Liminality: a major category of the experience of cancer illness

Lived experience of a child's chronic illness and death: A qualitative systematic review of the parental bereavement trajectory

To understand the lived experience of parents who have lost their child to a chronic life-limiting condition, six major databases were searched by adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Articles were screened for appropriateness using the Sample, Phenomenon of Interest, Design, Evaluation, Research type tool, and relevant qualitative studies were selected for full-text data analysis using Thematic Synthesis. Findings were categorized into 13 themes that were further organized into a four-phase trajectory of parental bereavement experience of child loss, namely: Liminal Margin, Holding Space, Navigating Losses, and Reconstructing Lives. The findings are discussed in the light of existing literature with practical recommendations for enhancing parental bereavement support services.

Liminality as a dimension of the experience of living with terminal cancer

Objective

This paper is concerned with the phenomenology of death awareness within the context of being diagnosed with terminal cancer. The objective of the research presented here is to provide a deeper insight into terminally ill cancer patients’ engagement with their mortality.

Method

The analysis forms part of a wider project that involved conducting a metasynthesis of 23 phenomenological studies of the experience of living with the awareness of having terminal cancer published between 2011 and 2016.

Result

The metasynthesis identified four master themes that represent distinct experiential dimensions of living with terminal cancer. This paper focuses on one of these themes, liminality, to provide novel insights into the structure of death awareness whilst living with terminal cancer.

Significance of results

The results suggest that liminality describes an experiential space from within which terminal cancer patients encounter a new relationship with their existence. Liminality offers opportunities for both connection (e.g., with the natural world) as well as disconnection (e.g., from loved ones and others who still have a future) and therefore contains the potential for suffering and distress as well as for joy and a sense of fulfillment. This understanding of liminality can help healthcare professionals provide psychological support for this client group.

Striving for liminality: Eating disorders and social suffering

In this article, I argue that eating disorders constitute a form of social suffering, in which sufferers embody liminality as a response to, and a reflection of, oppressive sociality, structural violence, and institutional constraints. Based on the illness narratives of people with anorexia nervosa, bulimia nervosa, and their subclinical variants in Israel, the analysis draws the experiential, the social, and the structural into critical focus. These narratives, which delineate lived experiences of self-starving, bingeing, and purging, and the attendant viscerality of hunger, fullness, and emptiness, reveal how participants developed an embodied drawing inward and away, being at once within and without society for extended periods of time, through eating disordered practices. This liminal positioning, I argue, was a mode through which participants cultivated alternative (if temporary) personal spaces, negotiated identities, and anesthetized pain: processes many deemed essential to survival. Embedding the participants' narratives of eating disordered experiences within familial, societal, and political-economic forces that shaped their individual lives, I examine the participants' striving for liminality as at once intimately embodied and structurally mapped. The analysis suggests that policy initiatives for eating disorder prevention must address the social suffering that eating disorders manifest: suffering caused by structures and institutions that reinforce social inequality, violence, and injustice.

My Sister's Keeper: Sibling Social Support and Chronic Illness

Through her stories and mine, my sister and I allow the outside world to see the ways in which we grapple with a critical health incident along her journey of living with lupus. Lupus is a chronic, autoimmune disease that is difficult to recognize and to diagnose. The ambiguous nature of the disease creates considerable confusion for the ill person as well as her support system. Using an illness narrative, I analyze a real life event linked to chronic illness, invisibility, living loss, liminality and family-and more specifically, to social support within the sibling relationship.

Using social media to assess care coordination goals and plans for leukemia patients and survivors

Care coordination has been shown to have a positive effect on the management of chronic disease. Specific to the management of leukemia, coordination may occur between primary care physician, medical and radiation oncologists, surgeons, cardiologists, and genetics specialists. Experiencing gaps in communication and care coordination, many health consumers seek instrumental support in their social circles, including online forums and networks. The goal of this theory-guided study was to provide an in-depth assessment of how individuals use online forums to deliberate about their goals and plans for leukemia care coordination. Guided by the planning theory of communication, the data were collected from the American Cancer Society Cancer Survivors Network and included 125 original posts and 1,248 responses. Thematic analysis and axial coding were applied to analyze the data. Goal-related themes included overcoming the diffusion of care coordination and achieving health management cohesion. Planning themes included social health management, communication self-efficacy, and role deliberation. Online patient forums provide an interactive platform for patients and caregivers to engage in active conversations, which in turn can serve as identifiers of care coordination needs. Communication with those who share similar experiences allows cancer patients and survivors to accumulate functional health literacy, gain communication self-efficacy, and articulate a care coordination role acceptable to them.

