chase - the body multiple

THE BODY MULTIPLEIntegral Medicine as Heuristic of How

Michele Chase

Reviewed: Mol, A. (2002). The Body Multiple: Ontology in Medical Practice. Durham, NC, and London, United Kingdom: Duke University Press.

The Integral framework provides us with foci of awareness (quadrants, levels, lines, states, types) that we use as lenses for viewing various disciplinary localesfor instance, medicine. We sometimes think of this elegant tool as a view from above (which is also the perspective from which we engage in scholarship). However, while acknowledging the AQAL models power, let us focus here on what is normally considered subtextnot the view from the ground so much as a complementary Integral: what I am calling the Heuris-tic of How. This heuristic changes the metaphor: Integral inquiry not now enacted through using AQAL as a tool to map aspects of something else (by viewing, locating, differentiating, applying) but through practicing Integralthe ever-present subject being How. As we go along, we will see implications for medicine, not the least of which is integration in practice. In The Body Multiple: Ontology in Medical Practice, Annemarie Mol (2002), Socrates Professor of Political Theory at the University of Twente in the Netherlands, practices a research and scholarship of How (rather than focusing on Whatdisease, modalities, or the discipline of medicine; or Whopractitioners, pa-tients, caretakers).1 Her four-year ethnographic praxiology, investigating atherosclerosis of the lower limbs as addressed in a Dutch hospital, brings us into a medical microcosman intimate view. But she entices us to read it with an eye to the How rather than to the details of What and Who: she says her book is not a field report but an exercise in empirical philosophy (p. 4). Note subtle differences arising from a focus on How, as Mol describes: It is possible to refrain from understanding objects as the central points of focus of different peoples perspectives. It is possible to understand them instead as things manipulated in practices. If we do thisif instead of bracketing the practices in which objects are handled we foreground themthis has far-reaching effects. Reality multiplies. If the practices are foregrounded there is no longer a single passive object in the middle, waiting to be seen from the point of view of seemingly endless series of perspectives. Instead, objects come into be-ingand disappearwith the practices in which they are manipulated. And since the object of manipulation tends to differ from one practice to another, reality multiplies. The body, the patient, the disease, the doctor, the technician, the technology: all of these are more than one. More than singular. This begs the question of how they are related. For even if objects differ from one practice to another, there are relations between these practices. Thus, far from necessarily falling into fragments, multiple objects tend to hang together somehow (pp. 4-5).2 The integrating question is How. Mol tells us that foregrounding practice turns doing anthropology into a philosophical movebut away from epistemology, or the relation between knowing subjects and their objects. The ethnographic study of practices does not search for knowledge in subjects who have it in their minds and may talk about it. Instead, it locates knowledge primarily in activities, events, buildings, instru-ments, procedures, and so on. Objects, in their turn, are not taken from here as entities waiting out there to be

Journal of Integral Theory and Practice, 6(4), pp. 137145

Correspondence: Michele Chase, 39490 Albany Common Unit V, Fremont, CA 94538. E-mail: [email protected].

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represented but neither are they the constructions shaped by the subject-knowers. How they are is the subject (p. 32)always situated, in relation (p. 54)in doingand thus, always having local meanings. She claims that although in a single hospital building there are many different, and even competing, atheroscleroses (or any illness we can name), the different versions are not a result of closed-off paradigms, and the practices are not fragmented but hang together (p. 55). Studies of multiple entities that go by the same name (e.g., atherosclerosis) reveal a body that is multiple without being fragmented into many (p. 151). For me this claim is stunning in its implications, challenging the premises that a search for integration (and hoping to integrate via the Integral model) is based upon. It is possible that doing Integral as a map-making practice that focuses on singular objects is as likely to lead to fragmentation as to integration. In The Body Multiple, Mol doesnt describe medical practices (Hows), but enacts how-based inquiry in both her research and in her writing, recognizing that attending to the multiplicity of reality is also an act, done or left undone (p. 6). That is, she recognizes that different scholarly practices uncover different knowl-edge. She considers her work reflective rather than argumentative (p. viii) and enacts her message with two separate streams of text: the usual one that describes her study and its findings, often with stories, sometimes with charts and photos, and always with thick description (Geertz, 1973); and a second substantial stream (at the bottom of most pages) describing and questioning salient practices of research and scholarship as she is doing them (or choosing not to)mentioning choices in citations, relating to the literature and which fields one calls upon, how far knowledge claims can be taken, the role of norming, and so much more embed-ded in our practice as researchers, scholars, and practitioners. In this Heuristic of How, the subtext rises to the surface: How becomes the subject, and in multiple ways. Tongue-in-cheek, Mol acknowledges that this textual presentation will be more easily processed by those who regularly surf between television channels (p. ix). I will not separate the text and subtext into two streams in this review, but as you read, please notice the How of scholarly reading and writing practices (as Ive pointed out in earlier articles, e.g., Chase, 2010; In press). Book reviews tend to be views from the outside or from above (so to speak), but I hope youll join me in pondering alternative forms of scholarly engagement and what they might lead to. As I review this book Im enacting Integralpracticing Integral in form, rather than adopting it as a perspective that I apply to talking about something else, such as medicine or The Body Multiple. Like Mol, my intention is less to pro-vide answers than to make a certain kind of inquiry possible.

