Corresponding Author: Casey Rentmeester, PhD Email: casey.rentmeester@bellincollege.edu Journal of Applied Hermeneutics ISSN: 1927-4416 March 10, 2021 ©The Author(s) 2021 Hermeneutical Healing: Physical Therapy with a Gadamerian Twist Casey Rentmeester, Eric Chaconas, Jon Weiss, Mark Bake Abstract In recent decades, phenomenology has been utilized not only as a conceptual framework from which to understand medical encounters in healthcare settings, but also to guide medical professionals in providing care. In the realm of physical therapy, phenomenology has been touted as a philosophically-based avenue to aid in helping to understand what it means to be a patient. The works of Edmund Husserl and Martin Heidegger have been utilized as paths to approach phenomenologically-informed care in physical therapy. However, to our knowledge, no significant connection has been made in regard to the work of Hans-Georg Gadamer’s phenomenology and hermeneutics in the realm of physical therapy. The authors aim to close that gap by showing the ways in which Gadamer’s philosophy can help physical therapists provide phenomenologically-informed patient care. They begin by outlining some of the touchpoints between phenomenology and healthcare and then introduce Gadamer as a figure who deserves attention in the question of how to apply phenomenology to healthcare settings. Upon analyzing Gadamer’s account of what it means to experience an altered body, they outline Gadamer’s understanding of tact, practical knowledge, and good sense in order to show how to understand at a conceptual level what it means to empathize with patients on the path to building therapeutic alliance, that is, a cooperative working relationship. They then look closely at Gadamer’s hermeneutics and particularly his comments on how to cultivate a fusion of horizons in order to attempt to help guide physical therapists in theoretically understanding how to empathize with their patients. Ultimately, they argue that physical therapists who practice phenomenologically- informed care, which they call “hermeneutical healing,” are positioned well to form strong working relationships with their patients. Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 2 Keywords Medical Humanities, Phenomenology, Hermeneutics, Gadamer, Fusion of Horizons In recent decades, phenomenology has been utilized not only as a conceptual framework from which to understand medical encounters in healthcare settings, but also to guide medical professionals in providing care (Zahavi & Martiny, 2019). In the realm of physical therapy, phenomenology has been touted as a philosophically-based avenue to aid in helping to understand what it means to be a patient (Greenfield & Jensen, 2010). The works of the two titans in the realm of phenomenology, Edmund Husserl and Martin Heidegger, have been utilized as paths to approach phenomenologically-informed care in physical therapy (Shaw & Connelly, 2013). However, to our knowledge, no significant connection has been made in regard to the work of Hans-Georg Gadamer’s phenomenology and hermeneutics in the realm of physical therapy. We aim to close that gap by showing how Gadamer’s philosophy can help physical therapists provide phenomenologically-informed patient care. We begin by outlining some of the touchpoints between phenomenology and healthcare and then introduce Gadamer as a figure who deserves attention in the question of how to apply phenomenology to physical therapy settings. Upon analyzing Gadamer’s account of what it means to experience an altered body, we outline Gadamer’s understanding of tact, practical knowledge, and good sense in order to show how to understand at a conceptual level what it means to empathize with patients on the path to building therapeutic alliance, that is, a cooperative working relationship. We then look closely at Gadamer’s hermeneutics and particularly his comments on how to cultivate a fusion of horizons in order to attempt to help guide physical therapists in theoretically understanding how to empathize with their patients. Ultimately, we argue that physical therapists who practice phenomenologically-informed care, which we call “hermeneutical healing,” are positioned well to form strong working relationships with their patients. Phenomenology and Physical Therapy Phenomenology has a rich and fruitful history in philosophy. Founded by the German philosopher Edmund Husserl in the early 1900s, phenomenology’s goal is to get “to the things themselves!” [Zu den Sachen selbst] (Husserl, 1900/2001, p. 50), which means to stay true to the way things are as they appear in context, rather than appealing to abstract theoretical constructs. Although most philosophical doctrines are abstract by their very nature, phenomenology was deliberately created to be more practical as it deals with everyday life rather than speculative theories and systems. This makes it a fitting candidate to influence professional practice. Two of the most famous phenomenologists, Martin Heidegger, who studied under Husserl, and Hans- Georg Gadamer, who studied under Heidegger, attempted to apply phenomenological methods to healthcare. In Heidegger’s Zollikon Seminars, which were delivered exclusively to health professionals on a two-week, annual basis from 1959-1969, he tries to demonstrate “the highest need for doctors who think and who do not wish to leave the field entirely to scientific