The Integral Model Answering the Call for Whole Systems Health Care Continuing Education

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• Perm J
• v.12(2); Spring 2008
• PMC3042294

Perm J. 2008 Spring; 12(2): 61–68.

The Integral Model: Answering the Call for Whole Systems Health Care

There has been a revolution in medicine over the past century. Enormous successes can be heralded, from advances in public health to the recent developments in molecular biology, neuroscience, biomedical engineering, and pharmacology. Of course, not all the changes have been good. Indeed, there are many indications that medicine in the 21st century is in crisis. Millions of Americans are without medical coverage and the costs associated with health care continue to spiral upward, making it harder and harder for people to get the help they need. Iatrogenic (medically induced) illness is another significant challenge with the large number of new treatments, resistant strains of microbes, and work overload of many health professionals. Economic pressures reduce the amount of time clinicians can spend with patients, which also contributes to burnout among many on the front lines.

It is clear that science and technology have resulted in vastly improved understanding, diagnosis, and treatment of disease. But the emphasis on science and technology to the exclusion of other elements of healing has also served to limit the development of a model that humanizes the health care encounter. Far too often, modern medicine ignores the importance of the personal and interpersonal dimensions of our experience. Compassion is rarely a selection criterion for medical training and bedside manner is not featured in the core curriculum of most academic health care programs. Physicians are often taught to avoid or suppress the emotions that are connected to states of disease and healing—the patient's and the physician's. For patients and professionals alike, the biomedical model often fails to offer a system that embraces the vast potentials of healing—ignoring or negating completely the possibility for human growth and development in the face of illness.1

And yet, we are meaning-making creatures. As Kaiser Permanente's recent "Thrive" advertising campaign accurately reveals, we are calling for something deeper in our lives, both individually and collectively, as we confront the complexities of illness, disease, and aging. Although there is ample reason for concern about the challenges facing health care today, crisis can also lead to breakthrough and transformation.2 Indeed, we see this happening already. A fresh breeze is blowing through many corridors of our hospitals and clinics. Patients and clinicians alike are demanding that the heart and soul of healing be reinstated. There are many positive developments that speak to an emerging new model for health care—one that acknowledges multiple dimensions of living, healing, and curing—dimensions that go beyond reduction of symptoms. One name for this new model is integral health care.

An integral perspective promotes our capacity to thrive, even under the most adverse circumstances. As emergency room physician, William Benda, MD, writes: "Integral Medicine proposes to be the next step in health care, one that incorporates all dimensions of healing, from physical to spiritual, and ecological to cosmological. This evolution is not only necessary but inevitable and fundamental to solving the conundrum that is our current health care system."^3p33 The purpose of this essay is to give an overview of this emerging new model—and to consider specific ways to apply an integral perspective in your own life and work.

What is Integral Health Care?

The integral model is based on an intuitive understanding of life and reality as an undivided whole. Franklin Merrell-Wolf captured the essence of the integral impulse in his conviction that science, in its fullest sense, cannot be restricted only to objective material, but must, as well, be open to other ways of knowing and being.4 This speaks to the need to attend both to the rational and to the intuitive; the thinking as well as the feeling; and the biological, sociological, and spiritual dimensions of our human experience. An integral approach is dynamic and grounded in an appreciation for the only constant in nature being change and transformation.

One of the first modern attempts to bring an integral approach to health care was advanced more than 20 years ago in a book entitled Mind, Body & Health: Toward an Integral Medicine, by James Gordon, Dennis Jaffe, and David Bresler.5 Speaking to the many challenges of western medicine at that time, they noted that integral medicine physicians were rediscovering the healing potentials of the patient-physician relationship. Being concerned with the whole person rather than the disease, the authors called on physicians to consider the possibility of a life force that is manifested mentally, physically, and spiritually, and that is at the ground of human development and healing.