Integrally Mapping What and WhoYoull notice that I do not give much detail about the particulars of Mols studyabout the setting (a small Dutch university research hospital), her methods (observations, interviews, study of literature and texts), and the participants (patients, surgeons, radiologists, etc.). Her emphasis on practice subtly changes the flavor of her report. Mol doesnt present the usual kind of findings followed by generalizations and claims typi-cal of research reports. Since her research methods were qualitative, this might be expected, but she also avoids the usual qualitative moves of suggesting how findings from a particular setting can be generalized to something larger or used to generate hypotheses or conundrums to be further investigated. In fact, shes careful to claim that shes describing particular events and not making claims about Western medicine as a whole; she wants to leave open questions about possible variations in practice and suggests that the notion of standard practice in a monolithic discipline (medicine) relates more to the professional literature than to whats practiced on the ground (pp. 2-4). Theres an implication that she could almost be studying anything, anywhereWhat is not the focus, but Howa dynamic created via the Hows of her research (practice) and writing (and our Hows, reading). Mol found radical differences in atherosclerosis as enacted in the clinic and atherosclerosis as enacted in the lab (i.e., in practices and how knowledge is found [as enacting] in them, and the form of her writing

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stays true to knowledge as multiple, and a function of practices). Here, Im enacting the Heuristic of How by mentioning Mols findings (the What and Who) as though they are the subtextoccasions for highlighting How (practices)with How being subject (knowledge). In case this sounds nonsensical, let me step back a bit (or again go up into the clouds). The call for papers for this issue of the Journal of Integral Theory and Practice framed inquiry in ways that invited authors to use an Integral lens to explore how the AQAL model helps both patients and health-care practitioners quickly navigate through any illness. In particular, authors were invited to submit papers on issues organized under the four quadrants as headings (i.e., we apply AQAL to medicine by tapping into its powerful mapping aspects). In A Theory of Everything, Wilber (2001) includes a section on Integral Medicine in which he presents a similar four-quadrant outline of areas of concern.3 You could say that working with this mapping function is a focus on Whats and Whos, whether we focus on the quadrants as dimensions of individuals or as quadrivia of possible perspectives on specific illnesses (a distinction explained by Esbjrn-Hargens, 2010, p. 38). By bringing together the body, mind, and spirit elements of each of us, promoting Integral Methodological Pluralism in research (Esbjrn-Hargens, 2008), and acknowledging other integra-tive aspects mentioned above, Integral mapping brings benefits to medicine. Integral mapping also helps by questioning the premises behind difficult issues such as:

The apparent conflict between subjectivity and objectivity that requires practitioners to avoid emotional involvement with patients. (Astin & Astin, 2005, pp. 27-28; Wilber, 2005, pp. xvi-xvii)

Mind and body dualism, which for one thing, causes us to negatively label and dismiss the placebo effect. (Astin & Astin, 2005, pp. 25-27; Wilber, 2005)

Different frameworks of assumptions related to causes of illness and factors in health (Wilber, 2005, pp. xviii-xix) and to validity claims for research and practice of the many healthcare modalities and techniques, conventional and alternative.

Overly specialized solutions to healthcare management issues (e.g., hospital accreditation and patient safety). (Goddard, 2006)

There are many more ways that looking at medicine as a four-quadrant matter is useful, including consider-ing ways to reform the healthcare system; a great start on that reform is presented in Len Saputos A Return to Healing (2009).

