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research-article2014

QHRXXX10.1177/1049732314533425Qualitative Health ResearchKlinke et al.

Article

Advancing Phenomenological Research: Applications of “Body Schema,” “Body Image,” and “Affordances” in Neglect

Qualitative Health Research 2014, Vol. 24(6) 824­–836 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314533425 qhr.sagepub.com

Marianne E. Klinke1, Björn Thorsteinsson1, and Helga Jónsdóttir1

Abstract In this article, we review the latest trends of data collection methods in phenomenological nursing studies. Subsequently, by using a philosophical analysis, mainly inspired by Merleau-Ponty’s embodied phenomenology and a case construction of an individual with hemi-spatial neglect—a common disorder following stroke—we explore the concepts “body schema,” “body image,” and “affordances.” Applying these concepts helps to illuminate the temporal, spatial, and perceptual world of people encountering discrepancy between perception and reality because of disease—a discrepancy seen in hemi-spatial neglect. Concepts to capture the multifaceted challenges that occur under these circumstances are lacking. Systematically incorporating the aforementioned concepts might help to advance phenomenological research and articulate these difficulties. We propose suggestions on data generation to reveal situated, meaning-infused, embodied experiences in patients with hemi-spatial neglect. The need to step beyond the privileged emphasis on interviews, toward experimenting with other approaches of data collection, is underscored. Keywords body image; data collection and management; embodiment / bodily experiences; interviews; lived experience; neurology; nursing; observation, participant; phenomenology; qualitative analysis In this article, we address existing conventions in phenomenological research, particularly in instances of illness in which patients are restrained in their ability to unequivocally express their experiences. In phenomenological nursing investigations, the rudimentary ambition is to scrutinize the changed subjectivity of experience. This in part involves a description of “what it is like” for the person(s) we investigate. Describing changes of selfhood in situations in which patients have complex perceptual problems is a challenge. A focus on the self often presupposes nonobjectifying experiential “givenness” and a distinguishing feeling of “mineness” related to a first-person perspective. Simply put, we act in a certain way because of the experiences we have (Zahavi, 2008). A comprehensive account of the self goes beyond the scope of this article; however, we briefly present elements of central importance for nursing research, such as the social and narrative selves and their mutual interdependence.1 The narrative self is often grasped by means of storytelling: I attain insight into who I am by situating my character traits, the values I endorse, the goals I pursue within a life story that traces their origin and development; a life story that tells where I am coming from and where I am heading. (Zahavi, 2008, p. 107)

The self is not exclusively reliant on a person’s own interpretation (or self-narrative) but is always bound to coauthors and various settings: “We enter upon a stage which we did not design and we find ourselves part of an action that was not of our making” (MacIntyre, 1981, p. 199). The social constituted self can therefore be seen as the reciprocal relationship between me, others, and world. Because of this interconnectedness, the insight into changes of self in illness requires pivotal elucidation of these three cornerstones, which might be accomplished by assuming an embodied phenomenological perspective.

Phenomenology and Embodiment Phenomenology was inaugurated by Edmund Husserl in the very beginning of the 20th Century (Zahavi, 2003). Phenomenology is concerned with appearances and experience and therefore includes a subjective first-person perspective (Zahavi, 2003). In the flow of experience, our 1

University of Iceland, Reykjavik, Iceland

Corresponding Author: Marianne E. Klinke, Faculty of Nursing, University of Iceland, Eirberg, Eiriksgata 34, 101 Reykjavik, Iceland. Email: [email protected]

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Klinke et al. awareness directs itself toward the world by its intentionality—object-directedness. We do not “merely love, fear, see, or judge, one loves a beloved, fears something fearful, sees an object, and judges a state of affairs” (Zahavi, 2003, p. 14). All forms of consciousness and experiencing, seen against this background, are related to a subjective system of worldly relations in which the body is the perceptual nexus (Husserl, 1954/1970). This is captured in the phenomenological expression “embodiment,” which embraces the uniqueness of the human body, a physical object through which we live, interact with, and experience the world (Merleau-Ponty, 1945/2012). Merleau-Ponty (1945/2012) elaborated even further on intentionality, exquisitely describing how the living body operates as a mediating agent between subjectivity and world, where subjective experiences and bodily function are linked with the environment through threads of intentionality. In Merleau-Ponty’s words, the body carries “with it the intentional threads that unite it to its surroundings and that, in the end, will reveal to us the perceiving subject as well as the perceived world” (p. 74). The threads of intentionality effectuate a synthesis between a given situation, the living body, and the world, and hence unravel the Cartesian mind–body dichotomy (Fuchs, Sattel, & Henningsen, 2010; Merleau-Ponty). The lived body also plays a role for experiencing the body of others through intersubjectivity and is thereby central in shaping our social encounters. Phenomenologically speaking, the body perceives, experiences, judges, and anticipates possibilities in life and is a constituting unity in mediating all experiences (Zahavi, 2003).

Exploring Changes in Embodiment Under normal circumstances, people might effectively express various dimensions of their lived experiences— or phenomena—as they appear to them. However, in many diseases, such as dementia and psychiatric and neurological diseases, the usual coherence between the person, others, and world is incomplete (e.g., Zahavi, 2008). When the bodily unity is disturbed, it can be complicated, even impossible, for individuals to overtly characterize what has changed for them with respect to the lifetransforming process of illness. The self dynamically evolves in action. For this reason, it relies deeply on amalgamation of temporality and spatiality of experiencing. A temporal unit should be understood as a synchronized whole formed by the immediacy of the concrete intentional act (“now phase”/primal impression), the prior intentional content (retention), and the indeterminate anticipation of what is about to occur (protention). This forms our time perception and thus frames present and future experiences in our immersed engagement of everyday life (Carel, 2011; Zahavi, 2003).

