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  • Writer's pictureKit Wisdom

Warm data: what does it look like in healthcare and where does it fit?

Updated: Aug 30, 2020

Do we see our heart skills as part of our communication skills?

Yesterday, I heard a story of someone who has been in pain since she was 7, and had never told anyone about it, nor acknowledged it herself. 

Her pain was heavy, her pain came in fits and spurts, when it came it was unrelenting; her pain was weighing her down, it didn't let her breathe; her pain was everywhere and yet also nowhere. She described it sitting in her throat, gagging her. And yet we were also talking about back pain. 

This beautiful 35 year-old women shared with me, for the first time in her life, a memory that had only surfaced in the last 2 weeks. This memory jolted her nervous system, rebounding around her thoughts, her heart, her gut like a never-ending out-of-control bouncy ball; reminiscent of the random intensity of her described back pain.

The way she shared with me was symbolic. She had listened to my explanation about the complexity of pain, of having related the definition of pain to be inclusive of emotions and thoughts - it being an experience, not a sensation. 

She started crying silently, shaking, rocking slightly, hiccuping through shallow breaths. We sat together, I didn't say anything. I did not move, I was soft in my posture. I was there, my body was turned to her - I was open. I was me. 

When she was ready, she started sharing. She chose the pace, she chose the order of thoughts, she chose to leave the tears streaming down her face, she chose to let the snot form. She chose to share. 

I felt her need to tell me, talking through streams of tears. I heard her need for me to stay still, to listen with my heart and gut open. I listened intently to someone be open to their own internal terrain, knowing it was trauma that had never been validated, knowing it was going to unearth things she didn't want to know about, have to deal with, have to work through.

I still said nothing, allowing a space between stories - nothing I could say would help in that moment. I needed to listen with all my senses. 

And when she said, 

Fuck this. I have done enough work already. 

I replied, yes, yes you have.  


Relational experiences are hard - they can be raw, uncomfortable, even nauseating - they can make our palms sweat, our throats constrict, our hearts hammer so fast despite sitting so still. They can feel hot - too hot, sticky, and prickly all at once.

Nora Bateson, of The International Bateson Institute, calls this interrelational information Warm Data. Warm Data is the messy stuff, the muli-contextual, non-measurable relational information - it is the movement within a complex living system. It is the information that is alive. Warm Data is not about the practitioner or the patient or the evidence-based information presiding over the 'problem' - it is the relationship, the movement, the connections, the conversations between them. Warm Data is the kind of information that fosters our belief that a deeply human response to complexity is conceivable.

To me, in the healthcare world, Warm Data has the potential to become (if you allow it) an agent of change for practitioners traversing between the 'old' and 'new' healthcare paradigms. It is the glue to fostering meaningful, quality, collaborative care - whilst vulnerably stepping into the uncertainty of "I don't know". Isn't this what we are hoping to evolve amongst a healthcare landscape that is increasingly failing both its patients and practitioners?

And yet, we do not seem to place much value on Warm Data.

It exists as a distant-second-cousin (what was their name again?) to cold data. Cold data exists everywhere throughout our frame of choice, the biopsychosocial model. Within it, we are taught to critically think our way through the evidence for load management, pain-science, biomechanical requirements, optimal exercise programs, nervous system responses, psychologically-informed practices. The list goes on. All the things we need to 'know', to have a grip on, to be able to put into practice to help 'solve' our patient's problems. We use systematic controlled trials to measure, validate, fail, learn. And yet, despite all this constantly evolving, hugely important, and hard-worked-for evidence, it doesn't seem to be impacting our worldwide prevalence of persistent pain, loneliness, disconnection, and, mental health issues.

It makes me wonder, is our emphasis on the 'measurable' cold data taking too much of our attention, creating too much of our worry, draining too much of our energy, fostering too much of a power dynamic; and in doing so, taking our humanness away from how we could relate to the people in our care?

I've heard people say in response to this, "yeah, I know what you're talking about" and go on to describe things such as, banter, getting buy-in with the patient, shooting the shit, the stuff we talk about to distract the patient from their pain, and of course, the more official therapeutic alliance and third space; even the newly popular what's your story? that is making its way around the traps, frustratingly more often than not as lip-service than genuine inquiry. Moments that are being taught and created in our move towards a more collaborative, shared, patient-centered care.

Yet, I wonder if we are merely using this way of relating to emphasize what "needs to be done" according to the evidence; only the cold data.

What if sitting and listening to an uncomfortable story, what if not having the answer, what if humbly inquiring, what if sharing your own shit, what if building a psychologically and emotionally safe space, what if being vulnerable, what if exploring the potential for multiple truths, what if placing value on trust, silences, complexity, courage, and reflection, ... what if relating is what needs to be done?
What if Warm Data, the immeasurable, relational, uncomfortable, conversational 'stuff' is inherently just as valuable - or dare I even suggest it - at times more valuable than the cold data?

We have emerging models of care that do explicitly value a different approach. Narrative-based practice (John Launer), narrative therapy (Michael White), and narrative medicine (Rita Charon) are differing examples that centre the humble inquiry of lived experiences and the human interactions that lie within them.

Narrative-based practice is an approach that insists on the detailed attentiveness to language, and where achievable, non-predetermined goals to a conversation. (This is where it differs from motivational interviewing.) It defines itself as being "dogmatically undogmatic" by applying an inquiry approach that ultimately minimizes the language and any formulaic prejudice of the practitioner. Instead of presenting as a "fixer," the practitioner becomes a conversational partner. "Choice" is therefore embedded in every moment of every interaction, not just in the management decisions.

