Tapping into the unimpossible: Philosophical health in lives with spinal cord injury

Background: We investigated the personal philosophies of eight persons with a tetraplegic condition (four male, four female), all living in Sweden with a chronic spinal cord injury (SCI) and all reporting a good life. Our purpose was to discover if there is a philosophical mindset that may play a role in living a good life with a traumatic SCI. Methods: Two rounds of in ‐ depth qualitative interviews were performed by the same interviewer, a philosophical practitioner by training (de Miranda). The second round systematically covered the following elements: bodily sense, sense of self, sense of belonging, sense of the possible, sense of purpose and philosophical sense. This six ‐ step method developed by de Miranda is called SMILE_PH, an acronym for Sense ‐ Making Interviews Looking at Elements of Philosophical Health. Results: All the interviewees, as a consequence of their trauma, reported having gone through a reinvention of themselves which implied questioning the meaning and purpose of their life in particular and life in general. A philosophical rather than realistic sense of the possible was abstracted toward teleological growth. All interviewees developed a sense of purpose based on self ‐ interested altruism and solidarity with disabled peers. Conclusions: To reinvent a good life with SCI, in addition to physical training and willpower, one needs to consider philosophical questions about the self and life, what Kant called the cosmic interests of reason: What may I hope? What must I


| BACKGROUND: 'WE HAVE SOMETHING THE WORLD NEEDS'
What role may philosophical health-sometimes called existential health 1 -play in a posttraumatic rehabilitation process?Which philosophical perspectives may promote human flourishing in people with severe trauma?The background for our study is the domain of philosophical health [2][3][4] : 'Philosophical health is a state of fruitful coherence between a person's ways of thinking and speaking and their ways of acting, such that the possibilities for a sublime life are increased and the need for self-and intersubjective flourishing satisfied'. 4,p. 1 Binswanger spoke of existential therapy as Wiederermöglichung, 'repossibilization'. 5,p.255The sense of the possible is, from the philosophical health point of view, a good candidate for a nonmechanistic and more holistic approach to health.Hadot, 6 Foucault 7 and Nussbaum 8 have made it clear that philosophy was originally linked to a deep concern for therapy.
Foucault locates the source of the idea of philosophical health in the Platonic and Socratic conception of 'epimeleia heautou', 7,p.65 the care for the soul or self.Epistemic care is conceived by Plato as a necessary condition to become a good citizen via healthy embodied ethics. 9The philosophical self was an inspirational reconnection with the divine and the sublime in us, or entheos, 10,p.195,11What is a truly healthy person if not a mere functioning biological body?'The True is the whole', writes Hegel in the Phenomenology of Spirit 12,p.11: philosophy has always been the discipline that attempts to care about a whole rather than some of its parts.p.2447][18][19] But could the philosophical health approach be applied to severe trauma, such as for example spinal cord injury (SCI)?
Traumatic SCI is a major life event with very challenging and permanent physical consequences.This typically elicits an existential crisis for the newly-injured person.p.9SCI comprises severe physical disability in the presence of intact mental functions and the current rehabilitation paradigm for SCI has been criticized for being too focused on physical coping, for basing interventions on preconceived assumptions about which goals and outcomes are desirable for the patient, and for imposing priorities in goal-setting without properly investigating what matters deeply to each patient. 24,25The primary rehabilitation period following acute SCI has been perceived as focusing on establishing maximum physical function and developing a homogenized SCI identity. 25,26Psychopharmacological prescriptions and intensive physical training dominate, 27 and deep regular dialogue is usually avoided.
The authors of Re-Thinking Rehabilitation 24 suggest that rehabilitative care should be more holistically viewed, as 'a process of enhanced engagement in living'.Practice models have recently argued for the inclusion of patient perspectives or values in clinical decision-making, 28 suggesting a reframing of the patient as an expert with a central role in the production of rehabilitation knowledge.Research is also moving away from the perspective that equates 'disability' with inevitably detrimental effects on well-being. 29Fricker 32 highlights that in cases of testimonial injustice, a speaker may not be believed or given due credence specifically because they are a member of a group that is the subject of stigma; disability-positive philosophers recently noted a troubling tendency to dismiss what disabled people say about their well-being. 30e should not ignore reports by persons having sustained an SCI who, after completing the rehabilitation process, indicate spiritual/personal growth. 23Despite social and individual obstacles, such individuals seem, we would propose, able to transcend their condition of dis-ability into one of expand-ability: we will show here that although an SCI (or any other severe condition) will indeed put restrictions on certain activities, it is nevertheless possible for the patient to articulate a good sense of the possible, an active affirmation of an 'unimpossible' future. 33garding overall life satisfaction, Western people with SCI were found to be at a similar level as the general population. 34Individuals with a higher level of impairment may report lower life satisfaction and physical well-being, but higher mental well-being. 35A growing body of evidence suggests that the self-reported welfare levels of disabled individuals are no worse, and even sometimes better, than those of nondisabled people.This has been called the 'disability paradox' 22 : '[Before the accident] I remember thinking clearly […] that if it ever happened to me, I could not stand it.I would want to kill myself.p.211Recently, several authors with a disability have offered accounts of how their disabilities have made their life more valuable: 'Are we [disabled people] "worse off"?I don't think so.Not in any meaningful sense.[…] We take constraints that no one would choose and build rich and satisfying lives within them. p.138