technicians” (1987/2001, p. 103). In Gadamer’s The Enigma of Health, he provides a phenomenology of health and illness in which he attempts to show how it is only when something goes wrong with the body (e.g., a broken bone, an aching back, etc.) that we explicitly attend to its dysfunctionality, as its functionality is normally taken for granted when healthy (1993/1996). Gadamer did his part to try to help medical professionals understand what it is like Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 3 to be a patient with the hope of helping to initiate more patient-centered care. While both thinkers gained some ground in making phenomenology applicable to healthcare, it is only recently that health professionals are truly applying phenomenological methods to professional practice. One of the first clear attempts to connect phenomenology and healthcare was made by Patricia Benner, who was drawn to the work of the famed Heideggerian Hubert Dreyfus during her graduate studies at the University of California in the late 1970s and 1980s. Benner leveraged Dreyfus’s work in phenomenology to write From Novice to Expert: Excellence and Power in Clinical Nursing Practice in 1984 in which she attempts to demonstrate phenomenologically how a nurse moves from novice to expert via experiential skills acquisition (Benner, 1984/2001). Since Benner’s work, phenomenology has been utilized in various ways in the realm of nursing.1 In the realm of physical therapy, though, phenomenology is relatively new. In 2010, Havi Carel published a paper on how phenomenology can be applied in various medical contexts in order to provide better patient care (Carel, 2010). Later that year, Bruce Greenfield and Gail Jensen argued that “the tools of phenomenology provide opportunities to understand the illness experiences of [physical therapists’] patients” (2010, 92). In a phenomenological context, illness refers to the patient’s subjective experience of a disease or injury, rather than the objective dysfunctionality itself. Thus, rather than focusing exclusively on the body of the patient, a phenomenological approach to physical therapy attempts to understand the patient’s experience of the injury and how it has affected the patient’s life in a broader context, his or her expectations regarding recovery, and what matters most to the patient in the grand scheme of his or her life. In other words, to put it simply, the phenomenological approach to healthcare emphasizes meanings to complement the focus on measurements. Greenfield and Jensen cite both Husserl and Heidegger as helpful avenues in the quest to achieve phenomenologically-informed physical therapy practice in clinical settings. Two years after the Greenfield and Jensen publication, James Shaw and Denise Connelly (2012) explicitly utilize Husserl and Heidegger as theoretical underlays to positively affect patient care in physical therapy practice. To our knowledge, no one has explicitly utilized Gadamer’s phenomenology and applied it to the field of physical therapy. We aim to try to close that gap by showing the ways in which Gadamer’s philosophy can be practically applied in physical therapy settings to better care for patients as persons, and not simply a list of bodily impairments, activity limitations, and participation restrictions. We begin by examining Gadamer’s phenomenology of illness, which provides insight into what it often means to experience an altered body from the point of view of the patient, which is sometimes referred to as “the broken body” (Dahl et al., 2019). We then turn to Gadamer’s hermeneutics, i.e., his theory of interpretation in communication, to provide guidance to physical therapists attempting to understand what matters to their patients with the hope of achieving therapeutic alliance, which can be defined broadly as the overall bond between the physical therapist and patient (Horvath et al., 2011). Therapeutic alliance is a tenet of healthcare practice that originated in psychotherapy with the work of Sigmund Freud (1958a; 1958b) but is now utilized broadly across various healthcare specialties. In recent years, physical therapy literature 1 This is evidenced by the fact that the main peer-reviewed nursing journals, including Nursing Inquiry, Qualitative Health Research, Nursing Philosophy, International Journal of Nursing Studies, Nurse Researcher, and Journal of Research in Nursing have showcased articles on the phenomenology of nursing since Benner. Indeed, the fact that we have the Journal of Applied Hermeneutics is a testament itself of the influence of practical phenomenology. Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 4 has adopted therapeutic alliance as a fundamental component to successful outcomes in the rehabilitation of patients along with movement dysfunction. For instance, Ferreira et al. (2013) identified positive therapeutic alliance ratings by physical therapists and their patients as being associated with improved outcomes for individuals with chronic low back pain. Moreover, a strong therapeutic alliance has demonstrated positive impact in the physical rehabilitation from stroke (Lawton et al., 2016) and cardiac procedures (Burns & Evon, 2007). Indeed, a recent study identified 42 sub-themes within the context of therapeutic alliance across 130 publications related to physical and occupational therapy practice (Babatunde et al., 2017). Thus, it is safe to say that therapeutic alliance is referred to widely in the realm of physical therapy. While broad application of concepts relevant to therapeutic alliance may be currently employed clinically, such application has been informed more by psychological concepts than philosophical concepts, which is understandable given its historical roots. Our goal is to help to guide physical therapists in their attempt to form therapeutic alliance with their patients through the lens of the philosophical subdiscipline of phenomenology in order to complement the work that has already been theoretically undergirded by psychology. Gadamer argues that hermeneutics, which we can understand as a conceptual framework to guide interpretation and communication, plays a different role than psychology: “hermeneutical work is based on a polarity of familiarity and strangeness; but this polarity is not to be regarded psychologically” (1960/2004, p. 295). Our goal is to outline the role in which Gadamerian hermeneutics can play. In order to cover that terrain, though, we need to begin with what it means to experience a broken body and thus enter the realm of phenomenology. The Broken Body Gadamer calls health an enigma in that when we are healthy, our bodily functionality is taken for granted as it lays in the background of our awareness. It is only when there is a disruption in this seamless functionality that we typically explicitly attend to the body. He states, “I know only too well how illness can make us insistently aware of our bodily nature by creating a disturbance in something which normally, in its very freedom from disturbance, almost completely escapes our attention” (1993/1996, p. 73). When this happens, the body becomes the object of attention and “thus appears as something set over against us, as an ‘object’ (Gegenstand), as that which offers resistance (Widerstand) and must be broken” (1993/1996, p. 96). Instead of receding into the background, the body all of a sudden becomes present due to its inability to perform tasks that were once routine. When this happens, we objectify the aspect of the body that is not functioning and attempt to bring it back to functionality. Sometimes we are unable to heal the body by ourselves and thus seek the expertise of medical professionals. Physical therapists often play a role on the road to recovery when the injury results in impairments affecting the musculoskeletal, cardiovascular, or neurological systems. Gadamer cautions us that “modern science and its ideal of objectification demands of all of us a violent estrangement from ourselves” (1993/1996, p. 70) since, by focusing myopically on the body, we lose sight of the person. By the very nature of the profession, physical therapists need to objectify the body in order to provide appropriate assessments and treatment measures (it is, after all, called physical therapy). However, it is important to understand the context of the injury that has been experienced by the patient—as well as the patient’s interpretation of that injury—in order to provide proper patient care. The following examples provide a small sample of the types of injuries that physical therapists come across to help us understand just how broad the treatment spectrum can be. Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 5 Physical therapists are sometimes dealing with patients who have an acute injury that can be overcome with treatment such that the person is able to retread back to a healthy state in which the body falls back into the background. Consider a 52-year-old male who begins to experience Achilles tendon pain upon running and is hopeful this new pain in the back of his ankle will go away with treatment so he can still participate in his planned half marathon next month. His prognosis and hope that his body will return to its prior status is good, and he does not anticipate the injury to bar him from participating in the race for which he has prepared. When given proper therapy, in this case, the patient can easily tread back to a state of well-being in which the body is “unhindered” and “ready for and open to everything” (Gadamer, 1993/1996, p. 73). At other times, though, regaining health as one once experienced is simply not a live option—all that can be hoped for is managing the condition as one attempts to navigate the new version of themselves that is somehow “less” (Cassel, 1982). For example, consider a 39-year-old female who endures repeated lumbar spine injuries related to her employment that requires heavy lifting. Her new standard is living with chronic pain coupled with a limited range of motion. In this scenario the physical therapist must create a level of trust and confidence that therapy will yield a positive result of improved function through a reduction in pain severity, although the process may be slow, knowing full well that the distress of chronic pain is often related to feelings of helplessness (Kusch & Ratcliffe, 2018). In such chronic cases, as Gadamer notes, “it is a question of tending to the ill, which also requires attending to their mental and emotional well- being” (Gadamer, 1993/1996, p. 76). The physical therapist needs to empathize with what it means for the patient to have endured this changed life situation that includes living with an altered body, recognizing that “one must learn to accept such illness and attempt to live with it as far as the