Seeking certainty through narrative closure: men's stories of prostate cancer treatments in a state of liminality

Radical treatments of prostate cancer often lead to a pervasive liminal state that is characterised by multiple uncertainties that relate both to a possible recurrence of cancer and recovery from side effects, such as erectile and urinary dysfunctions. Liminality can make it difficult for cancer patients to narrate their experiences, as their stories lack a definite ending. After interviews with 22 Finnish men who had undergone radical prostatectomy, we analysed how men produce closure in their illness narratives. Focusing on the timelines of control visits or their anticipated recovery from side effects, these interviewees sought provisional certainty within a seemingly chaotic future. By locating erectile dysfunction in the wider context of a life-course and interpreting their fading sexuality as a 'natural' consequence of ageing, these men were adjusting to their post-operative lives. Our study further shows that the inability to adjust personal experiences to positive culturally available storylines that provide a chance for the narrative reconstruction of life, can cause materialised negative consequences, such as relationship breakdowns.

A qualitative exploration of the meaning of the term "survivor" to young women living with a history of breast cancer

There has been a recent increase in research considering the perceptions of the term "cancer survivor" held by individuals who have or have had cancer. This article explores the meaning of the term to young women living with a history of breast cancer. Twenty women participated in semi-structured interviews about their experience of breast cancer. The methodology was informed by social constructionist grounded theory. Three of the women interviewed said they would use the term survivor to describe themselves, but most of the women felt it did not fit with their experiences. The accounts of those who accepted and rejected the survivor identity are explored, and subthemes in the latter are "survivor as somebody else" and "cancer's ongoing presence." This article calls into question the basing of intervention strategies on the notion of the "cancer survivor," and the assumption that younger women favour the survivor identity. Participants struggled with the demand to live up to the ideal of the survivor, which implied a high degree of agency where in reality, cancer was a disempowering experience. Being labelled a survivor obscured ongoing impacts of cancer on the young women's lives.

A systematic review of quantitative observational studies investigating psychological distress in testicular cancer survivors

OBJECTIVE

Testicular cancer (TC) affects young men and may cause psychological distress despite a good prognosis. This systematic review evaluated the prevalence, severity, and correlates of anxiety, depression, fear of cancer recurrence (FCR), and distress in TC survivors.

METHODS

A systematic search of literature published 1977 to 2017 was conducted to find quantitative studies including TC survivor-reported outcomes relevant to review objectives. The quality of included articles was assessed, and a narrative synthesis conducted.

RESULTS

Of 6717 articles identified, 66 (39 good, 20 fair, and 7 poor quality) reporting results from 36 studies were included. Testicular cancer survivors' mean anxiety levels were higher than in the general population, while mean depression and distress were no different. Clinically significant anxiety (≈1 in 5) and to a lesser extent distress (≈1 in 7), but not depression, were more prevalent in TC survivors than the general population. Approximately 1 in 3 TC survivors experienced elevated FCR. Poorer psychological outcomes were more common among TC survivors who were single, unemployed/low socio-economic status, suffering from co-morbidities, experiencing worse symptoms/side effects, and using passive coping strategies.

CONCLUSIONS

Many TC survivors do not experience significant psychological morbidity, but anxiety and FCR are prevalent. Inadequate coping resources (eg, low socio-economic status and social support) and strategies (eg, avoidance) and greater symptoms/side effects were associated with poorer outcomes. Theoretically driven prospective studies would aid understanding of how outcomes change over time and how to screen for risk. Age and gender appropriate interventions that prevent and manage issues specific to TC survivors are also needed.

Unveiling the Maelstrom of the Early Breast Cancer Trajectory

Length and complexity of illness and treatment in early breast cancer mean that the acute phase may extend over months. Employing concepts of "trajectory" and "work" from chronic illness, we explored the temporality of the illness experience for women as it unfolded from diagnosis through acute treatment. We performed multiple, qualitative interviews with 14 women at critical points in their first year postdiagnosis. We differentiated between subphases of the acute breast cancer trajectory: becoming a person with breast cancer: a turning point; first steps in treatment: struggling to protect self-concept; being and feeling ill: "cure" as suffering; and conditional "recovering": an uncertain future. Each subphase represented the distinctive context in which illness management took place with consequences for the work women and those close to them engaged in, to manage the practical, emotional, relational, and existential demands of an illness that intruded every aspect of their lives.

The Transliminal Self: The Ebb and Flow of the Kidney Transplant Experience

For people with kidney disease, transplantation is considered a better treatment option than dialysis. A kidney transplant does not, however, ensure an illness-free existence. Compared with the wealth of literature produced from a biomedical perspective, there is little qualitative research focused on the young adult transplant experience. This article presents the findings of a phenomenological study exploring young adults' kidney transplant experiences. Using a qualitative phenomenological approach, semidirected interviews were conducted with five people. Analysis of the transcribed interviews revealed that these individuals' kidney transplant experiences were paradoxical in nature: Participants described an existence between sickness and health, self and other, life and death. Consequently, liminality was identified as one of the experience's key elements and used together with the concept of rites of passage in its analysis. To incorporate these experiences, the term transliminal self is proposed.

