A SEARCH FOR “PRACTICAL WISDOM”?

Until such a new paradigm and language truly emerge, a potential guiding principle for psycho-oncology's investigations into “what helps?” when living with the impact of cancer could be drawn from recent research on Aristotle's notion of phronesis, or “the virtue of practical wisdom,” in practitioner and research practices (Kinsella, Reference Kinsella2006; Reference Kinsella, Whihteford and Hocking2012a ; Reference Kinsella, Kinsella and Pitman2012b ; Polkinghorne, Reference Polkinghorne2004). Kinsella (Reference Kinsella, Kinsella and Pitman2012b ) suggested that phronesis “emphasizes reflection (both deliberative and that revealed through action) as a means to inform wise action, to assist one to navigate the variable contexts of practice, and as directed toward the end of practical wisdom” (p. 35). Are patients perhaps best served by researchers and clinicians working together to elicit such practical wisdom from the crucial experts, who are those living with the impact of cancer, rather than debating about which conceptual spaces have been occupied by which academic research disciplines (Salander, Reference Salander2014, p. 1)?

IS PSYCHO-ONCOLOGY ON A “SOUL QUEST”?

Edmund Husserl (b. 1859–1938) vigorously challenged the abstracting tendencies in objectivist sciences predicated upon the mind/body dualism by introducing phenomenology as both a science and a philosophy aimed at “elucidating lived experience” (van Manen, Reference van Manen1997, p. 25). Van Manen (Reference van Manen1997) suggested that such inquiry offers “plausible insights that bring you in more direct contact with the world” (p. 9). Smythe and coworkers (2008) contended that a hermeneutic-phenomenological approach grounds academic discussions in a focus on the experience of individuals that “resists being pinned down, refuses to be a set of steps, is enacted differently by each one of us, and yet shares a common quest” (Smythe et al., Reference Smythe, Ironside and Sims2008, p. 1390). Moreover, medical historian Donald Bates (Reference Bates2009) suggested that “medicine is the domain where soul and science are most uncomfortable, and yet most obliged to interact” (p. 70). Indeed, human interior life as well as the day-to-day “embodied reason” (Polkinghorne, Reference Polkinghorne2004) within clinical judgment in a clinician's unpredictable daily practice has a tendency to refuse being “pinned down” and rarely conforms to the “set of steps” required by academic conceptual analyses or even in evidence-based clinical guidelines (Fenwick, Reference Fenwick2014). Perhaps due to psycho-oncology's interests being situated in cancer care where the intangible realm of human interiority meets the biomedical evidence-based paradigm, such debates might reflect the uncomfortable interaction between soul and medicine.

With cancer rates on the rise (Statistics Canada, 2014) and its impact touching us all deeply, both professionally and personally, a new psychology healing the Cartesian split of mind and body becomes deeply compelling. Engaging in this uncomfortable interaction might well be our crucial contemporary challenge. Indeed, a bio-psycho-spiritual model of care has been explicitly suggested (Sulmasy, Reference Sulmasy2002). Yet, this model, as well as the term, is a building-block approach to the separated parts of biomedicine and the psychiatric/psychological/spiritual domains. So far, this proposed concept has not generated the necessary paradigm shift and ensuing conceptual transformation for a truly integrative approach within oncology. In clinical teams, these “parts” still tend to remain separated into clinical disciplines, each with their own specialized discourses with varying domains of power and influence within the medical institutions where oncology is practiced.

An appeal arising from the impact of this separation of domains calling for a reintegration of some notion of soul in medicine was expressed by Anatole Broyard (Reference Broyard1992), an editor for the New York Times Book Review, writing during treatment for the cancer that would eventually take his life:

Broyard exemplifies in this quote how soul, as a term, is functioning as a subtle courier for the intangible dimensions of human life and experiences of illness. He is describing a “soul loss” as an aspect of the cancer experience that clinical interventions still seem unable to reach.

This point is illustrated by such physician leaders as Rachel Remen (Remen, Reference Remen2006), who have called for the re-ensouling of medicine. Remen (Reference Remen2008) linked this process to the need to embody and reclaim healing wisdom in medicine, and, as one means to this end, she pioneered a program for integrative training and formation of physicians as whole persons, reintegrating exposure to the humanities and the notion of the “healer's art” within the practice of medicine (Rabow et al., Reference Rabow, Remen and Parmelee2010). David Whyte, renowned poet and a consultant for a variety of healthcare institutions, once proposed that “the soul of medicine is on trial at the moment” (Reece, Reference Reece2000). Discussions using the term soul in connection with medicine are being engaged in by contemporary psychotherapists (Cornett, Reference Cornett1998; St. James O'Conner et al., Reference St. James O'Conner, Lund and Berendsen2013), bestselling authors (Moore, Reference Moore2010), patients (Broyard, Reference Broyard1992), clinicians (Byrne, Reference Byrne1999; Harvey, Reference Harvey1997; Murray, Reference Murray2000; Picard, Reference Picard1997; Sinclair & Pereira, Reference Sinclair and Pereira2006), and medical educators (Kuczewski, Reference Kuczewski2007). Soul is thus emerging into contemporary discourses about medicine with a broad range of meanings. In some cases, it is merged with spirituality (Peteet & D'Ambra, Reference Peteet and D'Ambra2011; Sinclair & Pereira, Reference Sinclair and Pereira2006), while in others it mediates distinctly intangible meanings such as articulating a need for “reclaiming the soul of medicine” (Gale, Reference Gale2009; Hill, Reference Hill2005). As such, this non-academically defined term—soul—seems to be pointing Western medicine toward an intangible “something missing” dwelling in the “in-betweens” (Kalschad, Reference Kalschad2013) rendered inarticulate in the liminal interstices between academically circumscribed clinical and research discourses and their vigorous debates.