Changes in embodiment also affect the spatial structure of experience. In short, spatiality captures the synthesis of how the world appears to a person (felt space) and the space we prereflectively attune ourselves to during daily life (lived space): How the body inhabits space (and time, for that matter) can be seen more clearly by considering the body in motion because movement is not content with passively undergoing space and time, it actively assumes them, it takes them up in their original signification that is effaced in the banality of established situations. (Merleau-Ponty, 1945/2012, p. 105)

Multiple features that enlighten the temporality and spatiality of selfhood have been captured by Zahavi (2010): “[The self] will be intertwined with, shaped and contextualized by memories, expressive behavior and social interaction, by passively acquired habits, inclinations, associations, etc.” (pp. 5–6). This diverse multiplicity emphasizes the importance of using a rich variety of methods to disclose what has happened to a person during disease.

Trends in Nursing Phenomenological Research: The Pursuit of a New Emphasis The methods used by nurses to attain insight into patients’ experiences of changed embodiment during illness are almost exclusively in-depth interviews, widened by nonverbal expressions and description of contexts within the interview (e.g., Norlyk & Harder, 2010; Silverman, 1998). Such interviews have added substantial insight into how patients see things, and in most instances they provide an adequate foundation for describing disruptions of physical, psychological, and social well-being as experienced in illness (Silverman). An adequate phenomenological study, however, presupposes enhanced skills in providing details of contexts, reflecting and describing the directedness of the experience. Indisputably, this places extreme demands on the participants’ ability to submerge themselves in and communicate their experience. For some patients, this exercise is not an option, and their experiences have therefore been nearly absent from phenomenological scrutiny. People with mistaken perceptions, such as those occurring in hemi-spatial neglect or with inadequate ability to articulate and reflect sufficiently on their experiences—for example, persons with Alzheimer’s disease—are illustrative examples of cases that frequently have been placed outside the scope of phenomenological investigation (e.g., Cotrell & Schulz, 1993; Sundin, Jansson, & Norberg, 2002). It seems obvious that observations made by researchers might play an important role in illuminating the discrepancy between “beliefs and actions and between what people say and do” (Silverman, 1998, p. 114).

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Table 1.  Results of Search in Medline and CINAHL. Items Medline   Number of articles   Data sources

 Participants

CINAHL   Number of articles   Data sources

 Participants

Databases and Results   Initially, 96 hits occurred, but 33 were not phenomenological studies and were therefore excluded from further scrutiny; this left 63 articles for further inspection. Ninety-two percent of the studies used interviews/conversations as their data source, and 3% combined observations with interviews; 5% used either multiple sources or other forms of data such as communication through the Internet or reflective diaries. As is the case with the search in CINAHL, all studies in which observations were used were exclusively observing healthy participants such as nurses, students, or other health care professionals. Most participants were nurses, health care professionals, or nursing students (46%). Forty percent obtained data from patients, 11% from family or informal caregivers, and 3% were a mixture of those. None of the studies included patients who had difficulties in communicating or had distorted perceptional awareness.   The search initially produced 76 hits; however, 12 articles were excluded because they were not phenomenological studies; this left 64 articles for further inspection. Ninety-two percent of the studies only used interviews/conversations as their data source; 6% combined in-depth interviews with clinical observations and field notes, and 2% generated data from multiple sources, such as diaries, video recordings, and field notes. Studies using observations were exclusively observing healthy participants such as nurses, students, or other health care professionals. The majority of the studies (59%) gathered data from nurses, other health care professionals, and nursing students; 9% from caregivers/family; and 27% from interviews with patients. None of the studies included patients as data sources who had difficulties in communicating or had distorted perceptual awareness.

The potential of using observations in phenomenological research has recurrently been endorsed by prominent qualitative researchers (e.g., Benner, 1994; Dalberg, Drew, & Nyström, 2001; Munhall, 2003; Silverman, 1998; van Manen, 1990), albeit only sparsely revealed in the investigation of people with disordered perceptions. To determine the current trends of data collection involved in phenomenological studies, we systematically located studies published from January 2010 to December 2012 in the databases Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search terms “phenomenology” and “nursing” were applied. We included peer-reviewed research articles with available abstracts written in English. The search revealed that the vast majority (92%) of the phenomenological studies used only interviews to gather data. In 5% to 8% of instances, interviews were combined with observation or other data sources. None of the studies included patients who experienced distorted perceptions (see Table 1). The scarcity of using observations might be linked to inadequate concepts to explain the perceptual and temporal experiences of these people (cf. Sunvisson, Habermann, Weiss, & Benner, 2009). Accordingly, to rectify this situation, we suggest that the concepts body schema, body image, and affordances might enhance a phenomenological methodology that enables an

expression of changed embodiment. These concepts reflect knowledge from the first proponents of phenomenology such as Husserl (2002) and Merleau-Ponty (1945/2012), and have been further advanced by contemporary phenomenologists who have written about changes of embodiment in light of current developments within the cognitive sciences (e.g., Bermudez, 2005; Gallagher, 2005; Zahavi, 2008).2 Given that it would be impossible to account for all illnesses involving distorted perceptions in one article, the usability of body schema, body image, and affordances will revolve around a constructed patient case of an individual with hemi-spatial neglect. We hope that this article will bring attention to new ways of data collection in phenomenological research. In general, we hope to stimulate further debate of concepts that could be utilized to provide an increased sensitive account of the impact of illness, especially in situations in which discrepancy between perception and reality exist. The steps taken to conduct the philosophical analysis and to develop our argument in favor of expanding current concepts and methods used in phenomenological nursing research consist of the following: Initially we appraise contemporary conceptualizations of the body schema and body image. Subsequently, we describe the concept of affordances. We then suggest that affordances

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Klinke et al. provide an opening to describe the worldly yet situated changes occurring in the body schema and body image during illness. Variations of hemi-spatial neglect and typical clinical manifestations are described to illustrate the many ways it can disrupt normal perception. Finally, we construct a case of an individual with hemi-spatial neglect to reveal how pathological affordances can be captured in the phenomenological spirit. The practical implication of embracing the concepts body schema, body image, and affordances is presented, along with a brief description of how observations can be applied in phenomenological research of patients with hemi-spatial neglect.

