Noûs, 50(3), 629–658, Noûs, 49(4), 800–823, lower evidence-responsiveness and inferential efficacy than at least some implicit attitudes, defeating (i) and (ii). A better interpretation is that attitudes may be ordered along a continuum according to their responsiveness to content. At one extreme end, we find attitudes usually identified as implicit, and at the other, attitudes usually identified as beliefs, but in the middle, there is an area of overlap. I consider the consequences of the continuum view for existing folk psychological concepts.It has been proposed that, whilst implicit attitudes, alike beliefs, are propositionally structured (Mandelbaum  For instance, people perform more quickly and accurately on a range of time-pressured tasks when classifying concepts in accordance with a social stereotype compared to when classifying concepts counter to a social stereotype.a) unconscious; (b) associatively structured; (c) automatically activated, and cannot be intentionally inhibited; and (d) not avowed. Meanwhile, explicit attitudes inhabit “System 2”, and are (a1) conscious; (b1) propositionally structured, (c1) deliberatively controlled; and (d1) avowed  whether implicit attitudes are a sui generis class, or whether the distinction between them and more familiar attitudes such as beliefs is more graduated; (3) whether these features are stable attributes of attitudes; and even (4) whether “implicit” and “explicit” pick out distinctive features at all. Questions 1–4 also interact. For instance, implicit attitudes might form a sui generis class (as in 2) because they have features a…d necessarily (as in 1). Or, they might form a sui generis class, because to be designated implicit is to fulfil a homeostatic property cluster, whereby an attitude has a sufficient number of features a…d without having any particular feature necessarily.The precise nature of the distinction between the implicit and the explicit is up for philosophical discussion in various ways, including, for instance: (1) whether and even  whether b and b1, the associative-propositional distinction, and it is with this discussion (and its implications) that my paper is primarily concerned. Dominant psychological accounts  the dual-systems account: a distinction is reinstated, but this time, rather than applying as regards the attitudes’ structure, it holds as regards their responsiveness to content.Mandelbaum’s proposal that implicit attitudes are (standardly unconscious) beliefs, has been challenged by Neil Levy . Levy acas “patchy” as some implicit attitudes, and both (i) and (ii) are false.In this paper, I show that the patchy endorsements account is unsuccessful at distinguishing implicit attitudes from beliefs on the basis of the limited content-responsiveness of the former. Levy’s account comprises arguments for there being both a distinction in kind and a distinction in degree in the content-responsiveness of implicit attitudes and beliefs. I argue that the distinction in kind cannot be upheld (3.1), but that the distinction in degree carries force (3.2). I demonstrate that, in order to maintain this distinction, the patchy endorsements theorist is committed to the truth of two claims: (i) that implicit attitudes and beliefs inhabit a continuum as regards the breadth of the content-driven processing that they exhibit, but do not overlap on this continuum; and (ii) that there is a sufficient gap between the last implicit attitude and the first belief on the continuum to uphold that the former constitute a sui generis class. In section a, c and d), are implicit, and at the other, only attitudes such as beliefs , but in the middle, there is an area of overlap of both beliefs and implicit attitudes. That we find this overlap means we’ve been assigning a category distinction, “patchiness” vs. “inferential promiscuity”, where no such robust distinction really exists.I propose that a better interpretation of the evidence is that attitudes, both implicit and explicit, are ordered along a continuum as regards the breadth of content-driven processes in which they feature, and upon which no principled sui generis class – as regards content-responsiveness – is identifiable. At one extreme end, we find only attitudes that, in other relevant respects  feature(s) then sui generis class claims do not carve psychological reality at its joints.a/a1, c/c1 and d/d1 characterise implicit and explicit attitudes. However, full enquiries into the robustness of each of these distinctions will be important for providing satisfactory answers to questions 1–4. In the final section In arguing for the claim that patchiness vs inferential promiscuity is not a sufficiently robust distinction to uphold a sui generis class, I’ve not engaged with other features of attitudes, such as consciousness, control and avowal. For the purposes of this argument, I follow dual-systems theorists in holding that distinctions On a notable psychological model of the mind, there are two kinds of mental structures: propositions and associations Sloman , 2014. PAssociations encode the extent to which an individual has experienced their constituent concepts in spatiotemporal contiguity. Associative mental structures were posited following evidence which demonstrates that the activation of one concept primes a set of other nearby concepts which are then apt to feature in processing. For example, individuals are quicker to recognise ‘butter’ as an English word when first presented with the word ‘bread’, compared to when they were first presented with a word that is unrelated to ‘butter’, such as ‘window’ or ‘doctor’  described them negatively. Implicit evaluations distinguished truth from positivity and negation from negativity.Peters and Gawronski  conducteThese findings demonstrate that at least some implicit social preferences and evaluations are modulated by propositional information regarding the relationship between concepts, leaving the associative theory of implicit evaluations unable to explain these results.as efficacious a behavioural response on the IAT as extensive associative conditioning. That participants who have seen two concepts in spatiotemporal contiguity only once have as strong an implicit attitude as those who have seen the concepts in spatiotemporal contiguity 240 times is not explainable on the associative hypothesis  can be as strong as implicit attitudes formed as the result of extensive associative conditioning. In a study by Gregg et al. , half ofhad in part adjusted in line with the new information, as they were shown to be less extreme than attitudes on the first test, and less extreme than those in the associative condition.Further, additional propositional information modulates these implicit attitudes to a greater extent than further associative conditioning. In a subsequent study, participants in the propositional instruction condition were required to read a sentence in which the adjectives which originally described the first tribe now described the second, and vice versa. Those in the associative condition underwent extensive counter-conditioning trials to switch their associations accordingly. This counter-conditioning failed to have any effect on subjects’ attitudes. However, an IAT of those in the propositional instruction condition revealed that their implicit attitudes Modification of implicit attitudes by abstract propositional information also occurs in non-social attitudes, as demonstrated by De Houwer  who claiSechrist and Stangor  measureda1, c1 and d1 as discussed in the introduction, for instance). Rather, his claim is that implicit biases have the requisite structural properties of beliefs. If true, then the b/b1 distinction does not hold, and things are not as clear-cut as the dual-systems theorist would have it.Mandelbaum does not conclude from this evidence that implicit attitudes have all of the relevant properties that one might maintain are necessary for prototypical beliefs .The content-responsiveness that, according to Levy, distinguishes beliefs from implicit attitudes manifests in two ways. Firstly, beliefs are “inferentially promiscuous” in that they tend to cause the update of other propositional attitudes, in “normatively respectable” ways , 805. Ledegree to which implicit attitudes feature in content-driven transitions: implicit attitudes interact with content in a limited manner, whilst beliefs interact promiscuously. There is also a claim about the kind of transitions that implicit attitudes (fail to) feature in, and this, according to Levy, rules out implicit attitudes as being properly considered as featuring in inference all. The latter is a stronger claim, so let’s address it first.Whilst implicit attitudes may feature in content-driven processing, “they are not beliefs because their responsiveness to content is fragmented, and often the responsiveness they exhibit is of the wrong sort to count as genuine inference” : 801. Thall implicit attitudes lack (or vice versa). I maintain that the evidence that Levy supplies on the way that implicit attitudes are processed does not give us sufficient reason to buy into this stronger distinction, the distinction in kind. Even though he presents evidence that some implicit attitudes fail to respond to some kinds of content, further evidence demonstrates that other implicit attitudes do respond to such content, as I will now discuss.To maintain a difference in kind between the content-responsiveness of implicit attitudes and that of beliefs it must be the case that all beliefs have some kind of responsiveness – to whatever degree – that kind of responsiveness to count as doxastic  but it exists long enough to manifest in behaviour. Once again, the subliminally presented primes entail that that the attitudes guiding behaviour have features a, c and d. These attitudes are, in other important respects, implicit. So, sensitivity to negation and other logical rules does not mark a difference in kind between the content-responsiveness of implicit attitudes and beliefs, just one of degree. We should perhaps not find this surprising: once implicit attitudes are modelled as fundamentally propositional, we might expect to find evidence of content-driven processing in many scenarios, even if this kind of processing is usually somewhat limited.It’s salient that a similar picture emerges elsewhere concerning the responsiveness of implicit attitudes to logical and semantic information. People may unconsciously differentiate congruent from incongruent subliminally presented symbolic representations  entailing that the meaning of symbolic representations may be processed unconsciously .Findings in clinical settings also demonstrate evidence-sensitive implicit attitudes which go on to guide behaviour after corresponding explicit attitudes have decayed. Edouard Claparède describes a patient in his care with Korsakoff’s syndrome (1951). Confabulation, in which a person gives an ill-grounded narrative of some occurrence without the intention to deceive, often in the absence of accurate memories of the occurrence in question, is a common feature of Korsakoff’s, and one