‘Getting back to the matters’: Why the existential matters in care
Kathleen Galvin
Abstract
My scholarly journey has been and continues to be guided by wanting to really understand and communicate the significant experiences of others and believe that this kind of knowledge can lead care and help services. Further, meaningful experiences, such as when people 'have to go through something', can easily get lost in systems and technologies, adding to the terribleness of the experience of those we are caring for, but also obscuring directions that practitioners could take in delivering humanly sensitive care. I hope that this editorial offers a kind of resonance that opens up a linking of the 'I' to the 'thou' – our common humanity, that is a red thread through my work. I hope that what is offered here is a touchstone to my values and draws coherence across the ways in which I have been thinking about and trying to understand the world of caring. I would like to warmly thank the Editorial Board for their invitation to participate as Editorial Board member of SJCS and to contribute this discussion paper. First, I will say a little about the foundation given by lifeworld theory and where it comes from; in this part, I will introduce what I mean by the relevance of the existential and why we need to get back to the matters, back to the existential issues, standing on the shoulders of giants from continental philosophy. Secondly, I will point to the complexities of practice, how practical wisdom is central and how philosophical ideas about the good (ethics), the true (knowledge) and the beautiful (aesthetics) are integrated in the kind of practical responsiveness that comes from being attuned to a foundation that sensitises practitioners to the existential [1]. Here, caring involves a certain kind of attunement that relies on sensitisation of what people go through and a certain kind of openness to the other. Building on this earlier work that metaphorises the true, good and beautiful as head, hand and heart, my purpose is to make a case for how we know what to do in caring practices. In other words, thinking about the 'head', in my work I am attempting to offer a vocabulary and theory for positively understanding the existential issue of well-being and its absence. For the 'heart', a pointing to arts-based ways of engaging the empathic imagination in presenting well-being and its absence, suffering. And 'hand': actionable implications that may arise out of this. Third, I conclude with how these ideas are one way to remember the essence of care, rightly taking care back to the matters of human well-being, freedom, vulnerability and dignity, with the implications of all of this for the essence of health-related caring. Where knowledge is increasingly contested, and our professional notions about evidence seem to evolve as narrower and narrower, sometimes by the necessities of science and technological development, and sometimes to do with the problems of our culture at large, it seems to me that there is no more an urgent time to 'get back to the matters'. Husserl the founder of phenomenology made this his great task – his project of phenomenology guides us to get back to peoples everyday experiences and to understand human experience in the way that it is seamlessly lived. Edmund Husserl, precisely 104 years ago, first employed the term the lifeworld to set out his ideas about the physical sciences and the human sciences: the sciences of the human spirit. His attempts are set out in two key texts, he uses two terms 'the surrounding world' in his book Ideas II and in his later 1917 text, Crisis of the European Sciences, and he refers to the spatiotemporal world of things as we experience them in our prescientific life and life outside our science (Crisis 141 (138)). This is a world that is not only about objects perceived through the senses, but rather of objects that are valuable, objects that are beautiful, objects that are significant and meaningful and objects that are dangerous. It is the world in all its richness, as we experience it, and it corresponds with our everyday involvement and awareness of our involvement with it. Just as a fish takes for granted the water in which it is swimming, we too, in everyday ways take for granted all the relations we have in the world in time, in space, in body, and with others, most often without thinking about them. An important and well-rehearsed point here is that we are not just physiological collections of things that require maintenance and fixing, but we live in the seamless flow of happenings that are immediate and sometimes unnoticed by us, for example the experience of 'fresh air, natural light, quiet, sleep and rest, comfort, activity and movement, contentment, sense of place and continuity and sometimes we are assailed by happenings, as in the experience of loss of dignity, anguish, humiliation, pain, anger, artificial light, restlessness, thirst, sleeplessness, discomfort, being confined to bed'. A world that is humanly lived, this is the lifeworld. The seamless experiential happenings of the everyday that constitute how we are in ourselves, our sense of our well-being, its absence, our sense of dignity, or indignity and our sense of our vulnerabilities. It is these matters that we need to draw attention to. 