Body Schema and Body Image The concepts body schema and body image are not innovative within a nursing context. Nurses have paid particular attention to the body image, primarily to clarify how people perceive their body and might experience difficulties in relating to themselves (Biordi, 2009; Niel & Barrell, 1998; Price, 1990). In contrast, the body schema has only been remotely referred to in nursing literature, and has even been described as just another term for body image (e.g., Biordi). Generally, these concepts have been detached from phenomenological interpretation. Nevertheless, the body schema has a strong phenomenological background, with Merleau-Ponty’s (1945/2012) explication of the “schéma corporel.” According to Merleau-Ponty, the body schema is integral to a unifying theory of perception—a theory in which all forms of experiences are mediated by close interaction between the body and the environment: [T]his is insofar as my body is polarized by its tasks, insofar as it exists toward them, insofar as it coils up upon itself in order to reach its goal, and the “body schema” is, in the end, a manner of expressing that my body is in and toward the world. (p. 103, emphasis in original).

In this quote, it is valued that a person’s bodily experiences are acquired through worldly (inter)action. The gestalt of bodily experiences involves the total sum of the body in prereflective action abilities linked to the world by threads of intentionality. The plastic nature of the body schema becomes obvious by its capacity to learn new skills, enrich, and reorganize itself to maintain bodily equilibrium (Merleau-Ponty, 1945/2012). Drawing on many ideas derived from Merleau-Ponty’s (1945/2012) embodied phenomenology and encouraged by important studies within the cognitive sciences, Gallagher (2005) pioneered the modern field of concept clarification of the body schema and body image. He located the body schema and body image within an embodied way of thinking, experiencing, and acting, and

with overlapping interfaces, in particular, of proprioception, vision, and touch. A key feature in Gallagher’s conceptualization is that a distinction between the body schema and body image becomes clear in situations of change. Changes, for instance, occur following brain lesions, when the body converts to a hindrance, or when usual functions are impeded. The body schema primarily consists of nonconscious, tacit, and amendable mechanisms that create possibilities within the perceptual field. It is infused with habit in an immediate, plastic use of the body, making the body capable of saturating goals and accomplishing daily tasks (Gallagher, 2005). This is equivalent to what MerleauPonty (1945/2012) would call operative intentionality: interconnected sequences in the enduring arc of perception and action. Practically, this function can be exemplified by the situation in which one hears the telephone ringing and stands up to answer the telephone, which is placed on the opposite side of the living room. While walking toward the telephone, the person’s intentions are not directed at his moving body but toward the ringing telephone—the object of his attention. The body schema seems to fulfil his intentions without any conscious reflection. During activities, the body constantly recalibrates according to the demands of the environment. Involuntarily, someone steps aside when somebody is about to collide with him, and after a night shift, the car seems to find its way home by itself. In these situations, a person might not proficiently be able to recall all the movements he made or even possess the ability to explicate them precisely. However, he would never doubt the fact that he was the one who stepped aside, and he most certainly would claim that he was in total control of the car. The body schema has incorporated these movements into its automatic fine-tuning ability. This provides instant holistic information about the “now” in the fluid interplay between self, others, and the world. When the body schema is at work, the intentional threads are aimed at objects or events outside of the physical body (Gallagher, 2005; Merleau-Ponty, 1945/2012). The fact that the body schema is not confined to the physical boundaries of the body increases the area for potential interaction between the body and the environment (Gallagher; Merleau-Ponty). The body image, unlike the holistic functions of the body schema, is often activated in situations in which a person focuses on his own body. This often occurs during medical examination or when people experience fatigue, stressful situations, pain, or pleasure. When such physical challenges occur, our awareness becomes directed toward isolated parts of the body; in other words, the body becomes its own intentional arc of directed emotions (Gallagher, 2005). Three main categories of the body

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image have been described, namely (a) body percept: individuals’ experiences of their own body; (b) body concept: individuals’ overall appreciation of their body; and (c) body affect: individuals’ emotional attitude toward their body (Gallagher, 2005). As might be appreciated, the body image always entails affectability and some degree of conscious awareness of one’s own body (Gallagher). The body also plays a dominant role in forming our perception of others, which can partly be explained through mirror mechanisms (Gallese & Sinigaglia, 2011). When people act, their intentions become “mirrored in our own capabilities for action [and]…their belief or desire is [therefore] expressed directly in their behavior” (Gallagher, 2005, p. 224). Intersubjectivity exists in all encounters with other persons and involves the ability to connect to others as subjects. This creates a built-in resonance between their expressions and our reactions: “Another’s tears make me feel sad, or I may be infected by his laughter. The body works as a tacitly felt mirror of the other” (Fuchs, 2005, p. 96); this inherently makes experiences a part of a shared emphatic world and surpasses a solipsistic line of thought (Zahavi, 2008). The body schema and body image can be extended with artifacts; for example, the visually impaired person’s use of a cane (Merleau-Ponty, 1945/2012). In this situation, the body schema might incorporate the cane into habitual bodily movement and the body image might integrate it into the overall body concept (de Preester & Tsakiris, 2009; de Vignemont & Farné, 2010; Gallagher, 2005). New skills can be also be developed and incorporated into the body schema, which has been exemplified by the nearly automatic movement of the typist’s fingers moving across the keyboard (Merleau-Ponty). In instances of sudden loss of function in either the body schema or the body image, the other system endeavors to redress the balance (Gallagher, 2005). This can be observed in the famous and often-referred-to patient case of Ian Waterman initially presented by Cole (1995).3 Ian Waterman suffered from acute sensory neuropathy and lost his sense of touch, proprioception, and tactile sense from the neck down. Consequently, he was incapable of locating his extremities but nevertheless could mobilize, ostensibly in a normal way, by using his vision to guide appropriate movement. If Ian Waterman closed his eyes or was placed within a dim space, he would collapse. Enhanced abilities of his body image apparently counterbalanced his failing body schema (Gallagher). When changes occur in the body schema and body image, these changes are always linked to a meaning (Zahavi, 2008). According to Merleau-Ponty (1945/2012) and Gallagher (2005), the anchoring of embodiment becomes obvious in the person’s confrontation with everyday demands. People primarily perceive in action,

