A Shared Reading, Different Ways of Seeing

Recently, I shared three papers by Richard Hovey with colleagues in PRISM. Read together, they seemed to trace an intriguing line of thought about narrative, chronic illness and healing.

In an earlier paper with Jim Paul, Hovey explored the relationship between telling and listening. When chronic illness disrupts a person’s previous sense of self, the significance of a story may lie not simply in the information it contains, but in what becomes possible between teller and listener. [1]

Nearly a decade later, writing from his own experience of severe chronic pain, Hovey described thinking itself becoming chaotic. Importantly, that chaos did not first need to be tidied into a coherent account. It needed somewhere safe to be expressed. Through conversation, writing and reflection, another way of living with pain might gradually become imaginable. [2]

A later paper, written with Khayat and Feig, developed these ideas through the distinction between Chronos and Kairos: measurable clock time on the one hand, and lived time on the other — including the time between consultations, in which suffering, reflection, relationships and changing meanings continue to unfold. [3]

What stayed with me across the three papers was a possibility: perhaps healing sometimes depends less on producing a better explanation of someone’s experience than on creating conditions in which that experience can be spoken and heard, and in which different meanings or ways of living may become possible. I shared that reflection with the PRISM group. What happened next was more interesting than I had expected.

A space for ideas before they are ready

Myriam connected the papers with a project she was working on, exploring how knowledge exchanged between GPs and patients evolves and changes over time, but also how it may be lost between consultations. She reflected on the notion that chaotic ideas may need a safe space in which they can be shared before they can become narratives. From there, she turned the question back towards PRISM: could PRISM itself be one such space?

Who gets to interpret?

Anna then paused over one word in my original reflection: interpreted. If we create a space in which a patient can speak, who should do the interpreting? Drawing on Winnicott, she reminded us of the danger of the clinician’s own need to explain. Winnicott reflected on how his desire to interpret could sometimes prevent or delay a patient arriving at understanding for themselves.[4] Anna described one of the challenges of clinical practice as learning how to ‘get out of the way’ of patients finding their own words and stories, while still fulfilling our normative responsibilities as doctors. The question had subtly changed. It was no longer only about creating space. It was also about what we do — and do not do — once that space exists.

Openness to something not yet known

Junichiro connected the discussion with Hinton and Kirmayer’s ‘flexibility hypothesis’ of healing. [5] Their account considers how healing practices may shift a person towards greater openness to new ways of being. That added another possibility. Perhaps creating space does not mean guiding someone towards a particular new interpretation. It may instead mean allowing enough flexibility for something not yet known to emerge. This seemed to resonate with Anna’s concern about agency: change may matter precisely because its destination is not fully determined in advance by the clinician.

Whose knowledge counts?

Molly brought another perspective from her PhD work on epistemic injustice in patient and public research involvement. For her, the clinical urge to interpret, label or ‘fix’ is also about power. When a patient’s lived experience is rapidly translated into medical language, whose account is given authority? What happens to aspects of experience that do not fit easily into the categories clinicians already possess? She connected this with Havi Carel’s phenomenology of illness, Gabbay and le May’s concept of mindlines, Arthur Frank’s work on illness narratives, and Iona Heath’s account of the generalist doctor as a witness to suffering. Together, these perspectives raised questions not only about how clinicians interpret experience, but also about when our role is to act, when it is to listen, and how we avoid allowing medical knowledge to crowd out the patient’s own account. Her response shifted attention again: from interpretation itself to the knowledge and power relations surrounding interpretation.

What happens when continuity is missing?

Joanne then introduced a personal experience that complicated the conversation in another direction. After many years without contact with a particular specialist service, she recently attended a specialist consultation. There was little continuity in terms of relationship, management or even information. Yet she experienced it as one of the most profound generalist consultations she had encountered personally. She described a convergence of narratives: her own, the doctor’s and those of a specialist team. Existing narratives were brought together, continued and intertwined, allowing something new to emerge. Her reflection opened another question for us: what exactly is continuity doing when it supports good care, and what may still be possible when continuity with the same clinician is absent? We did not try to answer that question in the email thread. Perhaps this is something worth pursuing through our research and collaborations.

What became visible through the conversation

Looking back, what strikes me is that we did not arrive at a single interpretation of Hovey’s papers. Myriam noticed space. Anna noticed agency. Junichiro noticed flexibility and openness. Molly noticed epistemic power and whose knowledge counts. Joanne noticed the convergence of narratives. None of these responses simply repeated what was already in the papers. Each emerged from a different clinical, academic or personal position. The original reflection changed as it travelled. That may be one small example of what PRISM can offer.

International and interdisciplinary learning is often imagined as an exchange of knowledge: learning about another healthcare system, another theoretical tradition or another way of practising. But difference can do something else. It can change what becomes visible in something we thought we already understood. A shared paper, clinical experience or unfinished idea can become a starting point. Different people notice different things, question different assumptions and bring different forms of knowledge into view. In the process, we also begin to learn something about one another: the questions that draw our attention, the traditions we reach for, and the particular strengths each person brings to the group. Perhaps the aim is not to reach agreement quickly. Sometimes it may be enough to create a place where an unfinished idea can travel, encounter other ways of seeing, and return changed.

Written by Dr Koki Kato.

Contributors: Dr Myriam Dell'Olio, Dr Anna Beug, Dr Junichiro Miyachi, Ms Molly Megson, Prof Joanne Reeve

Note: AI-assisted editing tools were used to enhance the clarity, structure and format of the text. The ideas, reflections and interpretations are drawn from the original contributions of PRISM members.

References

1. Hovey R, Paul J. Healing, the patient narrative-story and the medical practitioner: a relationship to enhance care for the chronically ill patient. International Journal of Qualitative Methods. 2007;6(4):53–66.

2. Hovey RB. Cathartic narratives for chaotic thinking. CMAJ. 2016;188(17–18):E543–E544.

3. Hovey RB, Curro Khayat V, Feig E. Listening to and letting pain speak: poetic reflections. British Journal of Pain. 2018;12(2):95–103.

4. Winnicott DW. Playing and Reality. London: Routledge; 2005.

5. Hinton DE, Kirmayer LJ. The flexibility hypothesis of healing. Culture, Medicine, and Psychiatry. 2017;41(1):3–34.

6. Carel H. Phenomenology of Illness. Oxford: Oxford University Press; 2016.

7. Gabbay J, le May A. Practice-Based Evidence for Healthcare: Clinical Mindlines. London: Routledge; 2011.

8. Frank AW. The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of Chicago Press; 1995.

9. Heath I. The Mystery of General Practice. London: Nuffield Provincial Hospitals Trust; 1995.