1 INTRODUCTION

Documenting why an intervention is effective is acknowledged as almost impossible. This is echoed by Cochrane (1971), who argues that the randomised controlled design (RCT) is the gold standard for determining which therapeutic elements work towards the intended outcome, and which do not. However, most treatments harbour a complexity that makes them unamenable to determining that a for sure leads to b and that it was a alone that led to b. An example may illustrate the complexity of even a simple study of testing the effect of a pill. Even though it may seem clear that the result a is caused by the intervention, the pill b remains an isolated event. It may be possible to decide if the new pill gave a better result than treatment as usual in the isolated trial investigated. However, in those cases where a lack of difference between the pill and its placebo is found, other possible factors or rather combinations of possible factors may be at play. One such factor may be the relationship between the patient and the healthcare professional, which has also been recognised as having a therapeutic effect (Jonas, 2019). Furthermore, the longer the treatment takes and the less isolated from everyday life the chosen therapeutic modality is, the more other factors may intervene in the cause-effect relationship; and the more complex it becomes to determine that a for sure leads to b. This is a central issue when testing complex interventions (Craig et al., 2008; Moore et al., 2017) and lies at the very root of the recognition that it is difficult to isolate any single effective factor. Hence, we may be left without true knowledge of what works in clinical practice. Therefore, we need to investigate helpful factors.

The need for investigating helpful factors applies to low-back pain, which can be invalidating physically as well as mentally. Although it is one of the most common public health issues and although many interventions have been developed and tested, low-back pain continues to be a widespread problem for which no common solution has yet been found (Buchbinder et al., 2018; Foster et al., 2018; Hartvigsen et al., 2018; Meroni et al., 2019). Surgery, exercise and conservative treatment are used either alone or often in combination. However, defying therapeutic attempts to remedy it, low-back pain often persists, and so do the problems related to it (Buchbinder et al., 2018; Jensen et al., 2012). Indeed, it may persist both with and sometimes without any apparent physical reason; and sometimes an intervention (Jensen et al., 2012) is successful in reducing or eliminating pain without researchers being able to disclose which factors caused the outcome.

In the present paper, the focus is on an intervention towards low-back pain conducted to achieve a deeper understanding of factors related to professional support patients experienced as helpful. Access to the black box of understanding what worked for whom under which clinical circumstances is sought through interpretation of people's lived experiences of the intervention they received. This approach builds on the philosophy of Ricoeur (1983;1986) who argues that people understand themselves and their life through their narrations; linking past, present and future provides knowledge about their lifeworld. The narratives thus provide a possibility for others to understand the narrator as well. By listening to narratives in an interview, we may gain a deeper understanding of which factors patients experienced as helpful.

The empirical data stem from 20 purposefully selected interviews chosen among 110 patient interviews made to get insight into the patient perspective on intervention in an RCT study on reducing low-back pain (Jensen et al., 2012). This interview was conducted between the two sessions of the intervention. In the first session, the health professional explored the patient's perspective of the situation, doable physical activity and physical problems before proposing a plan for increased physical activity. The second session, which was conducted 12 weeks later, explored the patient's pain and perspective on the intervention (see Table 1).

Table 1. The intervention In the first session, the health professional The interview 6 weeks after the first session addressed the patient's The second session, 12 weeks after the first session, evaluated the intervention and the patient's pain.

A phenomenological-hermeneutic analysis of these 20 interviews (best vs. worst outcome to cover the breadth of patients’ experiences) showed that some had experienced that the intervention had helped them to deal with their low-back pain and some had not (Angel et al., 2012). This inspired the present investigation into what had been helpful. Therefore, another analysis was undertaken to explore which factors of the intervention the patients perceived as having been helpful in the healthcare professional support they received in relation to their low-back pain.