illness in question will allow” (Gadamer, 1993/1996, p. 76). In other cases, the situation is even more severe and significantly life-altering. Take, for instance, a 28-year-old woman who is injured in a mountain biking accident and sustains a complete C6 spinal cord injury. Her recovery process is much different with the realization that even with extensive rehabilitation, walking again independently is not likely to ever occur. Thus, the patient may be forced to reckon with the fact that in this situation, the body has truly become Gegenstand, that is, an object “which withstands our natural impulses and which we cannot simply incorporate [seamlessly] into the order of our lives” (Gadamer 1993/1996, p. 105). In such cases, the care team will likely recommend psychological counseling to help navigate her new life situation of living with an altered body, which is certainly appropriate. We think it is also appropriate, though, for the physical therapist to attempt to empathize with the patient and try to understand what it is like to undergo such a drastic change in life situation; phenomenology can help us on both of those fronts. Empathy is a commonly used concept in the realm of physical therapy, but it is poorly understood (Davis, 1990). We do know that there is strong evidence that empathy is an essential component of therapeutic alliance (Feller & Cottone, 2012). Therefore, it is important to understand what is meant by empathy as we help to provide guidance to physical therapists aiming to build therapeutic alliance with their patients. For the sake of this paper, we agree with Fernandez and Zahavi that “the most basic form of empathy acquaints you—in the most direct and immediate manner possible—with another’s experiential life” (2020, p. 21). They call this “the phenomenological concept of empathy,” which they juxtapose with other concepts of empathy that come from the field of psychology. A helpful way to dissect various Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 6 understandings of empathy is to differentiate empathetic understanding, which is the act of understanding the experiences of the other person, from empathetic feeling, which is the act of feeling with another person (Rentmeester & Hogan, 2020). Gadamer’s phenomenology provides us with a conceptual toolkit to help empathize with patients in the physical therapy settings at least at the level of empathetic understanding. Importantly, Gadamer argues that health professionals should approach each situation differently with an eye towards the context (1993/1996). Therefore, the following concepts should be understood as philosophical scaffolding to help aid physical therapists in providing empathetic care, rather than ethical prescriptions to guide practice. Tact, Practical Knowledge, and Good Sense Greenfield and Jensen argue that a phenomenological approach to patient care allows physical therapists to go beyond the code of ethics of the profession and provide truly individualized and context-mindful care (2010). They put the point the following way: Although a code of ethics provides a moral framework for physical therapy, and provides a consistent and common moral language to base ethical decisions, many find the principles contained in codes of ethics too abstract or impersonal to address their day-to- day moral concerns and issues. (Greenfield & Jensen, 2010, pp. 88-89) Gadamer’s hermeneutics provides a wealth of concepts that physical therapists can use in order to provide what we refer to as “hermeneutical healing,” that is, patient care that acknowledges the unique perspective and world of the patient while also attempting to achieve the best possible patient outcomes. First and foremost, let us begin with why professional codes of ethics in and of themselves should not be the sole guide for ethical conduct in a profession. Since they are meant to serve as a general guide for the profession in its practices, they are not well-constituted to guide specific provider-patient interactions. In other words, codes of ethics are great at providing general principles to keep in mind as one practices in the profession, but not as good at giving details as to how to approach patient care in context. Thus, there is a need for more nuanced approaches that go beyond the code of ethics and help practitioners navigate everyday patient interactions. Indeed, Theodore George (2020) has argued recently that understanding what “doing the right thing” means in any given situation cannot be given to us by a template; rather, “what the good means–right here and now” (p. 2) requires an “openness, attunement, imagination and decisiveness” that is particular to each unique situation (p. 9).2 Thus, if we are to understand professional codes of ethics as templates, we need to complement their use in order to ethically practice in the profession. As a phenomenologist, Gadamer is committed to the idea that one should approach the world as it is lived in context, rather than appeal to broad principles, and his hermeneutics provides a lens to investigate a more nuanced approach. The first three Gadamerian concepts that we think are helpful in conceptualizing hermeneutical healing are tact, practical knowledge, and good sense. 