The placebo as performance: speaking across domains of healing

Placebo From an Enactive Perspective

Due to their complexity and variability, placebo effects remain controversial. We suggest this is also due to a set of problematic assumptions (dualism, reductionism, individualism, passivity). We critically assess current explanations and empirical evidence and propose an alternative theoretical framework-the enactive approach to life and mind-based on recent developments in embodied cognitive science. We review core enactive concepts such as autonomy, agency, and sense-making. Following these ideas, we propose a move from binary distinctions (e.g., conscious vs. non-conscious) to the more workable categories of reflective and pre-reflective activity. We introduce an ontology of individuation, following the work of Gilbert Simondon, that allow us to see placebo interventions not as originating causal chains, but as modulators and triggers in the regulation of tensions between ongoing embodied and interpersonal processes. We describe these interrelated processes involving looping effects through three intertwined dimensions of embodiment: organic, sensorimotor, and intersubjective. Finally, we defend the need to investigate therapeutic interactions in terms of participatory sense-making, going beyond the identification of individual social traits (e.g., empathy, trust) that contribute to placebo effects. We discuss resonances and differences between the enactive proposal, popular explanations such as expectations and conditioning, and other approaches based on meaning responses and phenomenological/ecological ideas.

Subjunctive medicine: A manifesto

Despite the manifest advantages of modern medicine, many aspects of the experience of illness and healing are not reducible to bodily dysfunction and its restoration. Clinicians and researchers now largely understand that medical practice needs to accommodate a dual aspectivity of the physical body and the lived body. This is increasingly operationalised through the framework of person-centred care, focussed on initiating, integrating, and safeguarding the partnership between the patient-as-person and the clinician-as-person, informed by a narrative perspective on selfhood. In this manifesto, we develop the narrative focus of person-centred care into an alternative framework for medical practice - subjunctive medicine - grounded in ritual efficacy and an explicit appeal to the imagination. We argue that the healing effects of a clinical encounter are reliant on the subjunctive co-construction of a temporary shared social world for a particular purpose. More explicit awareness of the subjunctive nature of the clinical encounter may expand clinicians' opportunities for healing, whilst fostering resilience. We further suggest that, to be fully actualised, subjunctive medicine requires a shift towards conscious appreciation of the nature of subjunctivity at the social level; a social reawakening to the power of the imagination in modern medicine.

Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

Subjective concepts of chronically ill patients using distant healing

Distant healing procedures consist of benevolent intentions, often taking the form of prayers for a patient. Despite inconclusive evidence regarding distant healing, prayers are a widespread health-related technique. We studied subjective concepts of distant healing in 17 patients suffering from chronic fatigue syndrome and multiple chemical sensitivity who were given distant healing during a randomized controlled trial. We applied reconstructive interview analysis when analyzing the results. The overall theme was the tension between mainstream medicine and the immaterial healing procedure. Several components highlighted this tension: (a) patterns of legitimizing the use of distant healing, (b) distant healing and the social setting, (c) integrating distant healing into their belief system, and (d) reconstruction of effects by means of hindsight. The interviews showed that patients felt the need to legitimize having tried distant healing. They had to bear the full ambiguity of biomedicine being in competition with distant healing, though also experiencing distant healing as giving support.

From parallel to intersecting narratives in cases of sexual assault

Restorative justice alternatives to criminal justice are designed to balance the needs of victims, offenders, families, friends, and the community at large to achieve social justice, repair of victims, and deterrence of crime. In the model we evaluated from RESTORE (Responsibility and Equity for Sexual Transgressions Offering a Restorative Experience), each offender and victim received individual services and met in guided conferencing to mutually determine reparative actions for the offender. At the exit meeting, the offender, as the responsible person, read a written apology to the survivor/victim. In this article, we analyze the expression of empathy in the apology, in which the initial mitigation of responsibility in early documents was replaced by acknowledgment of harm to the survivor/victim and acceptance of responsibility for the assault. Those accused of felony rape and those targeting a visible person in cases of misdemeanor indecent exposure expressed greater regret and remorse than offenders of indecent exposure with an indeterminate victim.