Jennifer Bullington

Embodiment and chronic pain: implications for rehabilitation practice.

Throughout the Western world people turn towards the health care system seeking help for a variety of psychosomatic/psychosocial health problems. They become “patients” and find themselves within a system of practises that conceptualizes their bodies as “objective” bodies, treats their ill health in terms of the malfunctioning machine, and compartmentalizes their lived experiences into medically interpreted symptoms and signs of underlying biological dysfunction. The aim of this article is to present an alternative way of describing ill health and rehabilitation using the philosophy of Maurice Merleau-Ponty in order to deepen our understanding of the rehabilitation process. I will explore how the experience of chronic pain ruptures the natural connection between body and world and how the rehabilitation process can be understood as the re-insertion of the body into the flow of experience, where the body “disappears” into its natural silence in order to allow the world to once again unfold. The experience of chronic pain places the painful body in focus, resulting in a diminished articulation of both self and world. Persons with illness suffer not only from the physical aspects of pain and discomfort but also from a loss of identity where one feels alienated and detached from things that used to give meaning to ones life. Rehabilitation must not only address the material (medical) body but also the diminished sense of self as well as the retreat from the world outside of the painful body.

My prosthesis as a part of me: a qualitative analysis of living with an osseointegrated prosthetic limb:

Background: Bone-anchored prosthesis is still a rather unusual treatment for patients with limb loss. Objectives: The aim of this study was to improve our understanding about the experience of living with an osseointegrated prosthesis (OI-prosthesis) compared to one suspended with a socket, through the use of qualitative research methodology. Study design: A qualitative phenomenological research method. Methods: Thirteen Swedish patients (37–67 years) with unilateral upper or lower limb amputation (10 transfemoral, 2 transhumeral, 1 transradial), who had been using OI-prostheses for 3 to 15 years, were recruited by means of purposive sampling. An audio-taped in-depth interview was performed. The guiding question was ‘How do you experience living with your osseointegrated prosthesis compared to your earlier prostheses suspended with sockets?’. The empirical phenomenological psychological method was used for data analysis. Results: The results showed that all participants described living with an OI-prosthesis as a revolutionary change. These experiences were described in terms of three typologies, called ‘Practical prosthesis’, ‘Pretend limb’ and ‘A part of me’. Conclusions: The most important finding was that the change went beyond the functional improvements, integrating the existential implications in the concept of quality of life. Clinical relevance This qualitative in-depth interview study on patients using bone-anchored prosthetic limbs showed that all described a revolutionary change in their lives as amputees and the meaning of that change went beyond the functional improvements, integrating existential implications in the concept of quality of life.

Patients perspective of change processes in affect-focused body psychotherapy for generalized anxiety disorder

In a previous study, 61 patients with generalised anxiety disorder were randomised to participate in affect-focused body psychotherapy (ABP) or treatment as usual. In this current study a sub sample, 30 of the patients in the ABP group has been interviewed. A qualitative interview was used in order to investigate how the patients experienced participation in one year of ABP therapy. It was found that an initial open attitude towards the treatment and an understanding of the mind-body unity seemed to be a crucial factor in motivating the patient to take an active part in treatment. Key themes concerning shame and control were found in the material. Getting in touch with ones body eventually gave rise to a feeling of being in control, e.g. noticing muscular tension and being able to influence it as well as understanding the connection between bodily symptoms and emotions. Anxiety signals become transformed into meaningful signals about ones life situation instead of provoking fear. The end result of therapy could be understood in terms of how patients managed to integrate bodily feelings into their perception of themselves, thus attaining a deeper experience of their lived body. The clinical implications of the study are that the therapist should be flexible and sensitive, adjusting the treatment in accordance to the patients own understanding of the body. The therapist should also initially limit shameful feelings and anxiety by ensuring that the patient understands the meaning of the interventions and what is expected from him/her, thus giving the patient a sense of control.

The fuzzy concept of 'holistic care': a critical examination.

