making and the taking are more than the chemistry. There is ceremony in it, and time, and attention, and those are not decoration laid over the real medicine. They may be a good part of the medicine. The cup of bitter tea before the evening meal, the tincture taken at the same hour each morning, the steeping and the smell and the small wait, all of it gives a day a shape and a person something to return to, and the ordering of a day and the settling of a mind are themselves two of the six. A remedy taken with attention is a technology of attention. It is one of the few reliable ways I know to get a hurried person to slow down and do one quiet deliberate thing on their own behalf, every day, which is worth a great deal regardless of what is dissolved in the cup.

Then there is the plain fact that the plant does shift your qualities, and shifts them in the same register as everything else here. The warming herb warms. Not by ferrying a heat-substance into you, but in the lived, felt way warm and cold work on a person, the way a hot meal or a brisk walk or a settled mind warms you. The plant belongs inside the non-naturals. It is one more lever in the same system, working in the same currency of qualities as food and air and motion and rest, which is exactly why it pairs with them so well. Ginger in the tea and a walk in the cold morning and a warmer room are not three different kinds of intervention. They are three turns of the same dial.

The plant was never the exception to the rule that you have to live differently to feel differently. It is one of the most beautiful ways of doing the living. The enemy was never the plant. It was the bullet-shaped relationship to the plant, the swallow-and-wait, the capsule standing in for the life. Made and taken as a practice, the plant is regimen of the richest kind. Reached for as a magic bullet against a pattern it cannot touch, it is the same old fantasy in a prettier label.

The door

When someone finally takes it in, really takes it to heart, that there is no remedy that will let them feel different without living different, often the first thing they feel is loss. They came in hoping to be handed something, and they are being told the thing they hoped for does not exist for the kind of problem they have. That lands hard (and maybe it should). Which is why most folks leave my clinic with something to ease that realization and soften the landing, a little linden and the ceremony of making tea. The disappointment is the door, because on the other side of it are the six things they can actually do to alter their own health.

But not everyone can walk through that door. Picture the patient who arrives melancholic and sleepless, who has lost fifty pounds and cannot eat, whose will has gone out like a pilot light. Tell that person the answer is better sleep and a daily walk and a bitter tea, and you have failed them at the moment it counts most. The active work asks for a capacity to act, and the capacity is exactly what has collapsed. That person does not need a regimen. They need their agency back, and getting it back can sometimes take blunt and serious tools, the medication, sometimes the hospital, sometimes more, none of which is a magic bullet and none of which cures the way penicillin cures, but any of which can carry a person from the edge back to the place where willing and eating and choosing are possible again.

What good medicine is for

Which is the whole thing, finally. The question of what medicine is for usually gets answered with a list, and the lists never quite cohere, because it was never a list. Good medicine does three things, and the three are not three kinds of problem. They are three relations to a single question. Can a person take part fully in their own life. When that capacity has collapsed, medicine works to restore it. When it is present, medicine works to direct it toward the wider range Canguilhem meant by health. Not a setpoint. The room to take a hit, recover, and set new terms with a changing world. And when the capacity will only diminish, when the disease is one that will not turn, medicine works to ease the going, to keep a person comfortable and met and themselves for as long as there is a self to keep. Restore it, direct it, ease its ending. All three are done on a constitution the person never chose, the genes and the temperament and the loaded dice, which is the ground the work stands on and never the work itself.

What holds the three together is one thing. In every one of them the person stays an agent. The drug that brings the melancholic back serves a participation that had failed; it does not replace it. The regimen is participation directed. Even the easing at the end is the care of someone who is, until the last, taking part in a life that is theirs. Medicine at its best serves that taking-part. It never stands in for it.

So the non-naturals are not the whole of medicine. They are its middle act, the directing of a participation that first has to be possible and that will one day end. But they are the act that covers most of a human life, the long stretch when a person can act and the only question is how.

The whole tradition, underneath the humors and history and names, said the same thing the whole time. To feel different, you have to live different. And for the long middle of a life, while you still can, you are the only one who can.

-Thomas Easley, Registered Herbalist (AHG)

threenotchcommunityhealth.com

eclecticschoolofherbalmedicine.com

Scope Note:

This essay is the history of the realm of health, one of five interconnected realms in my clinical model. The other four, experience, maladaptation, disease, and the eco-social-political context that holds them all, are each their own piece.

Moncrieff and Barnes: The Dualists of Critical Psychiatry

Thomas Easley — Wed, 17 Jun 2026 20:49:35 GMT

In June 2026, Dr. Joanna Moncrieff posted a short blog arguing that mental health problems are a different kind of thing from medical conditions.¹ Less than two weeks earlier, James Barnes had argued in Psychology Today that psychiatry should be decentered from medicine altogether.² Both are widely read critics of biological psychiatry, and they were arguing, as it happened, with the same man: Awais Aftab. From a distance they looked like they were on the same side.

They are not on the same side, and the place where they split open tells you something neither of them means to say. They are dualists.

I am not calling either of them a substance dualist, the Descartes-with-a-soul kind who thinks the mind is a separate stuff floating free of the meat. Both would reject that. Barnes has written more than one essay blaming Descartes for ruining our understanding of mental health.^3,4 Moncrieff says plainly that there is “no need to postulate any non-material entity like mind or soul.”⁵ But it is a dualism all the same. Call it a demarcation dualism: body and person treated as two different kinds of thing, sortable into two domains, so that any given condition lands on one side of a line or the other. Both of them argue for a version of that split, Moncrieff at length through Szasz and Wittgenstein, Barnes through psychiatry’s missing biomarkers. What neither argues for is the premise underneath it, the one that turns a distinction into a verdict: that to be a real disease just is to be a condition of the body. That they take as given. It is the floor every one of their arguments stands on, and the one thing none of them digs under.

Both critics need body and person to be separable kinds, the sort you can file a condition between, in order to draw their boundary. That need, and the inherited criterion that feeds it, is the dualism. Everything after that is which bin they drop mental disorder into.

The shared floor

Lay the three positions side by side.

Biological psychiatry, in its most quotable form, says mental disorder is bodily, and therefore medical. The old NIMH line is Steven Hyman’s: “Mental illnesses are real, diagnosable, treatable brain disorders.”⁶ Real means in the body. The whole research program, the imaging, the genetics, the decades of hunting for a marker, is an attempt to make that sentence true.

Moncrieff says mental disorder is not bodily, and therefore not really medical. Her criterion is explicit. Illness and disease, she writes, “have two defining features,” that “they are conditions of the body and that that they cause suffering or are unwanted for one reason or another,” and while the suffering part is admittedly subjective, “the physical or biological nature of the condition is not.” The core feature that picks out a real disease is “that they are caused by specific bodily processes.”¹ Mental disorders aren’t, so they aren’t diseases.

Barnes says mental disorder cannot be objectively specified, and therefore psychiatry should be moved out of the center of medicine. Because psychiatry has never found its biomarkers, he argues, “the burden now falls on psychiatry to justify its authority, not on critics to justify their opposition,” and the cleaner move is to admit that this kind of suffering “belong[s] primarily within relational, psychological, social, existential, developmental and cultural domains.”²

Three conclusions, pointing three directions. All three stand on the same floor: real disease is a condition of the body. The biologist affirms it and goes looking for the body. Moncrieff affirms it and concludes the body isn’t there. Barnes affirms it and concludes the search has failed. The premise never moves. And the critics, oddly, are more committed to the somatic criterion than the biologists are. The biologist at least treats it as a hypothesis and tries to satisfy it in a scanner. Moncrieff and Barnes treat it as settled, the fixed point they measure everything else against. They don’t test the criterion. They wield it.

The odd man out in this fight is the one both of them are fighting. Aftab isn’t defending the somatic criterion. He’s dropped it. “I take it for granted,” he writes, “that the project of defining the authority of medicine and clinical disciplines in terms of disorder concepts on the basis of objective, value-free facts has failed.” There is, he says, “no objective or a priori way of determining the authority of medicine,” whose scope is instead “pragmatic and institutional in nature.”⁷ Aftab is a pragmatist. He thinks medicine’s boundaries are negotiated, historical, revisable, and that this is fine. You don’t have to buy his rescue of psychiatry to see that he’s the only one in the room who isn’t reaching for a clean body-or-not test. He’s the one who let go of the floor. Which is why both critics are arguing with him, and why he is closer to dissolving the problem than either of the people who think they’re the radicals.

Two roads to the same wall

Barnes’s road runs through objectivity. His test for real medicine is mind-independence: a disease has to be the kind of thing whose existence doesn’t depend on us agreeing that it exists. “A broken leg, pneumonia, or cancer are not matters of interpretation,” he writes. “They are identifiable biological conditions whose existence does not depend on social negotiation or professional consensus.”² Psychiatry can’t produce objects like that, so by this test it sits outside the part of medicine that can. His strongest version is legit. Psychiatry has in fact spent enormous money and prestige looking for biomarkers and has, for the vast majority of diagnoses, come up empty, and a lot of harm has been done by pretending otherwise. Barnes is not wrong about that record. His whole positive program, the relational model of mind he’s spent years building, is an attempt to take human distress seriously as meaning rather than as malfunction. It’s a great project and I have no quarrel with it.

Moncrieff’s road runs through the body directly. She inherits it from Szasz: an illness is a condition of the body, mental events are patterns of behavior, and “if you loosen the association between the concepts of illness and disease and the body, you empty them of their distinctive meaning.”⁸ Her 2020 paper in Philosophy, Psychiatry, & Psychology makes the same case at length, that mental disorders “cannot, therefore, be aligned with biological conditions, unless there is evidence of an underlying disease.”⁹ Her strong version is just as real. The disease model has been used to flood the population with drugs sold on a chemical-imbalance story that was never established, and to justify doing things to people, against their will, that we would not accept if we called them what they are. Moncrieff’s deepest objection is that treating distress as a disease strips it of meaning, that it turns a person’s life into a malfunction to be corrected, and she is describing something real that happens to real patients.

Keeping the boundary costs each of them something. Barnes, who made his name attacking Descartes, has to treat the body as a value-free mechanism whose states are simply there, independent of any human judgment. Moncrieff, who insists she is no dualist, has to keep “the human world and the natural world” as two domains we “relate to, or ‘know,’” in different ways, the body being “a material object that is part of the natural world” that “can be studied using the methods and techniques of natural science,” and the person being something else. She even says, in so many words, that her view “emphasises rather than dissolves the difference between the human world and the natural world.”⁵ That is the demarcation dualism, stated by someone who has just finished denying she’s a dualist. She has thrown out Descartes’s soul-stuff and kept his floor plan.

Two roads. One wall. They start from different commitments and walk to the same line, which is the first sign the line is pulling rather than waiting to be found: body on one side, person on the other, treated by both as a feature of reality rather than a thing somebody drew.

Watch the line move

Push on either criterion until it fails and the boundary doesn’t move; the criterion does. The person reaches for a different one and leaves the line exactly where it was.

Take Barnes first. In the Psychology Today piece the test is interpretation: real diseases, he writes, “are not matters of interpretation.” I put it to him that this only works if you run naive realism for the body and normativism for psychiatry, since every diagnosis draws a value-laden line, the 130-over-80 that turned millions of people into hypertensives overnight as much as anything in the DSM. He wrote back overnight, and there’s the tell: “That’s not my argument. Of course medicine is value-laden.” The article had run two claims together, the value-free one and a second about mind-independence; pressed on the first, he lets it go and stands on the second. The test now is “whether those judgements are being made about objectively identifiable biological processes,” whether “the object being classified exists independently of the classification itself.”¹⁰ Value-freedom conceded, mind-independence kept, and the boundary hasn’t moved an inch. But the half he kept fails the other way. Chronic fatigue, irritable bowel, fibromyalgia: medicine carries them all, and for none of them has anyone produced the kind of mind-independent disease-object his contrast demands. They are medical because the clinic finds them worth treating, not because the object was ever found. The line he’s defending runs right through the middle of general medicine, and he can’t see it because he’s looking at psychiatry.

Now Moncrieff. The blog criterion is “caused by specific bodily processes.” It didn’t take long for someone to put the obvious case to her. A reader pointed out that her “strict criteria would exclude many conditions from medicine, such as fibromyalgia, IBS, chronic fatigue syndrome.”¹¹ By the next morning the criterion had changed. Now the mark of a medical condition is that it is “manifested in physical symptoms (pain, discomfort, cognitive impairment) not in feelings or behaviours like mental health problems.”¹² She’s retreated from a claim about causes to a claim about how a condition shows up. Matthew Zirwas, posed the problem it in six words: “Explain how discomfort isn’t a feeling?”¹³ He’s right to ask. Fibromyalgia is diagnosed on a patient telling you where it hurts. There is no scope finding, no marker; the whole diagnosis is reported pain and fatigue, which is to say feelings. And panic, the other direction, comes with a pounding chest, sweating, muscle tension and the conviction you’re dying, which sure feels like physical symptoms to me. The reworded criterion sorts nothing. It just gestures at the boundary again with different words.

And here the two come apart. Pressed, Moncrieff puts fibromyalgia, IBS, and chronic fatigue squarely inside medicine; they show up in “physical symptoms,” so they qualify. Barnes’s line on these conditions is the harder one: years back, pressed on the same ones by a defender of the medical model, he called fibromyalgia “just a Latinised redescription of the complaint: pain of the body (tissues).”¹⁵ So Moncrieff lets them into medicine and Barnes treats one of them as a fancy name for a subjective symptom. Same vocabulary, opposite verdicts on the same conditions. When two careful people using the same criterion sort the same conditions onto opposite sides, the criterion isn’t carving nature at a joint. The line gets drawn first; the criterion shows up to bless it.

The line has a date on it

So where did the wall come from? It has not always been there.

The split between body and person, organic and functional, real disease and mere distress, looks like the bedrock of medicine and isn’t. It is a particular settlement, one that hardened into medical doctrine over the nineteenth century, Cartesian in its bones. Before it, medicine drew different lines. For most of its recorded history it took the whole person as its object, and the particular seam these critics lean on, bodily disease on one side and everything else on the other, had not yet been cut.

Galen, the physician whose system ran Western medicine for over a millennium, wrote a clinical treatise called The Diagnosis and Cure of the Soul’s Passions.¹⁶ Not a philosophical aside, a treatise, sitting in his medical corpus, on the diagnosis and cure of anger, fear, grief, and envy. To Galen the passions were a physician’s business in the same plain sense that fevers were. The idea that you’d hand the body to the doctor and the passions to someone else would have struck him as a category mistake, because the faculties of the soul, he argued in another treatise, follow the mixtures of the body. Robert Burton’s Anatomy of Melancholy, in 1621, is still doing the same thing: a single condition worked through its bodily, psychological, social, and spiritual registers at once, and the whole thing is medicine.¹⁷ None of these people were working our line. They made distinctions of their own, some of them strange to us: soul and body, reason and the passions, the natural and the divine. What they didn’t have was the modern sorting test, where to be a real disease is to be a bodily lesion and everything else becomes interpretation, morality, or distress.

Descartes is where the line gets drawn, and Barnes has described its drawing better than I could. In splitting mind from body to keep a domain safe for God and hand the rest to mechanical science, Descartes left us, in Barnes’s words, “the children of the disenchanted bifurcation,” our experience “characterised by the separation of ‘mind’ and ‘nature.’” Nature became, in that same essay of his, “a deaf and blind apparatus of indifferent and value-free law.”³

Then around 1800 the philosophical split became a clinical method. Bichat relocated disease out of the whole sick person and into the tissues, the membranes, the specific lesion.¹⁸ The Paris hospitals turned the new method into a way of seeing, the gaze that Foucault tracked in The Birth of the Clinic, in which disease becomes a thing with a location you could in principle open a body and find.¹⁹ Virchow took it down to the cell in 1858,²⁰ germ theory supplied the outside causes, and by the end of the century real disease meant a lesion or a microbe, something you could put under glass. That is when the somatic criterion stopped being one idea among several and hardened into the definition. Moncrieff and Barnes are not appealing to the timeless nature of medicine when they demand a bodily lesion. They are appealing to the nineteenth century.

Medicine itself has been walking back from that settlement for fifty years, from the inside. Engel made the case for “a new medical model” in 1977 because the lesion model had grown too narrow to hold an actual patient.²¹ Gastroenterology went further, and did it on purpose. With Rome IV in 2016 it renamed the functional gut disorders “disorders of gut-brain interaction,”²² because “functional” had come to mean nonorganic, which is to say not-real, which is to say psychiatric. Gastroenterologists looked at the organic/functional split, saw that “functional” had become a byword for not-real, the kind that sticks to conditions like IBS, the very ones Moncrieff and Barnes can’t agree how to sort, and deliberately stepped away from it. The specialty that owns IBS judged the old stigma was doing harm and moved off it. The critics of psychiatry are still defending a line their colleagues in gastroenterology have walked back from.

Barnes, to his credit, says the quiet part himself. To keep psychiatry inside medicine, he objects, Aftab has to “broaden the concept of medicine until it loses the very features that distinguish medicine from pastoral care, education, law, or, indeed, medicine of the 17th century.”² Seventeenth-century medicine, the medicine of Burton and the tail end of Galen, is offered as a self-evident example of not-real-medicine, the absurd endpoint you slide to if you loosen the criterion. Barnes has told us exactly when real medicine begins. It begins after the line was drawn. His whole argument rests on treating a roughly 1800 settlement as the essence of the thing.

Dissolving the line

Once you see that the wall has a date on it, the trap the critics are caught in stops being a trap, because the dilemma only exists if you’ve already agreed to sort.

The value-free criterion is the load-bearing beam. Georges Canguilhem spent a career showing that the pathological is not a value-free fact at all.²³ There is no purely natural, observer-independent line between the normal and the diseased; what counts as pathological is always relative to a living thing’s norms, what it can do, what it needs, what threatens it. Disease is a normative concept all the way down, in cardiology as much as in psychiatry. But the norms in question are the living body’s own, not society’s preferences pasted onto biology; this is still biology, only biology that takes the organism’s own standpoint into account. So Canguilhem hands psychiatry no blank check, and he is not Aftab. He destroys one thing exactly: the value-free somatic criterion, the idea that “real disease” is a fact you could read straight off a body with no reference to a form of life. Take that away and Barnes’s contrast has nothing left to stand on. He wanted real medicine to be the value-free domain and psychiatry the value-laden one, and there is no value-free domain. Psychiatry isn’t uniquely value-laden. It just hasn’t got the lesions and lab values to hide it behind.

Moncrieff reaches for Canguilhem. In her Philosophy series she quotes him to prop up the somatic criterion, the line that you can speak of medicine proper only once “diseases came to be treated as bodily disorders.”⁸ But that’s a historical observation about when a way of seeing arrived, not a defense of it as truth, and the larger argument of the man she’s quoting cuts against her. You can’t borrow Canguilhem’s authority for the body-criterion while leaving behind his demonstration that the body-criterion was never value-free to begin with. He’s not a witness for the demarcation. He’s the one who shows it has no natural ground to stand on.

None of this needs a new theory; the correction is already in print, more than once. John Dewey had a word for the mistake and a word for the fix. The mistake is “interaction,” two finished things meeting across a boundary. The fix is “transaction,” organism and environment as a single ongoing exchange that we only carve into “organism” and “environment” after the fact.²⁴ Phenomenology makes the point about the body in particular: the body you live from the inside is already personal and already meaningful, and the “value-free body” medicine claims as its own is an abstraction lifted out of it.²⁵ And the enactive strand of cognitive science, which treats a mind as what a living body does in engaging its world rather than a thing sealed in a skull,²⁶ is a tradition Barnes reaches for himself: in the Descartes essay he cites Evan Thompson, approvingly, to dissolve the split between mind and world.³ He just won’t follow it into medicine. Set any of these beside the critics’ picture and it comes apart the same way. There is no body sitting in a box with a person seated inside it; there is a living thing in exchange with a world, and “the body” and “the person” are two ways of describing that one process, not two parts you could separate and assign to different professionals. There is no clean body to hand to medicine and no separable person to withhold from it. The thing medicine treats was never just a body, and the thing the critics want to protect from medicine was never sitting somewhere outside one.

So the question that the whole fight is organized around, is psychiatry really medicine, only has force if you’ve already accepted the dualist sort. It assumes there’s a body-bin and a person-bin and we’re trying to figure out which one mental disorder goes in. Refuse the sort and the question doesn’t get answered, it dissolves. It was malformed from the start.

None of this hands psychiatry a clean bill of health. Refusing the sort doesn’t make the drugging legitimate, or the coercion, or the diagnostic inflation, or the power to decide whose suffering counts. Those are real, and most of what Moncrieff and Barnes are angry about is real, and I’m also angry about it. My point is narrower, and I think more useful. You can’t settle any of the problems of psychiatry by working out which bin mental disorder belongs in. The body/person line was never going to carry that weight. Whether a given practice helps or harms a given person is a question for the clinic, case by case, not for the border between two domains that was drawn in the first place to keep God safe from Galileo. Dissolving the line clears away a bad question. It leaves every hard one standing.

What would actually be radical

Critical psychiatry thinks of itself as the radical wing, the people willing to say the emperor has no scan. But moving mental disorder to the far side of the body/person line is not a radical act. It is the most conservative move available, because it leaves the line exactly where the nineteenth century put it and just relocates one item to the other side. You can spend a career relitigating which bin things go in and never once question that there are bins.

The radical critique is the one that dissolves the line, and the strange thing is that it doesn’t come from outside medicine. It comes from medicine’s own older and longer tradition, the whole-person tradition that ran from Galen to Burton and that the lesion model interrupted.

Barnes named the wound himself. He called us the children of Descartes’s bifurcation and set out to heal it, and he is no crude materialist about the body: in other essays he argues that the brain itself develops in relationship, not in isolation.²⁷ He can re-enchant the mind, and even the brain. The one body he keeps disenchanted is the one medicine treats, the value-free mechanism he makes the test of real disease. He leaves it exactly where Descartes put it, “a deaf and blind apparatus of indifferent and value-free law,” and uses it to put psychiatry outside the door. He’ll relationalize the brain and not the bowels. He names the objection himself and sets it aside in advance: the critical stance, he insists, rests on a real category difference and “not some form of caricatured ‘mind-body dualism.’”²⁸ Grant him the word. It changes nothing, because the difference he defends is the bifurcation in work clothes, and he draws it every time he’s asked. Moncrieff, for her part, threw out the soul and kept the floor plan, and calls the result anti-dualism. That is the move in both of them: disown the label, keep the practice. They are defending the wall they think they’re tearing down. It was poured around 1800, and if you look closely at the arguments, you can still see the formwork.

Notes

Joanna Moncrieff, “Why mental health problems are different from medical conditions,” joannamoncrieff.com, 16 June 2026. https://joannamoncrieff.wordpress.com/2026/06/16/why-mental-health-problems-are-different-from-medical-conditions/
James Barnes, “Who Gets to Define Human Suffering?”, Psychology Today, “The Between Us,” updated 3 June 2026. https://www.psychologytoday.com/us/blog/the-between-us/202606/who-gets-to-define-human-suffering
James Barnes, “How the dualism of Descartes ruined our mental health,” Aeon, 10 May 2019. https://aeon.co/ideas/how-the-dualism-of-descartes-ruined-our-mental-health
James Barnes, “The Space Between Us” (originally “how the interpersonal model explains and heals mental pain”), Aeon, 21 February 2023.
Joanna Moncrieff, “Philosophy Part 4: Dualism and the mind-body ‘problem,’” 1 November 2017. https://joannamoncrieff.wordpress.com/2017/11/01/philosophy-part-4-dualism-and-the-mind-body-problem/
Steven E. Hyman, then director of the NIMH, 1998: “Mental illnesses are real, diagnosable, treatable brain disorders.” Widely quoted; American Journal of Psychiatry 155 (Suppl., 1998), p. 36.
Awais Aftab, “The Ground Beneath the Clinic,” Psychiatry at the Margins, 30 May 2026. https://www.psychiatrymargins.com/p/the-ground-beneath-the-clinic
Joanna Moncrieff, “Philosophy Part 5: Why disease and illness are concepts of the body,” 10 November 2017. https://joannamoncrieff.wordpress.com/2017/11/10/philosophy-part-5-why-disease-and-illness-are-concepts-of-the-body/ The Canguilhem line she quotes is from Writings on Medicine (Fordham, 2012), p. 35.
Joanna Moncrieff, “‘It Was the Brain Tumor That Done It!’: Szasz and Wittgenstein on the Importance of Distinguishing Disease from Behavior and Implications for the Nature of Mental Disorder,” Philosophy, Psychiatry, & Psychology 27, no. 2 (2020): 169–181. doi:10.1353/ppp.2020.0017.
The exchange on X: Thomas Easley (@eclecticherbal), 4 June 2026
OptimizeLess (@LessOptimize), X, 16 June 2026.
Joanna Moncrieff (@joannamoncrieff), X, 17 June 2026.
Matthew Zirwas, MD (@MattZirwas), X, reply in the 17 June 2026 thread.
OptimizeLess (@LessOptimize), X, reply in the 17 June 2026 thread, tagging @psychgeist52. [Permalink to pin.]
James Barnes (@psychgeist52), X, 14 September 2023, in reply to @MarkLRuffalo.
Galen, The Diagnosis and Cure of the Soul’s Passions, in Galen on the Passions and Errors of the Soul, trans. Paul W. Harkins (Columbus: Ohio State University Press, 1963), and That the Faculties of the Soul Follow the Mixtures of the Body; see Galen: Psychological Writings, ed. P. N. Singer (Cambridge: Cambridge University Press, 2013).
Robert Burton, The Anatomy of Melancholy (Oxford, 1621).
Xavier Bichat, General Anatomy, Applied to Physiology and Medicine (1801); see also Physiological Researches on Life and Death (1809).
Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M. Sheridan Smith (New York: Vintage, 1994 [French 1963]).
Rudolf Virchow, Cellular Pathology (1858).
George L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196, no. 4286 (1977): 129–136. doi:10.1126/science.847460.
Douglas A. Drossman, “Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV,” Gastroenterology 150, no. 6 (2016): 1262–1279 (doi:10.1053/j.gastro.2016.02.032); and Douglas A. Drossman & William L. Hasler, “Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction,” Gastroenterology 150, no. 6 (2016): 1257–1261 (doi:10.1053/j.gastro.2016.03.035).
Georges Canguilhem, The Normal and the Pathological, trans. Carolyn R. Fawcett (New York: Zone Books, 1991 [French 1966]); see also Knowledge of Life (Fordham, 2008) and Writings on Medicine (Fordham, 2012).
John Dewey & Arthur F. Bentley, Knowing and the Known (Boston: Beacon Press, 1949); cf. Dewey, Experience and Nature (1929). On the Canguilhem–Dewey pairing, see Charpentier, Canguilhem and Dewey (2023).
Maurice Merleau-Ponty, Phenomenology of Perception, trans. Colin Smith (London: Routledge & Kegan Paul, 1962 [French 1945]).
Francisco J. Varela, Evan Thompson & Eleanor Rosch, The Embodied Mind: Cognitive Science and Human Experience (Cambridge, MA: MIT Press, 1991).
James Barnes, “The Brain Does Not Develop in Isolation,” Psychology Today, “The Between Us,” April 2026. https://www.psychologytoday.com/us/blog/the-between-us/202604/the-brain-does-not-develop-in-isolation
James Barnes, “Are critics of psychiatry stranded in a ‘Jurassic world?’”, Mad in the UK, 27 October 2020. https://www.madintheuk.com/2020/10/critics-psychiatry-stranded-jurassic-world/

Purity Doesn’t Have Units

Thomas Easley — Mon, 25 May 2026 19:26:20 GMT

The first time M came to clinic she brought a notebook with eight years of supplements written down. Eight years. She’d brought it because she thought I might want to see what she’d already tried (I did). The pages were color-coded. Adaptogens in green, antioxidants in blue, “mood support” in purple, with a small key inside the front cover. She apologized when she handed it over. Said she was sorry she wasn’t more organized.

What had brought her in, eventually, was that she hadn’t slept more than a few restless hours a night in months. She’d been crying in her car before work and crying in her car after. Her husband had asked if she was thinking about hurting herself and she’d said no, but she wasn’t sure that was true. She told me this matter-of-factly, the way someone reads off the symptoms on an intake form they’ve filled out before. Which was correct. She had filled this form out before. In the last year she’d been to two herbalists, an acupuncturist, a functional medicine doctor, and a Reiki practitioner. She’d done two ten-day cleanses. She’d been on a strict autoimmune protocol for the better part of three years despite no autoimmune diagnosis.

She had not seen her primary care doctor or had any labs in eight years. She recognized her depression and had never tried an antidepressant. When I asked her why not, she said, very simply, “I don’t put that stuff in my body.”

I don’t put that stuff in my body.

Eight years before, when she first got interested in herbal medicine and went to study with a teacher whose name doesn’t matter because so many say similar things, she was told that pharmaceutical antidepressants would “block her growth.” That she would never know who she really was if she was numbing herself. That serotonin reuptake inhibitors damaged the brain and the people who took them got stuck in their patterns. The teacher had a story she liked to tell about a student who got off her medication and finally became herself. She told that story a lot. M heard it many times.

I have heard versions of this teacher all of my career. I have sat across from her students for twenty-five years. I am one of them, in a way, because the herbal community I came up in shared most of her assumptions, and it took me a long time to see past them.

What M believed when she walked into my office was not a theory about pharmacology. It was a moral commitment. Synthetic was contaminated. Natural was clean. Her depression and anxiety, however bad they got, were a kind of signal. Something her body was trying to tell her, which she would only obscure if she “covered it up” with chemicals. The shame she felt about not being well after eight years of doing everything right was not, in her mind, evidence that the framework was failing her. It was evidence that she had not done enough.

There is a particular flavor of grief that shows up in folks like M after starting successful treatment. It comes after the emptiness fades. It comes after sleep returns. It comes after the suicidal thoughts recede. It is grief for the years.

The story I just told about M is one I see, in some version, every few weeks. The teachers vary. The supplements vary. The specific way the community failed the person varies. What does not vary is the structure of the belief. What does not vary is the moral weight. What does not vary is the cost.

There’s the person whose hypothyroidism went unmanaged for six years because levothyroxine was “synthetic hormones” and she was going to support her thyroid with herbs and seaweed instead. Her TSH was over forty by the time she let me run the test. She cried when we reviewed the results together because, somewhere inside her, she already knew. There’s the person with type 2 diabetes whose fasting glucose was averaging over three hundred and who would not take insulin because insulin was for people who had given up. He’d built his protocol around berberine, gymnema, and cinnamon, then added strict carnivore for a year. By the time he came back to insulin his vision was blurry and his feet had started to numb. There’s the person with an LDL never less than 200, who refused statins for fifteen years and had a heart attack at fifty-two and survived it, and still, after surviving it, was not sure if he was going to take the statins. The pharmacist filled the prescription every month. The bottle stayed on the counter.

I’m not telling these stories to ridicule the people in them. I love them. I work with them. They are some of the most thoughtful, careful, intelligent folks I know. They read more than most clinicians I know. They take their health seriously in a way most people don’t. They do not deserve mockery and they will not get any from me.

What I want to do is name the framework that hurt them. Because it is a framework, and once you can see it you can see it operating everywhere in our community. It runs underneath every conversation about toxins and detoxes. It runs underneath every horrified gasp about seed oils and fluoride. It runs underneath every refusal of an intervention that might have helped, every embrace of an intervention that didn’t, every quiet shame at having to admit to the herbalist that yes, the doctor put you on a medication, and yes, you are taking it.

The framework is simple. Everything humans make is contaminating. Everything humans haven’t touched is clean.

That belief is not a finding. It is a purity creed. And purity doesn’t have units.

Who I’m Writing To

This framework operates in a lot of places, and I want to be clear about which one I’m addressing.

It runs through what’s now called the wellness industry: the supplement empires, the influencer ecosystem, the functional medicine clinics that charge four thousand dollars for a workup the labs cost two hundred to run, the Instagram feeds of every concerned parent in America. That world is enormous, and not mine, though my clients pass through it constantly. It picked up the categorical framework that already lived among us and made it the basis of a marketing strategy. It industrialized something that was already there.

I’m writing to us. The herbal community has a history that runs deeper than the wellness industry and is not the same thing. The plant folks I idolized fought for sustainable agriculture and against the industrial poisoning of land and water. They knew the names of the plants and where they grew. They made medicines for their neighbors. They taught what they knew, mostly for free, in living rooms and at conferences in old summer camps. They were the early voices for organic farming when organic farming was still considered cranky, for the small farm against agribusiness, for the local apothecary against the chain pharmacy. They fueled real positive change. The world is better for what they did. They made me, in many ways, and I am still grateful to them.

We were here first. We did not invent the supplement aisle and we are not in charge of the influencer economy. What we are in charge of is our own framework, and the framework has a problem that we have not been honest enough about, and the cost of not being honest about it is borne by the folks in our clinics.