This analysis was based on Ricoeur's (1976) interpretation theory; naïve reading of all the interviews and the text as a whole, performing a structural analysis to move from the surface to a deeper understanding of the text and to reach the most probable interpretation through critical analysis. We explored what had been experienced as helpful to reveal the factors underlying the feeling of being helped. The experience of being helped emerged as a confluence of many individual factors, each of which could be further analysed and interpreted in depth. Data on both positive and negative experiences allowed deeper insight. In the critical analysis, the most likely factors contributing to the feeling of being helped were outlined (Ricoeur, 1976), and a fuller picture of the mechanisms of the individual factors was obtained. In this process, we applied Heidegger's (1962) philosophy of existence, which helped us unveil the deeper meaning of helpful practice. Heidegger developed a structure of Being—the ontological level—that lies beyond and yet pertains to every entity (for instance, individuals) (§7, p. 62) from grasping entities in their Being (life as it is lived) (§7, p. 63)—the ontical level (i.e., physical, real or factual existence). Parts of this philosophy of being were used to unveil experiences of consulting healthcare professionals due to low-back pain and to obtain a deeper understanding of the experience of being helped at a more general level. Heidegger's philosophy was also used in the initial description of the patient's situation when they need help facing disabling low-back pain.

2 FACING DISABLING LOW-BACK PAIN

Pain itself more or less takes a person's attention; it may mute everything else or it may be just a low undertone apart from the pain itself; the very fear that pain may appear may do the same. This affects the person's mood, understood as his or her basic “state of mind” or more precisely his or her entire experience of being. This is what Heidegger calls Befindlichkeit, which is the first fundamental existentialia that he found counts for all humans (1962, §34, p. 203-4[160-1]).1 This state of mind (Sich zu befinden) refers to the actual moment, the present, and covers how the person is. The state of mind is the sum of the “being” and the situation “there”, which includes what has happened until this present (being already in the world) and what is going to come. Thus, being there in the present includes the projection of oneself into the future. This projection is undertaken in light of the interpretation of the present factual state and its imagined consequences.

When somebody experiences low-back pain, pain is part of being. This invites questions as to what does the pain means and how bad is it with me? Thus, the bodily agony implies mental struggling to understand what the pain means. This need for understanding may be elaborated by Heidegger's philosophy of understanding Verstehen, which is the second fundamental existentialia in Heidegger's philosophy (Heidegger, 1962, §34, p. 203-4[160-1]). Heidegger writes; “Understanding is the existential Being of Dasein's own potentiality-for-Being; and it is so in such a way that this Being discloses in itself what its Being is capable of.” (Heidegger, 1962, §31, p. 184[144]). Thus, the patient's struggle is related to the present but may have consequences for the individual's expectations of the future. Furthermore,”… understanding has in itself the existential structure which we call “projection.” (Heidegger, 1962, §31, p. 184-5[145]). This projection is not towards an arranged plan or towards something that has been considered beforehand, but towards a sense of possibilities. These two fundamental existentialia: Befindlichkeit and Verstehen are equiprimordial with the third fundamental existential discourse Reden (Heidegger, 1962, §34, p. 203-4 [160-1]). Heidegger used the word talking, Reden, to emphasise the person's verbalisation of his/her state of mind, Befindlichkeit, and understanding, Verstehen, and thereby, disclosing understanding, which is implied in the word ‘discourse’. He writes, ‘Discoursing or talking is the way in which we articulate “significantly” the intelligibility of Being-in-the world.’ (Heidegger, 1962, §34, p. 204[161]). Reden is when Befindlichkeit and Verstehen are verbalised; the very putting into words of these two dimensions leading to new understanding. These fundamental existentialia are equiprimordial, which means that in the person's experience of the actual total being, Befindlichkeit, understanding, Verstehen, and discourse, Reden, are inseparable. Understanding arises when words are spoken and exchanged through discourse. Heidegger (1962) argues being implies “befinden sich” and understanding of persons as being fundamentally social beings who relate to others through discourse.

3 THE FACTUAL PAIN AND THE MEANING THEREOF

For a patient suffering from low-back pain, the prime goal is to get rid of the pain. The question that arises is “what is the problem”. Pain is only a symptom, a hint that something may be wrong, and this leads to a call for an understanding of what this something could be. The person who suffers from low-back pain searches for explanations to address the warning of which pain is an expression; is s/he in danger, and what to do? The patient cannot begin to deal with the pain until he or she understands what the symptom is a sign of. Trying to understand low-back pain, the patient perceives the back issue as a mere fact. The problem is localised in the back and calls for attention. This focus on the localisation of the pain lies in its very cause-effect nature and is essential, as knowledge of its aetiology is fundamental to solving the problem from a medical perspective, thereby stopping the unpleasant and worrying symptom. The physical problem and its symptom represent mere facts. Heidegger calls this the person's “factuality” (Heidegger, 2008). In relation to the experience of pain, the patient may have an immediate understanding and may verbalise that understanding and may decide to share it with others. In the patient's understanding, the pain has already become a facticity in the sense that the patient understands what this fact means from his or her personal perspective. Heidegger distinguishes between “factuality” and “facticity” (Heidegger, 2008). “Factuality” is the factual world, and facticity represents how the facts of this world are interpreted. Heidegger writes: “It [facticity] is not a free-floating self-projection; but its character is determined by thrownness as a Fact of the entity…” (Heidegger, 1962, §57, p. 321[276]). Thus, facticity is the way that the fact gives meaning to a person based on his or her lived life.