'The matters' concern for example: Otherness, limitations of human life [facticity] and how suffering, well-being and dignity are real things experienced by people. Here, I am following Husserl where he thought considerable illumination about the nature of physical science could be achieved by attending to how it arises out of our everyday nontheoretical dealings with the world: A focus on what things are, their whatness, he proposed a scientific discipline, one of slowing down, taking a step back from what we already know, to attend to the things in themselves. What are these things in themselves relevant to care? All the ways in which we humans have limited freedoms, are frail and experience kinds of vulnerabilities but do not notice until something goes wrong, from a body or body parts that do not function as before through to having to live facing one's demise on a daily basis. These are issues that the existing qualitative research literature in health is replete with. And as participants in the human condition, we all know something of these. These are the matters that have drawn my interest towards what can possibly guide care in these situations that transcend or cut across all our diagnostic and specialist categories of the professional world, and these are the matters that emerge as super important within a now vast qualitative literature base. We are afforded the possibility of felt knowledge, of what something might be like from the inside. But what kind of evidence for care do we need to apprehend and respond to ruptures in the lifeworld, such as these? In reading lifeworld oriented research from many allied scholars you might notice how deeply the rupture of the lifeworld goes. My key point is that an evidence foundation for care that begins in the lifeworld is complex enough to do justice to meaningful understandings of human life, with all its joys, dignity, its sorrows and vulnerabilities. 'The matters' such as these can be addressed by the growing body of qualitative research, and particularly phenomenological research. For example, there are very many lifeworld studies that point to absences of well-being and deep lifeworld rupture that could be named as kinds of suffering, for example where there is no belonging – sense of exile, sense of aversion and sense of alienation. Where there can be no sense of settledness – sense of agitation, no well-being in spatial ways such as sense of imprisonment, no well-being in temporal was such as a sense of a blocked future, situations where the present eludes, and in embodied ways, a sense of stasis and exhaustion and so on, to name just a few emphases here, but there are many more. Responding to human life, also requires an evidence base that includes 'the evidential'. I say this because to evidence the human condition must be to provide an account of the modes of existence, and when the lifeworld is ruptured new modes of existence are manifest. Qualitative research teaches us that these modes are important to attend to in care if care is to be caring. The evidential is also important because it includes the constant flux and movement of the world, and appreciates both the uniqueness and banality of things and situations. To understand human life is to apprehend both its immensity and its ordinariness, and because these ideas are of relevance to all social science, to use some words from anthropologist Nigel Rapport, 'human life is an inward personal adventure, of each in the face of the other' [from his 2017 text 'Being undisciplined: Doing Justice to the immensity of human experience']. Some of my work has also been concerned with drawing knowledge from the arts and literature to provide language that is qualitative and resonant with human experience, that can do justice to this immensity, and further, we can draw help from philosophies of human qualitative experiencing such as phenomenology and existentialism in this regard. Philosophical theory [such as the work of Husserl, Heidegger, Merleau-Ponty, Levinas, Buber, De Beauvior, Stein and others] can act as a navigation and ground to build a knowledge foundation that is deep enough to shed light on what constitutes the deepest experience of well-being, and its absence, the deepest experience of suffering to guide what can be done in practice, and can also benefit from wide ranging interdisciplinary perspectives, for example as applied to wellbeing [3]. In answering the question why we need the existential in care, my focus is on two key areas: Firstly, the need to develop a vocabulary of existential knowledge – we are still only in the beginning phases of articulating existential phenomena that can guide caring practice. Existential knowledge refers to the predisciplinary concerns of the meaning of living – the meaning of living through significant life conditions is important to understand when engaged in meaningful caring. Qualitative research has made an important contribution but it now needs to be deepened and systematised. We do not yet have a positive language for well-being nor a holistic language for its absence. In considering the depth and details of what people go through holistic lived phenomenon come into view – such as sense of homelessness, sense of abandonment, sense of assailed dignity, sense of fragmentation, sense of roomlessness, sense of persecution, sense of stasis and exhaustion, bodily discomfort and pain, even torture to name a few kinds of wellbeing absences. And existential knowledge about them is more than just their psychology or sociology, something which Husserl articulated in the Crisis of the European Sciences. So we need an existential, more qualitative vocabulary. Secondly, the