This “something missing” signposted by the reemergent soul was lost, according to some medical historians (de Pablo & Evans, Reference de Pablo and Evans1994; Hacking, Reference Hacking1995), along with the philosophical and biomedical splitting of body and mind. Prior to the 18th century, the soul was at least a dimension of medical discourse and medical care regardless of its contested meanings and implications within medical practices (Dolan, Reference Dolan2007; Hankinson, Reference Hankinson2009; Yoshikawa, Reference Yoshikawa2009). Yet, questions need to be asked: “What do these discourses mean when using this term soul within ‘medicine?’” And, more importantly, what might soul's meaning(s) be for those living with cancer in our treatment centers? Further, how does the term soul, proclaimed in IPOS's email, help or hinder the ongoing debate about human interiority when living with a disease such as cancer? Not all of these questions can be answered. However, they are currently being explored in Soul Medicine research studies, employing a hermeneutic-phenomenological methodology, turning to patients as the acknowledged experts in an endeavor to mine for soul's meaning in daily life and its potential relation to practical wisdom.

SOUL MEDICINE: A PARADIGMATIC EXAMPLE ILLUMINATING “WISDOM-IN-ACTION”

Commencing in 2009, some 10 support groups with an explicit focus on eliciting individuals' personal and practical wisdom on “What helps me to live with this cancer in daily life?” have been facilitated deliberately utilizing this term—soul. The groups have been given the name Soul Medicine, and they explore what “medicines” for this intangible dimension—soul—might mean in the daily lives of participants. Each group runs in 1.5-hour sessions for six weeks. Soul is engaged using Hillman's later articulation of its meaning(s) (Moore, Reference Moore1989):

Soul has thus been given a pragmatic meaning, rather than only a religious or spiritual meaning, linking it to our capacity to imagine, create, lament, and celebrate and, most importantly, to discover a participant's own unique wisdom. Content includes art, music/meditations, story, poetry, collage, and readings from fiction and nonfiction, including diverse spiritual and philosophical writers arranged weekly around the themes that have emerged from group to group. This notion bypasses the debate about “spiritual” or “existential” for those participants, who do not relate to either of these concepts. Soul Medicine's intent is to engage Freeman's (Reference Freeman1998a ; Reference Freeman1998b ) sense of the “poetic self,” where the “narrative fabric of the self ” that lies beyond the reach of biomedical discourses holds potentiality to “knit [the self] back together” (Freeman, Reference Freeman1998b ).

The benefits perceived by the participants in the first six groups were presented at two international conferences (Battler, Reference Battler [Butlin]2010; Reference Battler [Butlin]2011). Doctoral research began in 2013 focusing on the notion of phronesis: practical and embodied wisdom gleaned through the group process exploring “soul medicine(s)” in day-to-day life. Hermeneutic phenomenology is the chosen methodology due to its focus on illuminating intangibles within lived experiences (Finlay, Reference Finlay2011). Participants are encouraged to be their own investigators seeking lived experiences, rather than conceptual definitions, that best source a sense of hope, peace, balance, strength, and connectedness in the day-to-day, as well as discover their uniquely personal meanings for these concepts. The groups also provide a means to give voice, if needed, in story, art, and tears, to the painful feelings of despair and hopelessness, and the struggle for meaning in life. Expressions of lament or mourning are given equal value as “soul medicines,” as well as silence and wordlessness, lest a subtle “tyranny of positive thinking” (Holland & Lewis, Reference Holland and Lewis2000) and pressure for verbal forms of expression forms tacitly. The group sessions provide a place to return and share stories of their findings gleaned from day-to-day life. Group sharing may or may not include discussions on spiritual matters or beliefs; rather, it is driven by stories as sources of wisdom and therapeutic healing of distress (Frank, Reference Frank1995; Mehl-Madrona, Reference Mehl-Madrona2007) from living with cancer. Each participant, through the telling of their discovered “soul medicines,” contributes to an imaginative “wisdom epistemology” of word and image about “what helps in the day-to-day,” gathered cumulatively throughout the six weeks.

Soul Medicine groups thus offer an alternate discourse space within biomedical “chart talk” (Mattingly & Hayes, Reference Mattingly and Hayes1994; Mattingly, Reference Mattingly1998) that include, in our center at least, repeated screening assessments focusing on algorithms for anxiety and depression. These algorithms can often exclude other types of assessments or discourses of distress, such as “spiritual” or “existential,” unless individual clinicians choose to invite such assessment conversations. In discussions with referring clinicians, anecdotally, the language of “soul medicine” within our center's clinical context has opened up a different type of conversation in the screening conversations with social workers, psychiatrists, physicians, and nursing and radiation therapists assessing appropriateness for each group.