and the world signifies meaning because of what we “can” do in it. Accordingly, meaning can be found by perceiving possibilities or affordances of a given situation, acting on them, and attuning oneself to opportunities.

Affordances The notion of affordances was first introduced by the psychologist J. J. Gibson (1986) and remains close in its basic motivation and content to Merleau-Ponty’s (1945/2012) embodied phenomenology. The theory of affordances thus complements embodied phenomenology and vice versa (Sanders, 1993). In principle, affordances can be characterized as possibilities of action that are inherent in the environment. To exemplify what an affordance is, a pen affords writing, a book affords reading, and so forth: [An] affordance is neither an objective property nor a subjective property; or it is both if you like. An affordance cuts across the dichotomy of subjective–objective and helps us to understand its inadequacy. It is equally a fact of the environment and a fact of behavior. It is both physical and psychical, yet neither. An affordance points both ways, to the environment and to the observer. (Gibson, p. 129).

Hence, the theory of affordances discerns values and meanings and seeks to unite dichotomous views, such as perceiver/perceived, inner/outer, sensation/perception, and mental/physical by collapsing their binaries. Unfortunately, we do not have the capacity to perceive all affordances in the world and therefore have a limited focus on perceiving affordances relevant to our activities. Quoting Gallagher and Zahavi (2012): Some object is at the centre of my focus, while others are in the background, or on the horizon.…I can shift my focus and make something else come into the foreground, but only at the cost of shifting the first object attended to out of focus and into the horizon. (p. 9)

An affordance necessitates a view from an individual person; it is always an affordance for someone. This might be independent of the person’s ability in a concrete situation to perceive a given affordance (Gibson, 1986). For instance, a car, stationary beside me, affords driving and transportation regardless of the fact that I might prefer to stand at that time. Even though my Halloween costume is hidden away in my closet and I do not think about it while working at the hospital, it still affords dressing up in it. If I imagine the costume formed as a huge sausage, it would still afford dressing up in it; however, it would not afford eating just because I perceived it as a sausage. If I tried to eat my Halloween costume, mistaking it for a sausage, one could truly say that I misperceived the

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Klinke et al. affordance or acted as though the environment offered an affordance which it did not (cf. Dohn, 2009).4 We suggest that these unrealistic, not-possible-to-cash-in affordances, when they occur because of disease, can be captured using the term “pathological affordances.” Pathological affordances are intimately related to a person’s belief system. A belief “is a mental state that aims to fit the way the world is [and] thus exhibits a mind-to-world direction of fit” (Clark, 2012, p. 56). When people misperceive affordances, the mind-to-world fit of beliefs has disintegrated. Actions undertaken by people who experience pathological affordances might seem peculiar to others. This can be traced to the fact that they see the world differently and out of proportion to common understanding. Gibson (1986) briefly mentioned the danger of mistaken perceptions: “Errors in the perception…are serious for a terrestrial animal. If quicksand is mistaken for sand, the perceiver is in deep trouble” (p. 142). However, a thorough account of the bias involved in these misperceived affordances is not available from Gibson’s analysis. Affordances are more than opportunities of the “I can”; they also encompass an ethical judgment of whether a person ought to make use of an affordance. When I go to work as a hospital nurse, I could choose to take my aforementioned Halloween costume with me and dress up in it while nursing patients; however, even though this is an available affordance, if I decide to make use of it, this might be viewed as outrageous from multiple angles: social, cultural, and practical (Heft, 2003). Affordances are always linked to possibilities of actions in individual circumstances. To exemplify, we return to the example of the car that affords driving. This affordance is personal, an affordance for me, not for everyone. For a 4-year-old child placed in the driver’s seat, the car would possibly afford honking the horn and making funny noises. The car would not afford driving because the child has inadequate capabilities to use it as such. In a similar vein, a standard chair would not afford sitting on if I were paralyzed from my neck and down, but would afford collapsing and possibly cause an injury (cf. Dohn, 2009). In these situations, it is obvious that we do not merely perceive affordances, but affordances are perceived in context and through possibilities, which again depend on knowledge and experience (Heft, 2003). Affordances are not just possibilities for actions by an individual; they also afford prospects of something acting upon him or her: “Each thing says what it is…a fruit says ‘Eat me’; water says ‘Drink me’; thunder says ‘Fear me’; and…[a person]…says ‘Love me’” (Koffka, as cited in Gibson, 1986, p. 138). A nurse might afford the ability for a patient to take a shower in a situation in which he otherwise would not be able to shower without assistance. In this way, affordances must not be reduced to an internal

realm of perceiving but extend to a form of coupling with the outer world. Thus, affordances encompass potentials through a constant flow of perception in a bidirectional relationship between oneself, others, and the world.