We are concerned by the fact that the concept of ‘holistic care’ is used in a variety of contexts without any clear definition of what is meant by the term. Generally, one finds the term used in the caring scientific literature, as a way of being attentive to individual, emotional, social, psychological, existential (and sometimes spiritual) dimensions of the human being. There is often a reference to notions of ‘balance’, ‘harmony’ and ‘wholeness’, but these terms are not defined either. There is nothing inherently wrong with a holistic perspective. On the contrary, it is laudable. However, the texts that use the term ‘holistic’ are often riddled by a vagueness and lack of philosophical rigour which gives the entire approach an air of the New Age movement which does not further the cause. We need a sound, scientific concept that can contribute in a meaningful way to the study of health and illness in order to have credibility in the evidencebased paradigm of today. Unfortunately, such a concept is lacking. In the following editorial, we would like to problematise the way the term ‘holistic’ is used in caring science literature and present a way to remedy some of the vagaries that surround this terminology Finally, we have noted that the same type of conceptual vagueness found in ‘holistic care’ seems to be emerging in relation to the recent concept of ‘person-centred care’. We believe that it is important to ground all scientific concepts in appropriate philosophical and epistemological frames of reference and be clear about the definitions and boundaries of the concepts one is using. For that reason, it is our hope that our criticism of ‘holistic care’ can give rise to a critical reflection on the use of this kind of terminology in general. References to ‘holistic care’ found in Swedish healthcare documents and healthcare rhetoric have to do with regarding the patient as a ‘whole person’, that is, with biological, psychological and social needs. A search on the Internet for scientific articles on ‘holistic care’, ‘holistic medicine’ and ‘holistic treatment’ yields thousands of hits. We found several attempts in the literature to define what ‘holistic care’ means (1–3) as well as a variety of empirical studies purporting to use a ‘holistic’ framework in clinical practice (4–7). The term ‘holistic’ functions most often in these texts as a negative category, that is, as a name for that which is not reductionist medicine. For example, holistic care is characterised as nontechnical, nontask oriented (relation-oriented), nonfragmented, nonutilitarian, nonstatistical and so on. The term is introduced as an alternative to the strictly medical approach, although what it actually entails is not clearly defined. The ‘whole’ in holism seems to be the idea that the whole (the human being) is more than the sum of the parts, an implicit (sometimes explicit) criticism of the biomedical tradition that only tends to the somatic ‘part’ of the human being. There are good intentions behind challenging the one-sided reductionist approach of the traditional biomedical approach, and focusing on patients’ experiences is not wrong, but in order to fill the term ‘holistic care’ with meaning, we will need more than declamations that one is interested in the ‘life-world’ of the patient. The concept of holistic care needs to be grounded in a sound philosophical perspective in order to contribute to a nonreductionist conceptualisation of the human being. We believe that the phenomenology of Maurice Merleau-Ponty (8) can offer such a philosophical grounding, as his work on the body provides us with the fruitful concept of the ‘lived body’, which is not to be confused with the objective body that is characterised by medical science. Merleau-Ponty’s work is especially relevant in this context since his notion of the lived body is an attempt to philosophically define and characterise the ‘whole’ human being through a radically new conceptualisation of mind/body and world. The concept of the lived body is the term used by Merleau-Ponty to designate the lived unity of the mind–body–world system. The lived body is necessarily ambiguous, since it is both material and self-consciousness, both physiological and psychological. But these realms of existence (mind, body and experience of the world) are not as dichotomous as one would imagine. The self, the body and the world of things and others are neither separated from each other nor to be confused with each other, but can rather be seen as three sectors or levels of a unique field. Where there is a body, there is a personal world, an opening upon the world which is unique. This uniqueness has to do with our life as mind, as persons, with the fact that we have language, history and culture and can ask questions about our own existence. Likewise, there is no personal life or mind without a body, nor any bodies without a person. Finally, this intertwined mind–body unity is always embedded in and present to a concrete situation. There is no world (as perceived) without a human to experience it, and there is no human experience that is not of the world. Thus, we cannot discuss the body as if it were something cut off from both mind and world. In order to do justice to this profound given of human experience, we need to reformulate our conceptualisations of personhood, bodies and lived situations. This conceptual work would clearly benefit all discussions concerning holistic care. The lack of a genuine conceptualisation of the human being as a whole, grounded in philosophically

The Lived Body

This chapter focuses on the early writings of Maurice Merleau-Ponty (The Structure of Behavior and Phenomenology of Perception). Firstly, an introduction to the science of phenomenology places the reader within the correct philosophical framework in order to understand the aim of Merleau-Ponty’s work on the body. Concepts from these two early works, such as “the lived body”, “the intentional arc”, “motor intentionality”, “structure” and “structure transformation” are presented. These concepts will be used in Chap. 5 as a new way to understand the “mystery” of psychosomatic pathology. Merleau-Ponty’s explication of the meaning-constitution of the (lived) body solves many of the mind–body problems associated with psychosomatics. In this chapter (and Chaps. 3 and 4), the philosophical groundwork for a phenomenological theory of psychosomatics ( Chap. 5) is laid out.

