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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
How real is reality?
The theory decides what we can observe.
Albert Einstein
How real is reality?
Understanding communication implies that both parties find themselves in an identical reality. This in turn implies that there is no absolute reality, but countless perceptions of reality, which can be very contradictory. Mutual understanding is impossible if a "sender" and a "receiver" are unable to communicate in identical reality with one another.
The identity of realities is therefore the absolute and indispensable prerequisite of an understanding doctor-patient discussion.
If it is not possible to find an identical reality with the other, not only is discussion useless but it can be downright dangerous, since misunderstandings are inevitable. Not finding a mutual reality is probably one of the major reasons for disordered communication between people, ranging from conflict between tenant and landlord, through the generation differences right up to conflicts between international power blocks.

The phenomenon of differing realities and their relationship to transactions in communication has been described in particular detail by Paul Watzlawick in his book "Wie wirklich ist die Wirklichkeit?" (How real is reality?), which should be read by anyone concerned with communication. The following 3 examples, which should clearly explain the phenomenon of differing realities, have been taken from Watzlawick's book.

1st Example:

A laboratory rat explained the behaviour of the research worker to another rat: "I have trained this human, so that he gives me food whenever I press on this lever". It is obvious that the rat applies another law to that of the research worker to the same sequence of reactions. The researcher sees the pressure of the rat on the lever as a trained reaction to a stimulus that he has just given it. However the reality of the rat is that pressing the lever is a stimulus with which it lets the man know that it wants food, to which he provides food as he has been trained to do by the rat. Watzlawick: "In spite of the fact that both see the same thing (event), they both attribute different meanings to it, and experience two completely different realities from it".

2nd Example:

Tables of random numbers are produced by a randomizer, which creates long lists of the 10 characters in our system of counting. In one of the obviously random series of numbers, 0-1-2-3-4-5-6-7-8-9 suddenly appears. Our immediate impression would be that the randomizer has "failed", as this series is completely organized and could not be a coincidence or random. However the mathematician will tell us otherwise; the series 0-1-2-3-4-5-6-7-8-9 is just as likely to be ordered or random as any other combination of ciphers in our decimal system. It is after all our arbitrariness which decides what counts as a series and what not. The presumption that the series of numbers is ordered is a typical reversal of the first (objective) and second (subjective) order of reality. In objective reality, the series of numbers is just as unordered as the series 4-1-5-9-2-6-3-7, but it appears to us to be ordered in the subjective reality, as it follows principles that we have laid down.

3rd Example:

A man arrived in heaven and met an old friend, on whose knee sat a beautiful girl. "Wonderful", exclaimed the newcomer, "is she your reward?" "Oh no", replied the old man sadly, "I am her punishment".

Watzlawick calls the belief that there is only one reality, "the most dangerous of all self-deceptions". He insists "that there are more suppositions of reality than can be counted, which can be very contradictory, all of which are the results of communication and none of which reflect eternal objective reality".

There is said to be no absolute reality, but only subjective, in part completely contradictory, presumptions of reality. It is naive as well as dangerous to presume that one's own subjective reality is the "true" reality. First order reality is that in which aspects of reality are agreed upon by all concerned, and based on experimental, repeatable and thereby verifiable evidence. Reality of the first order can be defined unequivocally into physical and chemical categories by scientific methods.

At first glance at the picture ...Watzlawick gives the example of gold: "The first order reality of gold (that is its physical characteristics) are completely known and can be verified whenever necessary. The meaning that gold has had in human life since ancient times and the fact that it is given a value (which is a totally specific aspect of reality) twice a day in the City of London, and that this attribution of worth largely determines many other aspects of our reality - all this has very little, if at all, to do with its physical characteristics. It is however this second order reality of gold which can make one immensely rich or bankrupt."

Discussion about the meaning and the worth of events, facts or situations, although they may be clearly defined in the first order of reality, is completely different as they cannot be clearly defined. Meaning is highly subjective and arbitrary. In fact a single thing may have very many realities of the second order, and each of them is subjective and by itself "real". It is absurd to fight over what is really "real" in second order reality. As the subjective reality of the second order is as convincingly "real" as is reality of the first order, there is a very great danger that we forget the difference. It may be that we are not even aware of the existence of two different sorts of reality.