Affordances, Body Schema, and Body Image in Hemi-Spatial Neglect Important points that can be derived from the previous sections are that affordances are constantly transformed throughout a lifetime and are strongly linked to capacities of the body schema and body image. Affordances are founded on perception–action interdependence of intentional threads between a person and his world. In these relationships, individuals can extend, maintain, or lose their embodied skills. Affordances cannot be confined to what an individual agent perceives as an affordance but should also be considered with regard to whether perceived affordances are real or pathological. Affordances are relative to an individual’s capacity for (inter)action, which is determined by experience, knowledge, beliefs, and proficiencies. These factors, in turn, are shaped by the social, cultural, and ethical background—their appropriateness. In this way, affordances are always infused with personal meaning.

Affordances and Hemi-Spatial Neglect Altered abilities of body schema and body image and changes of affordances become evident in people with hemi-spatial neglect, a heterogeneous syndrome that often transpires following lesion(s) in the right brain hemisphere. This, in particular, leads to inadequate perception, attention, and response to visual, tactile, and/or auditory stimulus of the contralesional (left) space. Difficulties that patients with neglect encounter might include—but always surpass—sensory and motor deficits (Robertson & Halligan, 1999). Neglect is manifested when patients, for instance, leave half their dinner untouched, fail to notice people who approach them from the left, or collide with obstacles in the environment when mobilizing (Heilman, 2009). In extreme cases, patients have persistent gazeand head fixation toward the unaffected (right) side (Robertson & Halligan, 1999). Patients with neglect might also omit to move their left arm and leg, or have a postponed pace of movements, even when their motor abilities are intact. Additionally, they might fail to shave, clean, and dress themselves on the neglected body side (Heilman). In representational neglect, the ability to recall experiences is altered; for this reason, patients might only draw or verbally describe the right side of a remembered place or image (Brozzoli, Dematté, Pavani, Frassinetti & Farné, 2006). Many patients with neglect

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proficiently provide detail on their disability, but they are incapable of balancing those during task performance and might repeatedly collide with the same obstacles when ambulating (Heilman). Adjunct to the neglect syndrome are denial and anosognosia. Anosognosia encompasses ignorance and unconcern regarding personal disabilities. Thus, patients seem to lack information about themselves, and clinically, they might refute the existence of disabilities or act nonchalant/ perplexed when getting feedback about their problems (Orfei et al., 2007). Patients with denial might display augmented reactions, such as resistance or anger, when told about their difficulties (Orfei et al.). Denial and anosognosia can potentially put patients in danger because of overestimating their own skills (Heilman, 2009). In most circumstances, people with neglect, in spite of divergent (re)actions, have complete intellectual capabilities and unrestrained verbal communicative skills. The failure seen in hemi-spatial neglect severs the harmony of embodiment and interferes with “bodily intentionality, primary meaning, contextual organization, body [schema],5 gestural display, lived spatiality and temporality [which causes]…a concurrent disorganization of the patient’s self and world” (Toombs, 1988, p. 201). In a sudden loss of function of the body schema and/or body image, one “loses the ordinary sense of the world as ‘affording’” (Colombetti & Ratcliffe, 2012, p. 147). Therefore, when confronted with hemi-spatial neglect and related disorders, people need to redefine their embodied affordances because, as Gibson (1986) noticed, affordances are tied to our bodily action capabilities. In the following, we reveal how changes in affordances might be described within a Merleau-Pontian–inspired framework (1945/2012) of the phenomenology of the body schema and body image through a clinical case of a patient with hemi-spatial neglect. This will exemplify how the subjective phenomenological perspective can be illuminated. In a similar way, the concepts might elucidate the heterogeneity of the neglect syndrome while continuing to accomplish a unifying account. The clinical example was constructed based on the first author’s practical experience of nursing neurological patients.

The Case of Rachel Rachel suffered a stroke in the right hemisphere of the brain. When she woke up at the hospital, she seemed completely unaware that anything was wrong with her, despite the fact that she was paralyzed on the left side. When she was asked to lift up her left arm, she consistently raised her right arm, claiming that this was her left arm. Rachel repeatedly attempted to walk by herself, even though she was not capable of mobilizing independently. This placed her in danger of injury.

Subjective experiences of persons with hemi-spatial neglect have only been vaguely described in phenomenological health research (Tham, Borell, & Gustavsson, 2000; Tham & Kielhofner 2003), not reflecting experiences in the acute phase. However, the reader is encouraged to empathize with how Rachel might feel: not perceiving the challenges that appeared so obvious to everyone else. Imagine waking up in the hospital feeling confused and wondering, “What happened?”—asking yourself, “Why am I here?” You are informed by the staff that you had a stroke and now your left side is completely paralyzed. This makes no sense at all; you are clearly able to move your left arm—can lift it high in the air—and it is obvious that your arm is in fine working order. Your family arrives and you inform them that the physicians and nurses have lost their minds. It comes as a severe blow when they—the persons that you implicitly trust— also confirm that you are paralyzed. You feel trapped in a bizarre movie in which everyone insists that you are paralyzed and you endeavor to prove them wrong. Commonly, people with neglect show decreased severity of symptoms as time passes. In the case of Rachel, the neglect developed as follows. Rachel began to realize that it was true when other people told her that her left side was not functioning correctly. Nevertheless, she forgot it when she was not reminded. One day, she was accompanied to the bathroom for toileting and requested by staff to call for assistance before standing up. However, she temporarily forgot her inability to mobilize independently, stood up against advice, and collapsed. She realized that once again she had gotten it all wrong and felt deeply betrayed by her own body. Rachel then began to monitor other people’s reactions to observe if she was behaving appropriately. Subsequent to several months of rehabilitation, Rachel’s left-side paralysis had almost resolved itself and she returned home. Rachel had learned to provide herself cues to focus attention on her left side. She could now complete most chores successfully. Nevertheless, if distracted—by grandchildren, for example—she would frequently drop items carried by her left hand.