The mechanisms underpinning peer support: a literature review

Background: The employment of Peer Support Workers, who themselves have experience of significant emotional distress, can promote recovery at an individual and organisational level. While research examining the benefits of peer support within mental health services continues to grow, an understanding of how, and through what processes, these benefits are reached remains under-developed.Aims: To review the published research literature relating to the process of peer support and its underpinning mechanisms to better understand how and why it works.Method: A scoping review of published literature identified studies relating to peer support mechanisms, processes and relationships. Studies were summarised and findings analysed.Results: Five mechanisms were found to underpin peer support relationships (lived experience, love labour, the liminal position of the peer worker, strengths-focussed social and practical support, and the helper role).Conclusions: The identified mechanisms can underpin both the success and difficulties associated with peer support relationships. Further research should review a broader range of literature and clarify how these mechanisms contribute to peer support in different contexts.

Usefulness and engagement with a guided workbook intervention (WorkPlan) to support work related goals among cancer survivors

BACKGROUND

Returning to work after cancer is associated with improved physical and psychological functioning, but managing this return can be a challenging process. A workbook based intervention (WorkPlan) was developed to support return-to-work among cancer survivors. The aim of this study was to explore how participants using the workbook engaged with the intervention and utilised the content of the intervention in their plan to return-to-work.

METHODS

As part of a feasibility randomised controlled trial, 23 participants from the intervention group were interviewed 4-weeks post intervention. Interviews focussed on intervention delivery and data was analysed using Framework analysis.

RESULTS

Participants revealed a sense of empowerment and changes in their outlook as they transitioned from patient to employee, citing the act of writing as a medium for creating their own return-to-work narrative. Participants found the generation of a return-to-work plan useful for identifying potential problems and solutions, which also served as a tool for aiding discussion with the employer on return-to-work. Additionally, participants reported feeling less uncertain and anxious about returning to work. Timing of the intervention in coordination with ongoing cancer treatments was crucial to perceived effectiveness; participants identified the sole or final treatment as the ideal time to receive the intervention.

CONCLUSIONS

The self-guided workbook supports people diagnosed with cancer to build their communication and planning skills to successfully manage their return-to-work. Further research could examine how writing plays a role in this process.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56342476 . Retrospectively registered 14 October 2015.

Holding Firm: Power, Push-Back, and Opportunities in Navigating the Liminal Space of Critical Qualitative Health Research

Critical qualitative health researchers typically occupy and navigate liminal academic spaces and statuses, with one foot planted in the arts and social sciences and the other in biomedical science. We are at once marginalized and empowered, and this liminality presents both challenges and opportunities. In this article, we draw on our experiences of being (often the lone) critical qualitative health scholars on thesis advisory committees and dissertation examinations, as well as our experiences of publishing and securing funding, to illuminate how power and knowledge relations create conditions that shape the nature of our roles. We share strategies we have developed for standing our theoretical and methodological ground. We discuss how we use the power of our liminality to hold firm, push back, and push forward, to ensure that critical qualitative research is not further relegated to the margins and its quality and integrity sustained.

The liminality of the patient with dementia in hospital

AIMS AND OBJECTIVES

The aim was to explore the experiences of people with dementia in subacute geriatric rehabilitation hospitals to critically evaluate the care received by such patients.

BACKGROUND

Globally, the number of people with dementia is growing and is expected to impact progressively more on health systems. People with dementia can become deconditioned and deteriorate in cognitive function while in hospital. The unfamiliar environment and people can cause the person to become disorientated, which then leads to behavioural symptoms which complicate care.

DESIGN

Critical ethnography.

METHODS

Methods included observation with field notes and 30 audio-recorded conversational interviews with patients with dementia in an Australian subacute care setting. Data were collected in May-December 2014, transcribed verbatim and analysed using thematic analysis.

RESULTS

The central theme identified that patients with dementia described a liminal experience and felt like outsiders in the hospital environment. This was supported by the subthemes of not understanding why they were being kept in hospital, feeling lost in the space, bored, anxious about discharge plans and lacking intersubjective relationships. Many felt imprisoned by the locked wards. There was little evidence of nursing care delivered in an empathetic person-centred way. Nurses were busy and engaged with the patients only superficially.

CONCLUSIONS

People with dementia can have a liminal experience and feel like outsiders in this environment, which does not cater for the specific needs of this patient group. It should be acknowledged that people with dementia require additional resources. A caring nurse-patient relationship is fundamental to the patient experience. Nurses require further support and education about dementia in order to deliver quality care to this patient group.

RELEVANCE TO CLINICAL PRACTICE

These findings will influence nurse leaders to advocate for improved resources for nurses to provide appropriate care for patients with dementia in subacute geriatric hospitals. The clinical practice of nurses needs to be supported with education, pyschological and material support to improve the therapeutic environment for patients with cognitive impairment resulting from dementia.

