Understand that sufferers of intense structural and

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understand that sufferers of intense structural and political violence are often not going to follow convention by providing emotionally moving illness narratives that fulfil the expectations of their advocates. 179,180 For some well-intentioned therapists, attempts to evoke deep mean- ing can often be met with silence. 181 Time and again, silence—what cannot be said in clinical settings—reveals much about the limits of social engagement in moments of extreme suffering. Eliciting clinical responses, therefore, should be tempered by an awareness of what cannot be said. Even the most sensitive care providers might not only miss what is culturally important, 64 but, in favouring some forms of empathic narrative, also wholly eliminate alternative idioms (behaviours at home, at work, and in moments of heightened ritual engagement) that help the patient to make themselves better. If carers cannot become aware of how another’s normality can be medicalised by their own prejudices—ie, acknowledge their own cultural dispositions—they will surely not see which of those dispositions are helpful or damaging. 78 Such erasure of an individual’s personal and cultural context of meaning is evidenced in the long-term eff ects of short-term clinical priorities, especially when exchange between carer and patient is minimised. When people overdetermine, confi ne, or reduce care practices, they not only limit expression of other voices; they also eliminate their own ability to recognise when they have done so. In Symbolic violence is defined as socially dominant forms of persuasion and coercion that occur without the use of physical force
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The Lancet Commissions 1626 Vol 384 November 1, 2014 the UK, for instance, a much applauded 2010 NHS survey 182 of quality of care for antenatal maternity services improved provider–patient communication by increased use of online advice and related information services; however, the response rate was only just higher than 50%. Almost 50% of voices were therefore not heard, and those who customarily fall through the net in antenatal (as in any other medical) care were over-represented in the voiceless group. The views of those not represented are impossible to know; but not being represented more or less defi nes a key dimension of being vulnerable. As many vulnerability assessments stress, those who fall through the net are always invisible when results are based on research participation. Motivation, capability, and opportunity might be buzzwords of behaviour change, but they also hold true for individuals’ complete disengagement with services (and their inability to fi ll out a maternity services survey). The experiences and opinions of those more, and perhaps most, vulnerable were precisely those voices that remained unheard.
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  • Summer '18
  • Jeanne Hughes
  • Lancet

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