The Case of Rachel in the Context of the Phenomenology of Body Schema, Body Image, and Affordances The example of Rachel clearly illustrates how the deeprooted architecture of the body schema and body image suddenly transforms from a synchronous, familiar pattern of action and experience to a distorted one. Prior to the stroke, the border between Rachel’s self and the world was almost imperceptible; this habitual encounter provided predictability and afforded comfort and a sense of being in charge. Prior to the stroke, Rachel’s body schema

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Klinke et al. unreflectively processed the enduring flow of information. These deeply anchored intentional threads provided background information related to posture, position, experience, anticipations, and so forth. For Rachel, the salient, taken-for-granted grip on the world had escaped her control. It can be maintained that her body image, because of the neglect and denial/ anosognosia, had not incorporated changes of the body schema (the actual left-side paralysis) into awareness; therefore, she was oblivious to the contradiction in her own performance. This deficit can be characterized as a left-sided bypass of awareness including abnormal spatial dynamics. Hence, implicit lived spatial knowledge related to the position of her left body parts was absent, along with decreased recognition of objective spatial properties within the left space. For Rachel, spatial freedom was significantly reduced, yet the subjective perception remained intact. Rachel’s self-awareness within the temporal flow of action initially seemed located in the past, seen by her perception of unchanged bodily coherence. Consequently, her implicit expectations (protentions) were unaffected. From a phenomenological perspective, Rachel’s perception of the Merleau-Pontian “I can” (1945/2012) appeared undamaged even though she “cannot.” The collapsed alliance between the body schema and body image can be explained as a mismatch between perceived and real affordances, or the aforementioned pathological affordances. This discrepancy was noticeable in Rachel’s recurrent attempts to mobilize; in these situations, believed capacities failed to integrate with actual ones. The breakdown in Rachel’s body systems indisputably made her (re)actions bizarre to others—for example to her closest family—when she insisted that she could elevate her paralyzed extremity, but she failed to register that something was wrong. The losses obstructed her intersubjective relationships; her experience had evolved into a form of semisolipsism and diverged substantially from common understanding. This provoked feelings of isolation and an almost depersonalized perception of the world. Hence, she felt as though she were trapped in a bizarre movie. When Rachel initially was told that she was paralyzed, this remained in sharp contrast with her immediacy of bodily experience. Rachel first embraced the disparity between her body schema and body image when expected outcomes of action—temporal protentions—recurrently failed. The body moved to the forefront, and she noticed other people’s reactions and used them to evaluate if she was acting appropriately. This can be compared to a pronounced self-consciousness disturbing the normal temporal flow, but which nevertheless, with time, occurred in an almost involuntary way (cf. Sass & Parnas, 2003; Zahavi, 2008). Rachel needed to maintain a consistent level of alertness.

This continuous vigilance can be classified as a compensatory mechanism to counterbalance the rupture in temporal reflexivity in which the relation between the “now” experience and anticipation of consequences related to response had become an overtly mediated process; the intentional threads had been loosened. Thus, to fulfill her anticipations and fuse those into action, she needed to thoroughly contemplate her bodily abilities, mirror real abilities against former habits, and deploy cues to prevent bodily infidelity. Rachel’s experiences were clearly not confined to an egocentric form of processing, because she also perceived, compared, and responded to prompts from her surroundings. This assisted her in recalibrating the deficits of her body image and body schema to a level at which she was able to function without acting on pathological affordances. Even after Rachel was discharged to her own home and subsequent to noteworthy progression, her temporal flow of action performance was still compromised. The increased self-alertness had become incorporated into habit; however, the reclaimed equilibrium was fragile and easily disturbed by unexpected events. For a summary of characteristics of the disruption of embodiment seen in Rachel’s situation, see Table 2.

Incorporating Body Schema, Body Image, and Affordances Into Phenomenological Nursing Research Across different phenomenological traditions, some essential points used to describe phenomena have achieved near unanimous consensus among most nursing researchers. These points originate from Benner (1994) and encompass the subsequent (a) situation, both present and historical; issues for description are here related to social functioning, breakdown, confusion, and so forth; (b) embodiment; i.e., the exploration of embodied understanding and perceptual and emotional responses as well as the more habitual, taken-for-granted embodied reactions; (c) temporality; i.e., the projection of oneself into the future along with self-awareness that arises from past experiences; (d) concerns, or what matters for the individual; and (e) common meanings among a group of people sharing an experience (Benner). A residual challenge remains unsolved in how to describe and communicate experiences of hemi-spatial neglect so that they resonate actual embodied changes. A prerequisite for attaining parsimonious descriptions is to pinpoint concepts that sufficiently explicate the complexity of experiences that come into play in persons with disordered perceptions. For patients with hemi-spatial neglect, it is of particular importance to explore how the spatial intentional structure has changed, or how the changes in embodiment might lead to alterations in “what

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Table 2.  Summary of Characteristics for the Case of Rachel. Characteristics Acute phase Normal temporal reflexivity Unfulfilled protentions Surpassed experience of changes in the capacities of the body schema Decreased lived spatial freedom for perception/action; intact subjective perception of spatial freedom

Acting on pathological affordances Lack of intersubjective connectedness Chronic phase Rupture in temporal reflexivity Enhanced body image to guide movement for the purpose of not acting on pathological affordances Decreased felt spatial freedom, restructuring of lived space Monitoring capabilities of the body schema via exaggerated awareness of own body (image) Changes of intersubjective relations