Enacting Integration: How?Do you remember how you felt when you first encountered the AQAL model and thought about how it might be applied to understanding and working with problems in medicine? It offers the promise of wholeness: integrating and thereby healing a fragmented heap of needs and dimensions, represented by specializations within medicine (focused on different populations and bolstered by competing versions of science), on mo-dalities of practice, alternative and conventional, on arenas (clinical practice, research, education and train-ing, policy and planning), and body, mind, and spirit. As integral readers understand, wholeness requires respectfully and completely accounting for all aspects of What and Who (quadrants, lines, levels, states, and types). But after a while, did you find this completeness quest to be fairly easy (and fun) to integrate in a map (or curriculum), but overwhelming or challenging to integrate in practice? Having mapped out, well, all the moving parts of everything, how do we turn it on and use it? When we reflect upon the design of integrative centers we can see some of the difficulties of realizing integration in practice. For instance, does integrative mean practitioners of many types of healing modali-


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ties having offices in the same hallway, whether or not they ever speak (or work) together on treatment of particular patients (i.e., integration as being in the same medical practice/group, sharing a name, rent, and administrative expenses)? Integral mapping enacts a similar understanding of what integration means. Its essential to have a tool for including, differentiating, and showing relationships between all the salient features in healthcare, just as we need to call upon many different kinds of expertise to treat whole people. And yet the map is not the territorywhat moves us from integration as accounting for all the salient elements in a model into integrally practicing medicine? In reality, this question may not be productiveits expecting something that maps are not designed to do. Maps are for locating, and even the biggest and most complete map only allows us to do what we might do with a telescopic lens: zoom in and zoom out. Thats very useful, of course! Operating the zoom feature allows us to ask better questions and to define spaces that include more or less as we design innovative ap-plications. It also gives a method for understanding and skillfully dealing with less complete visions of the territory, especially those represented by focusing on only one of the quadrants as opposed to working from a unified metatheory (e.g., as discussed by Jarrn, 2007). But at some point in the zoom out, as the map gets more detailed and complete, it becomes a series of conceptually related features, an abstraction (flying over a field at 35,000 feet is quite different from working in one). To integrate in practice requires landinginclud-ing and transcending the map. A possible move is becoming aware of What and Who as enacted, rather than found (as Whats) or constructed (by Whos). Lets go back to Mol to make this clearer. In her subtext, Mol says she uses the verb enact because its relatively innocent, with fewer agendas than other words, and she avoids giving citations for it because she wants readers to come to this word afresh (p. 41). She suggests that activities take place, carried out by actors, but that we look at HowWhat and Who as enacted in our practice (pp. 32-33)and only really alive there, on the ground, so to speak.4 This uncov-ers interesting conundrums, for instance, her finding almost unbridgeable differences created by the differing techniques that make atherosclerosis visible, audible, tangible, and knowable in the outpatient client (e.g., palpation and asking questions) and the pathology lab (dissecting tissues and looking with microscopes) (p. 33). She claims that the incommensurability should not be thought to result from a difference in perspective but is instead a practical matterof patients who speak as against body parts that are sectioned. Of talking about pain as against estimating the size of cells. Of asking questions as against preparing slides. In the clinic and in the lab, atherosclerosis is done differently (pp. 35-36). And yet it all hangs together. The Integral model maps perspectives. But as Mol points out, even when we recognize that doctors and patients have (sometimes competing) perspectives, and that illness is a matter of interpretation and meaning, this focus causes disease to recede behind the interpretations and the physical body to become lonely, un-touchedonly looked at, as if it were in the middle of a circle. A crowd of faces assembles around it. They seem to get to know it by their eyes only (pp. 11-12). She traces currents in medical sociologys locating of knowledge: first was to add a (social science) distinction between disease and illnesswhat wed think of as Left-Hand added to Right-Hand quadrants. The second was to stress that whatever is said about disease is relative to the specific person doing the talkingwhich we might work with by considering lines, levels, states, and types. The third step consists of foregrounding practicalities, materialities, events. If we take this step, disease becomes a part of what is done in practice, Mol says (pp. 12-13). A different kind of whole-ness emerges.

