Philosophical Hermeneutics and Teaching Through Behandlung: The Treatment and Handling of Patients With Care.

The purpose of this Feature article is to share a teaching approach for academic researchers and clinicians about the treatment of patients beyond their biomedical needs. To achieve this objective, we will delve into the writings of H-G Gadamer which offer a relational approach to the healing process through the exploration of how the German word Behandlung applies to medical and dental education. Through conversational philosophical hermeneutics, Gadamer endeavors to unite the consciousness of one subject with that of the others and refers to the process as appropriation whereby the researcher/clinician is working toward understanding the experience of the individual within the context of a community of patient experiences.

Introduction

When engaging with topics that speak of whole-person or person-centered health care, we have come to recognize the divide between the theoretical and physiological as well as the lived experience and psychological aspects of chronic pain. Although the theoretical aspect is primarily located in a quantitative understanding and treating chronic pain, the lived experience–being the pain narratives–is qualitative. How should we reconcile this divide? One way to do so is by teaching from a philosophical perspective that addresses the way we treat people beyond the purely biomedical issues. When teaching graduate students, we begin with reading and discussing the above-mentioned quote from H-G Gadamer, a hermeneutic scholar, educator, and author of countless essays on medical encounters.In particular, we read Gadamer’s book entitled “The Enigma of Health: The Art of Healing in a Scientific Age.” These graduate students come from different disciplines, but all have the common passion and desire to learn about professional practice that engages with other human beings. Behandlung can also be interpreted as a form of relational healing whereby compassion and empathy applied with knowledge and skill complete the medical experience for the patient. Below is a quote from Rachel Szwimer (a McGill Master of Science student), who explains her experience from a course grounded in philosophical interpretations of practice.

Within the word Behandlung ones literally hears the word “hand”, the skilled and practiced hand that can recognize problems simply through feeling and touching the affected parts of the patient’s body. “Treatment” in this sense is something that goes far beyond mere progress in modern techniques. Here it is not only a question of the skilled hand but of the sensitive ear which is attentive to the significance of what the patients says, and of the doctor’s observant and unobtrusive eye which knows how to protect the patient from unnecessary distress. There is so much of importance which depends on just how the patient undergoes this treatment” (1, p. 99).

Philosophical hermeneutics is philosophical in that it strives to discern the objectivities within the subjective voice and hermeneutical in that it enquires into how the subjective experiences and engages with those objectivities (2, p. 249).

Coming from a physiological undergraduate degree, I am used to analyzing “patient-like cases” from a purely biomedical model: which gene is mutated, thereby making which channel non-functional, underlying which disease, and requiring which pharmacological treatment. If you would have asked me what I thought of this model of medicine prior to embarking on my master’s degree, I would have sung words of praise for this methodological, rational, and objective approach that most expert physicians follow. However, I now understand that patients carry with them a degree of expertise to which most physicians are not privy: the expertise in understanding the personal and social implications related to living day-in and day-out with a chronic condition. As captured so perfectly by one of my participants, “we’re not specialists, but we’re almost like specialists in what we live” (3).

Theory Into Practice

What makes a practice a true practice rather than a method is precisely the fact that said approach is based upon acquired and accumulated experience. Any first experience offers the potential for anxiety of failure and/or error. However, with practice one becomes more aware of other aspects related to experiences which may have been missed previously. The acquisition of discernment, judgment, and insight is based not upon a given experience but upon what comes to us through our involvement and participation in a multiplicity of experiences (4).

…[b]ecoming experienced (practiced) involves memory, skill, and demands that we adjust what we know and expect according to what was evoked vs. provoked and what that experience has taught us. An experience of this order evolves a form of wisdom only achieved from practice (2, p. 245).

