Author Eivind Hasvik
(#5 in the Whole Person reflections series)
Gazing through my window, I’m enriched by a muted but beautiful December twilight-palette. The remains of autumn covered by a thin layer of snow. It’s said that every culture has its own sense of the different hues. I’m reading a beautiful passage in White by Kenya Hara about the traditional Japanese way of naming colours. Contrary to the modern way of categorizing a given spectrum of light, such as greens, magentas or yellows, it’s said that red, blue, white and black were the only basic colour adjectives in 8th century Japan. The tradition was not to classify, but to describe and texturize, capturing the seasons and surroundings. This narrative heritage is beautifully documented in the book The traditional colours of Japan.
I’m imagining a metaphorical link from all this to the difficulties of describing experience—sensations, emotions, pain or pleasure. I recently interviewed a number of people all ‘sharing’ the same ICD-10 diagnostic code, hoping to bring forth their thoughts about a questionnaire to grade pain, between 0-10. Although this was a fairly wordy and ‘multidimensional’ questionnaire, it’s still about classifying suffering—the end goal being to standardize expression. Still ruminating on the issues explored during the September CauseHealth whole person seminar, the interviews left me with an important reminder of just how unique our experiential subjectivity is and what potential powers lie in context.
One ‘advantage’ of quantitative studies, with their strict inclusion and exclusion criteria, is the highly homogeneous group of people one is left with. Homogeneous from a biomedical classification standpoint—that is… When everyone is ‘quite similar’, the wondrous differences become all the more tangible. Not two remotely comparable narratives emerged. Some felt the questionnaire as helpful, as a way of qualifying their story. Others felt it limiting. Most found it difficult—especially the between 0–10 part. What grabbed my attention was the distinct ways of understanding, relating and reacting to the questionnaire. Variation resulting in more than irrelevant ‘noise in the data’. All exceptions from ‘regularity’. Almost all needed a larger narrative to explain just the basics of their problems and how the questionnaire ‘fit’ in their story. It’s perhaps trivial to simplify the richness of colour—but surely it can be critical when we do it with human suffering. Descriptors are at best crude approximations to a very small part of a huge experiential ‘range’.
It’s worth noting; almost everyone felt positive towards using it… Which touches another matter I think; of how we as healthcare providers perhaps condition our patients to translate stories to measurable ‘numbers’ for our convenience. Even after completing the questionnaire, the terms sort of stuck for a while. Descriptors hijacking the personal voice. I’m afraid of the extent similar phenomena impacts us as therapists. When a clinical phenomenon is placed in ‘this or that box’ it shapes the way we act. Classification systems have probably hijacked the ‘choice of palette’ in my reasoning more times than I like to admit.
Some loss in translation is, of course, unavoidable when putting experience into words—for most of us non-poets at least. And no matter how masterly a writer’s words describe a phenomenon, it will always represent something other. That’s not to say it doesn’t capture the phenomenon correctly. The descriptions in The traditional colours brings forth more than I perceive by just viewing the colour itself—as is the case with art, music, literature or any good ‘abstraction’. And for experience as well. Imagine the endless spectral variation between the colours violet and green, all lumped together in one category—blue. A nice starting point for painting a sky, but if you want to convey meaning, probably not enough. As Van Gogh said, ‘there is no blue without yellow and without orange’ (no wonder perhaps, that my skies never look good). I imagine the same applies to most diagnoses as well. Still, we do this to patients all the time and leave it at that. Suffering is complex. Interacting is complexity in action—and probably only captured by a whole person, full colour-spectrum, approach. It is still only the singular narrative that reflects the reality of the subjective.
All these issues are of course a given with any classification, and I do believe judicious use can give important narratives by itself—but can be harmful when left without scrutiny. Bowker and Star in their book Sorting Things Out, highlight the inherent danger in how categories can be invisible to us, become embedded in our practice, and I think even embodied in us. Perhaps a kind of ‘we are what we classify’. As they argue; to classify is human and unavoidable, but “each standard and each category valorizes some point of view and silences another.” It’s therefore a moral issue to make an effort to reveal these structures.
The people invited to these conversations were asked explicitly for their help, their insights and their feedback. As I’ve always been interested in ‘individualizing’ context, the power inherent in this simple swapping of roles was striking. After an initial bewildered 3–4 minutes, our improvisation took form. Being outside the setting of a usual consultation, some unusually rich medical history-descriptions emerged, and this without any prior acquaintance. Perhaps because none had the feeling of judgement. The questionnaire was a mutual endeavour of exploration. No strings, or expectations, attached. As Hara writes: “…, emptiness provides a space within which our imaginations can run free, vastly enriching our powers of perceptions and our mutual comprehension.” Sorry, going a bit too zen—I know—, but I do think there is something to it. The difficulty of uncertainty in medicine is somehow related to situations where the real world does not fit into our preconceived box. The box creates ambiguity. Without it uncertainty can be transformed into novelty and possibilities for rewarding insight.
Same diagnostic code—all unique. Life-pain, good pain, surprising pain, lost pain, unknown pain, weird pain, absolutely horrendous pain, family pain, bad pain, and even funny pain (I could go on, but I feel another blog post is «emerging» here). Just as a poetic description can unfold hidden meaning and make a colour more ‘valuable’, the right relational context has the same power. For a few people, the interview even seemed deeply therapeutic—including me. ‘Gained in translation’.
Hara K. White. Lars Müller Publishers, 2010.
The Traditional Colors of Japan. PIE International, 2007.
Bowker GC, Star SL. Sorting Things Out: Classification and Its Consequences. MIT Press, 2000.