by Stephen Tyreman
This is an extract from a recent article written by Stephen Tyreman for the International Journal of Osteopathic Medicine. The full text can be found here.
Understanding what person-centred means is much more complex and multi-factorial than I once assumed. It is not merely a question of considering a person’s individual needs and concerns and putting them first. It is recognising that human beings face up to the challenge of illness, pain and disability differently from how we might understand and seek to correct a fault in a car, say.
It also raises the question of how we understand it for our patients. The pain or disease that comes “out of nowhere’” as it did for me (and as it does for much LBP) to threaten our sense of identity and challenge us to re-evaluate who and what we are, and what our body is, is as challenging as Semmelweis’s evidence was to usual medical practice in 19th Century Vienna.
The cognitive dissonance and confirmation bias that Kahneman and colleagues have drawn attention to in decision-making is the inadequate, human response to this contradiction. They have their equivalents in how we develop our sense of self and the ways that illness, among other things, disrupts and challenges it. Being person-centred entails recognising and integrating these into care for patients. That is not to say that we must go all-out to get patients to understand the science of what has happened to their body; in fact it is explicitly not just that. It is somehow to help them to establish new norms and to accept a different and hopefully, enhanced sense of self–a new narrative that incorporates the new health ‘evidence’ in a way that is meaningful and which can provide a foundation for going forward. Semmelweis assumed his colleagues would adopt a new narrative of maternity care that incorporated cleanliness and hygiene. But for them it was a narrative that did not fit with their older, familiar, more dominant one. It was a narrative that not only did they not understand, they felt threatened by. The authors of The Lancet Series on LBP are asking practitioners to support patients in generating a different kind of narrative that focuses on living well and not on correcting body faults.
Before my diagnosis was made I experienced myself as ‘me’ in a way that I had taken for granted throughout my life. Of course I knew that I was getting older and that eventually I would die, but that was an abstract concept, in the distance, to be faced eventually; it was unlikely that anything significant would change in a long time. I have lived healthily and demographics suggested that I should have at least another two decades to go; “sixty is the new forty” and so on. That was the story I had told myself. Suddenly new, threatening facts are making me re-evaluate who I am, what I am, how I relate to the world and to other people, what it means for my future, even my understanding of future. This new ‘evidence’ is not part of the old story of ‘me’, it does not fit, it isn’t comfortable and it holds the ultimate threat. A new person will emerge from this as a new person emerges from any challenge we face and work through. The usually ignored question for the practitioner is how we support a patient in this aspect of their healing. This, I suggest, is what it really means to be holistic and person-centred.
To be person-centred in healthcare is to recognise that although we know that such things as eating healthily, exercising, getting sufficient sleep and so on, are good for us, we can find them almost impossible to achieve when the world around us, the world that provides the meaning-structure for our lives, demonstrates and offers something else that is easier, comforting and unchallenging. Pain, illness, disease and impending death are some of the greatest challenges we each face. Unlike the Viennese doctors we cannot ignore, avoid or defer those challenges; they force themselves on us. The practitioner’s task is not merely to explain and treat, but to provide support and insight into the meaning of illness experiences in order to enable a patient to develop a better, life-enhancing narrative and become a more whole person.
Tyreman, S. (2018) Evidence, alternative facts and narrative: A personal reflection on person-centred care and the role of stories in healthcare, International Journal of Osteopathic Medicine, 28: 1–3.
Causality, Complexity and Evidence in Health Sciences 