Philosophical Hermeneutics

Hermeneutical inquiry as an applied research approach can be described as the theory and practice of the interpretation of human experiences. Philosophical hermeneutics is particularly interested in the experiences of difficulty, trauma, and suffering, otherwise known as the “negativity of experience” (2, p. 51). At the core of philosophical hermeneutics is scholarship that encounters personal meaning about a topic, experience, or narrative as a common ground found in between the person-as-a-patient and the clinician/researcher. This engagement through conversation enables an understanding to surface through the act of interpreting the suffering person’s experiences. Philosophical hermeneutics acknowledges that the meaning of an experience and understanding are interwoven and can become available only through interpretation. The facts about what happened to the suffering person and the experienced events are humanized ontologically by its personal interpretation and meaning. Through conversational engagements, the person-as-a-patient and health-care practitioner open and reopen the hermeneutical space through conversations in which the possibility of deeper understanding from both the scientific (explanatory) and the philosophical (reflective) offers a wholistic approach to treating the person living with chronic pain (5,6).

Learning From the Other

Learning from individuals living with chronic pain means something different than learning about them through numbers on Likert scales or a checklist of questions. Doing the latter maintains distance between the person-as-a-patient and the health-care practitioner. Although this factual exchange may be perfectly acceptable in acute cases with routine treatments, it may not the case for individuals living with chronic pain.

Chronic pain evolves into its own narrative as the months and years pass by, the treatment objective is no longer about curing the ailment alone but rather focuses on long-term management and healing the person as a whole. These treatments require a different kind of listening, one where both the patient and the health-care provider are vulnerably open to what the other has to say. Being vulnerable and open to the other helps to provide a conversational space of trust and shared generosity fuelled by compassion and authentic engagement. Britzman delineates the differences between learning about and from the other (7). Learning about the other assumes an element of distance to view the qualities, attributes, or facts of the experience, whereas learning from the other prefaces insight, proximity, and relationship: “Learning from demands both a patience with the incommensurability of understanding and an interest in tolerating the ways meaning becomes, for the learner, fractured, broken, and lost, exceeding the affirmation of rationality, consciousness, and consolation” (6, p. 118). Furthermore, according to Levinas, learning from the other is an intensely ethical event (7). An authentic encounter with a person that is different from us may lead to a relationship of open receptivity. Being present for the vulnerable person is a transformation from their perception of isolation to unity (8). Simultaneously, this 2-way communication benefits the researcher by provoking an inward reflection of said phenomenon, thereby making the process of learning from one another more intuitive and meaningful (9). Mona Jillani, a dentist and McGill Master of Science student wrote,Therefore, learning supported by genuine connection, conversation, and reflection allow us to understand how someone comes to their suffering, specifically through their traumatic event; the personal meaning of how these events affect their life serves to contextualize their suffering. And, as we work through the experience of suffering, the researcher along with the person endeavor to understand together and share with others this meaning. This process is a treatment comprised of care, compassion, and understanding.

The process of learning the language of phenomenology and the analysis were insightful. It not only helped understand the lived experiences of my participants but also allowed me to reflect upon my own experiences. […] Guiding me through my transition from a quantitative clinician into a qualitative researcher; introducing me to the world of interpretative phenomenology and hermeneutics; an approach I naturally resonated with but was completely oblivious to before reading this work. This style of teaching has made me a better researcher, clinician, humanitarian and all in all a better human being (10).

Working Toward Understanding

The language and experience of living with chronic pain may be something distant to those who do not live with chronic pain. However, we can learn from the other person if we are open to this kind of engagement. Understanding another person’s experience of suffering is the scholarly work of philosophical hermeneutics. As expressed by Gadamer,Understanding the experience of the other means to suffer together, meaning to be available to the other person as a researcher or clinician and human being. We choose this for ourselves as hermeneutic researchers. This relationship between researcher/clinician and person living with chronic pain cannot be bound by method, positivistic objectivity, distance, or randomness. Instead, it is essential that we step onto this rough ground with the people who were or are currently suffering in order to hear their words which call for being understood.

…to understand means to come to an understanding with each other. Understanding is, primarily agreement. Thus, people usually understand each other immediately or they make themselves understood with a view toward reaching agreement. Coming to an understanding, then, is always coming to an understanding about something. Understanding each other is always understanding each other with respect to something (11, p. 180).