4 SEARCHING FOR A SOLUTION TO SOLVE THE PAIN ISSUE

In a situation with a body that causes pain and imposes a restriction, patients strive for understanding to make the pain stop. Patient counselling spans from disseminating simple facts about pain to the (potential) meaning pain may have to the patient in question, that is from the factual to facticity (Heidegger, 1962, §57). When a patient with low-back pain asks for help, the healthcare professional will seek a medical understanding focused on understanding and removing the symptoms. However, just as important to the patient are the consequences for the present moment and the future. The present and the future are both embraced in an effort to understand the patient's search for meaning in relation to her/his life and the world.

A patient's interpretation of the signification of his or her symptoms lies at the very heart of his or her existential predicament. However, when the healthcare professional explores the patient's pain, the facts are in focus. Thus, the symptoms can mean one thing to the healthcare professionals and an entirely different thing to the patient. To support the patient, healthcare professionals need to know the patient's perspective on the pain. After a first question addressing the reason behind the symptom, the healthcare professional's second question should address the present and future consequences of the pain for the patient. This is the patient's facticity speaking, and the professional's help should build on the understanding of what this means to the patient. The patient struggles with questions like “I am no longer the person I used to be. Who am I now? What is life going to be like? Am I no longer a capable person and is this the beginning to the end?” When the patient's facticity forms the basis for professional help, the healthcare professional's “goal” widens. The goal is, of course, to obtain an understanding as close as possible to the facts, providing important cause-effect knowledge, helping the patient decide what to do and what to avoid, informing the patient about the outcome and maybe even solving the problem. This understanding not only provides the basis for the healthcare professional's help but also forms the basis for a future life for the patient in question. Hence, the consultation may be divided into two distinct but not necessarily separated parts. The first part is the very foundation, that is the search for the biological explanation for the patient's pain, which reveals the healthcare professional's ‘directionality’—a part of their ‘circumspection’—what they look for when they scan a region of concern (Heidegger, 1962, §69). The second part is the search for the patient's understanding and interpretation of the situation, which holds the key to how life can be lived both in the present moment and in the future.

5 CONSULTING A HEALTHCARE PROFESSIONAL

When a patient with low-back pain consults a healthcare professional, s/he solicits support to interpret the pain. The low-back pain hinders the patient's activities. Furthermore, the symptoms tell the patient that something is not as it used to be and that this something may threaten what the patient is and can become; that is, his/her “potentiality-for-Being, it [the person] is not yet.” (Heidegger, 1962, §31, p. 186[145]). Thus, the pain is a threat to the patient's present as well as future life. For the healthcare professional, meeting patients at this stage creates an opportunity, in the words of Kierkegaard (1998), to search for the patient where s/he is, and from there to bring the patient to a new level of understanding. Due to the importance of the cause-effect relation in medicine, the healthcare professional searched for that factual dimension of the pain; that is where it is located, the kind of pain in question, its characteristic features and its frequency.

This search for a biological explanation of the pain involves the patient and their way of presenting their body and symptom experience. Thereby the patient presentation is aligned with what the healthcare professional looks for when they scan a region of concern (Heidegger, 1962, §69). The patient's part in shaping the healthcare professional's help is essential. In the healthcare professional's search for facts, the patient is the source of information, supporting and verifying medical tests. The healthcare professional may make his/her conclusion without consulting the patient's perspective—the patient's facticity (the patient's factical life self-interpretation of his/her circumstances). If the healthcare professionals can solve the problem, the patient may not take any offence—happy to be well again. If the symptoms are benign, that is they cannot be traced to a specific diagnosis, the healthcare professional may tell the patient that nothing is wrong, indeed that the disease is idiopathic: there may be something there, but we do not know what it is. For some, this may help, and they may feel safe, paying no further attention to the symptoms. Pushed into the background, the symptom may be reduced and even disappear. To other patients, the symptoms are still there. Even though the healthcare professional could not relate the symptoms to the back condition, the symptoms may be very much in the patient's mind. If the problem continues, the patient may keep struggling to get well again or at least reach an understanding. What is the right thing to do to make it go away and not to worsen it?

