Meta-Approaches to Asian Medicine, Part 4: A Polyperspectival Asian Medicine Practice

This post explores in depth how polyperspectivalism leads to greater conceptual flexibility, and therefore more clinical options, when treating patients.

So many to choose from... but which one of these is the RIGHT one?

Articles in this four-part series were published simultaneously on AMZ and Medium.com.

My last three posts have dealt with meta-level epistemic questions in the study of Asian medicine. It is now time to focus in on how these big-picture concerns play out in day-to-day decision making in the clinic. This post explores in more depth the concept of polyperspectivalism. I discussed previously how polyperspectivalism is a key to developing more productive collaborations with colleagues. Here, I argue that it also leads to greater conceptual flexibility, and therefore more clinical options, when treating patients.

Polyperspectivalism is the ability to allow multiple, mutually-incommensurable perspectives to coexist and inform your practice. It is like picking up multiple camera lenses to view an object using a variety of different perspectives, without feeling the need to stitch those perspectives into a single coherent image. It’s not about trying to square what you see through one lens with what you see through another; rather, it’s about using each lens in turn to discover what it reveals or conceals.

An example of incommensurability

Polyperspectivalism is a critically important strategy for overcoming one of the central problems in the contemporary practice of traditional Asian medicine: the cognitive dissonance caused by incommensurable interpretations. For purposes of illustration, let me use an example from my own experience that I think will be generally recognizable by practitioners of all forms of traditional Asian medicine.

My own career as a practitioner lasted for about 10 years before I abandoned it to become a full-time academic. In the early portion of that time, I spent two and a half years in Thailand studying a variety of traditional healing practices. Circulating between classes in traditional medicine clinics, apprenticeships with individual healers, and retreats at Buddhist monasteries and meditation centers, I was exposed to a very wide range of healing techniques and approaches. All of these were deemed “traditional” by the practitioners who were teaching me.

Despite the Thai government’s recent efforts to develop an integrated system officially called “Thai Traditional Medicine” (abbreviated TTM in obvious mimicry of China’s TCM), traditional medicine in Thailand is not a unitary or coherent system. The government has created various regulatory schemes for herbal medicine since the early 20th century and for massage beginning in the early 21st, but there has to this day been little success in producing an overarching systematization or codification on the ground. In the 1990s, Thai medicine was even less homogeneous than it is today. Someone like myself learning from a variety of sources invariably encountered not only a wide range of different practices, but also radically different theoretical justifications—even completely different models of health, disease, and the body—from the teachers we learned with.

Take lom ลม, a concept that is often said to be central to the practice of traditional Thai bodywork.This is a common Thai word that means wind, air, breath, or gas. In the specialized context of bodywork, however, I heard this word interpreted in various different ways:

• From some teachers, I learned that lom was the last of the four elements (i.e., earth, water, fire, and wind), a term that referred to the breath and the mobility of the physical body. These teachers would say that Thai bodywork focuses on pressing and manipulating the material or physical aspect of the body (i.e., the earth element) in order to achieve fluidity of lom (i.e., the wind element). Saying that Thai bodywork helps with lommeans simply that it is intended to improve the mobility of the physical body.

• Meanwhile, other teachers said that lom is a kind of energy or vital force that animates the body. It flows from the core to the extremities along invisible pathways, and ultimately connects the individual body to the mind and the rest of the world around us. The therapist’s focus on lom, according to these teachings, is not about mobility of the physical body per se, but rather the vitality of the underlying subtle body or energy system. In fact, addressing a problem with lom might not involve working with the physical body at all. I was taught to work directly on the system of wind-energy pathways through visualization and meditation practices that were integrated into the bodywork session.

• In addition to these two perspectives, I briefly studied with a teacher who taught that lom was interchangeable with the Chinese concept of qi. She also taught movements that would generate or dissipate lom from the specific organs, in order to tonify or regulate the body’s overall level of yin and yang energy.