| METHOD: FROM BODILY SENSE TO PHILOSOPHICAL SENSE
Phenomenologically-minded researchers seek to understand lived experiences by listening deeply 3 to subjective evocations of experiences. 36Common tools are the phenomenological qualitative interview 37 and other approaches to sense-making. 38In all cases, subjects contribute to the knowledge generation process in reciprocal interaction with the interviewer. 39Rather than a measuring or rationalist stance, an empathic and understanding stance is needed to co-create or approach meaning during these first-person exchanges. 40p.480 .
With the approval of the Swedish Ethical Review Authority (Dnr 2021-04898), and the recruiting help of the Swedish NGO Aktiv Rehabilitering, we conducted between January and April 2022 a series of individual in-depth interviews with 8 persons (four females, four males) who had been living with tetraplegia due to SCI for more than 15 years.All these interviewers were previously identified-by their community and themselves-as flourishing.The interviews (45 min each on average), were conducted by one of us (de Miranda) face-to-face via the internet.With the authorization of the interviewees, the conversations were recorded for image and sound and then transcribed into text.
The first set of interviews was conducted according to what could be defined as a rationalist approach, epistemic but 'beyond method'. 42The interviewer started the conversation by asking the participant: 'What is your personal philosophy of life?' or 'What is most important for you in life?'.Even though the interviewees had been informed that this study was to focus on their philosophical stance, they were, in the first few seconds or minutes, taken aback by the magnitude of the question, often expressing some form of puzzlement or difficulty in answering.This is not without analogy to the puzzlement of Socrates' interlocutors in Plato's dialogues, partly due to his stubborn insistence on epistemic utterances.The Socratic dialogue or epistemic interview is an interview form that wishes to reveal knowledge (episteme) rather than opinions (doxa), and this can seem particularly fit for studies about philosophical stances. 43But this can turn into an overly conceptual, rationalist approach that forgets that while we are all capable of philosophizing, this form of dialogue needs ideally a progressive and pedagogic tempo.How the interviewer calls forth the interviewee's thoughts and impressions has a direct impact on the quality and specificity of the answers. 42 preparation for the second round of interviews, which happened some 3-6 weeks later on average, de Miranda elaborated a more progressive, heuristic and structured sense-making approach (SMILE_PH: Sense-Making Interviews Looking at Elements of Philosophical Health) based on six steps: 1-the bodily sense, 2the sense of self, 3-the sense of belonging, 4-the sense of the possible, 5-the sense of purpose, and 6-the philosophical sense.By talking with the interviewees consecutively through these six elements in that order, such that the philosophical sense was this time only addressed toward the end of the interview rather than its beginning, we observed that the interviewees were much less disoriented and more comfortable in their words and capable of generating sharper, more specific insights.De Miranda's sense-making method does not focus only and immediately on the higher-cognitive dimension of our philosophical sense but rather proceeds step by step from a primary dimension of embodiment and sense of self, to awaken, sooner or later, the conceptual worldview.Sense-making is about continually redrafting an emerging narrative.44 The goal of sense-making dialogue is to cocreate an epistemically just understanding of experiences, values and views that often go unexamined.Sense refers to an embodied perception that attempts to evaluate its environment and code it into meaningful action or thinking.
The six steps of the SMILE_PH method are:

| Bodily sense
'Tell me about your bodily sense; how you feel and perceive your body'.The first step in the SMILE-PH conversation is connected to our irrefutable experience of physical presence in the world. 45p.90 .We are embodied living creatures with a continuous inner relationship to life, the variations of which we can sense. 47

| Sense of self
'Tell me about your sense of self, how you perceive and feel about your self'.A sense of self arises after considering our embodied connections. 36Human subjects define themselves as distinct individuals.Our experience tends to distinguish the body and the self.

| Sense of belonging
'Tell me about your sense of belonging…' Like the previous senses, it can be perceived as depleted, problematic or fulfilled.Theories about this particular sense distinguish, on the one hand, pathological forms of belonging such as groupthink, and on the other hand, eudynamic forms of belonging or 'well-belonging'. 48

| Sense of the possible
This step of our SMILE_PH method wonders about the sense of the possible of the interviewee.pp.246-247The possible is the core concept in de Miranda's crealectic approach to philosophical health. 2,3,51Husserl, 52 Binswanger, 5,p.255  produce something which may or may not become actualized; it is the intuited gateway to transforming virtuality into reality. 51

| Sense of purpose
'Do you have a sustained sense of purpose?'An agent acts and thus self-regulates to achieve something, and in so doing the attempt can either succeed or fail. 55Actions, unlike random movements, are teleological, goal-directed and hence normative, but they are also teleological in the more elaborate sense that they may be related to a higher meaning and value-guided conduct 56 ; in some cases, a vocation in the Weberian sense. 57It is not frequent to find a clear and explicit sense of purpose in individuals.

| Philosophical sense
This step arrives at the end of a SMILE_PH interview to espouse the common phenomenological experience of the world and of ourselves, as opposed to what we have called the rationalist or epistemic approach, which tends to assume that everyone is a spontaneous philosopher capable or answering the question of philosophical sense without the mediation of progressive steps.Philosophical sense requires more than searching for particular solutions to perceived problems; it requires the ability to look beyond the immediate needs, into a wholesome state of consideration based on evolving metaphysical, social, political and economical ways of living in and seeing the world. 58The philosophical impulse is the impulse not only to interrogate but also to de-and reconstruct our understanding of our lived experience. 59 the SMILE_PH interview unfolds, dialogical listening and sense-making empower the interviewee by raising awareness about their understanding of (their) life and helping them to articulate at least fragments of a personal philosophy.We prefer the phrase philosophical sense to, for example, meaning in life, 60 because it is more inclusive: one can be awakened to the philosophical energy of thinking about life's meaning without necessarily achieving a clear systematic worldview.The ambiguity of the term sense is useful: sense can be meaning, or it can be an impression, an intuition.Most of us can intuit a deep orientation, a conceptual mood of our destiny, without always being able to formulate it.Philosophy is not a set of dogmatic results and definite truths reserved to a minority of elite thinkers, but rather the persistent quest for epistemological coherence, manifested implicitly as soon as we talk, whether we are or not aware of it.It is difficult for most people to express their philosophical worldview explicitly, and people with SCI are no exception.Philosophical sense is an awakening to the intellectual energy in us that wonders and searches for an overarching explanation.This cognitive enquiry attempts to consider the whole lived world rather than only one or a few of its parts.

| RESULTS: 'EVERYTHING IS POSSIBLE'
All the interviewees, as a consequence of their trauma, reported having gone through a reinvention or redefinition of themselves that implied questioning the meaning and purpose of their life in particular and of life in general.Following the structure of the SMILE_PH method, we present below perceptions that most interviewees shared.In quotes, we will include anonymous sentences pronounced by different interviewees to illustrate stances shared by most of them with some differences in degree or qualification.

