Applying Petitmengin's Explicitation Interview Method to Elicit the Lived Experience of Breathing Upon Waking by an Individual With Cystic Fibrosis.

Breathing is an act that most people do not consciously evoke unless there is a presence of illness that affects the respiratory system. Adults generally take in 12 to 15 breaths per minute without even a thought about the body's mechanics that allow for proper oxygenation and ventilation. However, for those with pulmonary compromise, breathing becomes a very conscious, deliberate, and sometimes laborious act. The purpose of this paper is to demonstrate the use of the explicitation method by Petitmengin by interviewing a subject to elicit the lived experience of breathing by an individual with end-stage cystic fibrosis (CF). To apply the interview method, the following phenomenological question guided the interviewer's approach: What is the lived experience of breathing upon waking for an individual with CF? This paper includes a transcription of the interview followed by a self-critique, textual analysis, and discussion of the implications to health care.

Breathing is an act that most people do not consciously evoke unless there is a presence of illness that affects the respiratory system. Adults generally take in 12 to 15 breaths per minute without even a thought about the body’s mechanics that allow for proper oxygenation. However, for those with pulmonary compromise, breathing becomes a very conscious, deliberate, and sometimes laborious act. For instance, people with emphysema, asthma, or cystic fibrosis (CF) are acutely aware of their breathing, especially during episodes of dyspnea.

Emphysema and asthma are both acquired respiratory illnesses, whereas CF is genetic and follows an autosomal recessive pattern of inheritance. While emphysema and asthma are well-understood and well-publicized, CF is not as known by the lay public despite the fact that it is the number one genetic disease among Caucasians, affecting approximately 30 000 people in the United States (1). Cystic fibrosis is a multisystem, progressive, life-shortening disease. An abnormality in chromosome 7 results in the alteration of the body’s ability to transport sodium and chloride across ion channels, thus producing excessively thick, tenacious mucus (1). The mucus becomes entrapped in various areas, primarily affecting the lungs, intestines, pancreas, and reproductive organs (1). Due to the advancement in medicine and technology, CF is no longer a disease of childhood. Recently approved highly effective modulator therapies that target the underlying genetic protein defect in CF are available to treat approximately 90% of individuals with CF and have been shown to improve quality of life and lung function, among other clinical indicators (1). Survival age for people with CF is now in the late-forties with complications from pneumonia as the most common cause of death (1).

Detailed reports on the experience and struggle of breathing by those affected with CF is lacking in the literature. A deep understanding of this experience can only be obtained through phenomenological studies as well as specific qualitative interviewing techniques. The purpose of this paper is to demonstrate the use of the explicitation method by Petitmengin by interviewing a subject to elicit the lived experience of breathing by an individual with end-stage CF (2). To apply the interview method, the following phenomenological question guided the interviewer’s approach: What is the lived experience of breathing upon waking for an individual with CF? This paper will include a transcription of the interview followed by a self-critique, textual analysis, and discussion of the implications to health care.

Brief Overview of Phenomenology

Phenomenology is most commonly described as a philosophy, perspective, research approach, and less often described as a method. The goal of phenomenological inquiry is to fully describe a lived experience (3). Phenomenology’s history is complex, and its current applications are diverse and continually evolving. Phenomenology was originated in the early 20th century by Edmund Husserl who believed that knowledge cannot be gleaned simply by empirical data or by what can be quantitatively measured and manipulated. Instead, he believed that great knowledge can be achieved by understanding one’s experience and “going back to the things themselves” (4 –7). Husserl had several students and scholars (eg, Heidegger, Sartre, and Merleau-Ponty) who incorporated his original ideas into their own set of modified phenomenological principles (5). These phenomenologists believed that a person’s subjective experience is a powerful source of knowledge (5).

Phenomenology is a research approach frequently used in the social–behavioral sciences wherein each interaction between 2 persons creates a situated context embedded in time, space, embodiment, and relationships (8). Phenomenology seeks the meaning of life’s nuances as described by the person experiencing them and by being a theoretical, liberating oneself from prescribed steps or formulas, and requiring the researcher to be open to receive whatever is revealed while being aware of, and setting aside biases, presuppositions, and prejudices (8).