'Betwixt and between'; liminality in recovery stories from people with myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS)

This paper explores experiences of 16 people claiming to have recovered from Myalgic Encephalomyelitis (ME) or Chronic Fatigue Syndrome (CFS) using the concept of liminality. Liminality describes the status of those falling between socially recognised and medically sanctioned categories, and illuminates both the experience of illness and the process of recovery from ME/CFS. The liminality experienced during illness was akin to that described by Turner with a degree of communitas among sufferers. As recovery progressed, participants stressed the percentage to which they had improved, and compared themselves with peers and themselves prior to the illness. Recovery did not mean transition into a post-liminal phase, but involved a new liminality, characterised by straddling boundaries between illness and wellness. Participants continued strategies such as rest, pacing and meditation. This second liminal state included difficulty in communicating the experience convincingly, and estrangement from the ME/CFS community. Thus, recoverees moved from the liminality of illness to a second, and less legible state of sustained liminality in recovery, described as having one foot in the ill world, one foot in the well world. This suggests that more needs to be understood about the recovery experience to assist those making the transition toward wellness.

From paradox to pattern shift: Conceptualising liminal hotspots and their affective dynamics

This article introduces the concept of liminal hotspots as a specifically psychosocial and sociopsychological type of wicked problem, best addressed in a process-theoretical framework. A liminal hotspot is defined as an occasion characterised by the experience of being trapped in the interstitial dimension between different forms-of-process. The paper has two main aims. First, to articulate a nexus of concepts associated with liminal hotspots that together provide general analytic purchase on a wide range of problems concerning “troubled” becoming. Second, to provide concrete illustrations through examples drawn from the health domain. In the conclusion, we briefly indicate the sense in which liminal hotspots are part of broader and deeper historical processes associated with changing modes for the management and navigation of liminality.

The Liminal and the Parallax: Living and Dying at the End of Life

Transitions to palliative care can involve a shift in philosophy from life-prolonging to life-enhancing care. People living with a life-limiting illness will often receive palliative care through specialist outpatient clinics, while also being cared for by another medical specialty. Experiences of this point of care have been described as being liminal in character, that is, somewhere between living and dying. Drawing on experiences of illness and care taken from semistructured interviews with 30 palliative care outpatients in Australia, we found that this phase was frequently understood as concurrently living and dying. We suggest that this is a "parallax experience" involving narratives of a coherent linear self that is able to understand both realities, in a way that acknowledges the benefits of being multiple. These findings have significant implications for the ways in which palliative care is understood and how the self and subjectivity might be conceptualized at the end of life.

Phantom/liminal fat and feminist theories of the body

This article brings together two concepts, ‘phantom fat’ and ‘liminal fat’, which both aim to grasp how fat in contemporary culture becomes a kind of material immateriality, corporeality in suspension. Comparing the spheres of representation and experience, we examine the challenges and usefulness of these concepts, and feminist fat studies perspectives more broadly, to feminist scholarship on the body. We ask what connects and disconnects fat corporeality and fat studies from ways of theorising other embodied differences, like gender, ‘race’, disability, class and sexuality, especially when thinking through their perceived mutability or removability, and assumptions about their relevance for subjectivity. While it is important to consider corporeality and selfhood as malleable and open to change in order to mobilise oppressive normativities around gendered bodies and selves, we argue that more attention should also be paid to the persistence of corporeality and a feeling of a relatively stable self, and the potential for empowerment in not engaging with or idealising continuous transformation and becoming. Furthermore, we suggest that the concepts of phantom fat and liminal fat can help shed light on some problematic ways in which feminist studies have approached – or not approached – questions of fat corporeality in relation to the politics of health and bodily appearance. Questions of weight, when critically interrogated together with other axes of difference, highlight how experiential and subjugated knowledges, as well as critical inquiry of internal prejudices, must remain of continued key importance to feminist projects.

Living and dying with metastatic bowel cancer: Serial in-depth interviews with patients

Colorectal cancer is the second highest cause of cancer deaths. There are significant physical and psycho‐social effects on quality of life with advanced disease. Despite this, there are few accounts of the patient experience from advanced illness through to dying. We elicited the longitudinal experiences of living and dying with incurable metastatic colorectal cancer by conducting serial interviews with patients for 12 months or until they died. The interviews were analysed, using a narrative approach, longitudinally as case studies and then together. Thirty‐six interviews with 16 patients were conducted. Patients experience metastatic colorectal cancer in three phases; (1) Diagnosis and initial treatment; (2) Deterioration and social isolation and (3) Death and dying. Many patients initially said they hoped to survive, but, as “private” and in‐depth accounts of the experience emerged in further interviews, so did the understanding that this hope co‐existed with the knowledge that death was near. Palliative chemotherapy and the challenge of accessing private accounts of patient experience can inhibit care planning and prevent patients benefitting from an active holistic palliative care approach earlier in the disease trajectory. This study has immediate clinical relevance for health care professionals in oncology, palliative care and primary care.

