Embodied Knowledge – the Phenomenon of Subjective Health Complaints reflected upon by Norwegian Psychomotor Physiotherapy specialists

ABSTRACT

Background

Many patients report subjective health complaints (SHCs) during primary health care consultations.

Objective

To elucidate Norwegian Psychomotor Physiotherapy (NPMP) specialists’ clinical experiences in treatment of patients suffering from SHCs.

Methods

Twelve NPMP specialists were interviewed. The transcripts were qualitatively analyzed using systematic text condensation.

Results

“Embodied knowledge” seemed to be an unfamiliar concept to those suffering from SHCs. The NPMP specialists regarded increased body awareness to be a vital element in the process of recovery from SHCs. Differences between NPMP specialists’ professional view and that of some medical doctors were reported. Three categories emerged from the material: 1) “The process of establishing a joint understanding of subjective health complaints”; 2) “The process of increasing the patients’ embodied awareness”; and 3) “The challenge of sharing embodied knowledge in inter-professional communication.”

Conclusion

The NPMP specialists emphasized the importance of increasing patients’ consciousness of their embodied knowledge. They searched to adjust their therapeutic approaches, depending on the individual patient’s specific problems and degree of emotional and/or bodily strain. The NPMP specialists experienced the importance of creating a shared understanding of the meaning embedded in SHCs between patients, NPMP specialists, and medical doctors.

KEYWORDS:

• Norwegian psychomotor physiotherapy
• subjective health complaints
• shared professional language
• embodied knowledge

INTRODUCTION

The focus of the present study was to explore Norwegian Psychomotor Physiotherapy (NPMP) specialists’ reflections on the concept of subjective health complaints (SHCs). We wanted to access their experiences from working with patients with this diagnosis as well as their experiences from collaborating with medical doctors who had referred patients with SHCs for NPMP. Rosendal et al. (2017) stated that many patients consult their medical doctors because they experience bodily symptoms, yet the clinical picture does not meet the existing diagnostic criteria for diseases or disorders. Accordingly, the medical doctors find no results from clinical investigation, and the complaints are attributed to “medically unexplained symptoms.” This concept has been replaced by the concept of “subjective health complaints,” which is considered a better and more neutral medical term, because it does not entail assumptions about disease, etiology, or diagnoses (Eriksen and Ursin, 2004).

Complaints of pain and bodily dysfunction are the single most prevalent class of symptoms in primary care. They also have high prevalence in specialist care and are responsible for a significant proportion of disability in the workforce (Henningsen, Zimmermann, and Sattel, 2003; Nimmo, 2015; Rosendal et al., 2017). In Norway, studies by Eriksen, Ihlebaek, and Ursin (1999) and by Eriksen and Ihlebaek (2002) reported that 80% to 90% of the population suffer from SHCs. Studies published by Ihlebaek, Eriksen, and Ursin (2002) and by Bergland, Fromholt Olsen, and Ekerholt (2018) reported that participants had experienced SHCs during the 30 days prior to the reported studies. The health complaints commonly reported by patients can be classified into five major groups: musculoskeletal, gastrointestinal, pseudoneurological complaints, allergy symptoms, and cold (Ihlebaek, Eriksen, and Ursin, 2002). Patients also report fatigue, tiredness, dizziness, vertigo, headaches, and mood disorders (Eriksen and Ursin, 2004; Eriksen, Ursin, and Ursin, 1998; Nimmo, 2015). Individuals with these kinds of health problems typically lack adequate coping strategies and vitality (Ihlebaek, Eriksen, and Ursin, 2002).

The biomedical model of disease is strictly concerned with organic malfunction, and in human medicine, it is exclusively concerned with the physical aspects of illness (Farre and Rapley, 2017; Malterud, 2000). Solli and Da Silva (2018) stated that according to the biomedical model of disease, “objective finding” is the traditional criterion of objectivity, that is, observable phenomena such as laboratory tests or X-rays that can be observed or verified by someone other than the person evaluated. However, descriptions of illnesses and conditions that involve SHCs do not entail objective findings.