Brief Overview of Petitmengin’s Explicitation Interview Method

Claire Petitmengin, a French psychotherapist and phenomenologist, developed an interview method that allows her study participants to “gain consciousness of their own cognitive processes, and to make them explicit” (2). She is a leading expert in studying the subjective experiences of people with epilepsy and uses the explicitation interview method to delve deeply into the participants’ lifeworld. The interview process requires the participants to describe their experiences with precision and in great detail. There are 6 nonlinear, iterative steps in the interview process: (a) stabilize attention; (b) turn the attention from “what” to “how”; (c) move from a general representation to a singular experience; (d) retrospectively access the lived experience; (e) direct attention to the various dimensions of the experience; and (e) deepen the description to the required level of precision.

In order to stabilize the interviewee’s attention, the interviewer must be firm in his ability to refocus the former back to the experience itself (step 1). The process begins by having the interviewer state the overall objective as well as the context and conditions of the interview (2). For example, the interviewer begins by stating: “Please know that I am often going to repeat what you say to me to check that I have understood you correctly, and whether anything has been left out. Don’t hesitate to interrupt me.”

To achieve steps 5 and 6 which involve the verbalization of rich descriptions of the experience’s multilayered dimensions, the interviewer must use step 2 as an effective way of gathering the interviewee’s internal dialogue (2). Questions posed must begin with “how” rather than “what.” This facilitates a vivid account of the various dimensions within the experience. These dimensions are visual, auditory, olfactory, gustatory, and tactile (also commonly known as the sense of sight, hearing, smell, taste, and touch, respectively).

Finally, in order to truly capture one’s lived experience, it must be precisely situated in space and time (2). Thus, a singular experience must be chosen and retrospectively accessed, rediscovered, and reenacted (steps 3 and 4). The goal is to move the interviewer from a general description or explanation to a highly contextualized, sensorial response. An interviewee is noted as effectively reliving his experience when certain nonverbal cues and behaviors are seen. For instance, the use of the present tense in description signals the arrival of the interviewee within the exact spatiotemporal context of his previous experience (2). Furthermore, the slowing of the word flow, the unfocusing and shifting downward of the eyes, and other gestures are clues that the interviewee has effectively transformed his past into his present during the evocation process (2).

As described by Petitmengin, the explicitation interview method is both noninductive and directive (2). It is noninductive because it starts with a tabula rasa and remains open to drawing the structural characteristics of the experience without inducing any content. Yet it is also directive because the interviewer is firm in his ability to reformulate and refocus the interviewee back to the singular experience in order to achieve depth and precision in description. This interview method requires a high level of trust between the interviewer and interviewee in order for the vividness of description to emerge (2). The interviewer must understand and safeguard the interviewee’s state of vulnerability as the latter’s life experience is intimately invaded.

Method

An audiotaped, in-depth interview was conducted with an individual with CF using Petitmengin’s explicitation method to elicit the meaning of breathing.

Background of the Participant

J.D. (a pseudonym) is a 36-year-old Caucasian male who was diagnosed with CF immediately after birth. He had emergency surgery at day 2 of life to repair an intestinal obstruction from trapped mucus and meconium. Physicians told J.D.’s mother that he had, at most, 1 year to live with CF. Now in his mid-30s, J.D.’s intrinsic motivation to live fully and healthily has helped him recover from several surgeries including bilateral upper lobectomies to remove necrotic lung tissue and exploratory laparoscopy to remove intestinal adhesions and obstruction. He is followed by a multidisciplinary care team (eg, pulmonologist, gastroenterologist, respiratory therapist, physical therapist, pharmacist, etc) and sees his care team for quarterly routine visits and more often when acutely ill. He is hospitalized at least twice each year, with each hospital stay ranging from 10 to 14 days. The most common reason for hospitalization is pulmonary exacerbation secondary to CF.

At the time of the interview, J.D. was hospitalized for pneumonia. After explaining the purpose of the interview, J.D. gave his consent to participate. The interview was conducted in his hospital room and lasted for 40 minutes. It was audiotaped and transcribed verbatim (See Appendix for Transcript).

Background of the Interviewer

At the time of the interview, I was a PhD student and immersed in learning about qualitative research methods. I am also a pediatric nurse practitioner and nurse educator. I have conducted interviews prior to my interview with J.D. as part of my training and employment as a nurse, however, I have never used Petitmengin’s interview method. J.D. is my husband, and this is the first time I have ever interviewed him using a prescriptive approach. While I am witness to his daily challenges related to CF, I have never conducted an interview with him to elicit a vivid description of his breathing experience. In preparation for the interview, I started to journal about my preconceptions, biases, and suppositions. Even though complete bracketing may not be possible, I continuously strove to set aside my personal and professional assessments of what J.D. shared with me. I arrived at the interview with a few written questions that I used to help guide and focus the interview.