seen in Claparède’s patient. In an (undoubtably cruel) attempt to determine the limits of his patient’s memory, Claparède pricked her hand with a pin held between two fingers. This episode was apparently swiftly forgotten by the patient. However, when he reached for her hand again, she drew it away, but gave reasons other than that he had recently pricked her with a pin in explanation. As such, the attitude driving the withdrawal of her hand was neither conscious nor avowed. Uleman et al. , who disdegree: it must be cashed out in terms of the breadth of content-driven transitions in which each sort of attitude figures.So, to conclude this section, Levy has not provided evidence that all beliefs have content-responsiveness characteristics that all implicit attitudes lack (or vice versa). This means that the proposed distinction must be one of Levy makes a persuasive case for thinking that there is a difference in the breadth of content-driven processes in which each sort of attitude features. For instance, he cites evidence in which implicit attitudes about fictional characters update in line with information given in testimony, but fail to update in line with the instruction that this information is incorrect . If a difference in degree at some point generates a difference in kind, then the patchy endorsements theorist is committed to the following two claims:Ordered continuum claim (OCC)What, then, are the core commitments of the patchy endorsements theory? Recall that Levy thinks that patchy endorsements are a sui generis class, as regards their limited content-responsiveness : 800. Budoxastic : 806. Neb1, b2, b3...bn, is responsive to content more frequently than each and every state in the set of implicit attitudes ia1, ia2, ia3...ian.Sufficient gap claim (SGC)Each and every state in the set of beliefs, bL, and the most content-responsive implicit attitude, iaM such that bL is properly considered a different kind of state to iaM.There is a sufficient gap between the least content-responsive belief, b23, responds to content c1, c2, c3, c4, and c5, whilst some implicit attitude, ia67, responds only to c1 and c2. In other words, whilst ia67 may be somewhat responsive to content, only b23 is promiscuously responsive to content.OCC just specifies the commitment to the difference being one of degree, not kind. The distinction has to lie in the frequency with which attitudes respond to content: for example, some belief, satisfaction of content-responsiveness requirements, but one might wonder whether the patchy endorsements theorist might advocate something a little less committal: that beliefs must only be subject to content-responsiveness requirements, without necessarily fulfilling them all of the time. This requires an account of the relevant distinction between an implicit attitude that doesn’t update because it isn’t subject to particular content-responsiveness norms, and a belief that doesn’t update because, whilst it is subject to these norms, it simply isn’t complying today. Such an account can be given by someone who thinks that implicit attitudes are associative, because the relevant distinction is simply that implicit attitudes do not have the requisite structure to update in light of new inferential content. But this strategy isn’t open to the patchy endorsement theorist, who accepts that implicit attitudes, being propositional, do have the requisite structure to update in light of new content. So, the patchy endorsements theorist must give the relevant distinction in terms of satisfaction of content-responsiveness requirements, rather than simply being subject to such requirements.OCC is spelled out as claim regarding beliefs’ higher degree than all implicit attitudes, in that it orders implicit attitudes and beliefs on a continuum of content-responsiveness. It does not, however, determine the distance between the most content-responsive implicit attitude, and the least content-responsive belief. If that distance is relatively small, then one may well wonder why we should draw a line at that point on the continuum and designate everything on one side of it a belief and everything on the other side a member of a sui generis class, the implicit attitudes. The distinction would not then be principled, but arbitrary.OCC is the minimum commitment for the patchy endorsement theorist to be able to say that all beliefs are responsive to content to a why the distinction is drawn where it is. In fact, for patchy endorsement theorists, the gap will be quite noticeable. To account for why a sui generis class, the implicit attitudes, is identifiable on what would otherwise be a continuum of steadily increasing content-responsivness, the extent to which iaM responds to content must be more comparable to the extent to which iaL (the least content-responsive implicit attitude) responds to content than it is to the extent to which bL responds to content. Put simply, the claim is that, as regards content-responsiveness, all beliefs are more like each other than they are like any implicit attitudes, and, likewise, all implicit attitudes are more like each other than they are like any beliefs, justifying the postulation of a sui generis class as regards content-responsiveness.SGC is the stronger commitment which delivers the desired difference in kind, because it accounts for So, OCC establishes the implicit attitude-belief continuum as regards breadth of content-responsiveness, and SGC specifies the gap between implicit attitudes and beliefs which justifies the sui generis class claim. One might accept OCC, but reject SGC. For example, one might maintain that implicit attitudes and beliefs are ordered along a continuum of responsiveness to content, but that the gap between the most content-responsive implicit attitude and the least content-responsive belief is not sufficient to account for a difference in kind between implicit attitudes and beliefs. However, if we found as much as one belief that was less content-responsive than at least one implicit attitude, then OCC would fail to hold. Such a discovery would entail an area of overlap on the continuum such that we wouldn’t be able to draw even an arbitrary line between the last implicit attitude and the first belief, because this line would have both implicit attitudes and beliefs on either side. If we find this area of overlap, then “implicit” and “explicit” do not designate a clean distinction, at least as regards these attitudes’ content-responsiveness. In section In this section, I argue that it is not the case that implicit attitudes are, by their nature, regularly unresponsive to content. This gives us reason for thinking that, in order to include the most evidence-responsive, inferentially efficacious implicit attitudes, the sui generis class will end up occupying space rather far up the content-responsiveness continuum. I also demonstrate that it is not the case that beliefs are, by their nature, regularly responsive to content, and that a great many beliefs may be subject to encapsulated reasoning and resistant to evidence, persisting even when this is brought to the agent’s attention. Not only does this give us reason to think that implicit attitudes and beliefs are much closer on the content-responsiveness continuum than SGC predicts, we can only account for these results by positing an area of overlap (where some implicit attitudes are found higher up the continuum than some beliefs) thus violating even the weaker OCC. As a result, some beliefs are just as “patchy” as some implicit attitudes, giving us a reason to think that the content-responsiveness continuum does not contain genuine sui generis classes.biases regularly interact inferentially with a wide variety of beliefs. For example, an implicit bias regarding the superiority of white men in professional environments is apt to update a number of beliefs with content concerning white men: beliefs about who to hire, beliefs about who to promote, beliefs about who to praise in a meeting, etc. That implicit biases are apt to do this is part of why they’re so concerning. Furthermore, such transitions involving implicit biases would often seem to count as normatively respectable. Even though we might think that implicit biases themselves are false or ill-grounded, once they are part of an individual’s psychological economy, they can figure in normatively respectable transitions. An entrenched implicit bias with the content that men are superior in professional environments is the right kind of thing to lend normative support to the belief that one should hire the white man – even if in fact one shouldn’t hire the white man. Of course, one might object to this by insisting that normatively respectable transitions can only occur between well-grounded attitudes. But this wouldn’t serve to distinguish the kind of inferences implicit biases are involved in from those involving beliefs, as ill-grounded and false beliefs frequently figure in inferences.It’s not clear that implicit attitudes are, by their nature, inferentially inert. Implicit Levy  maintaina1, c1 and d1: they are conscious when they guide behaviour; they guide deliberative behaviour; and the individual is disposed to avow their contents.But there is trouble here. Attitudes which look much like beliefs are regularly involved in inferences which are encapsulated from a significant subset of an individual’s other beliefs. The forthcoming examples look much like beliefs because they exhibit properties Consider David Lewis in the following:I used to think that Nassau Street ran roughly east-west; that the railroad nearby ran roughly north-south; and that the two were roughly parallel… So each sentence in an inconsistent triple was true according to my beliefs, but not everything was true according to my beliefs. Lewis , 436Lewis might often token two of the above three beliefs, and because any two beliefs in the above set are consistent, they were able to persist and feature in relevant inferences for some time. Examples like this are possible because we often form beliefs without consulting the entirety of our belief set to check for consistency.a1, c1 and d1.Lisa Bortolotti  providesBortolotti also invokes superstitions that persist in otherwise rational individuals. Consider the case of Nishad who wears a charm because he believes it brings him luck, despite also believing that physical objects have no special luck-bringing qualities  will end up counting as beliefs, and this would be a somewhat counterintuitive result.By Levy’s reasoning, because both Lewis’s inferences, as well as those made by participants in the range of situations described by Bortolotti, ignore the content of other beliefs, they do not meet the necessary content-responsiveness requirements to count as beliefs. But insistence on this principle may well vastly shrink the set of attitudes that intuitively ought to count as beliefs. That dissonant beliefs arise in such a breadth of scenarios – from valuing lottery tickets and various health outcome scenarios to policy, town planning and medical spending decisions – suggests that there is a general