Pollution and Order

The belief is a creed because it isn’t held the way scientific claims are held. It isn’t tested. It isn’t revised when contrary evidence comes in. It isn’t graded for confidence depending on the strength of the data. It is held the way moral commitments are held, and like other moral commitments, it organizes behavior, identity, and community. When M told me she didn’t put that stuff in her body, she wasn’t reporting an empirical observation. She was telling me who she was.

The person I want to bring into this conversation is Mary Douglas, a British anthropologist whose 1966 book Purity and Danger asked one question of an enormous range of human cultures, from biblical food laws to central African ritual practice to modern European table manners. Her question was what those beliefs were doing in the cultures that held them, not whether they were true. Her answer reframed the field. Pollution beliefs look like they’re about hygiene and danger, but they’re often doing something else entirely. They’re systems of classification, ways of organizing what belongs where. Dirt, in her famous formulation, is matter out of place.

Hair is clean on the head and disgusting in the soup. The hair has not changed chemically. What changed was its place in an ordered world. A shoe belongs by the door; on the pillow it becomes filthy. Food belongs on a plate; smeared on the wall it becomes dirt. Things become unclean when they violate the classification. The dirt is dangerous for what it represents, not for what it physically is.

The herbal and wellness world has its own version of this. The clean side contains the natural, the ancestral, the traditional, the whole, the unprocessed, the plant, the earth. The contaminating side contains the synthetic, the laboratory, the factory, the industrial, the processed, the artificial. Once that system is in place, the empirical question gets quietly displaced. We stop asking, “What does this substance do, at what dose, in what body, under what conditions?” and start asking, “Which side of the line is it on?”

That is why canola oil feels contaminating while coconut oil feels clean. That is why white sugar feels like poison while maple syrup feels like nourishment. That is why an SSRI can feel like an invasion while a capsule of imported, standardized, industrially extracted ashwagandha feels like nature. The category is doing the work before the chemistry ever gets a hearing.

This is also why the empirical incoherence of the framework doesn’t bother the framework. The natural world produces some of the most acutely lethal substances known to science, and the laboratory produces some of the most life-saving. We’ll get to the chemistry in a minute. The point here is that the category tracks belonging, not danger.

Douglas had a second observation worth holding onto. Pollution rules tend to intensify when a community feels its boundaries under threat. When a group is anxious about its identity, about who is in and who is out, about whether its way of life is going to survive, pollution rules proliferate. The body becomes a microcosm of the social body. Defending the body against contamination becomes a way of defending the community against dissolution.

It is not a coincidence that purity rhetoric in the herbal world I came up in has intensified over the last twenty years, the same period in which Western herbalism has struggled with its place in a medical landscape that has both absorbed pieces of what we do and dismissed the rest. The community feels embattled. Its boundaries feel porous. The purity framework, with its sharp lines between us and them, between clean and contaminated, between authentic and corrupted, performs the work of holding the boundary. Every refusal of a synthetic intervention is a small ritual affirming that we are still us.

I want to be careful here. I’m not saying anyone who avoids “toxins” is consciously enacting a tribal boundary ritual. I’m saying the structure does this work whether or not any of us can articulate it. M wasn’t thinking about boundary maintenance when she told me she didn’t put that stuff in her body. She was telling me something true about herself, in the moral vocabulary our community had given her. The framework was doing the work behind her words.

The list of “toxins” we refuse changes constantly. Twenty years ago it was aspartame, MSG and saccharin. Then it was gluten and soy. Then it was seed oils. Now it’s carbohydrates and EMF. The list updates almost as fast as fashion. If the framework were tracking actual chemistry, you’d expect some stability: substances dangerous in 2005 would still be dangerous in 2025, and the same evidence would govern the same fears. Instead the list changes with the community’s mood. New threats arise; old ones quietly drop off. This is what pollution rules do. They track the community’s sense of what is threatening it, not reliably what is dangerous, and not in proportion to danger.

Take seed oils, the strong one right now. The biochemistry that gets invoked is not fake. Linoleic acid is a real fatty acid. It enters real pathways. Oxidation chemistry is real. Industrial extraction is real. There is a real conversation to be had about the modern rise in added fats, the displacement of whole foods, repeated heating in restaurant fryers, and the hedonic value of ultra-processed food. That conversation should happen.

But that is not usually the conversation happening. The conversation happening is: seed oils are toxic.

That is a category judgment pretending to be biochemistry.

You can see it because the refusal does not track omega-6 consistently. The same person who will not touch canola oil in a salad dressing may happily eat almond flour crackers, tahini, walnuts, pumpkin seeds, chicken thighs, pork fat, or “ancestral” snack foods made from nuts and seeds. Many of those foods contribute meaningful linoleic acid. Some may contribute more to the day’s omega-6 load than the teaspoon of oil being refused. But they do not feel contaminating in the same way. They are whole, traditional, earthy, ancestral, crunchy, farmer’s-market coded. They belong on the clean side.

The oil does not.

That is the tell. The dose-thinking conversation almost never happens. Total intake, food matrix, what’s being replaced, background diet, what the human evidence actually shows when polyunsaturated fats replace other macros: these are the questions toxicology would ask.

Purity frameworks ask belonging questions, not replacement questions. Canola oil belongs to the factory. Sunflower seeds belong to nature. Tahini belongs to traditional foodways. Almonds belong to clean eating. The fatty acid may be similar enough to deserve comparison, but the moral meanings are completely different.

That is why “seed oils are toxic” is not really a toxicological claim. It is a purity claim with a biochemical footnote.

Sugar works the same way. White sugar is contaminating; maple syrup and honey and coconut sugar are clean, though the body’s metabolic response to comparable doses is broadly similar. The moral difference outruns the metabolic one.

This has been a lot. There’s more. Let’s pause for a breath and stretch. Wouldn’t a cup of tea be nice before resuming?

None of this is easy to write, and changing my beliefs about these things has been difficult. I spent a decade eliminating seed oils from my diet and teaching others to do the same. The omega-6 to omega-3 ratio argument made sense to me. The biochemistry sounded right. I had students who would not touch a salad if there was canola in the dressing because I had taught them not to.

Then I was challenged to review the science again. I did, and wondered if I’d misinterpreted things. So I experimented on myself. Reintroduced seed oils. Felt fine. Maybe a little better, honestly. Then I went back to the research with even more careful eyes, and was forced to admit that what I had been confidently teaching was not what the evidence actually supported. I had been wrong. I’ve been trying to correct that with students for the last five or six years.

After reviewing hundreds of studies and rebuttals and criticisms of studies, I’m more confident than ever that the categorical refusal isn’t doing the toxicological work it claims to be doing, and I still have a mental hangup about canola oil. I know it’s fine. I know it’s probably better than several of the oils I’d reach for in its place. And when I’m in the grocery store, I still grab something else if it’s available. The intellectual position changed. The unconscious reach didn’t, not fully, not yet.

Same for organic produce. The research on health outcomes for people eating conventional versus organic vegetables shows no clinically significant difference. I know that. I have known that for years. I still know which side of the produce aisle I head for first.

This stuff is baked in deeply. Working it out of yourself is slow. It is not a matter of reading one essay and changing your habits the next day. It is a matter of years of noticing what you reach for, asking why, and sometimes choosing the other thing on purpose just to see if the world ends. The world does not end. The hangup loosens a little. Then you notice another one. Slowly, over time, life opens a little. Constraints we didn’t realize the weight of, ease. We say yes more. We fear less.

That is the move I’m asking of all of us. Whatever each of us thinks about sugar, or seed oils, or any of the rest, the question is whether we are thinking about it on chemistry and dose and bodies, or on which side of a categorical line the substance falls on. If a refusal is doing moral work for us, the refusal is the thing to examine. The substance may be doing nothing we actually need to worry about.

What Paracelsus Knew

If we wanted to actually track danger, instead of category, the answer has been around for about five hundred years. What’s strange is that it was given to us by someone we already claim as ancestor.

In 1538, in the third of his Septem Defensiones, Paracelsus wrote a sentence that has been more or less the foundation of toxicology ever since. In modern translation: all things are poison, and nothing is without poison; the dose alone makes it so a thing is not a poison.

Paracelsus was responding to charges. His critics, who were many, accused him of poisoning his patients by giving them mercury and antimony and other metals. His defense was that everything is a poison at sufficient dose, and that the question of whether a substance harms or heals is never settled by what the substance is. It’s settled by how much of it ends up where, in whom, under what conditions.

Paracelsus shows up on our shelves all the time. His central sentence almost never shows up in the conversation. He gets the lineage treatment. The doctrine of signatures, which has had a long and complicated career in herbal medicine, gets attributed to him. He is named as the father of alchemy, of pharmacology, and sometimes the father of modern medicine. The herbal world is generally proud to count him as one of ours, an early voice in the long tradition of working with substances drawn from the natural world. Open most introductory herb books and you’ll find him somewhere in the first hundred pages.

But the thing he is most known for outside our tradition is the thing our tradition has never figured out how to integrate. He did not say that natural substances are safe and synthetic substances are dangerous. He said everything is a poison at the wrong dose, and that this is true of everything. The plants we love. The substances we make. The water we drink and the air we breathe. The categorical distinction was not one he allowed himself, even though he lived in a century that drew categorical lines between the natural and the artful much sharper than ours. He spent his career working with substances that other physicians of his day considered too dangerous, too aggressive, too unnatural to give to patients. He gave them anyway, sometimes badly. He defended himself by saying, look at the dose. It was always the dose.

Paracelsus spent his career transforming substances through human craft, distilling, calcining, working with mercury, antimony, sulfur, salt, the metals and minerals. He coined the word “spagyric,” which he meant as the alchemical processing of plant matter, separation and purification and recombination, into preparations stronger and more refined than what nature handed you. His pharmacy was a workshop pharmacy, not a wild-harvested-tincture pharmacy. He took what nature provided and worked on it, sometimes aggressively, to produce something new. The “natural medicine” identity that the modern herbal world tends to project onto him would have puzzled him. He did not consider the unmodified plant the highest form of medicine. He considered it a starting material. The categorical line we draw between the natural and the human-made would not have made sense to him; he spent his life crossing it.

If we want to claim him as ancestor, we have to grapple with what he said and what he did. Otherwise we are holding his name as a kind of talisman, invoking the authority of the lineage while contradicting its central insight every time we sort a substance into the contaminating pile. Either Paracelsus is in our tradition with his most-quoted line and his actual practice, or we should stop putting him in the books. I’d rather we kept him. But that means letting his sentence and his workshop do the work they’re supposed to do.

The toxicological tradition that grew out of his sentence has been refined enormously over five centuries, but the core insight has held. The relevant variables when you want to know whether something will hurt you are dose, route of exposure, duration, individual susceptibility, and mechanism. They are not natural versus synthetic.

Look at the actual chemistry. Botulinum toxin is the most acutely lethal substance known to science; an amount you could fit on the head of a pin would kill a roomful of people, and it’s entirely natural. Hemlock, which killed Socrates, is a wild plant that grows in damp meadows. Ricin is extracted from castor beans. Aflatoxin, one of the most potent carcinogens we know, is produced by mold growing on natural agricultural products. Tetrodotoxin in pufferfish, batrachotoxin in poison dart frogs, abrin in rosary peas, oleander in oleanders: every one is natural in the strongest sense, and every one will kill you faster than most things in a chemistry catalog. The plant world is full of substances that evolved specifically to harm other organisms, because plants can’t run from their predators and have to settle disputes chemically. We of all people should know this. We work with these plants.

Now look at the synthetic side. Insulin is synthetic. People who need it live because of it; people who need it and don’t take it die. Antibiotics are synthetic, or close enough that the distinction has stopped meaning much. Before antibiotics, a strep infection could kill you. A small cut could kill you. Childbirth fever killed millions of women. Antibiotics changed all of that. They are not less life-saving for being synthetic. Vaccines have prevented an almost unfathomable amount of suffering and death.

If we organized our beliefs about danger and safety around what the data actually says, the natural/synthetic distinction would carry no predictive weight at all. Both categories contain substances that will harm you. Both contain substances that will heal you. The categories don’t track danger. Dose tracks danger. Mechanism tracks danger. Individual susceptibility tracks danger. Route of exposure tracks danger.

Toxicology isn’t perfect. Regulatory science misses cumulative and low-dose effects. The endocrine disruption literature is complex, contested, and hard to study well. Industry-funded research on industrial chemicals deserves exactly the scrutiny you would expect. Real concerns about specific exposures, PFAS in drinking water, certain pesticides, microplastics, are legitimate. I’ll come back to that.

But none of those concerns are well-served by the natural/synthetic binary. The binary doesn’t tell us what dose matters, which exposures are worth worrying about, whether a concentration in tap water is meaningful or trivial, whether the dose a child gets from a vaccine is in any way comparable to the dose that same child gets from environmental contamination. The binary is a moral sorting hat, not a toxicological instrument.

Suppose someone comes to me concerned about pesticide residues on their food. That’s a reasonable concern. There’s good science on it. We can talk about which pesticides have residues that linger, which crops carry higher loads, which washing methods reduce exposure, what the actual measured exposures look like in food surveys, and how to think about the risk in proportion. We can talk about glyphosate specifically, and about the actual evidence on its toxicity at the doses people are actually exposed to. We can locate the concern in a real conversation about chemistry and risk.

Now suppose someone comes to me concerned about toxins generally. We can’t have that conversation. The word “toxins” in their mouth doesn’t refer to anything specific. It refers to the wrong side of the categorical divide. There is no measurement that can settle the question, because the question isn’t a measurement question. It’s a purity question.

This is what should matter to us specifically. Toxicology is what Paracelsus gave us. It is part of our inheritance. When we refuse it, we are refusing the lessons of our own ancestor.

The Body in the World

The relational view Paracelsus pointed toward has a more developed philosophical version, and it’s the formal framework I’ve been working out for years. I call it transactional naturalism. It draws on the work of Georges Canguilhem and John Dewey, twentieth-century philosophers who spent their careers thinking about what living organisms are. Canguilhem’s contribution is that health isn’t the absence of measurable deviation; it’s the capacity to set new norms when conditions change. Dewey’s is that you can’t cleanly separate an organism from its environment; what happens between them he called a transaction. I’ll save the philosophical mechanics for elsewhere. What the framework gives you, clinically, is this: a substance isn’t intrinsically toxic or safe. Toxicity emerges in the relationship between a specific substance at a specific dose meeting a specific body in a specific state in a specific context. Change any of those variables and the toxicity changes.

Salt. Salt is necessary to life. The sodium gradient across cell membranes is what makes nerves fire and muscles contract. Without sodium you die. Take too much salt and you die; acute hypernatremia is a real medical emergency. Take a moderate amount and you live, but if you have heart failure or kidney disease, the same moderate amount can push you into trouble. Salt is not toxic. Salt is not safe. Salt is a substance whose effects emerge in relationship with the body that’s eating it.

The same logic applies across the board. Water can kill you fast enough. Oxygen at high concentrations damages the lungs. Vitamin A in moderate excess is teratogenic. Iron pills have long been one of the leading causes of pediatric poisoning deaths in the United States. None of these are “toxic” or “safe” as adjectives. They have effects in contexts.

The same logic applies to synthetic medications. An SSRI at the right dose, in someone whose depression is being driven by patterns that serotonergic medication can interrupt, has a good chance of helping. The same SSRI in someone whose depression isn’t being driven that way may not. In someone with bipolar disorder it may trigger a manic episode. Insulin, levothyroxine, antibiotics, vaccines: same logic. They are tools whose value emerges in the encounter with a specific situation, not intrinsic goods or evils.

What the purity framework can’t do is think this way. The substance was already morally charged before the person ever met it. The framework tells you what to do before you’ve examined what’s actually happening, and what gets lost is the person, the one whose body is in the relationship.

What the Concern Was Actually About

If I leave the argument where it is, I’ll have done something I don’t want to do. I’ll have left the impression that worry about industrial exposures is silly, that we made this up out of moral panic. That isn’t right. The original concern was a real concern. It got hijacked by a moral framework, but the underlying observation was sound, and it was our community that first sounded the alarm.

Over the last two centuries, and especially in the last seventy years, industrial chemistry has produced an enormous number of novel compounds that human bodies and ecosystems have never encountered before. Some are inert. Some are useful. Some are dangerous. The dangerous ones have done real damage we are still learning to recognize. DDT in the bird populations of the 1960s. Lead in the children of the 1970s. CFCs in the ozone layer. PFAS in nearly every water supply on the planet. Endocrine disruptors at low doses with effects that wouldn’t have been predicted from earlier toxicology models. Microplastics in tissues across the food web. These are real. They matter.

The legitimate concern is that industrial production has moved so fast that regulatory science has not kept up. The doses we are exposed to are the result of choices made by industries with a financial interest in our continued exposure. The health effects are often slow, often subtle, often individual, and very hard to study in the ways that produce confident conclusions. In the absence of good data, ordinary people have to make decisions about what they let into their bodies and their kids’ bodies and their homes. Being thoughtful about that, choosing the less-industrialized option when other things are equal, supporting agricultural systems that minimize exposures, these are reasonable responses to a real situation.

What I want to name is the shift from this reasonable position to the purity framework. They sound similar from a distance. They are not the same thing, and the difference is the load-bearing distinction in this whole essay.

The reasonable position says: let’s be thoughtful about novel exposures, ask good questions, use the toxicology we have, and err on the side of caution where the science is genuinely uncertain. The purity framework says: synthetic is bad, natural is good, the more thoroughly you can purge synthetic exposures from your life the better.

Here’s what those look like in practice. Someone holding the reasonable position buys organic produce when they can afford it and doesn’t worry about it when they can’t. They run their tap water through a decent filter because the data on PFAS justifies it. They avoid non-stick pans because the chemistry on those is concerning. They also take their antibiotic when they have a strep infection, accept the vaccine the math supports, and start the levothyroxine when their thyroid stops working. They make case-by-case decisions because each case is, in fact, a case, with its own evidence and its own stakes.

Someone holding the purity framework cannot do the second half of that list. The categorical commitment forecloses it. The same person who is thoughtfully filtering their water may refuse the antibiotic that would clear an infection, refuse the vaccine that would prevent measles in their kid, refuse the antidepressant that would have brought them back to their life. Not because they did the case-by-case math and concluded the risk outweighed the benefit. Because the substance is on the wrong side of the line.

That is the distinction I want everyone reading this to hold. Thoughtful caution about industrial exposures is good practice. The purity framework that looks like thoughtful caution from outside but operates categorically is what hurts the folks in our clinics. They are not the same thing, even though they often live in the same head.

The first stance is where our community has done its actual work in the world. The pressure to reduce pesticide use in agriculture, the push for safer cosmetics, the attention to indoor air quality, the questioning of food additives, the early advocacy for organic farming, the defense of the small farm against agribusiness, the long argument against the industrial poisoning of soil and water: much of this came from the plant folks and their allies long before “wellness” became a marketing category. That work was real. The world is better for it.

The second stance is what hurts the people in the community. It costs them their medications. It costs them their relationships with conventional care. It sometimes costs them years of their lives.

What we need is not less concern about industrial exposures. We need more refined concern. Concern with units. Concern that knows the difference between meaningful and trivial. Concern that uses the toxicological tools that exist, the ones our own ancestor handed us, and doesn’t pretend chemistry is a moral category.

The Cost

The structure I’ve been laying out has a body count. Folks I know have died inside this framework. Folks have lost years, lost relationships, lost capacities they didn’t know they were going to lose. The framework matters because it has costs, and the costs are paid by people we love.

The first cost is the refusal of interventions that would have helped. The person whose mental illness goes untreated because they won’t take psychiatric medication. The folks with diabetes who refuse insulin. The folks whose hypothyroidism worsens for years because levothyroxine is “synthetic hormones.” The person with high blood pressure who refuses the medication because it’s synthetic. These are not edge cases. They happen in every herbal practice I know of, in every functional medicine practice I know of, in every alternative-leaning clinic I’ve ever heard of. The person sits with treatable suffering for years because the framework says the treatment is contaminating. The years don’t come back.

Then comes restrictive eating. Orthorexia is a recognized clinical pattern now, and the purity framework feeds it directly. Folks who started by trying to “eat clean” end up with a list of forbidden foods that grows and grows. First it was gluten. Then dairy. Then nightshades. Then anything with oxalates. Then anything not organic. Then anything from outside their bioregion. Then anything they didn’t grow themselves. The world of edible food shrinks around them until they can’t eat at a friend’s house or a restaurant or a relative’s holiday table. They become socially isolated. They lose weight they didn’t need to lose. They become anxious around food. They start to develop the nutritional deficiencies the restrictive eating was supposed to prevent.

The framework also reproduces itself socially, in ways that hollow out the relationships closest to the people inside it. The parent who has gone deep into the framework and the parent who hasn’t end up fighting about what to feed the kids, what cleaning products to use, what to do when someone gets sick. The fight is not really about cleaning products. It’s about which categorical system organizes the household. I have folks in my practice whose marriages didn’t survive when one spouse went deep into the framework. I have folks whose marriages didn’t survive when one spouse came back out of it, and the spouse who stayed inside resented them for giving up. And kids don’t choose the framework their parents apply to them. Inside it, a child learns that their body is in a constant state of being threatened by the contaminating world. They learn that conventional medicine is suspect before they are old enough to understand the difference between a bad doctor, a limited system, and a useful tool. The interventions refused on those grounds aren’t always trivial. Vaccines for illnesses still capable of killing children. Antibiotics for infections that actually needed them. The mental health support that would have changed the shape of adolescence. Dental and vision care, treated as suspect because they come from the medical system. Children inside the framework also grow up with a quiet shame about food and products that are normal in other houses, and a low background vigilance about what they’re being exposed to. Some rebel in adulthood and overshoot the other way. Some stay inside the framework and replicate it for their own kids. The bills come due over generations.

The financial cost is enormous and rarely talked about. People inside the purity framework spend astonishing amounts of money. Supplements. Cleanses. Sensitivity tests. Functional medicine workups. Healers. Retreats. Water filters. Air purifiers. Protocols. I know folks who have spent ten or twenty thousand dollars a year, for years on end, chasing the next thing that’s going to make the symptoms go away. The wellness industry takes most of this money. Our community sees almost none of it. The supplement empires and the influencer platforms and the functional medicine clinics with their proprietary panels and their custom protocols are extracting wealth from the same community that came up advocating for the small farm and the local apothecary. A framework that started as a critique of industrial capture has been turned into one of its most efficient extraction mechanisms. The people paying are not the wellness CEOs. They are our folks, the ones in our living rooms and classrooms, the ones spending money they don’t have on protocols that don’t work because the framework tells them their suffering means they haven’t done enough.

There is also the cost to the herbal community itself, which is the one I think about a lot. The herbal medicine I practice, the kind I teach, the kind that has actually helped folks for as long as people have been making teas from plants, is in danger of being smothered by a moral framework that has very little to do with herbal medicine and a great deal to do with identity work disguised as clinical judgment. The reasonable practice of using plants to support bodies through real conditions is being conflated with the categorical refusal of conventional medicine. The two are not the same and have never been the same. But to the public they look like the same thing, because some of the loudest voices in the herbal world are the ones broadcasting the categorical refusal.

A Different Way of Caring

If the framework is causing harm, we need to be able to say what we’d put in its place. What works, when it’s working, isn’t complicated. It’s the slow kind of attention most of medicine has been losing for decades.

I listen first. Not to the framework the person was handed by their last teacher, but to what they’re actually experiencing in their body, in their day, in their relationships. I take the conventional medical workup seriously. If they have labs, I read them. If they have a diagnosis, I ask what that diagnosis means in their case, and I make sure they understand it and what their options are. I don’t sneer at the diagnosis. I don’t tell them their medications are poisoning them. I work with the picture as it actually is.

The tools are several. Herbs are part of the toolkit, and an important part. So is nutrition. So is sleep and movement and stress and connection. So are conventional medications, when those are what’s called for, even though I’m not the one prescribing them. I don’t divide the world into my tools and their tools. I think about which tools the person needs in what combination at what point in their care, and I support whatever combination actually helps.

Real risks I take seriously. If someone is working with industrial chemicals at their job, that’s worth thinking about. If their water supply is contaminated, that’s worth assessing. The toxicological tools that exist, exposure assessment, dose-response thinking, biomarkers when those exist, mechanism analysis, are useful here. I don’t categorically dismiss the concern, and I don’t categorically validate it. I think about what’s actually likely to be happening and what’s likely to help.

I watch the language. The word “toxin” is doing damage in our community, and clinicians can refuse to use it in ways that conserve the categorical framework. When someone tells me they want to detox, I ask them what they think is in their body that shouldn’t be. I ask them what they think detoxing would change. I work with what’s actually there, not with the category.

I stay humble about uncertainty. Most of what folks come to me with is not fully understood by medicine, alternative or otherwise. I don’t know what’s causing their fatigue with confidence. I don’t know whether the herbs I’m suggesting will help. I don’t know whether their condition is going to progress or remit. I tell them what I think and why I think it, and I tell them what I’m uncertain about. I revisit and adjust. I stay willing to be wrong. The framework that pretends to know what’s contaminating you and what isn’t is selling certainty it doesn’t have. Honest practice doesn’t sell that.

The job is to help folks have the information they need to know what they’re actually doing. What their suffering is, what their options are, what each option is likely to cost and likely to give. Then the choice is theirs. If they choose conventional medication, I support them. If they choose to try herbs first, I support that. If they choose to refuse something I think they need, I tell them honestly what I think, stay clear about the risks, and keep caring for the person in front of me.

I stay in relationship with conventional care where I can. Some of the best work I do is in conversation with the doctors of folks I’m working with. We compare notes. We split the labor. We disagree sometimes, and we work through the disagreements. Some doctors don’t want to talk to me. Some are great. None of this is enemy territory. The other clinician is also trying to help. The categorical framework that treats biomedicine as the contaminator is poisoning a relationship that should be one of the most valuable things in the field.

M, A Year Later

What tends to happen, when this works, is something like this.

The first thing was that she went back to her primary care doctor. That took a while. She was ashamed. The doctor was kind about it. They drew labs. Her TSH was high. Her B12 was low. Her vitamin D was low. She had been “supporting” her thyroid with seaweed and ashwagandha for years, while her thyroid had quietly given up. Levothyroxine was prescribed. She took it, with reluctance, because by that point she was tired enough to try anything.

Within two months her cognition came back. The fog she had been calling depression was, in large part, hypothyroidism. The depression pattern was still there underneath, but it was less of everything. She slept. She stopped crying in her car.

About four months in we talked about the lingering depression. She was open to therapy. She was not open to medication. We did what we could with that. I worked with her on the herbs (she had gobs of them left over that we had discontinued, and we went back through them together). I worked with her on sleep, movement, light exposure, and social engagement. The depression got better and stayed harder than she wanted it to be.

Sometime in the second year, her husband lost his job, and the stress triggered a worsening of the depression pattern. We ramped up herbal support. It got expensive fast. After three months of hard work, we had a conversation about what an SSRI would and wouldn’t do. She had spent a long time inside a story about what those medications were. We talked through what the actual evidence shows: modest effects, real for some people, real side effects, real benefits, useful in combination with the other things she was already doing. She thought about it for several weeks. She talked with her therapist. She talked with her husband. She decided to try one.

She didn’t tell anyone in her old community. She still hasn’t, as far as I know. The shame about it is still there. But it helped. She works. She sleeps. She brought her husband to an appointment recently and he cried a little, because the woman he married is back.

The grief about the years is what stays. There’s the family trip in 2019 she barely remembers because she was too tired to be present for it. The friend who stopped calling somewhere around year three because M had cancelled too many times. The years her daughter was in elementary school, which M describes as a blur she watched from inside a fog she didn’t know she could leave. She doesn’t dwell on it. But it sits in her, and sometimes when she’s talking about something else, you can see it.

This is not a story about how she saw the light and became enlightened. It is a story about a person inside a framework slowly finding her way to a different framework that served her better. It took years. It is still happening. There are days when she goes back to checking her supplements with more anxiety than usual, when she gets pulled by an Instagram post into worrying about the levothyroxine, when she has to relitigate decisions she thought she’d already made. The framework she came from is still alive in her. It’s alive in all of us who grew up in this world. We do not get free of it by deciding to be free. We get free of it slowly, by living in different relationships, by paying attention to what actually helps, by extending grace to ourselves when we backslide, by being in community with people who are doing the same work.

She still uses herbs. Of course she does. I’m her clinical herbalist, and herbs are part of what’s holding her together. She’s not less of an herbalist now. She’s a more thoughtful one. The herbs are tools again instead of being a moral position. She uses them for what they actually do. She doesn’t have to refuse the other tools to use these tools.

The belief that everything humans make is contaminating, and that anything they haven’t touched is clean, is not a fact about the world. It is a moral system, and like all moral systems it organizes who we are and how we live and what we will not do. It is durable because it does real work for the people inside it. Work of identity, of belonging, of meaning. And it is costly because the work it does is purchased at the price of the actual bodies and lives of the people it organizes.

We can do better than this. Many of us are already trying. What matters is that we get past the categorical refusal and back to the work of actually caring for people in the world they actually live in, with the tools that actually help them, including the ones that come from outside our tradition, and including the ones, like dose-thinking, that have been inside our tradition the whole time and that we have somehow forgotten to use.

The plants will still be there. They have always been there. They will not be diminished by our willingness to think clearly.

Epilogue

If you’ve read this far, thank you. Also, I suspect you may be feeling some things.

Abandoning a categorical framework removes the error, but also the floor. The natural/synthetic line was doing real work, badly, but really. It gave people a heuristic, a shortcut, a way to know what to reach for and what to refuse without having to think everything through from the ground up every time. Pull it out and some folks land somewhere worse than where they started: in the cynicism of it’s all probably bad, or it’s all probably fine, so who cares. That can feel like freedom. Sometimes it is just a quieter surrender.

Changing a belief this deep is a loss, not only a correction. The framework gave people a world: a way to belong, a way to know they were doing right, a community that knew them back. When it goes, that goes too, at least for a while. I’ve felt the disenchantment that follows, and it is not nothing. I don’t think the answer is to keep a comforting story. But I’m not going to pretend it costs nothing to put one down.

There’s another piece coming, written with my friend and thought partner Forrest Chalmers, on what to build instead. It takes up the question I’ve left open here. Not what’s contaminated, that was the wrong question, but what the word natural was reaching for before it got turned into a border wall.

The moral framework defined natural by what it keeps out. The more useful version might be defined by what it holds. Diversity. Complexity. Relationship. The whole food instead of the extracted fraction. The plant or meal or walk outside whose effects come from a pattern larger than any one isolated constituent. The body in an environment it can recognize and that can recognize it back. That is not a purity rule. It is a different floor. It doesn’t tell you what to refuse. It tells you what to look for. And I think it is one we can build on.

—Thomas Easley, Herbalist

Thinking Tools: Philosophy of Science for the Rest of Us

Thomas Easley — Tue, 27 Jan 2026 15:21:56 GMT

Before I get into the substance of this essay, I want to explain what you’re looking at, because it’s something new.

This is the first of what I hope will be many long-form essays paired with an interactive, free, AI-powered study tool called NotebookLM (link at the bottom). The essay you’re reading now is about 10,000 words—longer than any magazine article, shorter than a book, the kind of mid-length deep dive that used to thrive in the age of pamphlets but that modern publishing economics have nearly killed. But unlike a pamphlet, this essay comes with a curated NotebookLM notebook containing all the source material that shaped my thinking, structured into a complete guided learning experience.

If you haven’t encountered NotebookLM, it’s a Google tool that lets you upload sources—articles, papers, videos, websites—and then interact with them through AI. You can ask questions and get answers grounded in those specific sources. You can generate audio explanations in multiple formats: quick overviews, extended deep dives, even debates between AI hosts exploring different positions. You can create quizzes, flashcards, slide decks, and reference documents. It turns a pile of documents into something alive, something you can explore and interrogate.

The problem with most information consumption is that it’s passive. You read something, you nod along, you feel like you understand—and then two weeks later you can’t remember any of it. Real learning requires engagement: asking questions, testing yourself, applying concepts to real problems, struggling with ideas that don’t come easily. NotebookLM provides infrastructure for that kind of engagement at scale.

What I’ve done is curate the best sources I could find on philosophy of science—entries from the Stanford Encyclopedia of Philosophy (the gold standard for philosophy reference), lectures from Oxford and Leiden, academic papers—and built a structured curriculum around them. The notebook offers two paths: an Birds Eye View infotainment path where you just listen to a few audios and explore casually, or a three-week structured Learning Journey with lectures, quizzes, slide decks, and debate assignments where you argue positions against your natural inclinations.

I spent decades as an educator wishing I could provide this kind of experience. I’ve always hated sharing information without knowing the person can ask questions or get feedback. It’s so easy to become falsely confident about what you know if you don’t actually assess yourself and get challenged on it. One-way information transfer produces exposure, not learning. AI has finally gotten good enough to change that. Given quality source material, these tools can now provide the feedback loop that real learning requires.

This particular essay and notebook are free—my gift to anyone who wants better tools for thinking. If this model resonates, paid subscribers will get access to future essay-notebook pairings, starting with a notebook on the Dreyfus model of skill acquisition (how expertise actually develops, and why it matters for education and practice). I’m still figuring out the cadence, but the idea is that longer-form writing will come bundled with the source material and learning tools that let you go as deep as you want.