When a person decides to see a medical doctor, symptoms are presented, interpreted, and negotiated in a medical context, as the person expects an explanation and hopes for relief from the expert (Malterud, Guassora, Graungaard, and Reventlow, 2015). Patients assess and interpret medical doctors’ explanations or recommendations in the context of their own beliefs, and they can reject explanations that they find unacceptable, especially psychological explanations, which are interpreted as blaming them for their symptoms (Eriksen and Ihlebaek, 2002; Salmon, 2007). Presentation of bodily sensations and symptoms is a crucial task for patients when interacting with medical doctors or other health professionals in primary health care. Patients have expertise regarding their own bodies, and health professionals can only gain access to these experiences through the patients’ presentation of them. Health professionals are thereby dependent on patients’ presentations to be able to make assessments, which focuses attention on the ability of both patients and health professionals to include each other in their interactions during the encounter. If the process of interpreting and negotiating symptoms intends to include the patient, all health professionals must use nonmedical language to discuss the patient’s health complaints (Salmon, 2007). One goal of negotiating is to reach a mutual solution through the combination of expertise, power, understanding, and compassion (Malterud, 2000; Sacks, 1992). Consequently, the primacy of individual experience and limited access to the experiences of others constantly orient the health professional toward interpersonal interactions (Hayano, 2016; Heritage, 2011; Heritage and Lindström, 2012; Heritage and Raymond, 2005; Kuroshima and Iwata, 2016).

Most of the qualitative research studies on NPMP focus on patients’ experiences of it. Patients’ descriptions of their experiences entail a combination of bodily, cognitive, and affective processes (Dragesund and Råheim, 2008; Ekerholt, 2011; Ekerholt and Bergland, 2004, 2006, 2008; Øien, Iversen, and Stensland, 2007; Øien, Råheim, Iversen, and Steihaug, 2009; Sviland, Råheim, and Martinsen, 2012). Other research studies on NPMP focus on how NPMP specialists adjust their therapeutic interventions based on patients’ needs and preferences (Thornquist, 1990, 1991, 1994, 1995, 2001a, 2001b, 2010). However, few studies investigate how NPMP specialists reflect upon the therapeutic processes they have shared with their patients. To our knowledge, there is one study by Øien, Steihaug, Iversen, and Råheim (2011) which includes both patients’ perspectives and NPMP specialists’ descriptions of communicative patterns about changes in demanding physiotherapy treatment situations. There are also three studies that focus on NPMP specialists’ reflections on patients’ experiences with NPMP (Dragesund and Øien, 2019; Ekerholt and Bergland, 2019; Ekerholt, Schau, Mathismoen, and Bergland, 2014).

The first study focuses on NPMP specialists’ experiences with demanding treatment processes and how such situations might generate the potential for developing and improving the treatment outcome. The second study explores NPMP specialists’ reflections upon the importance of “listening to the body” and the threshold beyond which there may be “too much listening to the body.” In the third study, an NPMP specialist and a clinical psychologist are interviewed to investigate the therapists’ understanding of their patients and the therapeutic processes. The study also tries to develop concepts that could further our understanding of concurrent therapeutic processes.

To our knowledge, no study has examined NPMP specialists’ experiences of and reflections upon the phenomenon of SHCs. We want to contribute to the existing literature on NPMP by furthering our understanding of NPMP specialists’ experiences of and reflections upon this concept. Therefore, the aim of the present study was to elucidate NPMP specialists’ experiences and knowledge about SHCs, gained from their work with patients and from their collaboration with referring medical doctors.

THEORETICAL FRAMEWORK

The theoretical framework of NPMP posits that physical, psychological, and social strains influence the whole person and affect muscle tension, breathing, posture, balance, movements, and flexibility. This suggests that there is a reciprocal relationship between increased or decreased bodily tension and autonomous (dys)function and regulation and the restrictions of emotions. This means that an individual’s localized complaints and symptoms should be interpreted and understood in connection with the person’s bodily functions and dysfunctions, which in turn are closely connected to their life experiences and current situation (Breitve, Hynninen, and Kvåle, 2010; Bunkan, 2010; Ekerholt and Gretland, 2018; Thornquist, 2001a, 2001b, 2010; Thornquist and Bunkan, 1991). NPMP specialists significantly rely on the patients’ histories about their social situation both during body examination and NPMP treatment (Ekerholt and Gretland, 2018). During treatment, NPMP specialists encourage patients to become aware of embodied reactions and to reflect upon them. Changes in movements, posture, and breathing alter perceptions and emotional regulation, which may change the patients way of understanding themselves, and their ways of acting as well as interacting with others (Ekerholt and Bergland, 2019).