deficit in the mechanism for checking beliefs about the value of some outcome for consistency with other relevant beliefs. The deficit in this mechanism means that inconsistency may manifest whenever we form beliefs about the value of outcomes: our beliefs about how good really believe that.” It’s likely they would respond with belief-consonant behaviour, such as reaffirming the content of belief, and providing further reasons for which they believe it .sic). But exactly how much evidence insensitivity and inferential inefficacy a belief will tolerate before it is relegated to sub-doxastic status is exactly what is at issue in the patchy endorsement theorist’s argument. I submit that if we accept Lewis and Bortolotti’s examples of attitudes as beliefs , then the degree of inferential efficacy that is necessary for attributing a belief does not clearly exceed the degree of inferential efficacy achieved by many implicit attitudes. We have a picture where beliefs and implicit attitudes overlap on the content-responsiveness continuum. This constitutes a challenge to both SGC, the stronger patchy endorsements claim, and OCC, the weaker claim.Levy acknowledges Bortolotti’s view that some degree of insensitivity to evidence and low inferential efficacy is characteristic of attitudes that appear in other respects to be belief-like, but suggests that supporters of this view “would surely agree, however, that excessive evidence insensivity and encapsulation blocks the ascription of a correlative belief to an agent” Levy : 806 sicexplicit social prejudices. Not all explicitly believed biases will turn out to be resistant to evidence update. It’s possible that someone who believes that women are bad at maths might modify this belief after meeting a brilliant maths professor, or someone who believes that men are not nurturing enough to raise children, might modify their belief after witnessing a capable and loving single father. But there are plenty of other cases of explicitly biased beliefs that are more recalcitrant than the aforementioned, cases which persist in the face of continued counter-evidence. In fact, some suggest that this very tendency characterises explicit prejudice:Finally, consider the systematic resistance to evidence of at least some Prejudgements become prejudices only if they are not reversible when exposed to new knowledge. A prejudice, unlike a simple misconception, is actively resistant to all evidence that would unseat it.  these implicit attitudes count as evidence-responsive. Once again, we find overlap on the content-responsiveness continuum.So, the least evidence-responsive belief has set the bar of responsiveness to evidence—a bar which, for the patchy endorsements theorist, must not be exceeded by Let us take stock. We saw that the stronger commitment of the patchy endorsements theorist, SGC, does not stand up to scrutiny. There are at least some beliefs which respond to evidence and cause inferential updates in much the same way as at least some implicit attitudes. The weaker commitment of OCC, the ordered continuum claim, may get things broadly right in that there may well be a number of highly content-responsive beliefs and a number of highly content-unresponsive implicit attitudes that occupy the extreme ends of a continuum. But it is not wholly right. In fact, it’s a patchier picture still: at least some implicit attitudes are more content-responsive than at least some beliefs, and so rather than a clear divide between the last implicit attitude and the first belief, we’ll instead find a patch of overlap on the content-responsiveness continuum.This result not only has theoretical consequences for how we carve up the psychological landscape. It also reopens ethical questions that Levy  considera, c, and d) and beliefs  are ordered on a continuum just as regards their content-responsiveness, in the middle of this continuum there is an area of overlap comprising both implicit attitudes and beliefs. For the purposes of this argument, I have been assuming that features a/a1, c/c1, and d/d1 do admit of clean distinctions which enable us to demarcate implicit attitudes from beliefs. So, I have not shown, all features considered, that implicit attitudes do not constitute a sui-generis class. Rather, the conclusion is more modest: it is that no distinction as regards content-responsiveness will uphold the sui generis class claim: Contra-Levy (I this paper, I have established that recent efforts to reinstate a sharp distinction between implicit attitudes and beliefs on the basis that the former necessarily respond to content in a different manner to the latter do not achieve their aim. This argument establishes that when implicit attitudes (demarcated by features tra-Levy , patchina, c and d, constitute a sui generis class. It’s simply that content-responsiveness plays no part in this story. In what remains, however, I briefly acknowledge results that may present a challenge to distinctions on the basis of a/a1, c/c1, and d/d1 and indicate how future research could help to illuminate whether these putatively distinguishing features really are up to the job.It is consistent with what I have presented here that implicit attitudes, qua attitudes that harbour features observational awareness, in which one infers the content of one’s attitude from one’s behaviour, not to introspective awareness, in which one is acquainted more directly with this content through introspection. This amounts to there still being a distinction between the kind of awareness that we have of implicit attitudes as compared with that which we have of beliefs. However, one might take issue with her interpretation of these results. In the Hahn et al. (predict discrepancies in their behaviour on the IAT before they take the test. One might argue that observational awareness is insufficient for the successful prediction of future behaviour. After all, one cannot observe a behaviour that one has not yet performed. If this is correct, then it might be that one can sometimes be aware of one’s implicit attitudes in just the same way that one is aware of one’s beliefs. It would be premature to affirm that conclusion here, but this possibility may form the basis of future research on awareness of implicit attitudes.Studies demonstrate that some implicit attitudes are sometimes accessible to awareness (Monteith et al. n et al.  study, pcan be intentionally inhibited through “ecological control”, a form of control in which cognition is distributed across environmental artefacts, or achieved through cognitive rehearsal techniques (Holroyd and Kelly beliefs are only amenable to ecological control, then the distinction between all implicit attitudes and all beliefs as regards how they are controlled may collapse.Jules Holroyd and Daniel Kelly argue that implicit attitudes ensure that one’s experiment measures genuinely avowed attitudes, especially in the case of social attitudes. This is because avowal can be mediated by what experimental psychologists call “social desirability” concerns (e.g. Holtgraves Whilst I have taken participants’ avowal at face value in this paper, I acknowledge that it is difficult to likely to find the attitude in question, as opposed to where an attitude is guaranteed to lie. Or perhaps we will discover that the features considered in this section are not stable attributes of attitudes themselves, but are determined by incidental features, such as the social context in which we find ourselves. Such research will help to settle the wider question as to whether “implicit” and “explicit” in general latch onto genuine sui generis classes; or perhaps identify homeostatic property clusters; or even pick out no stably occurring distinctive features at all, elucidating important questions in the metaphysics of implicit attitudes.These are preliminary considerations, and more extensive research would be required to settle whether awareness, control or avowal distinguish implicit attitudes from beliefs following these considerations. Such research would enable us to provide more substantive answers to questions 1–4 as laid out in the introduction. A similar methodology to that employed here may be used, where attitudes are ordered according to their characteristics, and we look to see if there is any overlap. Further research may demonstrate that robust distinctions remain as regards awareness, control and avowal. Or it may demonstrate that these distinctions give way to further continuums featuring overlap. Perhaps, then, “implicit” and “explicit” designate only regions in which one is


Pediatric integrative therapy programs are essential to the treatment and well-being of patients. Identifying an effective integrative therapy model within conventional pediatric medical settings, however, often proves difficult. Our goal in this article is to explore varied solutions to increase access and inclusion of integrative therapies in an effort to promote best practice and holistic care. The main methods applied in this article are vignettes that illustrate how the integrative therapies in a metropolitan academic hospital successfully treat the patient by complementing conventional medicine. This leads to comprehensive care. The central finding of the article proposes viable solutions to increase interdisciplinary collaboration both internally within the institution and externally. Integrative therapists detail how they were able to increase visibility and yield best practice through increased educational initiatives and interdisciplinary collaboration. And so these men of Indostan, disputed loud and long,each in his own opinion, exceeding stiff and strong,Though each was partly in the right, and all were in the wrong!So, oft in theologic wars, the disputants, I ween,Rail on in utter ignorance, of what each other mean,And prate about an ElephantNot one of them has seen!John Godfried Saxe The parable of the blind men and the elephant has long illustrated the importance of considering multiple viewpoints in order to see the full picture. The story tells of a group of blind men who are asked to characterize an elephant by touching a different part of its body, such as the tail, the ear, or the trunk. The result is that the elephant is universally mischaracterized because each man makes assumptions based on his partial interaction with the animal. The moral of the parable is that in order to attain a comprehensive version of the truth, we must first acknowledge our limitations and seek out other perspectives.This parable mirrors conventional healthcare. Current medical practice routinely emphasizes treating the “diagnosis” at the expense of the patient. Doing so results in clinical “blindness” that inhibits best practice and limits comprehensive care.For this reason, conventional medicine is increasingly trending toward interdisciplinary practice ,3,4. ThiOne way to increase interdisciplinary practice is to promote integrative health care. This involves combining standard medical treatment with mind-body practices. This holistic approach to health care includes treating all parts of the