From Map to NetHow the Internet works might be an apt metaphor for AQAL, enacted. Its not that Whats and Whos disap-pear so much as that they stop being matters of location (objects on a map). My music collection is mine in a different way, now that its stored in the cloud rather than in CDs on my bookshelf or even on my computer, unless Im listening to it. Many others can be listening to the same music at the same time. My


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music lives in a kind of intangible nexus rather than as a locatable object, and theres no conflict in the fact that my computer recognizes it as a bunch of ones and zeroes and I as something that vibrates my eardrums. Mol writes about and enacts this kind of wholenessin practice and not in place: to be is not only to be represented, to be known, but also enacted in whatever imaginable other way (p. 55), which includes (in the case of atherosclerosis) in drawings and notes, slides, charts, knives, slides, microscopes, and also in patients walking distance, looking or not looking into patients eyes, and patients own assessments (p. 54). But we need this multiplicity to hang together. According to Mol, you could say that different diagnostic tests (asking questions about pain and walking, palpation, taking tissue samples) and possibilities of different treat-ment methods (amputation, angioplasty, walking therapy) assess and treat different forms of atherosclerosis, but these are added, subtracted, balanced together (p. 70) because one treatment option has to be selected. She finds two methods of coordination for dealing with coherence-in-tension related to diagnosis: addition and calibration. Addition comes in two forms: one is to add up test outcomes, assuming a common object behind the results, with one result made to win. A hierarchy is established and the discrepancy be-tween the tests is explained away (p. 84). In the second form of addition, discrepancies are ignored because a common object is not assumed. The tests then are suggestions for action, weighing need to treat. In cali-bration of test outcomes, the tests are not viewed as discrete, arising from their own paradigms, but correlated and compared via establishing common measures. Mol says this makes translation possible (p. 85). Rather than being a challenge to be overcome, divergence in diagnostic methods and treatment options might be necessary for wholeness in practice, allowing possibilities for frames of reference, depending on scale and boundaries (using the zoom lens). Frictions are vital elements of wholes (p. 115). Mol reminds us that we often aim for universal scientific knowledge, leading to controversy, and in research this requires that experimental design be made similar from one setting to another. However, in hospital practice (of treatment and prevention), a coherent shared ontology isnt required, and incompatibilities are not obstacles. This then, is what happens. The possible tensions between different variants of a disease disappear into the back-ground when these variants are distributed over different sites. She means, for instance, the clinic and the labthe worlds of vascular surgeons and hematologists. Medicines incoherence is no flaw that requires to be mended; it does not designate a sad lack of scientificity. That the ontology enacted in medical practice is an amalgam of variants-in-tension is more likely to contribute to the rich, adaptable, and yet tenacious character of medical practice (p. 115). She describes different forms of distribution that separate what might otherwise clash. The first relates to time and flowshe uses the word itinerary to describe the process of diagnosis and treatment, saying that the atherosclerosis diagnosed and treated need not be the same, that there are not necessarily competing sides, nor fragmentation, so long as a flow is maintained. The patients itinerary is held together by ap-pointments, forms, and conversations. The second form of distribution is indication criteria. While there are different patients in different situations and, in this case, three different types of invasive treatment, none is seen as superior; they are linked by the indication criteria. This, again, does not lead to fragmentation, for the various treatments come together in a central point: the place where the indication criteria are set. This is the place where the object enacted and the practicalities that matter are determined interdependently (p. 116). The third form of distribution works by each enacted atherosclerosis taking into account the others (e.g, by relating an earlier stage as a risk factor for a latter and more serious condition). And the fourth form of dis-tribution, Mol says, is over conditions of possibility (p. 116). That is, certain enactments of atherosclerosis that are now possible may later change as whats available for treatment changesfor instance, availability of a drug that intervenes in the blood-clotting mechanism might make it more difficult to enact atherosclerosis as an encroached artery. While I think these methods of coordination and distribution are interestingand we can look for them playing out elsewhere, especially guided by the Integral mapId like us to especially notice the point Mol


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makes as she closes Chapter Four: the power of the name. She says that her informants dont use atheroscle-rosis as persistently as she does, having their local vocabulary of claudication, stenosis, vascular disease, plaque formation, macrovascular complications (p. 117). But atherosclerosis is the term the different pro-fessionals use when they talk to each otherthe word in itself a grand coordinating mechanism. It might be interesting to investigate integration as this kind of anchor word/concept that holds different versions of practice together.