• There was another teacher I worked with who refused to say anything concrete about lom—or any other concept for that matter. If I asked any questions about the theoretical side of the bodywork, she would tell me to stop worrying about such things and instead to pray to Jīvaka, the “father doctor” of medicine and the Buddha’s doctor. I was told I should stop trying to use thought to figure out what to do, and instead to let his spirit enter into my body to guide my hands during the massage himself.

• One teacher I was acquainted with, when questioned about lom, insisted to me that all of the above was a load of superstitious nonsense. In her view, massage therapists should focus strictly on physical, anatomical, fleshly realities: pressing the muscles, nerves, tendons, flesh right in front of our eyes and beneath our thumbs. Nothing more, nothing less.

• Finally, several years later after I had left Thailand and was conducting research for my Masters thesis, I learned that the Thai word lom is used as a translation term for various different concepts. On the one hand, it can be a translation of the Pāli term vāyu, the wind element, which is integral to early Indian medical and cosmological theory and entered into the Thai lexicon via Theravāda Buddhism. But, it can also translate the Sanskrit term prāṇa, which is associated with Indian tantric or yogic practices that circulated widely in Southeast Asia in the late medieval period and that are becoming increasingly popular today. And, I learned that in certain cases lom can also be a translation for the Chinese notion of qi. Because these concepts are all translated with the same word, I began to see that lom could have completely different cultural resonances and clinical implications to different teachers. I also began to see that differences in how people thought about lom often depended on specific social factors such as the teachers’ level of formal education, status in the community, gender, religious commitments, and ethnic affinity.

Before I continue, let’s just stop for a moment to appreciate the fact that, on their face, the six different interpretations of lom above are truly incommensurate. Either lom refers in a general way to the breath and the mobility of the physical body, or it’s a complex system of specific energy channels that lies beyond the physical body. Either it’s the central concern of the therapist, or it’s superstitious nonsense. Either practitioners should intentionally understand how to work with lom, or we should stop thinking about it. Either this is a natural feature of how the human body works, or a sociocultural construct. Confronted with these divergent interpretations, it may be possible for me to create a theory where some—or even all six—of these perspectives are integrated into a coherent framework, but that would be my interpretation and none of my Thai teachers would have subscribed to it. Likewise, it may be possible for the Thai government or another organization intent on systematizing to step in and mandate some compromise or orthodoxy, but again that would be their interpretation and not my teachers’.

How do you navigate differences?

Whether you practice Chinese medicine, Ayurveda, Sowa Rigpa, therapeutic yoga, Buddhist healing meditation, or any other tradition, I think all practitioners of Asian medicine will recognize the underlying issues here. Even if you don’t know anything about lom or Thai medicine, I’m sure you have encountered similarly fundamental differences between schools, texts, lineages, or teachers that cannot be reconciled with one another in your own tradition. You no doubt have yourself grappled with how to navigate those differences in different educational settings, and how to decide which approach to take in the clinic.

When presented with incommensurate interpretations such as these, practitioners often feel forced to commit to one viewpoint—or to integrate several of them together if possible—and to jettison the ones that can’t be made to fit. This impulse is understandable, as it is a way of minimizing the cognitive dissonance that comes from incompatible truth-claims. But, how do you decide what to keep and what to discard? In a previous post, I outlined three different “epistemes” or worldviews that many practitioners can get locked into when making these decisions.

When I was first starting out, like many practitioners of Thai medicine Western and Thai alike, I was convinced that the only legitimate place to look for the answer to what lom “really is” is within the tradition itself. In other words, back then I subscribed to what I now call the “traditionalist episteme.” Traditionalists agree that the definitive source that will solve the problem for once and for all will be a text, a book, or a teaching by someone inside the tradition; however, they differ vociferously on which exact source they deem most authoritative. One may feel that the answer is to be found in this or that particular manuscript, while another may feel that Dr. So-and-So is the most knowledgable authority. In Thailand, well-respected teachers routinely scoff at the interpretations being offered by other equally well-respected teachers, and many of these animosities have developed into high profile feuds between their students around the globe. The stakes in these debates seem high because traditionalists in one camp feel that the others are misunderstanding, misrepresenting, or even disgracing the tradition. They likely disagree about what exactly “the tradition” even means. But, ultimately, they are all seeking the resolution of the problem from within the tradition, however they define or understand that term.