Steven Johnson, who developed NotebookLM, has been experimenting with similar models—publishing essays alongside curated notebooks. I think he’s onto something important. In an age where AI can transform how we engage with ideas, authors and educators have new ways to create value for readers beyond just the text itself. You’re getting access to my conclusions in this essay, but, more importantly, now you have access to the sources and tools to reach your own conclusions.

Now, onto the substance.

Part One: The Problem

Two Useless Slogans

We’re stuck between two useless slogans.

“Trust the science” asks for blind faith in institutions that have repeatedly earned skepticism. “Do your own research” pretends you can become an expert in virology, climate modeling, or oncology over a long weekend with Google. Neither one is serious. Neither one helps.

And yet we have to make decisions. Should you take this medication? Is this treatment worth trying? Is that study your friend sent you actually good evidence, or is it one of the thousands of papers that will never replicate? These aren’t abstract questions. They affect your health, your family, your livelihood.

The people shouting “trust the science” often can’t explain what makes science trustworthy in the first place. The people shouting “do your own research” often lack the statistical training, domain expertise, and access to primary sources that actual research requires. Both camps are essentially asking you to pick a team and stop thinking.

I’ve spent my career as a clinical herbalist and educator living in the tension between these camps. My field is dismissed by mainstream medicine as unscientific, while simultaneously being flooded with practitioners making claims far beyond what evidence supports. I’ve had to develop frameworks for navigating this—for knowing when the conventional view is probably right, when the alternative view has merit, and when everyone is just guessing. Philosophy of science gave me those frameworks. And I think everyone needs them.

There’s a third option between blind trust and impossible self-reliance, but almost nobody talks about it. It’s the intellectual self-defense course you never got.

Why “Doing Your Own Research” Is Mostly Impossible

Let’s be honest about what research actually requires.

To evaluate a single clinical trial, you’d need to understand study design, statistical power, p-values, confidence intervals, effect sizes, intention-to-treat analysis, blinding procedures, selection bias, publication bias, and the specific biological mechanisms at play. You’d need access to the full paper, not just the abstract. You’d need to know the track record of the researchers and the journal. You’d need familiarity with the other studies in that area to know whether this one confirms, contradicts, or extends existing knowledge.

That’s for one study. On one question. In one field.

This isn’t a criticism of your intelligence. I have decades of experience in my field, and I can’t “do my own research” on quantum computing or monetary policy or epidemiological modeling. Nobody can be an expert in everything. The knowledge required to legitimately evaluate primary research is the work of years, not hours.

Consider what it would actually take to evaluate the claim that a particular vaccine is safe and effective. You’d need to understand immunology well enough to evaluate whether the proposed mechanism makes sense. You’d need to understand the trial design well enough to spot methodological weaknesses. You’d need statistical training to interpret the results correctly. You’d need familiarity with the regulatory process to know what the approval actually means. You’d need knowledge of the post-market surveillance systems to evaluate safety signals. You’d need historical context about similar vaccines to calibrate your expectations. You’d need access to the raw data, which is often proprietary.

Even professional scientists typically can’t evaluate research outside their specific sub-specialty. A molecular biologist might not be equipped to evaluate an epidemiological study. A statistician might not understand the biological plausibility of a proposed mechanism. Science works because specialists evaluate work in their own domains and trust other specialists to do the same in theirs. There’s no view from nowhere, no position from which you can evaluate everything yourself.

So when someone says they’ve “done their own research” on vaccines or climate change or whatever controversy is burning this week, what they usually mean is they’ve read some articles, watched some videos, and encountered claims that feel compelling. Let’s just call it what it is - exposure to information of varying quality, filtered through algorithms designed to maximize engagement, not accuracy.

The problem is the less you know about a field, the less equipped you are to recognize your own ignorance. Someone who’s read three blog posts about immunology might feel confident in their evaluation of vaccine research precisely because they don’t know enough to recognize what they’re missing. The expert, who sees all the complexity and uncertainty, often appears less confident—which can paradoxically make them seem less credible to a lay audience.

I’m not saying this to be dismissive. I’m saying it because pretending otherwise leads to false confidence, which is more dangerous than honest uncertainty. The person who thinks they’ve figured it out after a weekend of Googling is more dangerous than the person who knows they’re out of their depth.

Why “Trusting the Science” Doesn’t Work Either

The “trust the science” camp fares no better under scrutiny.

“Trust the science” treats science as a monolith that speaks with one voice. It doesn’t. Scientists disagree constantly—about methods, interpretations, priorities, and conclusions. That disagreement is actually how science works. It’s a feature, not a bug. But it means there’s no single “science” to trust.

When someone says “trust the science,” which scientists should you trust? The ones who say saturated fat causes heart disease, or the ones who say the evidence for that was always weak? The ones who say low-dose radiation is dangerous at any level, or the ones who say there’s a threshold below which it’s harmless? The ones who say antidepressants work primarily through chemical mechanisms, or the ones who say the evidence points mostly to placebo effects? On any given question, you can find credentialed experts on multiple sides.

“Trust the science” also ignores the very real ways that scientific institutions can fail. Fraud happens—not commonly, but regularly enough that major journals retract papers every week. Groupthink happens—when everyone in a field shares the same assumptions, certain questions don’t get asked. Publication bias systematically distorts the literature, because journals prefer positive findings and researchers learn to produce them. Pharmaceutical companies fund studies designed to make their products look good. Researchers face career incentives that reward positive findings and punish null results.

The replication crisis revealed the scale of these problems. In psychology, attempts to replicate major published findings succeeded only about 40% of the time. In cancer biology, the success rate was even worse—perhaps 10-25% depending on who you ask. We’re talking about well-known studies from prestigious journals that simply don’t hold up when other researchers try to reproduce them.

Consider some specific examples. The “ego depletion” effect—the idea that willpower is a limited resource that gets depleted—was one of the most cited findings in social psychology. Hundreds of studies built on it. It turned out to be essentially non-existent when tested rigorously. The “power pose” research, claiming that standing in expansive postures increases testosterone and confidence, became a TED talk sensation before failing to replicate. Candidate genes for depression, schizophrenia, and other conditions were confidently linked to specific variants for years before massive genome-wide studies showed those links were statistical noise.

In medicine, John Ioannidis’s 2005 paper “Why Most Published Research Findings Are False” made a simple, uncomfortable point: when you combine underpowered studies, small effect sizes, lots of analytic degrees of freedom, and a publication system that rewards “positive” results, a large share of claimed discoveries won’t hold up. The pushback early on wasn’t surprising—he was attacking the machinery that produces reputations and careers—but over the last two decades the field has largely absorbed the underlying message: reliability isn’t a given, and “statistically significant” is often a weak filter for truth.

The upshot: the published literature systematically overstates effect sizes and understates uncertainty. A single study, even in a good journal, is weak evidence. You need replication, meta-analysis, and mechanistic understanding before high confidence is warranted.

Science remains our best tool for understanding the world—a human enterprise, with human flaws, that nonetheless manages to generate real knowledge through mechanisms of criticism, replication, and revision. But those mechanisms require scrutiny to function. “Just trust it” shuts down scrutiny.

The COVID years made this painfully clear. Official guidance changed repeatedly, sometimes contradicting what officials had said with great confidence weeks earlier. Masks don’t help. Actually, masks are essential. The virus doesn’t spread through aerosols. Actually, aerosol transmission is the primary route. Lab leak is a conspiracy theory. Actually, it’s a plausible hypothesis. People who asked questions were told to trust the experts. Then the experts turned out to be wrong about things. Then asking questions became more acceptable. The whole experience left a lot of reasonable people unsure what to believe about anything.

I’m not interested in relitigating specific COVID debates. I’m pointing out that “trust the science” fails as a strategy because it gives you no tools for what to do when the science is uncertain, contested, or actively changing. It’s a demand for faith dressed up in secular language.

How We Got Here

The current crisis of trust in scientific institutions didn’t come from nowhere. It’s the product of decades of missteps that have eroded the social contract between science and the public.

Scientists promised certainty and delivered probability. The public was taught that science proves things, when what science actually does is generate evidence that supports or undermines theories to varying degrees. When scientists say something is “very likely” but turn out to be wrong, the public feels lied to—even though the scientists were accurately communicating their uncertainty.

Institutions oversold their conclusions. When nutrition scientists told us with great confidence that dietary fat was the enemy, they were overstating what the evidence actually showed. When the result was an epidemic of obesity fueled partly by the refined carbohydrates people substituted for fat, trust suffered. Not because science failed, but because the communication of science failed.

The boundaries between science and policy got blurred. There’s a difference between the scientific question “what are the effects of X?” and the policy question “should we mandate Y?” Scientists have expertise on the first question but no special authority on the second, which involves value judgments about tradeoffs. When scientists speak as if their expertise extends to policy, and when they’re wrong or when people disagree with their values, the whole enterprise looks politicized.

Some scientific institutions were captured by political or financial interests. The sugar industry funded research downplaying sugar’s health effects. The opioid crisis was fueled partly by pharmaceutical companies manipulating the scientific literature on addiction risk. Climate science became so politicized that both sides cherry-pick studies to support predetermined conclusions.

Meanwhile, the internet democratized access to information while destroying the gatekeepers who once filtered quality. Anyone can find credentialed experts saying almost anything. Anyone can find studies that seem to support almost any conclusion. The result is not more knowledge but more confusion—more options for motivated reasoning disguised as research.

We need a way out of this mess that doesn’t require either naive trust or impossible expertise. We need tools for thinking about how science works, why it sometimes fails, and how to calibrate our confidence appropriately.

Those tools exist. They’re just not taught to anyone except philosophy students.

Part Two: The Thinking Toolkit

Philosophy of Science as the Missing Education

How do you evaluate claims that you can’t directly verify yourself?

You can’t personally check whether a drug works. You can’t run your own climate models. You can’t replicate the experiments. You’re necessarily dependent on other people’s reports about what they found. So on what basis do you decide which reports to believe?

This is actually one of the oldest questions in philosophy. It’s called epistemology—the study of knowledge and justified belief. And there’s a specific branch of it focused exactly on this problem: philosophy of science.

Philosophy of science asks questions like: What makes something scientific in the first place? How should evidence relate to theory? Why do scientists sometimes hold onto theories despite contradictory evidence? When is it rational to change your mind? How do we know if a field is making progress or just spinning its wheels? Should we believe that scientific theories describe reality as it actually is, or just treat them as useful tools?

These are practical tools for anyone trying to navigate a world full of claims they can’t personally verify.

The weird thing is, almost nobody learns this. You can get a PhD in a scientific field without ever taking a course on what science actually is and how it works. The scientists themselves are often operating on intuition and training rather than explicit frameworks. Which means when they disagree with each other, they often can’t articulate why they disagree, and the public has no way to evaluate the disagreement.

Philosophy of science gives you that framework. Let me walk you through the key concepts.

Concept 1: Falsifiability and The Demarcation Problem (What Makes Science Scientific?)

The first question philosophy of science tackles is deceptively simple: How do you tell science from pseudoscience?

This matters practically because lots of things claim the mantle of science. Pharmaceutical research claims it. So does homeopathy. Evolutionary biology claims it. So does intelligent design. Mainstream nutrition science claims it. So do various gurus with conflicting advice. They can’t all be equally scientific. What’s the difference?

The classic answer comes from Karl Popper, one of the most influential philosophers of science. His insight: science makes risky predictions that could be proven wrong. A scientific theory sticks its neck out. It says “if X is true, then Y should happen”—and if Y doesn’t happen, the theory is in trouble.

Popper contrasted Einstein’s theory of relativity with Freudian psychoanalysis. Einstein’s theory made specific, testable predictions—like that light from distant stars would bend as it passed the sun by a precise amount. When Arthur Eddington tested this during a solar eclipse, the prediction was confirmed. But the prediction could have failed. Einstein was taking a risk.

Freud’s theories, by contrast, seemed to explain everything. Patient confirms the theory? That supports Freud. Patient denies the theory? That’s resistance, which also supports Freud. There was no possible observation that could count against the theory, which meant the theory wasn’t really saying anything testable about the world.

This is the criterion of falsifiability: genuine science makes claims that could, in principle, be shown to be wrong. A theory that can explain any possible outcome has abandoned science for storytelling.

This is useful. When someone presents you with a framework that conveniently explains everything, including all the evidence against it, that’s a red flag. When proponents of a theory keep reinterpreting failures as successes, when no possible result could ever count against their view, you’re probably not dealing with science.

Falsifiability matters, but the story gets more complicated. Philosophers since Popper have shown that the relationship between theory and evidence resists simple falsification. This brings us to one of the most important concepts for practical reasoning.

The Duhem-Quine Problem: Why Evidence Is Never Simple

Here’s a puzzle that complicates the tidy picture of falsification: When a scientific prediction fails, what exactly has been proven wrong?

Suppose you have a theory that predicts a certain chemical reaction will produce a specific result. You run the experiment and don’t get that result. Has the theory been falsified?

Not necessarily. The prediction didn’t come from the theory alone. It came from the theory plus a bunch of auxiliary assumptions: that your instruments are working correctly, that your chemicals are pure, that the room temperature is what you think it is, that there are no interfering factors you haven’t considered. When the prediction fails, the problem could be with any of these auxiliary assumptions rather than the theory itself.

This is the Duhem-Quine thesis: theories are never tested in isolation. They’re tested together with a web of background assumptions. When something goes wrong, you have to decide what to blame. And that decision isn’t dictated by the evidence alone—it requires judgment.

This explains a lot about how science actually works. When a theory’s prediction fails, scientists don’t immediately abandon the theory. They look for problems with the experiment, the measurements, the auxiliary assumptions. Sometimes they find them. The failed prediction was due to impure chemicals or a faulty instrument, and the theory is fine.

But this also means that any theory can be saved from falsification if you’re willing to adjust your auxiliary assumptions enough. Geocentric astronomy could explain planetary motion by adding more and more epicycles. At some point, this becomes ridiculous—but where exactly is that point? There’s no algorithm that tells you when to abandon a theory versus when to blame auxiliary assumptions.

This has practical implications. When you see a study that seems to contradict a well-established theory, you should ask: What are the auxiliary assumptions? Could the problem be there rather than with the core theory? But you should also ask: Is this theory being protected by an ever-growing pile of auxiliary assumptions? Is the research program generating new predictions, or just explaining away failures?

Concept 2: Kuhn, Paradigms and Normal Science

Thomas Kuhn introduced concepts that have become part of our everyday vocabulary, though often misunderstood.

Kuhn studied the history of science and noticed that it didn’t match Popper’s idealized picture. Scientists mostly don’t spend their time trying to falsify their theories. Instead, they work within shared frameworks—what Kuhn called paradigms—that define what questions are worth asking, what methods are legitimate, and what counts as a good solution.

A paradigm is more than a theory. It’s a whole worldview shared by a scientific community. It includes the fundamental assumptions, the exemplary solutions to problems, the standards for what counts as good work. Scientists who share a paradigm can communicate easily because they share so much background. They don’t have to argue about fundamentals; they can focus on extending the paradigm to new problems.

Kuhn called this normal science: the puzzle-solving work that scientists do within an established paradigm. Most science is normal science—working out details, applying established methods to new cases, extending the framework to new domains. Unglamorous, but productive precisely because the big questions are settled, allowing focus on smaller ones.

The problem comes when anomalies accumulate. An anomaly is a puzzle that the paradigm can’t solve—an observation that doesn’t fit, a prediction that keeps failing. A few anomalies are normal; every paradigm has unsolved problems. But when anomalies pile up, when the best minds can’t make them go away, the paradigm enters crisis.

Crisis is when revolutionary science becomes possible. Someone proposes a new paradigm that handles the anomalies better. At first, the new paradigm is resisted—it’s incomplete, it challenges established ways of thinking, and the old guard has spent careers building on the old foundations. But if the new paradigm keeps succeeding where the old one fails, eventually it wins. This is a scientific revolution.

Here’s the controversial part — Kuhn argued that paradigm shifts resist purely rational reconstruction. The new paradigm often changes what counts as evidence, what questions matter, what methods are legitimate—so it can’t simply be “better supported by evidence” when the standards for evidence themselves have shifted. Scientists working in different paradigms are, in a sense, working in different worlds. They see different things when they look at the same data. Kuhn called this incommensurability.

This sounds relativistic, and Kuhn was often accused of making science seem irrational. But I think his insight is actually useful for understanding scientific controversies. When you see two groups of scientists in fundamental disagreement, ask: Is this a disagreement within a shared paradigm, or a clash between different paradigms?

Disagreements within a paradigm can be resolved with more evidence, because everyone agrees on what counts as evidence and how to interpret it. Paradigm clashes are messier. The two sides might be talking past each other because they’re using the same words to mean different things, or because they have different standards for what would count as resolution. Understanding this helps you calibrate your expectations for how the controversy might resolve.

Concept 3: Research Programs and How to Tell If a Field Is Making Progress

Imre Lakatos tried to rescue scientific rationality from Kuhn’s challenge while still taking the history of science seriously. His framework is one of the most useful for practical evaluation.

Lakatos introduced the concept of a research programme—not a single theory, but a series of theories sharing a common hard core of fundamental commitments. The hard core is protected by a protective belt of auxiliary hypotheses that can be modified to handle anomalies. This is rational—it’s how science should work, because abandoning fundamental theories at the first sign of trouble would make science impossible.

Lakatos’s key insight was that research programs can be evaluated by whether they’re progressive or degenerating.

A progressive research program generates new predictions that get confirmed. It doesn’t just explain away failures; it anticipates new phenomena, and when scientists go looking, they find what the program predicted. The program is growing, extending into new domains, producing novel insights.

A degenerating research program, by contrast, mostly reacts to failures. Its modifications are ad hoc—designed to save the theory from specific refutations rather than to generate new predictions. Each time a problem arises, another epicycle gets added. Defense replaces growth.

This distinction is incredibly useful for evaluating fields and claims. When someone tells you about a theory or approach, ask: Is this research program progressive or degenerating? Is it generating novel confirmed predictions, or just explaining away anomalies? Is it expanding into new areas, or circling the wagons?

A degenerating research program can survive indefinitely if its proponents are committed enough. They can always add more auxiliary hypotheses, always find ways to interpret failures as successes. But that doesn’t mean you should trust it. The pattern of purely defensive modifications, the absence of novel predictive success—these are warning signs.

Consider a health claim: “X supplement improves cognitive function.” Ask: Is this part of a progressive research program? Have researchers using this framework made predictions about other phenomena that turned out to be correct? Or is the evidence limited to this one claim, defended against failures by increasingly complex explanations?

Concept 4: Confirmation and Evidence and What It Takes to Support a Claim

So far we’ve talked about theories and paradigms. But what about the relationship between evidence and belief? What does it actually take for evidence to support a conclusion?

The naive view is simple, positive instances confirm generalizations. See a white swan? That confirms “all swans are white.” See a drug work in a clinical trial? That confirms “this drug works.” But philosophers have shown this is too simple.

Consider Hempel’s paradox. The statement “all ravens are black” is logically equivalent to “all non-black things are non-ravens.” So if seeing a black raven confirms the first statement, seeing a red apple (a non-black non-raven) should confirm the second—and therefore the first. But that seems absurd. How can a red apple tell you anything about ravens?

The paradox reveals that confirmation runs deeper than “positive instances support generalizations.” Something else is going on—something about relevance, about what kinds of evidence actually bear on what kinds of claims.

Then there’s the problem of underdetermination: any set of evidence is compatible with multiple theories. The data alone never force a unique conclusion. You can always construct different theories that explain the same observations. Some theories remain better than others—simpler, more unified, more fruitful—but evidence alone doesn’t mechanically dictate belief.

Bayesianism offers one framework for thinking about this more carefully. In Bayesian terms, confirmation is about probability updates. Evidence confirms a hypothesis if it raises the probability of that hypothesis being true. The key equation involves prior probability (how likely you thought the hypothesis was before the evidence), likelihood (how probable the evidence would be if the hypothesis is true), and posterior probability (how likely the hypothesis is after seeing the evidence).

You don’t need to do the math to use the insight. When evaluating evidence, ask: How probable would this evidence be if the hypothesis were true? How probable would it be if the hypothesis were false? If the evidence is much more likely given the hypothesis than given the alternative, it’s strong confirmation. If the evidence is about equally likely either way, it’s weak or no confirmation.

This explains why some evidence is more convincing than others. A predicted novel result that would be very unlikely if the theory were false—that’s strong evidence. An observation that’s about equally likely whether the theory is true or false—that’s weak evidence, even if it’s “consistent with” the theory.

But Bayesianism has its own problems. Where do prior probabilities come from? How do we handle genuinely novel concepts that we couldn’t have assigned probabilities to before encountering them? There’s no mechanical procedure that takes evidence in and spits belief out. Judgment is always involved.

Scientific Realism: Should We Believe Theories Are True?

Here’s a deeper question that might seem academic but actually matters for how you think about scientific claims: When a scientific theory succeeds, should you believe it’s true—that it describes reality as it actually is?

Scientific realists say yes. Our best theories, the ones that make successful predictions, are probably approximately true. They succeed because they’ve latched onto real features of the world. Electrons exist. Genes exist. The mechanisms described by our best theories are, more or less, how things actually work.

The main argument for realism is the “no miracles” argument: It would be a miracle if our theories were so predictively successful without being at least approximately true. When a theory predicts a novel phenomenon with great precision, and we go looking and find exactly what was predicted, the best explanation for that success is that the theory is onto something real.

But there’s a powerful argument against realism too: the pessimistic induction. Look at the history of science. It’s littered with theories that were wildly successful in their day but turned out to be false. Newtonian physics made stunning predictions for centuries before being replaced by relativity. Caloric theory of heat, phlogiston theory of combustion, the ether theory of light—all were productive research programs that turned out to be fundamentally mistaken. Why should we think our current theories are different?

The anti-realist response, associated with philosophers like Bas van Fraassen, is that we should only believe our theories are empirically adequate—that they save the phenomena, that they work for prediction and intervention. But we shouldn’t believe claims about unobservable entities like electrons or quarks or molecular mechanisms. Those might be useful fictions rather than descriptions of reality.

Why does this matter practically? Because it affects how much you should believe the mechanisms proposed in scientific explanations.

When a study reports that Drug X works through Mechanism Y, should you believe in Mechanism Y? The realist says yes, if the evidence is strong. The anti-realist says be cautious—what you can really trust is that Drug X produces the observed effects. The mechanism is a story that might be useful but might also be replaced by a completely different story that makes the same predictions.

For a practitioner, this suggests epistemic humility about mechanistic claims. The effect might be real even if the proposed mechanism is wrong. Historical medicine is full of treatments that worked (or seemed to) for completely wrong reasons.

Scientific Explanation: What Counts as Understanding?

One more concept worth having: What makes something a scientific explanation? When do we actually understand why something happens?

The traditional view was the covering-law model: an explanation shows that the phenomenon was to be expected, given the laws of nature and initial conditions. If you can derive the outcome from laws plus circumstances, you’ve explained it.

Yet scientific practice demands more. Sometimes we want mechanisms—causal stories about how the outcome was produced. Knowing that symptoms follow infection according to statistical laws feels less satisfying than understanding the biological process by which the pathogen causes those symptoms. Mechanistic explanation traces the causal pathway.

Sometimes we want unification—showing that seemingly different phenomena are manifestations of the same underlying process. Darwin’s theory explains both the diversity of species and their adaptation to environments, unifying what seemed like separate puzzles. Explanatory unification reduces the number of independent things we need to accept.

For practical evaluation, ask: What kind of explanation is being offered? Is it just a statistical regularity (X correlates with Y), or is there a proposed mechanism? If a mechanism, how well-established is it? Does the theory unify multiple phenomena, or is it specific to this one case?

Mechanistic explanations are generally more robust—if you understand why something works, you can predict when it will and won’t work in new situations. Purely statistical claims, without mechanistic backing, might not generalize as well.

Part Three: Putting It Together

A Framework for Evaluating Claims

Let me synthesize these concepts into something you can actually use.

When you encounter a scientific claim, run through these questions:

1. Is the claim falsifiable? What would count as evidence against it? If proponents can reinterpret any possible result as supportive, that’s a red flag. Genuine science takes risks.

2. What’s the paradigm context? Is this claim part of established normal science, or is it challenging fundamental assumptions? Challenges to paradigms aren’t wrong by default, but they face a higher burden of proof. If it’s a paradigm clash, don’t expect quick resolution.

3. What’s the research program status? Is this part of a progressive program that’s generating novel confirmed predictions? Or a degenerating program that’s mostly explaining away failures? Track records matter.

4. How strong is the evidence? Apply Bayesian thinking: How likely is this evidence if the claim is true? How likely if it’s false? Strong evidence is evidence that would be very unlikely if the claim were false. Also consider: Is this a single study or a replicated finding? How good were the methods? What’s the publication and replication context?

5. What’s the proposed mechanism? Is there a causal story, or just a correlation? How well-established is the mechanism? Be appropriately skeptical of mechanistic claims—they’re often revised even when the effect is real.

6. What’s the appropriate confidence level? Given all the above, how much should you believe this claim? Not “is it true or false” but “how confident should I be?” Express your credence in terms of probability if it helps: Am I 95% confident? 60%? 30%?

No algorithm can do this for you. It requires judgment. But judgment informed by these frameworks beats the alternatives: blind trust, impossible self-research, or tribal loyalty.

An Example: Evaluating a Health Claim

Let’s say someone shares a study claiming that a particular supplement improves cognitive function. Here’s how philosophy of science changes your evaluation:

Before these tools: Does this confirm what I already believe? Do I trust the person who shared it? Is it from a “good” source? Does the headline sound confident?

After these tools:

Is the claim falsifiable? Yes—cognitive function can be measured, and the supplement could fail to improve it. So far so good. But watch out for hedging: if the claim is “this supplement supports cognitive health” rather than “this supplement improves performance on X measure by Y amount,” that’s less falsifiable. The vaguer the claim, the easier it is to reinterpret failures as successes.

What’s the paradigm context? The idea that nutritional supplements affect cognitive function is not paradigm-challenging. It’s within mainstream biomedical assumptions. But it is in a domain (supplements) where publication bias and commercial interest are known problems. Also ask: Who funded this study? What are the researchers’ track records? What journal published it, and what are that journal’s standards?

What’s the research program status? This is key. Is this one study making a surprising claim, or part of an established line of research? Have researchers in this program made other predictions that held up? Or is this the kind of claim that keeps appearing in preliminary studies but never replicates? If you look at the broader literature on this supplement, what do you see? A progressive research program generating novel predictions? Or a series of p-hacked studies with ever-shifting outcome measures?

How strong is the evidence? What kind of study? A randomized controlled trial is stronger than observational data. Double-blind is stronger than open-label. Pre-registered is stronger than not. How large was the effect size? A tiny effect in a large sample might be statistically significant but practically meaningless. Has it been replicated? A single unreplicated study is much weaker than a finding that holds up across multiple labs. What’s the sample size? Were there multiple comparisons that might inflate false positive rates?

What’s the proposed mechanism? Is there a plausible biological story for how this supplement affects cognitive function? How well-established is that mechanism? Be cautious—many proposed mechanisms turn out to be wrong even when effects are real. The mechanism might be marketing rather than science.

What’s the appropriate confidence level? Given all the above, I might conclude: This is an interesting preliminary finding, but I should assign relatively low probability (say, 30-40%) to the specific claim being correct, because it’s a single study in a field with replication problems, the effect size is modest, and while the mechanism is plausible, it’s not proven. I wouldn’t bet my health on it, but I’d follow subsequent research. If three more well-designed studies replicate the finding, I’d revise upward. If replication attempts fail, I’d revise toward zero.

This is very different from “the study says it works!” or “supplements are all scams.” It’s calibrated confidence, based on an evaluation of the evidence quality and the research context. It’s what “doing your own research” should actually mean—not becoming an expert, but thinking like one.

The Herbalist’s Dilemma

Let me get specific about why this matters in my field.

Clinical herbalism exists in a peculiar position. On one side, we face dismissal from mainstream medicine, which often treats anything outside pharmaceutical intervention as unscientific quackery. On the other side, we’re surrounded by practitioners making claims far beyond what evidence supports—treating herbs as magic bullets, ignoring contraindications, dismissing the value of modern research entirely.

Philosophy of science helps navigate this.

The mainstream dismissal often fails the paradigm test. The assumption that only pharmaceutical interventions can be therapeutic functions as a paradigm commitment, not a conclusion from evidence. When researchers refuse to study herbal interventions seriously, or design studies that miss how herbs are actually used, they’ve stopped being scientific and started being paradigm-bound.

Consider how herbal research often gets done. A researcher isolates a single compound from a plant and tests it at arbitrary doses, then concludes “the herb doesn’t work” when the compound fails. But herbalists don’t use isolated compounds at arbitrary doses—they use whole plant preparations, often in combination, dosed according to traditional guidelines refined over generations. Testing the isolated compound doesn’t test herbalism any more than testing the effects of pure sodium would test the effects of food. It’s a paradigm mismatch: the reductionist biomedical approach can’t easily evaluate the holistic herbal approach, so it dismisses rather than adapts.

But the uncritical acceptance of traditional claims also fails. Traditional use is evidence—sometimes questionable evidence, but evidence. It raises the prior probability that something might work. But it doesn’t establish dosing, safety, mechanism, or efficacy compared to alternatives.

I’ve seen herbalists make confident claims about treatments that, when you trace the evidence, rest entirely on one anecdote from an herb student. People who would rightly reject pharmaceutical company claims based on weak evidence sometimes accept equally weak evidence for herbal claims because it fits their worldview.

A scientifically-informed herbalist takes traditional knowledge seriously as a source of hypotheses while demanding better evidence before strong claims. They recognize that absence of evidence (this herb hasn’t been studied) isn’t evidence of absence (this herb doesn’t work), but also isn’t license to claim efficacy. They calibrate their confidence to the actual evidence available for each intervention.

They also recognize when they’re facing a paradigm clash rather than a simple factual disagreement. The debate between conventional and alternative medicine goes deeper than which treatments work—it encompasses what counts as evidence, what counts as a treatment, what the goals of medicine should be. Understanding this helps you avoid the frustration of expecting resolution from evidence alone.

This position is uncomfortable. It doesn’t give you the certainty that true believers or dogmatic skeptics enjoy. But it’s honest. And it’s what good practice requires, imo.

Calibrated Confidence as the Goal

The goal here is calibrated confidence, not certainty. You’re never going to reach a place where you know, for sure, what’s true. Knowledge doesn’t work that way, and anyone promising you certainty is selling something.

The goal is calibrated confidence. Knowing when you have good reason to believe something, when you should suspend judgment, and when you should be actively skeptical. Matching your credence to the actual strength of the evidence.

This sounds simple, but almost nobody does it. People are either credulous or cynical, depending on whether the claim fits their priors. The person who’s hyper-skeptical of pharmaceutical company studies will uncritically accept claims about supplements. The person who dismisses alternative medicine will credulously accept whatever their doctor says. Both are failing at the same skill.

The stakes are higher now than they’ve been in a long time. Trust in institutions is at historic lows—and not without reason. Individual research capacity can’t replace institutional trust; it doesn’t scale. Better tools for thinking can. Tools that let you evaluate claims without requiring full expertise. Tools that help you distinguish genuine uncertainty from pseudo-controversy, legitimate scientific debate from manufactured doubt.

The information environment will only get more confusing. AI will make plausible-sounding content easier to generate. Social media algorithms will continue optimizing for engagement over accuracy. Interest groups will continue funding research that supports their positions. The only durable solution is to get better at thinking—better at asking the right questions, better at evaluating evidence, better at calibrating confidence.

Philosophy of science doesn’t tell you which claims are true. It gives you tools for thinking about why you might believe a claim, how much you should believe it, and what would change your mind. It makes you a better thinker, not just a better-informed one.

And in a world where information is abundant, trust is scarce, and everyone is trying to manipulate you, being a better thinker is worth more than having the right answers handed to you.

Part Four: The Notebook

What’s In the Philosophy of Science Notebook

I’ve built a comprehensive learning resource around these ideas. It’s a NotebookLM notebook containing:

24 curated sources:

11 entries from the Stanford Encyclopedia of Philosophy (the gold standard for philosophy reference)
4 entries from the Internet Encyclopedia of Philosophy
9 video lectures from Oxford, Leiden, and other academic sources

Two engagement paths:

Birds Eye View Path (1.5 hours): You just want to understand this stuff better without commitment. Listen to the Video Overview (10 minutes), then pick 2-3 Deep Dives that interest you—I’d recommend the ones on demarcation and on Popper vs. Kuhn. Use the chat feature to ask questions as they come up. Keep the Briefing Doc as a reference. Done.