From Objects of Perspective to Nexus of InterventionMol does not define wholeness as a matter of parts adding up or relating in overlapping circles of inclusion. She does not speak of insides and outsides, bigger and smaller views, simple or more complex objects, or whole people being reduced to body parts. In daily hospital practice, arteries and patients do not have a transitive relation. Instead, they are distributed over different sites. The patient speaks in the outpatient clinic while the artery is enacted as a deviant entity in the radiology department. Or: first the patient speaks, later on, the arteries are treated. So the reality of deviant arteries is not situated inside but alongside that of sick patients. This implies that interventions in vessels arent a matter of reducing patients to vessels. Something more complex is going on. (p. 123). Mol speaks of switches between enacted objects, for instance in the operating theater, when the patient switches from body on the table to someone whose wife needs to be called. She explains that this is not a switch from attention to a part of a person to the whole, from intervention in a body to intervention in a lifenot a zooming in and zooming outbut moving the camera sideways and focusing it on another object (p. 124). The switch might come about as a matter of timing or of enacting different repertoires (surgeon as cutter vs. informant to patients). Other objects can also signal switches, and she gives an example of the off-white cotton cloth in a dissection room that signals moving between two creatures: the one having its insides taken out and sliced, and the one being accorded human dignity by having its face covered (p. 126). In fact, Mol says, a praxiology can follow other objects of enactment, and not just diseaseso central to medicine. She mentions surgeons as an example, reminding us of the obvious, that in operating theaters (and nowhere else) they are authorized to use knives to cut into peoples flesh as though this were a techni-cal and not a violent matter (p. 142). This example, and noticing other possible objects, shows us, she states, the advantage of knowledge as enacting, leaving open who or what the actor is. Many entities are involved: knives, questions, telephones, forms, files, pictures, trousers, technicians, and so on, and all of them mul-tiple. Interferences are possible: two or three multiple objects (e.g., atherosclerosis and sex differences) might collide, as do waves that come at each other at an angle. Ontology-in-practice means no stable vari-ables, because they shift in practice (p. 143). Praxiology (partaking in reality, p. 154) might mean no longer being able to think of science as a pyramid, with similar methods being used to study objects of different sizes as though belonging to different layers of reality. Ontology-in-practice requires reckoning with the multiplicity of objects, and not by separat-ing out each aspect but by looking for points of leverage, realizing the many points of entanglement (pp. 155-156). Praxiology stands in an oblique relation to explanatory knowledge and the static pyramid of objects it refers to (p. 157). But oblique must not be taken to mean that the pyramid remains standing, as though we just now look at it in a new way. In one situation an object may be part of another, but in another, the whole-part relationship might be different. She says that objects in practice relate to one another like pages in a sketchbookdifferent images with no fixed point of reference. Mol ends Chapter Five by stating, Coexistence side by side, mutual inclusion, inclusion in tension, interference: the relations between objects enacted are complex. Ontology in practice comes with objects that do not so much cohere as assemble (p. 150). The same can be said of the practices of research and scholar-ship as enacting. Our focus might be on matters such as these: Which one of its [a diseases] various versions


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is enacted at any specific site or in any specific situation? Is it an X-ray picture and the atherosclerosis that encroaches on the arterial lumen; or is it a patient history that gives pain-on-walking? She says this is the big question: when ontology is accepted as multiple, What is being done and what, in doing so, is reality in practice made out to be? (p. 160) She suggests some of the politics of this ontology of practice, includ-ing those related to living in an underdetermined world where doubt can always be raised (p. 165). She wonders what are the consequences if what to do isnt answered with reference to what is realand might one implication be that we pay even closer attention to whether practices are good for the subjects involved (p. 165)? In her final chapter Mol presents a thoughtful and involving discussion of the politics of what and who arising from an ontology of practice.