6 HELPFUL FACTORS

The issues explored in the present analysis showed that to patients, the phrase “being taken seriously” seemed to capture the essence of what was perceived as being helpful in their current situation. This experience arose when the healthcare professional's starting point was the problems as experienced by the patient, and when this problem was explored in relation to the patient's particular biography and situation. Thus, being taken seriously implied an empathic encountering; engaging in the patient's situation with compassion, understanding what it is like to being-in-the-world while suffering from low-back pain and participating in the struggle to find a solution (Table 2).

Table 2. Being taken seriously encompassed several helpful factors 1. Being invited to unveil one's own perspective 2. Being met with trust 3. Being listened to 4. Being understood 5. Being relieved of a burden 6. Being guided physically 7. Being offered knowledge helped create a new understanding 8. Being consulted for a fitting intervention 9. Being legitimised as ill due to the healthcare professionals’ acknowledgement 10. Being followed up

Transferring the findings to practice, the experience of a successful intervention and helpful factors are illustrated with quotes in the context of a coherent story from one of the patients, a younger female's story of suffering from invalidating low-back pain. “Ann's” pain began suddenly. From being an active person, Ann suddenly could do nothing due to the pain. Moreover, she was afraid to do anything that could worsen the pain. Being taken seriously implied that the healthcare professional took Ann's experience of her symptoms as the starting point. This showed when Ann met the healthcare professional for help. Ann expresses appreciation of being taken seriously, which reveals her prior experiences of not being taken seriously (Table 3).

Interviewer

If you were to put into words the very essence of it: What is the essence of what we are doing? Or what is helpful in terms of what you have gone through?

Ann

Well, but that is being taken seriously

Interviewer

Hm

Ann

That is to be listened to and being taken seriously

Interviewer

yes

Ann

Yes! That it is. Because I sometimes think; no, Ann, now you are hysterical. The pain is unbelievably strong; well, people will think you are hysterical. Well, it is that somebody understands what it means when your back hurts that much

6.1 Being invited to unveil one's own perspective

The quotation addresses that the patient's story was unveiled in response to the healthcare professional's request and questions. The central part was that the patient perceived the healthcare professional as someone who looked for the patient's perspective and acknowledged the problem as the patient saw it. This is in line with Heidegger's (1962) philosophy of how a person's telling about his or her state of mind leads to understanding; that is, the healthcare professional supported the patient in reaching an understanding. Heidegger (1962, §34, p. 208[164]) emphasises that understanding springs from the exchange. By requesting Ann to unveil her experience, the healthcare professional gave her space to tell about her situation in a reciprocal action between speaking and keeping silent. At the healthcare professional's request and in response to her questions, the patient unveiled the story and configured the narrative of low-back pain.

6.2 Being met with trust

When the healthcare professional engages with the patient's perspective, s/he addresses the patient's perspective in the form of the patient's facticity and does not merely seek facts to establish a biomedical cause-effect relation. This approach communicates to the patient that the healthcare professional trusts the authenticity of the patient's story and is sincerely interested in the patient, wishing to improve his/her life situation. The healthcare professional is attentive to more than merely data collection that fitted to establish a diagnosis. The trust in what the patient expresses allows the healthcare professional to take part in what the patient wishes to express, neither over-interpreting nor under-interpreting what is narrated. The healthcare professional was not only interested in collecting data to assist his/her professional interpretation but also interested in what this meant to the patient; the healthcare professional trusted the patient's interpretation and believed the patient, for example, when Ann told about her unbelievably strong pain. Thus, the patient's understanding of the pain was not questioned but explored by the healthcare professionals asking for the patient's perspective. This made the patient feel believed, and this was the starting point for trust in the healthcare professional and for further exploration.