Our study calls for a theoretical and methodological framework that bridges the gap between subjective experience and the physical processes of the body. Merleau-Ponty (2012), who was a proponent of phenomenology, put the body at the center of his philosophy. He also emphasized the constitutive role it plays in subjective experience, contending that one’s experience of and knowledge about the world does not originate solely from reflective consciousness but also from one’s bodily engagement with the world. While intentionality is the most essential feature of consciousness, the notion of intentionality is grounded in the body. To fully understand sensorimotor problems, it is necessary to approach bodily issues as a subjective activity and to understand how they shape and affect the individual’s way of experiencing and engaging with the world. Since the body cannot be understood as a purely physical system, we must turn our attention to the body and its relationship with the person’s subjectivity and life and the fact that the body is experienced as their own. Thus, the body cannot be understood merely as a complex constellation of parts; rather, it presents itself as an undivided, although implicit, unity (Merleau-Ponty, 2012). Guiding patients to reflect upon their own unreflected-on behavior is a fundamental part of NPMP working processes and the therapeutic relationship. Discovering what is currently meaningful to a patient is critical in promoting recovery.

METHODS

Design

In order to explore NPMP specialists’ experiences of and reflections upon SHCs, which they had gained from their work with patients and from their collaboration with referring medical doctors, we employed a qualitative approach using individual semi-structured interviews, following Cresswell and Poth (2018). Given that one must be open to lived experience to see things as they are, we sought to gain a deeper insight into the research phenomena by adopting a phenomenological approach (Creswell and Poth, 2018; Smith, Flowers, and Larkin, 2009). A phenomenological perspective explores how human beings make sense of experiences and transform those experiences into consciousness, both individually and with a shared meaning (Forde and Slater, 2006). A phenomenological perspective incorporates the perceptions and feelings that people associate with what they experience, involving an exploration, description, and interpretation of life as the participants experience it, not just the observation of the experience itself (Creswell and Poth, 2018). This implies that understanding and knowledge are rooted in everyday life and that subjective meaning can be discovered through life experiences (Miles, Chapman, and Francis, 2015). The goal is to summarize individual experiences and to provide descriptions that include “what” people experience and “how” they experience it (Grbich, 2013; Hand). In our project, the intention was to understand the complexity of factors that influence the NPMP specialists’ experiences of and reflections upon SHCs, which they had obtained from their clinical practice.

Recruitment and Participants

This paper is the second follow-up paper from a randomized clinical study that examined the effect of NPMP on quality of life, social support, coping, self-esteem, and pain (Bergland, Fromholt Olsen, and Ekerholt, 2018). This present study used purposive sampling, involving 12 NPMP specialists (11 women and one man) out of 36 NPMP specialists who had recruited participants to the abovementioned study. The inclusion criteria in the present study were: 1) being an NPMP specialist; and 2) having participated in the abovementioned randomized controlled study. The participants were selected according to their geographical location. Four of them were working in different rural districts, four were working in areas close to the capital of Norway, and four were working in areas closely connected to an academic city in the middle of Norway. All those invited to participate in the present study accepted the invitation. The ages of the participants ranged from 41 to 61 years. Their NPMP experience ranged from 5 to 28 years, with an average 19.5 years of clinical practice. Nine worked full-time, and three worked 50%–85% of the time. Nine participants had their own clinical practice, while the other three participants worked part-time in specialized mental health care sectors and part-time in their own clinical practices. The Regional Committee of Ethics approved the present study. All the participants provided written informed consent.

Interviews

First author interviewed all the NPMP specialists individually in their respective clinics. Each interview lasted for approximately one hour. An interview guide was used, consisting of three main questions and an additional list of keywords that could assist the researcher in elucidating the lived, clinical experiences of working with patients suffering from SHCs. The initial questions that were posed to the NPMP specialists were the following: “What do you think about the concepts ‘subjective health complaints’ and ‘objective health complaints’?” and “What are your experiences and thoughts about your patients’ ways of referring to these concepts?” In addition to these central questions, a third question was presented: “Could you please describe how you understand and meet these complaints in your clinical practice both in therapeutic encounters with patients and in professional collaboration with the referring medical doctors?”

The intention was for the participants to be able to speak freely, with the interviewer encouraging them to share their reflections. The interviewer, who is an experienced NPMP specialist, was able to pose follow-up questions on the various topics that emerged. However, being a NPMP specialist herself, there was a danger that she could take statements for granted without asking relevant questions that an outsider might have asked. To counteract bias as much as possible, the interviewer asked open-ended follow-up questions, giving the informants sufficient time to reflect upon their experiences. Data collection was terminated when the contents of participants’ reflections had reached “saturation point,” that is, when the interviewer began to recognize statements, stories, and elements that had been articulated in previous interviews (Strauss and Corbin, 1998). The number of participants was guided by Malterud’s model of information power, which depends on the specific aim of the study, the sample specificity, the use of established theory, dialogue quality, and the strategy of analysis (Malterud, 2012). All interviews were taped and transcribed by the interviewer.