Doing Integral as a Heuristic of HowIn a number of places in her book Mol mentions what she has done and left undone. Likewise, here, I admit to having glossed quickly over the complexity presented in her work, wanting in the end to use this review as an occasion to open up conversation about how we practice Integral as much as about how we practice medicine. The book will certainly repay your reading of it, and I hope you will. Youll have to take my word that The Body Multiple could be considered as enacting Integral Medicine. So instead, as you read this article, enacting Integralyou can engage by wondering How. What do we enact when we review a book? It becomes an object, something we can write and read abouta What (writ-ten by a Who). To write or read about enactment is enacting of one kindfrom above, from outside, from my perspective now versus back then (when I read the book, or thought about medicine as a field, or when the study was done). This separates knower from known and hides the fact that this form, and the doing of this writing, is integral to the meaning you can glean from it. How is What. Mol experimented with her own writing as enacting her message of knowing as practicingthe re-search and writing process itself was a knowing-by-doing, creating a particular textual object whose form also mattered. She explains that this book is part of a recent wave of studies that takes a further step away from disembodied contemplation. This means that it no longer follows a gaze that tries to see objects but instead follows objects while they are being enacted in practice. . . .Instead of the observers eyes, the practi-tioners hands become the focus point of theorizing (p. 152). So, like Mol, let me avoid drawing conclusions as though there is a knowledge out there that can be captured, and locate it instead in practice, our doings here as we write and read Integral Medicine. With Mol, Im suggesting that enacting is a living integration. Integral scholarship can be viewed as a respectful accounting for as many perspectives as possible in our research studies and articles. We can think of the practice of medicine in just the same way: first ac-counting for everything that falls into the four quadrants (differentiating) and then building structures that allow them to live and breathe in practice. But this gets cumbersomeas, for instance, in writing, trying to use first-, second-, and third-person voices and finding a place for every salient concept/perspective. What if side by side with mapping Whats using the Integral model, we realized Integralintegrating by knowing objects (including people) only as they are enacted in (multiple) practices? This means attention to How we are doing and thus the Whats we are creating. The work of mapping Integral Medicine is extremely important and must continue. We can then zoom in and out seeking nexus points of practice, especially those created at the intersections between the quadrants and in such multiple objects as educational curricula, questions on intake forms, or investigations that use multiple methods. Id predict that these nexus points will initially show themselves in points of contention or apparent fragmentation or reduction. But realizing the body, illness, disease, the discipline of medicine, and every other aspect of health as multiple, we begin to see how practices hang together. We can assume that they do (rather than that they are singular and/or fragmented) and look for How. But we are looking at knowledge in practice and not as something that could be pointed to, represented on a map.


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Think again of that mythical integrative center, with many offices up and down the hall. Different mo-dalities of treatment and practice yield different health and illnessesHow? And how do they come together (if they do)? Sometimes integration is taken to mean coordinating (possibly competing needs and perspec-tives): one patient or illness and several treatments; or one patient seen as a whole person; or one medicine that might focus on systems rather than symptoms; or treatment of illness along with creating wellness and preventing illness; or perspectives of patients, caretakers, and various health professionals. Coordinating is indeed a challenge! But what if integration is not a matter of Whats and Whos in harmony but of some-thing practiced when living with objects being multiple and knowledge as not located in any one place? The Heuristic of How does not replace Integral mapping. Im not proposing a sixth element of AQAL (in addition to quadrants, levels, lines, states, and types) but suggesting a further step that changes the Integral model from a theoretical body of knowledge that we apply to disciplines such as medicine to a living body of practice. That objects are multiple, found in enacting, doesnt have to be insurmountably complex and we can get used to and have fun with practicing new integral modalities. We have already become used to seeing identity as complex and shifting, a matter of waves of lines and levelsand of moments and methodology. A first move toward enacting Integral Medicine is to question what is behind the call for integration, realizing that our own knowledge-making practices can show us a sadly fragmented discipline in need of healing, but that in practice it need not be so.

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1 Please note that the (possibly annoying) labels of How and What and Who throughout are mine and not Mols (although she does discuss a politics of Who and a politics of What in the final chapter of her book). As a scholar of language I tend to understand and relate in these terms. Sean Esbjrn-Hargens and Michael Zimmerman have also used the terminology of What and Who and How in their book, Integral Ecology (2009). They describe a multiplica-tion of W(ho) x H(ow) x W(hat) as tetra-enacting one another in a truly Integral framework (e.g., pp. 180-181). A dif-ference between their work and Mols is that she experiments with the scholarly textual form as enacting the message.2 In this review, I have deliberately not used the convention of offsetting long quotations. The intent is to enact less separation between my commentary and Mols work.3 Many in the healthcare field today consider the biggest challenge to be integration, as we can see from the growing popularity of the integrative medicine movement. Different modalities, methods, specializations, and definitions of health, as well as individual, collective, and systematic needs and views, can be usefully integrated with an Integral rubric, using the quadrants, for instance, as do some in Consciousness and Healing: Integral Approaches to Mind-Body Medicine (Schlitz & Amorok, 2005). Integral-savvy readers will note that while Wilber has written a thoughtful forward to this book, and some authors appear to be familiar with the quadrants element of the AQAL model, most authors take integral to be a synonym for integrative.4 I am aware that we can think of How as a What, an AQAL object (of study). This requires asking from what perspec-tiveWhos looking, using what method. But I am not suggesting that we study How (from inside or outside) but that we enact: doing How as Subject (actor) and subject (predicate), simultaneously.