The Learning Journey (20-30 hours over 3 weeks): You want to actually internalize this material. This path uses evidence-based learning science: spaced repetition, retrieval practice, scaffolded difficulty. It includes:

Pre-assessment questions so you can see how far you come. Before you consume any content, you write down what you currently think about questions like “What makes something scientific vs. unscientific?” and “Should you believe scientific theories are true, or just useful?” These become your baseline for measuring growth.
Six parts covering demarcation, scientific change (Kuhn), research programs (Lakatos), confirmation and evidence, scientific explanation, and scientific realism. Each part follows the same learning cycle: recommended video lecture from an academic source, Deep Dive audio exploration that you can interrupt to ask questions, Slide Deck for visual reinforcement, and Quiz to check comprehension.
Video lectures from Oxford, Leiden, and other academic sources. You watch these before the Deep Dives so you’re hearing the ideas in multiple voices. There’s something valuable about encountering Popper explained by a Leiden professor and then again by an AI—the repetition with variation helps concepts stick.
Flashcards covering all key terms in one comprehensive deck. You’ll return to it at different points in the journey with increasing expectations. Day 1 is familiarization—just read through them, get a feel for the vocabulary. Week 2 you start actively testing yourself. Week 3 is mastery mode—you should be able to recall definitions without hints. The progression is intentional: struggling to retrieve a term you almost-but-not-quite remember strengthens memory more than easy recognition does.
Quizzes for each part, retaken on review days. Don’t worry about repeating the same questions—spaced repetition with the same material is exactly how durable memory forms. Returning to Part 1 material in Week 2, after you’ve started to forget it, builds stronger retention than reviewing immediately. Your goal isn’t to remember the answers from last time; it’s to retrieve the concepts from understanding.
Two argument practice sessions that are my favorite part of the curriculum. First, you identify your intellectual tendencies: Are you a reductionist who likes clean criteria and logical frameworks, or a holist who thinks context matters and things are messier than simple rules suggest? Are you a pragmatist who cares more about “does it work?” or a truth-seeker who believes science discovers how the world actually is? Then you argue for the opposite position. If you’re a reductionist, you re-listen to the Popper and Kuhn Deep Dives and interrupt to argue for Kuhn. If you’re a truth-seeker, you re-listen to the Scientific Realism Deep Dive and interrupt to argue for constructive empiricism. It’s uncomfortable, which is the point. Arguing for positions that feel foreign is how you actually understand them.
A final reflection on Day 21 where you re-answer the pre-assessment questions and compare to your Day 1 answers. People are often surprised at how much their thinking has changed. That comparison consolidates the learning and shows you concretely what you’ve gained.

The idea is that passive listening doesn’t create lasting learning. You need retrieval practice, you need to struggle with ideas, you need to apply concepts to real problems. The Learning Journey builds all of that in.

Why This Pairing Works

The essay you just read provides an overview. It’s the map. But maps aren’t the territory.

The notebook lets you explore the territory. Want to understand Kuhn’s paradigm concept more deeply? There’s an entire Stanford Encyclopedia entry on it, plus academic lectures, plus Deep Dives that explore implications. Want to test whether you actually understood falsifiability? There are flashcards and quizzes.

This is what AI-powered learning makes possible. The notebook functions as an interactive tutor that can answer your questions, test your understanding, and adapt to your pace. My role is curation and design: selecting the best sources, structuring the journey, writing prompts that elicit useful outputs. The AI handles the delivery at scale.

I think this model—polished essays paired with explorable knowledge bundles—is going to be an important part of how ideas spread in the coming years. You’re not just reading my conclusions you’re also getting access to my sources and the tools to reach your own.

What’s Free, What’s Paid

This particular essay and notebook are free. Consider it a demonstration of the model, and my contribution to a world that badly needs better tools for thinking about science.

If you want more, paid subscribers get access to additional essay-notebook pairings like one that covers the Dreyfus model of skill acquisition from my last article. If you’re a practitioner or educator thinking about how people learn complex skills, it’s directly relevant.

I’m still figuring out the rhythm. These take real time to curate and design. But my goal is to create a library of these resources for the Eclectic School community and beyond—topics that serious practitioners should understand but that don’t fit neatly into standardized curricula. Philosophy of science. Research methods. Cognitive biases in clinical practice. Statistics literacy. History of medicine. The intellectual foundations of good practice.

What Makes This Different

Let me set expectations.

This offers practical frameworks, not philosophical sophistication. I’m not trying to produce amateur philosophers who can debate the fine points of logical positivism or parse the nuances of structural realism. Professional philosophers would find the treatment here simplified, and they’d be right—I’ve left out enormous amounts of detail and nuance in service of accessibility.

This also differs from conventional “science literacy” courses. I’m not teaching you how to read a paper, interpret statistics, or evaluate study design. Those are valuable skills, but different skills. What I’m offering is more fundamental: frameworks for thinking about what science is, how it works, and why it’s both more trustworthy and more fallible than most people assume.

What makes the notebook approach different from just reading about these ideas is the active engagement. The Learning Journey doesn’t let you passively consume. It tests you. It makes you argue positions you don’t naturally hold. It asks you to apply concepts to real claims from your own field. It spaces out the material so you forget some of it and have to retrieve it again—which, counterintuitively, strengthens memory more than constant review.

This design reflects my conviction, developed over decades of teaching, that understanding and remembering are not the same thing. You can understand something in the moment of reading and have it vanish from your mind by next week. Durable learning requires effort, retrieval, and application. The notebook is designed to make that happen, not just to transmit information.

Conclusion

We started with two useless slogans: “trust the science” and “do your own research.” I hope I’ve convinced you that there’s a third path—The Path Between.

You can’t trust science blindly, because science is a human enterprise that fails in predictable ways. The replication crisis, publication bias, paradigm-bound thinking, institutional capture—all documented features of how science actually works, not conspiracy theories. Understanding why science sometimes fails puts you in a better position to recognize when it’s working well.

You can’t do your own research, because actual expertise takes years and nobody has time to become expert in everything. Forget the fantasy of the informed citizen who evaluates primary sources on every important question. We’re necessarily dependent on the testimony of others. The question is how to evaluate that testimony wisely, how to distinguish reliable expertise from confident assertion, how to know when you should defer and when you should remain skeptical.

But you can learn to think about how science works, why it sometimes fails, and how to calibrate your confidence appropriately. You can develop frameworks that help you ask better questions, spot red flags, and match your beliefs to the actual strength of the evidence. You can become the kind of person who holds beliefs lightly, updates them when evidence warrants, and acknowledges uncertainty without being paralyzed by it.

Philosophy of science gives you that toolkit. Falsifiability helps you spot unfalsifiable nonsense—claims that can explain any outcome, that shift their predictions to match whatever happens. The Duhem-Quine thesis reminds you that evidence is always interpreted through theoretical lenses, that failed predictions don’t automatically tell you what went wrong, and that reasonable people can sometimes disagree about what the data means. Kuhn’s paradigms explain why scientific communities sometimes resist legitimate challenges, why deep disagreements aren’t always resolvable with more data, and why asking “is this a disagreement within a paradigm or between paradigms?” is a useful diagnostic question. Lakatos’s research programs help you evaluate whether a field is progressing or degenerating—whether it’s generating novel confirmed predictions or just explaining away failures. Bayesian thinking clarifies what strong versus weak evidence actually means, why some findings are more convincing than others, and how to update your beliefs proportionally to the strength of new information. And the realism debate encourages appropriate humility about mechanistic claims, reminding you that even when effects are real, the proposed explanations might be wrong.

These tools won’t make you an expert. They won’t give you certainty. But they’ll make you a better thinker—someone who asks good questions, who knows what to look for, who can calibrate confidence to evidence. Someone who can hold uncertainty without either collapsing into credulity or hardening into cynicism.

The Broader Stakes

I think this matters beyond individual decision-making.

We’re living through a crisis of epistemic trust. Institutions that used to command authority—scientific journals, medical associations, public health agencies, universities—have seen their credibility erode. Some of this erosion is undeserved, the product of bad faith attacks and motivated reasoning. But some of it is deserved, the consequence of institutions that overstated their certainty, that confused expertise with authority, that expected deference without earning it.

The response to this crisis matters enormously. One path leads to fragmentation—everyone retreating to their own information bubbles, trusting only sources that confirm their priors, treating disagreement as evidence of the other side’s bad faith. This path is already well-traveled, and it leads nowhere good. When people can’t agree on basic facts, democratic deliberation becomes impossible. When expertise is indistinguishable from opinion, we lose the ability to coordinate around complex challenges like pandemics and climate change.

Another path leads to authoritarianism—demanding that people trust designated authorities whether those authorities have earned it or not, treating skepticism as pathology, enforcing consensus through social pressure rather than persuasion. This path is also well-traveled, and it’s not much better than the first. Authority that demands obedience rather than earning trust eventually loses the trust it demands.

The third path—the hard path—is rebuilding trust on better foundations. This means experts being more honest about uncertainty, more willing to acknowledge what they don’t know, more transparent about the limitations of their methods. It means institutions taking responsibility for their failures rather than circling the wagons. It means cultivating an educated public that can evaluate claims without deferring blindly or rejecting reflexively.

Philosophy of science is a small part of that third path, but I think it’s an important part. It gives people tools for engaging with scientific claims beyond the false binary of naive acceptance and cynical dismissal. It explains why science is trustworthy in general while being fallible in particular cases. It provides a vocabulary for talking about evidence, uncertainty, and rational disagreement.

I’m under no illusions that a 10,000-word essay and a NotebookLM curriculum are going to fix our epistemic crisis. But I do believe that each person who develops better tools for thinking contributes to a healthier intellectual commons. And I believe that the kind of person who seeks out material like this—who wants to understand how science works, who’s willing to engage with difficult ideas, who values intellectual integrity over tribal loyalty—is exactly the kind of person we need more of.

An Invitation

If you’ve read this far, you’re probably that kind of person. So here’s my invitation:

Don’t just read this essay and nod along. Do something with it.

If you’re busy and just want a quick win, open the notebook and listen to one Deep Dive while you’re doing something else. The one on Popper vs. Kuhn is a good starting point. It’s about half an hour, and it’ll give you a framework for thinking about scientific change that you can apply immediately.

If you’re willing to invest more, try the Learning Journey. Yes, it’s three weeks. Yes, it requires actual effort. But at the end of it, you’ll have genuinely internalized these concepts, not just encountered them. You’ll have argued positions against your inclinations and tested your understanding repeatedly. You’ll own this material in a way that passive reading never provides.

And if you find value in this, consider supporting the work. Paid subscriptions fund the time it takes to curate sources, design curricula, and write these essays. They’ll also get you access to future notebooks on topics like skill acquisition, research methods, and the intellectual foundations of clinical practice.

Either way, thanks for reading. In a world that optimizes for engagement over understanding, for hot takes over careful thinking, for group solidarity over intellectual integrity, I appreciate anyone who’s willing to slow down and engage with ideas seriously.

The notebook is available here. Take the Birds Eye View path if you just want interesting ideas. Take the Learning Journey if you want the concepts to stick. Either way, you’ll come out with tools I wish I’d been given a long time ago.

Thomas Easley is a clinical herbalist, author, and educator at the Eclectic School of Herbal Medicine. He thinks about learning probably more than is healthy.

Developing Clinical Thinking - The Theory of Dents

Thomas Easley — Thu, 15 Jan 2026 15:18:24 GMT

Someone asked me recently how I categorize the herbs that other people call adaptogens. It’s a reasonable question—if I’ve abandoned the adaptogen category, what do I use instead?

I’m going to answer that directly. But then I want to talk about something bigger: how we think about herbalism, the stages of learning, and why categorical thinking—while absolutely necessary when you’re starting out—often becomes the very thing that keeps herbalists stuck. Not because categories are wrong, but because nobody told them that categories are training wheels. You need them to start. But at some point you have to take them off.

The Nature of Categories

Some categories carve nature at its joints. Philosophers call these “natural kinds”—they correspond to real discontinuities in the world that exist independently of human interests. Carbon is different from nitrogen. Gold is different from iron. The periodic table is full of natural kinds.

Other categories are what we might call practical kinds—useful heuristic constructs that carve up some domain in ways that serve our purposes. They’re not arbitrary (they have to track something real to be useful), but they don’t correspond to sharp boundaries in nature. They’re tools, not discoveries.

Many medical categories are practical kinds. “Hypertension” isn’t a natural kind—blood pressure exists on a continuum, and any cutoff is a decision point, not a discontinuity in nature. The line 140/90 is a practical kind real enough to be useful, but it doesn’t mark a discontinuity in nature. Someone at 139/89 isn’t fundamentally different from someone at 141/91.

What matters is that practical kinds can be more or less well-constructed. A good practical kind tracks something real, predicts outcomes, and guides intervention. A bad practical kind gives you the feeling of understanding without the predictive power.

“Adaptogen” is a poorly constructed practical kind. It groups together plants that have almost nothing in common except that Soviet scientists studied them during the Cold War and they don’t fit neatly into other categories. Ashwagandha, rhodiola, eleuthero, schisandra, cordyceps—these plants have wildly different chemistry, different physiological effects, different safety profiles. The category implies a shared mechanism (”normalizing stress response”) that doesn’t actually exist. The strongest version of the adaptogen concept is something like: plants that tend to improve stress tolerance, fatigue resistance, or recovery in at least some contexts, often via HPA-axis modulation. That’s not nothing—it’s a real cluster of effects. The problem is it’s still too coarse to guide herb selection safely, because plants in this cluster have nearly opposite qualities and contraindications.

Contrast this with a category like “cholagogue”—herbs that stimulate bile production. This is also a practical kind (there’s no sharp line between “stimulates bile” and “doesn’t stimulate bile”), but it’s well-constructed. The mechanisms vary—bitters work through vagal reflexes, lipotropics support hepatocyte function, direct choleretics like artichoke act on bile production itself—but the clinical outcome is consistent enough. Give someone with sluggish bile flow a cholagogue, and you tend to get improved bile flow and better fat digestion. Even good categories have edge cases, but this one predicts more than it obscures.

With “adaptogens,” the clinical outcome is incoherent. “Normalizes stress response” could mean stimulating (rhodiola), calming (ashwagandha), immunomodulating (cordyceps), or liver-supporting (schisandra). These aren’t interchangeable. The category implies a unified therapeutic effect that doesn’t exist.

The question isn’t whether to use categories. The question is whether your categories are earning their keep.

So to answer the original question. I don’t categorize the “adaptogens” as a group at all. I think about each of those plants individually, in terms of their qualities, actions, and effects—which I’ll explain later in this piece. Ashwagandha and rhodiola have almost nothing in common. Grouping them together obscures exactly the information you need to use them well.

But this raises a deeper issue. The problem isn’t just that “adaptogen” is a bad category. Categorical thinking itself—while essential for learning—becomes an obstacle to clinical development if you don’t eventually move beyond it.

The Seduction of Categories

Categorical thinking is efficiently wrong.

When I say categorical thinking, I mean the kind of reasoning that goes: “This herb is an adaptogen. Adaptogens help with stress. I’m stressed. I’ll take this herb.” Or slightly more sophisticated: “Ashwagandha is a calming adaptogen. Rhodiola is a stimulating adaptogen. I need calming, so I’ll take ashwagandha.”

This is how we all start learning anything complex. Categories give you handles to grab onto. They let you make decisions without understanding the underlying complexity. And for a lot of purposes, that’s exactly what you need.

Categories also work by flattening. They take something complex—a plant with dozens of active compounds, multiple physiological effects, and different impacts depending on who’s taking it—and reduce it to a single label. That label lets you make quick decisions. But it does so by discarding exactly the information you need when the quick decision doesn’t work.

Where Categories Actually Work

Before I tear into categorical thinking too much, let me be clear about the context where it works just fine.

If you’re taking care of yourself and your family—in the long tradition of what my friend Stephany Hoffelt called domestic herbalism—categories are often adequate. You’re working with gentle remedies, the stakes are relatively low, and trial-and-error is a perfectly reasonable approach. Chamomile didn’t help you sleep? Try valerian. That made you groggy? Try passionflower. You’re iterating based on your own experience, and you can afford to iterate because you’re using herbs with wide safety margins on someone you know well.

In this context, “nervines for anxiety” and “adaptogens for stress” are fine starting points. They get you into the right neighborhood. Your body provides the feedback that categories can’t. This isn’t because the stakes are lower—ashwagandha can still aggravate a hyperthyroid family member. It’s because the feedback loop is different. You’re embedded in the person’s life, noticing subtle shifts daily, adjusting in real-time. If your partner gets agitated, you see it at breakfast. That relational proximity does some of the work that clinical skill has to do explicitly. The feedback is continuous rather than delayed by weeks between appointments. When chamomile works for you, you don’t need to understand why it works—you just need to know that it does.

The same goes for mild acute problems. Your kid has an upset stomach? Peppermint or ginger. Either one is likely to help, neither one is going to cause harm, and you don’t need a sophisticated understanding of carminative action versus prokinetic effects to make a good choice.

Categories fail when you need precision. When the gentle remedy didn’t work. When the person has a complex presentation. When they’ve already tried the obvious things. When the stakes go up. When you’re responsible for someone else’s outcome and they’re trusting you to see what they can’t see themselves.

That’s clinical work. And clinical work requires a different kind of thinking.

The Dreyfus Model: How Expertise Actually Develops

In the 1980s, two philosophers named Hubert and Stuart Dreyfus studied how people actually develop expertise—chess players, pilots, nurses, anyone mastering a complex skill. They found that people move through recognizable stages, and that each stage involves a fundamentally different way of thinking and relationship to rules and categories.

Categorical thinking isn’t just one way of thinking among many. It’s a developmental stage. And like all developmental stages, you have to move through it to get beyond it.

Dreyfus Stage One: The Novice

Novices follow rules. They have to—they don’t have anything else. A novice chess player learns “control the center” and “develop your pieces early.” A novice herbalist learns “adaptogens for stress” and “nervines for anxiety.” These rules are context-free. They apply the same way regardless of the situation.

Here’s what novice thinking looks like:

[stress = adaptogen] [anxiety = nervine] [indigestion = bitters] [dryness = demulcent]

Or on the assessment side:

[fatigue + stress = adaptogen deficiency]

Clean categories. Clear boxes. This goes here, that goes there. The novice mind is a filing system—efficient, organized, and completely inadequate for the complexity of real people.

Someone in your family complains of fatigue and poor stress tolerance. You think: “Fatigue plus stress equals adaptogen. Ashwagandha is a well-researched adaptogen. I’ll recommend ashwagandha.”

This isn’t wrong, exactly. It’s just thin. You’ve matched a symptom to a category to an herb. You’ve followed the rule correctly. For domestic practice with gentle herbs, this works fine. Your family member tries it, tells you how it went, you adjust.

The novice stage is necessary. You have to start somewhere. The problem isn’t being a novice—it’s staying one.

Dreyfus Stage Two: The Advanced Beginner

As you gain experience, you start noticing that context matters. The rules don’t always apply. Some situations feel different from others, though you might not be able to articulate exactly how. You’re developing what Dreyfus calls “situational recognition”—the ability to notice when a situation has features that matter, even if you can’t yet say why they matter.

Now the mental structure starts getting more complex:

[stress = adaptogen (unless also low mood which might be depression like I had so maybe mood elevators) (unless overstimulated → calming adaptogen)] [anxiety = nervine (unless exhausted-type anxiety → maybe adaptogen?)] [indigestion = bitters (unless already cold → warming bitters / skip bitters)]

Notice that categorical thinking isn’t limited to how we think about plants. It shapes how we think about conditions too—and often through the lens of our own history. ‘Depression’ is as much a category as ‘adaptogen’—and heterogeneous disorders get the same problematic flattening that herb categories create. Your experience of depression becomes the template for what depression looks like. The person in front of you has fatigue and low mood and loss of interest, so they go in the depression box—which is really your depression box—and the depression box has its standard interventions. But depression isn’t a natural kind any more than adaptogen is. It’s a practical kind that groups together wildly different presentations, etiologies, and trajectories under one label.

Your partner complains of fatigue and poor stress tolerance—similar to what you helped your friend with last month. But something feels different. This person seems... wound up. Anxious. Their fatigue has a wired quality, not a depleted quality. You think: “This might be a situation where stimulating adaptogens would make things worse—I learned that one the hard way. Maybe I should try something more calming first.”

Notice what’s happening: you’re still thinking in categories (”stimulating adaptogens” vs “calming adaptogens”), but you’re starting to recognize that different situations call for different categorical choices. You’re not just following rules; you’re noticing exceptions to rules. Dreyfus calls these context-dependent guidelines maxims. Unlike the context-free rules of the novice (’stress equals adaptogen’), a maxim requires you to have already experienced the situation to interpret it. ‘If the person looks wired, avoid stimulation’ is a maxim. It sounds like a rule, but it’s useless until you’ve seen enough people to recognize what ‘wired’ actually looks like in a clinical context. You can’t look up ‘wired’ in a dictionary; you have to have seen it.

Thinking with maxims is progress. But you’re still fundamentally operating within a categorical framework. You’ve added nuance to which category you apply, but you haven’t questioned the categories themselves.

Both novice and advanced beginner are appropriate stages for domestic herbalism. You’re working with people you know, herbs with wide safety margins, feedback loops that let you adjust. Categories, exceptions and maxims work well enough here. The danger zone is the domestic herbalist who starts doing clinical work with domestic tools—taking responsibility for strangers’ health trajectories while still thinking in categories and maxims.

The Advanced Beginner Wall

Here’s where most herbalists stop.

You can get to advanced beginner through study. You can read books, take classes, memorize herb profiles, learn differential indications. You can accumulate exceptions to rules until you have a fairly sophisticated decision tree. You can talk about advanced concepts. Maybe you’ve been taking classes for decades.

But clinical work—working with people you don’t know intimately, with complex presentations, where you’re responsible for seeing what they can’t see themselves—requires a different kind of thinking. And that different kind of thinking can’t develop just from books, classes, or your own body’s feedback.

Think about it this way: your mind is like a soft surface. Experiences make dents in it. Those dents become the shapes that let you recognize patterns later. But if the only dents you have are from your own body and the handful of people you’ve given herbs to, you only have a handful of dents. The ashwagandha personpattern requires seeing dozens of ashwagandha responsive people before your mind has enough dents to recognize the shape.

I’m going to say this a different way, and I ask that you read this slowly, because this is what took me years to understand and where the whole piece hangs.

Categories are maps. You consult them. You look at the territory—the person in front of you—then look at the map, then decide where you are. The map is separate from you, a tool you use.

Dents aren’t maps. Maps represent territory from outside. Dents are the organismenvironment relationship itself—not an impression left on a passive surface, but the mutual shaping that happens when you and ashwagandha, you and ashwagandha-patternpeople, encounter each other repeatedly. You don’t consult your dents. You are your dents.

Stuart Dreyfus—one of the brothers who created the model—eventually coined a term for these dents. We all know System 1 (fast, instinctual) and System 2 (slow, analytical). Dreyfus proposed System 0. System 0 is not ‘fast reasoning.’ It is instruction that has been physically inscribed into the neural pathways of the brain through experience. It is the literal shaping of the instrument. When you have enough dents, you don’t ‘think’ about the answer; the answer is simply the shape of your mind reacting to the shape of the problem.

The novice has maps. The expert has become territory.

That’s why you can hand someone a map—teach them categories—but you can’t hand someone dents. And it’s why the expert often can’t fully explain what they know. They’re not reading a map they could show you. They’ve been shaped. The knowing is in the shape itself.

Classes convey categorical knowledge—maps. That’s what classes are for—organizing information into teachable units. There’s nothing wrong with this; it’s how you build the scaffolding. But taking a class on pattern recognition isn’t learning pattern recognition. You can only develop pattern recognition by exposing yourself to patterns. By making dents. By letting the territory walk through you and you through it.

This means the transition to competence requires specific stimuli that self-study and domestic practice can’t provide:

Observing experts work. Not reading about how experts work. Watching them. Seeing how they conduct intakes, how they follow threads of information, how they formulate assessments. Your mind makes dents from watching that it can’t make from reading.

Working with many different people. Your own body is one data point. Your family is a few more. You need variation—different constitutions, different presentations, different responses—to develop the pattern recognition that clinical work requires.

Getting feedback. Having someone more experienced say “you missed something there” or “here are three other possibilities.” This calibrates your pattern recognition against reality.

Without these specific stimuli, you can take every workshop and read every book and your pattern recognition won’t develop. You’ll have more maps, more detailed maps, more exceptions annotated on your maps. But you won’t make the transition to actually being shaped by the territory.

Dreyfus Stage Three: Competence

The competent herbalist sees broader patterns and makes conscious choices. They can prioritize among competing considerations. They engage in deliberate analysis and feel genuinely responsible for outcomes in a new way—because they’re making real choices, not just following rules.

The mental structure is getting messier now—still structured, but the branches multiply:

[ FATIGUE | ANXIETY | COLD ] → [ MATCH: Ashwagandha ] → [ STOP: Thyroid Stimulating? ] → [ STOP: Serotonergic / SSRI? ] → [ AMBIGUITY: Palpitations == Warming? OR Anxiety? OR Thyroid? ] → [ RECALL: Hyperthyroid Case (Negative Outcome) ] → [ PLAN: Verify Thyroid Status First ]

Notice how much machinery this requires. The competent mind is working hard.

A client presents with fatigue, anxiety, and poor stress tolerance. You notice: runs cold, poor sleep, feels ungrounded and scattered, history of prolonged stress, tends toward obsessive thinking. You think: “This person needs warming, grounding, something that supports sleep. Ashwagandha fits that pattern—but wait, they also mentioned heart palpitations and feeling jittery sometimes. I need to ask more about that. Could be anxiety, could be thyroid, could be the palpitations are unrelated. If it’s thyroid and they’re hyperthyroid, ashwagandha’s thyroid stimulation could be a problem. Let me ask about thyroid history before deciding.”

The competent herbalist is doing real clinical thinking. They’re weighing multiple factors, making judgment calls, feeling the weight of being wrong. This is progress. But they’re still reasoning about categories and rules, even as those categories and rules get more complex and context-dependent. The thinking is still sequential—if this, then that; but what about this other thing; okay, but then consider this. Categories, exceptions, context that shapes the exceptions, all swirling around but still being consciously processed.

For some clinical tasks, this is exactly the right level. There are domains where systematic approaches outperform expert intuition—rare presentations, cognitive bias traps, anything where the base rate is low and the cost of missing something is high. Checklists beat experts at ‘did you rule out X.’ But ‘what intervention fits this personpattern’ isn’t a checklist question. You can’t algorithimize resonance. The sequential checking of competence is genuinely valuable—and it’s also not the destination.

Dreyfus Stage Four: Proficiency

At the proficient stage, something shifts. Situations start presenting themselves as wholes rather than as collections of features you have to consciously analyze. You walk into a room and something about the person in front of you suggests a direction before you’ve consciously thought it through.

The mental structure is compressing—the categories are dissolving into patterns:

[ Cold-Ungrounded-Depleted-Scattered—that quality of fatigue where they just look like they’ve never slept—Obsessive-quality-thoughts-get-trapped—she keeps ruminating—pale-weak-thinning-eyebrows—she hasn’t mentioned thyroid but I should ask because feels like match to ashwagandha—Warming-Grounding-Moistening-Settling—the cold anemic woman who slept again—Calms-the-mind-ruts—that five hour drive with fresh dug ashwaganda where I felt like I’d sink into the road I was so grounded—builds-blood-thyroid-stimulating-check-TSH ]

The proficient herbalist sits with a new client. Before the client has finished describing their situation, something clicks. The herbalist doesn’t think “fatigue plus cold plus ungrounded equals ashwagandha.” They just... feel an ashwagandha patternperson. They still deliberate about dosing, about whether to combine it with other herbs, about whether to ask about thyroid first. But they no longer deliberate about what’s relevant. The relevant features just show up.

This is a qualitatively different kind of cognition. The proficient herbalist isn’t applying categories faster—they’re recognizing patterns directly. Categories have become transparent; the herbalist sees through them to the underlying reality they were trying to track.

You can only get here by making a lot of dents. By seeing the ashwagandha patternperson so many times that your mind has a deep groove for that shape. There’s no shortcut.

Dreyfus Stage Five: Expertise

The expert doesn’t think in categories at all. Or rather—they think in categories when it’s useful, but the categories have become malleable. Something to play with, smash together with other concepts, compress or stretch as the situation requires.

For a novice, “warming” is a box. You learn what goes in it. Ashwagandha: warming. Ginger: warming. The box has edges.

For an expert, “warming” is more like... a texture? A tendency? Something you can stretch thin across a formula or concentrate in one plant. You can dial it up or down. You can offset it with something cooling elsewhere. The category hasn’t disappeared—it’s become a tool you can manipulate rather than a box you sort things into.

When I think about ashwagandha now, I don’t think “nervine tonic” or “adaptogen.” What I have in my mind is more like:

[warminggroundingthyroid-stimulatingserotonergicnervytonic*—thatfivehourdrivewithfiftypoundsoffreshlydugrootfeltsogroundedIwasgoingtosinkthroughthedriverseat*smelledsomuchlikedirtandsomethingsweet—thecoldanemic-lookingwomanwhosleptfortenyearsagainafterthreemonthsshecriedinthefollowupTSHGTGtheobsessiverutsofthoughttheygetcaughtinpalenailbedsdarkundereyesrunningonfumes*thatonetimeIgaveittosomeonehotterthantheyletonearlyandshefeltagitatedforaweekandIlearned.....feelsmatchescantnameitsometimeintonemaybeherdaughterwhocamebackyearslaterwiththesamepatterngeneticsmaybeorjustfamiliesmysassygirldiedthatweekandIrememberthemomwhosleptsodeeptheyfeltlikemotherearthembracedtheminoldgrowthdirtrenewalrootednessandwhatholdsustotheearthandwhyweneedthat*wintermorningprocessingrootsmyhandssmelledlikeitfordaysphyllisasayingoncethatashwagandhaisbetterforpeoplewhocantletgothantensepeopleandthatchangedeverythingthewomaninfrontofmerightnowhershouldersthewayherbodysaysexhaustedbuthereyessaywired**maybethyroidmaybe—no—thisfeelsrightlisteningquietwhatremainstobemadewholebutthisisastart]

That isn’t a compressed list of associations. It’s one gestalt. One bodymindplant relationshipunderstanding that you thinkfeel through when you encounter a personpattern and sense the appropriateness—or inappropriateness—of this plant for this person. You can’t separate it into categories because it doesn’t live as categories. It lives as a unified way of knowing that includes your body’s experience of the plant, every person you’ve given it to and what happened, the theoretical knowledge underneath, and something harder to name about how all of that feels when it fits.

First Categories. Then the embodied experience that you can’t fully articulate.Then exceptions. Then context that shifts everything. Then memorable cases that break the rules in ways that teach you something. Eventually it all becomes one thing—not swirling anymore, but settled into a shape. And when a personpattern walks into your practice, that plantpattern shape either resonates with them or it doesn’t. You thinkfeel the fit.

Case formulation and herbal formulation follow this same process. You thinkfeel through what’s missing in the intervention and can reasonably be added. What’s excess and can be tempered. What plantpatterns address which aspects of the personpattern. The formula emerges not from rules about combining categories but from sensing what the picture needs for wholeness, for balance.

To be clear, the expert isn’t allergic to categories. They simply keep them in their back pocket. When the gestalt fails—when a case is weird, or the intuition says ‘something is off’ but no pattern emerges—the expert deliberately downshifts. They ‘break the glass’ and return to the analytic, categorical thinking of the Competent stage to double-check their work. Expertise isn’t abandoning logic; it’s knowing when to transcend it and when to return to it.

A necessary caution: Advanced beginners can convince themselves that this gestalt is what they’re experiencing. They feel something that presents as intuition—a plant dream, a strong sense, an immediate knowing. But it’s false confidence parading as intuitive gestalt. Feels with few dents is illusion.

The difference between actual pattern recognition and premature certainty is the dents. The expert who “just knows” has seen this pattern hundreds of times. The advanced beginner who “just knows” has seen it twice and read about it once. Both experiences feel like intuition from the inside. Only one of them is.

The expert gestalt is non-ergodic. It’s path-dependent. It forms differently depending on which experiences you had, in what order, and how you processed them. Too many failures you didn’t understand, too many dents that didn’t get explained—and the swirl becomes overwhelming rather than settling into shape. The gestalt gets noisy. You start second-guessing patterns that are actually reliable because you can’t distinguish signal from noise in your own experience.

My personal method of gestalt verification is to track outcomes prospectively rather than remembering them retrospectively. After consultations, I share my expectations for the case with my practice partner, Shana. We discuss it after rechecks. I also seek feedback from practitioners trained in different lineages than mine to reduce the risk of lineage bias. Most importantly, I try to notice when my patterns fail, and let the failures reshape the gestalt rather than explaining them away.

This work, or something like it, is required because the gestalt isn’t self-validating. It has to keep being tested against bodies that don’t know what I expect. When the pale, obsessive, depleted woman takes ashwagandha and sleeps for the first time in years—and she had no idea that’s the pattern I saw, no idea why I chose that plant—that’s the pattern meeting reality.

But I hold it loosely. I’ve been wrong enough times to know the feeling of being wrong often arrives late, if it arrives at all.