Clarification Clarification of the characteristics seen in the acute phase Temporal flow has a normal velocity at which retentions/protentions merge together in the “now” moment of action The world appears chaotic; anticipations/protentions are not fulfilled, outcomes appear messy and unintelligible The capacities of the body schema have changed because of the constraints of the paralysis; appreciation is lacking because of denial and anosognosia. Rachel acts and assumes that coherence is still present between her body schema and body image. Her self-awareness is located in past capacities. Rachel lacks implicit spatial knowledge of the position of her left body parts (related to the body schema) and is detached from the objective spatial properties within the left space. Lived spatiality in the interaction between Rachel and her surroundings has decreased; she is incapable of perceiving/acting on stimuli presented on the left. Rachel’s subjective perception of spatial freedom is nevertheless intact. Usual affordances have become pathological. Rachel responds to the environment as if nonexistent affordances are available. Rachel experiences feelings of isolation and unpredictability because of diminished intersubjective connectedness with others. Clarification of the characteristics seen in the chronic phase Rachel needs to maintain a consistent level of alertness. The relation between the “now” experience and anticipations of consequences related to response has become an overtly mediated process. Even if augmented reflection can become near habitual, marginal self-attention is a prerequisite for Rachel to perceive affordances correctly. Rachel has lost perceptual faith in own abilities. She is on guard when sharing space with others because she knows that spatial abilities might be threatened by interference. The restructured spatial properties are not functioning in a complete prereflective way. Self-cuing and prompts from others/environment allow Rachel to adjust correctly to stimuli. The prior-to-stroke background features—usually belonging to the capacities of the body schema—are being consciously reflected on and have moved to the forefront. The changes have a subtle but profound impact on the equilibrium between Rachel’s self-others-world relations because the habitual can no longer be taken for granted.

I can see and what I can’t” (Gallagher & Zahavi, 2012, p. 8). This perspective mirrors both the implicit bodily understanding of space/spatial features and the person’s reflective understanding (Merleau-Ponty, 1945/2012). This might fruitfully be honored by portraying disruptions of the body schema (implicit spatiality), body image (reflective understanding), and the subsequent altered affordances. These concepts call for explicit incorporation into Benner’s (1994) aforementioned points. The seemingly standard elimination of persons with distorted perceptions from phenomenological scrutiny might be traced to the fact that people perceiving pathological affordances are considered unworthy candidates for participation, because worthy participants have been designated as those who give concise and precise answers; provide intelligible, clear accounts; do not continually

contradict themselves; and do not wander off (Kvale & Brinkmann, 2009). Yet incoherent reports and dissimilarity unavoidably awaken phenomenological curiosity and might be the very core of the phenomenon that we wish to investigate; e.g., hemi-spatial neglect. Merleau-Ponty (1945/2012) eloquently clarified that the sensor-motor abilities of the body contains a logic on its own, a logic that exists independent of explicit articulation. The body in action contains a primordial intentionality that shapes our immediate actions and picks up emotions displayed in other people’s faces. This innate bodily wisdom needs incorporation into phenomenological nursing research. The solutions can be found by sophisticating existing methods to study pathological affordances and incoherence between body schema and body image, and to assume a common

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Klinke et al. language to communicate them. Expanding the existing vocabulary by using the concepts body schema, body image, and affordances might facilitate new ways of describing alterations of embodiment during illness. Increased parsimony of research findings might also be achieved by virtue of the unavoidable move beyond interviewing—to merit the more anonymous functioning of embodiment as well—in which the active body, so to say, speaks in silence (Cutcliffe & Harder, 2009). Neglect and anosognosia affect the self because of the opacity that arises in bodily experiences; these emerging changes might, in short, be regarded as a temporal divorce between retention and protension and between the body schema and the body image. Under normal circumstances, the body functions behind the scene, but when unexpected bifurcation occurs, this opens an opportunity to describe the body’s ability to adjust on stage (Gallagher, 2005). Ambiguity in perception renders it inadequate to capture experiences by means of interviews only, because as Kvale and Brinkmann (2009) rightly would contest, such patients are not good interview subjects. They might speak confidently but lack proficiencies to illuminate spatial changes and perceptual biases. Committing to just interviewing, in patients with neglect, would therefore result in freefloating descriptions of experiences with little resemblance to—and anchoring in—reality. In contrast, the identification of phenomenal features must entail a synthesis of verbal exchange, sharing experiences, and observing. Describing both the seeing and doing of experience inevitably complicates the research process so as to make it appear fuzzy. Phenomenological investigation of hemispatial neglect certainly cannot be accomplished in a straightforward way. The remaining unanswered question is, How should we convey ideas presented in the foregoing sections into an approach pertinent to phenomenological nursing research?

Merging Phenomenology With Field Work For patients with neglect and anosognosia, phenomenological investigation in the acute stages—when the neglect is pronounced—necessitates that the researcher engages with the patients during daily nursing care. Notes from observation that provide a detailed account of the neglect-related activities, along with clarifications of the environment and patients’ verbal/nonverbal (re)actions, should be gathered. The insights that the researcher attains supply questions to use when connecting further with patients. To take an example, observations made when a patient only applies lipstick on the right side of the mouth can be additionally explored by asking, “Do you recall when we entered the dining room and your husband noticed that you had only put lipstick on the

