The PhOst Blog

18. Hermeneutic Healthcare: Osteopathic Reflections - Theory & Practice

Mon, 25 Apr 2022 15:41:50 GMT

In this post, I share a monologue I wrote while coming to understand the implications of using a hermeneutic model in osteopathic practice, particularly when using hands-on assessment and treatment approaches. I was thinking about the concept of hermeneutic realism and how it helps me understand what the phenomenological rallying cry, ‘back to the things themselves’ means - and applying this to the Mitsein I share with my patients.

Heideggarian scholar Thomas Sheehan distinguishes between what Husserl meant by ‘back to the things themselves’ - ‘back to the experience of things’; and what Heidegger meant - ‘back to the meaning of things’. This came to mind because of a wretched headache I had recently. I ‘knew’ that it was a stomatognathic headache – related to tension in my jaw – because I had a ‘felt sense’ of it. It was different from migraines, neuralgia, tension, sinus or other types of headaches I’ve had in the past. I considered waiting for it to shift, or seeing my cranial osteopath – who I knew, with her careful and skilful treatment, would find a way to treat the headache, addressing its somatic underpinnings.

Osteopathy has been moving away from its traditional roots in structural diagnosis and treatment; we are now disavowing the concept of ‘somatic dysfunction’ and the mechanical model of treatment. This leaves us with a problem: if our biomechanical diagnoses are fallacious, what business do osteopaths have trying to ease, release, bring back into alignment, coax or fix biomechanical-structural-postural findings?

And it occurred to me – something about osteopathy residing in the space between the intersecting comets’ tail swooshes left behind by the corporeal turn in psychology and the psychological turn in osteopathy – if we take a hermeneutic realist position on the manifold 'equal' and co-existing truths of the ways patients suffer, we can help by ‘being with’ them in a compassionate manner that resonates with their truth – and being hermeneuts, we can help them to uncover what that truth is, for them, today.

For one person, their painful sacrum might be the result of a whiplash injury; for another it might be associated with an aching loneliness; for another because of a slip on the ice; for another, a pelvis that feels out of alignment following child-birth; for another, referred pain from the L5/S1 disc. What is important here is ‘the thing in itself’ – both the Husserlian ‘thing’ (the experience of it) and the Heideggerian ‘thing’ (its meaning).

The critical argument against traditional osteopathic technique, challenges the use of history and/or assessment to diagnose a structural dysfunction, because of deficiencies in the validity of our diagnostic techniques. And, if we use what appears to be ‘exactly’ the same approach (or even different approaches) to help treat/release/support/stretch the sacrum or SIJs, and the person feels better, moves better, exercises better, functions better - that’s just natural resolution, or placebo.

I suggest here, however, that the problem is an ontological one: what the critics are failing to explore and account for, is the fact that we have had a meaningful encounter with the patient, helping them to make sense of, and resolve their symptoms (the experience and meaning of them).

It takes inter-personal curiosity, open-ness, resonance and judgement (not to mention skill to screen and account for a potential medical referral) to ‘be with’ a patient in a way that empowers or enables them. And it takes skill and imagination to adjust your register, in order to share your patient’s perspective and treat their structural dysfunction, when this is what makes sense to them. It takes ‘attunement’ to understand our patients: an ability to be hermeneuts in life-worlds that are shared for a moment in time and space, as our horizons of understanding merge.

In my next post...

I will write about the role of the osteopathic 'felt sense' in hermeneutic practice.

17. Hermeneutic Healthcare: Meaning / Materiality

Mon, 07 Mar 2022 01:46:25 GMT

Previously, I have discussed the concept of meaning in hermeneutic healthcare as an ontological partner to being – to have existence is to be engaged in sense-making (with meaning as the property that emerges from the interaction between a being and its environment). In this post, I am going to consider the structure of meaning as it pertains to health, particularly within a healthcare context, by discussing its ontology within two contrasting healthcare models (with an upfront caveat that these models are crude simplifications).

In the first, the positivist model, I explain that what is often meaningful to the patient, may be shoved aside. In the second, the phenomenological model, I explain that understanding what is meaningful to the patient, is key to medical practice. In healthcare (within the western world of biomedicine), there will be times when inhabiting the positivist model is necessary, inevitable and in any case preferred by the patient. There will be times, however, when the phenomenological model is more useful. I am interested in how we as healthcare practitioners, bridge the two models.

In the positivist model, ‘fact’ and ‘truth’ are not deemed to be human constructs, or context-bound, but to be unarguable. It is the work of science to come as close as possible to establishing fact. Medical research has the goal of showing that some intervention either works, or it doesn’t. Human feelings about treatment preferences are these days considered important, particularly in the realm of discussing side-effects, alternatives interventions and ‘compliance’ / ’adherence’ (yes, these terms are still widely used). They are, however, considered of peripheral importance when it comes to the work of establishing facts about what works. The meaning that a patient attaches to their health, their illness, their treatment and their recovery (or otherwise) is very rarely factored into the positivist model.

Physicians, surgeons and nurses who offer empathic care to their patients have not – in the past – been advised to speculate too deeply about what is meaningful to a patient. This thread of medical care, compassion and empathy can be considered patient-centred – to a degree: there is a human-to-human aspect of concern for patient wellbeing, and this can alleviate the experience of many patients who receive biomedical care. The fundamental ontology, however, remains one in which medical science predominates as the arbiter of fact; human interpretations are deemed irrelevant to scientific truth.

In the phenomenological model, ‘fact’ and ‘truth’ are always deemed to be contingent and situated, features of a lifeworld. Science is a strand of human ingenuity, and has its rules, its structures and its own historicity. The conglomeration between the methods of science and the healing arts has a long human history, and, in the west, it is sometimes hard to see past our immersion in the positivist (or call it post-positivist, or even constructivist, if you like) paradigm that structures our access to an experience of health.

Taking a side-step into an interpretative paradigm, such as phenomenology, allows for the fore-grounding of what is important to a patient – their lived experience, within their lifeworld. In many cases (perhaps the majority), the needs and wants of patients are met more than adequately within the positivist framework: the understanding a patient has of their body is formed by the same positivist epistemology as that which has formed medicine. They trust medicine and they feel cared for by their doctors and nurses. Healthcare interventions are administered in a spirit of utilitarian good will, and patients ‘have faith’ that they will work.

But consider the experiences of patients and doctors when the positivist model is inadequate to answer the needs of patients. Such as those who are sent away with ‘functional’ diagnoses, or whose symptoms are deemed inexplicable (labelled inelegantly and unimaginatively ‘medically unexplained’), those who wish to make choices that make sense to them within their own cultural paradigms, or those for whom their healthcare choices attract the ire of positivists. And what about those whose experiences of medicine have not been as benign and neutral as they expected? It is sobering to read about the gender gap between men’s and women’s experience of medicine and health outcomes (in the UK) discussed in 2021 in the UK Parliament.