These complexities are why the transition to competence requires external feedback. Your own felt sense can’t tell you whether your felt sense is trustworthy. You need someone with more dents to say “you’re seeing something real” or “you’re pattern-matching to noise.” Without that calibration, confidence grows faster than competence.

I’ve been telling you what doesn’t work. Now the practical question: what do you actually do instead?

What Replaces Categorical Thinking: The Three Dimensions

So if categories are scaffolding, what’s the structure you’re building toward?

When I teach, I ask students to think about herbs along three dimensions: qualities, actions, and effects. These aren’t categories—they’re dimensions. And that distinction matters.

A category asks: “What box does this belong in?” A dimension asks: “Where does this fall along a continuum?”

When you ask “Is ashwagandha an adaptogen?”, you’re asking a categorical question. The answer is yes or no (or maybe “sort of,” which really means the category isn’t well-constructed).

When you ask “How warming is ashwagandha?”, you’re asking a dimensional question. The answer is “moderately warming”—more warming than chamomile, less warming than ginger, about the same as cinnamon. That answer locates ashwagandha in relationship to other herbs along a continuum.

The dimensional framework is still a human construct—we chose to track temperature, moisture, tension. These aren’t the only ways to organize perception; they’re the ways that have proven clinically useful. But unlike categorical boxes, dimensions preserve gradation. They don’t flatten ashwagandha into ‘adaptogen’ or rhodiola into ‘stimulating adaptogen.’ They keep the information you need to make distinctions. Dimensional thinking is harder than categorical thinking because it requires you to hold multiple relationships in mind rather than just labels. But it’s also more accurate, because the underlying reality is dimensional.

Qualities: What You Can Directly Perceive

Qualities are what you can feel when you take an herb. The warming of ginger, the cooling of peppermint, the moistening of marshmallow, the drying of sage. These affect how people feel in real time. When you drink ginger tea, you feel warmer. That’s not a metaphor—your subjective experience of temperature actually shifts.

Qualities matter for two reasons.

First, sometimes shifting someone’s felt sense is exactly what they need. A person who feels cold and contracted might benefit from warming, relaxing herbs regardless of what else those herbs do. The quality itself is therapeutic.

Second—and this is important—you should try to never make someone’s existing state worse. If someone already feels super hot, dry and inflamed, you don’t give them ginger regardless of how good of an anti-inflammatory it is. This is basic safety, and it requires attending to qualities.

Qualities exist on continua. Temperature: cooling to warming. Moisture: drying to moistening. Density: lightening/dispersing to grounding/consolidating. Tension: relaxing to stimulating/toning.

Every herb has a profile across these dimensions. Ashwagandha is moderately warming, somewhat moistening in a fat extract, drying in infusion or tincture, strongly grounding, and mildly relaxing. Rhodiola is moderately cooling, strongly drying, lightening/dispersing, and stimulating. These profiles are nearly opposite—yet both get lumped into “adaptogens.”

Actions: What Herbs Do to Tissues Over Time

Actions are what herbs do to tissues and organs with repeated use. Cholagogues stimulate bile production. Galactagogues support breast milk. Carminatives reduce intestinal gas. Antispasmodics relax smooth muscle. Diuretics increase urine output.

You might not feel actions the first time you take an herb. But with repeated use, the effects become apparent. Actions are more predictable across people than qualities—most people who take a cholagogue will produce more bile, though how that feels will vary.

Actions also exist on dimensions, though they’re often described categorically for convenience. The value of thinking dimensionally about actions is that it lets you be precise about degree. Chamomile is mildly antispasmodic. Cramp bark is strongly antispasmodic. Knowing where each herb falls on this continuum helps you match intervention to severity.

Effects: How Herbs Interact with Disease Processes

Effects are how herbs interact with disease processes at the cellular and molecular level. Anti-inflammatory, antimicrobial, antifungal, immunomodulating, hepatoprotective. These often operate independently of qualities and actions.

A cooling herb might have anti-inflammatory effects, or it might not. A warming herb might be antimicrobial, or it might not. You can’t predict effects from qualities, and you can’t always predict them from actions either.

This is where modern research becomes useful. We can measure anti-inflammatory effects. We can test antimicrobial activity. We can study hepatoprotection. These are empirical questions with empirical answers.

The dimensional aspect here is dose-response. Most effects are dose-dependent—a little boswellia has mild anti-inflammatory effects, a lot has strong effects (and also starts causing GI upset in many people). Understanding where an herb sits on the dose-response curve for a particular effect helps you calibrate your recommendations.

Dimensional Independence

Here’s what categorical thinking misses entirely: these three dimensions can operate independently of each other.

When you call something an “adaptogen,” you’re implying it has a single unified property that operates the same way across all three dimensions. You’re implying that its qualities, actions, and effects all align toward “stress adaptation.” But plants don’t work like that.

Ashwagandha demonstrates this clearly:

Qualities: Warming, drying to moistening, grounding, mildly relaxing. These qualities make it appropriate for people who run cold and feel scattered—and inappropriate for people who run hot or feel agitated.

Actions: anxiolytic, nervine tonic. These actions explain its primary benefits (better sleep, less anxiety)

Effects: Thyroid-stimulating, serotonergic, possibly neuroprotective. These effects are largely independent of the qualities and actions and point towards its problems (overstimulation in hyperthyroid individuals, tolerance and withdrawal in a subset of users, and rare but clinically important destabilization—up to mania or psychosis—in vulnerable people).

The category “calming adaptogen” captures almost none of this. It flattens the warming quality that makes ashwagandha wrong for some people. It obscures the thyroid stimulation that explains why some thyroid folks paradoxically feel agitated. It implies a coherent mechanism (”calming stress response”) that doesn’t actually describe what the plant does.

Dimensional thinking is a powerful tool for organizing complexity, but it is still a form of analysis. It is the primary tool of the Competent practitioner. It forces you to stop filing and start measuring. But the Expert eventually transcends even this. They don’t consciously plot the client on X, Y, and Z axes before choosing an intervention. They perceive the shape of the need directly. Dimensions are the ladder you climb to get to that view; do not mistake them for the view itself.

Thinking in Patterns

Over time, herbalists develop an understanding of the pattern of qualities, actions, and effects that each plant has. And this is the key shift: plants resist being understood through single categories because each plant has a pattern. Clinical thinking means learning to see these patterns and match them to the patterns you see in people.

When I think about ashwagandha now, I don’t think “nervine tonic” or “adaptogen.” I think: this is the herb for someone who feels cold and depleted, often in the pelvis, maybe anemic, but who is also ungrounded—spacey, head in the clouds, could use some anchoring. This pattern often arises from poor sleep and prolonged stress. The person might be a little obsessive, stuck in thought ruts, unable to let things go. They might have dark circles under their eyes, pale nail beds, a tendency to startle easily.

That’s not a category. That’s a pattern—a picture of a person that the herb fits. And when someone walks into my practice who matches that picture, ashwagandha suggests itself. Not because I’ve matched a category to a symptom, but because I’ve recognized a pattern.

The pattern is multidimensional. It includes qualities the person manifests (cold, dry, scattered), actions they need (thyroid support, better sleep, less anxiety), and effects that would help their situation (maybe serotonergic, maybe neuroprotective). The herb’s pattern and the person’s pattern interlock.

This is what clinical expertise looks like. Not knowing more categories, but seeing patterns directly.

The Swirl and the Untangling

Let me try to make visible what this actually feels like from the inside.

When a person sits in front of you, they present as a whole. They’re not a checklist of symptoms—they’re a living complexity. Their words and their body tell slightly different stories. Their chief complaint might be fatigue, but you notice their jaw is clenched and their shoulders are up around their ears. They say they’re sleeping fine, but their eyes have that hollow, depleted look. They mention they’ve been stressed at work, but the way they say it suggests they’ve been stressed for years, not weeks.

All of this is information. And at first, it’s just a swirl. Too much to track, too much to hold, too much to make sense of.

Categorical thinking is one way to handle the swirl: grab onto something recognizable. “Stress and fatigue—that’s an adaptogen situation.” The category simplifies the complexity enough to act on it. This works sometimes. And when it doesn’t work, you grab a different category.

Dimensional thinking handles the swirl differently. Instead of reaching for a category, you start tracking along dimensions. How does this person feel—warm or cold? Moist or dry? Tense or depleted? You’re not trying to categorize them; you’re trying to locate them in a multidimensional space.

As you track, patterns start to emerge. This person is cold, dry, tense, and scattered—that’s a recognizable configuration. It’s not a category (there’s no name for it), but it’s a pattern you’ve seen before. Certain herbs fit this pattern. Others don’t.

Then you cross-reference. What actions does this person need? Better sleep, yes. Less anxiety, yes. But also—looking at their pallor and their tongue—maybe some blood-building, some digestive support. What effects might help? Given their inflammatory markers, is something anti-inflammatory warranted or is health building sufficient?

Now you have a three-dimensional picture. You’re looking for herbs whose pattern of qualities, actions, and effects matches this person’s pattern of needs across all three dimensions.

And when you’ve done this enough times, it stops feeling like analysis. The pattern just presents itself. You see the person and you see the herbs that fit. The swirl untangles itself.

This is what happens when you’ve made enough dents that the shapes become recognizable. The categories dissolve because you no longer need them. You’re seeing directly.

Everything I’ve said so far describes what expertise looks like. But how do you actually get there?

Making the Transition

If you’re practicing domestic herbalism—taking care of yourself and your family with gentle remedies—categorical thinking is fine. Keep doing what you’re doing. The herbs are gentle, the stakes are low, and your body provides the feedback that categories can’t.

If you want to develop clinical thinking, you need to understand what actually builds it. The answer isn’t more studying, though study has its place. The answer is making dents—accumulating experiences that shape your perception into patterns you can later recognize. But not all experiences make dents equally, and some things that feel like learning aren’t.

The Foundation: Embodied Experience

There’s a chicken-and-egg quality to how expertise develops. You need some categorical framework to even know what to pay attention to—it’s hard do a blind tasting and describe your bodily responses if you don’t have enough words for what you’re sensing, and you probably wouldn’t taste an unfamiliar plant without first knowing it’s safe. So categories come first in some sense. But categories without embodied experience are empty containers. They give you labels without referents.

This is why I teach qualities before actions and effects, and why I have students do blind tastings early. The qualities—warming, cooling, moistening, drying, relaxing, stimulating—are names for poles along dimensional continua. They're still practical constructs; we chose these dimensions because they've proven clinically useful. But unlike categorical boxes, these words point you toward your own body. They train perception rather than replacing it.

The embodied experience of taking herbs yourself is where everything starts. Not reading about what chamomile does, but drinking chamomile tea and noticing what happens in your body over the next hour. Not memorizing that ashwagandha is “warming and grounding,” but taking it for two weeks and discovering what warming and grounding actually feel like from the inside.

This experience deepens through variation. Taking the plant in different preparations—tea versus tincture versus capsule—teaches you how extraction method changes the experience. Taking it at different doses teaches you where the thresholds are. Taking it for different lengths of time teaches you what’s immediate versus what accumulates. Growing the plant, if you can, adds another dimension entirely. Even reading non-categorical plant narratives—writing that describes plants as complex individuals rather than filing them into therapeutic boxes—can extend your sense of what a plant is, though I’m not sure this makes dents in the same way direct experience does.

The point is that embodied experience gives you something to hang categories on. When you later learn that ashwagandha is “thyroid-stimulating” and “anxiolytic,” those words connect to something you’ve felt. Categories become descriptions of experience rather than substitutes for it.

It Takes Time and Volume

You probably edge into competence—meaning safe enough to work unsupervised, with still plenty of room to grow—after somewhere around 400 to 500 hours of clinical experience (roughly the experience level required for Registered Herbalist status with the American Herbalists Guild). But that number only means something if the hours include the right kind of feedback.

Clinical hours without feedback are just repetition. You might be repeating the same mistakes, reinforcing the same blind spots, building confidence without building accuracy. The problem is that outcomes in herbal practice are ambiguous. When someone improves, it might be your intervention. It might also be the natural course of their condition, or the Hawthorne effect, or something else they changed that they didn’t mention, or simple regression to the mean. When someone doesn’t improve, the same ambiguity applies. Without external feedback, you’ll systematically misattribute outcomes in ways that feel like learning but aren’t.

This is why mentor feedback matters. A mentor sees what you’re not looking for. They catch the attribution errors you’re making before those errors calcify into false confidence. They ask “why did you reach for that?” in ways that force you to articulate reasoning you didn’t know you had. Watching an expert work is valuable; having an expert watch you work and push back on your thinking is more valuable.

Follow-up appointments with clients provide a different kind of feedback—outcome data rather than process correction. You need both. The follow-ups tell you whether your interventions are working; the mentor helps you understand why they’re working or not working, and whether your explanations are accurate or just plausible-sounding stories.

So when I say 400 to 500 clinical hours, I mean hours that include both: feedback from follow-ups that lets you track outcomes, and feedback from mentors that critique your reasoning process. Hours without this dual feedback still count for something, but they count for less than you think.

Thoughts On Mentoring

The job of a good mentor is to help shape the forming gestalt. To affirm the dents that actually apply and explain why. To say “yes, that pattern you’re noticing is real—here’s what’s underneath it” or “no, that was a coincidence, don’t build on it.” And to soothe the pain of dents that hurt—the failures, the times you got it wrong—with the understanding of shared lessonsexperience. “I made that mistake too. Here’s what it taught me. Here’s how it fits.”

The mentor’s gestalt resonates with yours. Their settled shape helps yours settle. Not by giving you their patterns—you have to form your own—but by providing the relational container in which pattern formation happens cleanly rather than chaotically.

This is what you can’t convey in a class. Not because teachers are holding out on you—because the knowledge itself resists being organized into teachable units. The gestalt can only form through dents, and dents can only form through experience. But whether those dents form signal or noise depends on whether someone helped you make sense of them.

Given this responsibility, the person mentoring you should be substantially further along the developmental path than competent. Competence means you’re safe to practice independently—you’ve developed enough pattern recognition to avoid major errors and enough self-awareness to know when you’re out of your depth. It doesn’t mean you understand your own clinical thinking well enough to teach it.

Proficiency takes longer. If competence begins around 400 to 500 clinical hours, proficiency probably requires something like 1,000 to 2,000 hours—a couple of years of full-time clinical practice after you’ve reached competence. This is when you start to understand what you actually know and think, and how that’s different from what you were taught. Before proficiency, you’re still working within frameworks you inherited. At proficiency, you’ve had enough cases surprise you, enough predictions fail, enough exceptions accumulate, that your clinical understanding has genuinely become your own.

Expertise takes longer still. The commonly cited figure of 10,000 hours—roughly a decade of full-time clinical practice, constituting thousands of individual appointments and rechecks—is probably in the right neighborhood. At expertise, pattern recognition is largely automatic. You’re not applying frameworks; you’re seeing directly. You’ve encountered enough variation that new presentations register as variations on patterns you already carry rather than as novel problems requiring conscious analysis.

This matters because mentorship from someone who’s merely competent can actually impede development. I’ll say this plainly: competent practitioners shouldn’t be teaching clinical herbalism. There’s a difference between being ready to practice and being ready to teach clinical practice. Around the 400–500 hour mark, a student can often become “safe enough” to begin working independently in a limited scope—especially with conservative herbs, good intake habits, and follow-up. But teaching clinical herbalism is a different responsibility. When you teach “this herb for this presentation,” you aren’t just helping one person. You’re creating a replicable move that potentially dozens of students will carry into hundreds of clients. That multiplies your blind spots into other people’s outcomes. At that stage, most people don’t have enough dents yet—not enough pattern repetition, not enough failures, not enough edge cases—to reliably teach pattern-specific recommendations overgeneralizing from a small clinical world. This is exactly how advanced-beginner thinking spreads: it gets taught as if it were clinical reasoning.

That doesn’t mean early clinicians have nothing valuable to teach. They can be excellent teachers of medicine making, botany, safety, foundations, and general health-building. But pattern-specifics—especially for complex presentations—should have a higher bar, because the cost of premature certainty is paid by the people we haven’t met yet.

A few years of full-time practice after reaching competence tends to move you toward proficiency—and proficiency brings something competence usually lacks: a lived awareness of your own edges. You’ve been surprised enough times, wrong enough times, that you can feel where your patterns don’t reliably hold. That self-awareness protects students. You can say: “I’m teaching you this because it works often—here’s where I’ve seen it break.” That’s a fundamentally different kind of teaching than presenting a framework as if it were complete.

This creates a real bottleneck. There aren’t enough proficient and expert practitioners to mentor everyone who wants to learn clinical herbalism. That’s a problem. But the solution isn’t to lower the bar and call it “access.” The solution is to admit the constraint and build systems that protect the public while practitioners develop. Better to learn slowly from someone who knows their limits than quickly from someone who can’t yet see them.

Productive Struggle

Not all difficulty is productive. You can be confused for years without developing expertise if the confusion doesn’t drive curiosity. Productive struggle is the kind that makes you want to understand, that creates a tension between what you expected and what happened, that won’t let you rest until you’ve figured something out.

Some experiences reliably create productive struggle:

The case that almost fits a category but not quite. These teach more than cases that clearly don’t fit, because they force you to articulate what the category is actually tracking. When someone presents as “nervine territory” but something feels off and you can’t say what, that dissonance is productive. The work is learning to name what you’re sensing.

The herb that works when it shouldn’t, or fails when it should work. Categorical thinking predicts certain outcomes. When predictions fail, you can dismiss the failure as an anomaly, or you can let it make a dent. The second choice requires revising your mental model rather than protecting it, which is harder and more valuable.

The follow-up that surprises you in either direction. Unexpected improvement teaches you something; unexpected failure teaches you something different. Both are dents. But you have to be tracking predictions to notice when they’re violated—which means you have to make your predictions explicit rather than letting them remain vague intuitions that can be retrofitted to any outcome.

The expert who disagrees with your reasoning. Not just watching experts work, but having them push back. “Why did you reach for that?” is a different kind of learning than “watch what I do.” It forces you to articulate your implicit reasoning, which is often where the categorical shortcuts are hiding.

The case you got wrong and had to revisit. These are painful but disproportionately instructive. A case where you were confident and wrong teaches humility about your own pattern recognition. A case where you were uncertain and wrong teaches you what uncertainty feels like so you can recognize it next time.

Intermediate Practices

If you’re still working primarily within categories—and most people are for years—there are practices that build toward dimensional thinking without requiring you to abandon categories entirely.

Every time you reach for a category, note three things about this person that don’t fit the category. This is harder than it sounds. When someone walks in with anxiety and you think “nervine,” your mind wants to stop there. Making yourself articulate what’s different about this person—what doesn’t fit the nervine picture—trains you to see individuals rather than instances of categories.

Track your predictions explicitly. Before a follow-up appointment, write down what you expect to happen and why. When the outcome differs from your prediction, you have a record of what your mental model got wrong. This is how you catch your own attribution errors before a mentor has to point them out. It’s also how you build calibrated confidence—learning not just whether you’re right, but how often you’re right when you feel certain versus when you feel uncertain.

Practice dimensional description without category words. Take someone you’re working with and describe their presentation using only qualities, actions they need, and effects that might help. No category labels allowed—not “anxious,” not “depleted,” not “liver stagnation.” This forces you to actually look at what’s in front of you rather than pattern-matching to a label.

Compare herbs within the same category. Take two herbs you’d put in the same box—two “nervines,” two “adaptogens,” two “carminatives”—and list every way they’re different. Qualities, actions, effects, contraindications, the kind of person each one fits. This trains you to see through categories rather than stopping at them. If you can articulate why chamomile and valerian are different despite both being “nervines,” you’re already doing dimensional thinking.

Steelman the alternative. When you choose one herb or approach, articulate why a different choice might also have been right. This prevents premature closure and keeps you holding multiple possibilities, which is what dimensional thinking actually requires. It also protects against the confirmation bias that makes you remember your successes and forget your failures. Dreyfus calls this ‘deliberate rationality.’ It is the necessary check on intuition. Because expert pattern recognition feels like immediate perception, it can be seductive. Forcing yourself to rationally construct the alternative argument is how you verify if you are reacting to a genuine pattern or just your own bias.

Retrospective case analysis with a specific question: what did I notice that I didn’t act on? Often you’re sensing something that doesn’t fit your categorical framework, but you don’t have permission to trust it yet. Looking back at cases where your gut was right but you overrode it builds confidence in pattern recognition. Looking back at cases where your gut was wrong keeps you humble.

None of these practices require abandoning categories. They just prevent categories from becoming the ceiling of your development. You’re still using the training wheels, but you’re also starting to feel what balance is like.

Conclusion: Trusting the Dissonance

The transition from domestic to clinical herbalism is really the transition from categorical thinking to pattern recognition. It’s the journey from novice to expert. And concepts like “adaptogen”—which dress up categorical thinking in scientific clothing—actively prevent that journey. They make you feel like you’ve arrived when you’ve barely started.

Categories. Then embodied experience. Then exceptions. Then context that shifts everything. Then memorable cases that break the rules. Eventually it settles into something that isn’t categories anymore—a bodymindplant relationshipunderstanding you thinkfeel through.

That’s what clinical thinking looks like:

[shefeelscoldbutnottheusualcoldwarminggroundinglikethatfivehourdrivesinkingintotheseathershoulderssaysomethingaboutnotlettinggocantnameitstevensaidthatoncecantletgopeoplenottensepeoplepalenailbedsbuildsbloodthatwomanwhosleptfortenyearshereyessaywiredbutherposturesaysexhausteddepletedandwoundupIknowthispatternfromsomewherethyroidmaybebutnoashwagandhasuggestsitselfquietlisteningforthewhole]

—except it isn’t a list. It’s one thinkfeeling. The personpattern in front of you resonates (or doesn’t) with the plantpatterns you carry. When it fits, you know. When it doesn’t, you keep looking.

You can't get there by studying. You can only get there by making dents. By seeing people. By being wrong and learning from it. By watching experts and absorbing how they move through complexity. By letting someone with more dents help you make sense of yours.

The categories were never the point. The categories were training wheels. At some point, you have to take them off and actually learn to ride.

-Thomas Easley, Registered Herbalist (AHG)

Eclectic School of Herbal Medicine

Adaptogens Are Stimulants

Thomas Easley — Mon, 12 Jan 2026 17:55:30 GMT

After writing The Adaptogen Problem, my feeds shifted. Google and Instagram started pushing ashwagandha gummies and shilajit (shilajit to quit). But ResearchGate and Semantic Scholar, bless their algorithmic hearts, started serving me adaptogen research papers, day after day. Enter a 2005 paper by Alexander Panossian, which I had never read before, titled “Stimulating effect of adaptogens: an overview with particular reference to their efficacy following single dose administration.”

As I mentioned in the original article, Panossian is the most prolific “adaptogen” “researcher” alive. If anyone should be defending the concept, it’s him.

So what does his paper say?

The active compounds in Rhodiola, Schisandra, and Eleutherococcus are “phenylpropane and phenylethane derivatives” that are “structurally related to the catecholamines.” The single-dose effects work through the sympatho-adrenal system - the acute stress response pathway, same as other stimulants. Schisandra specifically is described as “evidently, a mild stimulant” based on correlation analysis showing it increases sympathetic tone, activates the adrenal cortex, and intensifies metabolic processes.

The research subjects referenced throughout the paper? Sailors on watch duty. Soldiers on 20km ski marathons in -28°C weather. Cosmonauts in isolation. Sprinters. Radio operators. The entire research program was built around pushing through fatigue, enhancing performance under stress, extending working capacity.

This was clearly stimulant research with different branding.

The paper includes a table (Table 2) comparing stimulants to adaptogens. The claimed differences - stimulants cause energy depletion, adaptogens don’t. Stimulants cause insomnia, adaptogens don’t. Stimulants have side effects, adaptogens don’t. All claims unsuported in the paper.

The same paper, in its empirical sections, reports that after 2-3 weeks of continuous Schisandra use, subjects developed “sleeplessness, excitability and a low level of general well-being.” It notes these negative effects were “similar to coffee.” It documents that high doses of Eleutherococcus made some subjects “feel sleepy and flabby” with decreased blood pressure - a comedown pattern.

The theoretical definition of adaptogens and the reported data contradict each other within the same document.

This is the problem with the adaptogen concept in miniature. The definition makes claims - non-specific resistance, normalizing effects, no side effects, fundamentally different from stimulants. The data shows catecholaminergic stimulation, sympathetic activation, insomnia, tolerance, and performance enhancement research conducted on soldiers and cosmonauts. The framework says one thing. The pharmacology says another.

Panossian knows what’s in his own paper. He wrote the table claiming adaptogens don’t cause insomnia, and he wrote the section documenting Schisandra causing insomnia. He titled it “Stimulating effect of adaptogens,” while maintaining that these aren’t stimulants. He seems to have had serious financial interest in “adaptogen” companies while conducting “research.”

Grifters gonna grift.

-Thomas

The American College of Gastroenterology Officially Endorses Herbal Medicine for Liver Disease

Thomas Easley — Thu, 08 Jan 2026 19:35:28 GMT

In May 2025, the American College of Gastroenterology published updated clinical guidelines on malnutrition in liver disease. Buried in the recommendations is something that might surprise you: an official endorsement of a hot water botanical extract for the prevention of hepatic fibrosis and hepatocellular carcinoma.

The preparation in question is made from the roasted seeds of a flowering plant in the Rubiaceae family. It contains over a thousand bioactive compounds, including chlorogenic acid and other polyphenols with documented antioxidant and anti-inflammatory properties. The guideline authors acknowledge that the mechanism of action remains unclear, noting that it’s “debated” which constituents are responsible for the hepatoprotective effects. Some studies suggest the primary alkaloid is key; others show benefits even when that alkaloid is removed, pointing toward the polyphenol fraction.

The evidence base? Primarily observational studies and epidemiological data. The recommendation strength? Conditional, based on low quality evidence.

The exact dosing recommendation from the ACG: two or more cups daily.

You’ve probably figured it out by now. The botanical in question is Coffea arabica. The hot water extract is coffee.

The Double Standard

I’m not pointing this out to mock the ACG or to argue that coffee doesn’t have hepatoprotective effects. It probably does. The observational data is fairly consistent, the proposed mechanisms are plausible, and the safety profile after centuries of widespread human use is well-established.

But, if you submitted a guideline recommending Silybum marianum (milk thistle) extract for hepatic fibrosis prevention—with a similar evidence base of observational studies, proposed polyphenol mechanisms, and an even longer history of traditional use specifically for liver conditions—it would be received very differently.

Actually, we don’t have to speculate. The same professional literature that endorses coffee explicitly dismisses milk thistle. The MSD Manual’s entry on alcohol-related liver disease—citing ACG guidelines—states flatly that “antioxidant remedies, such as silymarin (milk thistle) and vitamins A and E, are ineffective.” The American Association for the Study of Liver Diseases concludes that “clinical evidence does not support milk thistle for treatment of chronic liver diseases.”

The regulatory landscape in Europe looks quite different. The European Medicines Agency’s Committee on Herbal Medicinal Products (HMPC) has issued an official monograph recognizing milk thistle for digestive disorders and liver support. The European Scientific Cooperative on Phytotherapy (ESCOP) recommends it for toxic liver damage and as supportive treatment in chronic inflammatory liver conditions and cirrhosis. In several European countries, silymarin products are marketed as registered medicines, not unregulated supplements.

The HMPC’s assessment acknowledged that studies “indicated that milkthistle fruit may have positive effects on liver function and improve symptoms”—but noted that firm conclusions couldn’t be drawn due to study design limitations. Sound familiar? That’s essentially the same situation as coffee: observational signals pointing toward benefit, mechanistic plausibility, but no definitive proof from high-quality trials.

The evidence base for milk thistle and coffee is remarkably similar. Observational studies, proposed antioxidant and anti-inflammatory mechanisms via polyphenol constituents, long histories of human use, and excellent safety profiles. Yet one appears in American gastroenterology guidelines as a conditional recommendation while the other is declared “ineffective” in the same professional literature.

The evidence didn’t change crossing the Atlantic. The regulatory and cultural framework did.

What Makes Something “Medicine”?

The ACG guideline is recommending a specific plant preparation, at a specific dose, for a specific therapeutic outcome. That’s medicine by any functional definition. The fact that you can also buy it at Starbucks doesn’t change what’s actually happening physiologically.

Coffee made it through because it was grandfathered in as a food. If Coffea arabica were discovered today and someone tried to market it as a hepatoprotective botanical supplement—a caffeinated drink with cardiovascular effects, sleep disruption potential, and dependence liability—imagine the response.

Meanwhile, milk thistle sits in a regulatory limbo in the United States, relegated to the supplement aisle despite being marketed as a registered medicine in several European countries. An American hepatologist might tell a patient there’s “no evidence” for milk thistle—or worse, that it’s been proven “ineffective”—while simultaneously recommending coffee based on the same quality of observational data and unclear mechanisms. The irony is thick.

A Different Approach

This isn’t an argument against evidence-based medicine. It’s an argument for applying evidence standards consistently.

What might Medicine look like if we evaluated plants with long histories of relatively safe traditional use by the same standards we apparently apply to coffee? Many of these botanicals are considerably gentler—fewer cardiovascular effects, less impact on sleep architecture, no dependence potential, no jitteriness or anxiety at therapeutic doses.

The Europeans have been grappling with this for decades. Their current framework—while imperfect—at least attempts to systematically evaluate traditional medicines, creating official monographs with recognized indications, dosing guidelines, and safety data. The result is a system where physicians can consider herbal medicines within a regulatory structure, because those medicines have been evaluated through a consistent framework rather than being relegated to an unregulated gray zone.

The herbs that herbalists have used for centuries for liver support weren’t chosen randomly. They were selected through extensive empirical observation across generations—the same process by which humans figured out that coffee made them feel alert, combatted depression and improved stagnant digestive states. Traditional use isn’t proof of efficacy, but it’s a reasonable starting point for investigation. It’s exactly the kind of observational signal that apparently justifies a conditional ACG recommendation when the plant in question is culturally normalized.

I’m not advocating that we abandon evidentiary rigor. But maybe we should stop pretending we’re applying it consistently when we’re actually making cultural judgments dressed up as scientific ones. Maybe it’s time to have an honest conversation about what counts as evidence—and why the answer seems to depend on whether the plant in question comes from a barista or an herbalist.

-Thomas

P.S. This post was fueled by a liter of coffee. #notjustforyourliver

On Medicine

Thomas Easley — Sun, 04 Jan 2026 18:37:19 GMT

The word shows up everywhere now. Food is medicine. Movement is medicine. Sleep is medicine. Nature is medicine. Community is medicine. Music, art, gardening, breathwork, cold plunges, sunshine—medicine.

Something is happening in this linguistic expansion. The word medicine is doing conceptual work that we may not fully recognize, and that work may not serve us.

I want to think through what we actually mean when we call something medicine, what we’re hoping for when we seek it, and whether the word itself has become a barrier to clearer thinking about health and healing.

The Root

“Medicine” comes to us from Latin medicina, derived from mederi—to heal, to cure, to remedy. But the deeper root is more interesting. The Proto-Indo-European med- meant something like “to take appropriate measures.” It’s the root behind words like meditate (to reflect, to consider carefully), and a cluster of terms about moderation and fittingness—mode, modest, moderate.

There’s a useful nuance here: English also has a separate measuring root (the me- family) that gave us “measure” in the sense of quantifying. These roots live next door to each other conceptually—one about discernment and appropriateness, the other about calculation and proportion—and our language inherited both. That pairing matters. Medicine, at its oldest depth, isn’t just about treatments. It’s about discernment. What is fitting here?

This older sense is harder to hear now. When we hear “medicine” today, we tend to think of pills, procedures, prescriptions, hospitals, white coats, insurance claims. Something administered to us—external, targeted, and meant to fix a defined problem. The word often narrows from “appropriate measures” to “therapeutic interventions for pathology.”

That narrowing matters. It shapes what we think healing is, who gets to provide it, and what counts as a legitimate response to suffering.

Four Medicines

The word now carries at least four distinct meanings that blur together in everyday speech:

First: medicine as substance — the pill you swallow, the tincture you take, the injection you receive. “Take your medicine” refers to this concrete, material sense.

Second: medicine as practice and knowledge — the accumulated understanding of how bodies work, what goes wrong, and how to intervene. “She studied medicine” points to this disciplinary sense.

Third: medicine as institution — the vast system of hospitals, insurance companies, professional licensing, pharmaceutical corporations, research universities, regulatory agencies, and clinical protocols that organize healthcare in modern societies. “Medicine has failed these communities” uses the term this way.

Fourth: medicine as metaphor — anything with healing properties or beneficial effects. “Laughter is the best medicine” operates here. It doesn’t mean laughter is literally pharmaceutical; it means laughter helps.

When someone says “food is medicine,” which sense do they mean?

That specific foods function as therapeutic substances?
That nutrition should be part of clinical practice?
That our food system needs integration with healthcare institutions?
Or simply that eating well makes us healthier?

The ambiguity isn’t incidental. It borrows authority from the more concrete senses while operating primarily in the metaphorical sense.