right side of the mouth? How was that for you?” To illustrate another problem, the researcher might ask, “How was it for you when you discovered that there was more food left on your plate?” when the patient is confronted with overlooking half his dinner plate. People with distorted perceptions look at the world differently; therefore it is vital to describe for which issues the patient’s perspective differs from the researcher’s, and to compare the researcher’s observations with the patient’s account. In short, this can be understood by means of the following three overlapping dimensions: (a) subjective dimension; aspects encountered only by the person with neglect; (b) others’ dimension; i.e., the researcher (possibly others who experience the neglect behavior in proximity) identifies pathological affordances as encountered by the person with neglect but which remain absent from his or her immediate awareness; and (c) intersubjective dimension: sharing of an experience. This dimension contains a common stage of experience recognized by both the researcher and the person with neglect. A brief example of how these dimensions can be incorporated into phenomenological research is illustrated in Table 3. The balance between these dimensions cannot be predetermined but should be customized to the patient’s unique symptoms and the severity of neglect. Thus, it is likely that in the acute stages, there is less space for intersubjective understanding that might be counterbalanced by describing pathological affordances. Relying solely on the researcher’s observations, however, would prevent the phenomenological analysis from being placed within a temporal flow of perception, encompassing prior experiences, engagement, and expectations in a life with neglect. Nevertheless, interviews cannot stand alone, because they remove important issues of intersubjectivity and the spatial, action-related elements of the experience. The temporal/spatial analysis related to the body image, body schema, and affordances hence provides a launch pad for moving phenomenological nursing research forward into an enactive amalgamation of subjective experience and expressive behavior (cf. Zahavi, 2008). On a par with this, the prospect of engaging with patients for an extended period should be acknowledged. This long-time engagement might provide important data on how the organization of changed embodiment becomes adjusted with time. In a Gibsonian (Gibson, 1986) spirit, it can be spelled out how experiences that seem to leave existence in neglect re-enter existence; for example, during the course of rehabilitation (Gibson, Kaplan, Reynolds, & Wheeler, 1969). Such knowledge might potentially be of value when considering effective strategies to enhance recovery. Knowledge attained from the analysis of Rachel’s case reveals the importance of pushing the boundaries of what is considered appropriate context in nursing research.

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Table 3.  Incorporation of the Three Research Dimensions. Experience Situation Subjective dimension

Others’ dimension Intersubjective dimension

Incorporation What happened? The researcher describes the situation and contexts/environment in which the situation occurred. Were there any distracting/motivating elements present? Prior experiences, thoughts, feelings, anticipations of the patient are sought. The researcher might, for example, ask, How do you feel about this situation? Can you describe how you reacted/felt while this was going on? Have you experienced another similar situation that you could describe for me? Has this situation changed? Can you describe how this affects you? How did you experience the environment? Can you describe what you observed in the environment? Do you feel that anything is missing compared to how it was before? Can you provide details on that? The researcher’s actual observations from multiple daily common activities are used to explore further into the subjective dimension. Identification of pathological affordances. How did the researcher see the situation compared to the patient’s perspective? Here might also be included the perspectives of other persons who have experienced the problems related to neglect in proximity. Coformation of meaning between the researcher and patient. The researcher engages naturally in important/meaningful activities to see/experience the immediate implicit response related to daily life.

Recognizing that affordances in life with neglect are multidimensional and embedded in intentional structures of action helps in anchoring the phenomenological research to realms of value and motivation, and hence closer to lived reality. Accepting uncritically what others tell us, when their perceptions are mistaken, without considering other means of embodied expressions, is not phenomenology. Merging observation and interviews can bring us closer to avoiding a bias that occurs when mistaking “phenomenology for a subjective account of experience,” whereas this “subjective account of experience should be distinguished from an account of subjective experience” (Gallagher & Zahavi, 2012, p. 21). Phenomenological data collection cannot be confined to a rigid set of procedures. It needs to be amended in response to the distinctive phenomena we investigate. Affordances provide a fresh way of describing changes of the body schema and body image in illness, while keeping a phenomenologically unique perspective of embodiment at the forefront.

Concluding Remarks

would be free-floating, not reflecting the interplay of temporality/spatiality and perception/reality. Instead, alternative ways of investigating embodiment are called for. Merging observation, interaction, and first-person experiential perspectives provides important insights into the experience of people living with hemi-spatial neglect and similar challenges. The concepts body schema, body image, and affordances might help to carry phenomenological nursing research into new pathways of discerning and exploring discrepancies in embodiment. Acknowledgments The authors acknowledge helpful suggestions on a preliminary draft of the article from Dan Zahavi and Haukur Hjaltason. We owe gratitude to Esther Gunnarsson for assistance with the English language.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

In this article, we have expanded the potential use of phenomenology in nursing science and argued that various, diverse modes of human experience can be investigated from a phenomenological perspective. Interviewing people and uncritically accepting their expressed illness descriptions without a phenomenological description of how they act and respond in their worldly engagement is unsatisfactory in instances of hemi-spatial neglect and in other cases of disease in which people are challenged with distorted perceptions. Such illness descriptions

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Doctoral grant, recieved by Marianne E. Klinke, from the University of Iceland.

Notes 1. For a comprehensive discussion of different forms of selves, we refer the reader to the book Subjectivity and Selfhood: Investigating the First-Person Perspective, by Zahavi (2008).

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Klinke et al. 2. The cognitive sciences here denote psychology, neuroscience, philosophy of mind, and any other disciplines whose research projects revolve around “what the mind is,” “how it works,” and “how it can be investigated” (cf. Gallagher & Zahavi, 2012). 3. The case of Ian Waterman provides merely one example of a situation of dissociation between the body schema and body image. Several other diseases might result in other kinds of dissociation; for example, phantom limbs, anorexia nervosa, different disturbances related to hemispatial neglect, and so forth (Gallagher, 2005). 4. The idea of presenting affordances through these examples derived from Dohn’s (2009) explication of affordances as she described them in the context of computer-supportive collaborative learning. 5. Toombs deployed an incorrect translation of MerleauPonty’s “schéma corporel,” rendering it as body image instead of body schema (Toombs, 1988, p. 201).

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Author Biographies Marianne E. Klinke, RN, is a PhD student at the Faculty of Nursing, University of Iceland, and a clinical nurse in the Department of Neurology at Landspitali University Hospital, Reykjavik, Iceland. Björn Thorsteinsson, PhD, Phil, is a research scholar at the Institute of Philosophy, University of Iceland, Reykjavik, Iceland. Helga Jónsdóttir, PhD, RN, is a professor and dean of the Faculty of Nursing, University of Iceland, and head of Section Research and Development in Nursing Care for the Chronically Ill, Landspitali University Hospital, Reykjavik, Iceland.

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