Data Analysis

The data were analyzed by both authors in line with Malterud’s principles of systematic text condensation and guidelines for qualitative research (Malterud, 2001, 2012). Since we are NPMP specialists ourselves, we were aware of the role that our preconceptions might play in the research process. Therefore, to ensure transparency and dependability, we continuously returned to the data to search for a deeper understanding of the material and of the intended meanings of the text. We reached a consensus about three categories by means of discussions.

The analyzing process involved four steps. During the first step, we read the text several times to obtain overall impressions. During the next step, we searched for units of meaning that could represent different aspects of the research question. The units of meaning in this step were systematically obtained by perusing the text line by line, looking for content that could shed light on the objective of the study. During the third step, the content of each of the coded groups was condensed and summarized, condensing and abstracting the meaning within each code. The fourth step involved summarizing the contents of the codes into categories, abstracting descriptions and concepts in such a way as to reflect the informants’ most important experiences of and reflections upon SHCs. Quotations from participants serve to illustrate and exemplify participants’ experiences of the phenomenon of interest. In this article, quoted participant experiences are presented in italics.

RESULTS

In the following sections, the three categories that emerged from the data are presented, along with selected illustrative quotations from the interviews. The NPMP specialists highlighted the importance of increasing the patients’ conscious awareness of their body that might accompany various actions, perceptions, or thoughts. With increased embodied awareness, the patients’ ownership of their experiences could develop. The NPMP specialists also described their efforts to elaborate their non-medical as well as medical professional language, in order to facilitate the therapeutic processes. Subsection titles represent the condensed meaning of each category.

The Process of Establishing a Joint Understanding of SHCs

The first category reflects how the informants could easily identify patients who had been referred to NPMP by medical doctors who had not found any objective medical explanation for the patients’ problems and complaints, despite the fact that many patients had suffered from their complaints for more than ten years. Feedback about no medical findings and information about psychosomatic problems had often been provided to the patients, which had given them the impression that their symptoms were primarily rooted in emotional problems. The NPMP specialists reported that such experiences made the patients feel that the doctors did not take their complaints seriously, giving them the impression that their symptoms were not valid and that there was no cure or treatment that could help them recover from their symptoms. The following quotation represents the opinion of several NPMP specialists:

Lack of medical findings are actually positive for the patient, but if the doctor says, “This is psychosomatic—that is, you have somatic pain, but in fact, this is really about your mental health,” then the person’s somatic complaints are perceived as “not true,” also giving the patients the impression that there are no hopes for their health to improve.

The patients whom the NPMP specialists encountered tended to be very hardworking individuals who had set high standards for themselves. They were constantly busy and active, and they were often inattentive to the negative health consequences of such a lifestyle. The urgency and work overload that they experienced on a daily basis had often reduced their sensitivity to somatic sensations and reactions. This point is illustrated in the following reflections:

Many patients are people who are very ambitious, working nonstop, always trying to be the very best. Many of them “are” only in the head, they have reduced contact with the rest of the body. They sleep very badly, having headaches and digestion problems. They feel exhausted and have often muscular pain and breathing problems.

The NPMP specialists said that whatever the reason for the referral, they would conduct an NPMP body examination. That means that they did not focus solely on the presented symptoms but on the whole body. They described clinical findings that could indicate that their patients had high levels of sympathetic stress activation, which could be observed in the patients’ breathing patterns, local muscular contractions, and/or generalized muscular tension. The process of establishing a therapeutic alliance and finding relevant therapeutic approaches was based on clinical findings from the NPMP body examination as well as on the patients’ narratives and reflections about significant life experiences. This point is illustrated in the following reflection from one NPMP specialist:

I use to say, “We can’t analyze symptoms backwards, that means that we don’t know the reason for your symptoms. You must learn to recognize your reactions in the current circumstances.” When we succeed in a joint dialogue about what is going on in the body during therapy as well as everyday life, then the patients’ reflections and emotions might emerge. Many patients realize the close but often rather difficult connection between somatic and emotional pain. That is the reason why the emotional part very often becomes an integrated part of the NPMP therapeutic processes.

During the therapeutic process, the patients could gain access to previously disclosed traumatic experiences. Experiences that had been “forgotten” could be remembered, often evoking strong emotional reactions. Accordingly, several NPMP specialists described similar experiences:

For some, we might be the first ones to whom they tell their stories, stories of traumas that have haunted them for years, consciously or unconsciously. This is why the relationship between us becomes so strong.

The Process of Increasing the Patients’ Embodied Awareness

The second category refers to the NPMP specialists’ reports about how increased embodied awareness is a vital element of the process of recovery from SHCs. Embodiment, or embodied awareness, was described as a way of understanding the body. The body is not simply an external entity but is a lived experience, representing the key to meaning-making processes of embodied experiences that evolve over time through bodily perceptions.