| Bodily sense
After an SCI, the perceptive connection with the body is more or less

| Sense of self
The initial time period after sustaining an SCI, which may last a few months or a few years, typically elicits an identity crisis: 'I didn't know who I was because I could not perform anything that I did before'.Progressively, a problematic bodily sense can slowly be compensated by a strong and developing sense of self: 'I want to be more me'.The mind can affect not only the self but also the world: 'I can take charge of my life'.A good sense of self is about the 'fighting spirit' that self-esteem can bring.One aspect of self-respect can be connected to some form of self-directed gentleness: 'I never blamed myself for the accident'.The weight of the past is replaced with a forward-looking attitude: 'I felt that I am just going to make something out of this'.Consequently, the self can anew, and sometimes better, set existential goals and achieve them: a diploma, a new feature in the house, a driving license, a trip, a relationship.

| Sense of belonging
All interviewees reported living well with others, and insisted on the importance of the family and a community of peers.In particular, they emphasized the capacity to exchange with and learn from other people living with SCI in the months and years that follow the injury.
Meeting peers identified as 'role models' because they have

| Sense of the possible
This step of the interviews is fundamental to understanding the dimension of philosophical health.All interviewees expressed a high sense of the possible, sometimes even hyperbolically: 'Everything is possible'.As we have indicated earlier, such optimism should not be understood literally, when most of one's body is paralyzed.The sense of the possible, rather, is a teleological stance, a disposition to believe, a creative trust in life, value-admiration or will: 'It's not so often that I think I can't do that, or I can't do this, or this is impossible.
I don't think so much about that'.When the interviewees repeat that everything is possible, they might be talking about the consequence

| Sense of purpose
A good sense of the possible can be transmitted to others.As mentioned, all interviewees played, at the time of the study, a regular role in mentoring others who were in the early stages of SCI rehabilitation or were living with another serious condition: 'It's important to be a role model and to show the possibilities'.Not only is it important to have a professional activity to flourish, but it needs to be a meaningful activity, one that does not only satisfy the material conditions of the self but also serves an altruistic purpose, in helping certain groups in society, or acting for the greater good or higher purpose: 'To have a purpose in life is very important, to feel that you are part of something bigger, that you have a place in creation'.Solidarity is a chief value among our interviewees: 'The biggest idea is to help other people'.Helping is not only transmitting; it is also a learning process in which personal growth is not antithetical to altruism: 'My motto is that I have to learn something every day'.Two of our eight interviewees wrote and published a book to reflect and learn about themselves, thus transmitting lessons about their experience of life.All interviewees began to think much more about their purpose in life after their injury because the SCI condition is one where one 'has to rethink everything', provided one goes beyond the plateau of despair that tends to follow the accident.

| Philosophical sense
All our interviewees have discovered this reflexive possibilizing energy at some point in their life, and this has helped them develop a purpose and find full-minded self-enrichment.None of our interviewees became a philosopher stricto sensu (although one became a priest), but they all had to discover an indwelling interest in them through which their minds started working or aspiring to work selfreflexively, beyond the standard preoccupations of the domestic self.
Not that these mundane preoccupations or worries disappeared, quite the contrary since an SCI condition demands extreme everyday care and domestic planning.However, succeeding in managing the hard logistics of wheelchair living is not enough: 'I want to be richer in or destiny for their condition, rather they carve a purposeful, generous and meaningful perspective on life that slowly impacts their world.Such is the meaning of autonomy: to be active in the world such as to increase the collective domain of possibility: 'Meaningfulness for me is to do something that will give importance to other people'.