I suggest we build more bridges between the positivist and phenomenological models of healthcare – hermeneutic bridges as I like to consider them. Bridges that consist of work undertaken by patients and their healthcare practitioners, to establish what is meaningful - what is ‘material’ - as featured in the landmark UK healthcare 'communication and consent' case, Montgomery (2015) .

So, it is heartening to know that, certainly within allied spheres of healthcare such as osteopathy, we are engaged in efforts to equip ourselves with the skills to help our practitioners and patients ‘make sense’ of their symptoms and their options. We are already turning to psychological frameworks, narrative methods and person-centred practice. My hope is that we will continue to enrich our hermeneutic skills as practitioners, so that we are always attuned to what is meaningful or material for our patients - and that we see them not only as understanding beings (Svenaeus, 2000, p. 147) but self-understanding beings, within their own unique lifeworlds.

In my next post...

I will extend this discussion with some examples from research and practice.

16. Reflexive Non-Dualism in Research

Mon, 21 Feb 2022 06:00:03 GMT

The benefit of a non-dualistic ontological stance is that it liberates the phenomenologist from the constant challenge of having to agree that there is a distinction between internal things and external things, and in their manner of appearance to human consciousness.

You may remember in blog post 13 , I gave a brief definition of non-dualism as the ontological principle that objects of the world need not be categorised as either matter or energy (physical/mental; cosmos/consciousness; material/spiritual). But nor does it require a commitment to either materialism (the ontology underpinning post-Enlightenment western science prior to Einstein), or to idealism (as espoused by philosophers such as Hegel and Spinoza). Instead, “non-dualism” can accommodate both monist and pluralist ontologies, including hermeneutic realism.

For a phenomenologist, things may have the appearance of seeming to be either of an inner realm (eg. thoughts, ideas, dreams) or of an outer realm (eg. mountains, people, machines), but in “hermeneutic reality” what we actually have, is a stream of encountering the meaning of things as they appear to us, in a plane of immanence, without there ever being the need for a conclusive methodology to distinguish between the inner-ness and outer-ness of things.

As a westerner, substance dualism is my intellectual heritage (Christian and post-Enlightenment), and the process of understanding non-dualist ontologies is a faltering one. I constantly find myself using language that betrays my dualistic roots, such as, “I’m really struggling to get my head around the idea of non-dualism, even though I don’t believe that mind and body are two separate things”! But I have found that, over time, with research into the work of phenomenologists such as Maurice Merleau-Ponty and Eugene Gendlin, I was able to re-set my ontological assumptions (over and over again), so that I could more instinctively understand that mind-body is one; body-environment is one; person-world is one.

Then there is the challenge to remove those hyphens that still hint at dualism. I have found a work-around that makes sense to me; something that comes from the panps ychist phil osophy of consciousness and which is articulated by philosophers who are working within the field of Integrated Information Theory . In short, there appears to human understanding, to be two distinct forms of “stuff”: the mental (Cartesian “res cogitans”) and the material (“res extensa”), but a non-dualist interpretation suggests that these aspects of existent forms are merely appearances (“phenomenal characteristics”).

Instead, we can understand that the mind stuff/energy/force are aspects of being that can also manifest as matter. I am not qualified at all to talk about quantum mechanics, but I think we are all familiar with the proposition that light is now understood as both wave and particle. It is this scientific principle that shows the way towards philosophical non-dualism.

My method of committing to a non-dualist stance, when conducting my research, was to train myself to begin every thought with the reminder that - from a phenomenological starting point - I was not thinking about minds and bodies being separate things, but of being different manifestations of the same thing. This commitment became the “mirror, signal, manoeuvre” of my research activity.

So, whenever I find myself struggling to commit to non-dualism, eg. when I think of consciousness as something that arises from mental activity, or thoughts being the products of thinking, or minds being housed within bodies, I perform the discipline of recommitting to the principle of the unity of substance, and begin again.

In my next post...

I will talk some more about hermeneutic healthcare, and illustrate the model with some examples from my research and clinical practice.

15. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 3 (A model)

Sun, 06 Feb 2022 21:49:29 GMT

In the last blog, I delved into the work of philosopher Susan Stuart , who became interested in the phenomenon of cranial osteopathic palpation, describing it as a form of “ enkinaesthetic entanglement ”. Now I wish to explore further how we can model a form of hermeneutic healthcare - one that may involve touch - in the light of both enactivist, embodied theories of consciousness and communication, as well as the hermeneutic model proposed by Frederik Svenaeus (see Blogs 8 and 9 ).

First and foremost, a hermeneutic experience of healthcare entails sense-making. The patient seeking healthcare is an understanding being, who wishes to know as meaningfully as possible what ails them. The account of the diagnosis might be of as much significance as the options for treatment, or the prognosis.

Secondly, a hermeneutic model of healthcare will see the patient and their practitioners as co-agents, participating in an intersubjective therapeutic alliance.

Thirdly, within hermeneutic healthcare, there is an investment in skilful enactive communication: attending, being-alongside, participating, acknowledging, hearing, reflecting and sharing. This communication will, by virtue of its hermeneutic orientation, involve an intertwining and a fusion of horizons .

Finally, the very fact that healthcare has a hermeneutic character, imbues it with the potential to instantiate symbolic change (a meta-semiotic sense of alleviation or relief) in the patient’s experience of their health.

In my thesis, “ Making Sense of Cranial Osteopathy: an Interpretative Phenomenological Analysi s ”, I describe cranial osteopathy as a hermeneutic form of healthcare. Having analysed data which led me to understand that bodily empathy - the mutual incorporation ( in cranial osteopathic encounters ) , described by Fuchs and de Jaeghe r (2009) - involves a resonance in which the osteopath and the patient merge in their understanding, and what is meaningful is disclosed (ie. the clues to the diagnosis and to the re-orientation back to health).

In my next post...

I will return to the challenge presented to philosophers and practitioners of healthcare by non-dualism, and how we are used to thinking in dualistic and analytic, rather than holistic and gestalt, ways.

14. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 2 (The role of touch)

Mon, 24 Jan 2022 01:58:37 GMT

In the last blog, I provided some definitions and introductory explanations of the model of enactive, embodied communication. In this post, I extend that thinking by talking about its relevance to healthcare, particularly healthcare which is oriented towards hermeneusis (sense-making) - and that which involves the therapeutic use of touch.

To recap, enactive, embodied communication is something that inevitably occurs when people are physically present with each other, through complex processes of intersubjective, interoceptive attunement, mutual action, and shared-sense making. It happens whether we are conscious of the process or not. It is the context for social cognition, and (I posit) is likely to be operative even when we are not in the same location as our sense-making partner (I am thinking of the role of FaceTime and Zoom in enabling lived body intercorporeity - a topic for an interesting research project!)