Now in the 21st century, several new books and conferences have helped to fuel the development of this integral model. Philosopher Ken Wilber6 applies his philosophy to the field of health care. Developing a quadrant system, he maps the lines and levels of integral philosophy to include both inner and outer experience, and private and public spheres of exchange (Figure 1).7

Integral Medicine Typology.

Adapted and reprinted with permission from the author and the publisher, Wilber K. An integral theory of consciousness. Journal of Consciousness Studies 1997 Feb;4(1):71–92.

In Consciousness and Healing: Integral Approaches to Mind Body Medicine, my colleagues and I explore the integral terrain as it relates to health and healing through various forms of expression.8 Contributions by more than 65 authors represent both the depth and the breadth of this emergent field, including the personal and the collective aspects of health and healing. For physician Elliott Dacher, MD, integral involves a system that is "immune to life's adversities, including disease, aging, and death"^9p3—and that stops at nothing short of authentic happiness and genuine wholeness.

Patients and clinicians are each comprised of psychological, social, cultural, biological, and transpersonal (going beyond the personal) dimensions, which can come together in meaningful synergy in the context of health care1 and the creation of optimal healing environments.10 An integral practice exists in widening and deepening relationships with yourself, your family, your culture, your connection to the natural world, and to the great mystery of life. It includes your capacity to review what you did well today and to acknowledge yourself for the small things that happened in the day. In this way, the integral perspective is a holistic approach. It is multidimensional and recognizes that to focus exclusively on one level, the physical body for example, represents a temporary solution at best.

An integral perspective is as much about healing as it is about curing. Just as you might work to mobilize your patients' antibodies to fight disease, integral health care involves in equal measure harnessing your patients' desire for health and will to live. From the integral perspective, these qualitative domains are as significant as the role of scientific information and technology. In addition to the science of diagnosing, treating, or preventing disease and damage of the body or mind, this is a model that seeks to heal—even in the face of potential death and dying. Ultimately, the integral perspective calls for a whole system shift from a disease-centered to a healing-centered model for health care.

An integral perspective honors multiple ways of knowing—represented by different cultural views and systems of healing. It moves beyond cultural competence, in which you are required to consider different worldviews in the course of working with diverse ethnic and cultural groups, to cultivating a deep appreciation and humility for the divergent systems of health care that coexist in the modern medical context. Chinese medicine, curanderismo,^a spiritism, Christian Science, and evidence-based medicine—each offers insights into healing. In this way, an integral model is inclusive of both conventional and alternative approaches, but always with a sense of discernment for what is true for the needs of your patient. And in recognizing different ways of knowing and understanding, we need a model that includes the subjective (inner experiences), the intersubjective (shared cultural experiences), the societal (shared objective experience), and the scientific (third person/objective information). Each of these dimensions requires a different set of assumptions, methods, and means of communicating.

Ultimately, however, integral health care is not about the tools or techniques you carry in your medical bag. Rather, the key to an integral approach is you, the holder of the bag.6 Whether you are a doctor, nurse, social worker, educator, nutritionist, or administrator, it is about your own transformation as a healer and the nurturing of yourself as a healthy human being. By adopting an integral perspective, you may begin to restore wholeness in your life and work. By cultivating balance, whether at work or at home, you can find a supportive framework for your own growth and well-being. By considering the beauty of a wildflower, playing heartfully with a child, laughing with a friend, or expressing yourself through art, you are finding a deeper way of living.2 Integral health care is concerned with creating life-enhancing ways of being in the world, through your encounters with patients, coworkers, family, and finally yourself.

Applying Integral Health Care to Clinical Practice

Of course, this can be easier said than done. In the course of a busy day, is there really time to add one more thing? Or, in this case, to add everything? The answer is a simple yes. I base this on scores of in-depth interviews and focus group discussions I have conducted with nurses, doctors, social workers, and psychologists during which I asked them how they bring these philosophies into their practice. I have learned that it can be done in a variety of simple ways—ways that reduce the burden on the caregiver—and ultimately lead to greater fulfillment with each and every case. Whether you are treating heart disease, cancer, an immune disorder, or some type of stress-related condition, there is a place for integral health care in every facet of your life and work. Let us focus now on some very practical tools for including the personal, the interpersonal, the transpersonal, the institutional, and the scientific aspects of integral health care into your daily life and work (see sidebar: Essential tools to create integral health care).