Shifting dementia discourses from deficit to active citizenship

Within western cultures, portrayals of dementia as 'a living death' are being challenged by people living with the diagnosis. Yet dementia remains one of the most feared conditions. The sociological lens of citizenship provides a conceptual framework for reviewing the role of society and culture in repositioning dementia away from deficit to a discourse of agency and interdependence. Awareness of cognitive change, and engaging with the diagnostic process, moves people into a transitional, or 'liminal' state of uncertainty. They are no longer able to return to their previous status, but may resist the unwanted status of 'person with dementia'. Drawing on qualitative studies on social participation by people with dementia, we suggest that whether people are able to move beyond the liminal phase depends on acceptance of the diagnosis, social capital, personal and cultural beliefs, the responses of others and comorbidities. Some people publicly embrace a new identity whereas others withdraw, or are withdrawn, from society to live in the shadow of the fourth age. We suggest narratives of deficit fail to reflect the agency people with dementia can enact to shape their social worlds in ways which enable them to establish post-liminal citizen roles. (A Virtual Abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

The suspended self: Liminality in breast cancer narratives and implications for counselling

In the field of chronic and serious illness, meaning-making with regards to the illness experience has been shown to be a core process for patients. This study focuses on women's narratives of their experiences of living with breast cancer. Within the framework of narrative psychology, illness narratives are considered to provide the main means through which patients make sense of their illness experience and construct its place in their life story. In this paper, we present findings from a narrative study that aimed to explore the different meanings that breast cancer holds for Greek women. In the broader study, four basic narrative types about breast cancer emerged from the analysis. In this paper, we focus on one of these narrative types, in which illness is constructed as an entrance into a state of liminality and where the women's sense of self seems to be “suspended”. The core features of this narrative type are described and arguments are developed regarding its usefulness. We argue that this is a narrative type that deserves further attention, particularly as it seems to reflect a socially non-preferred storyline, which might result in these women's stories being sidestepped or silenced. The implications of this narrative type for healthcare and counselling in cancer care are discussed.

'Am I really gonna go sixty years without getting cancer again?' Uncertainty and liminality in young women's accounts of living with a history of breast cancer

Although much research has examined the experience of breast cancer, the distinctive perspectives and lives of young women have been relatively neglected. Women diagnosed with breast cancer under the age of 45, and who had completed their initial treatment, were interviewed, and social constructionist grounded theory methods were used to analyse the data. The end of initial treatment was accompanied by a sense of unease and uncertainty in relation to recurrence and survival, and also fertility and menopausal status. The young women's perceptions about the future were altered, and their fears about recurrence were magnified by the possibility of many decades ahead during which breast cancer could recur. The implications for the young women's life course, in terms of whether they would be able to have children, would not become clear for several years after initial treatment. This resulted in a liminal state, in which young women found themselves neither cancer-free nor cancer patients, neither pre- nor post-menopausal, neither definitively fertile nor infertile. This liminal state had a profound impact on young women's identities and sense of agency. This extends previous understanding of life after cancer, exploring the age-related dimensions of liminality.

Meeting the Self at the Crossroads: Thoughts on Aging as a Young Cancer Survivor

PURPOSE OF THE STUDY

With nearly 14.5 million cancer survivors currently alive in the United States, it is expected this will rise to roughly 19 million by 2024. As more people will age with a history of cancer than ever before, it is important to consider how experiences of cancer affect the life course through the bending of time and its interpretation. As such, aging as a cancer survivor must be at the forefront of health maintenance across the life course.

DESIGN AND METHODS

Through reference to my own cancer experiences in an auto-ethnographic format, this article interprets the illness experience as co-occurring in a young, aging body. This enhances our understanding of biographical reconstruction and individual liminality through descriptions of wisdom imparted by the cancer experience itself. Knowledge and wisdom are further interpreted as enhancing researchers' understandings of cancer and cancer survivorship.

RESULTS

In this article, I use my illness experiences as a young person to describe evolving interpretations of the life course, the aging body, and the self.

IMPLICATIONS

Concepts presented in this article aid researchers' understanding of how wisdom might be achieved through the experience of protracted illness over time. Such knowledge has important implications for the management of cancer as chronic, which may be most clearly described through the lens of the ill person.

Using liminality to understand mothers’ experiences of long-term breastfeeding: ‘Betwixt and between’, and ‘matter out of place’

Breastmilk is widely considered as the optimum nutrition source for babies and an important factor in both improving public health and reducing health inequalities. Current international/national policy supports long-term breastfeeding. UK breastfeeding initiation rates are high but rapidly decline, and the numbers breastfeeding in the second year and beyond are unknown. This study used the concept of liminality to explore the experiences of a group of women breastfeeding long-term in the United Kingdom, building on Mahon-Daly and Andrews. Over 80 breastfeeding women were included within the study, which used micro-ethnographic methods (participant observation in breastfeeding support groups, face-to-face interviews and online asynchronous interviews via email). Findings about women’s experiences are congruent with the existing literature, although it is mostly dated and from outside the United Kingdom. Liminality was found to be useful in providing insight into women’s experiences of long-term breastfeeding in relation to both time and place. Understanding women’s experience of breastfeeding beyond current usual norms can be used to inform work with breastfeeding mothers and to encourage more women to breastfeed for longer.