Results

J.D.’s experience with breathing upon waking involved multi-sensorial contexts. He described his experience using mainly the visual, auditory, and tactile dimensions. He described seeing his chest rise and fall upon waking, hearing wheezing or gurgling, and feeling tightness in his chest. All of this happens simultaneously and instantaneously and indicates to him whether he would have a “good breathing day” or not. He described how he would consciously stretch his lungs by taking deep breaths, just as another person would stretch his muscles upon waking. He described how his labored breathing can be tiring and frustrating, especially when his brain was willing, but his body was not. He described sensations of hypoxia and his struggle to regain oxygenation by using several metaphors. He described how he must relinquish control over his breathing during periods of bronchospasm. Finally, he described in great detail his meditative technique in conjuring up a “little man” to clean up his congested lungs. All of these descriptions characterize the primary phenomenological concept of embodiment which explains that through consciousness we become aware of being-in-the-world and that it is through the body that we gain access to this world (8).

Self-Critique

The interview went smoothly primarily because of the inherent trust that J.D. and I had with each other. This is a crucial element in completing thoughtful interviews as a lack of trust can deter open dialogue and full disclosure. Petitmengin acknowledged that it is the responsibility of the interviewer to protect the interviewee’s state of vulnerability (2). The trust undergirded the interview and allowed for positive exchange; however, it also permitted exploration of tangential topics which proved to be distracting from the targeted topic. There were instances when I was not directive in my approach and allowed J.D. to venture into discussions on exercise and discomfort, moving away from the focus of the interview which was the experience of breathing upon waking.

I made a concerted effort in following Petitmengin’s 6 interview steps in order to elicit the multidimensional aspects of J.D.’s experience with breathing. I did an adequate job of stabilizing his attention by refocusing, reformulating, and rechecking accuracy. I also achieved my goal of moving from a general representation to a singular experience and had J.D. retrospectively access his lived experience. During the interview, I kept and referred to a list of dimensions (eg, visual, auditory, tactile, olfactory, and gustatory) to ensure that I fully inquire about the experience. The explicitation of dimensions facilitated the deepening of description to a precise level (Petitmengin’s final step).

On the other hand, I could have improved in how I phrased certain questions. Rather than begin with “what,” it would have been more appropriate to ask “how.” Lastly, there were a few incidences where I asked leading questions which signified that I did not fully embody the ‘‘unknowing” principle of phenomenology. The proximity of my relationship to J.D. as well as my professional background of having worked with many individuals with CF served to introduce personal opinions and biases into what was supposed to have been “noninductive” (2). Bracketing and decentering myself was not an easy task to be maintained throughout the 40-minute interview. Being “unknowing” is a true art that requires constant introspection and a willingness to be open to the intersubjective interplay between interviewer and interviewee (8). It is challenging to continually liberate myself from presuppositions and assumptions to truly listen and grasp the meaning of someone’s lived experience and finally “become phenomenologic.”

Textual Analysis

To perform the textual analysis, I first read the transcript in its entirety to get a general appreciation for what was shared. Then I reread the transcript several times to “dwell with the data” in order to highlight and extract emerging descriptive expressions (8). I noted vivid descriptions using gerunds and in vivo codes on the transcript’s page margins. Since this is only 1 interview with 1 participant, themes were not the intended outcome of this analytical process. However, similar descriptions that surfaced throughout the text were recorded and brought back to J.D. for final validation that his experience was accurately captured.

J.D. described his frustrations with the physical and mental act of breathing because it is accompanied by an incessant cough that rendered him exhausted and at times, close to becoming unconscious. He used several metaphors to describe the experience of labored breathing, including: “Feels like you’ve got a plastic bag over you trying to take in air with a straw.” He also vividly described what it feels like to become hypoxic and feel lightheaded:These textual analyses demonstrated Petitmengin’s primary tenet of delving deeply into the person’s multilayered experience.

You just, the blood just you can literally feel it. It’s like pinching your finger for 30 seconds and then you release your finger and you can feel the blood flow…back…into their finger…Well, this is just the opposite. You can feel the blood like leave your brain. And you just can’t catch your breath…And in those seconds you get a little wobbly…because your brain is trying to process everything and yet you’re trying to balance yourself and focus on breathing.