This borrowing has consequences. It can legitimize something important (nutrition deserves serious attention). But it can also confuse (eating vegetables isn’t usually “treating a disease” in the same way insulin treats diabetes). And it often leaves unexamined whether the metaphorical sense actually captures what’s happening when food promotes health.

What We Want

When a person seeks medicine—in any of its senses—what are they actually after?

After sitting with patients wanting more than Medicine has to offer for 25 years, I think the honest answer involves several distinct desires that often interweave

We want relief from suffering. Pain, discomfort, distress, limitation—we want these to diminish or stop. This is the most primal dimension of seeking help.

We want restoration of capacity. Illness takes things from us—energy, function, ability, possibility. We want back what we’ve lost, or we want to build what we never had.

We want understanding. What’s happening to me? Why do I feel this way? Is this serious? What does it mean? The uncertainty of illness is itself a form of suffering.

We want validation. We want acknowledgment that our suffering is real, that we’re not making it up, that our experience deserves attention and response. For people whose pain has been dismissed or minimized, this can matter as much as any intervention.

We want hope and a path forward. Even when cure isn’t possible, we want to know that something can be done, that we’re not trapped. We want options, agency, a sense that our situation isn’t hopeless.

Notice what these desires have in common. They’re fundamentally phenomenological. They’re about lived experience—how it feels to be in this body, what this body can do, how we make sense of what’s happening, whether we feel seen and supported.

What Institutions Provide

The institution of medicine is organized around a different set of goals. I don’t mean this as condemnation—there are good reasons healthcare systems evolved the way they did. But the gap between what people want and what institutions optimize for is real.

Modern healthcare is exceptionally good at identifying and treating disease. A patient presents with symptoms; the clinician tries to determine what disease process might be causing them and chooses an evidence-based intervention. For many acute conditions, infections, injuries, and many specific pathologies, this is life-saving. But it’s organized around pathology more than the phenomenology of suffering or the restoration of human functioning.

It also practices inside courts and ledgers. Every clinical encounter sits inside a legal, regulatory, and reimbursement framework. Documentation, informed consent, standard of care, defensive testing, coding, billing... These shape what can be offered and how. Time spent listening, continuity of relationship, attention to context and meaning—these are harder to bill for and therefore harder to sustain.

And it runs on what can be measured and standardized. Systems measure disease incidence, mortality, complication rates, readmission rates, length of stay. These matter, but they aren’t the same as what patients want. Standardization improves consistency, training, and quality control. But it also abstracts away from the particularity of individual lives—constitution, context, values, experience. Protocols are powerful tools, but they can’t hold the whole person.

The Gap

There’s a substantial gap between what people want when they seek medicine and what institutional medicine is organized to provide. This isn’t because clinicians don’t care. Many care deeply and struggle against systemic constraints. It’s because the institution and the person seeking help have different goals and different categories of concern.

The person wants relief from suffering; the institution is organized around treating disease. These overlap, but they aren’t identical. Disease without suffering and suffering without an identifiable disease are both common, and the gap between them is where a lot of frustration with healthcare lives.

The person wants understanding and validation; the institution is organized around diagnosis and documentation. A diagnosis can offer understanding, but often it doesn’t. It can name without explaining, categorize without meaning. And the time pressure of modern clinical encounters leaves little room for the deeper kind of understanding people often seek.

The person wants to be seen as a whole person in context. The institution is built for standardized treatment of conditions. The same depression protocol whether you’re a new mother in isolation, a teenager facing social threat, or an elderly person grieving multiple losses. Context isn’t irrelevant to institutional medicine, but it isn’t central either.

This gap is why people leave clinical encounters unsatisfied even when they received technically competent care. It’s why people turn to alternative practitioners like me, who often provide more time, more attention, and a broader frame. And it helps explain why patient satisfaction is often only loosely aligned with technical quality—sometimes tracking it, sometimes not, depending on what’s being optimized.

The Expansion

Against this backdrop, the “X is medicine” expansion starts to make sense. It’s an attempt to fill the gap—to claim healing relevance for domains that institutional medicine doesn’t recognize or provide.

When someone says “community is medicine,” they’re pointing to something real. Social connection has measurable effects on health outcomes, and loneliness shows up in physiology, not just mood. And yet, institutional medicine doesn’t prescribe community. There’s no billing code for connection. The healthcare system isn’t structured to provide what might be one of the strongest determinants of health.

So people reach for the word “medicine” to legitimize what they know matters. If community is medicine, then it deserves seriousness, attention, resources—something closer to the weight we give pharmaceuticals and procedures. The word becomes a bid for recognition.

The same logic gets applied to food, movement, sleep, nature, meaning, creative expression. All of these have documented effects on health. Most fall outside what institutional medicine reliably provides. Calling them medicine is a way of saying these matter, these count, these belong in our picture of healing.

There’s something valuable in this move. The reductive biomedical frame that treats disease as purely biological malfunction occurring in isolated bodies has serious limits. Health emerges from the interaction between organism and environment—what we eat, how we move, whether we sleep, our relationships, our sense of meaning, our connection to place and community. Insisting on the health relevance of these domains pushes back against a narrow view where pills and procedures are treated as the only legitimate responses.

But there’s also something problematic in the move.

The Confusion

When we call health-building practices “medicine,” we import a disease-treatment frame into domains that work by cultivation. Pesticide thinking in fertilizer territory.

Medicine, in its institutional sense, is oriented around treating pathology. You have a disease; medicine intervenes. The relationship is therapeutic. Something is wrong, and medicine fixes it.

Food, movement, community, sleep build health through cultivation. Eating well creates adaptive capacity. Exercise develops strength and metabolic flexibility. Community provides relational context in which a nervous system can settle and meaning can be made. None of this works like an antibiotic clearing an infection—and the word ‘medicine’ carries that antibiotic logic with it.

This is the difference between pathogenesis (how disease develops and how we treat it) and salutogenesis (how health is built and sustained). They’re related, but they aren’t the same frame. Pathogenesis starts from disease and asks about causes and cures. Salutogenesis starts from health and asks about sources and cultivation.

When we call everything medicine, we collapse that distinction. We smuggle a pathogenic orientation into domains that are mostly salutogenic. The word carries its disease-treatment connotation into places where it doesn’t quite fit.

This creates subtle distortions.

If food is medicine, then eating becomes a therapeutic intervention—bringing performance pressure, optimization anxiety, and moralizing (“good foods” and “bad foods”) into what could be a more humane relationship with nourishment.

If movement is medicine, then I’m supposed to exercise “for my health” even when what might keep me moving for decades is enjoyment, competence, play, and the simple pleasure of inhabiting a body.

If rest is medicine, then sleep becomes a health behavior to perfect rather than a biological rhythm.

The medicalization of life has costs. It turns basic human activities into interventions requiring expertise. It creates anxiety around doing them correctly. It positions us as patients managing our health rather than people living our lives. It also invites an industry to sell us products and programs for things our ancestors just called living.

And perhaps most subtly, it keeps us inside an institutional frame even as we’re trying to escape it. By reaching for the authority of “medicine” to legitimize what we already value, we implicitly accept that medicine is the arbiter of what matters for health. We’re still asking the institution to validate our experience—just trying to expand what it validates. That may be strategically useful, but it isn’t freedom.

What We Might Say Instead

If medicine has become too narrow and “X is medicine” is both useful and problematic, what vocabulary might serve us better?

I don’t have a perfect answer, but I see some directions worth exploring.

Recover medicine as discernment. If we rehabilitate the older sense—appropriate measures in response to situation—the emphasis shifts from substances and institutions to judgment and fit. What does this situation call for? What would be fitting here? Sometimes the answer is antibiotics. Sometimes it’s rest. Sometimes it’s herbs. Sometimes it’s community. Sometimes it’s a walk outside. The question isn’t “is this medicine?” but “is this appropriate?”

Be more precise about what we’re doing. Building health is not the same as treating disease, and our language can honor that. Cultivation, nourishment, tending, strengthening—these words capture salutogenic practice better than “medicine” does. I’m not treating myself when I eat well; I’m nourishing myself. I’m not medicating when I move; I’m tending my body.

Put lived experience back at the center. Much of what people want when they seek help is relief from suffering, restoration of capacity, understanding, validation, hope. A vocabulary that centers experience rather than pathophysiology may serve the actual goals better: care, attention, presence, accompaniment, witness.

Rebuild the concept of health. Health in a robust sense isn’t the absence of disease. It’s dynamic adaptive capacity: resilience, flexibility, the ability to respond to life’s demands, the felt sense of vitality, the ability to engage with what matters. If we had a richer understanding of health, we might not need to call everything medicine. We could talk plainly about what builds health, what sustains it, what threatens it—without forcing it into a disease-treatment frame.

Name the plural nature of healing. What helps people heal is diverse: biological interventions, psychological support, social connection, meaning, environmental conditions, political realities. Medicine names one important domain, but it isn’t the whole territory. Healing exceeds medicine.

The Invitation

I’m not arguing that we should stop using the word medicine, or that the “X is medicine” formulation is simply wrong. Language shifts to carry the meanings we need it to carry. If calling food medicine helps people take nourishment seriously, that matters.

But it’s worth thinking more carefully about what we’re saying when we say it. The word carries baggage—institutional authority, disease-orientation, expert dependence, optimization pressure—that may not serve our actual goals. And there are other ways of talking about health and healing that may fit better.

The older sense of medicine as “taking appropriate measures” is worth remembering. It puts discernment at the center rather than intervention. It asks what the situation calls for rather than what treatment to apply. It’s humble about expertise and generous about what might help.

What do you actually need right now? Not what intervention, not what protocol. What's called for? Sometimes the answer is medicine. Sometimes it's something else entirely.

-Thomas

P.S. If this way of thinking about health resonates with you—and you want a framework that treats herbs as one tool inside a larger ecology of healing—you’ll probably like the Foundational Herbalism program at Eclectic School of Herbal Medicine.

The Adaptogen Problem

Thomas Easley — Wed, 17 Dec 2025 22:39:11 GMT

The term “adaptogen” is the most overused and least useful term in modern herbalism. You see it everywhere - marketing materials, product labels, blog posts, even in clinical conversations where it actively interferes with good decision-making. The adaptogen concept has confused practice and misdirected people for too long; it is time to put it to bed once and for all.

Clinical clarity matters. Vague, poorly-defined terms that promise everything and differentiate nothing lead to worse decisions for the people we’re trying to help. Over the next 15 pages, I’ll show how the adaptogen concept fails clinically, phenomenologically, definitionally, historically, and evidentially.

The Clinical Problem: A Term That Fails to Differentiate

Almost every other term we use in Western herbalism serves a clear clinical function. These terms help us differentiate what plants do so we can make informed choices.

Take qualities. When I say a plant is cooling, you know I’m not talking about something warming. Moistening means not drying. These perceptible states have immediate therapeutic relevance. You can feel the cooling of peppermint, the warming of ginger, the drying of sage, the moistening of marshmallow. That embodied feedback matters clinically because you can tell whether you’re moving someone’s experience in a helpful direction.

Then we have action terms - cholagogue, galactagogue, diuretic, expectorant, antispasmodic. These describe what herbs do to specific tissues or physiological functions. You can often feel these actions (the relaxation from an antispasmodic, the increased urination from a diuretic) and sometimes measure them directly (bile flow, milk production, urine output). Each term narrows down our choices and helps us match herbs to actual clinical needs.

Finally, effect terms describe impacts on disease processes - antibacterial, anti-inflammatory, antifungal. These identify specific, measurable outcomes on pathology. An antibacterial herb might not be anti-inflammatory. An anti-inflammatory herb might not be antibacterial. The terms tell us something specific.

This three-dimensional system - Qualities, Actions, and Effects - lets us identify herbs that will reliably shift experiential states, support specific organ systems, and in some instances, address disease processes directly. Each term narrows our choices and helps match herbs to real clinical situations.

But then we get to “adaptogen” - a term that doesn’t fit anywhere in this framework.

You can’t perceive it as a quality. It doesn’t specify which tissues or functions are affected. It doesn’t identify a particular disease process being addressed. Instead, some vague, broad ability to “help the body adapt to stress” or “normalize physiological functions” without explaining mechanism or differentiating between plants.

So what does “adaptogen” actually mean clinically? Who gets it? More importantly, who doesn’t? If someone comes to me exhausted and burned out, should I give them an adaptogen? What if they’re anxious and wired? What if they’re depleted and cold versus inflamed and hot? What if they have insomnia versus hypersomnia? The term offers no guidance.

This matters more than semantics. When a practitioner says “I gave them an adaptogen,” I have no idea what they actually did or why. Did they give Ashwagandha? Rhodiola? Schisandra? Eleutherococcus? These plants have dramatically different qualities, actions, and effects. The term “adaptogen” lumps them together based on a 1950s Soviet theoretical framework that obscures their actual differences rather than clarifying specific uses.

The Phenomenological Problem: These Herbs Feel Wildly Different

If adaptogens really represented some meaningful category of plants with similar effects on the stress response, you’d expect them to feel similar when you take them. They don’t. Not even remotely.

Ashwagandha tends to be calming, sometimes sedating, often helpful for anxious, wired states. Many people find it helps with sleep. Rhodiola, by contrast, is often stimulating, can increase energy and alertness, and may worsen anxiety or insomnia. Schisandra has a notable sour taste and appears to have biphasic effects - relaxing and calming at lower doses, but distinctly stimulating at higher doses, which fits with its original classification as a stimulant in Soviet research. Eleutherococcus is generally considered mildly stimulating.

We’re calling plants with opposite phenomenological effects by the same name. One makes you sleepy, another keeps you awake. One calms you down, another amps you up. The lived experience of taking these herbs is completely different.

Someone who is anxious, agitated, and not sleeping needs something fundamentally different than someone who is depleted, exhausted, and struggling with low energy. Calling both situations “stress” and both sets of herbs “adaptogens” actively interferes with making good matches.

And then there’s the dose-dependent complexity. Schisandra at low doses might provide some calming support, but push the dose higher and you’re looking at stimulation, potential insomnia, agitation - that doesn’t fit with the idea of an herb that intelligently “adapts” to what someone needs.

The phenomenological diversity among so-called adaptogens suggests we’re not dealing with a meaningful category. We’re dealing with plants with diverse qualities and actions that have been artificially grouped together based on theory rather than observable effects.

The Definitional Incoherence: Non-Specific Effects That Are Somehow Also Specific

Let’s look at how adaptogens are typically defined. The classic definition, from Brekhman and Dardymov’s 1969 paper, states that adaptogens must:

Be non-specific and help the body resist a wide variety of stressors
Have a normalizing influence independent of the nature of the pathological state
Be innocuous and cause minimal disorders in physiological functions

There’s a fundamental logical problem here. How can something have “non-specific” effects on stress while also having specific effects on particular conditions? Yet this is exactly what adaptogen research claims.

Look at the modern research on these plants. Ashwagandha is studied for anxiety. Rhodiola for depression and fatigue. Schisandra for cognitive function. These are specific effects on specific conditions. The research doesn’t show these plants “normalizing” everything - they have particular effects on particular problems, breaking the definition.

And then there’s the “innocuous” part. These plants aren’t always innocuous. We have documented case reports of serious harm. Ashwagandha has been associated with thyrotoxicosis in multiple published cases - thyroid storm severe enough to require hospitalization. There are case reports of acute psychosis following ashwagandha withdrawal. Rhodiola has triggered manic episodes in people with bipolar disorder. Chronic high-dose use of Panax ginseng produces Ginseng abuse syndrome - with symptoms including insomnia, hypertension, edema, skin eruptions, and morning diarrhea.

These aren’t side-effect-free substances that gently nudge everything toward balance. They have real, specific effects - and real potential for making some people significantly worse if used inappropriately. Calling them “innocuous” when we have case reports of thyroid storm, psychosis, and mania is both inaccurate and dangerous.

The adaptogen definition promises a kind of herbal panacea that doesn’t exist - plants that somehow transcend the normal rules of pharmacology and can intelligently sense what each individual person needs. This is magical thinking. I have no problem with magical thinking. Some people need more magical thinking and enchantment. But be honest about it. Find a nice amulet. Better yet, a nice house plant. Don’t pay supplement prices for enchantment while pretending you’re doing traditional herbal medicine.

The Practical Incoherence: Who Actually Needs These?

Let’s push on the adaptogen concept and force it to commit to something testable. Because right now it enjoys the luxury of vagueness - broad enough to never be proven wrong, which is a hallmark of pseudoscientific thinking.

The core claim is that adaptogens help the body cope with stress. Fair enough. But let’s follow that thought for a moment. Who experiences chronic stress in modern life? Essentially everyone. Work stress, financial stress, relationship stress, health stress, news-cycle stress, climate anxiety - pick your poison. If adaptogens address “the effects of stress,” and stress is nearly universal, then the logical conclusion is that adaptogens are necessary for nearly everyone.

Is that the claim? Should everyone be taking adaptogens?

The most prolific researcher/writer on adaptogens, Panossian says

The prophylactic use of adaptogens seems to be justified in healthy subjects for preventing aging-related diseases, and to attenuate stress-induced harmful effects.

So yes - the claim is everyone should be taking adaptogens, even healthy folks. So which adaptogens? Ginseng, starting with the introduction of solid food, or before? Ashwagandha for the anxious ones and Rhodiola for the depleted ones? What about people who are both anxious and depleted at different times of day? All of them in rotation? In what doses? For how long - forever, since stress isn’t going away? What happens when you stop? The concept offers no guidance because it was never designed to answer practical questions. It was designed to sell products.

And if everyone should be taking adaptogens, what weight of evidence would we expect to support such an extraordinary claim? When we say something benefits nearly everyone, that’s a massive assertion requiring proportionally robust evidence - large trials, replicated findings across different populations, clear dose-response relationships, long-term safety data. Instead, we have a number of trials that found no benefit, or found harm, no one wants to talk about, along with mountains of methodologically flawed Soviet research, a handful of positive industry-funded studies with conflicts of interest and, and multiple expert panel reviews of all available information explicitly stating the evidence doesn’t support efficacy claims. That’s the evidence base for a universal recommendation?

But maybe the claim isn’t that everyone needs adaptogens. Let’s set aside the opinion of the guy who’s built his whole reputation and career on the supposed efficacy of adaptogens and say the claim is more modest - just that they’re beneficial for people under significant stress. Okay, let’s work with that. Which people specifically? How do we identify them?

Is there a stress scale where, once you hit a certain threshold, adaptogens become warranted? Where is this threshold? What validated instrument measures it? The Perceived Stress Scale? The Holmes-Rahe Life Stress Inventory? Salivary cortisol levels? Some combination? I’ve never seen an adaptogen proponent specify what level of stress justifies adaptogen use, because that would require the kind of precision the concept can’t provide. It would also open up the uncomfortable question of what evidence demonstrates adaptogens help people above this threshold but not below it. That evidence doesn’t exist because the question has never been seriously asked.

Let’s say we accept, for the sake of argument, that adaptogens provide some benefit for stressed people. We still need to ask: compared to what? Among all the interventions considered beneficial for people under chronic stress - and there’s actually decent evidence for many of them - where do adaptogens rank?

Consider the things we know help with chronic stress: adequate sleep, regular movement, social connection, time in nature, reduced workload, nutrient-dense food, stress-reduction practices, meaningful work, financial stability. These aren’t exotic interventions. They’re foundational. And for all of them, we have substantially better evidence than we have for adaptogens.

But let’s stay in supplement territory for a moment, since that’s where adaptogens live. People often reach for adaptogens when they’re fatigued, mentally foggy, or feeling depleted. Fair enough - those are real problems worth addressing. But where would you rank adaptogens among your interventions for fatigue?

Take creatine. There’s reasonably strong evidence that creatine supplementation reduces cognitive fatigue, particularly under conditions of sleep deprivation or mental exhaustion. Multiple well-designed studies show improvements in working memory and processing speed when people are stressed or sleep-deprived. The mechanism is plausible - creatine supports ATP regeneration in the brain, and cognitive work is metabolically expensive. The effect sizes are modest but consistently replicated across independent research groups.

Or consider theanine. The evidence base shows improvements in stress levels and sleep quality. The mechanism makes sense - theanine promotes alpha wave activity and supports GABA function without sedation. Multiple independent trials, reasonable sample sizes, plausible pharmacology.

I’m not saying creatine and theanine are miracle supplements. They have modest effects for specific applications. But that’s exactly the point - we can describe what they do, for whom, through what mechanism, with what quality of evidence. Try doing that with “adaptogens.” The specificity disappears into vague claims about “supporting the stress response” and “normalizing function.”

If someone comes to me exhausted and depleted, and I’m thinking about supplements (after addressing sleep, nutrition, and the other foundational factors), I can make a reasoned case for creatine based on its evidence for cognitive fatigue. I can consider theanine if sleep quality seems like the rate-limiting factor. What’s the reasoned case for “an adaptogen”? Which one? Why that one over another? The framework gives me nothing to work with.

I’m a clinician working with real people who have to make real decisions. A few practical questions about adaptogens I’ve never seen addressed:

Should someone work longer hours to make more money to afford adaptogens? Supplements are expensive, and many people are choosing between financial priorities. If someone works an extra two hours a week to pay for their adaptogen habit, are they better off than if they’d used those couple of hours for sleep, movement, or time with people they care about? I’d bet heavily on the latter, but the adaptogen framework can’t even engage with this question because it treats these herbs as a special category rather than one option among many.

What if someone can afford fresh vegetables or adaptogens, but not both? Which gets priority? I think the answer is obvious, but I’ve watched people make the opposite choice because marketing has convinced them adaptogens are essential while vegetables are just, you know, food. The adaptogen concept, by positioning these herbs as uniquely important for stress, distorts reasonable priority-setting.

What’s the evidence that adaptogens provide more benefit per dollar than an extra hour of sleep per night? Than a daily walk? Than weekly time with friends? These comparisons are never made because adaptogens exist in a marketing bubble where they’re not competing against the mundane interventions that actually form the foundation of stress resilience. The concept insulates itself from practical cost-benefit analysis.

Any answer to these questions exposes the problem. If the answer is “everyone should take adaptogens,” that’s an extraordinary claim the evidence doesn’t support. If the answer is “only some people,” then we need specificity the concept refuses to provide. If the answer is “it depends on the individual,” then congratulations - you’ve just described every herb, and the term “adaptogen” isn’t doing any clinical work. It’s not differentiating. It’s not guiding decisions. It’s just... there, sounding vaguely scientific while meaning nothing precise.

A concept that can’t be pinned down to testable claims, that can’t specify who benefits and who doesn’t, that can’t be compared against alternatives, that can’t guide practical priority-setting… If you look closely at the concept of adaptogens, what you really find is clever marketing copy dressed up in scientific language, not a clinical concept.

The Historical Problem: Stimulants Rebranded

Many of these plants, later called adaptogens, were already being studied for other effects and got relabeled when a new theoretical framework emerged.

Research on Schisandra was formally initiated during World War II by Order 4654-p, which mandated studies “to study the Chinese herb Limonnik with the purpose of determining its possible use as a raw material for obtaining organic acids, ether oils and tonic substances.” During the initial research period from 1943-1947, Soviet scientists described Schisandra’s “stimulating activity” or “stimulatory effects” - not adaptogenic properties.

Why? Because the term “adaptogen” didn’t exist yet. It wasn’t published in scientific literature until 1958. Before that, Schisandra was studied and classified as a stimulant. It was recognized for causing, in larger doses, insomnia and agitation - effects we associate with stimulants, not with herbs that “normalize” stress responses.

So what changed? The adaptogen concept emerged in the late 1950s, was formally defined in 1969, and these existing stimulant herbs were retrospectively reclassified. Schisandra didn’t change. Its effects didn’t change. But the language used to describe it shifted from “stimulant” to “adaptogen.”

This matters more than you might think. When you call something a stimulant, practitioners know to be cautious about using it in people who are already wired, anxious, or not sleeping. When you call it an adaptogen, that caution disappears. The term suggests it will somehow intelligently adapt to what the person needs, when in reality you’re still looking at stimulating effects for many people - especially at higher doses where Schisandra’s biphasic nature shows its stimulant face.

The adaptogen concept emerged from Soviet research looking for ways to enhance soldier and worker productivity - substances that could help people work harder, longer, in difficult conditions. The goal was pushing through, not healing or building resilience.

The same Soviet labs that turned Schisandra into an “adaptogen” were also testing synthetic drugs like dibazol, bemitil, and bromantane AS ADAPTOGENS. If you wouldn’t be comfortable taking Soviet era performance enhancing drugs based on the strength of that research alone, it’s worth asking why the label feels so convincing when it’s attached to herbs.

The Research Quality Problem: Methodological Disasters and Acknowledged Flaws

The research base that supposedly supports the adaptogen concept is deeply flawed, and even the field’s leading researchers acknowledge this.

Alexander Panossian is arguably the most prolific adaptogen researcher, with approximately 200 publications on the topic. He’s been instrumental in promoting the adaptogen concept and has served as Head of Research & Development for the Swedish Herbal Institute (more on them shortly). If anyone has a vested interest in defending adaptogen research quality, you’d think it would be Panossian. Yet even Panossian admits that most of the Soviet-era trials were “poorly designed and conducted,” and summarized the USSR clinical studies as “the most questionable and poorly documented” in the entire adaptogen literature.

The problems extend well beyond the old Soviet data. In 2009, Blomkvist, Taube, and Larhammar published what is basically a forensic takedown of Rhodiola trials in Planta Medica. They went through seven “positive” studies and found serious problems in six of them. Not nitpicky details—things you’d expect in a sloppy student project, not in clinical research. Wrong or irrelevant statistics, trials with no placebo group, numbers and graphs that don’t match, conclusions resting on unpublished follow-up data, and a depression study where the placebo group somehow showed no improvement at all (which simply doesn’t happen in antidepressant trials).

Their bottom line was that these Rhodiola trials “are of poor scientific quality and their conclusions are not supported by the data.” And in four of the six problematic studies, a company that makes Rhodiola extract – the Swedish Herbal Institute – was involved, which only makes the whole situation look worse.

Short of outright accusing anyone of fraud, this is about as close as a formal paper gets to saying, “these results should not be trusted.” In any other field, a published criticism this harsh would be career-ending.

Multiple other systematic reviews have identified similar problems. Walker and Robergs (2006) found “equivocal results” and noted something curious - Eastern European studies consistently showed positive effects while Western European and North American studies “produced mixed results.” This geographic disparity in findings is a red flag. When research from one region consistently shows effects that other regions can’t replicate, you have to question the methodological rigor of that research tradition.

Hung, Perry, and Ernst (2011) found that only 5 of 10 randomized controlled trials scored above 3 on the Jadad scale (indicating good quality). Their major conclusion identified a critical problem: “The trials differed greatly in terms of condition tested, and independent replications of any given trial are missing.” They emphasized “a lack of independent replications of the single different studies.”

Ishaque et al. (2012) found that only 2 of 6 trials on physical fatigue showed Rhodiola effective, and only 3 of 5 trials on mental fatigue showed effectiveness. They concluded: “Research regarding R. rosea efficacy is contradictory,” and “While some evidence suggests that the herb may be helpful, methodological flaws limit accurate assessment of efficacy.”

The recurring methodological problems across these reviews include: small sample sizes, poor randomization, lack of blinding, short treatment periods, inappropriate statistical methods, selective outcome reporting, variable plant preparations, inconsistent extraction methods, different dosing regimens, and no independent replications.

What Good Trials Actually Show

It’s not just that the “positive” adaptogen literature is riddled with weak methods. What almost never gets talked about are the well-done trials where adaptogens either failed outright or actually made things worse.

1. Eleutherococcus for chronic fatigue – looked good… until you add placebo
Hartz et al. (2004, Psychological Medicine) randomized 96 people with idiopathic chronic fatigue or CFS to Eleutherococcus or placebo for two months. Both groups improved, but there was no difference at all between them on the primary fatigue scale in the full sample. The authors’ own conclusion: overall efficacy was not demonstrated; only a post-hoc subgroup with milder fatigue showed any signal.

2. Eleutherococcus added to stress management – the herb does nothing
Schäffler et al. (2013, Pharmacopsychiatry) put stressed employees into three arms: stress-management training alone, Eleutherococcus alone, or both together. Over 12 weeks, almost all parameters improved, but there were no meaningful differences between groups, and adding Eleutherococcus to a decent stress-management program gave no extra benefit. The authors summed it up: any effect of Eleutherococcus was “negligible.”

3. Rhodiola in nursing students – fatigue worse than placebo
Punja et al. (2014, PLOS ONE) randomized 48 nursing students on shift work to 42 days of Rhodiola or placebo. On both the SF-36 Vitality scale and a VAS for fatigue, placebo did better. By day 42, the change in fatigue scores was significantly in favour of placebo, leading the authors to state that Rhodiola worsened fatigue compared with placebo in this population (with all the cautious caveats you’d expect).

4. Ashwagandha for stressed, overweight adults – primary endpoint fails
Smith et al. (2023, Journal of Psychopharmacology) ran a 12-week double-blind RCT in 121 overweight or mildly obese adults aged 40–75 with high stress and fatigue, using a branded ashwagandha root extract (Witholytin®, 200 mg BID). Stress scores (PSS) fell in the ashwagandha group – but they fell just as much in the placebo group. The improvements on the primary outcome were not significantly different between groups (p = 0.867), even though this is exactly the kind of trial design adaptogen claims are supposed to shine in.

These are reasonably designed, placebo-controlled trials that go straight after the core promises of adaptogens – better fatigue, stress resilience, and energy – and either find no advantage over placebo or, in the case of Rhodiola in nursing students, a signal that people actually did worse on the herb.

The Conflict of Interest Problem: Commercial Entanglement

If you’re shaking your head and wondering how we got here, here’s where we name the problem - the extensive commercial conflicts of interest that permeate the field.

The Swedish Herbal Institute founded in 1975, describes itself as the “world leader in adaptogens” with “more than 35 years of research.” But this isn’t an independent research institution. It’s a commercial manufacturer with a GMP-certified manufacturing plant producing proprietary products sold internationally.

SHI’s flagship products are ADAPT-232 (sold as Chisan®), a combination formula of Rhodiola, Schisandra, and Eleutherococcus, and SHR-5 Extract, a proprietary Rhodiola rosea extract sold as “Arctic Root.” These products are marketed as “the only Rhodiola extract with proven efficacy in clinical studies published in international scientific journals.”

Alexander Panossian, the most prolific adaptogen researcher, served as Head of Research & Development for Swedish Herbal Institute from 2003-2016. During this period, he authored numerous papers testing SHI products while employed by the company manufacturing those products. In 2016, he founded his own R&D company, Phytomed AB, and became Head of Research & Development for EuroPharma USA Inc., another supplement manufacturer, while maintaining a consulting agreement with them.

Georg Wikman, co-author with Panossian on numerous papers, is the founder of Swedish Herbal Institute and developer of the ADAPT-232 formula. His institutional affiliation in publications is listed as “Swedish Herbal Institute Research & Development,” which obscures for many readers that this is a commercial entity rather than an independent research institution.

The same entity manufactures proprietary products, employs researchers, funds poorly designed research on its own products, publishes that weak research in peer-reviewed journals, then uses that research to market products with claims like “clinically tested” and “scientifically proven.” This creates a self-reinforcing system where studies authored by SHI-affiliated researchers cite other SHI-affiliated research.

Remember those four problematic Rhodiola studies identified by Blomkvist et al.? The Swedish Herbal Institute was involved in all four of them. Blomkvist shows a pattern where the same commercial entity repeatedly produces methodologically flawed research on its own products, publishes it, and uses it for marketing.

What This Means for Practice

So where does this leave us clinically? I think we need to make a clear distinction between the adaptogen concept and the actual plants that have been labeled with this term.

The adaptogen concept - this idea that certain plants have some special, non-specific ability to normalize stress responses and build resilience - lacks good supporting evidence. The term itself is clinically unhelpful because it doesn’t differentiate between plants with very different qualities, actions, and effects.

But that doesn’t mean these plants aren’t useful. We need to understand them based on their specifics rather than lumping them into a vague category.

Ashwagandha has documented effects on anxiety and sleep due to its calming, somewhat sedating properties. It also appears to have thyroid-stimulating effects, which means we need to be thoughtful about using it in people with hyperthyroidism or who are taking thyroid medication. And we have those case reports of thyrotoxicosis - not exactly an innocuous normalizer.

Rhodiola appears to have stimulating effects that might help some people with fatigue. This makes it potentially useful for someone who’s depleted and dragging, and potentially problematic for someone who’s already wired. We need to match the plant’s actual effects to what the person needs, not rely on ideas about intelligent adaptation. And we need to remember those case reports of mania in people with bipolar disorder.

Each plant, evaluated on its own, outside of a clinically useless concept.

When I work with someone experiencing what we might broadly call “stress,” I don’t reach for an adaptogen. I try to understand their specific experience. Are they wired or tired? Hot or cold? Tense, agitated, ruminating, catastrophising? Sleeping poorly because they can’t fall asleep, or because they can’t stay asleep? Are they anxious, depressed, or both? What’s their energy pattern throughout the day? What makes it better, what makes it worse? Even simple things like stress require thoughtful exploration.