6.3 Being listened to

Asking the patient to unveil his/her narrative, trusting the importance of the patient's perspective, implied listening to the patient's striving to make a coherent connection between the life that had been lived, the impact of the low-back pain, the present and the patient's imagination of what the future could be like. The healthcare professional took time to listen actively to the patient and made an effort to really hear and understand what was said. As seen in the quote, it was essential that the patient felt listened to. With the healthcare professional listening, the patient made the effort to describe her situation.

Not only the healthcare professional listened to how the patient in the telling strived more or less successfully to establish coherence between the past (the life that had been lived) and the events that had affected life; so did the patient as the story unveiled. Ann herself hears what she tells. Heidegger puts it as follows]: 'As a Being-in-the-world with Others, a Being which understands, Dasein is “in thrall” to Dasein-with and to itself; and in this thraldom it “belongs” to these'.2 (Heidegger, 1962, §34, p. 206[163]). This story, which unveils in interaction with the other, provided the basis for the patient as a listener to her own story to consider what the low-back pain meant in relation to her life. By giving voice to one's thoughts, it becomes possible to understand one's state of mind (Heidegger, 1962, §34, p. 205[162]). Thus, being listened to by the healthcare professional assists patients in listening to themselves. Thereby, the narrative, as the foundation for the consultation, paves the way for a new understanding of self and life for the patient.

6.4 Being understood

The healthcare professional's engagement in the configuration of the story was the basis for the patient's feeling of being understood. The engagement showed in the healthcare professional's asking for and allowing the further elaboration of the story until it made sense and listening instead of rejecting the patient's story. In Heidegger's words, the relation between hearing and understanding shows in that when we have not heard, “we say we have not ‘understood’.” (Heidegger, 1962, §34, p. 206[163]). What we are saying when we say that we have heard is not only that we have heard but also that we have understood. Heidegger explains that this is because: “Hearkening […] has the kind of Being of the hearing which understands.” (Heidegger, 1962, §34, p. 207[163]). This implies that sounds make us attentive to what lies beneath or behind the sound heard. The sounds transform into what we experience; thus, sound, for example, tones, may be experienced as music. Thus”…, we proximally understand what is said,” (Heidegger, 1962, §34, p. 207[164]) not just sounds and words but what they signify. This implies that”… we are already with him, in advance, alongside the entity which the discourse is about.” (Heidegger, 1962, §34, p. 207[164]). In the very same way, the healthcare professional who genuinely listens to the patient understands what the situation means to the patient.

Thus, an experience of not being listened to implies an experience of not being understood, and the experience of being understood implies that the healthcare professional resonates with the story told, and continually listens despite the mentioning of unbelievably strong pain. In Ann's words’: The pain is so unbelievably strong that people will think that you are hysterical”. This experience shows that the healthcare professional knows what the patient is talking about and recognises the patient's complaints. This discloses to the patient that this is real, known by others than the patient him/herself, and that this is not simply a matter of the patient having gone crazy.

6.5 Being relieved of a burden

The healthcare professional's recognition of the patient's situation was a relief because the pain had not been the only burden; being alone with the experience was devastating, especially if the patient had previously experienced a lack of resonance from healthcare professionals. This experience was hinted at by Ann, emphasising the importance of being taken seriously: “That is to be listened to and being taken seriously”. Being freed from the burden of being alone, stuck in a situation nobody recognised or believed can be explained by Heidegger's notion: “Through it [the Articulation] a co-state-of-mind [Mitbefindlichkeit] gets ‘shared’, and so does the understanding of Being-with”. (Heidegger, 1962, §34, p. 205[162]). Being fundamentally related to the other, “In discourse Being-with becomes ‘explicitly’ shared; …” (Heidegger, 1962, §34, p. 205[162]). The healthcare professional's understanding freed the patient from devasting isolation, alone with an experience not verified by others and thereby not necessarily true. This had the positive outcome that help could be provided.

6.6 Being guided physically

Heidegger writes: “Being-with develops in listening to one another [Aufeinander-hören], which can be done in several ways: following, going along with” (Heidegger, 1962 §34 p. 206[163]). A turning point in the intervention was when the patients had their physical capacity tested. It made a difference that this happened in a safe setting under the healthcare professional's observation. An example of it is when the physiotherapist said to (Table 4) Ann, “Go ahead. You won't damage anything”

Interviewer

If you were to put into words the very essence of it: What is the essence of what we are doing? Or what is helpful in terms of what you have gone through?

