The success of biomedicine has resulted in a shift in the burden of illness from acute infectious disease to chronic, often stress related, degenerative disease, the causes of which are largely a result of personal attitudes and lifestyles. Although biomedicine is well equipped to diagnose and treat these diseases, which are currently the major source of premature death and morbidity, its therapies rarely result in cure. The characteristics that have been responsible for biomedicine's many accomplishments by necessity also define its limits. A reductive system, by its very definition, is incapable of meaningfully including psychologic and psychosocial factors, which cannot be exclusively reduced to the level of biochemistry without losing their complex and interactive meaning and significance to the human experience. For this, we must extend our vision of healing to consider the mind/body healing system, which both incorporates the homeostatic and biomedical systems while extending them to include factors that were previously excluded.

System 3: The mindbody healing system
The mind/body healing system relies on the assumption of personal responsibility and the self-motivated effort to develop and use the personal skills and capacities-psychological, psychosocial, and physical-that are available to assist in the process of self-regulation and healing (Fig. 2). Mind/body healing is intentional and preferably proactive. Its focus is on personal attitudes and lifestyle, the central factors in the development of stress related degenerative disorders. The concern here is with psychological development, individuation, personal transformation, and mastery, to the extent possible, over the activities of the mind and body.

This aspect of healing finds its scientific legitimacy in the emerging research in the field of psychoneuroimmunology (Ader et al., 1991). The discovery of the interconnectedness of psychic and physiologic functions mediated by the mobile neuropeptide messenger system has assisted in establishing the biochemical pathways that account for the long accepted relationship between mind and body. Further, we are now able to demonstrate the specific psychological qualities and psychosocial influences that appear to provide enhanced resistance to the detrimental effects of physiologic stress (Antonovsky 1988, 1991; Kobassa 1979).

The shift in focus from diagnostic categories to issues of personal attitudes, lifestyle, and psychological development alters the relationship of the health practitioner to the patient, perhaps better referred to here as the client. The relationship is more of a partnership than the hierarchical relationship that characterizes biomedical healing. The focus is long term and the treatment modalities, which can more accurately be termed health promotion practices, are more internal than external. Examples include meditation, exercise, nutritional practices, psychosocial education, biofeedback, and yoga. The intent is more educational than therapeutic and the health practitioner serves more as an educator and coach.

As with each of the preceding systems, the defining focus of the mind/body healing system-psychological development and individuation-also accounts for its deficiencies and defines its limits. This system fails to consider the spiritual aspects of the human experience, which transcend and extend the boundaries of personal development, conveying to the individual a more comprehensive and sustaining understanding of the living experience.

System 4: The spiritual healing system
There are many definitions of spirituality, but for the purposes of this model I have chosen to define spirituality as an individual's capacity to view the living experience in the context of an organized and unifying perspective that transcends day-to-day experience and provides meaning and purpose to the essential human concerns about life and death. A spiritual perspective can have a profound effect on personal attitudes, values, and behaviors, and consequently on biochemistry and physiology. These effects on the mind and the body are termed spiritual healing.

Of the healing systems discussed in this paper, the spiritual healing system is the most difficult to define and presents the most significant challenge to our current research methodologies. Yet it conveys an essential completeness and wholeness to this comprehensive healing model by encouraging an existential exploration of the primal human issues of pain and suffering, disease, aging, and death, their meaning and purpose.

The Health Continuum
When these four healing systems are considered as an integrated comprehensive system certain characteristics appear that are not evident when each is taken separately. We are able to see the evolving characteristics of healing as we approach Figure 2 in a horizontal direction. For example, the expansion of consciousness from instinctual to reactive, intentional, and intuitive; the shift in resources from built-in automatic feedback loops to drugs and surgery, mind and body, and finally to an expanded consciousness. Similarly we can see an increasingly inclusive and comprehensive vision of health as we shift from the goal of maintaining a physiologic steady state to restoring function, to individuation, and finally to the attainment of wholeness. Taken as a whole, the movement through each healing system reflects the natural developmental sequence of a human life. We discover that much like this model, we are both parts and wholes; mechanical, interactive, and integrated all at the same time.

The adversarial distinction between conventional and holistic/alternative therapies disappears as we consider the intent, usefulness, and mechanism involved in each form of therapy and properly assign it to one of the four healing systems: homeostasis, treatment, mind/body, and spiritual. This is a more functional way to categorize a therapeutic practice than the current arbitrary and capricious view of its status as "conventional" or "holistic/ alternative." To the extent that a practice, conventional or holistic/alternative, fits within a specific system, it then, by necessity, must attain its legitimacy and credibility through the disciplined exploration of its efficacy by means of the research methodology appropriate to that specific system.