Essential tools to create integral health care

Personal/Subjective

With increasing emphasis on patient-centered care it's vital to consider your own inner experience. Do you get off-kilter as you rush from patient to patient on a busy day? Many health professionals have developed little practices to help them stay centered. These include taking a quick walk outside, meditating (either focusing gently but firmly on your breath, or repeating a meaningful or healing words to yourself repeatedly) for five or ten minutes, setting an intention for the well-being of yourself and those around you, listening to some inspiring music on your MP3 player, or finding "positive distractions" such as waterfalls, art work, or a beautiful view from a window. For some, it is helpful to take one or two minutes between patients of what educator and family physician, William Miller, MD, calls good "inner housekeeping" (personal communication, 2007).^b He suggests finding easy ways to clear the mental and emotional space between one complex case and another. For example, blow up a balloon and watch it fly away, releasing your focus on one person as you prepare to be fully present for the next. Or, find a moment for creative expression: writing a brief haiku or carrying a sketchpad and charcoal pencil with you. The practice can be anything, as long as it is done with a sense of purpose or intention.

By acknowledging the personal responsibility you carry, you may bring awareness to the ways in which you are unsure, vulnerable, or scared. Given that you deal with life and death matters everyday, these are healthy and realistic emotions. From this place of open self-disclosure, visualize being in a situation where you have been truly effective. Use your imagination to help you to bring your best self to the health care encounter.

You may wish to take a few minutes at the end of work to review what you did well and to acknowledge yourself. Keeping a journal has been shown to be very beneficial to people as they reflect on their lived experience.11 You can make more time in your week to spend with your family or find ways to get involved with your community in nonwork-related activities. In these moments, you are taking the opportunity to feed your soul and psyche, giving yourself resources to deal effectively with the many complex issues, emotions, and interactions that occur in the course of your work.

Whether you are a doctor, nurse, social worker, educator, nutritionist, or administrator … the key to an integral approach is you … your own transformation as a healer and the nurturing of yourself as a healthy human being.

Interpersonal

As you develop ways to center yourself in the midst of a storm, it becomes easier to bring more awareness to all the social interactions that define your day. For example, as you allow your attention to shift inward, you might inquire: are there ways in which, out of self-protectiveness, you have closed yourself off from your patients and coworkers? How can you find a place of personal wholeness and bring that grounded and authentic sense of presence to all of your personal encounters?

The interpersonal domain focuses on the nature of the connections between people. Tom Janisse, MD, editor of The Permanente Journal, describes a move from the physician-patient relationship to a person-person relationship.12 Remembering the beauty of our collective humanity can transform a routine examination into a deeply therapeutic exchange. By creating an intersubjective (person to person) space, through language that engages your patient, nonverbal communication that invites trust, and deep listening, the clinician-patient relationship can become a kind of "safe container with limitless creative possibility."13

Many patients today are calling for more personal connections with their clinicians—but not just any connection. Enhancing your capacity for authentic communication means learning about the most appropriate ways to express yourself. Good communication is not focused on you, or only on the delivery of information, it is about truly engaging with others, learning from them, actively listening, and even following their lead when appropriate (see sidebar: Engaging in an integral conversation). Adopting an "inquiry approach" allows you not just to solve or to interject, but to participate in a process of deep engagement and mutual learning (Cassandra Vieten, PhD, personal communication, 2007).^c Being respectful of the different ways each individual's illness experience can be viewed, you may wish to work with your patient's perceptions of their illness (in addition to yours) to clearly formulate a collaborative healing intention that you both can buy into over the course of treatment.