Ann

Well, but that is being taken seriously

Interviewer

Hm

Ann

That is to be listened to and being taken seriously

Interviewer

yes

Ann

Yes! That it is. Because I sometimes think; no, Ann, now you are hysterical. The pain is unbelievably strong; well, people will think you are hysterical. Well, it is that somebody understands what it means when your back hurts that much

Interviewer

But then what makes you trust the information you get? What does that give you? It is both the doctor and the physiotherapist I can tell

Ann

Well, and then that test there, where I…; at some point during the test, I say: “Oh – I feel like lying down and stretching my back”, but I didn't dare to, and Alan, (the physiotherapist) said: “Go ahead”.

Interviewer

Hm.

Ann

You won't damage anything (the physiotherapist said). So, I did it and it was like heaven, because I felt that I hadn't stretched my back for a long time. And, then, well he just put his hand around… But, it was such a blessing.

Being guided by the healthcare professional when moving, the patients experienced that they could exercise their back better than they had expected and dared hope to. In Ann's case, she moved only because she trusted the physiotherapist. Confident that when he said so, she would not damage anything; she felt safe and did as he said. The guiding consisted of the physiotherapist's attentive presence and the way he guided her movements with his hand. Stretching had been counter-intuitive because of the pain and the fear of making things worse. Movement tests made the prospects seem considerably brighter because patients’ felt what movement did to their bodies.

The healthcare professionals’ guiding added to the patient's trust in the healthcare professional, and their advice based on knowledge acquired from listening to the patient reduced the patient's level of anxiety and fear of provoking pain. The guidance included the healthcare professional's reassurance that the back would not be worse, the importance of frequent and challenging workouts, and specific advice on exercise that would work. This was a triple experience of being offered knowledge, being shown what to do, and feel on one's body that the exercise actually worked.

6.7 Being offered knowledge helped create a new understanding New knowledge was obtained through patient-healthcare professional communication. Heidegger writes: “‘Communication’ in which one makes assertions—giving information, for instance—is a special case of that communication which is grasped in principle existentially” (Heidegger, 1962, §34, p. 205[162]). Remarkably, the patient felt that the full story had been told and that the healthcare professional had listened and understood his/her situation. This left the patient confident that the healthcare professional had the required information about the patient's specific situation to consider the illness and its likely trajectory, and offer advice that would match the patient's need. Ann told:

The physician just said: ‘Training is what you need and you can just go ahead – you'll be OK’. It was just great hearing that from her

In addition, Ann emphasised that what she was advised to do was right: So, I did it and it was like heaven. Trust was necessary in the first place; to believe in what was being told and to dare do as told, and the success showed when it proved right.

6.8 Being consulted for a fitting intervention

The patients valued the healthcare professional's inquiry into their back problems. Not only did the healthcare professionals show interest in the patient's perspective but they also actively drew upon the patients’ descriptions of their understanding of their health issues, everyday life and work. Thereby, the healthcare professional showed openness towards the challenges that the patients were facing because of their low-back pain. The patients appreciated the fact that the healthcare professionals invited their active engagement in creating daily routines, involving manageable, engaging and accessible exercises that matched the recommendations. In this dialogue, the patient's perspective was disclosed and valued. The dialogue provided an understanding of what the patient was “capable of.” (Heidegger, 1962, §31, p. 184[144]) as a basis for negotiation of the best treatment. This enabled the design of an intervention tailored to the patient's needs and capabilities. This opened up new possibilities where there had previously seemed to be none. Heidegger points out that “Dasein always has understood itself and always will understand itself in terms of possibilities” (Heidegger, 1962, §31, p. 185[145]); with this new understanding came better chances that the patients would and could adhere to the plan and thereby improve their health behaviour.

6.9 Being legitimised as ill due to the healthcare professionals’ acknowledgement

The healthcare professional's support was highly valued by the patients. The support was founded on the patient's experience of the healthcare professional's acknowledgement of the low-back problems and the patient's problematic situation. The experience of “… Being with one another understandingly; … (Heidegger, 1962, §26, p. 161[123]) provides the patient with a feeling of no longer being alone with the experience, which made their situation more real and hindered the devastating feeling of making things worse, being a hypochondriac or as Ann said that: You are hysterical. The support entailed believing in the patient's story and the patient to an extent that the patient felt that the healthcare professional would vouch for the patient, for example, in relation to the patient's employer. The healthcare professional's support made the patients confident enough to cross the barriers. Professional support was crucial in encouraging the patients to stand up for themselves and to improve and change their situation by doing something themselves.