patient, including the “mental, emotional, functional, spiritual, social and community aspects” .Mind and body practices are centered around the patient-practitioner relationship and incorporate all available evidence-based therapies to treat the patient . AcupuncWhat Does Health Look Like in Healthcare Today? Sustaining Identity as an Integrative Therapist in Medicine”. They invited art, music, dance-movement and yoga therapists, chaplains, physicians, social workers, nurses, psychiatrists, and acupuncturists from major academic institutions to present and discuss numerous ways integrative therapists yield best practice, mitigate effects of invasive procedures, treat physical and emotional pain, and increase communication among staff and with family members for responsible care. This event was supported by NewYork-Presbyterian Morgan Stanley Children’s Hospital (NYP MSCH) and attended by approximately 100 professionals representing all levels of health care providers across New York State. Feedback from evaluations was overwhelmingly favorable and highlighted the need to make integrative healthcare a universal practice in conventional medical settings.At NewYork-Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, mind-body therapies serve a variety of diverse populations. In an effort to advance integrative health care within this major metropolitan academic institution, these writers embarked upon several hospital-wide initiatives to educate the medical community on evidence-based mind-body interventions. To change culture, they organized a full day conference entitled Creative Arts Therapies Conversations in Healthcare and Therapeutic Transformations (CAT CHATTs): “The following are vignettes from five different integrative clinicians at our urban teaching hospital. They serve to illustrate how integrative therapies are effective and evidence-based disciplines that when used in conjunction with standard medical treatment can promote best practice. All patients’ names and identifiers have been changed or replaced with initials to maintain anonymity and privacy.“Doc, need you in room 23 stat! We have an eight-year-old boy with paraphimosis since last night and clinic just sent him to us for reduction!” It’s now 1:30 p.m. and the foreskin has been in the retracted position since CJ showered last night over 15 h ago. CJ appeared anxious and tearful due to pain from a swollen and red foreskin. After placing him in a Trendelenburg position, topical 2% Lidocaine and D50W plus ice were placed on the area to decrease pain and swelling. Next, intranasal Fentanyl was administered for pain and a child life specialist was at the bedside, providing breathing coaching and an iPad for distraction. The first attempt to release the foreskin was met with such pain and crying that the procedure was aborted. Urology was in the operating room, unavailable to assist. Should I give CJ another dose of opioids? Inject local anesthetics, but risk causing further swelling and emotional trauma? In this case, I offered the family auricular acupuncture to decrease CJ’s pain and anxiety.Oftentimes, children who are in pain or waiting to undergo a painful procedure are already afraid and anxious. In order to break this tension and dispel their trepidation of acupuncture, I would often jokingly say, “The acupuncture needle is the biggest one in our whole emergency room”! and then dramatically pull out a tiny needle as everyone laughs. To introduce acupuncture to CJ and his family, I first showed them how filamentous the acupuncture needle is by bending it along my finger. Next, I mimicked the pin prick needle sensation by gently pinching the dorsum of his hand while saying, “You might feel the acupuncture needle like a little pinch”. This process helped to put CJ and his family more at ease and they agreed to give acupuncture a try. To further empower CJ at this time when he may feel especially vulnerable, I said, “Let me know if the needle bothers you. We can stop anytime you like”. Using the Battlefield auricular acupuncture protocol , CJ calmThis case demonstrates how a child benefited from a collaborative effort using standard pain medications and other non-pharmacologic therapies, including breathing techniques, distraction with iPad, and acupuncture. This multimodal, integrated approach resulted in a successful outcome- something no single therapy could have accomplished.Acupuncture has been used in China for thousands of years to treat pain  and is rAcupuncture is often offered to pediatric patients undergoing radiation and chemotherapy on the Hematology-Oncology service at NYP MSCH because it mitigates symptoms, including nausea, vomiting, pain, and anxiety ,15,16. FNursing and physician colleagues in the PED have witnessed first-hand the positive result of acupuncture. For this reason they frequently refer patients for acupuncture when standard of care, including pharmaceuticals, fails to achieve sufficient pain relief. In a study conducted at NYP MSCH PED, patients were treated with acupuncture for diverse painful conditions, including headaches, otitis externa, torticollis, constipation, dysmenorrhea, and knee and ankle sprains. Acupuncture was well accepted, with 96% of patients and families reporting satisfaction with acupuncture and 52% achieving complete pain resolution. Unlike pharmaceuticals, acupuncture offers the additional advantage of low adverse side effects, and avoids medication interactions. Given our nation’s opioid crisis, the integrative practices at NYP MSCH PED conform to the recommendations from the Centers for Disease Control and Prevention and the U.S Food and Drug Administration that nonpharmacologic therapies, including acupuncture, be offered to treat patients with pain ,19.It is gratifying to be able to relieve a patient’s pain and suffering; to see a child’s face change from a grimace to a smile. The practice of acupuncture has afforded me opportunities to show families and colleagues that medication alone is not always the solution, nor is it the only answer. With growing evidence on its efficacy and high safety profile, acupuncture may one day become an invaluable staple in our therapeutic armament to help treat pain in pediatrics.Ravi is a two-and-a-half-year-old boy with a hyphenated Jewish and Italian last name. He has been on the Neurology Unit for one month with seizures. Ravi’s skin is very dark in contrast to everyone else in the room who has very white skin. Ravi is stiff, his limbs are at odd angles, his head is fixed, and he is silent except for occasional moans. Mom and Dad tell me they adopted Ravi after many in vitro attempts and know there is epilepsy in his African-American family of origin. They adore him and Mom talks about how articulate and talented he is. In terms of religious affiliation, Mom is of Jewish heritage and non-practicing. Dad was raised Catholic, but non-practicing, and has for some time sought spiritual expression in Buddhism.As a chaplain, I am attuned to the different languages and styles people use to describe their values, the ways in which they cope, or do not. I am curious about how this couple navigates their different spiritual languages. These parents are at their wits’ end and I feel like they are leaking out of the boundaries of their bodies. I am a witness to the leaks; and I am a bucket to catch and hold them. Perhaps the collection will be helpful for later reflection for Mom and Dad, but for now I am a bucket brigade with big ears. Over the course of an hour, Mom unfurls a rage aria; they hate the hospital and everyone in it and are furious at how long it is taking for a diagnosis. Next, she laments, revealing she is terrified that their boy will never be their boy again. She cannot bear considering this loss and she declares herself “desperate” for anything that will help, “even Jewish prayer”. We both smile at “even Jewish prayer” as she tells me she never learned much about her Jewish heritage and is not sure what it might offer. I hear her curiosity expressed in the face of her desperation as a desire to connect to something, to claim something that is both a birth right and a tribal right, perhaps as intense as her desire to be a mother. I feel her words of anger and sorrow pierce my own body and consider the options. How to craft a communication from the depths of her soul to…God? She wants to regain her equanimity, but feels she cannot if she is going to continue to advocate effectively for Ravi. A prayer for healing, but for whom? I center the prayer on text written by a 19th century Moroccan rabbi because his origins are as far-flung as the circumstances. Dad is restrained, but cries when we pray in Hebrew and English around Ravi.Board certified hospital chaplains are responsible for assessing and supporting the emotional, religious, and/or spiritual needs of patients, families, and staff. In addition to supporting these needs, we are trained to listen and to help people access, re-access, or even develop new coping resources regardless of religious or spiritual affiliations. Chaplains help people remember who they are when they are not in the hospital. The conversations can be confessional, investigative, witnessing, and always confidential unless there is potential harm to self or others. Formal research in evidence-based chaplaincy is still in its infancy, however, existing research points to the power of narrative  and the Some weeks later, Ravi has suffered a brain hemorrhage and cardiac arrest, and is in the ICU. He is sedated on a ventilator, his cognitive condition unknown. Over the weeks, Mom and Dad’s spiritual engagement has consisted of meditation with a Buddhist chaplain and a perfunctory wave to the ICU chaplain. When I see them, their eyes are blank and their vitality is sapped. While Ravi has been steadily losing his muscle tone, his parents have begun to lose their person tone. They have so profoundly passed beyond the boundaries of their bodies that they have quietly imploded, and the outlines of who they are in the world as employees, co-workers, friends, and parents are slowly being erased. They tell me they are using meditation to have a moment to “shut down” their thinking and seek a moment of refuge “to not feel”. They are no longer seeking refuge in spiritual resources because they see no purpose. Ravi has become a stranger to them, and they to themselves. They appear as shadows.Pastoral care in the hospital setting is about identity recalibration. The chaplain looks for the shards of a shattered identity and the ways in which to help reunite them. The intention is to pause the chaos and co-create with the patient, or family, or staff a pathway through the obstacles to find and reclaim a sense of self.In Ravi’s case, however, there is no clear pathway to reunion, nor definitive resolution. The tragedy of this story is multi-layered. I cannot fix the situation. Instead, I listen to the loss and reflect back the confusion. I hold the myriad of desperate emotions flying around the room and help them to integrate this part of their life story while rebuilding their person tone through reflection of the unwanted emotions they are fiercely trying to shed. I intervene in the moment as each conversation unfolds and I can only hope that my practice in some way helps them to begin to find meaning in the shadows.