What factors do medical students in their clinical years perceive as moderating their perceptions of, and responses to, uncertainty?”Uncertainty tolerance (UT), a construct explicating individuals' response to perceived uncertainty, is increasingly considered a competency for effective medical practice. Lower UT among physicians is linked with negative outcomes, including less favorable attitudes toward patient-centered care, and increased burnout risk. Despite decades of research, as yet few have engaged methodological approaches aiming to understand the factors that may influence medical students' UT . Such knowledge, though, could inform teaching practices for fostering learners' skills for managing uncertainties. Accordingly, we asked “n = 230) and end of semester group or individual semi-structured interviews (n = 40). Data were analyzed using a team-based framework analysis approach.We conducted a qualitative study with forty-one medical students in clinical years at an Australian medical school, with data collected throughout 2020. Participants described their experiences of uncertainty through both in-semester reflective diary entries (Four major themes of UT moderators were identified: (1) Individual factors, (2) Sociocultural factors, (3) Academic factors and (4) Reflective learning. Aspects of individual, sociocultural and academic factors were perceived as having either positive or negative influences on students' perceptions of uncertainty. By contrast, reflective learning was described as having a predominantly positive influence on students' perceptions of uncertainty, with students noting learning opportunities and personal growth afforded through uncertain experiences.As healthcare becomes increasingly complex, a future challenge is equipping our medical students with strategies and skills to manage uncertainties. Our study identified multiple moderators of medical students' UT, key among them being reflective learning. We also identified UT moderators that contemporary and future medical educators may be able to harness in order to develop learner UT as a healthcare graduate attribute, especially through teaching practices such as intellectual candor. Further research is now required to evaluate the impact of proposed educational interventions, and to develop effective assessments of students' skills for managing clinical uncertainties. Despite significant advances in medical knowledge and evidence-based practice throughout the 20th century, uncertainty remains an inherent and pervasive aspect of healthcare practice . RecentlUT may be considered a future protecting skill for healthcare professionals, as advances in medical technology supersede human data processing abilities. For example, healthcare is increasingly engaging artificial intelligence (AI) in applications such as diagnosis, decision making and patient education , 7. AI fPresently, research demonstrates important links between physician and medical student UT with healthcare-related outcomes . Lower Ustimulus is the underlying source of uncertainty, and is defined in terms of ambiguity, probability and complexity. Thus, terms such as “tolerance for ambiguity”, which are also used within medical education research, may be considered subordinate to the UT construct. Hillen et al.  stimulus characteristics, (b) individual characteristics, (c) situational characteristics, (d) cultural factors, and (e) social factors, but are not further defined by Hillen et al. , and after completion of an undergraduate degree (“graduate entry”). Both entry streams accept students enrolling domestically and internationally. Although direct and graduate entry students are separated for an initial preclinical phase, the streams combine for the penultimate 3 years of the course constituting the clinical phase. The location of students' clinical placement sites includes metropolitan, suburban, regional and rural areas, ranging from primary to quaternary care settings. All students graduate with a Bachelor of Medical Science and Doctor of Medicine (MD).For the present study, students were purposively sampled from the first (year “3B”) and final (year “5D”) years of the clinical phase, during which students are primarily placed within hospital settings. Our prior research exploring UT among preclinical students identified that transitions in education are a key stimulus for uncertainty . StudentFollowing institutional ethics approval (Project ID 20933), we recruited participants through messages disseminated via the course learning management system. In addition, G.C.S. conducted in-person and Zoom  recruitment drives. A total of 41 students were recruited , among which 35 completed all eight stages of the study (see “Data Collection”). Following completion of study consent, participants answered a brief demographics survey. This revealed that the majority of participants identified as women (68%), were in the direct entry stream (85%), and enrolled domestically (83%). The mean age of commencement of medical school was 19.1 years. A small majority of students identified as non-religious (56%), and the dominant ancestral groups identified were East Asian (41%), European (24%) and South Asian (22%). Participant demographics were thus generally reflective of the broader student cohort at the study institution.Using the concept of information power , 38, we G.C.S. led communication with participants across all stages of data collection, and made herself known to participants in her role as a medical education doctoral candidate. M.D.L. had previously taught and assessed many participants in their preclinical anatomy education. As this could represent a power imbalance potentially impacting how students present themselves to a former teacher, all data were