Approval and Disapproval in the Narratives of Colorectal Cancer Patients and Their Carers

In examining the narratives of colorectal cancer patients and their carers, we have noted that approval and disapproval are expressed in many ways that reflect their importance in the process of medical care. When people construct free narratives that trace important segments of their biographies, they emphasize the approval and disapproval which others express for their choices, actions and moral qualities. They also want their own approval or disapproval for others to count in significant ways. Approval is widely recognized for its importance in human development, and it is generally a positive force. The seeking of inappropriate approval, however, may have unfortunate consequences. For health professionals, for example, conflicts may arise when they come to seek peer approval ahead of client approval, and when a career comes to matter more than the real social purposes for which the career is intended. Identification of the conflicts that this divided loyalty may induce helps in understanding some of the underlying issues which narratives raise. It is possible to construct a formal structure that can be used to examine the part which the seeking and receiving of approval play in the values expressed in medical narratives generally. Similar and equally powerful meanings attach to disapproval.

Discordant Feelings in the Lifeworld of Cancer Survivors

This article concerns persons who live in uncertainty following an earlier diagnosis of (and completed treatment for) cancer. Fear of recurrence of the disease underlies the uncertainty and the attendant perception of being profoundly endangered, more ‘at risk’ than anyone else. Such a reflective assessment engenders a sense of separation from the everyday ‘practical consciousness’ that seems effortlessly to be shared by ‘ordinary’ others. The mismatch between the interaction order and individual psychology gives rise to interpersonal emotional dissonance, which forms a significant aspect of the chronic suffering contained in the ‘at-risk illness’ experience of cancer survivors. The article examines the emotional patterns involved in their situation and seeks to elucidate the pain that accompanies their alienation from the lifeworld in which nonetheless they must continue to dwell.

Vulnerability in the Narratives of Patients and their Carers: Studies of Colorectal Cancer

Vulnerability is susceptibility to any kind of harm, whether physical, moral or spiritual, at the hands of an agent or agency. It is related to disempowerment and loss of autonomy. It is also a relational category that appears repeatedly in the narratives of colorectal cancer patients and their carers. Although one conventionally associates vulnerability with being ill and needing health care, the practice of health care has its own vulnerabilities that emerge as important in the biographies of health care workers. Vulnerability needs to be recognized and negotiated in health care transactions. This article examines a process of ‘reading-for’ vulnerability, and suggests a classification of vulnerability, at least as it appears in the narratives of cancer patients and their carers. Methods of managing vulnerability are also examined and categorized. Reading for vulnerability brings insight into an important aspect of the health care process. Recognition of its importance should translate into changes in medical education and patient information.

Discourse Communities and the Discourse of Experience

Discourse communities are groups of people who share common ideologies, and common ways of speaking about things. They can be sharply or loosely defined. We are each members of multiple discourse communities. Discourse can colonize the members of discourse communities, taking over domains of thought by means of ideology.

The development of new discourse communities can serve positive ends, but discourse communities create risks as well. In our own work on the narratives of people with interests in health care, for example, we find that patients speak of their illness experiences as victims of circumstance; policy makers construct adverse experiences and challenges as opportunities to be taken; health care workers speak from a mixed perspective, seeing themselves as both victims and opportunists depending on context. To be trapped within the discourse of a particular community is to put at risk the ability to communicate across discourses. Membership of a discourse community can impair the habit of critique, and deny opportunities for heteroglossic discourse. Privileging critique as a mode of discourse perhaps might define the ethical community, suggesting that ethical community may be an antidote to the constraining effects of conventional discourse community.

Witnessing a body in decline: Men's and women's perceptions of an altered physical appearance

There has been a tendency within the literature to ignore how men and women who are very ill and at the end of life perceive and experience their visibly altered bodies. This article aims to provide new insights about this matter. A qualitative research approach was adopted. In-depth interviews were conducted with 10 hospice patients, 20 family members, and 20 members of hospice staff. Findings reveal that because of masculine and feminine norms, physical appearance is more a matter of concern to women than to men who are close to death. This contradicts theories that suggest that patients experience a disinvestment on their sense of masculinity and femininity alongside the process of bodily deterioration and decay prior impending potential death.

Professional patienthood and mortality: Seán Ó Ríordáin's diaries 1974-1977

Unwieldy by nature, unsolicited diaries and their study, this article contends, have the potential to offer deeper insights into the experience of illness but only if they receive due consideration from scholars. This article uses a series of historic diaries to examine the concept of 'professional patienthood' or being a full-time patient, and, while it found the narrative medicine approach to be very useful, it also found it limiting. The recent methodological trends in biomedicine and social sciences towards structured mechanisms like questionnaires-surveying and evaluating performance, satisfaction and experience-can only go so far. This article makes a case for the unsolicited, the unorthodox and the unstructured.