“Ewww, Alan’s toilet has that thing hanging there with his urine in it, that’s gross”. Alan’s older brother was referring to the urinal. Alan is a tiny 10-year-old boy who speaks in a small inaudible voice, occupying little space in his room, contrary to his older brother and sister. His mother, nervous in nature, and his father, calm yet distant, routinely accompany him to the clinic where he receives treatments for his astrocytoma.I was consulted to assess for and provide art therapy services throughout Alan’s long and arduous treatment course. Initially he presented with flat affect, withholding of feelings and what appeared to be an absorption of his mother’s anxiety that was present during every medical encounter.The creative process of art making mirrors life itself. Both process and product serve as a bridge from an individual’s inner world to the outside. Art therapists actively look and listen for imagery, symbols and metaphors, and use them to help explore pre-conscious content with patients. The process of exploring art media, creating and talking about the art offers patients increased opportunities to find more compatible relationships to potentially overwhelming thoughts and feelings ,23.Hospitalized children may not have the words to express what they are thinking or feeling, or these words may not do their experience justice. Art, then, serves as a translator to communicate internalized emotions to the important people in the room. Images offer children opportunities to externalize their content safely while the art therapist helps them find personal meaning in their work . FindingAlan reported that his G-tube feedings resulted in “excruciating” pain, the primary symptom which led to his current hospitalization. In our first art therapy session, Alan approached the art making inauspiciously, carefully and with unwavering focus. He chose art materials with intention, requesting to work with non-traditional media, and repurposing mundane objects that he altered into a three-dimensional environment.Typically, children select paints, pastels or clay to form their visual expressions. Alan used a paint brush container as the central sculptural component in his artwork where he used string to attach plastic aquatic figurines from the top allowing them to dangle inside. In art therapy, these two attributes of using non-traditional materials and repurposing objects  indicate flexibility, creative problem solving and adaptability.“That’s not an art material Alan, choose something that is in her [my] basket”. His mother’s reprimands appeared to imply that Alan’s behavior was impolite or defying the rules- in contrast to what I assessed to be a series of creative and resilient solutions. I wondered if this was a mother’s instinct to protect her child and find control in this desperate situation. Adhering a plastic transparent circular container (paint brush cleaner) to the center of a green painted circular cardboard base, Alan began to redefine and transform the objects.Midway through the session, the oncology attending physician humbly entered the room. Alan’s mother stood up to meet him at the foot of the bed, his words stacking like bricks in her arms as he delivered the unresolved news about Alan’s G-tube infection. Upon his exit, Alan’s mother and father murmured their discouragement and concern for Alan’s unexplainable pain.Shortly after this, the surgical team arrived. “Looks like fun”, a resident commented to Alan about his art. Alan gave no response. Surrounded by the team, his infected G-tube site was examined. I transitioned to the back of the room to be with his siblings who were observing from a distance. “Ewwwww”, exclaimed his sister, “I just saw Alan’s feeding tube site, gross”.Alan remained quiet, frozen and naked.As the team discussed their impressions with the parents, Alan continued with his art, selecting a variety of jungle animal figurines and gluing more than twenty tigers, elephants, giraffes and hippos around the perimeter of the circular base, encircling the large ominous container in the center.“That’s too many animals, save some for the other children”, prompted Alan’s mother once again. Alan’s expressive non-verbal voice is scolded, minimized and criticized as if to say, ‘Don’t take up that much space, stop taking from others and use unforbidden objects. Stay quiet and unseen.’Unexpectedly, Alan’s roar pierced the room bringing everyone to a halt. “STOP!” He yelled in response to his brother’s persistent attempt to look at his feeding tube site. “Why can’t I see it?” he whined. He silenced the pervasive buzz in the room, “Because I don’t trust you!”“Whom do you trust?” I asked.His mother and father stood frozen, holding their son’s eyes with their own. Tears poured down Alan’s cheeks, “I’m scared”. His parents, like bookends, stood on alternate sides of him. “There’s a hole in my side”. Alan’s fear, resounding and exposed, was now unavoidable.Alan’s art- a depiction of animals surrounding the ‘watering hole’- communicated ‘observation’, ‘vigilance’ and ‘feeding’, all of which were prominent themes from his medical experience. In this moment he was surrounded by teams peering at his feeding tube, his family verbally and visually poking at an area which was the very hole that fed and sustained him. Throughout his exam he exhibited a hypervigilance to incoming danger . The container that water is poured into is the focal point in his art piece and a reflection of his own body. Occupying all dimensions of space, the animals’ small stillness reflects the vulnerable unknown. The myriad of feelings elicited from the imagery mirror different aspects of Alan and his experience during this pre-surgical exam and a visit from his physician. Alan’s voicelessness in his treatment was finally unleashed in this compelling moment, providing him an uncensored expression of his fears. Had the surgical team been in the room when Alan was able to clearly verbalize his fears, it’s possible that the team may have listened and responded differently throughout the exam. And alternatively, the response, “Looks like fun” to Alan’s ‘watering hole’ sculpture would not minimize his expression but rather validate it with “Looks like you have a lot to say”.As an art psychotherapist, I enter into symbolic and metaphoric language to meet the child in his/her inner world. It is humbling to be invited into this space and experience his/her story through imagery and expressive language. The presence of disease in the body can be without symptoms. So too, meaningful messages can exist in a child, and like that of disease, the meaning can be unknown until it is ready to be revealed. In the case of Alan, the unknown became a shared space for Alan, his illness, his art, and me.“We can beat the bad man, make him go away, if we sing loud enough...All the way up to GOD!” Josiah was a typically developing vivacious seven-year-old boy with a history of prolonged hospitalization and chronic illness awaiting heart transplant. During the first month of his admission, Josiah appeared to exhibit increased signs of anxiety and regression so the interdisciplinary team asked me to assess him for music therapy services. Music therapy as defined by the American Music Therapy Association is “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship” .In our first session, I quickly established rapport with Josiah through active music making and musical improvisation . His initial improvisations presented as playful, melodic, and heavily percussive displaying steady, organized rhythms and lively tempos. His final musical improvisation, however, changed significantly. It became increasingly chaotic, displayed sharp contrasting rhythms in a disorganized pattern and was punctuated by strong accentuated beats. Mid-way into this improvisation Josiah stopped abruptly and pointed directly to a Halloween face mask adjacent to him on the bed. He placed his finger over his mouth and with wide-eyed affect whispered, “we need to be very quiet... so we don’t wake the bad man”. He then proceeded to sing softly in an effort to avoid being captured by this “bad man” monster who wanted to “silence” his music.As a music psychotherapist, I use my modality to help patients explore, express, and discover their internal worlds by inviting ongoing musical and verbal dialogues between their conscious and unconscious selves . During Pre-transplant, my clinical work with Josiah was predominantly psychodynamic in that I continued to invite him to engage in musical dialogues between his conscious and unconscious selves. In these ongoing dialogues, he explored a variety of recurring themes in the music, including ‘silence/sound’, ‘dominance/submission’, ‘danger/safety’, ‘fear/courage’, ‘separation/reunion’, ‘helplessness/empowerment’, and ‘salvation’.Mid-way through his admission, Josiah was successfully transplanted, however, postoperative complications led to a cardiac arrest that resulted in anoxic brain injury and substantial decompensation. Following this event, the family was in crisis and the team reported uncertainty as to Josiah’s neurological outcome.For me, the shift was just as dramatic. In many ways, Josiah’s musical journey paralleled his cardiac journey; his music had stopped abruptly, unexpectedly, and without warning, leaving in its wake a painfully uncomfortable silence. Clinical music therapists are trained to create space in the music for our patients because rests are just as important as the notes. But how could I begin to honor Josiah’s notes when his voice as I knew it had been silenced?As a result of this experience, my clinical practice evolved to become more flexible, innovative, and creative. I began by increasing communication with team members to help identify common goals and innovative solutions aimed at addressing a variety of barriers to care. Josiah displayed extreme spasticity in his lower extremities, which created limited mobility, and he had difficulty maintaining autonomic stability. This was most evident during physical and occupational therapy sessions when he often became tachycardic and tachypneic. In these sessions, he also displayed visible and audible signs of distress and emotional dysregulation, including moaning, crying, contracted limbs, and a constricted, tearful affect.rhythmic entrainment  [In response to these barriers, I worked closely with the team to design individualized music therapy co-treatments. To encourage homeostasis during rehabilitation therapy sessions, I played improvised harmonies on the guitar, which emphasized regular, steady rhythms and slow tempos while singing improvised melodies with prolonged phrases or musical meter. This intervention known as h other)  helped tvibroacoustic therapy [In physical therapy sessions, I used a sound and vibration intervention known as  therapy ,32 to mi therapy . Suddenlvocal holding consists of the intentional