After exploring I think about which herbs have qualities, actions, and effects that match what this specific person needs. The adaptogen framework suggests you could use the same herb for someone anxious and hot versus someone depleted and cold. That makes no clinical sense.

I also think we need to be honest about what herb can and can’t do. If someone is experiencing significant stress-related symptoms, the foundational interventions need to come first: sleep, nutrition, movement, stress regulation, connection, circadian rhythm support. These aren’t sexy interventions, but they’re more important than any herb. Herbs can support these foundational changes. They can’t substitute for them.

When someone’s stress symptoms are severe enough that basic lifestyle changes and herbal support for those lifestyle changes (gnaw on that a bit) aren’t sufficient, that person may need more than herbs. They may need therapy, medication, changes to work or living situations, or treatment for underlying conditions like thyroid dysfunction or anemia. Calling something an adaptogen and suggesting it will magically fix all causes of stress obscures when we’re out of our depth and referral is appropriate.

The Bigger Picture

The adaptogen problem is really a case study in how marketing can hijack language and muddy clinical thinking. The term sounds scientific. It references research. Companies can charge premium prices for “adaptogenic” formulas.

But look closely at what we’ve covered: incoherent definitional criteria, foundational research acknowledged by field leaders as methodologically flawed, high-quality studies showing null effects, and research heavily funded by product manufacturers.

We can do better. We can understand these plants based on what they actually do. We can make informed choices about when each might be helpful and when it might not. We can acknowledge uncertainty while making clinically sound decisions based on empirical observation.

Time to retire “adaptogen” to the category of historically interesting but clinically unhelpful concepts. Let’s talk about these plants in terms of what they actually do, for whom they might be helpful, and when we should use something else instead.

The Plural of Anecdotes is Misinformation...and Case Series

Thomas Easley — Sat, 15 Mar 2025 00:18:31 GMT

"The plural of anecdote is not data."

I've heard this dismissive phrase thrown around in skeptic circles for years. It's the conversation-ender deployed whenever someone shares a personal experience as evidence for a claim—particularly about healthcare interventions. The message is clear and condescending: your individual story, no matter how compelling, cannot substitute for "real" scientific data.

Yet somehow, a few clicks into any medical journal will lead you to a section called "Case Reports" or "Case Series" where physicians publish detailed accounts of individual patient experiences. These anecdotes—because that's exactly what they are—aren't dismissed as irrelevant noise. They're considered valuable contributions to medical knowledge, worthy of peer review and publication in prestigious journals.

This creates a curious paradox that's bothered me for years. When a patient reports that an herb helped their chronic pain, it's "just an anecdote." When a physician documents that a pharmaceutical helped their patient's pain, it's potentially a "case report" worthy of publication. Both are systematically documented observations of individual responses, yet they're accorded vastly different levels of credibility.

I'm not suggesting that all anecdotes are equal to methodically documented, peer-reviewed case reports. There are meaningful differences in documentation standards, methodological rigor, and clinical context. But this institutional distinction often has less to do with the quality of the observation itself and more to do with who is doing the observing, where they practice, and how the observation fits with existing paradigms.

I believe there’s a middle path between dismissing all personal experiences as worthless anecdotes and treating every testimonial as unassailable truth. This piece is an invitation to walk that path.

A Story About Bone Infection and Last Resorts

Let me tell you a story from my clinical practice that illustrates why these distinctions matter.

I once worked with a client who had developed antibiotic-resistant osteomyelitis—a bone infection that began as a diabetic foot ulcer and eventually infiltrated the bone. This wasn't a matter of uncertain diagnosis—she had been working with a medical team consistently for three months, with a clear and confirmed diagnosis. Multiple rounds of antibiotics had failed to resolve the infection. The medical team had even performed surgical debridement, scraping infected tissue from the bone, followed by yet another course of antibiotics that still didn't work. At this point, her doctors informed her they would need to amputate to stop the spreading infection, as it was clearly not responding to any antibiotic interventions.

She was a former client who returned specifically for this crisis, scheduling an appointment just days after receiving the amputation news. I recommended three approaches: an immune tonic decoction containing Astragalus and Reishi mushroom, an immune synergist blend including Echinacea, Barberry leaf, and Goldenseal leaf, and a relatively new herb to my practice called Cryptolepis sanguinolenta, which had preliminary research supporting its broad-spectrum antimicrobial properties along with a traditional history of use for malaria and gastrointestinal infections. I designed this protocol to work alongside her prescribed antibiotics, not to replace them.

At her follow-up visit a few weeks later, she reported complete resolution of the infection. Upon deeper inquiry, I learned that the immune synergist hadn't been available, and the immune tonic had caused nausea, so she had only taken the Cryptolepis. Most surprisingly, against my explicit instructions and without my knowledge, she had discontinued all antibiotics the day she started the herbal protocol.

Now, this is where the story gets complicated. If I publish this as a case report in an herbal journal, it becomes a data point in herbal literature. If I share it at a conference, it's an intriguing clinical anecdote. If my client posts about it on Facebook, it's "just an anecdote" or worse, "misinformation" about treating serious infections with herbs instead of antibiotics.

But the observation itself—the resolution of an antibiotic-resistant infection following the use of Cryptolepis—remains the same regardless of who reports it or where. The question is: when does this kind of observation deserve our attention, and when should we dismiss it?

I think there's a desperately needed middle ground between blindly accepting every personal health story and dismissively rejecting anything that hasn't been validated through randomized controlled trials.

Medicine Began with Stories, Not Statistics

Here's something we often forget: medicine didn't begin with randomized controlled trials or even observational studies. It began with individual observations—what we might today call anecdotes. Hippocrates' detailed descriptions of individual patients with particular symptoms and outcomes form the foundation of Western medicine. His case histories, dating back to the 5th century BCE, weren't statistical analyses; they were structured narratives of what he observed in specific patients.

Many of medicine's greatest breakthroughs emerged from individual observations that generated hypotheses for further investigation. Edward Jenner's development of the smallpox vaccine began with his observation that milkmaids exposed to cowpox seemed protected from smallpox—an anecdote that led to one of medicine's greatest triumphs. Alexander Fleming's discovery of penicillin started as a single observation of a mold contaminating his bacterial cultures.

This iterative cycle between observation and experimentation drives medical progress. Observational evidence isn't in competition with experimental evidence—they're complementary. Case reports identify signals that controlled trials can later verify. Controlled trials establish general principles that clinicians then apply and refine through careful observation in practice.

The increasing devaluation of observational evidence as "mere anecdote" threatens to disrupt this cycle, particularly when certain types of observations—those from patients themselves or practitioners outside conventional medical settings—face systematic barriers to being documented, published, and taken seriously.

When Collections of Anecdotes Lead Us Astray

Don't get me wrong—there are excellent reasons for skepticism about anecdotal evidence. Human cognition is riddled with biases that can transform collections of individual experiences into dangerously misleading conclusions.

Confirmation bias inclines us to notice and remember experiences that confirm our existing beliefs while overlooking contradictory evidence. Selection bias means the anecdotes we encounter rarely represent the full spectrum of experiences. And the post hoc, ergo propter hoc fallacy—assuming that because B followed A, A must have caused B—plagues anecdotal reasoning, especially when we don't account for natural fluctuations in symptoms over time.

What's particularly insidious is how rarely negative anecdotes gain traction. For every viral success story about a miracle cure, there are countless experiences of treatments that failed or caused harm that never see the light of day. Who shares the story of "I tried this supplement and nothing happened" or "This herb gave me a rash and I threw it away"? These negative data points simply evaporate from our collective knowledge base, creating a distorted picture of what actually works and what doesn't.

Medical history offers sobering examples of how these biases can lead us astray. Bloodletting persisted for centuries, supported by countless physicians' observations that patients often improved following the procedure. Without controlling for natural recovery or regression to the mean, practitioners mistakenly attributed improvement to the intervention. More recently, arthroscopic knee surgery for osteoarthritis became standard treatment based on surgeons' observations that patients improved after the procedure—until sham-controlled studies revealed the surgery provided no benefit beyond placebo for most patients with osteoarthritis. Even more dramatically, antiarrhythmic drugs were widely prescribed after heart attacks based on the logical observation that they suppressed irregular heartbeats, until controlled trials revealed they actually increased mortality by 2-3 times compared to placebo.

The modern wellness industry provides countless examples of how curated anecdotes can mislead. Social media influencers share carefully selected testimonials claiming miraculous results from everything from celery juice to coffee enemas, creating the impression of overwhelming efficacy while systematically excluding negative experiences. This problem has been supercharged by algorithms that preferentially promote sensational claims and dramatic "transformation" stories. When a post claiming "this herb cured my incurable condition" gets 50,000 shares while "I tried this and nothing happened" gets buried, we're not just dealing with human bias anymore—we're dealing with structural amplification of misinformation.

So yes, when anecdotes are cherry-picked, uncritically accepted, and divorced from their contexts, they absolutely can lead to dangerous misinformation. The skeptical critique of anecdotal evidence is grounded in these very real dangers.

The Context of Clinical Herbalism: Last Resort Cases

Before I offer a framework for evaluating when anecdotal evidence deserves our attention, I should explain something about the context in which many clinical herbalists practice. Though the wellness industry has exploded in popularity over the past decade, with people now seeking herbal advice for everything from occasional sleeplessness to 'optimizing their energy,' my clinical experience, and that of many of my colleagues, was forged in a different landscape - before herbs became trendy Instagram content and wellness influencers started selling tinctures.

The people sitting across from me in consultation aren't typically the wellness-curious with minor complaints. More than a few of my clients came to me when mainstream medicine had exhausted all potential interventions, or when all that remained were surgical options they couldn't afford, couldn't tolerate, or desperately hoped to avoid (literally almost all herbalists have a story about someone saved from gallbladder removal).

My client base now consists almost entirely of people with multimorbidity—folks managing multiple concurrent chronic conditions. These aren't people with neat, singular diagnoses that fit established treatment guidelines but people navigating complex combinations of autoimmune disorders, chronic pain conditions, psychiatric diagnoses, and metabolic issues all at once. A typical client might have lupus alongside fibromyalgia, chronic migraines, POTS, anxiety, and depression. They often arrive on multiple medications, some working remarkably well, others providing little benefit despite being "evidence-based" for individual conditions they might have.

This complexity presents a fundamental challenge to conventional evidence-based approaches, because people with multiple complex conditions are typically excluded from clinical trials. The medication combinations they take have never been studied together. The way their conditions interact often falls outside established research parameters. For these individuals, careful clinical observation becomes not just valuable but essential, as it may provide the only meaningful evidence for what helps in their unique circumstances.

This context profoundly shapes the risk-benefit analysis that informs clinical decision-making and the weight we should give to clinical observations in these populations.

When to Take Anecdotes Seriously: A Different Approach

So how do we navigate this complex landscape? When should we pay attention to anecdotal evidence, and when should we dismiss it? I don't think there's a simple answer, but I do think we can develop a more nuanced approach—one that neither blindly accepts all personal experiences as definitive proof nor dismisses them out of hand.

Here's my attempt at a framework for evaluating when anecdotal evidence deserves serious consideration:

Objectivity of Outcomes

In the Cryptolepis case, the resolution of a confirmed antibiotic-resistant bone infection is a highly objective outcome, verifiable through medical examination and testing. That makes it fundamentally different from someone reporting that an herb gave them "more energy" or made them "feel more balanced"—subjective experiences that are real but much harder to verify independently.

This doesn't mean subjective improvements aren't real or valuable—they absolutely are. It simply means we should apply appropriate skepticism when evaluating claims based primarily on subjective experiences, particularly when making causal attributions. If someone reports "After taking this herb for one week, my morning blood pressure I record daily decreased from 160/95 to 135/85 and I confirmed this at my PCP's office," this carries more weight than "I felt more relaxed after taking this herb."

Placebo Response Rate for the Condition

Osteomyelitis has an extremely low placebo response rate, particularly when it has already proven resistant to multiple antibiotics and surgical interventions. By contrast, conditions like chronic pain, depression, anxiety, fatigue, nausea, and certain functional disorders like IBS show particularly high placebo response rates—often 30-40% or higher in clinical trials.

This difference matters tremendously when evaluating anecdotal reports. When someone reports that an intervention helped their chronic pain, we should acknowledge the high likelihood that expectation effects played at least some role. This doesn't invalidate their experience, but it should temper how strongly we allow that anecdote to influence our assessment of the intervention's intrinsic effectiveness.

Natural History of the Condition

Untreated or inadequately treated osteomyelitis is typically progressive rather than self-limiting, especially in the context of diabetes. In my client's case, the condition had been actively worsening despite aggressive treatment.

This is quite different from, say, reporting that an herb helped a common cold, which tends to resolve on its own within 7-10 days regardless of intervention. The anecdote about cold resolution provides very weak evidence because improvement would likely have occurred anyway.

When someone reports improvement in a typically stable or progressive condition—particularly one that had been worsening despite appropriate conventional treatment—that observation becomes significantly more noteworthy.

Specificity of Intervention and Response

In my case example, both the intervention (a single herb, Cryptolepis) and the outcome (resolution of a specific infection) were highly specific. This specificity makes the observation more precisely testable and less susceptible to confirmation bias. "I took 20 drops of Echinacea angustifolia fluid extract three times daily for 7 days, and my persistent lymph node swelling reduced by 50%" provides more useful information than "I took some immune herbs and felt better overall."

Timeline and Temporal Relationship

The improvement in the osteomyelitis case occurred within a timeframe consistent with an antimicrobial effect, after conventional antibiotics had failed for months. Moreover, there's a logical temporal relationship between the intervention and the outcome.

The timeline of intervention and response matters significantly. Immediate improvements following an intervention are more likely to be causally related than improvements that occur weeks or months later (though this varies by condition and mechanism). Similarly, a consistent pattern where symptoms improve with the intervention and return when it's discontinued (especially if this occurs multiple times) provides stronger evidence than a single instance of improvement that might be coincidental.

Replicability Across Different Observers

When multiple practitioners or patients independently report similar outcomes using the same intervention under analogous circumstances—without having influenced each other's expectations or observations—that repetition is far more compelling than a one-off success.

A single compelling anecdote might be a coincidence or a confluence of unrecognized factors. Ten similar reports from different observers start to look like a pattern worth investigating. A hundred similar observations from diverse sources suggest something real is happening, even if we don't yet understand the mechanism. This is why traditional knowledge that persists across generations and cultures often contains valuable insights—it represents observations that have been replicated countless times in diverse contexts.

This kind of "convergent anecdotal evidence" carries considerably more weight than isolated reports, particularly when the observers weren't aware of each other's experiences and thus couldn't have influenced each other's expectations or interpretations.

Risk-Benefit Analysis and Context

My recommendation of Cryptolepis wasn't a casual choice, but came after careful consideration of several factors. Unlike most herbal antimicrobials, which primarily act locally and aren't well-absorbed systemically, I knew from the limited studies available on Cryptolepis and its traditional use history that it achieved sufficient absorption to combat malaria parasites in the bloodstream. I also knew it was at least partially excreted through the urinary system, given its traditional use for UTIs. This, combined with a handful of informal case reports from colleagues, suggested potential systemic antimicrobial activity—a rare quality among herbs.

The risk-benefit analysis in this case was particularly nuanced. The client had already tried vancomycin and several other powerful antibiotics without success. She lacked health insurance and would be paying out-of-pocket for the amputation. Her financial situation was so constrained that she had chosen to forego an anesthetic for her previous debridement procedure, enduring severe pain because she couldn't afford anesthesia. Given Cryptolepis's established safety profile, its potential systemic activity, and the client's extremely limited options, I felt ethically comfortable recommending we try this herb, even though it was relatively new to my practice.

I should emphasize that this approach doesn't mean rejecting conventional medicine when it's appropriate. If someone came to me with newly diagnosed osteomyelitis and said they hadn't tried antibiotics and wanted to use herbs instead, I would insist they use antibiotics. In serious conditions, herbs can complement conventional care, and sometimes provide options when conventional approaches have failed, but they shouldn't replace effective first-line treatments when those are available and indicated.

The Politics of Who Gets to Observe

If the case I described had been documented by an infectious disease specialist at a major medical center rather than by an herbalist in private practice, it likely would have been published as a case report in a medical journal. The observation itself—antibiotic-resistant osteomyelitis resolving after administration of a botanical preparation—is identical. The difference lies not in the quality of the observation but in who made it and in what institutional context.

This institutional gatekeeping has consequences. It means that observations from outside conventional medicine—particularly those involving non-patentable interventions like herbs, dietary approaches, or mind-body practices—face higher barriers to entering the formal medical literature.

The funding landscape makes this problem even more pronounced. Research into non-patentable or tradition-based therapies often struggles to secure grants, so many promising leads remain permanently stuck at the level of anecdote or small pilot study. Without the potential for patent-protected profits to recoup research investments, who's going to spend millions on large clinical trials of common herbs or traditional practices? This creates a self-reinforcing cycle where potentially valuable therapies never advance beyond "promising but unproven" status—not because they lack merit, but because they lack financial backers with skin in the game.

Think about it: a pharmaceutical company might invest $800 million to bring a new drug to market because they can secure a 20-year patent monopoly. Who's going to invest even a fraction of that to prove that a common herb works for a particular condition when anyone could immediately sell that herb without restrictions? The lack of evidence for many traditional approaches isn't just about scientific standards—it's about economic structures that determine what questions are even worth asking.

This creates a situation where alternative approaches may remain perpetually "unproven" not because they lack merit, but because the observations that might prompt formal investigation face systemic hurdles to gaining scientific attention. This dynamic is well-documented in publishing more broadly, where factors like novelty bias, publication bias (favoring positive results), and institutional affiliations influence what appears in the literature.

The marginalization of certain types of observations doesn't just happen along conventional/alternative lines. Even within mainstream medicine, certain kinds of observations are systematically overlooked:

Patient-reported experiences often receive less weight than clinician observations, even when patients are reporting on symptoms only they can directly perceive
Observations from community practitioners may be dismissed in favor of those from academic centers
Negative outcomes or treatment failures are less likely to be documented and published than successes
Common but mundane clinical observations often go unpublished because they lack novelty, even if they're clinically important

These institutional dynamics don't just influence which observations get published—they shape which questions get asked in the first place. Research priorities are determined largely by funding availability, commercial interests, and academic prestige rather than by clinical need alone. This means that observations that don't align with these priorities, no matter how clinically valuable, may never generate the research needed to confirm or refute them.

From Storytelling to Science and Back Again

I'm not arguing that we should abandon rigorous research methods or accept all anecdotes uncritically. What I am suggesting is that we need a more nuanced understanding of how different forms of evidence contribute to our collective knowledge.

Rather than maintaining a rigid dichotomy between "anecdotes" (dismissed as worthless) and "evidence" (accepted as authoritative), we might recognize a continuum:

Individual observations serve as the raw material for knowledge development. When multiple similar observations accumulate, patterns may emerge that deserve closer attention. Formal or informal collections of similar cases can reveal consistent patterns and generate more specific hypotheses. These hypotheses can then be tested through increasingly rigorous methods, from observational studies to controlled trials to systematic reviews and meta-analyses.

Each step in this journey provides valuable information of different types. While controlled trials remain the gold standard for establishing causal efficacy, dismissing all information from earlier stages deprives us of important signals, particularly for conditions that are rare, complex, or highly individual in presentation.

What Can We Do With This Understanding?

If you're a practitioner (of any tradition), you can transform your observations into more valuable data by documenting them systematically: record specific interventions, dosages, patient characteristics, outcomes (both positive and negative), timelines, and confounding factors. Be alert to patterns across multiple patients while maintaining appropriate skepticism about subjective outcomes.

If you're a patient, you can document your experiences systematically too: keep detailed records of interventions, dosages, symptom changes, and potential confounding factors (lifestyle changes, other treatments, etc.). Be aware that while you're the expert on your own experience—no one knows how you feel better than you—your unique experience might not generalize to others.

If you're a researcher, you might mine case reports and clinical observations for research questions worth investigating in more structured research. Design studies that capture real-world complexity using pragmatic trial designs, N-of-1 trials, and mixed-methods approaches that better reflect clinical realities.

The Path Between

The phrase "the plural of anecdote is not data" contains a kernel of truth: individual experiences, subject to numerous biases and confounding factors, cannot provide the same level of certainty as well-designed systematic studies. But the categorical dismissal of anecdotal evidence represents an overcorrection that impoverishes our collective knowledge.

The reality is more nuanced: the plural of anecdote is sometimes misinformation and sometimes a valuable case series. The difference lies not in the number of anecdotes collected but in how they're collected, documented, and analyzed.

By developing a more nuanced approach to evaluating anecdotal evidence—one that considers factors like outcome objectivity, placebo response rates, natural history, specificity, and temporal relationships—we can extract valuable signals without succumbing to uncritical acceptance of every claim. This approach honors both the skeptical commitment to rigorous evaluation and the clinical reality that individual experiences contain valuable information not always captured by averaged trial results. It acknowledges that knowledge advances through multiple complementary pathways, not through controlled trials alone.

Between dismissing all anecdotes and accepting them uncritically lies the path between—an approach that sees individual human experiences as the starting point for discovery rather than a distraction from 'real' evidence. This path requires more nuanced thinking than either extreme, but it's through embracing rather than simplifying this complexity that medicine truly evolves.

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The Path Between: Where Herbalism Meets Philosophy, Science, and Medicine

Thomas Easley — Tue, 11 Mar 2025 14:58:07 GMT

For those who don't know me, I'm Thomas Easley. I've been studying herbal medicine since 1996, and I’ve been in clinical practice since 2001. In 2010, I founded the Eclectic School of Herbal Medicine, and in 2015, I co-authored The Modern Herbal Dispensatory, A Medicine-Making Guide. While I do a fair amount of writing, it's mostly been for my students or book projects, with the occasional series on my school blog.

When I started this Substack, I didn’t have a long-term plan, only a couple of pieces I needed to get off my chest. I've been thinking about how I want to use this platform, and I've decided to take a different approach than you might expect from an herbalist.

What You Won't Find Here

You won't find endless posts about individual plants and their properties. I won't be publishing the typical "10 herbs for [common condition]" content that proliferates across the internet. This isn't because I don't value materia medica—I absolutely do—but because I believe this approach often misses what's most important about herbal medicine.

The Problem with Decontextualized Materia Medica

While it's relatively easy to learn what medicinal plants do and even how to prepare them, the more challenging aspects of herbal medicine are understanding:

Why you might need an herbal intervention in the first place
When herbal approaches are appropriate versus when they might not be
How to determine which therapeutic actions are needed for a specific situation
Which herbs to select from many with similar or overlapping effects

This systematic approach to herbalism—the framework for clinical decision-making—is, in my opinion, far more important than accumulating knowledge about individual plants. Also, this is not something that can be easily learned independently. There are no Western herbal textbooks (yet) that teach clinical pattern identification and differential assessment in a comprehensive way - it’s all taught directly from teacher to student.

Without this systematic understanding, there's a real risk that decontextualized materia medica “facts” become an aesthetically pleasing illusion of control rather than a pathway to healing. People collect herbs and herb knowledge almost as consumer products, accumulating information and bottles without a coherent framework for application. The plants become disconnected objects rather than participants in a relationship.

This commodification serves capitalism more than healing. When herbs are reduced to "this herb for that condition" without systemic understanding, it's perfect for marketing but terrible for actual practice. Companies can sell you the "hot new herb" each month because you lack the framework to evaluate whether you need it or how it fits into a broader approach to your health.

I genuinely care about my plant friends. I don't want them wasted because someone didn't understand what was happening in their body, couldn't accurately interpret their symptoms, or didn't know how to select the right herb for the right situation.

It's easy to develop "herb lust" (a term I’m borrowing from my friend Howie Brownstein) —to become enthralled with the beauty of plants and the magic they can work when thoughtfully selected. But without a system to guide their application, our plant allies often end up as expensive additions to already crowded supplement shelves, used ineffectively or not at all, rather than as meaningful participants in our healing journey.

What This Substack Will Explore Instead

Rather than adding to the abundance of plant profiles already available, I'll be focusing on broader issues—the juicy areas where herbal medicine intersects with mainstream medicine, philosophy, and science.

I'll explore questions like:

How do we navigate between different systems of knowledge without falling into either uncritical acceptance or rigid dismissal?
What can traditional healing frameworks teach us about complex, multifactorial health conditions?
How might we develop more sophisticated approaches to evidence that respect both scientific rigor and clinical experience?
Where do current medical paradigms fall short, and how might herbal approaches help fill those gaps?

These explorations won't just be theoretical—they'll be grounded in my decades of clinical practice, teaching experience, and ongoing dialogue with plants and practitioners across multiple healing traditions.

My First Series: The Space Between Skepticism and Messy Reality

With that in mind, my first series will examine how oversimplified skeptical frameworks shape our understanding of medicine, exploring the gap between clean theoretical divides and messy reality.

I am both a skeptic and an herbalist. These two seemingly disparate approaches exist in dynamic tension within my practice and teaching. For me, skepticism means I hold my own beliefs—herbal or otherwise—up to scrutiny. If a cherished herb or approach fails under critical examination, I’m prepared to update my view. But that doesn’t mean throwing out centuries of accrued herbal knowledge just because it doesn’t fit neatly into a gold-standard RCT. Instead, I’m striving for a more nuanced approach where evidence-based medicine and lived clinical experience intersect. As a skeptic, I apply critical thinking to both conventional and herbal medicine alike - and most especially to my own thoughts, feelings, hunches and intuitions. In future writings, I'll address problematic concepts within herbalism itself - like how terms such as "adaptogen" have become clinically meaningless categories that serve marketing more than medicine.

But before critiquing specific practices or concepts, I believe we need to examine the very frameworks we use to evaluate claims in the first place. This series therefore begins not with an examination of particular herbal approaches, but with an exploration of how we understand, generate, and validate knowledge across healthcare domains.

The series will explore the problems with skepticism without complexity and the ways in which oversimplified frameworks fail both science and patients alike. It's about developing more sophisticated tools for evaluation before applying them to specific questions.

We'll examine topics like:

How identical medications face wildly different regulatory fates across borders
When "just the placebo effect" becomes a conversation-stopper rather than the beginning of deeper inquiry
How our evidence hierarchies illuminate some questions while rendering others invisible
The political economy that determines which research questions get asked and answered

My goal is to invite you into a more sophisticated relationship with evidence, uncertainty, and the inherent complexity of human healing.

What You Can Expect

My posts typically won't be short. They'll be detailed, nuanced explorations that resist oversimplification. I won't shy away from complexity or from acknowledging the limitations of my own perspective. I believe this depth is necessary to do justice to these topics.

I also won't be posting daily or even weekly. Quality takes time, and I'd rather share something substantive and thoughtful than rush to maintain a relentless publishing schedule.

What I can promise is content that:

Respects your intelligence and capacity for nuanced thinking
Draws from both traditional wisdom and contemporary science
Challenges oversimplifications from both mainstream and alternative perspectives
Offers practical insights alongside theoretical explorations

If you're looking for quick fixes or simple answers, this probably isn't the Substack for you. But if you're interested in exploring the path between scientific inquiry, philosophical examination, and herbal medicine, I welcome you to join me on this journey.

-Thomas

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An Analysis of Unaccredited Degree Use in Alternative Medicine

Thomas Easley — Wed, 01 Jan 2025 17:17:13 GMT

Introduction

This article presents a thorough examination of unaccredited degrees in alternative medicine, with a particular focus on herbal medicine. While discussions of credential misrepresentation exist in other fields, there has been a notable absence of a comprehensive analysis of this issue within alternative medicine itself. This piece aims to fill that gap, providing practitioners, students, and the broader healthcare community with a detailed exploration of the legal, ethical, and professional implications of unaccredited degrees.

The Scope of This Analysis

This examination spans several key areas:

The legal framework surrounding unaccredited degrees, including state regulations and federal consumer protection laws
Ethical implications for informed consent and professional integrity
The impact on the professionalization of herbal medicine
Practical guidance for practitioners, students, and educational institutions

Each section builds upon the others to create a complete picture of this complex issue. Rather than simply condemning the use of unaccredited credentials, this analysis seeks to understand why practitioners pursue these degrees, what harm they can cause, and how the field can move forward constructively.

Why This Matters

The issue of unaccredited degrees in alternative medicine extends far beyond credential inflation. It touches on fundamental questions about:

How we establish and maintain professional standards in an unlicensed field
What constitutes meaningful education in the traditional healing arts
How we balance traditional knowledge systems with modern academic frameworks
The role of credentials in establishing trust and competency
The future of alternative medicine in an increasingly integrated healthcare landscape

Most critically, this issue affects public trust and safety. When practitioners display credentials that suggest rigorous academic achievement but actually represent minimal oversight or standards, they compromise their clients' ability to make informed decisions about their care. However, before exploring these implications further, it's important to acknowledge the complex and often misunderstood context surrounding the use of unaccredited degrees

A Note on Context and Complexity

Many practitioners who hold unaccredited degrees obtained them with sincere intentions, often unaware of the distinctions between accredited and unaccredited education. The problem isn't just one of deliberate deception - it often stems from a complex mix of factors including:

Limited understanding of academic accreditation systems
Genuine desire for advanced education in alternative medicine
Lack of accessible, accredited programs in certain fields
Marketing by institutions that obscure their unaccredited status or what it means

This complex reality requires careful examination rather than blanket condemnation. At the same time, I think the impact of unaccredited degrees on public trust and professional credibility demands serious attention from the herbal medicine community.

While the motivations behind obtaining unaccredited degrees may be complex, the legal landscape surrounding their use is clear.

The Legal Framework: State Laws and Federal Consumer Protection

When practitioners or educators advertise unaccredited degrees, they enter a complex legal territory governed by state regulations, federal oversight, and consumer protection laws. While herbal medicine itself remains largely unregulated in many states, the use of academic credentials falls under strict legal frameworks designed to protect consumers from misrepresentation.

Federal Oversight and Interstate Commerce

The Federal Trade Commission (FTC) has jurisdiction over interstate commerce, including online education and consultations. This means that practitioners offering services or education across state lines must comply with both federal regulations and the laws of their state and the states where their students or clients reside. The rise of virtual consulting and online education has significantly expanded the reach of these regulations.

A practitioner in Arizona offering online consultations to clients in Florida must comply with both states' laws regarding the use of academic credentials. Similarly, someone teaching online courses must adhere to the credential requirements in every state where they have students. This creates a complex web of compliance requirements that many practitioners and educators may not fully appreciate.

The Federal Trade Commission Act provides broad authority to address deceptive practices in commerce. Section 5 of the Act specifically prohibits "unfair or deceptive acts or practices in or affecting commerce." The use of unaccredited degrees in professional practice can constitute such deception when used to promote services or establish expertise. This applies to any representation of credentials used to attract or maintain clients. The FTC considers such misrepresentation particularly serious when it influences healthcare decisions or involves payment for services.

The federal mail and wire fraud statutes (18 U.S.C. §§ 1341, 1343) provide additional oversight. These laws make it a federal crime to use mail, telephone, or electronic communications in schemes to defraud. Using unaccredited degrees in professional communications that cross state lines could trigger these statutes, especially when:

Using credentials to solicit clients or students
Promoting services based on misrepresented qualifications
Receiving payment for services while claiming false credentials
Advertising expertise based on unaccredited degrees

The penalties for mail and wire fraud can be severe, including substantial fines and potential imprisonment. The federal government takes particularly seriously any fraud involving healthcare services or educational claims.

While federal oversight provides broad regulatory framework, individual states have developed their own approaches to credential fraud. Let's examine how state-specific regulations complement and sometimes exceed federal protections

State-Specific Regulations

While federal oversight provides a broad framework, all states have consumer protection statutes on the books. These laws, designed to shield the public from deceptive business practices, broadly frown upon misrepresentation in any professional context, and academic credentials are no exception. Using a bogus degree to bolster one's credibility might raise red flags under any state's consumer protection laws, whether they explicitly address academic credentials or not. However some states have gone further than a general prohibition.

Twelve states have taken the extra step to enact legislation specifically targeting the misuse of academic credentials. Their statutes provide clear insights into how seriously state governments view this issue, explicitly outlining what constitutes acceptable credentials and establishing penalties for violations. Let's look at a few key examples of how these states approach credential misrepresentation:

New York's Framework

New York Education Law §224 establishes one of the most detailed frameworks for regulating academic credentials. The law states “…nor shall any person, with intent to deceive, falsely represent himself to have received any such degree or credential, nor shall any person append to his name any letters in the same form registered by the regents as entitled to the protection accorded to university degrees, unless he shall have received from a duly authorized institution the degree or certificate for which the letters are registered.”

Violations under New York law are classified as misdemeanors.

Illinois' Criminal Statute

Illinois takes a strong stance through Criminal Code 720 ILCS 5/17-2.5, which specifically criminalizes false academic degrees. The statute defines a "false academic degree" as any certificate, diploma, transcript, or document purporting to be issued by an institution of higher learning when the person has not completed the indicated academic program.