2 Nancy J. Moules provides an excellent review of George’s book in the 2020 issue of the Journal of Applied Hermeneutics (doi: 10.11575/jah.vi0.71086). https://journalhosting.ucalgary.ca/index.php/jah/article/view/71086 Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 7 Gadamer uses the term “tact” to refer to “a special sensitivity and sensitiveness to situations and how to behave in them, for which knowledge from general principles does not suffice. Hence an essential part of tact is that it is tacit and unformulable” (1960/2004, p. 14). Physical therapists practice in a wide array of contexts, including outpatient clinics, acute care hospitals, rehabilitation units, schools, athletic events, long-term care facilities or the homes of their patients. Gadamer can help us understand how a physical therapist should approach a situation in the outpatient clinical setting differently than in, say, a patient’s home. Consider the case of the 48-year-old male who is voluntarily seeking physical therapy for his aching back in a clinical setting. In this case, the patient knows what he wants and simply needs help achieving it; moreover, he is self-motivated to do so, as evidenced by his autonomous choice to seek out a physical therapist. Here, the physical therapist can look to tackle the problem at hand quickly and build a care plan together with the patient, as the values of the patient are clear and well-defined (Emanuel & Emanuel, 1992). On the other hand, consider the case of an 84-year-old female who is receiving in-home physical therapy for the first time on her back pain based largely on the authority of a referring provider. In this case, it would likely be inappropriate for the physical therapist to dive in with a medical analysis or even begin the conversation with a medical question. Rather, the physical therapist should work to get to know the patient as a person, perhaps aided by cues in the home itself such as pictures on the wall or artworks, etc. Once the physical therapist feels that he or she has established solid therapeutic alliance, he or she can then simply ask “Why were you referred to physical therapy?” to shift the narrative towards the medical context of the meeting. In all contexts, physical therapists require tact to do their jobs well since no two injuries are exactly alike nor are treatment plans going to be identical for the same types of injuries. Moreover, all patients are unique in regard to their background and life plans. The tactful physical therapist recognizes the nuances that are unique to each medical encounter in order to be positioned well to provide optimal care. The well-experienced physical therapist with tact understands how to adjust one’s communication to the context, and when he or she has done this consistently and combines his or her professional experience, he or she starts to build what Gadamer refers to as “practical knowledge” (phronesis), which is knowledge that is directed towards concrete situations (Gadamer, 1960/2004, p. 19). As Gadamer unpacks this concept, he speaks about it as “the grasp and moral control of the concrete situation” that allows one to always keep an eye towards “the goal that one is pursuing so that the right thing may result” (1960/2004, p. 19). Any physical therapist understands what the goal of treatment should be, namely, the restoration of the health of the patient in as much as is feasible given the circumstances. Ideally, the physical therapist aids the patient in taking the broken body that has become an object for the patient and assists in restoring it to the point of a healthy body so the patient can return seamlessly to engaging in life’s projects without pain or dysfunction getting in the way. However, the physical therapist with practical knowledge knows not only this overarching goal but also how to get there. In order to do so, the physical therapist must not only accumulate clinical experiences in Gadamer’s sense of lived experience (Erlebnis) that occur in isolated moments but also “gain better knowledge through [new experiences]” (Gadamer 1960/2004), p. 348), a reflective and developmental process that Gadamer refers to as Erfahrung (which is also translated as “experience”). 3 The 3 On the difference between Erlebnis and Erfahrung, see Joel Weinsheimer and Donald G. Marshall’s Preface to Gadamer’s Truth and Method, pages xii-xiv. Thank you to Dr. Graham McCaffrey for his insight about Gadamer’s distinction between Erlebnis and Erfahrung. Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 8 physical therapist with practical knowledge has synthesized his or her clinical experiences in a reflective, hermeneutical fashion via Erfahrung such that he or she understands how to navigate new clinical encounters. While tact allows the physical therapist to recognize the nuances of the situation that cannot be formulated via general principles, practical knowledge allows the physical therapist to navigate those nuanced concrete situations in order to restore the health of their patients. Again, an example may prove helpful. Consider the case of a 56-year-old male with chronic low back pain and a history of depression and anxiety. He constantly ruminates about his pain and informs the physical therapist that he has not had a day without pain in many years. The physical therapist with tact understands the role communication will play in this patient’s outcome, especially given the patient’s history of mental health issues. Tact provides the physical therapist with the first steps toward empathy, but practical knowledge ensures that the