One main prerequisite to recovery is familiarity with the mutual interconnectedness of one’s somatic and emotional reactions. A great number of the participants’ patients were suffering from depression and anxiety, and the NPMP specialists often saw the close connections between the patients’ physical and emotional pain. The NPMP specialists described how they informed the patients about the connection between their body and their emotions and how they encouraged their patients to observe and reflect upon what they perceived as somatic and emotional reactions. This quotation from one of the NPMP specialists is relevant to the experiences of all of our informants:

I often teach the patients the connection between anxiety and painful feelings. If you are always avoiding these feelings, the feeling of anxiety might increase. Patients who suffer from anxiety have to become more aware of their bodily reactions, of their autonomic reactions. These are patients who usually need rather longtime therapies. During the therapeutic process, most of the patients report that they become more familiar with their emotions, even if it sometimes might be rather overwhelming for them. Gradually, most of them manage to cope better with their daily experienced emotional challenges.

The NPMP specialists recounted how they encouraged their patients to reflect upon their ability to release tension and breathe freely and upon what they perceived as painful emotions and bodily reactions in different contexts.

“Be curious. What happens to you during the therapeutic sessions? What happens to you between two sessions? Pay attention to your bodily reactions, and notice if there is any tension in your body, and whether you could manage to release this tension.

Can you notice some differences or changes?” I encourage them to try to find a balance between activation of the sympathetic and parasympathetic system, as well as to become aware of stress-related elements in their daily life.

The therapeutic approaches may differ slightly, depending on the individual patient’s specific problems and degree of emotional or bodily strain. The NPMP specialists described how they adjusted their therapeutic approach by working with the patient in positions offering varying postural challenges, such as standing, sitting, a supine, or a prone position. This is illustrated in the following quotation:

If the patient is very much bodily and emotionally affected, the initial therapeutic approach has its focus on body awareness and stability through grounding exercises in standing and sitting positions. However, when the patient is comfortable with lying on the bench, I use the prone and supine positions. It is often easier for him/her to notice bodily and emotional reactions in these positions.

The Challenge of Sharing Embodied Knowledge in Inter-Professional Communication

The third category presents the challenges the NPMP specialists might meet when they present their clinical findings and assessments in written reports to the referring medical doctors. They reported that their therapeutic approach could be slightly different from those of medical doctors, owing to their different medical education and professional training. Accordingly, they described how the NPMP body examination, which focuses on bodily signs of stress-related autonomic activations, might reveal clinical findings that were not so easily observed by medical doctors. In such cases, there could be situations in which they found their professional language to be insufficient and unclear, and it became demanding to “translate” their clinical findings to their fellow medical doctors. However, some of the NPMP specialists stated that the best way to create a mutual professional understanding was to invite medical doctors to observe an NPMP body examination being performed and to explain how findings are interpreted and assessed:

Very often, medical doctors at the hospital refer patients who have no objective findings to our clinic. If possible, we invite the doctors to observe us when we do NPMP body examinations, with us explaining and analyzing our findings. During the following discussion of our findings, the medical doctors usually regard our body examination as providing relevant and important information.

The NPMP specialists argued that medical doctors mainly use biomedical evidence, where examination or tests give measurable findings. The NPMP body examination, on the other hand, focuses more on bodily signs of the level of somatic and emotional stress activation, such as high-costal breathing, reduced ability to release tension, or excessively high or low muscular tension. They considered their interpretations of the patients’ complaints to be founded on a dialectical theoretical framework that differs from the dualistic medical view that is an important part of other medical health professionals’ theoretical background and education. The differences in the theoretical frameworks may account for the inter-professional communication challenges described by our participants:

A biomedical understanding that focuses on “cause and effect” theories might become rather reductionistic and fragmented and is something different from dialectical theories about how human beings experience through the body and how these sensations are connected to our feelings, experiences, and reactions. As NPMP physiotherapists, we are connected to both theoretical frameworks, but we need to improve our professional language in order to increase our ability to describe our way of working.

DISCUSSION

In the discussion below, we focus on the main findings of the NPMP specialists’ experiences from treatment to patients suffering from SHCs. The NPMP specialists reported that their therapeutic approach increased the patients’ consciousness of their bodily experiences, which could facilitate explorations of habitual somatic and emotional patterns. This embodied knowledge proved to be of great importance for the recovery process. The NPMP specialists also highlighted the importance of sharing professional knowledge, experiences, and understanding with patients as well as with medical doctors. However, since their clinical assessment and understanding of patients’ symptoms and complaints could differ from the biomedical model of disease, in which “objective finding” is the traditional criterion, they experienced challenges when presenting their clinical assessments to medical doctors. The discussion proceeds with the following headings: 1) Lack of biomedical findings; 2) Process of recovery; and 3) Mutual understanding in cooperating therapeutic processes.