Meanings of “acceptance” for patients with long-term pain when starting rehabilitation

Abstract Purpose: The study aimed to elucidate the meaning of acceptance in relation to the lived body and sense of self when entering a pain rehabilitation programme. Methods: Six women and three men with long-term pain were interviewed. The interviews were analysed according to interpretative phenomenological analysis. Results: The analysis revealed three different meaning structures, first: acceptance as a process of personal empowerment, “the only way forward”. Here, the individuals expressed that the body felt integrated: a trusting cooperation between self and body gave rise to hope. Second: acceptance as an equivocal project, a possible but challenging way forward. The hopeful insight was there, acknowledging that acceptance was the way to move forward, but there was also uncertainty and doubt about one’s ability with a body ambiguous and confusing, difficult but important to understand. Third, in acceptance as a threat and a personal failure, “no way forward” the integration of the aching body in sense of self was impossible and pain was incomprehensible, unacceptable and unfair. Pain was the cause of feeling stuck in the body, affecting the sense of self and the person’s entire life. Conclusions: The meaning of acceptance was related to acceptance of the persistency of pain, to how the individual related to the lived body and the need for changes in core aspects of self, and to the issue of whether to include others in the struggle of learning to move on with a meaningful life. Implications for Rehabilitation Healthcare professionals should be aware that individuals with long-term pain conceptualize and hold different meanings of acceptance when starting rehabilitation; this should be considered and addressed in rehabilitation programmes. The meaning given to acceptance is related to the experience of the lived body and the sense of self, as well as to getting legitimization/acceptance by others; therefore these aspects need to be considered during rehabilitation. The process of achieving acceptance seems to embrace different processes which can be understood as, and facilitated by, an embodied learning process. The bodily existential challenges presented in the present study, for example to develop an integrated and cooperative relationship with the painful body, can inspire health professionals to develop interventions and communication strategies focusing on the lived body. A wide range of competencies in rehabilitation clinics seems to be needed.

The Lived Body (Phenomenology of Perception) and the Flesh (The Visible and the Invisible)

This chapter takes the reader into the late Merleau-Ponty (The Visible and the Invisible) where a visionary description of the relations between man and world is put forth in terms of “the flesh.” The goal of his last work was to bring the insights from his earlier (phenomenological) work to an ontological level. For example, what does it really mean to see? I find myself “with” the thing at the end of my gaze, but it is somehow also “in” me. The mysterious way we “have” the world is described in this last work a unitary movement where man and the world become together in one event. In order to understand this, the concepts of “chiasm”, “reversibility”, “ecart/dehiscence”, “the visible” and “the invisible” are presented. All the chapters on Merleau-Ponty’s philosophy ( Chaps. 2, 3 and this chapter) contain extensive quotes from his texts and explanatory footnotes.

Health and Illness and Holistic Health

This chapter examines the notion of “holistic” health. The literature today is full of references to “holistic care” and “holistic medicine” but one rarely sees any content to this term, except for some general phrases about man being a biological, psychological and social being. The chapter begins with an overview of different conceptions of health and illness throughout history, demonstrating that the notion of health has deep-rooted cultural associations to ideas about balance and harmony, virtue and morality, societal norms and behaviors. A brief presentation of modern theories of health follows. Afterwards, an analysis of scientific literature shows how the term “holistic” is in need of a philosophical grounding in order to make any genuine contributions to health care. Finally, a sound holistic view of health is extrapolated from the theory of psychosomatics presented in Chap. 5, which should be an appreciated contribution to the literature on health.

The Psychosomatic Problematic

The first part of this chapter introduces the problem of medically unexplained symptoms (MUS) and explains why we need an alternative theoretical understanding of psychosomatics in order to grasp the idea of a “speaking body.” The theoretical and clinical problems connecting to psychosomatic pathology are presented. The failure of traditional psychosomatic theories (psychodynamic, psychosomatic medicine and stress theory) to make psychosomatics comprehensible is demonstrated through text analyses, philosophical argumentation and exemplification from the literature. The final part of this chapter presents empirical evidence that psychosomatic symptoms in adults and children/young adults are common causes for seeking health care today. Four clinical challenges connected to the treatment of these patients is presented and discussed at the end of this first introductory chapter.

The Meaning of Meaning

Now that we have established that the body is involved in a rudimentary meaning-constitution, the question becomes, what is “meaning”? The chapter begins with a brief look at the traditional view of meaning, moving quickly into the texts of Merleau-Ponty that have to do with language and expression (Signs, Prose of the World, Consciousness and the Acquisition of Language) in order to explicate an entirely new way of understanding “meaning”, not simply as a way of designating thoughts and things, but rather, as the very bringing of thoughts and things into presence. The relationship between perception and language and the origin of meaning is in focus in these texts. Finally, the notion of “expression” finds its ultimate form in the ontology of the late Merleau-Ponty in his description of the meeting between man and world as “flesh” which will be the subject matter of the following chapter (4).