care provided will also be grounded in sound principles of therapeutic strategies and psychologically-informed care to complement the therapeutic methods based in exercise physiology and biomechanics. In this situation, the physical therapist should allow the patient to feel like his viewpoint, thoughts, fears, and anticipated difficulties will be heard and then work to create a safe environment for optimal patient recovery. The physical therapist should use tact and practical knowledge to utilize skilled communication to help the patient reshape his thoughts, better learn his body, and see the opportunities for progress. It is possible for a physical therapist to have tact but lack practical knowledge. This would entail being sensitive to the nuances of the situation but not being able to practically navigate it so as to ensure optimal health outcomes for the patient. In such situations, the physical therapist has good intentions and displays empathy but is not quite skilled enough to bring about the best results. It is less likely that a physical therapist has excellent practical knowledge but lacks tact, since a key feature of most clinical encounters in physical therapy is building therapeutic alliance, and tact is an essential component in doing so. Ideally, as the physical therapist begins to build a wealth of practical knowledge and is guided by tact, he or she can be said to form what Gadamer calls “good sense” (Gesunder Menschenverstand), which is the ability to judge holistically what situations call for (Gadamer, 1960/2004, p. 27). Gadamer argues that good sense “cannot be taught in the abstract but only practiced from case to case” (1960/2004, p. 27). This is why experience in the sense of Erfahrung is such an important aspect of physical therapy. Since all medical encounters are unique, particularly for physical therapists who practice in such a wide array of settings, the formation of good sense requires experience (Erfahrung). A physical therapist with good sense understands when he or she must spend more time building patient rapport in order to create a strong therapeutic alliance and also judges well when it is appropriate to engage in difficult conversations, such as when a patient is not being compliant with the care plan. Patient adherence has been demonstrated as greater when a strong therapeutic alliance exists between patient and clinician, which is why a good physical therapist will dedicate so much time to this process (Babatunde et al., 2017). From Gadamer’s perspective, the more experience a physical therapist has in these spheres, the stronger one’s good sense will be for future situations. Although there is no rulebook that could possibly guide all future patient scenarios and contexts in a Gadamerian understanding of patient care, one’s accumulation of practical knowledge does allow for the cultivation of good sense, which then prepares the physical therapist for similar situations in the future. One common approach to practicing empathetic care in the clinical encounter that has proved influential in physical therapy settings comes from the work of Geoff Maitland, who emphasized collaborative decision-making on the Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 9 part of physical therapists and patients with the ultimate goal of providing patient-centered care (Hangeveld & Banks, 2013). It has also been shown how engaging in bigger-picture types of discussions with patients (sometimes dubbed “ethical reasoning”) can be beneficial as a clinical reasoning strategy in physical therapy settings (Edwards et al., 2005). We hope to build on these already proven techniques in physical therapy by showing how Gadamer’s hermeneutics can be leveraged to better understand how to practice empathetic care towards patients. Cultivating A Fusion of Horizons Now that we have a sense as to the importance of tact, practical knowledge, and acquiring good sense, we can move on to more general concepts in Gadamer’s hermeneutics. To begin, we should note that the primary task of hermeneutics is to guide communication and interpretation. Gadamer makes it clear that “it would seem that there is something absurd about the whole idea of a unique, correct interpretation” (1960/2004, p. 118). Since interpretation and communication are more properly labeled as art than science, it is wrongheaded to suppose that a person can come upon the right interpretation or communicative technique. Rather, the goal of hermeneutics is to provide concepts to better prepare individuals to engage in the art of interpretation and communication. The ultimate goal of patient-provider communication is to reach an understanding, and Gadamer has a lot to say about what reaching an understanding entails. This longer quote provides a good starting point from which we can work: To understand means to come to an understanding with each other” (sich miteinander verstehen). Understanding is, primarily, agreement (Verständnis ist zunächst Einverständnis). Thus people usually understand (verstehen) each other immediately or they make themselves understood (verständigen sich) with a view toward reaching agreement (Einverständnis). Coming to an understanding (Verständigung), then, is always coming to an understanding about something. Understanding each other (sich verstehen) is always understanding each other with respect to something. (Gadamer, 1960/2004, p. 180) Three points