Someone who subscribes to the “modernist episteme,” on the other hand, would base their decision about what lom “really is” upon which interpretation is most compatible with modern science or biomedicine, or has the most empirical evidence behind it. Many modernists feel that the entire tradition as a whole is scientifically justifiable. Others argue that the tradition “gets it” even better than biomedicine. Modernist Thai medicine is the form of practice with the most official support, funding, and institutionalization both in Thailand and globally. Proponents of the Thai government’s officially sanctioned version of TTM, for example, offer modernist reinterpretations of Thai tradition in Thailand. Scientists at Thai universities conducting research on traditional medicine and publishing their results in internationally circulating journals also subscribe to this episteme. Western-trained massage therapists with strong backgrounds in the medical sciences also have been popularizing a modernist view of Thai massage in North America and Europe.

Finally, the “postmodernist episteme,” as I have defined it in previous posts, describes a stance that is most common among academic scholars of Asian medicine who are typically themselves not practitioners. Postmodernists have a different approach to incommensurability, in that they are not necessarily interested in “solving” the problem by determining which of the various interpretations is right. For example, I mentioned above that once I became an academic, I became more interested in investigating how context shapes practitioners’ interpretations of lom than in finding the one correct definition of the term. For an academic scholar, identifying the cultural settings, local histories, social positions, identity politics, and other similar factors behind the differing opinions is in itself a satisfying explanation. It resolves the question of incommensurability by placing all of the options into a larger intellectual framework. Of course, few practitioners would agree that these are satisfying answers, and they usually caricaturize postmodernists as irrelevant denizens of the “ivory tower.”

As an active participant in the westward spread of Thai massage and medicine in the 1990s and 2000s, and as an academic observer of this process since then, I have watched as adherentsof all three of these epistemes have struggled to discuss the question of lom and other similar conundrums in a constructive, productive, or even collegial way. In my view, conflicts between and among proponents of these different epistemes are preventing most practitioners from taking advantage of the full range of possibilities in their practice.

Is there a better way?

Polyperspectivalism is a new approach to the problem of incommensurability. Instead of looking through just one lens or trying to combine what you see through different lenses into a coherent picture, polyperspectivalism is about allowing all of the competing lenses to stand on equal footing as viable alternatives. Applied to the example of lom we have been talking about, a polyperspectival approach would mean acquiring as many different interpretations of this term as you can, studying them all as deeply as possible so that they can all become tools within your healing repertoire.

Rather than trying to smooth over differences between these lenses, the goal of polyperspectivalism is to learn from their juxtaposition. A temporary shift to a different conceptual system might clearly reveal what has been rendered invisible by the lens you’ve been accustomed to looking through. But, you can only see what has been hidden in plain sight if you fully remove your current lens and try a different one. Polyperspectivalism is therefore different than translation or “medical bilingualism.” When you translate something, the assumption is that there is a meaning that stays stable as you move from one language to the next. Polyperspectivalism has nothing to do with trying to keep anything stable across the epistemological divides. Rather, you could say, it is about intentionally looking for what is untranslatable within each episteme.

One of my recent posts described how this approach can also lead to more flexible collaborations with colleagues who don’t share our own particular worldview. When we encounter other practitioners who exhibit strong differences with our own understandings, rather than perceive them as misguided, threatening, or just plain wrong, we can approach them with deeper curiosity and perhaps even gratitude. What new lens might I pick up from someone with such a radically different interpretation than mine? What might their perspective illuminate that mine doesn’t? What might I be overlooking or misinterpreting that their lens can bring into focus? 