Enactive, embodied communication entails participatory sense-making, and when touch is involved, there is an additional modality of communication to take account of. Many philosophers of mind and consciousness use the modality of vision as representative of the entirety of our sensory engagement with the world. There are many ways in which the haptic senses, including those of interoception, kinaesthesia and proprioception, differ from the modality of vision, and it is interesting that touch is often left out of accounts of participatory sense-making and enactivist theory.

Maurice Merleau-Ponty was fascinated by the way we use touch to blend with the world in a fleshly way. And philosopher Susan Stuart (2016), in her reading of phenomenologists Merleau-Ponty and Eugene Gendlin, proposed a model for participatory communication via touch, after encountering the work of French cranial osteopath, Emmanuelle Roche. Stuart related Roche’s description of cranial osteopathic palpation to Merleau-Ponty’s ideas of intercorporeity, using the novel term “ enkinaesthetic entanglement ” to portray the reciprocally felt experience of understanding that occurs without linguistic articulation when touch is used in the process of sense-making.

Roche describes the palpatory experience of cranial osteopathic touch as an activity in which osteopath ‘listens’, ‘attends’ and ‘observes’ the interior of their patient - through a light palpatory contact - both the harmonious and discordant rhythms of the micro-movements that animate the patient’s whole body, such as “la croissance des cheveux, l’intérieur des viscères, le jeu des systems musculo-nerveuex et intraveineux” (the growth of the hair, the interior of the organs, the play of the neuro-muscular and intravenous systems) ( Gens et Roche , 2014, p. 5).

Stuart (2016) portrays this form of sensory engagement as a “synaesthetic listening-feeling process, the gentle touch - and even non-touch - of palpation listening for rhythms and arhythms”, characterised by non-striving receptivity and “an openness to what presents itself” (ibid., p. 27). Referencing Merleau-Ponty, she claims that this manner of cranial osteopathic intersubjectivity is “first and foremost an enkinaesthetic intertwining, a circle of the touched and the touching and what comes to light, that is, what is brought forth through the feeling shifting somatic sense” (ibid., p. 27).

In my next post...

Part 3 of Enactive, Embodied Communication in Hermeneutic Healthcare, I will consider the role of participatory sense-making within hermeneutic healthcare further, expanding beyond the current example of cranial osteopathic palpation.

13. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 1 (Introduction)

Sun, 09 Jan 2022 22:53:54 GMT

Before diving straight into the subject of “enactive, embodied communication”, I must begin by explaining something about the non-dualist ontological principles of phenomenology and hermeneutic realism, by way of introduction to an account of embodied consciousness and enactive communication.

First some definitions

Non-dualist is a way of referring to the ontological principle that the objects of the world need not be categorised as either matter or energy (physical/mental; cosmos/consciousness; material/spiritual). But nor does it require a commitment to either materialism (the ontology underpinning post-Enlightenment western science prior to Einstein), or to idealism (as espoused by philosophers such as Hegel and Spinoza). Instead, “non-dualism” can accommodate both monist and pluralist ontologies, including hermeneutic realism.

Embodied communication is a concept that arises from the philosophy of embodied consciousness and cognition developed by Francisco Varela, and his co-authors Evan Thompson and Eleanor Rosch. Their ground-breaking book The Embodied Mind , first published in 1991, challenged Cartesian dualism and argued that human consciousness is the consciousness that it is because of the bodies we have, and that it is false to consider the mind to be separate from the body.

Enactivism is the extension of the theories of embodied consciousness and cognition - first expressed by Evan Thompson - to account for the role of the environment in the expression of consciousness - the idea being that cognition arises in the process of sense-making between a being and its environment. Here is a link to a paper that gives an account of the development of enactivism .

My encounter with these philosophical ideas came when I was exploring the experience of haptic communication (assessing/therapeutic touch) in cranial osteopathic encounters whilst conducting my doctoral research. I found existing discourse about the role of touch in manual therapy/osteopathy to be under-developed (a subject for another post), and notions of the specialism of osteopathic palpation to be poorly explained. Haptic communication, involving touch, clearly involves embodied communication – but of what nature, and of what quality?

We can begin by thinking about embodied communication which is enactive (in the sense that meaning is the property emerging from the opening up between beings within a shared horizon of understanding) even without the involvement of touch.

Enactive, embodied communication is not about “body language” - the idea that what we communicate in words is backed up by sub-textual signals that emanate from our physical bodies which cannot hold back our subconscious intentions. The problem with the concept of “body language” is that it belongs to the dualist paradigm that humans are “low-life bodies with high-life minds”. Read philosopher, Maxine Sheets-Johnstone on this subject.

Instead, enactive, embodied communication is something that inevitably occurs when people are physically present with each other. It is described by enactivist philosophers, Thomas Fuchs and Hanne de Jaegher, as “ participatory sense-making and mutual incorporation ”, the claim being that through complex processes of intersubjective, interoceptive work, human beings effectively incorporate their fellow humans as they observe them and act alongside them; they attune with them, commingle with them, body-schema resonating with body-schema. Fuchs and de Jaegher (2009) give examples from studies in the realm of social neuroscience, such as those that analyse the ways in which people listening to others co-ordinate their movements and responses “with the changes in speed, direction and intonation of the movement and utterances of the speaker” (ibid, p. 470); those examining the way that musicians play together, observing “processes of synchronization and resonance, in-phase or phase-delayed behaviour, rhythmic co-variation of gestures, facial or vocal expression” (ibid, p. 470).

Fuchs and de Jaegher (2009) explain the process of mutual incorporation by first explaining what “incorporation” entails, giving the common examples of how the blind man’s stick is part of his “lived body” (the phenomenological term that describes our body as we experience it, as part of the world); and the tall hat, on account of which we duck through the doorway, is incorporated into the height of our lived body. They also show that we incorporate within our lived bodies objects that appear to be distant from us, such as the riverbank on which me must focus our sights so as to safely leap across the river; or the tennis ball speeding to meet our outstretched arm-racquet (ibid, pp. 472-473).

Mutual incorporation, they argue, entails the direct impact upon one’s lived body of another’s lived body, the opening-up of mutual experience in which shared action, observing, bodily empathy, mimicking and mirroring mean that we take into our lived body the very lived body of the other. Maurice Merleau-Ponty’s term for this is “intercorporeity” (ibid, pp. 474-475). They argue that it is during this intersubjective interaction, in which “the coordination of their body movements, utterances, gestures, gazes, etc. can gain such momentum that it overrides the individual intentions, and common sense-making emerges.” (ibid, p. 476).

The work of Fuchs and de Jaegher , and their other co-authors such as Ezequiel Di Paolo, give us a trans-disciplinary theoretical basis for understanding enactive, embodied consciousness and communication, but they rarely refer to the role of touch in communication.

In my next post...