Lack of Biomedical Findings

The NPMP specialists described how they often met patients who had been told that there were no objective findings that could explain their symptoms and whose health problems had been described as “psychosomatic.” Therefore, the patients believed that their problems were attributable to their mental health or lack thereof and that there was no hope for any improvement in their health condition. The NPMP specialists reported how their patients often had been left with the impression of not having been taken seriously in previous medical encounters. Medical opinions are difficult for patients to accept and can evoke immense uncertainty about the future (Kornelsen, Atkins, Brownell, and Woollard, 2016; Malterud, Guassora, Graungaard, and Reventlow, 2015). In such cases, NPMP is often considered to be the last therapeutic approach to try, a finding described by Aabakken et al. (1991) and Breitve, Hynninen, and Kvåle (2010).

Merleau-Ponty distinguishes between “my body for me” and “my body for others.” It is possible to view the body “objectively,” like any other object or thing. In this perspective, the body is a functional organism with objective processes taking place within it. This is the body that can be examined by health professionals, but this is not precisely the same body as “my body for me.” This might represent the experiences that are described in the category “The process of establishing a joint understanding of SHC.” If health professionals focus only on symptoms or a disease, their perspectives may be different from that of patients. The NPMP specialists noted that because of their theoretical framework and experiences, their therapeutic attitude did not distinguish between objective findings and SHCs when encountering new patients, being aware of the close connection between the patients’ SHCs and their life histories. This is in line with the view that the focus must be on the meaning of symptoms, pain, and dysfunction. Thornquist (2010) stated that NPMP understands the body to express the person’s total life history and that the body has to be seen as a functionally integrated entity. At the same time, one should be aware of how people who are suffering express that their existence is threatened through their suffering. This means that they are disturbed in their everyday life and usual tasks, and this is the reason why they seek professional assistance (Kirkengen and Thornquist, 2012).

The NPMP specialists argued that their clinical assessment could reveal how physical, psychological, and social strains can influence the whole body. They reported how they ask the patients questions about pain, sleeping disorders, dizziness, and other somatic problems in the first therapeutic encounters. They described how, during the body examination, they observe the patient’s balance and flexibility as well as breathing and moving patterns. The NPMP body examination would also examine the patient’s muscle tension and body awareness, searching for the patient’s habitual ways of functioning. These elements are addressed when grasping the patient’s history of complaints, searching for clinical findings that might correspond with these complaints, never doubting the reality of the presenting symptoms. These experiences might correspond to how Malterud, Guassora, Graungaard, and Reventlow (2015) discuss the manner in which medical doctors intend to clarify the patient’s personal needs by integrating knowledge of the patient’s medical state, psychosocial situation, and family history as well as the patient’s previous experiences of dealing with illness or disease. The patients in our material had been told that there were no objective medical findings that could explain their complaints; therefore, the NPMP specialists aimed to present their findings in a way that might make sense for the patient, thus searching for ways to create “bridges” between the patients’ SHCs and their own professional knowledge. This therapeutic approach might be in line with the phenomenological view that human beings both are and have their body and that illness and disability are not only a limited way of living but also represent the existence of opportunities. Bodily awareness is an immediate and vital aspect of our encounters with the world and can thus be experienced as an integration of subjectivity and life, shaping the way in which we experience the world, each other, and ourselves (Merleau-Ponty, 2012).

Process of Recovery

The NPMP specialists described how their therapeutic approaches, based on clinical findings from NPMP body examination as well as on the patients’ narratives and reflections about significant life experiences, were important in the process of establishing therapeutic alliances. Therapeutic approaches to patients who are suffering from undiagnosed illness are often longtime therapies, since the patients need consistent and enduring relationships in clinical encounters (Kornelsen, Atkins, Brownell, and Woollard, 2016). Being able to create a therapeutic alliance that is safe enough for the patients to encounter their inner experiences and narrate their untold stories is essential to profound therapeutic work (Martin, Garske, and Davis, 2000; Øien, Steihaug, Iversen, and Råheim, 2011; Sviland, Martinsen, and Råheim, 2014, 2018). Kirkengen (2001) and Kirkengen and Thornquist (2012) explained how previously experienced pain, fear, and powerlessness are vital, often unconscious elements in expressed pain, anxiety, and helplessness in cases of complex patterns of disorders. This in line with the experiences of the NPMP specialists; many patients were able to recall previous incidents that had been stressful and traumatizing, by turning their attention to their bodily reactions. Similar experiences are described in several studies on NPMP (Ekerholt and Bergland, 2006, 2008, 2019; Ekerholt, Schau, Mathismoen, and Bergland, 2014; Sviland, Martinsen, and Råheim, 2014; 2018; Øien, Råheim, Iversen, and Steihaug, 2009).