| DISCUSSION: THE UNIMPOSSIBLE IS NOT REALISTIC A PRIORI
We reported commonalities among most interviewees: given that this was a pilot study with a small population of eight persons, we did not want to over-emphasize traits or thoughts that were too singular but rather point to common views.There is a higher chance that if the majority of interviewees share some stance, it represents scalable information that can be extrapolated to be helpful in rehabilitation cases in general.This, of course, would need to be confirmed more robustly with further studies.
The reader might be puzzled by the relative optimism of the interviewees.When all interviewees say, in a way or another, that much is possible, this seems to reflect a leap of faith, a philosophical energy, a possible that points, not to normality, but to a dimension of transformation, coherence or transcendence of the self: 'I think positive energy; to me, it's sort of a belief that I can make things happen, that I can change things'.p.43 .A posteriori, we may conclude that such and such for the first time.So denial can also act as a buffer against our natural aversion of risk, enabling us to explore new ideas and behaviors that may eventually benefit the human population.p.250The sense of the possible is a capacity to focus on teleological goals or purposes.This skill may be enhanced over time in people who cannot move significant parts of their bodies but maintain full metacognitive capacity.'Because they cannot focus on how to move, they have to focus on how they think', said one of the interviewees about people who are seriously paralyzed.This mental focus is not only imaginary; it is an active energy of hope and belief that may slowly impact lived experience: 'Things that you focus on, they grow.
And if you focus on possibilities and good things, those things will grow'.
Because the philosophical possible is not the statistical possible and may appear to be in denial of reality as we know it, we propose to call Unimpossible the asymptotic horizon of a mind that wishes to redefine the domain of the possible in a given situation or domain.
This sense of the possible, to become a performative energy, cannot be the consequence of the rational analysis of what has been possible in the past, but rather a premise or creative principle-before further pragmatic assessment of real possibility-hence the term crealectics 51 as opposed to realism.The kind of rewiring of the connectome that is required to overcome traumatic events, we believe, cannot rely on mere incremental amelioration (if you work hard, realism shows that your life will be 5% better), but rather on a teleonomic ideal (my life should be flourishing and I will get closer to that point asymptotically).
Hence the importance of a sense of purpose to root or ground the philosophical sense.
Our results are certainly limited by the scale of our population we did not treat different bodies as outliers.Those cultural and philosophical perspectives are not merely theoretical: they can lead to concrete, circumscribed policy or rehabilitative changes needed by so-called disabled people. 65People living with chronic or traumatic illnesses may suffer hermeneutic injustice in being denied the epistemic resources to interpret their own experiences philosophically and act upon it. 32search has shown that patients' beliefs about their treatment can strongly influence their motivation and adherence. 66The philosophical ground of these beliefs has previously been overlooked by research.Another pitfall in research into the mindset or worldview of rehabilitants is that most studies are psychologically oriented, and therefore suppose the attribution of more or less standard scales and over-structured questionnaires to assess the state of mind of the patient. 67Philosophical health is about intellectual indwelling, which questions existential experiences such as impossibility and meaning, thus not best understood via over-structured nomenclatures.
We know that our study is limited in scope.
The mind is fantastic because it can change, and as it changes, you change your life'.It's about seeing the opportunities and being aware that the mind affects the way you live if you are not only reacting to adversity as a victim.Since the body's mobility is hindered, more time is dedicated to thinking or imagining: 'I can close my eyes and still feel how it felt to dance'.Autonomy is a strong ideal, and since the body's autonomy has become limited, special emphasis is put on the autonomy and independence of spirit, 'the ability to believe in one's own abilities'.While the period after the injury typically comprises a period of grieving, the regenerated or new self and mindset that emerge do not need to be affected by the new limitations: 'I have no disability in my mind'.The self becomes the captain of one's destiny:

'
meaningful lives' is essential to building courage, evaluating the sense of the possible and creating a new image of the self.There seems to be a salutary esprit de corps among people living with SCI and participating in rehabilitation camps: 'It was important seeing other people living fulfilling lives in the same situation'.Identification with people 'living in a wheelchair' creates a form of solidarity and a new sense of belonging, a belonging of condition.Belonging is not only something that you receive but also something that you create.This is expressed in the active solidarity that most of our interviewees also express in their own work, often dealing with the care of other persons living in the early stages of hardship, whether from SCI or another clinical condition.Belonging can then become a form of intellectual empathy rather than emotional adherence: 'I try to understand other people and to have a mutual understanding with people around me'.
of a deep orientation, a fidelity to a purpose or to a set of values, a trust in the future once a philosophical rather than material impetus has been found: 'All things are possible if you have a vision if you have a dream and strive for it'.Since the interviewees live in Sweden rather than in other parts of the world, they benefit from institutionalized conditions of support that allow them to rebuild a life, for instance, the right to have assistants: 'I could take charge of my life and learn as much as possible how to control my life'.Experiencing new constraints does not necessarily limit the possibilities; on the contrary, it can open some doors.All interviewees said that given the new limitations of their bodies, they invested more in their mind's possibilities (studying and writing, for instance) than they perhaps would have done absent the SCI.This 'ability to believe in one's abilities', may be considered an 'indwelling energy' to use the phrase of one interviewee.Perhaps this energy is a form of intellectual and existential courage: 'I think the possibilities are there, but you must gain the courage to grab the opportunity'.Ability is a keyword for those who are defined as disabled; they reinvent the definition of ability such that disability is not an obstacle to achieving goals: 'An able person is someone who is open-minded and who is not limited by all the hindrances.An able person is a person who thinks it's possible'.