Engaging in an integral conversation

Encourage your patient to bring their full self to the encounter, empowering them in various ways. Research shows that many means of expression and inquiry can aid the healing process.14,15 Through modalities such as art therapy, guided imagery, and journal writing, whether you guide them or recommend someone who can (now available in most major health care settings), you can help create a place for your patient to explore the meaning of their illness or disease. In this process, you gain a deeper appreciation for your own role in their life journey—and their role in yours. Even in the briefest recommendation for a patient to begin to keep a journal of their feelings, to draw, or to create poetry you are acknowledging their whole person—mind/body/spirit—in the context of their unique past, present, and future.

Working in a collaborative way with the families of your patients offers new paths to healing—remembering always that healing and curing may not be the same thing at all. With an appreciation for the cultural depths of experience, you may create openings to embrace other types of healing practitioners. By encouraging open communication that allows the curandero, herbalist, acupuncture expert, energy healer, or other practitioner to become part of the healing team, you can create a space for your patients to rely on their own healing systems in partnership with the medical model. Rather than feeling threatened, or even in the context of being honestly concerned for your patient's safety, an open-minded spirit of inquiry into healing approaches that are different from your own can validate your patient's motivation toward taking greater responsibility for their own health.

It's vital to remember that you can't be all things to all people. As such, the integral perspective is firmly rooted in a team approach. As nurse and author, Barbara Dossey noted during a recent conference on integral health care,16 creating a collaborative environment involves looking around for those who are there to support you. The simple act of appreciating what others bring to the complex issues within health care today makes their situation better, strengthens your collaboration, and ultimately builds more effective and supportive lines of communication. Working together as an integral whole serves you and your patients. Developing emotional intelligences including empathy and trust for the various people and roles of your health care team can enhance the work situation for everyone.

You may wish to engage in shared decision making, for example, as a way of building a collaborative health care relationship. Group visits are a strategy that Dr Miller has found helpful. You can use them to cultivate a greater sense of wholeness, allowing you to experience yourself in relationship to community, build collaborations, and develop respect for team members. Shared clinical appointments are also an option, as you look with your colleagues for points of agreement regarding any clinical encounter. Both of these approaches help create a collaborative environment that fosters trust, reduces stress, facilitates effective communication, and enhances team spirit.

For cardiologist, Mitchell Krucoff, MD,17 an integral approach can be as simple as taking 60 seconds prior to surgery to bring the team together, once the patient is on the operating table, to recite Mother Teresa's prayer for the physician. This brief ritual, according to Dr Krucoff, helps to transform the surgery suite into a healing center, reminding the medical team of the faith and trust the patient is putting into their hands. It also provides a way of bringing the spirituality of the clinicians into the mundane aspects of a clinical encounter. In your own practice, you may not wish to incorporate prayer, but even pausing for a collective intention for well-being can set a new frame for your health care encounters. Finding common rituals and symbols can deepen the shared culture of the clinical team, helping to support collective healing intentions and actions.

Another useful practice is to assess your social support system. Nurse educator, Carol Picard (personal communication, 2007)^d urges you to consider the resources that are available to you. Take a few minutes to reflect on what you are doing, who you are hanging around with, and whether or not these activities and people support and sustain you, or deplete you. Remember the power of humor to help move through difficult or challenging situations. Find a set of friends and colleagues with whom you can share a light or playful moment; this goes a long way on a busy day.

And as you expand the interpersonal in your life, you may find it helpful to talk with others about how you're feeling. Find opportunities to share the tools you have developed to enhance your work life and practice—and ask your colleagues to share what works for them. As you cultivate a culture of learning, you may wish to do some role playing about ways to deal with complex issues or difficult interpersonal relations.