R E F E R E N C E S

Astin, J., & Astin, A. (2005). An Integral approach to medicine. In M. Schlitz & T. Amorok (Eds.) Con-sciousness and healing: Integral approaches to mind-body medicine. St. Louis, MO: Elsevier Churchill Livingstone.

Chase, M. (2010). Writing to effect: Textual form as re-alization in an Integral community. In S. Esbjrn-Hargens (Ed.), Integral theory in action: Allied, theoretical, and constructive perspectives on the AQAL model. Albany, NY: SUNY Press.

Chase, M. (In press). Between attack and accommoda-tion: Integrally redefining devils advocate. In


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Esbjrn-Hargens, S. (Ed.), Enacting an integral future: New horizons for integral theory. Albany, NY: SUNY Press.

Esbjrn-Hargens, S. (2008). Integral ecological research: Using IMP to examine animal consciousness and sustainability. Journal of Integral Theory and Practice, 3(1), 15-60.

Esbjrn-Hargens, S. (Ed.) (2010). Integral Theory in action: Applied, theoretical, and constructive perspectives on the AQAL Model. Albany, NY: SUNY Press.

Esbjrn-Hargens, S., & Zimmerman, M. (2009). Inte-gral ecology: Uniting multiple perspectives on the natural world. Boston & London: Integral Books.

Geertz, C. (1973). The interpretation of cultures. New York, NY: Basic Books.

Goddard, T. (2006). Integral healthcare management: An introduction. Journal of Integral Theory and Practice, 1(1), 449458.

Jarrn, O. (2007). An integral philosophy and definition

of nursing. Journal of Integral Theory and Prac-tice, 2(4), 79101.

Mol, A. (2002). The body multiple: Ontology in medical practice. Durham, NC, and London, United King-dom: Duke University Press.

Saputo, L. (2009). A return to healing: Radical health-care reform and the future of medicine. San Ra-fael, CA: Origin Press.

Schlitz, M., Amorok, T., & Micozzi, M. (Eds.). (2005). Consciousness and healing: Integral approaches to mind body medicine. St. Louis, MO: Elsevier Churchill Livingstone.

Wilber, K. (2000). A theory of everything: An integral vision for business, politics, science and spiritual-ity. Boston, MA: Shambhala.

Wilber, K. (2005). The integral vision of healing. In M. Schlitz & T. Amorok (Eds.), Consciousness and healing: Integral approaches to mind-body medicine. St. Louis, MO: Elsevier Churchill Livingstone.

MICHELE CHASE, Ph.D., is an independent scholar, writing coach, and editor at Geist Writing Services (www.geist-writing.net) who sees her work as thinking through writing. Her doctoral training at the University of Michigan focused on discourse analysisstudying knowledge and text-making practices in disciplinary discourse communities. She won special acknowledgment for papers presented at the 2008 and 2010 Integral Theory conferences: the first ques-tioning how we might best enact the Integral model in scholarly writing practices, and the second exploring critique in Integral Land. Michele has also studied, practiced, and taught Qigong, Reiki, and Chi Nei Tsang, and continues to be very interested in subtle energy. She now has time to read widely in this area and others, having retired from university teaching after twenty-five yearsmost in composition, and recently, eight years as professor and chair of the integrally informed Holistic Health Education program at John F. Kennedy University. She is working on a book that is provision-ally titled Words for the Wind: Subtle (Integral) As a Heuristic of How, demonstrating a quirky new form of scholar-ship that allows a different engagement with the many koans created in discussing subtle energy, spirituality, and states of consciousness.

The Body Multiple: Integral Medicine as Heuristic of How [Book Review]Integrally Mapping What and WhoEnacting Integration: How?From Map to NetFrom Objects of Perspective to Nexus of InterventionDoing Integral as a Heuristic of HowNotesReferences

chase - the body multiple

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