use of playing two alternating chords on a harmonic instrument in combination with improvised singing in order to create a consistent and stable environment [A final collaboration with pastoral care led to a co-treatment that provided Josiah’s family the opportunity to give voice to overwhelming feelings of fear and anxiety. I played simple chord intervals  on the guitar and sang an improvised melody to create a musical environment that was secure, contained, and predictable while the chaplain led the family in prayer. This technique known as ironment . InitialAt this point in the session, Josiah, who had been sleeping in a bed adjacent to our prayer circle, opened his eyes and his mother moved bedside to take his hand. Softly, she began to sing his favorite song, “Oh, the itsy, bitsy spider, went up the water spout...” I quietly fingered chords on my guitar to accompany her as she continued to sing, “Down came the rain, and washed the spider out...” Slowly, family members gathered around the bed holding hands, encircling Josiah as he held her gaze. “Out came the sun, and dried up all the rain...” Josiah opened his mouth slowly, hesitantly groping as his mother sang the last line, “and the itsy, bitsy spider went up the spout ah…” Josiah completed the song, penetrating the silence with his voice at last, “...gin”.My favorite thing about music therapy is that it is inherently collaborative. Unlike conversation, music happens concurrently offering participants an “I” and “Thou”  experienThe chemotherapy charge nurse texted, “Please come to the Infusion Center to meet a new patient who wants to talk to you about yoga therapy and meditation during her cancer treatment”.The patient, Stacey, had recently celebrated her 18th birthday. Soon after, she had felt a lump near her right armpit. The staggering diagnosis of stage IV breast cancer with metastases to the liver and spine literally took her breath away. Today was the first of an anticipated 180-day chemotherapy treatment plan to be delivered once every three weeks.As I approached the infusion area, I paused to center myself so I could be fully present with Stacey—allowing her to be heard, to be seen; holding her in compassionate, loving space. Elizabeth Kubler-Ross said, “Telling your story often and in detail is primal to the grieving process. You must get it out. Grief must be witnessed to be healed  (p. 63)”I washed my hands, focusing on my own breath: “Take three deep belly breaths, relax into the exhalation, allow your awareness to rest on the present moment”. I continued to practice this deep breathing, and soon Stacey mirrored the gentle rise and fall of my abdomen. Her breathing slowed as I guided her through a 15-min meditation. She said she felt calmer and I saw on the monitor her systolic blood pressure had dropped 15 points. I showed her various breathing techniques to practice at home and during treatments to help manage anxiety and discomfort, and we began to create a plan for a daily meditation practice that was based on her personal preferences.As a Yoga Therapist in Integrative Oncology, I work closely with Psycho-Oncology and Palliative Care. The cornerstone of our team’s integrative approach is to partner with patients and families, providing attentive, empathic clinical care to address the needs of mind, body, and spirit. I was the first of our team to meet Stacey and immediately suggested she consult our Psychologist and Palliative Nurse Practitioner for help managing anxiety and prospective chemotherapy induced peripheral neuropathy. During her half-year of treatment, our team met regularly to discuss her case, and I supported my colleagues’ behavioral and pharmaceutical interventions by customizing weekly sessions of conscious breathing, meditation, and mindful movement to address her evolving physical and emotional needs.Mind-body interventions are important self-regulation practices that support psychosocial therapies by fostering general mental well-being, calmness, clarity, and concentration ,39,40. TThere is substantial evidence to support the efficacy of mind-body therapies in the outpatient clinical setting. At its June 2018 annual conference, the American Society of Clinical Oncology (ASCO) endorsed yoga and meditation as adjuvant therapy during conventional breast cancer treatment and survivorship to mitigate the sequelae of acute and late treatment side effects, including anxiety, mood disorder, depression, and to improve quality of life .no evidence of disease and told us that our integrative care had “saved her life” by teaching her how to manage her fear and anxiety, and to help her keep physically active during her difficult treatment. In her mother’s words, “Stacey’s medical oncologists may have eradicated the disease and put her in remission, but her integrative support team gave her back a life worth living”.At the end of her treatment Stacey was declared with It is imperative that we, as integrative therapists, spearhead the effort to create a paradigm shift in the way our healthcare system treats our patients and their loved ones. Mind-body therapies are evidence-based, drug free, cost effective, and available to everyone regardless of cultural background and socioeconomic status. Let us listen closely to our patients and their families, see the elephant in its entirety, and commit to treating the individual, not the disease.The above vignettes clearly illustrate how integrative therapies address the mental, emotional, functional, spiritual, social, and community domains of the patient, thereby improving the overall patient experience while supporting standard medical treatment outcomes. Despite the overwhelming evidence that points to the effectiveness of integrative healthcare, these writers encountered areas for further consideration.Currently, in conventional medical settings, integrative therapy positions are funded in a variety of ways. While many creative arts therapy positions are typically donor funded, at this institution, art and music therapy and pastoral care positions are billed to the cost of room and board. Yoga therapy is funded by a private donor, and acupuncture services in the pediatric emergency department are currently not separately reimbursed. It remains clear that additional cost analysis research is needed to find sustainable solutions to increased integrative programming.In conventional medical settings, mind-body practices are often misplaced, misunderstood, and misclassified. This leads to a misappropriation of services, impaired practice and, ultimately, identity confusion regarding the role integrative therapists play within the treatment team. For this reason, clarifying the scope of practice and managing staff and family expectations is paramount.Misplacement of integrative therapists creates confusion within the interdisciplinary team. Therapists are difficult to locate, often possessing job titles or embedded in departments unrelated to their discipline. For example, a pain specialist may have a hard time locating a mind-body therapist when he/she is identified on his/her identification badge as a recreational therapist and managed by a child life department.Integrative therapists are trained to facilitate and process the expression of anxiety and fear that accompany medical encounters that are interwoven with pain symptomatology ,47,48,49Despite the aforementioned barriers, these writers were able to identify a number of innovative solutions to minimize siloed practice and help break down existing barriers. Through workshops, targeted in-services, interdisciplinary rounding, co-treatments, lectures, grand rounds, and hospital-wide educational forums, including conferences and workshops, medical professionals are provided with opportunities to learn and experience firsthand the benefits of integrative therapies, including art, music, yoga, pastoral care, and acupuncture.The advancement of integrative health care in a major academic hospital takes time and strategy to promote complementary practice. Below are suggested actions steps to help increase visibility, awareness, and accessibility to integrative services. The recommendations listed are from these writers’ personal accounts and experiences of successful implementation of hospital-wide programs and initiatives.Create a customized website with a dedicated email address to promote understanding and classification of integrative therapies.Design and distribute educational brochures and marketing materials to staff detailing services and appropriate referral criteria.Facilitate weekly in-services for interdisciplinary staff, fellows, residents, medical students, and physicians that lead to better integration of mind-body services in treatment plans. This practice also generates potential funding for additional positions, including expanding services to outpatient or satellite clinics.Obtain funding through grant support from established national organizations, such as the American Academy of Pediatrics, Virginia Apgar Academy, American Art Therapy Association, private donors, and foundations to support educational workshops and research.Conduct workshops, lectures, and grand rounds for nurses, students, residents, and faculty members, thereby gaining more acceptance and understanding from providers across the hospital on integrative therapists’ role in medicine.Publish and present locally, nationally, and internationally on integrative therapy research and practices.Create an integrative rotation elective as part of residency training to educate and promote utilization of complementary practices located throughout the hospital.Involve integrative therapy students in the creation and co-facilitation of expressive therapy pilot programs for outpatient clinics, which increases complementary services to more patients and families in need.A cultural shift in this conventional medical setting is growing as a result of increased visibility, education, understanding, and collaboration, but the need for increased integration of mind-body practices still remains. Barriers to true integrative health care include limited funding, misappropriation of services, misclassification, misunderstanding, and continued siloed practice. To affect global change, it is incumbent for all mind-body clinicians in conventional medical settings to join this cultural revolution. This publication is just the first step. A restructuring of conventional medical frameworks is necessary in order to see and treat the whole patient. From revolutionary paradigm shifts and innovative practices to eradicating siloed services, integrative, complementary “wholistic” health is the future.Organizations that begin to successfully integrate humanistic medicine with evidence-based mind-body practices empower patients to become active partners in their treatment. Such integrative practice reduces harm, sustains ethical and legal professional standards, gives purposeful direction to therapeutic interventions, and enhances the efficacy of conventional treatment plans. It is the future of good medicine. This is the elephant that we can all see and heal.