Institutional

At times, the sociopolitical and economic dimensions of health care can seem overwhelming. There are so many interests at stake, and so many complex relationships between institutions and individuals. In the integral model, there is a shift from a disease-centered approach to one that seeks to build optimal healing environments.10 This requires attention to all aspects of the environment, from the buildings themselves, to the accessibility of those buildings by all the people who bring their life experiences or inner environments with them to the various health centers. What is being called for are organizations that align hospitals, physicians, nurses, alternative practitioners, and communities to optimize patient care. But the focus of a fully integral system also includes the workplace, the home, and the individual. It spans the distance from bedside to boardroom, janitors to CEOs.

As the old adage says, out of crisis comes opportunity. This unique moment in time is poised with potential for major structural changes in our health care system. The public is calling for something more, and many of the leaders in hospitals and government recognize the need for whole system change. As you aspire to change, remember that your voice as a clinician matters. Encourage leaders to create incentives for the adoption of integral principals and to allocate resources toward them.

If you are a hospital administrator, there are many ways to begin to bring the high-tech/high-touch dimensions together. A recent book, Reinventing the Patient Experience: Strategies for Hospital Leaders,18 is filled with valuable tips for increasing quality and renewing the trust of the community. Christianson et al found that many hospitals are beginning to employ a multi-faceted strategy to restructure the patient experience. This strategy includes environmental design, in which healing spaces are created to minimize stress through artwork, water features, gardens, soundproofing, optimizing family involvement by designing larger rooms with kitchens, and reducing the physical barriers between patients and caregivers. It includes the ways in which nurses and physicians are being encouraged to create more personalized relationships with patients to help reduce patient anxiety, enhance communication, and promote healing. It includes making complementary and alternative practices, as well as spiritual support, available to inpatients. And it also includes hiring and rewarding staff who embrace integral values, recognizing that change takes time and requires patience. Health care administrators who are leading the way are being supported by benefits in patient care, safety, communication, satisfaction, team building, and ultimately, bottom line health and economic benefits.

The Role of Science in Integral Health Care

Whereas much of the writing on the integral health care model focuses on aspects that are underemphasized in the current culture, it also incorporates and rests firmly on an evidence-based approach. Data from many scientific studies support the overall value and efficacy of various elements of integral health care.11,14,15,18 But how can you stay on top of the bountiful supply of new data that arrives in journals on a daily basis? How can you differentiate reliable data from data based on poor research designs?

Developing your skills as a clinician-learner is a first step. Learning to read and critically evaluate the evidence is essential. There are courses through continuing professional development that can help you to identify the key elements in evaluating a journal article, for example. Learning some very basic elements of statistics can deepen your understanding of what is claimed in various technical reports. In all of this, you may be served by finding problem-based learning programs that allow you to engage the new material with a focus on learning, self-evaluation and reflection, and use of evidence,19 rather than those that are more heavily subject oriented and didactic.20

Start a journal club to share what you are learning and to discuss the strengths and weaknesses of various reports. Recall that evidence can take many forms, from the randomized controlled trial, to the case study, to epidemiological reports, to first-person accounts. Acknowledge that the face of health care is changing as patients rely increasingly on the Internet to provide information on specific conditions and treatments. Get familiar with these Web sites and bookmark those that have the most reliable information. Engage in a collaborative process with your patients. Discuss these Web sites together and help guide them in their interpretation of what they are learning. Allow yourself to expand with their needs and perspectives.

As you seek to examine the data, it is helpful to consider your own biases and points of resistance to new information. How do you stay open to new ideas that may contradict some of your long-standing assumptions about the best ways to treat illness and disease and to promote health and healing? Researcher John Astin has conducted a survey of health professionals and looked at the way in which they resist new sources of data21—from being too busy to being reluctant to adopt approaches that were not part of their conventional training. Learning to address your own barriers to integration of new information is an important key to becoming an integral clinician. This is especially important as more and more data are being amassed to support or refute alternative and complementary forms of therapy—modalities that often have little in common with the principals of western-based treatments.

