Phenomenology as resource for patients

Discussion of a paper by Dr Havi Carel – Phenomenology as a Resource for Patients, published in the Journal of Medicine and Philosophy (37;96-113, 2012).

There is a long history of thinking and theorising about what goes on in general practice, and this has contributed I think, to more effective and meaningful communication, to greater empathy, understanding, trust, and ultimately a better outcome for patients, however you choose to define it. Two notable examples are the biopsychosocial model and narrative-based medicine. The narrative-based approach in many ways “turned the conventional biomedical approach and even patient-centred one on its head”, as wrote Dr John Launer in an editorial in the BJGP back in February 2003. He continued:

“…Instead of listening to ‘the patient’s history’ to determine what to do, it judges our actions by whether they contribute to an improvement in the patient’s narrative”.

The huge increase in projects, groups and websites which focus on patient’s stories and on personal experience of illness is increasingly valuable in providing a source of support and information of a sort that is so important but unfortunately just not possible, it seems, to provide in the conventional GP setting..DiPEX website and the Oxford Health Experiences Research Group being an obvious example.  

These developments have arisen from an unmet need or from dissatisfaction with conventional western medicine, and are underpinned by work in anthropology, sociology, philosophy and social sciences.

As a GP and someone with a lay interest in philosophy, I was interested to read a paper in the Journal of Medicine and Philosophy which described some work being carried out in Bristol between philosophers and medics, who are working towards using phenomenology as a resource for patients…. Does this seem ridiculous? Philosophy is after all often considered a very non-practical ‘head in the clouds’ discipline. On the contrary I think this work is thought-provoking and innovative, should complement the way in which we conceptualise illness, and importantly just may provide a new way for us to support patients in developing their own understanding and coping strategies in times of ill-health.

A useful route into describing this work is to mention the author of this paper and one of the leading academics involved in the project. Havi Carel is a philosopher who was diagnosed with a rare lung condition (LAM) in her thirties. She turned to her area of interest -phenomenology- to help her come to terms with this, and subsequently developed a project exploring how phenomenology could be used to enhance the “constricted concepts and dry medical language” which are generally used to describe illness. Phenomenology is a broad philosophical movement developed from work by Edmund Husserl at the start of the last century, but can be simply defined as the study of the structure of experience. Carel’s work involves discussions with health professionals and is now included in the medical curriculum at Bristol Medical School. You can read more about Havi Carel and her work here:  http://medicalhumanities.wordpress.com/2011/03/09/standing-on-the-shoulders-of-giants/

Literature and the arts have long been used to express the experience of illness, and Carel’s work is taking this concept forward in developing potential benefits from philosophy for patients and health provision more broadly, in a structured way. Developing a workshop for patients using this approach is especially interesting for doctors because the concepts used are in contrast to those we are familiar with from the bulk of our medical training. But the concepts do perhaps tap into our personal experiences of illness, or of those of our loved ones.

The toolkit proposed takes the form of a process that brings about redefinition of illness, with 3 phenomenological steps:

1.      Phenomenological reduction

This could be seen as something already engrained in us as GPs, namely seeing the person behind the diagnosis, but is expressed in the paper more as a shift away from the disease and towards the experience. It is suggested that illness forces a kind of phenomenal reduction on us when we are ill because it causes us to suspend our normal approach to the world. “Once the belief in the objective disease entity is bracketed and we are distanced from our usual way of experiencing, we can begin to explore how illness appears to the ill person, its structure and its essential features”.

2.      Thematizing illness

This part is about focusing on different aspects of the person’s experience of illness and also allows the many perspectives eg. of family members, friends, doctors etc. to be brought out and explored. This can help patients move to a more descriptive way of understanding their experience, bringing out a more adaptable and multidimensional view of illness, and away from seeing it as something objective and strictly defined. Different aspects can be explored depending on the individual.

3.      Review of one’s being in the world

This heading in laden with weighty philosophical discourse, and Heidegger’s broad understanding of ‘one’s being in the world’ is brought out in the article. But in summary this part of the workshop follows on from thematizing illness and involves exploring the overall effects of illness on one’s sense of place, interactions with surroundings and other people, on meanings and norms and on each aspect of that person’s individual world.  “By moving away from the narrow understanding of illness as a biological process a thick account of illness as a new way of being in the world can be developed by patients”.

This may all seem far removed from the consulting room, but I encourage you to consider the ideas brought out in this paper with an open mind. Carel and many philosophers not to mention practitioners before her have agreed that illness is ‘phenomenology in action’, but the work described in this paper is exciting in that it transforms the theory into a structured one-day workshop that is being planned by Carel and her collegues in Bristol. This has the potential to bring real benefits for patients although some details on how this will be run remain unclear. Another question is whether type of project can ever be made accessible to a broad variety of patients or will benefit a self-selecting minority.

Unfortunately the full text of the above article requires a subscription, but the abstract can be accessed for free: http://jmp.oxfordjournals.org/content/37/2/96.abstract

Zoe