6.10 Being followed up

The healthcare professional's support had succeeded if the healthcare professional managed to “Leap ahead of him (the patient) [vorausspringt]”…; it helps the Other [the patient] to become transparent to himself in his care …” (Heidegger, 1962, §26, p. 158-9[122]). Then, the patient was able to improve and change the situation on his/her own. However, in this responsibility, the patient could also feel alone, thus without the healthcare professional's presence and control, the patient had to manage the influence of their environment as well as their exercise regime and everyday life. Here, follow-up appointments were important to adherence to any agreements made (Table 5).

Ann

Yes, and the experience that I am not only on my own. Yes, but now you have been to the Back Ambulatory. We finish now. By-by, be well. We just hope you will manage. And if you don't, then you know where to find us next time. Well, there will be a follow-up, won't there! That is, I am being followed; not just dumped right away!

Interviewer

Yes.

Ann

That's nice knowing

Interviewer

Nice knowing. What do you mean? What it does to you? Now, if you imagine the opposite of that

Ann

Well, but I think I would be more nervous that something might happen. That, well, now what if. Now that I have been in the hands of professionals; and now I am here having just been told: Now, you are no longer ill, so you can just do. That is, the experience of being told that now you have to do like this for three months, and now. It is reassuring. For me, it has been reassuring. And then the experience, imagining: Well, if I don't recover completely or if I get new symptoms. Then I am part of the system. And then, I don't have to start all over again. And then I can sort of say: Uh, now everything goes entirely wrong. What should we do now?

Thus, although absent, the healthcare professional continued to be a partner in the patient's mind. This made the patient feel safe and encouraged to do as agreed with dedication and an eagerness not to disappoint and extend the experience of Being with one another understandingly; … (Heidegger, 1962, §26, p. 161[123]). This meant that the patient gave the implementation of the agreed exercise programme more than one chance, especially at follow-up. Furthermore, follow-up showed to play an important role in exploring the extent to which patients could handle the healthcare professional programme on their own. Here, a follow-up can play an important role in ensuring that the first evaluation was accurate, perhaps with additional follow-up meetings in cases where the patient faces many challenges.

7 DISCUSSION

This study unveils why patients with low-back pain found help in the healthcare professional's open inquiry into the problems they had with their back. This openness furthered the patients’ active engagement in creating new explanatory systems and incorporating these systems into their story, which was crucial for their benefits from the intervention. The findings of the present study hence support the importance of the healthcare professional's attitude as stated in McLoud & McLoud's (2015) meta-narrative review of embedded counselling. McLoud & McLoud's (2015) highlight the positive difference in counselling effectiveness when patients experienced that healthcare professionals engaged willingly. Such willing engagement implied that healthcare professionals mastered the art of being good listeners, being empathic and caring to emphasise the patient's perspective and experience of being. The helpful counselling was characterised by being personalised, “meaningful and practically relevant” (McLoud & McLoud, 2015, p. 35). The present study showed that the essential element was the patient's experience of being taken seriously, which implied that the healthcare professional adopted a responsive attitude and was willing to interact and communicate with the patient. This empathic encountering, engaging in the patient's situation with compassion, was central to the patient's experience of what was perceived as helpful. Therefore, this existential understanding is an important supplement to medical knowledge as a basis for the healthcare professional and the patient's mutual effort to find a solution. The knowledge of the working mechanisms provides a basis for the healthcare professional to be the person who resonates with the patient (Churchill, 2012); the person who meets the patient emphatically due to his or her human ability to access the life of the other (Svenaeus, 2014; Zahavi, 2014).