need for a kind of complex knowledge that is embodied, ethically sensitive and sustained for caring [4]. Although the content of knowledge is important (e.g. understanding different kinds of dignity or different kinds of well-being, this is technical knowledge that can be metaphorised as knowledge for the head), we also need knowledge of its aesthetic, its feel, what can be metaphorised as knowledge for the heart. And we also need actionable potential, which can be metaphorised as the hand. So knowledge of the head, hand and heart, of an existential phenomenon such as well-being, ruptures in the lifeworld or human dignity require existential resources that are up to this task. Further, we can't just do care, in an instrumental way, we need 'to be' caring. So as part of my scholarship journey, I have been attempting to point to existential resources that are up to the task of guiding' the head, the hand and the heart of care, thereby addressing human existence. I argue that care can be sensitised by what people go through and that such understandings can deepen understanding at 'common humanity level'. They can point in palpable ways to draw attention to 'what it is like', this can give directions for practice. It can also lead to empathic responses, and it is all this that can keep 'open' a capacity for care [1]. This has been a focus of co-authored work with Les Todres [1, 3, 5] where we develop a theoretical framework to describe existential well-being for understanding the deepest possibilities of well-being and also it's absence, suffering. A foundational point is that there is always some freedom, even if limited and some vulnerability in any condition, and always some possibility for moving forward as well as for settling in any condition. Through our collaboration between nursing and psychology, we point to 18 kinds of well-being that might be encouraged within practice, (adventurous horizons, at- homeness, abiding expanse, furture orientation, present centredness, renewal, mysterious interpersonal attraction, kinship and belonging, mutual complementarity, excitement, peacefulness, mirror-like multidimensional fullness, a sense of 'I can', a sense of 'I am', layered continuity, vitality, comfort, grounded vibrancy, although there may be many more. When these are dropped out or obscured, 18 kinds of suffering, that can act as a sensitising resource for humanly sensitive care. Our existential theory of well-being has three core emphases, one the one hand mobility or sense of possibility and on the other, dwelling or sense of settledness and peace, and a third when dwelling and mobility are intertwined which constitutes the deepest possibility of well-being. We used the basic structures of human experience as described by Husserl, Heidegger, Merleu Ponty and Medard Boss to guide our reflective work in this regard (see, e.g., [1,5]. And we can also imagine when dwelling and mobility are absent there can be no vitality, no sense of at homeness spatially or in the body, or with others. When a sense of mobility either literal or imagined, or a sense of dwelling, literal or imagined, are both absent there can be no vitality, no at homeness, no present centredness, no kinship or belonging, no peacefulness, no comfort, no sense of I am me, no sense of adventure. These are the deepest possibilities of suffering, but there may be many variations that are not as extreme. We can name kinds of suffering when both a sense of dwelling and a sense of mobility are absent. These are not things in themselves, they are emphases and there may be many variations but they open up the possibility of an existential vocabulary that can attend to 'the matters'. We can also name kinds of well-being, also as emphases, that can give directions for care practices. An existential qualitative vocabulary that points to 'the matters', and resources to 'imagine this', place emphasis on aesthetic knowing. In other words what it is like for the other and can open up the possibility of stepping into another's shoes and can be used alongside research findings, to help keep attention on 'the matters' in practice, and might resource empathic imagination. What do I mean by caring as attunement? If care is to address human existence then it needs: The kind of knowledge that is not already separate from ethics and action rather it integrates knowledge, ethics and action. Is a certain kind of attunement, not a technical top down prescription but rather a sensitising foundation that can provide such attunement to what vulnerable people need nurses and allied health professions to attend to. Here, we can look back to philosophy and ideas about a way of being in which knowing, doing and valuing are fundamentally inseparable [1]. Aristotle's idea of phronesis is a kind of knowledge that is already not separate from ethics and action. Knowledge as phronesis, practical wisdom is distinguished from the knowledge for making things – techne, and it can address a plurality of values. This is about actionable knowledge and the kind of practical responsiveness of the hand and is already integrated with specialised technical knowledge or theory (the true); aesthetic knowing that may be sensitised by 'imagine this' (the beautiful) and can address the complexity of living situations, enabling ethical sensitivity when it is difficult to act with 'top down' certainty. All this makes up a certain kind of integrated basis for getting the right fit in care that practitioners intuitively know something