Part 2 of Enactive, Embodied Communication in Hermeneutic Healthcare, I will discuss the role of therapeutic touch in intersubjective, enactive, embodied communication.

12. The Real Scaphoid

Sun, 14 Nov 2021 17:17:43 GMT

A detour, before discussing phenomenological models of embodied communication in healthcare settings, via some further consideration of the boat-like bone, the scaphoid, and hermeneutic realism.

What is the real bone, really?

That identified by the palaeontologist, who demonstrates how scaphoids evolved through epochs, through species, to attain their current form, supporting dextrous opposability of thumbs doing the most important of human work.

Or the radiological scaphoid - to be considered for first-line MRI instead of X-Ray - according to the UK NICE Guidelines of 2016?

Or the scaphoid, which, fractured and undiagnosed, requiring surgery as a last-ditch attempt to save the bone from necrosis, hastens the end of the career of the professional basketball player or cellist?

At the hospital, the radiologist, the orderly, the theatre nurse, the surgeon, the registrar and the physio all see “the same” scaphoid, but the scaphoid (and its human housing) have very different realities - discloses itself differently - to each of these protagonists.

And it is not a question of perspective. It’s not that there is one scaphoid which at bottom stands for all scaphoids; it’s not that one version of the scaphoid takes epistemological priority over the others; the argument here is that the scaphoid only ever has its being by virtue of its context.

To the patient, the scaphoid might be the painful thing or the career-ending thing; to the radiologist, the harbourer of the occult line indicating a fracture (and all that entails), the challenge, whether to go for the MRI just-in-case (bearing in mind the cost implications, and the NICE guidelines); to the surgeon, the fiddly but routine job-task (the last of the day); to the physio who signs off the patient, another box ticked.

Dutch philosopher and ethnographer, Anne-Marie Mol, presents her ideas on realism in her ontological enquiry into the multiple realities of atherosclerosis in "the body multiple" (2002); reading her work, with its innovative structure, allowed me to grapple with a concrete example of hermeneutic realism. A scaphoid, the wrist in which it belongs, the person who owns it, their family . . . concentric domains in which the fact, the salience, the significance and the meaning of a fracture present themselves.

In my next post...

Re-routing from this detour, I will expand my thoughts on the intersubjective, embodied sense-making that occurs within a hermeneutic healthcare encounter.

11. Hermeneutic Healthcare

Mon, 20 Sep 2021 13:43:28 GMT

A self-employed patient has a long drive to attend a trade event. He has fallen and injured his wrist which is painful and swollen so he books an appointment with his GP for the following day. A common enough scenario.

The GP suspects a scaphoid fracture, but knows that an X-Ray is unlikely to reveal a sufficiently clear image the day after the fall-on-the-outstretched hand. There is no justification for a plaster-cast, but a wrist splint might be required until the patient’s injury can be re-assessed in 10 days’ time.

In this scenario, there is what the patient knows - his left hand is stiff and painful (subtext: his gear-stick hand is going to hurt during this journey); and there is what the doctor is weighing up - is this a soft-tissue injury or has there been a fracture? (Subtext: the patient may not be safe to drive his car).

If the GP has a moment to reflect on the situation - in the midst of his communication with and assessment of the patient - he might catch sight of the epistemic gradient between his own stance and that of his patient. He might take care to use language which his patient - expert in his own field of professionalism, but naïve about bones and injuries and possible consequences of occult scaphoid fractures – will understand. He might skilfully bring to the foreground the principal issue “at hand”. With a gentle touch to the anatomical snuffbox, eliciting tenderness in the patient, the GP might make manifest to the patient a comprehension of the risk of undertaking the long drive.

By relating with the patient, the GP might find a way of opening up the possibility of not undertaking the drive - which was the only thing on the patient’s mind this morning, until he realised that he couldn’t use his gear-stick without pain. It is not, of course, the GP’s responsibility to consider the alternative ways the patient could make the journey. He doesn’t have to use up his energy on that. The point is that he took a moment to understand what was most meaningful for the patient, and he related to the patient with that in mind.

In my next post...

I will elaborate on the way the doctor’s knowing touch helped the patient to make sense of his injury, by discussing a phenomenological model of embodied communication.

10. Shared Being Shared Meaning

Sun, 12 Sep 2021 23:00:18 GMT

Previously, I have explored intersubjectivity in healthcare relationships using Gadamer’s fusion of horizons metaphor. In this post, I expand this exploration with a focus on the hermeneutic (sense-making) aspect of intersubjectivity.

This draws me back to the ontological question of what it is to have existence, and to share that existence with other beings. I do not claim to be an authoritative interpreter of Heidegger, but I am persuaded by the argument of Heideggerian scholar Thomas Sheehan , who - having met and interviewed Heidegger towards the end of his life - claims that the philosopher’s project was not an investigation of “Being” and “Time”, so much as an inquiry into how the intersection of these two vectors leads to an emergent property - meaning.

According to Sheehan, the property of meaning is at the heart of Dasein; with meaning being any or all of these things: the salience, sense, relevance, factuality or situatedness of a being amidst phenomena. Mitsein - the concept of being in the world together with others - is sometimes interpreted as “intersubjectivity” (the idea that we share our existence with others and in-so-doing fuse our horizons with them). If we take Sheehan’s perspective, we understand that intersubjectivity is only partially defined if, we consider it to be about sharing existence with others; fully defined, intersubjectivity entails shared sense-making; hence a human being is a hermeneut, and human beings collectively are by necessity - and are never not - engaged in shared sense-making.

This definition of sense-making may entail an explicitly cognitive and discursive togetherness or indeed dissonance; or it may entail an atavistic and unworded bumping along together. The point about human hermeneusis is not at all that it involves reason, purpose and language; the point about it is that it is an ever-operational background, midground and foreground condition of existence: a process of active-receptive sensing-responding to context.

Now a leap back from the abstract to a specific example: a hermeneutic healthcare relationship. An intersubjective, “person-centred” healthcare encounter is not characterised by the healthcare expert dispensing their empathy, attention and communication skills in an attempt to gain and share an explicit understanding with the patient about the nature of the problem and the options ahead. It is characterised, instead, by a meaningful, human, co-inhabitation of the world of the illness at-hand, and shared orientation towards helping the patient navigating this world.

In my next post...

I will describe a fictional case that illustrates hermeneutic healthcare in operation.

9. Patient-Practitioner Fusion of Horizons

Mon, 06 Sep 2021 05:17:26 GMT

If we are thinking about person-centred care, how should we conceptualise the patient being at the “centre” of that care?

For sure, Evidence-Based Medicine asks practitioners to pay attention to, and give weight to, the values and expectations of patients. But how do we deal with the tensions and paradoxes that arise in practice when the values and the expectations of the patient are set in exact opposition to either or both of the expert understanding of the practitioner or the guidelines which have been drawn from the best available evidence?