Gorgonia system. Thus, our challenge in the near future is to identify and resolve potential gaps in order to achieve a more comprehensive progress on coral disease research.Coral disease research encompasses five decades of undeniable progress. Since the first descriptions of anomalous signs, we have come to understand multiple processes and environmental drivers that interact with coral pathologies. In order to gain a better insight into the knowledge we already have, we explored how key topics in coral disease research have been related to each other using network analysis. We reviewed 719 papers and conference proceedings published from 1965 to 2017. From each study, four elements determined our network nodes: (1) studied disease(s); (2) host genus; (3) marine ecoregion(s) associated with the study site; and (4) research objectives. Basic properties of this network confirmed that there is a set of specific topics comprising the majority of research. The top five diseases, genera, and ecoregions studied accounted for over 48% of the research effort in all cases. The community structure analysis identified 15 clusters of topics with different degrees of overlap among them. These clusters represent the typical sets of elements that appear together for a given study. Our results show that while some coral diseases have been studied considering multiple aspects, the overall trend is for most diseases to be understood under a limited range of approaches, e.g., bacterial assemblages have been considerably studied in Yellow and Black band diseases while immune response has been better examined for the aspergillosis- Coral diseases have been an important factor responsible for the decline of coral reefs in the last decades . AlthougThe evolution of this body of knowledge has been compiled and updated frequently in multiple narrative reviews . HoweverHere we present a systematic review aimed at identifying groups of coral disease research topics that have been explored more frequently than others. To do this, we performed a network analysis approach. Network analysis is frequently used in systematic reviews  and alloGoogle scholar, Meta, and Peerus, using combinations of keywords with search modifiers, including “coral disease”, “syndrome”, “yellow”, “black”, “purple”, “spot”, “band”, “pox”, “dark”, “plague”, “growth”, “trematode”, “anomalies”, “ciliate”, “soft coral”, and “aspergillosis”. This included peer-reviewed papers and conference proceedings, since the latter would also provide information about research questions explored in a given time and a given location. We excluded thesis, preprints , and book chapters. Additionally, we compared our database with the list of papers analyzed by We reviewed a total of 719 publications spanning a period from 1969 to 2017. We searched for these in the search engines and databases  •What was the studied disease? Each disease was listed as an individual node and the cases where there was no specific disease of interest , we assigned the node “multiple diseases”. Additionally, we classified “White Syndrome” as all the descriptions of pathologies involving tissue discoloration and loss from the Pacific sensu  is included as a supplementary file at https://github.com/luismmontilla/CoDiRNet/tree/master/supplementary.Two of the authors (see author contributions) performed the assignation of nodes to each study, and in the case of disagreements, all the authors were consulted until a consensus was reached.ij was the frequency of co-occurrence of the keywords i and j in the same article . Additionally, we used the community centrality  using a modification of the method proposed by (roc) that allows the use of this coefficient for overlapping communities .To test the statistical robustness of the obtained communities, we measured the communities assortativity  revealed that the coral disease research network, like other natural networks, presented a highly skewed distribution, where most research topics share few connections and a comparatively small group of topics are heavily represented in scientific publications. This pattern persisted for the specific distribution of each type of nodes, suggesting that over the past 50 years, coral disease research has focused on a reduced number of questions in each category .Considering this, we explored the identity of the five most represented topics in each case. For all the categories, five topics accounted for over 40% of the total frequency of apparition in all the examined papers . We showhttps://github.com/luismmontilla/CoDiRNet. These excluded topics either encompass a set of highly-specific questions being scarcely explored  or new questions altogether.After applying the disparity filter, the initial network was reduced to 93 vertices and 233 edges. The set of excluded research questions were included as supplementary material at roc value of 0.23, indicating that the network effectively possess a community structure that departs from randomness. These groups ranged from small communities with low overlap, to rich and highly interconnected communities, e.g., C5 and C14 shared almost 50% of their members . We obtained a  members .The smaller communities were composed of six or less nodes. C3 represented four topics related to questions about temporal patterns; C6 represented four genera typically affected by Dark Spot disease; C8 was comprised of studies dealing with stress temperature and zooxanthellae damage in the Great Barrier Reef and nearby locations. C9 showed that an important group of studies related to White Band disease have been focused in determining the advance rate, transmission patterns, and usually a description of the signs. C10 included the effects of environmental factors on diseased and bleached corals .Acropora-centered community. This included topics related to the descriptions of signs, bacterial assemblages, transmission mechanisms and pattern of several affections like White Syndromes, White Pox, and Brown Band disease, in the Great Barrier Reef. C7 included studies around Caribbean Yellow band disease, mostly about changes in the microbial community, and also temporal and spatial patterns of the disease. C11 was a community constituted by studies about Vibrio as a coral pathogen, especially infecting the genera Oculina, Montipora, and Pocillopora. C13 was a community that incorporated two research trends. The most important node in this community was White Syndrome, associated to topics like pathogen characterization, transmission experiments, and changes in bacterial assemblages of the hosts. These hosts were mainly Montipora and Porites, which were the connection to the second group: research about growth anomalies and trematode infections in Hawaii. C15 was a community centered on gorgonian affections and immune processes  had two nodes in common: Black Band disease and Southern Caribbean. C2 was the most specific one, including objectives related to Black Band disease only. C4 also included Yellow Band disease and White Plague, in this case encompassing studies dealing with transmission experiments, effects of temperature and changes in the associated microbiota. C5 was a community covering reviews, meta-analysis, baseline studies, and outbreaks reports. C12 was very similar to C4, with the distinction of including studies about White Pox, pathogen characterization, particularly yndromes .The network approximation used in this study for analyzing the relationships between coral disease research topics provided a quantitative perspective on the intensity of the research and the extension of the field so far. The communities obtained summarized the dominant trends , with each community corresponding to the themes of interest that have accumulated most of the published papers up to 2017. It is important to notice that we expected some minimal community structure to arise in our network, for some diseases affect only a specific set of coral genera and in certain regions. However, our hypotheses was that the patterns of addressed questions would also contribute to the apparition of multiple communities in our network.Our results display some clear patterns. For example, Black Band disease occupies a preponderant place in coral disease research as the most connected disease that also appears in most communities with the highest centrality. There are several reasons contributing to this. Black Band disease affection has been studied since the emergence of the field  and it hOur findings also highlight the historical importance of environmental stressors for a broad number of diseases. In our network, temperature was consistently associated with several communities, and the role of sedimentation, turbidity, and nutrient loads (including input through sewage waters) were the main environmental factors associated with baseline studies. This was consistent with a previous review where the authors found that the temperature was the most frequently studied environmental variable in their sample, along with sedimentation, both variables having high influence over coral diseases .sensuThis contribution complements previous narrative reviews sensu about coFor example, research about coral immunity has been steadily progressing, however, there is so much room for exploration if we consider that the use of specific approaches can be tested on different coral diseases. For instance, topics like ‘gene expression’ and ‘protein expression’ were excluded from the backbone, probably because they represent emergent perspectives, but there are examples of the application of these methods like immune-related transcriptomic profiles that have been developed for Yellow Band disease , growth The knowledge about coral disease interactions with environmental stressful conditions can also be widely expanded if we increase the attention to other variables or their interactions with some better studied ones. The role of high temperatures has been the main environmental driver addressed, in coral research, however there are other conditions that have been explored in a few papers like changes in water pH , dissolvhttps://www.unep-wcmc.org/resources-and-data/global-coral-disease-database), especially considering that we found the topic ‘baseline’ as an important node in the network but most of this data is not freely available, and it would represent an invaluable resource for further analysis.Other relevant aspect of this field that can be improved in the future is the incorporation of open science practices, making available annotated coral disease specific datasets—represented in our network as the ‘database’ topic—e.g., In summary, we obtained a generalized representation of the most explored topics in coral disease research. However, these predominant themes and questions are yet to be generalized to the range of potential coral hosts and their diseases. One additional contribution of this work is the availability of a growing database that can be used for further and more diverse exploration of the trends in this field, including the detection of emerging topics and temporal trends, which will help to gain better insights of the development of coral disease research.10.7717/peerj.7041/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.7041/supp-2Supplemental Information 2Click here for additional data file.