The NPMP specialists encouraged their patients to observe, recognize, and reflect upon their bodily and emotional challenges in different everyday situations, especially in situations in which they might experience symptoms and pain, thus aiming to interpret and contextualize their bodily and emotional reactions. Patients who were living mainly “in their head,” were encouraged to pay attention to and become more familiar with their basic autonomic reactions. Treatment was directed toward an awareness of the way they reacted during interactions between themselves and others. It was essential to find a balance between activations of the sympathetic and parasympathetic systems in the process of improving patients’ daily function (Dragesund and Øien, 2020; Dragesund and Råheim, 2008; Ekerholt, Schau, Mathismoen, and Bergland, 2014; Gard, Nyboe, and Gyllensten, 2020). Merleau-Ponty (2012) described the experiencing of sensorimotor processes as a very basic form of self-awareness, and a failure to experience any specific bodily reactions attenuates the possibility of connecting bodily experiences to daily life. Positive bodily experiences can offer a way of generating glimpses of hope for persons suffering from SHCs. The feeling of good health can produce a feeling of pleasantness, whereas pathology is described as discomfort (Schwartz, 2015).

The NPMP specialists’ reflections, “not being able to analyze symptoms backwards, since one does not know the reason for symptoms, is why it is so important to learn to recognize one’s reactions in the current circumstances” implicitly conform to the four-step model of understanding medical symptoms, as described by Malterud, Guassora, Graungaard, and Reventlow (2015). The first step involves an explicit awareness of the moments of dysfunction, such as pain or disease, across different everyday situations. The patients need to reflect upon what had happened prior to the onset of symptoms, thus being able to interpret bodily phenomena and the attribution of meaning to the bodily message, realizing that being a person means to be in interaction with his/her social environment. A further contextually appropriate action and an enhanced understanding by the patient could thus increase their ability to become more aware of when pain and other symptoms increase or decrease. Gradually, the patient and health professionals should be able to discuss their symptoms and detect the reason for them (Malterud, Guassora, Graungaard, and Reventlow, 2015). This is in line with how the NPMP specialists described how a mutual exploration of the patient’ reactions might encourage the patient to explicate and verbalize tacit bodily knowledge. At the same time the NPMP specialists searched to adjust their therapeutic approach to the individual patient.

NPMP therapeutic processes are often long-lasting when it comes to persons who are heavily suffering from somatic and/or emotional complaints. The patients could become overwhelmed, experiencing an increased feeling of fear and anxiety if the therapeutic approach seemed too challenging (Sviland, Råheim, and Martinsen, 2012). However, the findings in our material describe how most of the patients gradually became more able to cope with their emotional challenges and be more confident in their interaction with others. Merleau-Ponty (2012) wrote that living with illness and disability does not mean a limited way of living but instead, the existence of opportunities, since the body opens us to a great variety of possibilities for new ways of using ourselves.

Mutual Understanding in the Collaborative Therapeutic Processes

The third category presents the NPMP specialists’ experiences with different professional views on SHCs and the challenges they faced caused by their different medical education and professional training when they discussed the patients’ clinical findings with referring medical doctors. The NPMP specialists reported that their NPMP body examination and assessment in some cases was regarded as less valid than medical body examinations, which search for objective, biomedical findings. Accordingly, some of the NPMP specialists experienced difficulties in communicating their professional knowledge to medical doctors, whom they perceived to have a more biomedical view of the patients’ complaints. The dualistic perspective permits the body to be treated as an object extrinsic to the self, as a collection of parts, with the attention of examination focused on a single body organ or region. Medical doctors, who are inclined to think in terms of a dichotomy, tend to separate body and soul, separating the “outer” and “inner” worlds (Gadow, 1980; Scheper-Hughes and Lock, 1987; Young, 1989).

According to Malterud (2001), medical doctors have two primary tasks: to understand the patient and to understand the disease. However, the NPMP specialists reported that their professional communication skills have three components. First, they need communicative skills that encourage the patients to “translate” their somatic sensations, that is, to verbalize their bodily experiences. Second, they need the ability to “translate” their clinical findings into a nonmedical language in the therapeutic encounters with their patients. Third, they need to be able to report their clinical findings in a medical language to any collaborating medical doctors. It was this third component that the NPMP specialists reported as sometimes challenging, saying that they wanted to improve their professional language in order to communicate better with collaborating medical doctors who were more aligned with biomedical medical knowledge.