I will discuss what I consider to be the epistemological conundrum that makes it difficult to practice real-world EBM in future posts – the epistemological incommensurability of its three propositions – but for now my focus is on the aspect of practice in which we value the patient as an individual person with whom we explore and share decisions about their care pathway.

Being a person-centred practitioner, in my view, is not first and foremost about empathy, or listening, or taking the time to understand the patient’s values and needs. These are important aspects of person-centred practice, and we could expand the list: being courteous, humane, collaborative; deliberately putting the patient and their story at the centre of the consultation and setting aside preconceptions; communicating options, risks and consent processes clearly and kindly. These are all – arguably – essential aspects of person-centred practice.

But if the ontological stance of the practitioner is that they are the expert and key-holder to unlocking the resources that the patient needs to regain health, we have a power gradient between practitioner and patient that means all attempts to demonstrate patient-centredness are – in essence – theatre.

Fredrick Svenaeus calls for a model of person-centred practice that shifts this power gradient with one simple manoeuvre: a reframing of the patient-practitioner relationship as an intersubjective commitment to “fusing horizons” (see previous blog). This entails not just time, empathy or attending to the patient’s story (important as these are), but a re-casting of the structure of the relationship. Instead of practitioner-expert and patient-supplicant, we have a relat ionship in which the practitioner understands that the patient is an understanding (sense-making) being. This is an ontological commitment, casting healthcare practice not as the prescription of resources in aid of a person’s cure, but as a shared human activity in which ontological beings (i.e. an understanding practitioner and an understanding patient) work together to make sense of the source of the patient’s ailment.

“The doctor must understand the patient as an understanding person, through projecting himself into the patient’s understanding and vice versa.” Svenaeus, F. (2000a) p. 147. The hermeneutics of medicine and the phenomenology of health . Dordrecht: Springer.

In my next post...

I will explore further the ontology of intersubjective (horizon-fusing) healthcare practice, and how we may consider it a hermeneutic (sense-making) activity. I will work though some of the implications this has for clinical practice and healthcare research.

8. Fusion of Horizons

Mon, 30 Aug 2021 00:49:43 GMT

In this post I discuss Hans-Georg Gadamer’s famous metaphor “fusion of horizons” - the Horizontverschmelzung - which describes the conditions in which individuals come to share understanding of phenomena.

Previously I introduced the concept of intersubjectivity as a means of accounting for the shared sense-making that occurs when different individuals inhabit the same meaning-making plane. Here I discuss the metaphor Gadamer introduced in his classic text on hermeneutics, Truth and Method .

Gadamer’s use of the metaphor was originally intended to shed light on the unwitting process whereby people achieve an understanding of a text or an artwork. The idea is that each reader or viewer has their own situatedness, which can be represented by the notion of their field of vision – or their horizon. As they read or view the text or artwork, their horizon merges with other possible horizons representing the situatedness of the original author or creator; as well as with the horizons representing other historical interpretations of the text or artwork.

There is a mixing, a melding, a fusion of these different horizons, meaning that it is never possible to say that one individual can encounter a work of art or a book in a purely critical and objective way. There is always a context – a rich, multi-layered, multi-perspectival background – that foregrounds the sense-making of the reader or viewer as they encounter the text or artwork.

The metaphor of the melding of fields of vision is not only helpful for describing how people make sense of art; it is also a helpful model that describes all human sense-making and meaning-finding. What it is not is a method for understanding other people’s points of view; instead it is a claim that all of our sense-making and meaning-finding is context-rich, partial, and defined by our own cultural and historical situatedness.

The Swedish philosopher, Fredrick Svenaeus , imported the metaphor of the fusion of horizons into the context of medicine, in his book, The Hermeneutics of Medicine and the Phenomenology of Health . He described the mutual sense-making of the clinician and the patient as a hermeneutic process in which the world of the patient and the world of the doctor merge during a consultation. It is almost a quaint notion in today’s world of big-data medicine delivered via algorithm and guideline; a distinctly human activity.

Here, author Austin Lam (2018) reflects on Svenaeus’ patient-centred interpretation of clinical hermeneutics in practice . It’s a really interesting read.

In my next post...

In future posts, I am going to revisit the idea that medicine is a practice that has sense-making at its heart. This will lead to further consideration of the human dimensions of medicine, and a debate about what is meant by “patient-centred”.

Engaging with these questions will contribute to a new ontology of clinical practice and – I hope – explanatory models and language that helps practitioners to communicate better with patients, regulators and academic collaborators.

7. Intersubjectivity

Mon, 23 Aug 2021 19:48:04 GMT

In this post, I discuss perspectives, and explain what I have come to understand about intersubjectivity.

One way of approaching the Phenomenosphere is to think again about the perspective we take towards the phenomena at hand; and by “perspective”, we can go back to that word’s etymological roots for a definition that likens it to a lens through which we look.

In western epistemologies, we tend to start with objective perspectives: third-person and impartial; and compare them with subjective perspectives: first- or second-person and partial. With the former, there is some authoritative and external ontological account of the way the world is; with the latter, there are limited and biased descriptions of the way that individual people (I - first person; or You - second person) perceive only aspects of what is real: we have to set aside our pre-conceptions and use reason and experiment to hypothesise and demonstrate what is really real.

Is there a mid-point between objective and subjective perspectives? I don’t believe that we can consider them binary opposites, nor at either end of a spectrum. Instead, “objectivity” and “subjectivity” are epistemological constructs, and their meaning is bestowed only within the context of the onto-epistemological framework which owns their usage. In the west, we most often encounter the perspectival concepts of objectivity and subjectivity within discourses that seek to establish ownership of “facts” or “truth” about the world. Generally speaking, objectivity is a good thing and subjectivity is fickle, flawed and fallible.

Does “intersubjectivity” take us to the mid-point between objectivity and subjectivity? I don’t believe it does. The idea of the intersubjective perspective may seem to get us out of the objective-subjective bind, but it is not as simple as that. Intersubjectivity is a useful concept, because it can be used to indicate that we are not buying into the black/white dichotomy of objectivity/subjectivity, nor the graded continuum of objectivity—subjectivity. Instead, the concept of an intersubjective viewpoint is one that necessarily suggests that facts are phenomena with contexts (embedded within “ fields of sense ”, as Markus Gabriel proposes.

In my next post...

I will discuss Gadamer’s metaphor that illuminates the idea of intersubjectivity: the fusion of horizons.

6. Why, even, Phenomonology?

Sun, 15 Aug 2021 17:11:52 GMT

In this post, I define some of the key concepts of the Phenomenosphere...