7 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.13874by Linkoping Universitet, Wiley Online Library on [09/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licenseperspectives'. Within their common flourishing and purposeful existence, they did not all reach the exact same conclusions or worldviews, but they all seem to share a form of existentialism, a philosophy of life in which, rather than blaming the past for who we are, in bad faith,60 one projects goals and a purpose into the future, attentive to the possible hiding behind hardship.'If you have a very hard time, it's very easy to look down and don't see the opportunities that appear', but when things go your way, they believe, 'it's a mental thing: you can actually affect how you live if you're openminded'.Philosophical health is about realizing that thoughts and actions, the life of the mind and lived experience are related and interconnected: 'I know that I shape my own way'.This does not mean that society does not exist, or that the interviewees are individualists: in fact, they cannot afford to be individualists and are often helped by assistants.But they do not blame society, themselves given action is, in fact, impossible.Such factual validation or invalidation, to avoid inhibition from action, should happen after the faithful absolutisation of the possible (sometimes called optimism bias) giving the energy, will and hope to thrive.Suppose a person is initially burdened a priori by the factual limitations of reality.In that case, the result may be sustained neurosis, depression or, at best, a nonimaginative mindset that merely adapts to the statistical average, the norm.The neuroscience of optimism is still in its infancy.Still, Sharot has shown that distinct regions of the prefrontal cortex of the brain track 'estimation errors', and that highly optimistic individuals seem to exhibit a reduced tracking of errors (associated with a pessimistic update).62The authors of Denial, for whom reality denial is the evolutionary advantage that distinguished humans from other animals, write: How many times have humans (individually or in groups) set out to do what seemed almost impossible and have yet succeeded?If it were not for the ability to deny reality, they would not even have tried!Denial also explains the human ability to take on dangerous and important challenges, such as exploring new territories or trying out new foods of unknown safety and demand wider confirmation to see if philosophical health can strengthen healthcare services in the future by making them more person-centred.We have attempted to show the therapeutic importance of sensemaking abilities in the context of disability.A better understanding of the impact of personal philosophies on rehabilitation and healthcare outcomes could contribute to more effective implementation of person-centred healthcare, to improve, for instance, current rehabilitation processes.Knowledge of the patient's conception of life and ways of recreating meaning in life may offer better chances to facilitate good outcomes than a treatment protocol focusing on bodily capacities or forced training only.Lessons from the personal philosophy of people with a long and flourishing SCI condition, that is, persons who had to reinvent their life in extremis and for whom there is no possible return to preinjury 'normal life', are of potential value to newly injured or chronically ill individuals.As noted by Baudry,64 scrutinizing the ideologies and social imaginaries underlying disability discourses opens the door to new explorations of what justice, beauty and morality could involve if But it indicates the necessity to conduct more research into the philosophical and teleological aspects of human flourishing.A healthy society should augment the sense of the possible in all, and promote self-enrichment and the flourishing of diverse forms of human life.
and Sartre and Heidegger considered the universe is a possible.53,p.364,54,p.244Whenone embodied living being starts to say and feel of a projected situation, idea, initiative, or way of life, that it is possible, they are connecting with their counterfactual dimension in a potentially transformative way.The sense of the possible is-at least asymptotically-performative: it begins to DE MIRANDA ET AL. | 1205 13652753, 2023, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.13874by Linkoping Universitet, Wiley Online Library on [09/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License