Theoretical differences between biomedical and objective approaches and a holistic, functional approach to SHCs could be regarded as a sort of “knowledge boundary” that demarcates specialized domains. Carlile (2004) described such boundaries as “both a source of and a barrier to innovation.” The greater the distance between different collaborators’ practices, the more difficult it will be to communicate the embedded knowledge they use. Carlile (2004) described the process of transferring, translating, and transforming knowledge as a way of sharing knowledge between the actors who are involved in a relationship, noting that there are complex processes involved in such professional encounters. This might also be the case in the relationship between the patients and medical health professionals when the patients are searching for medical assistance, especially when it comes to the huge areas of symptoms without objective findings that affect people with SHCs. In the search for useful treatments for patients, transferring, translating, and transforming knowledge may bridge the gap between, on the one hand, patients’ embodied experiences and knowledge, and on the other, the medical knowledge that is shared within inter-professional teams.

Strengths and Limitations

This study has both limitations and strengths that affect the trustworthiness of its findings. Lincoln and Guba (1985) proposed four criteria for a study to be considered trustworthy: 1) credibility; 2) dependability; 3) confirmability; and 4) transferability. In this paper, credibility refers to the fit between the experiences of the NPMP specialists and the researchers’ presentation of their experiences. A study is credible when it presents faithful descriptions of the phenomenon and when collaborators and readers who are confronted with the respective experiences recognize them. In the present study, credibility was enhanced by returning the original texts to the NPMP specialists to ensure that the data were firmly grounded in their experiences and statements. In order to enhance trustworthiness and facilitate the development of plausible interpretations of the data, two additional NPMP specialists served as “critical friends” (Norris, 1997) by reviewing the results of the qualitative analysis.

Long and Johnson (2000) define dependability in terms of confidence in the data collection procedure. In the present study, data collection was undertaken in a consistent manner, and the researchers were aware of the fact that there would be an interaction between the interviewer and NPMP specialists. Due to the NPMP specialists’ previous acquaintance with the interviewer, this may either have encouraged or inhibited the NPMP specialists in sharing their clinical experiences. The term confirmability refers to the researcher’s ability to adopt a neutral position during data analysis. However, it does not require the researcher to be a distanced and neutral observer; instead, the researcher must be able to reflect upon their preconceptions (Öhman, 2005).

Because this was a qualitative study that had a small sample size and used purposive sampling, generalization to other populations is cautioned against. Generalization of qualitative findings is usually not a goal of qualitative research, but transferability is. To address this, we aimed to provide rich, detailed descriptions of the participants’ views and experiences as well as the context of this study (Geertz and Darnton, 2017; Lincoln and Guba, 1985), so that the present study could make a valuable contribution to the field of NPMP and SHCs.

We believe that the descriptions presented in this article are sufficiently rich for others to judge whether the findings are transferable to other treatment settings or contexts. However, it is not our aim to generalize from our findings to other treatment contexts. Qualitative research is a time-consuming but innovative and open-minded enterprise (Öhman, 2005). It can be argued that more time should have been spent on the different steps of the research process and that the researcher should have been more open-minded and flexible.

CONCLUSION

NPMP specialists’ experiences, as described in this article, along with their reflections upon these experiences, have demonstrated their understanding of the complex disorders called SHCs. They have expressed a theoretical and clinical framework that seems basic in their therapeutic approach aiming to increase the patients’ trust in and ownership of bodily self-experiences. Our findings underscore the importance of a strong relationship between NPMP specialists and patients and demonstrate the importance of joint exploration of the patients’ SHCs, aiming to achieve a mutual understanding of their symptoms. The concept “embodied knowledge” that emerged from the interviews was used to describe how the patients were encouraged to transform their embodied knowledge into verbalized knowledge, thus becoming more familiar with their own way of reacting bodily and emotionally in different contexts. At the same time, the NPMP specialists elaborated upon their ways of presenting their clinical findings in nonmedical language in order to communicate as well as possible with their patients.

NPMP entails an integration of different sources of knowledge. The NPMP specialists reported that it could be challenging to transform their findings and clinical assessments into knowledge that could fit in with a biomedicine medical view. The process of explicating tacit knowledge and thereby bridging the gap between patients’ symptoms and medical knowledge had turned out to be a valuable element in their therapeutic as well as interprofessional encounters.

Declaration of Interest

The authors report no conflicts of interest.

Acknowledgments

We are very grateful to the 12 NPMP specialists who participated in our study.