can be gleaned from this quote regarding Gadamer’s conceptual analysis of understanding. First, understanding is always understanding with another and displays itself as agreement (we provide the original German above to show the etymological link between the words “understanding” and “agreement” in Gadamer’s native language). In order to come upon an understanding, one must “get on the same page” as the other and begin to see things eye to eye. Second, understanding sometimes comes very quickly but other times requires time. Those who have long-lasting relationships with one another—say, family members or good friends— may be able to come upon an understanding quickly since they have a wealth of experience with each other and already understand each other’s values and goals. In such situations, good sense may have been formed well by both persons who are thus able to practically navigate situations together in a seamless fashion. On the other hand, new acquaintances may require a significant time investment in order to reach an understanding. Physical therapists sometimes have patients with whom they have formed deep and lasting relationships and thus have strong therapeutic alliance but also sometimes have brand new patients in which it will take time in order to build Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 10 therapeutic alliance. Even when physical therapists have strong bonds with their patients, life sometimes “gets in the way” and they need to be poised to be patient towards the barriers that present themselves. Third, in understanding, the agreement that occurs is always with respect to something. In a physical therapy setting, this has not only to do with health goals but overarching life goals that are threatened by injury and need to be re-evaluated, re-prioritized, adjusted, or, in worst-case scenarios, abandoned. Understanding from Gadamer’s perspective “is always a movement in [the hermeneutical] kind of circle” (Gadamer, 1960/2004, p. 189). Phenomenologists in the hermeneutical tradition often refer to this as the hermeneutic circle wherein individuals who engage in communication and interpretation must simultaneously mediate the whole and the parts. Gadamer calls this the hermeneutical rule, which states that “we must understand the whole in terms of the detail and the detail in terms of the whole” (Gadamer, 1960/2004, p. 291). The “whole” is life itself, which includes one’s goals, hopes, projects, and, in a phrase, everything that matters to a person. The details or “parts” are more focused on the specifics of the particular situation. A physical therapist who only focuses on the patient’s injured body and how to restore its functionality without paying attention to the patient’s life as a whole is not demonstrating good sense by myopically being fixated on the parts and losing sight of the whole, which will therefore not likely produce the best possible results. In order to pay heed to the parts and the whole, Gadamer talks about the importance of attaining a “fusion of horizons” (Horizontverschmelzung), which is perhaps his most famous concept. For Gadamer, “the horizon is the range of vision that includes everything that can be seen from a particular vantage point” (1960/2004, p. 301). The physical therapist’s horizon includes expertise in how the body functions and how to restore dysfunctionality back to functionality, as well as the unique background that informs that expertise, which is bolstered by the tact, practical knowledge, and good sense that he or she has formed throughout his or her career. The patient’s horizon includes his or her own unique background and the range of options that make up his or her life’s projection. A fusion of horizons occurs when both persons acknowledge each other’s unique background and still come upon a common ground regarding the topic at hand. In order for this to occur, Gadamer argues that both participants in the dialogue should approach the conversation with an “openness to the other,” which he defines as “recognizing that I myself must accept some things that are against me” (1960/2004, p. 355). Critically, this attitude of openness includes the idea that the other is a possible authority for you that must be acknowledged (Gadamer, 1960/2004, p. 281). In a physical therapy context, the physical therapist, of course, is the authority regarding the medical aspects of treatment and the therapeutic plans needed to be put in place in order to restore health or manage pain. At the same time, the physical therapist must recognize the patient as an authority as well, not only in understanding his or her own body but in understanding his or her life and life plans, which provide the background of the treatment plan. From a Gadamerian perspective, the patient’s life and life plans oftentimes have more of an effect on the care plan than the patient’s body from the perspective of the patient since, from the patient’s perspective, when healthy, the bodily self often falls into the background, as noted above. One of the goals of the patient may simply be to return to the state in which the broken body no longer announces itself as broken so that life in general can go on without dysfunction or pain. In order to achieve the status of retreading back to a state of health, a fusion of horizons must occur in which “one learns to look beyond what is Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 