Narrative therapy is a form of psychotherapy that works with patients to identify their individual values and skills unique to them. It seeks to help the patient co-author an evolved narrative about themselves, through exploring their ability to live their values, and the history of those values, whilst successfully confronting current and future issues. Narrative therapy speaks to a social justice approach to therapeutic conversations, looking to challenge dominant discourses that shape people's lives in unhelpful ways.

Narrative medicine has a mission to restore humanity, moral engagement, and imagination to the medical world, by championing the importance of lived experience and its narration, against the dominant intellectual voice evident in modern medical practice. Narrative medicine commits to building 'narrative competence' in practitioners, where successful medical practice is not just about the technical outcomes, but also whether attention is paid to the patient's story and contributes to its cohesion, richness, and meaning.

By explicitly stepping into and leading with themes around exploration, choice, conversation, lived experience, and humanistic values, these ways of approaching healthcare relationships not only value the power of narrative, but they beautifully generate the sticky, tricky, messy, relational information that is Warm Data.

I can hear you asking, but how can we then teach more Warm Data generation?

As if that were the simple answer.

We are already teaching 'communication skills' throughout healthcare in various ways, and the importance of 'soft skills' (they are by far the most important and are not soft in the slightest) is growing moment by moment.

However, to me, Warm Data generation requires even more of a paradigm shift. One that leaves behind the old way of relating, the way that separates the practitioner and patient, even despite the collaborative approach - the way that attempts to 'protect' both parties by staying safe in their relationship.
One that leaves behind case study language purely mechanical and biomedical in nature as a way for practitioners to communicate about the humans in their care.
It requires vulnerability as spoken to by Nicole Piemonte; the approaching of suffering as a shared human experience. It requires compassion for the self; historically absent amongst Type A, perfectionistic-types, who strive for success and find it inherently difficult to access their own self-soothe.
It requires us to step into these scary places with our patients and with each other.
It requires the healthcare system, which has morphed into a big business, to value the skills that got people into it in the first place.
Our heart skills.

To me, if those skills were truly seen (not just lip-service seen) as most vital to care, Warm Data generated from hard, exploratory, relational conversations would more naturally emerge. We wouldn't need to 'teach them' as an add on to technical skills.

These relational skills are already there and waiting for the right conditions to be fostered to allow them to flourish and thrive. Empathy, storytelling, vulnerability, deep listening, inquiry, meaningful connection. We have these skills as a profession built to care, yet they need space and practice to emerge.

I wonder if we are willing to invest in them?

I recently engaged with an online 8-week course called The Bridge, designed by Julia Traylor and Lissanthea Taylor, two health practitioners who themselves studied under Narrative Medicine's Rita Charon at Columbia University, aimed at bridging the gap between pain care and the humanities.

The course is designed to bring healthcare providers together in a safe space to close read literature and write reflectively, whilst engaging in meaningful and often vulnerable peer discussions linking how we interpret the material as highlighting our own and others' biases.

This process undeniably shone a light on our self-awareness development, our ability to foster empathy for others (our patients), and our ability to explore connections and themes in stories perhaps missed in the past. It cleverly designed a space where we had to explore and consider other people's worldviews - it became central to the tasks at hand - as only one opinion of art does not make art, art.

We bravely wrote what we thought, what we saw, what resonated with us - and were then asked to closely read and comment on at least three of our classmate's thoughts. What ensued was beautiful to-and-fro's between participants, often traversing multiple contexts and numerous worldviews. To me, this epitomizes the listening we need in the clinic - listening for themes, for what matters most to another, to what currently shapes the worldview of that human in front of us.

Yet what it also did, was generate beautifully sticky, tricky, often uncomfortable, relational Warm Data.

The movement in this complex living system involved the relations between the art and the artists, the literature and the writers, their personal and historical context, the practitioners and their individual context, everyone's lived experiences in the clinic with patients, with family, and with friends, spanning multiple countries across the world, and of course the facilitators of the course itself. This complex living system existed amongst a worldwide context of Covid-19 and the voices of #blacklivesmatter.

We did not set out expecting this 'messy stuff' to be so vital to our learning, and yet we all experienced it and came to understand its inherent value, as the meaningful glue that tied us all to those transformational moments.

We cannot easily measure Warm Data. To our current dominant paradigm, it can seem too uncertain, emergent, complex, and time-consuming. It is not a defined, concrete process. This is itself could be deemed ineffective by the Scientific Method. If we can't measure it, what's the point?

Perhaps if we assign more value to it, humbly inquire with it, more openly wonder about its potential power, about how it might fit into a systems-based approach, about how it might work with and relate to cold data - through the lens that sees everyone as interrelated - we might find out more about it?

Perhaps we need to slow down, open ourselves up in a new way, and look for an experience of it?
Warm Data requires us to experience the relational process, in order to feel the value, to be curious, to learn, and to grow. By choosing to step into the experience, to connect via the very nature of humanity, we can learn the truth that our existence is relational.

We are currently existing in a crisis of meaning that is intersecting with every facet of society. The current state of our global upheaval has catalyzed the demise of the old way. It is not working.

Perhaps Warm Data is paramount to exploring our present-day narratives and the future shape we want for our healthcare world and our worldwide world - a place where people need people.
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