This model is inclusive rather than exclusive, honoring and respecting the contributions, independence, and interdependence of each of these healing systems and the integrity and professionalism of the many and varied practitioners whose practices, when proved efficacious through a rigorous system based research methodology, serve as accepted and valuable resources for one or more of the healing systems. Reductionistic and holistic thinking, and conventional and alternative practices are each seen as essential components of a comprehensive intellectual process and a unified approach to health and healing.

Clinical Decision Making
It is in the context of this model that we can now explore how practitioners-in-training and the active clinician can incorporate these perspectives into the daily practice of healing. In the biomedical system we are accustomed to using a symptom as the "ticket of admission" to the clinical setting and as the basis for the ensuing interview, which begins with a general review of the body systems and progresses, in a reductionistic manner, toward a subsequent focus on the particular single system most directly related to the presenting symptom. This process can be directly applied to the expanded approach proposed here by adding an initial level of triage, which precedes the more detailed interview process. This initial triage decision determines which one or more of the healing systems-homeostatic, treatment, mind/body, or spiritual-is to be applied to the presenting problem. This decision is based on three critical factors: intensity and severity of the illness, age, and mindstyle of the patient (Fig. 3).

For example, a minor acute illness is not the basis for a multisystem interview. In contrast, a myocardial infarction requires full attention to the homeostatic, treatment, mind/body, and spiritual healing systems. An individual's age further assists in determining the applicability and usefulness of the mind/body and spiritual healing systems. Mind/body healing cannot be introduced until the attainment of a certain level of maturity, and similarly, a spiritual approach is generally inappropriate for the adolescent or young adult. Mindstyle is the final indication of which direction to proceed. The latter two healing systems require a certain openness, interest, and intellect as they call upon the direct and enthusiastic participation of the client.

Fig. 3. Multidimensional Healing: The Clinical Process.

Once made, this triage decision defines the next level of inquiry, which consists of an interview related to the particular healing system(s) that have been selected. If the problem seems most appropriately resolved through the biomedical approach the traditional review of systems ensues. If an alternative approach is selected, the specific approach-based interview is conducted. If the problem calls for the mind/body or spiritual systems, the inquiry appropriate to these systems is inserted. Briefly, the homeostatic system is concerned with the circumstances environmental, dietary, and physical-that support the normal auto-regulatory functions of the mind and body; the treatment system focuses on the traditional issues of diagnosis and therapy, the mind/body system is concerned with personal attitudes and lifestyle, and the spiritual system considers issues of meaning and purpose. As with the traditional review of systems, an inquiry into each of these aspects of healing proceeds with a series of questions and responses between practitioner and client.

With the above considerations and the appropriate inquiry into the nature of the presenting problem, a comprehensive plan can be agreed upon in partnership with the client. This plan will apply the appropriate range of resources from each of the selected healing systems. In its most complete form such a plan would aim to support the normal operations of the homeostatic system, restore function where dysfunction has developed (the treatment system), expand personal resources and capacities (the mind/body healing system), and assist the individual in the attainment of a more whole and balanced life (the spiritual healing system). As with any plan, there is a continuing reiterative process that occurs throughout the life cycle.

To better illustrate this process let us consider the case of an individual who presents for the first time with the symptoms of atherosclerotic heart disease. The initial triage would suggest that the age at which this disease presents itself and the intensity and severity of this particular illness indicates the need to consider, at a minimum, the treatment and mind/body healing systems. Further inquiry, which may continue over weeks, will clarify whether this specific individual is amenable to viewing the implications of his or her disease within the framework of a spiritual perspective. Initially the appropriate steps related to treatment, diagnosis, and therapy are pursued. Concurrently, an inquiry into personal attitudes and lifestyle are initiated. Finally, if appropriate, a dialogue can be initiated, which is directed toward seeking an understanding of the meaning, purpose, significance, and implications of this disease for the individual's life.

In this case the development of a comprehensive plan would include a mixture of approaches: the use of appropriate diagnostic and therapeutic interventions (the treatment system), the introduction of attitudinal and lifestyle changes in the areas of stress management, nutrition, exercise, and insight based psychological counseling (the mind/body system), and an ongoing consideration of the impact of this illness on previously held values, beliefs, and priorities (the spiritual system). The goal for the practitioner is to begin to perceive disease and the individual in a larger context. For the individual, the goal is to use disease as a doorway into a more considered and expanded life-one that both serves to remedy the problem at hand, reverse the personal factors that have contributed to the development of the illness, and enhance the overall quality of life.