Discussion

I learned valuable lessons from my first attempt in using both a phenomenological approach to inquiry and Petitmengin’s explicitation interview method. I realized that becoming phenomenologic is a continuous and, oftentimes, challenging process. Despite my conscious effort to bracket biases and prior knowledge, I failed to personify the principle of “unknowing” in several instances. Having J.D. as my participant proved to be a double-edged sword. While he afforded me the ability to delve deeply into his experience, my personal relationship with him also made it easy to digress into other peripheral topics.

The interview method was relatively easy to implement especially for a novice interviewer like myself who does not have a psychology background. However, steps 2 (Turning the attention from “what” to “how”) and 6 (Deepening the description to the required level of precision) were arduous because they required careful phrasing and active listening on the part of the interviewer. Additionally, the transcription process was laborious. The multiple and thoughtful reviews of the text for analysis was equally laborious. However, I welcomed both as they were crucial in my development as a scholar and novice qualitative researcher.

Clinical Implications

The experience of breathing as described by J.D. was enlightening because several processes happen within him at once. Upon waking, he becomes conscious of seeing, hearing, and feeling his breathing. An individual without lung compromise breathes without much thought; however, for J.D., breathing is a conscious, deliberate act. Results from this interview add to the work by Haugdahl et al who reported that for patients on mechanical ventilation, their experiences before and after intubation were intertwined with the whole illness experience, and breathing was not always an easily separable experience from being ill (9). The authors described 4 themes that emerged from their interviews with 6 patients: (a) existential threat, (b) the tough time, (c) an amorphous and boundless body, and (d) getting through. J.D. similarly reported a feeling of an existential threat when his breathlessness worsened and he experienced a difficult time overcoming his sense of breathlessness, and finally surrendering his uncooperative body during intense bronchospasms hoping that he would get through to the “other side” and wake up.

J.D.’s experience of breathing was also echoed in a recent study by van der Meide et al wherein individuals with chronic obstructive pulmonary disease (COPD) were asked to describe what it was like to have COPD using phenomenological interviews (10). The themes that emerged describe how these individuals viewed each breath as a possibility and how they must be vigilant in their fight against a “losing battle” that is highly isolating. Lastly, J.D.’s vivid descriptions were also illustrated in the qualitative synthesis by Hutchinson and colleagues who extracted and synthesized findings from 101 qualitative articles that described the experience of breathlessness from the perspectives of patients, caregivers, and clinicians (11). Their meta-concept of “breathing space” highlighted the deployment of self-coping by the breathless patient and the engaged interaction by the patient, caregiver, and clinician to alleviate respiratory distress.

J.D.’s vivid descriptions of the visualization technique he employs using the “little man” in his lungs to gobble up trapped mucus and clear his airways may be of utility for other individuals with CF or non-CF lung disease. A recent randomized controlled trial found that using cognitive behavioral therapy with integrated visualization techniques improved the quality of life among women with hypothyroid disease (12). Similarly, another randomized controlled trial demonstrated that guided imagery exercises improved affect, optimism, self-efficacy in a group of patients with fibromyalgia (13). These findings support the development of targeted interventions for individuals with CF that include cognitive behavioral therapy and guided imagery.

Limitations and Future Research

While generally not regarded as a limitation in the area of qualitative research, especially when the purpose was to explicitly apply and describe the use of a particular method, the 1-person interviewee may be viewed as lacking by qualitative methodologists. Furthermore, while generalizability of findings was not the intent behind this project, there are several implications to future research and health care that are worth mentioning. First, additional work is necessary to fully understand the phenomenon of breathing, perhaps using a variety of participants who have different respiratory conditions and who do not have any respiratory issues to extract the fundamental essence of breathing. Second, future research is needed to investigate how Petitmengin’s explicitation interview method is similar to, and different from other interview techniques (eg, unstructured, semi-structured, structured) (2). Lastly, it is clear that in order to deliver individualized care, health care providers must learn to listen to their patients with phenomenological ears. To truly understand their patients’ perspective, health care providers must understand the meaning of their experiences.

Conclusion

Petitmengin’s explicitation interview method is one approach to use when asking thoughtful questions that allow patients to fully describe their experiences from multiple dimensions according to their situated contexts (2). Only then will health care providers be able to demonstrate care that is holistic and humanistic which are, interestingly, also both phenomenological concepts.