Misunderstanding

The process of understanding always risks misunderstanding as we work and live through our experiences, especially the ones that may disrupt and disorientate our attempts to make sense of them. This process speaks to the fine line that separates authentic understanding of that lived experience from the factual event itself. Tamas writes, “…sitting in the gore and confusion of our own suffering, my sane, readable account of loss may reinforce the expectation that our trauma ought to make sense, and if it does not, we must be somehow inadequate or failing” (12, p. 5). This is where experience from practice can evolve into wisdom as we experience, listen, learn, and remain open to other possibilities. In doing so, method is replaced by wisdom acquired through the interaction of knowledge, learning, and experience.

Language of Suffering

The hermeneutic approach to (qual)itative research and clinical practice means that we become more open to the relational qualities of our research participants or patients and the uniqueness of their experiences.

Gadamer writes,Interpretations of the suffering persons’ narratives are always limited at first because the language of their particular suffering is not familiar to us yet. The unfamiliarity lies within the in-between, which is the locus of hermeneutical understanding (11). We work to decipher this new language into words within a human context in which they become familiar to us, thereby forming an interpretation of an interpretation. However, we must be cautious so as to not change the language into words other than how they were told to us. Hermeneutically, the researcher or clinician’s humility requires openness to learn from the other and is necessary before they can begin to understand and interpret these experiences.

…Qual, meaning agony or anguish. Bohme interpreted ‘quality’ as Qual because quality is what distinguishes one existent from another. The being of each particular thing is characterized by the isolating pain or anguish which is unique to it. It perseveres in being in its own special way, gives itself form and so unfolds its own particular quality (1, p. 155).

Gadamer writes,Text from an interpretive perspective offers many opportunities for expression beyond the spoken or written word. The sketch below (Figure 1) by Rachel Szwimer is her presentation of the mask of chronic pain and represents how pain pervades almost every aspect of our lives despite our best efforts to hide or suppress this vulnerable part of ourselves. The philosophical hermeneutic researcher and clinician must recognize that language—however challenging in its raw form—is essential and necessary in order to bring the suffering narrative text back into the world. There is no interpretative certainty in hermeneutics; all interpretations are provisional, as the “text” awaits another perspective bringing it toward new and different understandings. Without a sense of what that traumatic experience was really like, how it felt, and what it means to live with it, the experience remains only as an academic or imagined understanding of suffering (1). Hermeneutic research envelops narratives to provide as close as possible the experience of suffering in order to enable interpretation of suffering to become more vicariously perceptible. Hermeneutic activity is collaborative as this process seeks the help of others to gain insightful understandings about the meanings that these experiences of trauma and suffering hold for the individual and collectively for others.

Figure 1.

Drawing by Rachel Szwimer (3). The mask of pain, we endeavour to wear a face that conceals our suffering.

Insofar as utterance is not merely an inner product of thought but also communication and has, as such, an external form, it is not simply the immediate manifestation of the thought but presupposes reflection. This is primarily true, of course, of what is fixed in writing and hence all text. They are always presentation through art. But where speaking is an art, so is understanding. Thus, all speech and all text are basically related to the art of understanding, hermeneutics (11, pp. 188,189).

“The text…if it is to be understood properly—i.e. according to the claim it makes—must be understood at every moment, in every concrete situation, in a new and different way. Understanding here is always application” (11, p. 309).

As mentioned by Manuella Widjaja (McGill Master of Science student),Problem-solving begins with understanding the underlying phenomenon. Compassion is a powerful tool when attempting to understand and learn from a patient’s experience and narrative. In practical terms, the science of medicine and art of healing require a whole person-centered care approach, being a practice that requires health-care providers to pay close attention to treating the patient as a person and focus on healing the whole person (14). Therefore, the addition of philosophical learning can help achieve a balance between physical and metaphysical dimensions of health, thereby allowing the health-care provider to recognize which subsequent interventions, support, and guidance are necessary to best manage chronic health conditions (14).

My biggest hope for you as a reader (of my thesis), is that you appreciate and acknowledge the bravery behind the smiles that they tirelessly harness every day. In reading their accounts, you will soon realize the weight that chronic pain has—and continue to place on these adolescents; in their case, plans are interrupted, and goals are dismissed, no matter how important. They need an advocate—a cheerleader if you will— and I want to be that person for them (13).