Stepping into the world of Phenomenology reminds me of encountering Philip Pullman’s His Dark Materials for the first time. With Pullman, there are elaborate representations of alternative realities with their own cultures, institutions, topographies and languages. As a reader, one suspends disbelief. This manoeuvre - a stepping away from the conventions of the non-fictive world - entering into a conspiracy with the author - is comparable to the readjustment one makes to see what Husserl, Heidegger and Merleau-Ponty were proposing. I am not suggesting that we should consider the Phenomenological project merely a grand narrative, a work of imagination. But it may help to understand it as a creative venture, a work of re -imagination. This helps to set the scene for an account of some of the language used in the Phenomenosphere.

Why, even, “Phenomenology”? In pre- and para-Phenomenological accounts, “phenomena” were objects of the world that were perceptible to observers. And in the objectivist world of western science and analytic philosophy, they are in the same category: objects (material or imaginary) that can be perceived, imagined or experienced. The Phenomenological project asks questions of this supposition, and proposes that the most interesting thing about phenomena is not that they are objects with their particular features and properties, but that they make their appearance to human consciousness at all. Put simply, Phenomenology is concerned with the way we become aware of phenomena - the structure of the relationship between the perceiver and the perceived.

The interaction between the perceiver and the phenomenon perceived is a process known as “intentionality”. Intentionality - in the Phenomenosphere - is not the same thing as performing an action knowingly and with free will. As with Pullman, the language of Phenomenology taxes us a little. We think we know what is meant, but we have to bend our thoughts a little to come to an understanding. “Intentionality” is used by Phenomenologists in its etymological sense of “stretching ones attention towards”. In some forms of Phenomenology, the idea is that the object draws ones attention towards it; in others, one aims ones attention towards the object; in others, there is a mutual and reciprocal magnetism between the perceiver and the object. This is a rather reductive account of intentionality, and in later posts I hope to be able to show that the relationship between phenomena and their perceivers can be explained more elegantly, holistically and with due attention to the multi-dimensional, multi-directional complexity of object-consciousness.

Dwelling on the definitions of Phenomenology and intentionality paves the way for explaining the idea of “Disclosure” (which can also be called “Unconcealment”). In an objectivist world, phenomena are things or happenings that have either material or conceptual existence. They “are”. The rock has existence, the city has existence, the parliament has existence, the person has existence, the ideas have existence. These are different categories of object, and they plainly have different categories of existence, but nonetheless they have their existence, and they can be seen, witnessed, owned, argued about and disputed by any objective viewer. But in the Phenomenosphere, there are no objective viewers. As Thomas Nagel has famously claimed, “There is no view from nowhere”. There is no possibility of an objective viewpoint; and, for Phenomenologists, this is equivalent to saying that no object has objectively verifiable existence. Instead, what we have is this relationship between phenomenon and perceiver, which is always embedded within a particular context, defined by its unique and of-the-moment meaningfulness, and marked by the manner of its appearance - its disclosure to consciousness.

Phenomenologists see not one world, but multiple worlds, and it is in the stepping away - the suspension of our disbelief (or, perhaps, the setting aside of our naive beliefs) - that we can straddle the objectivist world of our western heritage, the alternative universe of Philip Pullman, and the inter-subjective conceptual realm of Phenomenology. This process of stepping away is one I will return to in future posts, when I look at the philosophical concept of “epoche”. But...

In my next post...

I will tackle the concept of inter-subjectivity, and explore its meaning for qualitative research and healthcare practice.

5. Lived Experience

Sun, 08 Aug 2021 19:50:19 GMT

What does it mean to have “lived” experience, as opposed to any other type of experience of experience?

In the realm of phenomenology, experience that is “lived” is experience - the undergoing of anything - in a manner that is meaningful, integrated, embedded and situated. By definition, it is meaningful, because in phenomenological terms, being IS synonymous with having to do with meaning (i.e., sensing, making sense, finding significance, interpreting, identifying meaning). It is integrated, because we undergo things wholly, in our entirety. It is embedded, because - without any effort and often without any conscious awareness - what we undergo is always contextualised by everything else we have already undergone, are undergoing and anticipate undergoing in the future. It is situated, because it takes place in our own particular temporo-spatial locus, within our Lifeworld.

This wordy explanation of lived experience is probably unarguable - but then, so what? Why do we need to keep on adding that unnecessary verbal adjective, “lived”? What’s wrong with just “experience”, or “direct”, “personal” or “first-hand” experience. Each of those is, on the face of it, a satisfactory alternative to “lived”. But the point about “lived” is that it indicates a commitment to the phenomenological ontological position of plural or hermeneutic realism. It’s not the case that the world and facts about it exist objectively and are independently verifiable (a phenomenologist will argue), with certain people having better access to and ownership of the things of the world and knowledge of the facts about it. Instead, “lived” experience speaks of every being participating meaningfully in their Lifeworld.

“Lived Experience” currently has a progressive inflection in activist, academic and inclusionary political circles. Hear Baljeet Sandhu making a case for epistemological diversity in the service of what she is calling “knowledge equity”. In this episode of “ Positive Thinking ”, listen to the clash of ontologies playing out as Tracey Herrington, manager of Thrive Teesside , politely challenges David Willetts, about which people are best placed to inform decision-making about the implementation of Universal Credit (welfare benefits). Lord Willetts claims that it is the job of the policy-makers to empathise with those who would be recipients of welfare payments. Tracey Herrington counters this claim with the argument that empathy is no substitute for the wisdom that arises from the lived experience of those in the circumstances that lead them to require welfare support: perhaps better, and more sustainable solutions would arise, if decision-making were informed by those with direct, personal, first-hand “lived” experience of intergenerational unemployment and poverty.

In my next post.. .

In future posts, I will carry on trying to untangle the meanings of the phenomenological lexicon: next week, “phenomenology” itself, “intentionality”, and why we use the term “disclosure” to mean “existence”.

4. Hermeneutic Realism

Sun, 01 Aug 2021 18:47:51 GMT

In this post, I write a little more about the subject of Hermeneutic Realism (which I am capitalising today), and to give an illustration of how we can understand it.

Realist ontology accepts that the things of the world do indeed have substantive existence, and are not (as the counter-example would claim) projections or illusions (think of the world conjured by the Wachowskis in The Matrix ). Even projections and illusions, from a realist stance, have substantive existence (in that they originated from some real source that has existence). Realism has champions from different disciplines (e.g. Roy Bhaskar’s Critical Realism ), and is considered to be an ontological stance that challenges both scientific positivism and post-modern constructivism.

Hermeneutic Realism (closely related to Dreyfus & Taylor’s Plural Realism and Gabriel’s Fields-of-Sense Realism – see last week’s blog) is a version of realism which makes an ontological claim that the world and its phenomena are indeed real, but that they are only ever meaningfully real within the context of their manifestation. This is not about perspectives: it is about what is disclosed. This sounds such a mangled way of putting it, that perhaps an example would help.