Women's Construction of Embodiment and the Abject Sexual Body After Cancer

Cancer and cancer treatments can cause significant changes to women's sexual well-being. We explored how women construct a sense of their bodies and sexual "selves" in the context of cancer. Sixteen women, across a range of ages (20-71 years), cancer types, and cancer stages, took part in in-depth semistructured interviews. We conducted a thematic discourse analysis, drawing on feminist poststructuralist theory, identifying "the abject body" as a dominant theme. Participants constructed abject bodies as being "beyond abnormality," "outside idealized discourses of embodied femininity," and "out of control." The women's accounts varied in management and resistance of the abject body discourse, through bodily practices of concealment, resisting discourses of feminine beauty, and repositioning the body as a site of personal transformation. The corporeality of the cancerous body can be seen to disrupt hegemonic discourses of femininity and sexuality, with implications for how women practice and make meaning of embodied sexual subjectivity.

The Immediacy of Illness and Existential Crisis: Patients' lived experience of under-going allogeneic stem cell transplantation for haematological malignancy. A phenomenological study

PURPOSE

This paper reports a study exploring the lived experience of fifteen men and women treated with allogeneic stem cell transplant (SCT) for haematological malignancy.

METHOD

The study followed an interpretive phenomenological methodology using semi-structured interviews. Participants aged between 22 and 68 years were purposively recruited from two specialist treatment centres and were interviewed within three months to one year post SCT between April and September 2013. Data were then analysed using interpretive phenomenological analysis.

RESULTS

An overarching theme that emerged from the data was: The Immediacy of Illness and Existential Crisis. The Immediacy of Illness and Existential Crisis developed from participants' experiences of critical events accompanied by enduring uncertainty continuing into the recovery period. Participants suffer major disruption to their lives physically, psychosocially and emotionally, including facing their own mortality, without a sense of when they may resume the normality of their former lives.

CONCLUSIONS

Ambiguity and uncertainty characterise the experiences of those with haematological malignancy. Whilst participants have access to specialist teams, there are opportunities for health and social care professionals to provide more support for individuals to come to terms with the critical events they have faced and to prepare them for their return home and to continue former lives and aspirations following prolonged hospitalisation.

The body mechanical: Building a caring community, crafting a functioning body

When Hansen's disease became treatable in Taiwan in the mid-20th century, a group of Hansen's disease patients lost their sick role despite still having lingering symptoms that continued to evolve. While sociologists have explored in-depth situations in which the social role of the sick is ambiguous, few studies have investigated body experiences under liminality that requires sick people to find a new sick role. Living with lingering symptoms in a post-Hansen's disease world, the Hansen's disease patients I have studied face the conundrum of having to find an alternative sick role. Ethnographic fieldwork demonstrates how patients develop a specific set of body techniques that shape and are shaped by their membership in a patient community. Exploring the reinforcing projects of re-embodiment and sociality around Hansen's disease, I argue that patients are able both to legitimate each other's feelings of sickness and to use those feelings to manage their illness and, as such, to collectively acquire an alternative sick role. Adding to existing discussions of active patients, this article identifies the body mechanical as a way of practicing active patienthood organized around fixing, trials, mending and functionality.

Liminality in Pediatric Palliative Care

Palliative care for infants, children, and adolescents encompasses numerous transitions and thresholds of uncertainty that challenge conventional clinical medicine. Palliative care clinicians have opportunities to be more comfortable amid such challenges, or perhaps even overcome them, if they are attuned to the unique times and places in which patients, their families, and caregivers find themselves throughout illness and recovery or transitioning toward the end of life. Patient-clinician encounters often dwell in these liminal places. The concept of liminality gives validation to the patient or family's being "stuck in places betwixt and between" a past life rich with relationship and purpose and an acute, chronic, or critical illness. Or having resolved the acute crisis of hospitalization that place between the past bounds of illness and the uncertain path forward, perhaps even toward death. Liminality provides a framework for addressing the unbound spaces that patients and families occupy: What is past is behind-the present place is tenuous and temporary, and what is ahead uncertain. This place is where palliative care clinicians can offer clinicians and families guidance.

Between Two Worlds: Liminality and Late-Stage Cancer-Directed Therapy

Disease-directed therapy near death is a growing trend among persons living with late-stage cancer. As a sociocultural phenomenon, cancer-directed therapy (e.g., chemotherapy) when given for very advanced disease is a process that offers questionable benefits and portends further suffering, but also suggests potential for growth and transcendence. Theories and concepts drawn from cultural anthropology, sociology, and existentialism illustrate how contextual factors contribute to the creation of a "liminal space"; the latter part of the cancer trajectory where living and dying can overlap. When applied to clinical practice, this theoretical framework gives the patient, family, and health care provider a way of "unmasking" a period of transition during terminal illness when aggressive disease-directed care continues to be provided. The liminal space may function as an existential plane; a gateway or threshold with inherent potential for psychospiritual development during the final stage of life.