11 close at hand—not in order to look away from it but to see it better, within a larger whole and in truer proportion” (Gadamer, 1960/2004, 304). Sometimes, restoring health to the point where one’s bodily being falls into the background is simply not possible in the near future, and it may be the case that in such contexts, understanding what matters most to the patient becomes of paramount importance. Take, for instance, a 78-year-old female who has fractured a hip but desperately wants to attend her granddaughter’s birthday party, which would require her to climb five steps. In such a context, while the progression of healing for the hip is undoubtedly important in creating a care plan, the explicit goal of the patient to climb the five steps means that the physical therapist should focus in on stair training to accomplish that goal. This stair climbing focus may occur earlier in the rehabilitation phase than is ideal from a general practice perspective, but in building the care plan with the patient in order to achieve the patient’s goal, an investment is established on the part of the patient and the plan is crafted explicitly with the patient’s goals in mind, thereby displaying empathy and accomplishing a fusion of horizons. Even when a care plan is created mutually with the physical therapist and the patient, the patient may be unable to follow through on the plan. While this can be frustrating for the physical therapist and the patient alike, Gadamer does provide some guidance as to how to navigate such a situation. He states, “Reaching an understanding in conversation presupposes that both partners are ready for it and are trying to recognize the full value of what is alien and opposed to them” (1960/2004, p. 388). In some situations, the patient is not ready to commit fully to the care plan, even though the patient may act as if he or she is ready. Addiction to opioids would be one example in which a patient may not be ready to participate in a rehabilitation program, as the physiological changes that occur in the brain might block any desire to take an active approach to recovery. In other situations, the lack of adherence to the care plan is much more nuanced. In the situation of noncompliance, the physical therapist should do his or her best to understand the barriers to patient adherence, which may have nothing to do with the “will power” of the patient. Take, for instance, the patient who is consistently not able to make the appointments on time, which places a strain on the physical therapist, who already has a very busy schedule. In this context, the physical therapist should attempt to understand the world of the patient: is the patient having issues with transportation? If so, perhaps he or she can be referred to a case manager who can facilitate rides for the patient. Is an in-home physical therapy setting more appropriate, given the barrier at hand and the treatment plan? Are there other reasons for the non-compliance that can be addressed? In the contemporary era in which we strive for patient-centered care, physical therapists must be willing to think outside of the box and meet the patients where they are in order to achieve the best possible health outcomes, and also understand that some of the barriers to achieving success in regard to those outcomes have nothing to do with health. We know that a strong relationship exists between therapeutic alliance and program adherence for a variety of conditions (Babatunde et al., 2017). Thus, physical therapists should emphasize building therapeutic alliance in such situations. We believe that, on the whole, the physical therapist that interweaves “hermeneutical healing” with contemporary patient management strategies can help to build therapeutic alliance, which will thereby help in achieving optimal health outcomes on the whole. Rentmeester et al. Journal of Applied Hermeneutics 2021 Article 5 12 Concluding Thoughts As with many professions, physical therapists often point to their code of ethics to guide practice; however, the general nature of such codes is not well-suited to guide physical therapy practice in context. We have argued that physical therapists who seek to provide patient-centered care that is mindful of the context in which the care occurs may benefit from a phenomenological approach to patient care, and we have shown how Gadamer’s hermeneutics can be applied as a phenomenological resource for physical therapists. Upon exploring what it means to experience a broken body from Gadamer’s perspective, we have highlighted key concepts from Gadamer’s philosophy in our attempt to showcase what we call “hermeneutical healing,” including his notion of tact, practical knowledge, and good sense. Ultimately, we think that Gadamer’s concept of cultivating a fusion of horizons that acknowledges the authoritative expertise of the physical therapist and the patient is appropriate, and we have provided some examples of cases in which physical therapists can approach situations differently, depending on the context, in the quest to build therapeutic alliance. Gadamer’s notion that understanding is always understanding with another is especially helpful in the quest to provide patient-centered care, which also helps in overcoming common barriers face in the physical therapist relationship, such as lack of compliance. 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