I drive past a hill on my way to work, once a week. Some days I notice it, and some days I don’t. If it’s raining, my eyes are on the road and I don’t look. Sometimes I forget about it (it’s only a hill and I’m on my way to work). Sometimes I look at it, on my way back from work, and notice daffodils on the hill, and this pleases me. Once every now and then, I might walk up the hill, and from there I can look over the city. If I turn in the other way, I can see the mountains that border onto Scotland. If I take the dog for a walk, she might speed past me and run up the hill, and if there are cattle on the hill, I put the dog on the lead. A friend walks with me one day and takes faster strides than me and notices how puffed I am by the time I get to the top – it’s barely EVEN a hill, he thinks! This hill discloses itself to the cattle, to the moonshine, to my dog, to my friend and to the joggers and sledgers in its unique way, in any given temporo-spatial context.

This might sound as though I am saying that the perspective of each of the “users” of the hill is what defines Hermeneutic Realism; but this is not the case. The ontological claim of Hermeneutic Realism does not depend on the observer’s perspective (or their epistemology), but on the way the hill fits into any given context – how it is situated. So, there is no one, true hill that is more fundamentally real than any other manifestation of the hill. It is not the stone, earth and heathland first and foremost. It is not its location on the map, either. The hill makes its appearance, within its network of relevance – its meaningfulness – according to its participation with other factors – people, animals, history, geography, botany (and on and on). Science doesn’t have the first claim on defining the hill; neither does history (look down from the top of the hill, and you can see the outline of an old race-course); and, having the last laugh on us, nor does economics (the hill is an artificial mound made from spoil in the formation of the central motorway!).

In my next post...

The relevance of this to a phenomenological research project will take some further explaining – in my next post.

3. Demystifying (the process of defining one’s) ontology

Tue, 27 Jul 2021 00:51:11 GMT

In this post, I dip into ontology and say a little bit about hermeneutic realism and its relation with positivist and constructivist ontologies.

This is not a full-blown attempt to define or demystify “ontology”; it is more akin to sidling up to the subject, which is what any doctoral student will have to do at some point when writing a research proposal or writing up their thesis. It helps to have an idea of your research question and your methodology, but you could also say that working out your ontology helps to define and refine your research question and to clarify the arguments you have for choosing your research methods. And how? Well, through the process of establishing your theoretical fore-structure, jotting down your notes in your journal, working through the knotty questions that remain stubbornly hard to loosen for a very long time.

Ontology describes the way the world is, the nature of things, what we understand to be real or factual. Human cultures have always attempted to answer these questions, and (as Thomas Kuhn famously argued ) as we shift from one paradigm to another, we replace one set of preoccupations and orthodoxies with another set. In the west, there is a tradition claiming that the way we understand the world has progressed in linear fashion, towards an ever-more complete and sophisticated account: from mythic, to religious, through rational and empiricist, to scientific frameworks of understanding. And the positivist ontology of the natural sciences has tended to predominate and to colonise philosophical, cultural and traditional scientific understanding across the rest of the world. Julian Baggini gives an authoritative but accessible account of this process in his 2018 book, How the World Thinks .

Until recently, Evidence-Based Medicine has been rooted exclusively within the western scientific ontology that developed in post-Enlightenment Europe (“Enlightenment” is one of those concepts that we have not yet learned to use with irony, although philosophers of other traditions have referred to it as the “Endarkenment” – see Tyson Yunkaporta’s Sand Talk - and I think it is time we took note). Qualitative health researchers working within the EBM paradigm used to be swimming against the tide if they diverged from the ontological foundation of positivism. The positivist proposition is that the world and the things it contains are first and foremost capable of being explained by the objective methods and theories of western science (and anything not yet explained is because science still has some way to go on its trajectory of explaining everything). The positivist argument is that humans may have different perspectives on the world and the things it contains, which explains why there are differences between cultures, but that - in the end - everything that exists has the potential to be explicable by the objective methods of science.

When you grow up and are schooled in a western way of thinking, this argument - usually in the background - pervades your thinking to the extent that it almost seems heretical to argue against it, should the thought ever bubble up into your mind. The charge of “anything-goes” relativism is often an inhibitor to exploring complexity in non-simplistic ways. Turning away from the natural sciences and towards the social and political sciences, and we find ontological frameworks that give us different accounts about the way the world is, and which are capable of complexity. These often have to do with the structure of the human world and language, how societies are structured, how myths, cultures and discourses are constructed.

When starting out with my research project, as I grappled with defining my stance and my research question, I was pleased to become acquainted with the question of ontology within phenomenological philosophy, particularly filtered through the work of Hubert Dreyfus and Thomas Sheehan . Since ontology is one of phenomenology’s pre-eminent concerns, it would be rash of me to do more than touch upon the subject in this blog. Perhaps suffice to introduce the ontological proposition of hermeneutic realism , the intriguing and intuitive claim that “the” world does not exist (I can recommend Markus Gabriel’s witty and relentlessly persuasive explanation of how this is so). “The” world does not exist, because many worlds exist, and these worlds disclose themselves only ever in the domain of a particular “field of sense”; only in context; only within the intentional relationship between subject and object; only ever as part of a Gestalt of meaning. By the way, “hermeneutic” is a term almost synonymous with “interpretative”, and it implies a human attempt to seek an understanding (objective or subjective, definitive or infinite) of human cultures and artefacts, language and text, and – from the phenomenological perspective – experience.

In my next post...

I will try to develop these ideas a little further, to show how they are relevant when the topic of a research project is human experience and meaning-making, topics that may require more than a positivist or a constructivist ontology to help us analyse and understand them.

2. Theoretical fore-structure: like sparks from a fire

Mon, 19 Jul 2021 17:42:22 GMT

Here I relate how I worked to identify a dynamic theoretical fore-structure and the ways I found it indispensable.

I always bridled at the concept of researcher “bias” - as though there could ever be a pure, unfiltered, unmediated way of establishing truths about the world! It might be because my first degree was in history, but I always had a struggle with the concept that the phenomena of the world are stable, objective and independently verifiable. My first encounters with phenomenology gave me the confidence to explore ontologies that counter the dominant tradition of post-Enlightenment positivism which underpins much of the “evidence” that justifies western medical practice. I will write more about this in the next blog, but for now, my focus is on the theoretical fore-structure.

Hubert Dreyfus and Hans-Georg Gadamer have written about their interpretation of Heidegger’s notion of the fore-structure, and the uses of this concept for hermeneutic philosophy. Briefly, the fore-structure is a product of our situatedness within a world of meaning. It is not only our researcher positionality, nor our “lens on the world”, and nor is it our subconscious beliefs and prejudices that we call “biases”. It is not only the cultural norms that structure our education, define our outlook and underpin our values. It is not merely the sum of all of the streams of thought and belief that construct our universe, nor the gestalt of our lived experience; and it is not the product of our reflexive self-examination. It is a combination of all of these facets of our comprehension of the world, and more besides: a philosophical reflexion. For me, it is Maurice Merleau-Ponty who describes the fore-structure most expressively; he represents the act of philosophical reflexion as

“step(ping) back to watch the forms of transcendence fly up like sparks from a fire; it slackens the intentional threads which attach us to the world and thus brings them to our notice”

It is Merleau-Ponty’s famous description that helps me to remember that - unlike its concrete-sounding name, we should view our fore-structure as a dynamic, evanescent and constantly re-creating stream of encountering with our ever-transforming world. “Intentional threads” is a metaphor for the content, style and trajectory of our active engagement – through active perception and perceptive action – with the phenomena of our world.