Complex and dynamic times of being chronically ill: Beyond disease trajectories of patients with ulcerative colitis

This article contributes to health research literature by problematizing the linear, sequential and intelligible understanding of time in the studies of illness. Drawing on the work of Martin Heidegger, it attempts to overcome the problem of considering the time of illness as either a framework controlling patients' experiences or a mind-dependent feature of their lives. The paper offers a conceptual analysis of the stories of ulcerative colitis patients from a recent clinical trial to present temporalities of illness as both objective and subjective, relational and dynamic. We attend to a combination of temporalities related to the ambiguous unfolding of illness and patients' relationships with such an unpredictable world of changing bodies, medical practices and temporal norms. Furthermore, our analysis reveals openness of times and considers ulcerative colitis patients as constantly evolving beings, with multiple possibilities brought about by illness. The paper highlights co-existence of times and considers patients' lives as incorporating a multiplicity of futures, presents and pasts. It concludes with conceptual observations about the consequences of developing complex approaches to illness in health research, which can better highlight the situatedness of patients and their multi-dimensional temporal foundations.

Men's strategies for preserving emotional well-being in advanced prostate cancer: An interpretative phenomenological analysis

OBJECTIVE

This study explores men with advanced prostate cancers' own practices for promoting and maintaining emotional well-being using Interpretative Phenomenological Analysis.

DESIGN

Five men with advanced prostate cancer participated in face-to-face, semi-structured, in-depth interviews.

RESULTS

Within rich narratives of lost and regained well-being, two super-ordinate themes emerged--'living with an imminent and uncertain death' and 'holding on to life.' Well-being was threatened by reduced sense of the future, isolation and uncertainty. Yet, the men pursued well-being by managing their emotions, striving for the future whilst enjoying life in the present, taking care of their families and renegotiating purpose. Running through participant's accounts was a preference for taking action and problem-solving. Sense of purpose, social connectedness, and life engagement were revealed as concepts central to improving well-being, indicating areas which practitioners could explore with men to help them re-establish personal goals and life purpose.

CONCLUSIONS

The findings also add weight to the evidence base for the potential value of psychological interventions such as cognitive behaviour therapy and mindfulness in men with prostate cancer.

Celebrities and spiritual gurus: Comparing two biographical accounts of kidney transplantation and recovery

BACKGROUND

As a kidney transplant recipient I have long been exposed to a shortage of renal narratives and to a dominant theme in those that exist: transplant as restitution or redemption. My lived experience has, however, shown me that post-transplant life is more complex. Even after transplantation, chronic kidney disease requires lifelong health care with varying degrees of impairment, resulting in ongoing liminality for those who experience it. Nonetheless, as a transplant recipient I find the restitution or redemptive narrative pervasive and difficult to escape.

OBJECTIVE

I examined two seemingly very dissimilar insider renal biographies, Janet Hermans's Perfect match: A kidney transplant reveals the ultimate second chance, and Steven Cojocaru's Glamour, interrupted: How I became the best-dressed patient in Hollywood, to explore how the narrators treat chronic kidney disease and transplantation.

METHODS

In addition to a close textual reading of the biographies, I used my own experience of meaning-making to problematize concepts around restitution or redemptive narratives.

RESULTS

I found that the two biographies are, despite appearances and despite the attempts of one author to escape the redemptive form, very much the same type of narrative. The accounts end with the transplant, as is common, but the recipients' lives continue after this, as they learn to live with their transplants, and this is not addressed.

CONCLUSIONS

Emphasising restitution or redemption might prevent an understanding of post-transplant liminality that has unique characteristics. The narrator evading this narrative form must come to terms with a changed identity and, sometimes, fight to evade the pervasive narratives others impose.

Existential well-being and meaning making in the context of primary brain tumor: conceptualization and implications for intervention

When faced with a significant threat to life, people tend to reflect more intensely upon existential issues, such as the meaning and purpose of one's life. Brain tumor poses a serious threat to a person's life, functioning, and personhood. Although recognized as an important dimension of quality of life, existential well-being is not well understood and reflects an overlooked area of support for people with brain tumor. This perspective article reviews the historical underpinnings of the concept of existential well-being and integrates this discussion with theoretical perspectives and research on meaning making and psychological adjustment to primary brain tumor. We then provide an overview of psychosocial support interventions for people with brain tumor and describe the findings of a recently published psychotherapy trial targeting existential well-being. Overall, this article highlights the importance of assessing the existential support needs of people with primary brain tumor and their family members, and providing different avenues of support to facilitate the meaning-making process across the illness trajectory.

Resilience in adults with cancer: development of a conceptual model

OBJECTIVE

Resilience is a construct addressed in the psycho-oncology literature and is especially relevant to cancer survivorship. The purpose of this paper is to propose a model for resilience that is specific to adults diagnosed with cancer.

METHODS

To establish the proposed model, a brief review of the various definitions of resilience and of the resilience literature in oncology is provided.

RESULTS

The proposed model includes baseline attributes (personal and environmental) which impact how an individual responds to an adverse event, which in this paper is cancer-related. The survivor has an initial response that fits somewhere on the distress-resilience continuum; however, post-cancer experiences (and interventions) can modify the initial response through a process of recalibration.

CONCLUSIONS

The literature reviewed indicates that resilience is a common response to cancer diagnosis or treatment. The proposed model supports the view of resilience as both an outcome and a dynamic process. Given the process of recalibration, a discussion is provided of interventions that might facilitate resilience in adults with cancer.