Ultimately, an integral perspective requires a deep examination of your core assumptions about reality and your place in it. Standard science holds that objective truth is arrived at through discovery of causal laws of the natural world that exist independently for all time and for all human beings. When it comes to the human condition, an integral perspective suggests that so-called objectivity may need to be fundamentally transformed. In fact, no science and no medicine is possible independent of consciousness and the awareness that you bring to your personal experiences, and to those you treat.

Integral Transformation

As you open to pain and suffering, as well as joy and human flourishing, you begin to see these experiences as catalysts for transformation—your own, your patients, your colleagues, your society, the institutions that you work with, and ultimately your relationship to the sacredness of life. Holding this view of transformation can liberate suffering into a vehicle for healing. As physician Rachel Remen tells us:

"In times of difficulty, meaning strengthens us not by changing our lives but by transforming our experience of our lives. The Italian psychiatrist Roberto Assagioli tells a parable about three stonecutters building a cathedral in the Middle Ages. You approach the first man and ask him what he's doing. Angrily, he turns to you and says, "Idiot! Use your eyes! They bring me a rock, I cut it into a block, they take it away, and they bring me another rock. I've been doing this since I was old enough to work, and I'm going to be doing it until the day that I die." Quickly you withdraw, go to the next man, and ask him the same question. He smiles at you warmly and tells you, "I'm earning a living for my beloved family. With my wages I have built a home, there is food on our table, the children are growing strong." Moving on, you approach the third man with the same question. Pausing, he gives you a look of deep fulfillment and tells you, "I am building a great cathedral, a holy lighthouse where people lost in the dark can find their strength and remember their way. And it will stand for a thousand years!" Each of these men is doing the identical task. Finding a personal meaning in your work opens even the most routine of tasks to the dimension of satisfaction and even joy. We may need to recognize meaning for the resource it is and find ways to pursue it and preserve it."^22p446–7

As this story reminds us, we are meaning-making creatures. We can choose how to ascribe meaning to any aspect of our experience … and to help others in this search to make sense of what they are coping with in their health care journey.

Ultimately, an integral health care philosophy is a call to action for clinicians and patients alike. Medicine is in trouble. Each of us carries the responsibility to help craft a new, better-fitting model. Simply by taking the time to consider an integral perspective, you serve as a hospice worker for a dying paradigm. In so doing, you must be gentle with yourself, with others, and with a system of medicine that is struggling with its very existence. Change can be hard. But it is also revitalizing and ultimately transformative.

Just as one paradigm dies, so another is born. For this, you may enthusiastically offer yourself up as midwife. As you engage in this endeavor to bring a new life into the world, you are not alone. Together we can change the future. Karen Wyatt, a hospice physician and integral practitioner, writes so poetically: "To practice medicine from an integral perspective is certainly no easy task. But it offers an opportunity to transcend the limits of reductionistic thinking and the possibility of true spiritual growth for ourselves. And once the first step is taken toward the larger view, there is no turning back. To become an integral practitioner is to reach, ever and unceasingly, like the tenacious tendrils of a budding seed, toward the transcendent, ineffable light."^24p220 As you build an integral perspective into your life and practice, may you find nourishment for all aspects of your being.

Footnotes

^a curanderismo, also known as Latin American healing or Latin American folk medicine, is a holistic form of folk healing based on traditional beliefs common in Latino communities, particularly in the southwestern US, using prayer, herbal medicine, spiritualism, etc.

^b William Miller, MD, Family Medicine, Lehigh Valley Hospital and Health Network. Interview by Marilyn Schlitz, MD, at the Esalen Institute, Meeting on Optimal Healing Environments, 2007 Sep 25.

^c Cassandra Vieten, PhD, Research Psychologist, Institute of Noetic Sciences. Interview by Marilyn Schlitz, MD, at the Esalen Institute, Meeting on Optimal Healing Environments, 2007 Sep 25.

^d Carol Picard, President of the Honor Society of Nursing, Sigma Theta Tau International. Interview by Marilyn Schlitz, MD, at the Esalen Institute, Meeting on Optimal Healing Environments, 2007 Sep 26.

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Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042294/

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