Keeping a reflexive journal is one way I found I could explore my fore-structure. Using the reflexive methods of Prof. Christopher Johns was another. I also found that my generous supervisors were happy to take the time to get into a dialogue with me, to help me to define my thoughts, attitudes, preconceptions and prejudices.

1. Finding a stance through reflexive journalling

Mon, 12 Jul 2021 14:21:08 GMT

In this post I discuss the challenge of identifying a stance (or positionality) as a practitioner-researcher, and how I found keeping a reflexive research journal the most useful tool to keep myself always alive to my positionality.

A few years after graduating as an osteopath, I had one foot in clinical practice and the other in pedagogy (lecturing on the Leeds Beckett University, Master of Osteopathy programme). As a way of trying to resolve some of the challenges I encountered developing a module in Evidence-Based Practice, I applied to the University College of Osteopathy for a place on its Professional Doctorate programme. I knew for sure that my interest lay in finding a way to study the mechanism of cranial osteopathy. However, I found myself facing a dilemma – one that is surely common to all practitioners who want to study aspects of their own practice: how to find a position from which to appraise and critique the discipline within which I spent my days practicing and teaching.

Did I want to stand aside from osteopathy and apply an objectivist gaze towards my practice? Or adopt the attitude of an ethnographer with a ready-formed insider perspective? I was drawn to a critical analytical stance but had to consider the ethical consequences of my authenticity as a practitioner, subjecting my daily work – my vocation! – to deconstruction. These issues preceded the development of my research question and caused me great despair, until I came across the work of Linda Finlay, the psychotherapist and academic who pioneered the use of phenomenological research methods for practitioner-researchers. I encourage you to read her book online - Phenomenology for Therapists: Researching the Lived World (2011) . Linda Finlay’s work was my first introduction to phenomenological research methods, and I took from her publications some confidence that I would be able to find a position – a stance – towards osteopathy that was both critical and compatible with my own understanding of its practice.

I hadn’t yet encountered the concept of the theoretical fore-structure but knew that the first step I should take was to change my attitude towards my research journal. Up until that point, it was written as a formal record of literature searches, references I would happen upon and contacts to follow up. After reading about phenomenology and accepting that I would be researching with an insider’s perspective, I began to write down anything that sparked inspiration. I recorded ideas in the middle of the night, whilst travelling on the train, when on holiday, listening to the radio - and at the end of each clinic day. My research journal soon started to build into a creative repository of stream-of-consciousness out-pourings, insights that seemed to write themselves and disquisitions that provided their own resolutions.

I am so glad I kept that journal - wholeheartedly and almost compulsively - because these screeds - legible and intelligible only to myself - became the means through which I found my stance, and began to test my own ideas about ontology and epistemology. Little did I know then how much these scribblings would form a tangible stream of evidence to sit beside my data-set, illustrating how my perceptions and preconceptions were active influences on every aspect of my research project, from the formulation of my question, to the selection of methodology, and on to the analysis of the data.

The PhOst Blog

18. Hermeneutic Healthcare: Osteopathic Reflections - Theory & Practice

In my next post...

17. Hermeneutic Healthcare: Meaning / Materiality

In my next post...

16. Reflexive Non-Dualism in Research

The benefit of a non-dualistic ontological stance is that it liberates the phenomenologist from the constant challenge of having to agree that there is a distinction between internal things and external things, and in their manner of appearance to human consciousness.

In my next post...

15. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 3 (A model)

In my next post...

14. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 2 (The role of touch)

In my next post...

13. Enactive, Embodied Communication in Hermeneutic Healthcare - Part 1 (Introduction)

Before diving straight into the subject of “enactive, embodied communication”, I must begin by explaining something about the non-dualist ontological principles of phenomenology and hermeneutic realism, by way of introduction to an account of embodied consciousness and enactive communication.

First some definitions

In my next post...

12. The Real Scaphoid

A detour, before discussing phenomenological models of embodied communication in healthcare settings, via some further consideration of the boat-like bone, the scaphoid, and hermeneutic realism.

What is the real bone, really?

In my next post...

11. Hermeneutic Healthcare

A self-employed patient has a long drive to attend a trade event. He has fallen and injured his wrist which is painful and swollen so he books an appointment with his GP for the following day. A common enough scenario.

In my next post...

10. Shared Being Shared Meaning

Previously, I have explored intersubjectivity in healthcare relationships using Gadamer’s fusion of horizons metaphor. In this post, I expand this exploration with a focus on the hermeneutic (sense-making) aspect of intersubjectivity. ﻿

In my next post...

9. Patient-Practitioner Fusion of Horizons

If we are thinking about person-centred care, how should we conceptualise the patient being at the “centre” of that care?

In my next post...

8. Fusion of Horizons

In this post I discuss Hans-Georg Gadamer’s famous metaphor “fusion of horizons” - the Horizontverschmelzung - which describes the conditions in which individuals come to share understanding of phenomena.

In my next post...

7. Intersubjectivity

In this post, I discuss perspectives, and explain what I have come to understand about intersubjectivity.

In my next post...

6. Why, even, Phenomonology?

In this post, I define some of the key concepts of the Phenomenosphere...

In my next post...

5. Lived Experience

What does it mean to have “lived” experience, as opposed to any other type of experience of experience?

In my next post.. .

4. Hermeneutic Realism

In this post, I write a little more about the subject of Hermeneutic Realism (which I am capitalising today), and to give an illustration of how we can understand it.

In my next post...

3. Demystifying (the process of defining one’s) ontology

In this post, I dip into ontology and say a little bit about hermeneutic realism and its relation with positivist and constructivist ontologies.

In my next post...

2. Theoretical fore-structure: like sparks from a fire

Here I relate how I worked to identify a dynamic theoretical fore-structure and the ways I found it indispensable.

1. Finding a stance through reflexive journalling

In this post I discuss the challenge of identifying a stance (or positionality) as a practitioner-researcher, and how I found keeping a reflexive research journal the most useful tool to keep myself always alive to my positionality.

Previously, I have explored intersubjectivity in healthcare relationships using Gadamer’s fusion of horizons metaphor. In this post, I expand this exploration with a focus on the hermeneutic (sense-making) aspect of intersubjectivity.