At first glance at the picture most people see the profile of a young lady, but others the face of an old woman. The observer who does not manage to "switch" from seeing one to suddenly seeing the other, can be given the following cues. The cheek and jawline of the young lady makes up the long nose of the old woman. The left eye of the old lady is the left ear of the young one.

The velvet neck-band of the young lady is the mouth of the other and the right eye of the old woman is a bit of the nose of the young one. Whichever woman was seen first is the "right" one. However this was not the only "right" face that could be seen in the picture. In other words, our perceptions of truth are always "correct", but they may not be the only single, correct and possible perception. It is the differing individual perceptions of one and the same thing which create the various subjective realities, of which that of one person is just as real as that of another.

It cannot be overemphasized just how vital it is to recognize the phenomenon of first and second order realities, and what fatal misunderstandings can arise from ignorance of differing realities or not taking them into account.

If the doctor is unsuccessful in grasping the individual reality of a patient with whom he is speaking, and in finding a common reality, all his efforts will be in vain and perhaps even dangerous. Asking oneself: "Am I and my patient talking about an identical reality?" is of fundamental importance. It is amazing that even brilliant scientists have difficulties in accepting that there is not only one reality. For example, in 1926 Heisenberg attempted to convince Einstein that only things which could be observed should be used for the construction of a theory. It appears that Einstein had changed his views in the meanwhile and is said to have answered: "It is thoroughly incorrect to try to construct a theory only out of that which can be observed. In reality, the opposite applies. The theory decides what we can observe." In other words, it is not what we see that decides our perception, but our perception decides what we see.

Von Uexküll also emphasized the fundamental importance of the phenomenon of differing realities. He insists that human life is characterized by a fundamental paradox: "We live in two apparently mutually exclusive forms of existence. On one hand we are unable to extricate ourselves from enclosure in our individual reality. Each of us can only be sensitive to his own sensitivities, feel his own feelings, think his own thoughts. However hard we try, we can never ever be sensitive to what others are sensitive to, feel their feelings as they feel them or think their thoughts, even when they are those we know best. We can not overcome the boundaries which separate our world from that of others. Every one remains an outsider with regard to the reality of the other." He goes on: "On the other hand it is irrefutable that we are just as much bound up with other people in common realities. These common realities also have limits (barriers) which separate the insider from the outsider. We recognize the common reality of theoretical physicists, barristers or doctors, just to name a few examples ... Our social world is a highly complicated tissue, in which the boundaries of the most varied sorts of realities overlap. Recognition of this fact touches on the basic question of how communication (that is, a connection between two individual realities) is actually possible." Von Uexküll gives the answer: "Only if a common reality can be achieved".

The linkages in discussions between doctor and patient
The linkages in discussions between doctor and patient.
This poses the problem of how a common reality can be found. To solve this, it is very important to recognize so-called semantic barriers where the realities differ. Semantic barriers separate insiders (who understand the code) from outsiders (who have not achieved this code). The signs by which the insiders interpret their reality and understand one another, must remain incomprehensible to the outsider. This fact can be better understood if the term "rules of play" are used instead of the word "code". If one knows the rules of chess, one can either play or watch the common reality of "playing chess" - one is an insider; those who do not know the rules remain outsiders, for whom chess presents a completely incomprehensible reality. "The problem of communication can be described as the search for common rules of play or common codes", says von Uexküll.
The determination of a common reality is the foundation of communication between doctor and patient and of course also the foundation of communication between all people.
Only on finding a common reality are people able to understand each other and to deal with each other correctly. Discussion is the ideal method by which people seek a common code, find it and at the same time make sure that they have found this code.

Von Uexküll: "Doctors and patients live in different realities. Doctors and nurses see pain, of which patients complain, as a symptom of disease which has an objective course. This is above the head of the patient as an outsider. He is enclosed within his own reality, in which pain and illness have a fateful meaning." The task of the doctor is to determine a common code for these different realities, or common rules of play: that is, to find an identical reality with the patient. Understanding and successful communication is impossible without it. 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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