The notion of being taken seriously was also highlighted as the core in meaningful encounters in Snellman et al.'s (2012) study, which found that patients appreciated healthcare professionals being available by granting time, creating mutuality, guiding, giving information, knowledge, support and assistance. The present study showed the working mechanism of the patient's experience of being taken seriously in the sense that they were invited to unveil their own perspective and they were met with trust, listened to, understood, relieved of a burden, guided physically, offered knowledge to form a new understanding, consulted for a fitting intervention, being legitimised as ill by the healthcare professionals’ acknowledgement and followed up. The starting point was that the healthcare professional adopted a responsive attitude and was willing to interact and accept the patient's perception of the situation as the patient perceived it. This is mirrored in Uhrenfeldt et al.'s study (2018), underscoring that dialogue with openness, trust and negotiation towards understanding is foundational for the relationship.

Translating this understanding into practice in the clinic, it is important to let the patient formulate his or her perspective. Unveiled by Heidegger's philosophy, the helpful factors were shown to be related to the intra- and interpersonal processes. By making this open inquiry, the healthcare professional supported the patient in understanding the situation and what it meant to the patient. By listening to the patient's perspective and listening to understand, ‘Hearkening’, this became a mutual starting point for a sharing of knowledge and for investigating a possible way forward. The core seemed to be ‘hearing to understand’. This emphasises the process of engaging in the patient's perspective, i.e. the importance of meeting the patient where the patient was. Otherwise, the healthcare professional could unwillingly add to the experience of not being able to manage (Angel et al., 2012). This meant that instead of furthering the patients’ active engagement in creating new explanatory systems and incorporating these systems into their story, the patient experienced being stuck (Angel et al., 2017).

Follow-up showed to be an important part of the helpful intervention. In a healthcare system with limited time, meeting again provided time for the individual's process. Incorporating more meetings over time made it possible to spend sufficient time with the patient, create a private atmosphere for personal conversation and have enough meetings with the patient to be able to provide the required help. This supplements McLoud & McLoud (2015) emphasis on the importance of being helpful, which also demanded sufficient time, privacy for personal conversation and an adequate number of meetings. The offer of follow-up gave the patient an experience of not being left alone; this feeling was rooted in his or her expectations to the next meeting and the effort the patient displayed due to his or her conscience towards the healthcare professional. This is supported by a study by Zotterman et al. (2016) of 10 chronically ill patients’ narratives in which follow-up was seen as essential to the experience of being cared for. Furthermore, Zotterman et al. (2016) also showed that professional attention made the patient feel seen as an important person and made the patient feel well. The present study adds to this knowledge of that professional engagement, which both increases trust in the professionals and their suggestions as well as enhances the patient's understanding of him- or herself and the situation. In addition, the experience of being cared for creates an experience of togetherness. Furthermore, the study showed how the expectation of meeting the healthcare professional also had a therapeutic effect because the patients felt obliged to the health professional and to being a person who themselves did what they could to heal.

Knowledge of the cause-effect relation is essential to any action taken or treatment instituted to alleviate the patient's pain and to reduce its consequences. If the condition is healed, this may be enough to help the patient. However, if the pain continues, these biological facts are the starting points for the patient to attribute meaning to the situation, which is essential to the patient's recovery. Therefore, it is important to involve the patient's understanding of what the symptoms mean to who s/he is, and how s/he can live his/her life is fundamental to providing a satisfying answer to these questions. To the patient, the factual and the facticity are intertwined; and to provide the best support (in some cases any support at all), the healthcare professional needs access to the patient's facticity (Heidegger, 2008). The challenge is that for the healthcare professional, these two perspectives are not necessarily intertwined. So, the consultation deals with the facts, the meaning of the facts to the healthcare professional (medical knowledge) and the meaning of the facts to the patient (personal identity, life). This becomes so important because unveiling the meaning of the health condition to the patient's life adds to the understanding for both and increases the understanding of the shared third. The present study showed that this mechanism of helpful interventions works by eliciting the patient's perspective by asking, listening, going into dialogue and negotiating the decisions. The central mechanism was that the professional contribution supports the patient in creating self-understanding, and this paves a way forward. This study further argues that Heidegger's philosophy may help us understand the patient-healthcare professional encounter. By unveiling the factors in counselling, it is possible to show in an operational way what we already know more abstractly. Showing the mechanism may make it more assessable for healthcare professionals and make it more transparent what is required to engage in helpful interventions. This may provide insight into why a relationship achieves therapeutic importance as demonstrated in the previous research (Aveline, 2001; Dryden & Palmer, 1997; Ruddell & Curwen, 2001; Ruddell,