However valuable it may be for collaborations, in this post, I am focusing on how polyperspectivalism can be an asset in clinical practice. I’ll give two brief examples of polyperspectival approaches to lom in order to illustrate the value of the approach. Even if you’re not a practitioner of Thai bodywork, I think you will see clear parallels with your own practice.

Two examples of polyperspectivalism

The first example involves the so-called “blood stop” (also known as “opening the wind gates”), a maneuver that was common in bodywork circles in Thailand in the 1990s. I was taught by multiple traditionalist teachers that the principal way of opening up the flow of lom in the body is to release lom from the limbs into the abdominal cavity. This was done, I was taught, by placing your hands on the patient’s femoral and brachial arteries, and pressing down with enough force to stop or severely curtail the blood flow. You held the pressure for up to 10 heartbeats, and then released. You knew you had done it with enough pressure if the patient’s limbs went numb during the press and tingled strongly with “pins and needles” after the release.

There were some differences in how this step was performed. Different practitioners held the press for different amounts of time. Some teachers taught it should be done with the open palms, while others taught that it should be done with the fingertips while the hand was held open rigidly. One teacher taught me that the “blood stop” should be done on the carotid arteries as well as the arms and legs. A purely traditionalist viewpoint would try to figure out which of these methods was the most “authentic” while staying within the traditionalist episteme. You might decide which technique to use on the basis of which teacher was the most respected, the most wise, or the most authoritative. Or, if you thought historical antiquity was the main criteria for authenticity, you might try to consult ancient manuscripts to find a description of how this step was performed in the past.

By staying within the tradition, however, you would forever miss the crucial fact that this maneuver is extremely dangerous from a biomedical perspective. As soon as you switch to looking at this step through a modernist lens, the risks to the cardiovascular system become glaringly obvious. Seeing in this new way opens up a set of questions beyond just which teacher’s method is the most authentic. You might now find yourself wondering if you should discard the “blood stop” altogether. Or, you might decide to depart from tradition and invent a compromise in order to make the maneuver safe from a modernist perspective while still fitting within an energetic interpretation of lom.

A second example of how polyperspectivalism might open up new areas of inquiry is the teaching that you should always begin bodywork on the left-hand side when working on women, and on the right when working with men. I heard this countless times when I was studying in Thailand, and there are all kinds of traditionalist reasons why this makes sense that have to do with solar and lunar influences on the body. If we apply the modernist lens, as we did in the previous example, this time we will see that biomedicine has no opinion whatsoever on this question. But, as soon as we apply a postmodernist lens, we suddenly find a whole new dimension immediately comes into focus. What do maleness and femaleness actually mean in Thai culture? What are the implications of this male-female gender binary being mapped onto the body in this way? How do these left-right associations change if the patient is gay, transgender, or gender fluid? Do these distinctions make sense in my own culture? Do I want to be reinforcing traditional Thai gender norms through my own bodywork practice? What other connotations are there in Thai culture that I might be unconsciously inscribing onto my patient’s body during a massage session?

Again, my point here is not to answer these specific questions or to tell you what to do in the clinic. I just want to underscore how previously hidden dimensions of inquiry become glaringly obvious when you start looking through other lenses. Once you’ve seen these incommensurabilities you have the ability (and, of course, the responsibility) to make new clinical choices in light of these insights.

You’re no doubt already polyperspectival, so just embrace it already!

If you are a traditionalist in any Asian medicine tradition, ask yourself how would you respond to these two examples? Can you imagine yourself respecting your teachers’ traditionalist interpretations of lom, but discarding or modifying the “blood stop” because you take the biomedical understanding of the contraindications seriously? Can you see yourself also breaking with your teachers’ left-right protocol in order to accommodate a fluid postmodern stance on gender? If your answer to either one of these questions is “yes,” then you are already doing polyperspectivalism. If you can see the value of the new perspective brought by non-traditionalist epistemes in either these two examples, then you’re obviously not completely locked into a traditionalist stance. You are willing—at least on occasion—to oscillate into other epistemes, and to allow them to take precedence over traditionalist sources of wisdom.

