understanding

Ways to avoid “othering”


After my last post on “othering” I thought I should write something about what we know reduces the distancing that othering produces. To refresh your memory, othering is what happens when we identify positive characteristics about ourselves and simultaneously identify the absence of these positives in another person. Othering is a common part of any interaction but it seems to become less helpful as views become more polarised.

Lehti, Fjellman-Wiklund, Stalnacke and colleagues (2016) describe “walking down ‘Via Dolorosa'” as the “way of pain and suffering… from primary healthcare to [a] specialty rehabilitation clinic.” This depiction also captured the way gender and sociocultural context influenced that journey: chronic pain is a ‘low status’ illness (especially compared with high status diseases like cancer, heart disease, orthopaedic problems), while those patients with higher education and similarities to treating clinicians were viewed as “easier to interact with”. This study provides an insight into the norms expected as part of “being a proper patient – ready for change”.

Norms are a part of culture, assumptions about what “is done” in a particular context. Just as health professionals learn to “be professionals”, people seeking help for their health are also expected to behave in certain ways. Othering is, as I’ve indicated above, a normal or common part of interactions – some authors suggest we need an “other” in order to for our self to “know itself and define its boundaries” (Krumer-Nevo, 2012). At the same time, once the “other” is identified in less positive terms than “self”, it’s far easier to distance oneself from the other person.

One step towards reducing the distancing between “us” as health professionals and “them” seeking help is to create moments of “belongingness”. What this means is using overt means to help people feel welcome. In New Zealand, this may mean ensuring signs are written in both Maori and English. For people with pain, it may mean explicitly indicating to people with pain that it’s OK to stand up and move around during an initial assessment.

Another way is to raise the idea of the person living with pain as an expert. “Expert?” I hear you say…Yes, expert in “what it is like to be this person living with this pain in this context”. For us to demonstrate our understanding that the person living with pain is the expert on his or her experience, we need to provide safe and welcoming opportunities for the person to tell us what it is like. Narrative medicine, if you like.

Tonini and Chesi (2018) used Charon and Remen’s definition of narrative medicine “a way of dealing with the disease through narration, aimed at understanding the complexity of the patient that will no longer be seen as a set of objective data but as a unique individual with needs” in a study of the stories given by people living with migraine. The stories were of people with a chaotic narrative where migraine was a mystery, full of disorientation and few solutions, moving through to restitution where knowledge and efffective treatment allowed the person to progress. Other narratives were “stable” leading to improvement in understanding and management, and regression, where people gave up and remained disoriented.

How might this help us reduce our sense of “othering”? In one way, learning to hear what people have to say should be fairly simple for health professionals. We’re trained to listen carefully. But what we’re often focusing on is some sort of diagnosis: “what is going on here, what’s going wrong, what’s the pathology?” Hearing another’s narrative is a different process: this involves empathising with, understanding the journey from feeling unwell to seeking help, beginning to acknowledge the similarities between this person and ourselves. How might we respond to illness if we were faced with the same circumstances? the same prior history? the same choices?

Lajos Brons, philosopher (Brons, 2015), argues that charity, or the “reasonableness argument” could help us to deal with othering. Reasonableness is an assumption that the other person has rational, coherent, and true reasons for doing and saying what they do – even if, at first, we may not discern the underlying reasons. By invoking a charitable interpretation on another’s actions, we are in turn asked to question our own preconceptions, our assumptions about the reasons the person did what they did.

Imagine that kind of humanity being brought into our judgements of people who are apparently “lacking motivation”, or “seeking secondary gain”, or “noncompliant”?



Brons, Lajos. (2015). Othering: An analysis. Transcience, 6(1), p. 69 – 90

Krumer-Nevo, M. (2012). Researching against othering. Qualitative inquiry and the politics of advocacy, 7.

Lehti, A., Fjellman-Wiklund, A., Stalnacke, B.-M., Hammarstrom, A., & Wiklund, M. (2017). Walking down ‘Via Dolorosa’ from primary health care to the specialty pain clinic-Patient and professional perceptions of inequity in rehabilitation of chronic pain. Scandinavian Journal of Caring Sciences, 31(1), 45-53.

Tonini, M. C., & Chesi, P. (2018). Narrative medicine, an innovative approach to migraine management. Neurological Sciences, 39(Suppl 1), S137-S138.

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Health literacy: if you can’t read it, you don’t get it


ResearchBlogging.org

For a long time I’ve been a fan of ‘plainspeak’ or eliminating gobbledegook.  I know my writing is often quite complex, but I try to write as if I’m talking directly to someone – and yes, I do use all those complicated words in real life!

But after working in pain management for a while certain themes keep coming up, and one of them is the large number of people who don’t read and write well.  I value the concept of multiple intelligences, and some people are simply ‘practical’ and hands-on, and don’t like books much – but to actually not be able to read and write well enough to understand common labels and warnings and instructions, that is an incredible handicap.

I have just been reading a paper by Don Nutbeam called ‘The evolving concept of health literacy’ in which he discusses the concept of poor health literacy as a risk factor for poor health status, and conversely, the idea that by improving health literacy it can become an asset to enable people to take control over their health and the factors that shape their health.

Poor health literacy is associated with lower socioeconomic status, reduced use of health resources and information, poorer adherence to treatments and higher drop-out rates.  It’s easy to see why both direct and indirect effects of not being able to make sense of written information might have an effect on health.

Nutbeam’s paper makes the point that decisions about health are made in a context, part of which is the ability of the individual to make their way through the health care system.  This system inevitably involves negotiating paperwork, being aware of pre-requisites for care, being able to clearly state what is needed – and to the right person. More than that, it’s being able to retain the complex information that a health care decision is based on, and maintain that working knowledge to understand why certain actions need to be taken at certain times.  It’s clearly not just about an individual being able to read – its about an interaction between health care systems and individuals, and it includes, according to Nutbeam, three critical points at which literacy directly influences health – access (who do I see? where do I go?), the interaction between the person and the provider (how does the provider ensure the person understands and retains the information?) and self-care (how does the person continue to take best care without directly drawing on the ‘system’).

The alternative view of health literacy as an asset suggests that by improving literacy, it becomes integral to empowering the person to carry out self care – and to receive appropriately tailored information so they can engage in activities that increase wellbeing.

That’s a big ask for a health care system that often does view health as ‘the absense of disease’.

What can you and I do?  Check with our patients whether they can read the information we provide – write simply in bullet point, avoid jargon, make sure patients have time to absorb information before making a decision, and in the end – listening, listening, listening.

D NUTBEAM (2008). The evolving concept of health literacy☆ Social Science & Medicine DOI: 10.1016/j.socscimed.2008.09.050