about and this reflects a certain kind of attunement. Judgement based practice [care] draws on all our human sensitivities, including our emotions, and integrates background understandings, felt meanings of a situation, imaginative scenarios, prior experiences and perceptive awareness. Background understandings involve not a set of logically ordered rules about what to do and when to do it, but is a holistic web of understandings about how to go about and get things done in the world [p.84]. While useful and essential, protocols don't always guide us as to what to do in complicated human situations, we need more than just technological solutions to give humanly sensitive service. This judgement based approach integrates the kinds of understandings that are required 'to walk in another's' shoes', can be resourced by imaginative capacity, can make use of the integration of technical expert evidence and personal understandings with imaginative capacity. Three kinds of knowledge are already integrated here: These three emphases, hand, head and heart cannot be absolutely separated from each other, and are already fluid and integrated in practice, as all practitioners intuitively know. And all of this strikes at what is needed for a capacity to care [6, 7]. So in summary, my work is attempting to offer vocabulary and theory for positively understanding the existential issue of well-being and it absences (knowledge for the head), and I have been trying to find ways to facilitate engagement of the empathic imagination [1, 4, 8, 9]. Some might ask if attending to the existential is a luxury in the context of a curative journey that gets a person from A to a better B. Well, my answer is no because if we do not attend to the matters, especially when there is a deep rupture of the lifeworld, we can add to human suffering of people in our care, and we have qualitative research literature of just that. Further, there is an important point about how we know what we know, and why this existential knowledge base is needed: Science gets to its necessary work when it abstracts from the immediate and intuitive world that we live in, referred to as the lifeworld. In the interest of a necessary objectivity and precision the lifeworld is stripped of all values and context. Now I want to be really clear that this does not mean I am disparaging hypothetico-deductive science, it has its purpose in distinct realms, nor is this an attempt to argue that 'anything goes', but rather, I am attempting to point to some problems that are pertinent in worlds that are teeming with all the vulnerabilities of human life, these worlds are where professionals in health care and in social care practice are up close to human vulnerability, and we have a problem with evidence if we conceive of it in only narrow hierarchical ways. This is because of what this might mean for a knowledge foundation for practices that can be meaningfully termed 'caring practices'. If we don't attend to these matters then we are at risk of dehumanising situations and of overly objectifying people, when what we need is to engage with a range of ways to expand the evidential and a range of kinds of knowing that are in the everyday and which are relevant to everyday lives. She says: 'The myth to which is especially want to draw attention to now is the one that credits science – physical science with a rather odd central role in our lives. This myth pictures our world as a vast mass of physical objects that are being observed at great distance by an anonymous observer through a huge array of telescopes. It is not by chance that the observer himself is anonymous, and indeed invisible, because he is not a proper object at all. Like the telescopes he is simply part of the apparatus that is needed to observe and record this endless range of facts. The whole process of observing and recording is called Science and it is seen as constituting a central purpose of human life' (p.4) Thankfully, human kind has successfully made use of science and technology to successfully master great threats, but something of our human selves is at great risk of becoming fragmented, or obscured altogether if this is the only way we are to look at ourselves. At its extreme, this is a problematic stripping out of our very selves and the metaphorical water in which we swim. If we strip out the essence of human life and we enframe it in more dry ways then something fundamental gets covered over, or may even be forgotten altogether. So rather than a luxury, my argument that we need the existential, particularly in the caring arena and this is vital, it should be a primary concern in health and social care. Paying attention to what it is like and how people experience situations, and naming that is a resource that keeps open a capacity for care and it allows us to do justice to the immensity of human experience in our practice and research, particularly when so many pressures threaten and can erode this essential focus. It may be a way to sustain a capacity to care in the face of inevitable instrumental forces. So now to draw to a close and to conclude with what have I been attempting to point to: This is a value-based agenda that feeds and nourishes a capacity to care. And it is also relevant for our culture at large. Deep respect for otherness, a sense of what life is like for others is an important sensitising agent in all our culture, and in any academic pursuit that has relevance for practice and in our world where human beings matter.