Most contemporary practitioners I know would in fact respond “yes” to those questions and would in fact have no problem deviating from tradition in these two cases. However, in my experience, many of these same people would in the very next breath boldly declare on social media that “allopathic medicine is a big scam” or “academics are parasites who don’t know anything about practice” or “doctors and scholars may have one or two good ideas but most of what they say is complete bullshit.” (These are paraphrases of comments I have actually received on Facebook about some of my previous posts). I don’t think that this is necessarily intentional hypocrisy, but it certainly suggests a lack of self-awareness and a lack of appreciation for where some important correctives to their practice have come from. And it also is clear evidence that they are willfully shutting themselves off from vast areas of learning that they already know from experience will expand, enrich, or enliven — not “corrupt” — their practice.

I’ve used traditionalists as the example here, but the same conclusion applies if you are clinging to the modernist or postmodernist epistemes. A practitioner who is completely locked into scientific approaches or a scholar who is completely locked into postmodern frames of analysis is equally selling themselves short. My question for all such individuals is: why insist on epistemological purity when you already know that other viewpoints can be beneficial? Instead of all the posturing and fighting with your colleagues from other fields, why not embrace the different lenses they are making available to you, which in fact you are already using? Why not read and study as many traditional perspectives from as many teachers as possible? Why not read the science related to your practice—especially the studies that raise problems with it? Why not read the academic literature that deconstructs and critiques your tradition (Thai practitioners click here)? Why not lean into these differences, and see what new vistas some new lenses might reveal?

Once you are no longer limited by self-imposed epistemological constraints, you will find that you have many more options for how to think and act in the clinic than you previously thought. One day, a patient might present with a set of symptoms that seem not to make sense within one way of looking, but then they may cohere together when seen through another lens. You might treat one person with an entire protocol that is based on an energetic interpretation of lom, and treat the next with a strictly mechanical approach that was concerned only with the body’s anatomical structures. You might be in the middle of a difficult session that is grounded in the four elements theory, and suddenly throw up your hands in despair and channel the “father doctor” for inspiration. You might be planning out your protocol for working with lom to help manage the patient’s anxiety, and spontaneously be inspired to take a closer look at how the space you are practicing in is signaling cultural appropriation, white supremacy, or ableism. You might, instead of seeing these approaches as conflicting models, come to understand them as a set of diverse interpretive tools that are all equally available for you to draw upon, to selectively and skillfully meet different clinical situations as they arise.

On not being “right”

While in other fields, fundamental discrepancies can be treated more casually, in medicine it’s a matter of grave ethical responsibility to “get it right” — possibly even a matter of life and death. When there is an incommensurable difference of opinion over what should be done and why, the anxiety to cling to the tried-and-true is understandable. To me, though, the high stakes of the endeavor is all the more reason that polyperspectivalism is needed in the clinic. In my opinion, rather than being afraid to get it wrong, the bigger danger is thinking that you’ve got it right!

For anyone to think that they have found one episteme, viewpoint, or system that contains all the answers is, I have argued, sheer hubris. There is always something to learn from another viewpoint, and chances are it could be vitally important. To remain committed to a single episteme may seem safer, but like in the example of the blood stop and the left-right binary your blind spots are likely to be undermining the wellbeing of your patients in subtle or not-so-subtle ways. Given the complexities we are responding to in the clinic, how could trying on a variety of different lenses possibly be wrong?

Human health is a multidimensional, mysterious and unpindownable thing that cannot be reduced to a single narrow way of thinking. We already know this, so let’s just embrace it.