The law makes it a Class A misdemeanor to:

Manufacture or produce false academic degrees for profit or sale
Use false academic degrees for employment, admission to higher education, or career advancement

Illinois law specifically addresses "institutions of higher learning," defining them as properly authorized public or private colleges, universities, or community colleges located within Illinois or legally constituted to offer degrees in their state of origin.

Florida's Direct Approach

Florida Statute §817.567 takes a particularly direct approach to credential misrepresentation. The law specifically prohibits claiming any academic degree unless it was awarded by an institution meeting strict criteria, including accreditation by agencies recognized by the U.S. Department of Education.

Florida law explicitly addresses the use of doctoral titles, prohibiting individuals with unaccredited doctorates from using "Dr." before their name or using post-nominal letters like "Ph.D.," "Ed.D.," or similar designations that imply doctoral qualification.

Violations in Florida constitute a first-degree misdemeanor and can trigger additional professional consequences, including license or certification suspension.

Legal Implications

The combination of state laws, federal oversight, and interstate commerce regulations creates significant legal exposure for educators and practitioners using unaccredited academic credentials. Each client interaction or class sale, especially across state lines, potentially triggers multiple jurisdictions' requirements.

Educators and practitioners must comply with:

Their own state's laws regarding credential use
The laws of each state where they have clients
Federal regulations governing interstate commerce
Consumer protection laws in multiple jurisdictions

For practitioners operating online, a single online consultation or course could be subject to oversight from multiple state authorities and federal regulators.

These regulations create significant legal exposure for practitioners using unaccredited credentials in professional practice or education. But the law only sets minimum standards for behavior. Even in jurisdictions with limited regulation, practitioners face deeper questions about their obligations to clients and profession.

The Ethical Dimensions of Unaccredited Degrees in Alternative Medicine

Beyond the legal ramifications, the use of unaccredited degrees raises deep ethical questions about the practitioner-client relationship and the integrity of the herbal medicine profession. When we grapple with these questions today, we're engaging with ethical principles that healers have wrestled with for millennia. Every time we think about how to represent our training honestly or acknowledge the limits of our expertise, we're touching on fundamental issues that have shaped healthcare ethics throughout history.

The earliest known code of medical ethics, the Hippocratic Oath (circa 400 BCE), established foundational principles that continue to be relevant in contemporary practice. While most people know the oath for its iconic phrase "first, do no harm," it also addressed issues of professional integrity and the honest representation of one's abilities. Physicians swore to acknowledge the limitations of their training and to refer patients to more qualified practitioners when necessary. This was about recognizing the inherent power imbalance in the healer-patient relationship and the need for humility and transparency.

But the Greeks weren't alone in wrestling with these issues. Traditional healing systems across the globe developed their own ethical frameworks. Chinese medicine embraced the 醫德 (yi de) or "medical morality" tradition, emphasizing the moral character of the healer as integral to the practice of medicine. Ancient Ayurvedic texts like the Charaka Samhita discussed practitioner ethics, highlighting the importance of proper training and the profound ethical responsibilities that accompany the power to heal. These traditions, diverse in their specifics, shared a common understanding: the ability to intervene in another's health and well-being demands a deep ethical commitment.

In the West, the 18th and 19th centuries ushered in efforts to professionalize medicine and establish clear ethical standards. Thomas Percival's seminal work, "Medical Ethics" (1803), spoke of the importance of honest representation of qualifications – a direct ancestor to our current concerns. In the 20th century, the work of medical philosophers like Tom Beauchamp and James Childress gave us the four core principles of modern bioethics: autonomy (respect for individual choice), beneficence (promoting good), non-maleficence (avoiding harm), and justice (fairness and equitable treatment). These principles now provide a robust framework for evaluating ethical issues in all forms of healthcare.

So, why does this historical journey or modern bioethics matter for herbalists today? Because the relationship between practitioner and client has always rested on a foundation of trust. Throughout history, societies have sought ways to ensure that practitioners are properly trained and honestly represent their abilities. We, as herbalists, inherit both the wisdom and the ethical obligations of our predecessors. Traditional healers throughout history maintained their integrity through demonstrated competence, ethical practice, and a deep commitment to the well-being of those they served. Ethical practice isn't just about following rules; it's about honoring a legacy of trust and responsibility that stretches back through the ages.

It is with these principles at the forefront that we can truly begin to evaluate the ethical dimensions of unaccredited degrees in our field. One of the core principles of modern bioethics, particularly relevant to this discussion, is that of autonomy.

Autonomy and Informed Consent

The principle of autonomy - respect for an individual's right to make informed decisions about their own care - forms the heart of ethical practice. When practitioners present credentials that suggest a level of academic achievement they haven't actually attained, they compromise their clients' autonomy in several critical ways:

First, they distort the information clients use to make healthcare decisions. Credentials serve as proxies for expertise and training. When these credentials misrepresent the practitioner's actual education, clients make choices based on false premises about their provider's qualifications.

Second, they create an imbalance in the therapeutic relationship. Clients naturally defer to practitioners they believe hold advanced degrees, potentially placing more trust in recommendations than they would if they understood the true nature of the practitioner's training.

Third, they undermine the very foundation of informed consent. True informed consent requires not just disclosure of intervention options, but also accurate information about the qualifications and expertise of the person providing care. When credentials are misrepresented, even unintentionally, the entire framework of informed consent becomes compromised.

Beneficence and Non-maleficence

Beneficence demands that those involved in healthcare and health education act in their client's best interests. This includes being honest about their qualifications and limitations. Using unaccredited degrees may seem harmless - after all, the practitioner still provides the same care regardless of their credentials. However, this view overlooks several important considerations:

The degree itself may represent inadequate training, potentially leaving the practitioner ill-equipped to recognize conditions beyond their expertise.
Clients may make different healthcare choices if they understood their practitioner's actual qualifications.
The relationship of trust becomes compromised when built on misrepresented credentials.

Non-maleficence extends beyond avoiding direct physical harm. Psychological harm can occur when clients discover their trust was misplaced. Financial harm may result from paying for services based on falsely implied expertise. Professional harm affects the entire field when credential misrepresentation damages public trust in alternative medicine.

Justice and Fairness

The principle of justice in healthcare ethics encompasses both fair distribution of resources and equitable treatment of individuals, and unaccredited degrees pose several significant challenges to these principles. First, they create fundamentally unfair competition with practitioners who have invested substantial time and resources in accredited education. This goes beyond simple market advantage - it actively distorts the professional landscape and devalues legitimate academic achievement in ways that undermine the field's integrity.

The impact of unaccredited degrees on vulnerable communities raises additional ethical concerns. In disadvantaged neighborhoods and among populations with limited healthcare options, people often lack the resources and background knowledge to investigate practitioners' credentials. They may place their trust in impressive-sounding degrees without understanding that these credentials lack legitimate oversight or standards. This dynamic doesn't just mislead - it exploits existing inequities in healthcare access.

The widespread use of unaccredited degrees also undermines efforts to build equitable professional standards within alternative medicine. As our field works toward greater integration with conventional healthcare, credential misrepresentation creates significant barriers to establishing fair and consistent standards. This ultimately affects not just individual practitioners but the credibility and accessibility of alternative medicine as a whole.

Professional Ethics and Truth Telling

Let's start with something fundamental: the obligation to be truthful about who we are and what we know. In herbal medicine this extends beyond just being honest about interventions - it means being completely transparent about our qualifications and the limits of our expertise.

When practitioners use unaccredited degrees, they often engage in subtle forms of deception that can be hard to recognize at first. It's not usually about outright lying - it's more about creating implications that don't match reality. For example, when someone uses the title "Dr." from an unaccredited institution, they're suggesting an equivalence with accredited doctoral education that simply isn't there. Even if they believe deeply in the quality of their education, presenting it through unaccredited credentials implies a type of external validation that doesn't exist.

When practitioners display questionable credentials, the damage ripples through our entire field. The public's discovery that an herbalist's qualifications aren't what they seem doesn't just erode trust in that individual - it casts doubt on all of us. Each revelation of misrepresented credentials makes it harder for the next herbalist to establish the trust necessary for effective care, regardless of their training or expertise.

The impact extends beyond our immediate practice into our relationships with conventional healthcare providers. Many doctors, nurses, and other medical professionals have shown genuine interest in collaborating with qualified herbalists. They recognize the value we can bring to patient care, but they need confidence in our training and professional standards. When they encounter practitioners with questionable credentials, their willingness to refer patients or engage in collaborative care understandably diminishes. This breakdown in professional trust ultimately limits our ability to serve our clients effectively and integrate herbal medicine into broader healthcare conversations.

The ethical problems of credential misrepresentation run even deeper when we look at how systematically some institutions manufacture an illusion of legitimacy. These organizations don't just offer questionable degrees - they create entire ecosystems designed to obscure their lack of legitimate oversight.

Manufactured Legitimacy

When we look closely at how diploma mills operate (a phenomenon so widespread it warrants its own Wikipedia entry), we see that their tactics deliberately exploit gaps in public understanding about professional credentials. They don't just offer questionable degrees; they create entire ecosystems of false legitimacy that can deceive even well-meaning practitioners.

The Accreditation Facade

Many diploma mills create or join their own "accrediting bodies"—often called “accreditation mills.” These organizations sound official but lack recognition from legitimate oversight agencies. They might call themselves the "American Association of Drugless Practitioners” or the "The Examining Board of Natural Medicine Practitioners,” using impressive-sounding names to mask their lack of actual authority or standards.

These organizations often cross-validate each other, creating circular networks of false legitimacy. School A might be "accredited" by Organization B, which is "recognized" by Association C, which was founded by the same people running School A. To an outsider, this web of relationships can appear legitimate, but it's essentially an elaborate shell game.

Professional Association Manipulation and the Perpetuation of Mediocrity

Some diploma mills affiliate themselves with professional associations designed to provide a veneer of credibility - impressive-sounding groups like the "Association of Natural Health Practitioners" or various self-created "Boards" of Alternative Medicine. While legitimate professional associations exist in alternative medicine, these questionable organizations often share common red flags: extremely high acceptance rates, minimal verification of member credentials, and leadership comprised of individuals often holding unaccredited degrees themselves.

I think what makes this system particularly dangerous is how these organizations then create certification processes to perpetuate their legitimacy. Their board examinations typically feature remarkably high pass rates compared to legitimate professional exams, content that reinforces problematic or outdated information, and testing methods that fail to adequately assess clinical competency. This creates a dangerous cycle of incompetence where inadequately trained individuals become "board certified" to practice and teach others, perpetuating and amplifying misinformation throughout the field.

This ecosystem of manufactured legitimacy creates an even more fundamental problem: the corruption and degradation of herbal medicine knowledge itself. When institutions prioritize empty credentials over deep understanding, both traditional wisdom and scientific understanding suffer.

The Degradation and Corruption of Knowledge

Traditional herbal medicine developed through careful observation over generations, with practitioners learning to recognize subtle patterns and understanding the complex interactions between plants and people. This depth of knowledge requires years of careful study and practical experience to master.

Diploma mills replace this rich tradition with oversimplified formulas and protocols. They often reduce complex traditional systems to cookbook-style approaches, teaching students to match symptoms with herbs without understanding the underlying principles or potential complications. This creates practitioners who know enough terminology to sound knowledgeable but lack the depth of understanding necessary for safe and effective practice.

Many of these institutions claim to teach "traditional" or "ancient" healing wisdom. In reality, they often present a dangerous mishmash of poorly understood concepts pulled from various traditions without proper context. This leads to several serious problems:

Traditional knowledge gets stripped of its cultural context and safety frameworks, leading to inappropriate applications of potentially dangerous practices.
Complex traditional concepts get reduced to marketable soundbites, losing the subtle understanding that made them effective in their original context.
Legitimate traditional practitioners find their carefully preserved knowledge being misrepresented and commodified by people with minimal understanding of their traditions.

It’s not just traditional practices, these institutions often promote a fundamentally flawed understanding of science while claiming scientific validity. Their approach typically involves:

Cherry-picking research studies without understanding research methodology or context
Making sweeping claims based on preliminary or poorly designed studies
Misinterpreting basic scientific concepts to support predetermined conclusions
Creating false equivalences between scientific evidence and anecdotal observations

This degradation of knowledge creates a cascade of consequences throughout the profession. When traditional wisdom gets reduced to simplistic protocols, and scientific understanding becomes just a veneer of legitimacy, practitioners emerge with a distorted sense of their own expertise. I think this creates a dangerous form of overconfidence—one where individuals don't just misunderstand herbal medicine, but fundamentally misjudge their own capacity to practice it safely. This manifests not just in clinical errors but in a kind of intellectual isolation that makes meaningful growth difficult. Practitioners trained in environments that discourage critical thinking tend to resist the very experiences that could expand their understanding. They may avoid peer review, dismiss constructive feedback, and react defensively to evidence that challenges their beliefs or competency. This creates isolated pockets within the profession where questionable practices can grow unchallenged.

Having examined the legal requirements, ethical implications, and systemic challenges of credential misrepresentation, we can now consider constructive solutions. The path forward requires careful attention to both individual and collective responsibility.

Conclusion: A Path Forward Through Collective Action

The future of herbal medicine rests largely in our own hands. While the challenge of addressing unaccredited degrees might seem daunting, the solution emerges from practitioners' collective commitment to transparency and service. This isn't about condemning alternative educational pathways—many roads lead to plant medicine expertise—but rather about ensuring that we represent our training with absolute clarity and truth.

The most immediate step toward strengthening our profession involves unflinching honesty about educational credentials. When practitioners have learned through apprenticeships, certificate programs, mentored clinical experience, or independent study, they should say so directly. These pathways often provide invaluable, experience-rich learning, especially when combined with ongoing study and peer review. But clear communication about the nature of one's training builds trust far more effectively than impressive-sounding but questionable titles.

In herbal medicine, the most respected practitioners demonstrate their competence not through displayed certificates but through their ability to engage thoughtfully with peers, share detailed case studies, and participate in continued professional development. Their willingness to acknowledge the boundaries of their knowledge and seek guidance when needed speaks volumes about their professional integrity.

Professional associations can and should play a key role in maintaining ethical standards and promoting transparency. Organizations like the American Herbalists Guild require all members to abide by a code of ethics, which, among other things, requires an honest disclosure of one's educational background. These guidelines remind us that trust builds on truth—that clients deserve to understand exactly what training and expertise inform their care.

The herbal community must also take active responsibility for addressing credential misrepresentation when we encounter it. This means having difficult but necessary conversations about questionable degrees and misleading claims. Silence in these situations implies acceptance, potentially undermining years of work building professional credibility. While these discussions require diplomatic skill, they demonstrate our field's capacity for self-regulation and commitment to high standards.

By consistently choosing integrity over the hollow appeal of unaccredited titles, we demonstrate that herbal medicine represents a vibrant, evolving healthcare discipline committed to the highest professional standards. This commitment sends a powerful message to allied health professionals, prospective students, and the public - while many paths lead to plant medicine expertise, we share an unwavering dedication to honest representation of our qualifications and rigorous development of our skills.

The solution emerges from our collective choices. Each time a practitioner clearly explains their educational background, each time an educator helps students understand accreditation standards, each time a professional organization upholds ethical guidelines, we strengthen the foundation of trust essential to our field's future. This becomes our shared promise - that while the path to plant medicine expertise takes many forms, transparency and integrity light the way forward.

-Thomas M. Easley, Herbalist

A Letter to Mental Healthcare Professionals from an Herbal Practitioner

Thomas Easley — Mon, 09 Dec 2024 12:21:26 GMT

We need to talk about culture. Not primarily the vital work of understanding and honoring ethno-cultural diversity - though that remains essential to healthcare. The systematic barriers, historical traumas, and health disparities faced by marginalized racial and ethnic groups demand our ongoing attention and action.

Instead, I want to discuss a different kind of cultural group you interact with daily, often without recognizing us as a distinct culture at all. We're your "difficult" patients who question conventional treatments. Your clients who bring up herbs, meditation, or environmental factors. The ones who make some of you sigh internally when we start asking about alternatives to medication.

I believe the holistic health-oriented community represents more than just a collection of personal preferences—we are a distinct cultural group with our own values, beliefs, and most importantly, ways of understanding health and illness. While our experiences cannot be equated with the systemic challenges faced by marginalized racial and ethnic groups, recognizing us as a cultural group might transform challenging clinical encounters into opportunities for genuine understanding and improved patient outcomes.

My Journey: Bridging Two Worlds

I write this from multiple perspectives: as a herbal clinician who has worked alongside conventional and within holistic paradigms, as someone who has experienced being that "difficult patient," and as an educator who has spent years teaching healthcare professionals about herbal medicine and our philosophy and culture. Through these lenses, I've witnessed countless interactions between healthcare providers and holistic health-oriented individuals go sideways—not because either party was wrong, but because they were speaking different cultural languages without realizing it.

Let me be clear: I deeply respect conventional medicine and psychiatry. Two of my dear friends with bipolar disorder struggled for years trying natural treatments and finally found life-restoring relief from pharmaceuticals. My father's life was saved by ECT. My goal isn't to challenge the validity of psychiatry but to facilitate better understanding between two often-opposing worldviews.

Understanding Culture in Healthcare

In its broadest sense, culture refers to the shared values, beliefs, practices, and symbols that shape a group’s worldview and behaviors. Anthropologist Edward Tylor, who famously defined culture in Primitive Culture (1871), emphasized that culture encompasses "knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by [humans] as a member of society." Within psychology and psychiatry, culture is often understood as a lens through which individuals interpret their experiences, including health and illness.

While the term “culture” is typically applied to ethnic or national groups, it is equally valid when considering subcultures defined by shared philosophical or lifestyle values. Pierre Bourdieu’s concept of "habitus" captures this well: cultural groups develop shared ways of thinking, perceiving, and acting based on their collective history and practices. In this sense, the Holistic Health-Oriented population —those who value holistic health, anti-reductionism, and natural approaches to wellness—constitutes a culture with distinct explanatory models for health, illness, and healing.

Research Perspectives on Cultural Competency

I think it's important to ground our discussion in existing research on cultural competency in healthcare. Research in cross-cultural psychiatry, particularly Arthur Kleinman's work in Patients and Healers in the Context of Culture, emphasizes that imposing biomedical narratives on individuals with alternative worldviews risks alienating them and undermining the therapeutic alliance. Laurence Kirmayer's research further demonstrates how cultural narratives fundamentally shape how people make sense of their symptoms and what interventions feel appropriate.

This isn't just theoretical - when healthcare providers fail to recognize and respect alternative cultural frameworks, it leads to measurable impacts on health outcomes and treatment adherence. It's worth noting that this dynamic plays out daily in clinical settings, where the disconnect between biomedical and holistic worldviews can create barriers to effective care.

I hope that understanding this research context helps explain why our cultural values and framework are so important to effective healthcare interactions.

Core Cultural Values and Framework

Our cultural framework is built on several foundational principles, each of which manifests in specific ways during clinical interactions:

Holism: We see health as an integration of mind, body, spirit, and environment. This isn't a rejection of science but rather a contextual understanding that views bodies as intelligent systems seeking balance, not machines with broken parts.

In Practice: When a holistic health-oriented patient presents with anxiety, they may resist focusing solely on neurotransmitter function. Instead, they might describe their symptoms in relation to their diet, sleep patterns, work stress, and spiritual disconnection. A culturally competent provider might say, "I hear how interconnected these different aspects are for you. Let's look at how addressing sleep and stress might complement any other interventions we consider."

Anti-Reductionism: Skepticism toward the biomedical model's tendency to reduce complex phenomena, such as depression, to singular causes like serotonin imbalances. This isn't just a rejection of simplistic explanations - it reflects our positive belief in the inherent complexity and interconnectedness of living systems. We seek to understand how multiple factors interact and influence each other, rather than isolating single causes or mechanisms. For us, being "anti-reductionist" means actively embracing the complexity of health and illness

In Practice: A patient might bring in research about gut-brain connection, environmental toxins, and trauma's role in depression. Rather than dismissing these as distractions from "real" treatment, a culturally aware provider might respond, "These connections you're drawing are important. How can we create a treatment plan that addresses these various factors while also ensuring you have support for immediate symptom relief?"

Self-Empowerment: A strong emphasis on personal agency and self-healing, often accompanied by a preference for natural interventions such as diet, herbs, and mindfulness practices over pharmaceuticals or invasive treatments.

In Practice: When discussing treatment options, these patients often want to know not just what to do, but why and how it works. They might ask detailed questions about mechanism of action or request resources for self-study. A culturally aligned response would be to provide in-depth explanations and frame treatments as tools they can actively engage with rather than passive solutions.

Skepticism of Authority: A wariness of institutionalized medicine, often rooted in historical experiences of medical harm or perceived overreach, contributes to resistance toward conventional psychiatric diagnoses and treatments.

In Practice: These patients may challenge standard diagnostic criteria or question the long-term safety data of medications. Instead of becoming defensive, effective providers might say, "I appreciate your careful consideration of these issues. Let me share what we know about both the benefits and limitations of our current diagnostic framework."

Emotional Understanding: We understand emotions - even the deeply challenging ones - as carrying important messages about our relationship with ourselves, our communities, and our environment.

In Practice: A patient experiencing depression might resist framing it purely as an illness to be eliminated. They might say, "I feel like my depression is telling me something important about my life." A culturally competent response would be to explore this meaning while also addressing functional impacts: "Let's honor what this experience might be telling you while also making sure you have support for daily functioning."

The Impact of Medical Trauma on Cultural Identity

I believe it's important to address how medical trauma shapes our cultural identity and healthcare interactions. Many in our community carry experiences of dismissal, invalidation, or harm from conventional medical systems. This isn't just individual experience—it's part of our collective cultural narrative that influences how we approach healthcare.

In my clinical practice, I've seen this manifest in various ways:

People so deeply traumatized by medical experiences that they would rather risk literal death than return to conventional care
Individuals who withhold information about herb and supplement use due to past experiences of being dismissed
Patients who need extensive support from alternative practitioners to rebuild trust with even the most compassionate, informed biomedical clinicians

Understanding this context helps explain why thorough information sharing and respect for our cultural framework isn't just nice to have—it's essential for building therapeutic trust.

A Personal-Professional Perspective

While these theoretical frameworks help explain the importance of cultural recognition, they come to life most vividly in the day-to-day reality of clinical practice. Let me share what this looks like from my perspective as someone who straddles both worlds. When a holistic-health oriented person encounters simplified biological explanations of mental health, they don't just disagree with the framing—they experience it as a form of cultural invalidation. It's worth noting that while modern psychiatric education emphasizes the biopsychosocial model, the practical reality of brief appointments and medication-focused visits can sometimes lead to oversimplified explanations from the most well intended practitioners, that feel reductionist to our community.

I think it's important to recognize that we don't deny biological factors—quite the opposite. We understand biology as inseparable from the whole—environment, spirit, community, purpose. When clinical discussions focus primarily on neurotransmitters or brain chemistry (even when acknowledging other factors), it can feel like our entire contextual framework is being dismissed. Even well-intentioned explanations about "balancing brain chemistry" or "correcting neurotransmitter levels" can inadvertently minimize the complex interplay between biological, psychological, social, and environmental factors that we see as fundamental to mental health.

This is where more nuanced conversations become helpful. For instance, consider how you might discuss depression and its treatment. Instead of focusing primarily on neurobiology, you might acknowledge that while certain medications can be helpful tools, their mechanisms are complex and interconnected with many aspects of how we process emotions and experiences. This approach validates both the potential utility of medication and our cultural understanding of health as a dynamic, interconnected system.

The Power of Nuanced Explanation: A Case Study with SSRIs

I think it's worth examining how this approach works in practice, using SSRIs as an example. When we ask questions about how these medications work, we're not just seeking technical details—we're looking to understand how they might fit within our holistic framework of healing. This is where some research actually aligns beautifully with our cultural preference for complex, interconnected explanations.

2016 research published in Translational Psychiatry revealed something fascinating about how SSRIs work—something that speaks directly to our understanding of the mind-body connection – they begin modifying emotional processing in some people within just seven days of starting treatment, long before the commonly recognized mood improvements at 3+ weeks. This early shift isn't just a side effect—it's fundamental to how the medications work.

This aligns with the cognitive neuropsychological model of antidepressant action that suggests that, when SSRI’s work, rather than directly "fixing" mood, SSRIs first help normalize how we process emotional information—like reducing our tendency to fixate on negative experiences. These shifts in emotional processing create a foundation for the mood improvements that emerge weeks later.

Maybe even more intriguing, neuroimaging studies have shown that in people with depression SSRIs can quickly begin normalizing activity in the amygdala, a brain region deeply involved in emotional processing. This kind of explanation—showing how the medication influences our emotional processing systems rather than just "fixing" brain chemistry—respects both the complexity we value and our understanding of mind-body interconnection.

When you explain medications this way—through their observed effects on emotional processing rather than through outdated chemical imbalance narratives—you're demonstrating something key to working successfully with us: that scientific understanding can enhance rather than reduce our appreciation for the complexity of human experience. You're also showing respect for our cultural preference for detailed understanding and our belief in the interconnected nature of mental health.

The Importance of Full Disclosure

When working with holistic health-oriented patients, this more precise explanation of mechanism needs to be paired with thorough disclosure of potential risks. I understand the clinical rationale for abbreviated discussions about side effects—time constraints, concerns about nocebo effects, and managing health anxiety all factor into these decisions. Some patients prefer minimal detail, just wanting to feel better. However, I'm telling you directly: when you identify someone from our cultural group, we want—and need—all the details.

Volunteering comprehensive information about both common and rare side effects demonstrates not just goodwill but cultural competency. We need to know what to watch for if side effects occur, both common and rare. When you proactively share this information without us having to dig or advocate for it, you build trust and demonstrate respect for our cultural values around informed decision-making. This thorough approach to informed consent aligns with our cultural framework while potentially improving treatment motivation and outcomes. When we understand both the mechanisms and the risks, we're better equipped to make decisions that align with our values while benefiting from conventional treatments when appropriate.

This transparency might seem at odds with conventional clinical wisdom about managing patient anxiety. However, for our cultural group, withholding information—even with good intentions—can damage the therapeutic alliance and reinforce existing mistrust of conventional medicine. Full disclosure isn't just an ethical imperative; it's a cultural one.

Identifying Our Cultural Group

You might wonder how to identify us in clinical settings. While many of us make our perspectives known immediately, others may be more hesitant due to past experiences. A review of reported medications, herbs, and supplements is a good starting place. Be aware that patients who present with a "crunchy" or "hippie" appearance but list no herbs or supplements may be withholding information due to trust concerns.

Common indicators in supplement use often hint at underlying mental wellness challenges that patients are attempting to address through natural means, including:

Ashwagandha
Saffron
Mimosa/Albizzia
Holy Basil
Various "adaptogenic" herbs like:
- Eleuthero, Ginseng, Rhodiola
5-HTP
l-tryptophan
L-theanine
lithium orotate
magnesium threonate
Lavender (tincture, essential oil capsules brand name silexan)

Bridging Trust Gaps

Certain conversation patterns can signal cultural alignment and offer opportunities for building trust. When a patient proactively asks about drug-herb interactions, expresses concerns about long-term medication use, or inquires about "root causes," they're often doing more than gathering information—they're expressing core cultural values around health and healing.

Understanding this cultural framework through the lens of locus of control – a concept familiar to mental health providers – can help explain why respecting these beliefs is crucial for treatment engagement. When holistic-health oriented clients feel their worldview is understood rather than dismissed, it strengthens their internal locus of control and positions them as active participants in their healing journey. This sense of partnership and empowerment often makes them more open to considering interventions outside their usual framework.

To build trust and provide culturally appropriate care for holistic health-oriented clients, mental health providers should consider:

Validating the Client's Worldview: Begin by affirming the client's values and beliefs. For example, acknowledge the legitimacy of their concerns about overmedicalization while introducing alternative ways to understand their experience. Recognize that trust and understanding develop gradually - treatment decisions don't need to be rushed when a client needs time to process information and feel fully heard.

Bridging Explanatory Models: Introduce biological concepts gradually, framing them within the client's holistic perspective. For instance, describe how unprocessed stress affects both the nervous system and emotional resilience, highlighting the interconnectedness of mind and body.

Empowering the Client: Natural-minded individuals value self-agency. Frame interventions as tools they can use to support their natural healing capacity, whether those are chemical, mindfulness practices, herbal remedies, or evidence-based psychotherapies. It's worth noting that providing access to reliable resources is particularly valuable for our cultural group—whether that's detailed information about medications, recommended reading about various treatment approaches, or reputable sources for exploring integrative options. Many of us appreciate having written materials or digital resources we can review thoughtfully at home, especially when making significant treatment decisions. This kind of resource-sharing demonstrates respect for our cultural value of informed decision-making while supporting meaningful collaboration.

These strategies might seem like small adjustments to your practice, but to us they represent something much larger—a fundamental shift in how you approach the therapeutic relationship. When practitioners embrace these methods, they're not just adopting new communication techniques; they're acknowledging and respecting a distinct cultural framework. And this brings me to the heart of what I'm suggesting...

Moving Forward Together

We're not asking you to abandon your training or the valuable insights of modern medicine. We're asking you to apply the same cultural competency you'd use with any other distinct cultural group. This means understanding that our preference for natural approaches isn't just personal choice but part of a coherent cultural framework for understanding health and healing.

Our communities often provide support and validation that we might not find in conventional healthcare settings. Our cultural practices—from herb ceremonies to meditation groups to nature connection practices—aren't just hobbies but vital expressions of cultural identity and healing.

What if your 'problem patients' aren't actually anti-science or anti-medicine? (Sure, some are, but in my experience, they're the minority.) What if, by simply shifting your language and communication style, you could create better therapeutic relationships and potentially improve clinical outcomes? That's all this letter suggests—or perhaps more accurately, postulates.

I encourage you to try this framework on. After all, working with us isn't exactly a walk in the park as things stand now, so what do you have to lose? Maybe, just maybe, viewing these interactions through a cultural lens—whether or not you fully agree with the premise or the definitions—could become a practical tool for overcoming friction and building stronger therapeutic relationships.

I believe the path forward requires openness and nuance from both sides. We in the holistic health-oriented community need to acknowledge when our frameworks oversimplify complex issues, just as we ask conventional medicine to examine its own reductionist tendencies. True integration comes not from defending our respective territories, but from acknowledging the limitations and strengths of each approach while working toward a more complete understanding of human health and healing.

As someone who bridges these worlds daily, I see the immense potential in creating understanding that honors both scientific rigor and cultural wisdom. The first step is recognition—seeing the Holistic Health-Oriented population as a distinct cultural group worthy of the same respect and accommodation you'd give to any other culture. From there, we can build bridges that serve everyone better.

-Thomas M. Easley, Herbalist

Coming soon

Thomas Easley — Fri, 06 Dec 2024 13:09:40 GMT

This is The Path Between.

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The Path Between

Every Medicine Is a Construct

Modern Western Medicine

Traditional Chinese Medicine

Ayurvedic Medicine

Modern Western Herbal Medicine

Why am I telling you all of this?

References

Modern Western Medicine

Traditional Chinese Medicine

Ayurvedic Medicine

Modern Western Herbal Medicine

Other traditions, same pattern

The general case

In Defense of Ouija Boards as Clinical Assessment Tools

It treats the whole person

It has an established history of use

Absence of evidence is not evidence of absence

The method resists standardization, which is a point in its favor

It is safe

It works

The therapeutic relationship carries the work

To Feel Different, You Have to Live Different

Two ways to want to be well

The ancient root: a way of life

How the doctrine got its strange name

The six, one at a time

Air

Food and drink

Sleep and waking

Motion and rest

Retention and evacuation

The passions of the soul

Salerno put it in verse

The man who weighed himself for thirty years

When the bullet really is magic

But not normally

The making and the taking

The door

What good medicine is for

Scope Note:

Further Reading

Moncrieff and Barnes: The Dualists of Critical Psychiatry

The shared floor

Two roads to the same wall

Watch the line move

The line has a date on it

Dissolving the line

What would actually be radical

Notes

Purity Doesn’t Have Units

Who I’m Writing To

Pollution and Order

What Paracelsus Knew

The Body in the World

What the Concern Was Actually About

The Cost

A Different Way of Caring

M, A Year Later

Epilogue

Thinking Tools: Philosophy of Science for the Rest of Us

Part One: The Problem

Two Useless Slogans

Why “Doing Your Own Research” Is Mostly Impossible

Why “Trusting the Science” Doesn’t Work Either

How We Got Here

Part Two: The Thinking Toolkit

Philosophy of Science as the Missing Education

Concept 1: Falsifiability and The Demarcation Problem (What Makes Science Scientific?)

The Duhem-Quine Problem: Why Evidence Is Never Simple

Concept 2: Kuhn, Paradigms and Normal Science

Concept 3: Research Programs and How to Tell If a Field Is Making Progress

Concept 4: Confirmation and Evidence and What It Takes to Support a Claim

Scientific Realism: Should We Believe Theories Are True?

Scientific Explanation: What Counts as Understanding?

Part Three: Putting It Together

A Framework for Evaluating Claims

An Example: Evaluating a Health Claim

The Herbalist’s Dilemma

Calibrated Confidence as the Goal