Mendel and Darwin were contemporaries, with much overlap in their scientifically productive years. Available evidence shows that Mendel knew much about Darwin, whereas Darwin knew nothing of Mendel. Because of the fragmentary nature of this evidence, published inferences regarding Mendel’s views on Darwinian evolution are contradictory and enigmatic, with claims ranging from enthusiastic acceptance to outright rejection. The objective of this review is to examine evidence from Mendel’s published and private writings on evolution and Darwin, and the influence of the scientific environment in which he was immersed. Much of this evidence lies in Mendel’s handwritten annotations in his copies of Darwin’s books, which this review scrutinises in detail. Darwin’s writings directly influenced Mendel’s classic 1866 paper, and his letters to Nägeli. He commended and criticised Darwin on specific issues pertinent to his research, including the provisional hypothesis of pangenesis, the role of pollen in fertilisation, and the influence of “conditions of life” on heritable variation. In his final letter to Nägeli, Mendel proposed a Darwinian scenario for natural selection using the same German term for “struggle for existence” as in his copies of Darwin’s books. His published and private scientific writings are entirely objective, devoid of polemics or religious allusions, and address evolutionary questions in a manner consistent with that of his scientific contemporaries. The image that emerges of Mendel is of a meticulous scientist who accepted the tenets of Darwinian evolution, while privately pinpointing aspects of Darwin’s views of inheritance that were not supported by Mendel’s own experiments. Gregor Mendel and Charles Darwin are arguably the two most influential nineteenth-century founders of modern biology. Darwin’s theory of evolution through natural selection revolutionised the science of his day and beyond, trumpeted by his supporters and vilified by his detractors from the time it was published to the present. Mendel’s theory, by contrast, lay mostly dormant until the dawn of the twentieth century when it rapidly drew both fame and criticism through its dramatic rediscovery. Mendel and Darwin were contemporaries, yet the path connecting them during their lifetimes was entirely a one-way street: Mendel was familiar with Darwin’s books, having read and annotated German translations of them, whereas all available evidence indicates that Darwin knew nothing of Mendel.Much of Darwin’s writings, both published and private, are remarkably well-conserved and documented, providing a plethora of evidence of his activities and thoughts throughout his life. The near opposite is the case for Mendel. Documentation is sparse and fragmentary, much of it lost or destroyed, some of it circumstantial and second-hand. This scarcity of evidence has led to considerable controversy (as reviewed by Fairbanks and Rytting Johann Mendel was born in 1822 in Hynčice (Heizendorf)From that time forward, he found himself in extraordinary intellectual surroundings. He was a friar, not a monk, in that the Augustinian friars of his monastery served the public by openly interacting with the local people, pursuing advanced education in secular subjects, participating in scholarly societies, serving in civic roles, pursuing research and writing, and teaching their academic specialties in schools. The consequence of Mendel’s attempt to serve as a priest is best described in the words of his abbot, Cyrill Napp: “he is very diligent in the study of the sciences; but…is much less fitted for work as a parish priest, the reason being that he is seized by an unconquerable timidity…[which] is why I found it necessary to relieve him from service as a parish priest” Iltis, , p. 58. A fortuitous consequence of Mendel’s timidity was the fact that it motivated Napp to assign him to teach natural sciences in Znojmo (Znaim), southwest of Brno. This assignment freed him to pursue science with students, unencumbered by parish-priest duties. He was a superb and popular teacher, though not certified. In November 1849, the Austrian government issued an edict that all teachers must be certified through a university examination , which Mendel cited. Given Mendel’s acceptance of old-earth catastrophism at this early stage of his career, it is unclear whether he viewed descent from surviving species, as opposed to de novo creation, as the mechanism for the emergence of new species. Notably, Orel et al. .Mendel’s examiners in physics, Andreas von Baumgartner and Christian Doppler, praised his physics essay. The examiner for geology and natural history, Rudolph Kner, determined that Mendel’s account and sources were inadequate and outdated. Nonetheless, Mendel was invited for the written and oral sessions on-site at the University of Vienna. He exceled in some portions and failed others, and thus did not pass the certification examination. Nonetheless, his examiners agreed that he was well-prepared for university studies, allowing him to attend the University of Vienna. According to Orel : “Had heIn November 1851, Mendel enroled at the University of Vienna as an “extraordinary” student, meaning that he did not pursue a degree, audited his classes, and was not formally evaluated  in the Wiener Zeitung (Vienna News), later compiled into a book , which was well received in Vienna (Gliboff Unger espoused the view that new species emerged from previous ones in a passage that is remarkable in foretelling the theme of genetic recombination in evolution that Mendel would address in his research (as noted by Olby  Gliboff .Wiener Kirchenzeitung (Vienna Church News), who published several editorials ridiculing him. The first appeared on October 25, 1851, just two days before Mendel’s arrival. Brunner claimed , which Mendel obtained, probably while at university. His personal copy contains his annotations  at about the same time as his second teacher-certification examination, in the spring of 1856. He had planned well for these experiments, spending the two previous summers (1854 and 1855) growing and examining the varieties he would choose as parents to ensure that they were true-breeding. His classic paper, “Versuche über Pflanzen Hybriden” (“Experiments on Plant Hybrids”) would be published a decade later (Mendel Mendel began his hybridisation experiments with garden pea (r Mendel .Origin of Species (1859) and The Variation of Animals and Plants Under Domestication (1868).At the encouragement of Charles Lyell, Darwin began writing what he intended to be a massive multi-volume work on natural selection this same spring, on May 14, 1856 Darwin , p. 67. Origin of Species first appeared in November 1859  appear in three of the passages Mendel annotated, each translated from Darwin’s “conditions of life”, which Fairbanks and Abbott (Origin of Species” (p. 404). Mendel used “Lebensbedingungen” twice in his classic paper, both times in the paragraph Fisher emphasised as reflecting Darwin’s thought. This word alone provides evidence supporting Fisher’s assertion, but was only the beginning of such evidence.Fairbanks and Rytting  published Abbott  characteOrigin of Species while writing his manuscript, Abbott and Fairbanks , which can be translated as either “evolutionary history” or “developmental history”. “Evolution” (spelled the same in German and English) was not as common a word in either language at the time to denote what became twentieth-century biological evolution. In German, “Entwicklung”, and its derivatives, brought development and evolution together as a unified whole. It is often stated that Darwin never used the word “evolution” in ” Darwin , p. 490.descent with modification….” (p. 41), and “Mendelism came into being historically as a sophisticated form of the doctrine of Special Creation”, which “stripped of overt references to a Creator, stood in open conflict with the Darwinian conception of evolution” (p. 72).Mendel was a scientist and cleric during a time when the conflict between evolution and religion had reached a feverish pitch, which raises questions regarding his views. Most historians who have examined Mendel’s history conclude that he accepted evolution and viewed his experiments and theory as compatible with Darwin’s . Bishop attempted to show that Mendel initiated his experiments in 1861 (not 1856 as Mendel stated) as a direct reaction to learning of Darwin. This argument is based on the notion proposed by Bateson  was in Darwin’s library, with summaries of Mendel’s experiments, yet the pages of these summaries remain uncut. The fact that Darwin owned this book probably morphed into the rumour that he had an uncut offprint of Mendel’s paper, when in reality he had an uncut reference to it, acquired little more than a year before his death .Another question is why there is no evidence that anyone, including Mendel, attempted to inform Darwin of his work. Mendel sent an offprint to Carl Wilhelm von Nägeli, who responded, initiating a collaboration lasting from 1867 through 1873. Nägeli is often criticised for failing to fully grasp Mendel’s Hieracium is not well founded. Mendel fully expected the results he observed in Hieracium, for it confirmed his description of constant hybrids in his classic 1866 paper  referred to Nägeli twice, first without naming him but connecting him with Darwin: “The question of the origin of the numerous and constant intermediate forms has recently acquired no small interest since a famous Hieracium specialist has, in the spirit of the Darwinian teaching, defended the view that these forms are to be regarded as [arising] from the transmutation of lost or still-existing species” , three are in Chapter 15, (On Crossing), one is in Chapter 22 (Causes of Variability), and one is in Chapter 26 (Laws of Variation Continued—Summary). They recount observations that Darwin is unable to explain, but are fully explainable by Mendel’s theory. For example, the second annotated passage recounts a Mendelian dominant-recessive pattern, albeit in non-quantitative terms : “these colours were never blended, but the offspring bore either pure white or pure yellow blossoms; the former in the larger proportion”. .The vast majority of annotations are highly clustered (52 of 57) in Chapter 27, , and are focused on three themes: (1) pangenesis itself, (2) the relative contributions of female and male parents during fertilisation, and (3) the influence of changing conditions of life on inherited variation. Mendel addressed these latter two themes in his classic paper Mendel .Mendel’s annotations in Chapter 27 tend to highlight Darwin’s uncertainties regarding pangenesis, as well as inferences by Darwin that are inconsistent with Mendel’s experimental observations. The first marked passage in this chapter reads, “As Whewell, the historian of the inductive sciences, remarks:—‘Hypotheses may often be of service to science, when they involve a certain portion of incompleteness, and even of error’” . Later Mendel marked, “The existence of free gemmules is a gratuitous assumption...” . In both of these passages, Darwin admits that his hypothesis of pangenesis is highly speculative with little evidentiary support, and Mendel’s annotations, both here and later, reveal his agreement.The part of the book that apparently caught Mendel’s attention more than any other is one he marked with double vertical lines in the margin, next to it a large exclamation point, some underlining of the words, and a handwritten note at the bottom of the page . Mendel provided a very satisfactory explanation of such reversion in his classic paper (1866), observing that the proportion of homozygotes increases with repeated self-fertilisation, a phenomenon he demonstrated both experimentally and mathematically, whereas propagation by buds is vegetative, not sexual. Mendel’s explanation, of course, contradicts pangenesis. A brief perusal of the 52 passages Mendel marked in this chapter, most of which are inconsistent with his discoveries, makes it abundantly clear why he wrote to Nägeli, “Darwin’s statements concerning hybrids of the genera mentioned in ‘The Variation of Animals and Plants Under Domestication’, based on reports of others, need to be corrected in many respects” .Mirabilis jalappa with single pollen grains, and, contradictory to Darwin’s claim in this passage, obtained “18 well developed seeds and an equal number of plants, of which 10 are already in bloom”  is perhaps the most Darwinian passage among his existing writings. Here Mendel inferred that several wild species of e, Iltis  exclaimeHieracium hybrids to Nägeli. From that time forward, Mendel dramatically curtailed his plant hybridisation research. Nägeli would twice again write to Mendel, but there is no record that Mendel responded  The Variation of Animals and Plants Under Domestication, v. 2