de-identified prior to analysis by M.D.L (as well as M.S.). None of the authors were involved in teaching or assessment of students during or following the study period.What? So what? Now what?” approach  was proAt the end of each semester, students had the option of participating in either an individual or group interview according to their preference and/or availability. Both approaches were engaged to further explore potential moderators that were identified through preliminary analysis of diary entries, facilitating crystallization of our findings . This duIn your experiences of uncertainty, are there any factors that have impacted your experience of uncertainty either positively or negatively? These might be to do with the people involved, the setting or features of the situation itself, but could be anything you can think of that has changed your experience of uncertainty in some way.” Further questions were guided by participants' responses, with specific prompts added about potential moderators identified in participants' diaries where required. These prompts related to potential moderators included the influence of experience, personal characteristics, other people, assessments, and approaches to teaching and learning (including reflective learning)  was reflective of these. Participants were first asked “earning) . The proUltimately, we completed 20 individual interviews  and 20 group interviews . Average duration by interview type, student year level and timepoint are provided in We analyzed all data using reflective, team-based framework analysis . Our anaFollowing establishment of the research team, we engaged in a team reflexivity exercise . This enAn overview of the thematic structure of our results is provided in These were self-identified factors which clinical-years medical students described as influencing their UT. Subthemes encompassed students' (a) experiences, (b) personal characteristics, (c) sense of purpose, and (d) social comparison.experience as having a dominant influence on their UT, with the accumulation of clinical experience acting as an aid to navigating future experiences of uncertainty:Participants described their medical student [Uncertainty in medicine] gets easier with time and experience. And as students, we've only had…three years of clinical experiences…whereas…most of the doctors have had like, decades of it. And they still experience uncertainty, but it's that [clinical] experience and past experiences, which help and guide us the most.” Nisha, Year 5D, Group Interview.“failing” to complete a procedural skill despite prior success:Experience was described both in terms of gaining experience with medicine and healthcare in general, as well as in relation to practicing specific clinical skills. Although experience in general was described as facilitating students' UT, the moderating influence of specific clinical skills-based experiences varied according to students' perceptions. For some, practicing skills could facilitate UT development. Alternatively, experiences of inconsistent performance seemed to hinder some students' development of UT. A typical example was “One scenario in which I felt uncertain was my inconsistency in being able to cannulate patients. I had ended the previous rotation able to do straightforward cannulations in patients with good veins. The patients I encountered on this rotation however often had worse veins that were not as easy to cannulate... It was disheartening for me to come off my previous rotation with some confidence in my ability to cannulate and suddenly missing almost every cannulation I attempted.” Pallavi, Year 5D, Diary.“This negative experience was sometimes described alongside hesitation in approaching skill development opportunities in the future, whereas other students perceived similar failures as inherent to the learning process:Even when say you're uncertain in doing the procedure, and it doesn't end up working in the end, you know that you've walked away with more experience and most of the time your supervisor will give you some tips so that you're more prepared for your next experience.” Alice, Year 5D, Group Interview.“In this way, experience as a moderator of UT is conceptualized not only in quantitative terms, but is also related to the qualitative nature of an individual's particular experiences and their perceptions of outcomes.Personal characteristics students described in their diary entries and interviews as influencing their UT included demographic, personality traits, and mental health factors. Students described a wide array of demographic factors moderating their UT, including their living arrangements, employment status, relationship status, medical school enrolment intermissions, and the location of their familial home in relation to the study institution. Amongst these factors, some had a variable influence on students' UT depending on individual student perceptions , whereas others were described exclusively as hindering UT . For example, living alongside fellow students was described as facilitating UT through sharing and learning from others' experiences, but was also described as enabling the negative aspects of social comparison (further described below):But now that I'm like, literally in the same house, it's much harder to distance myself… I'm sort of force fed, like, my friends' study habits, I don't want to see them but like, I have no choice but to see them and like when you see them, you have no choice…to like, compare yourself…it's hard to sort of figure out where you should be sitting in the middle of that…so that's definitely been something I'm uncertain of.” Toby, Year 3B, Group Interview.“Personality traits and mental health factors were described only in relation to negative impacts on UT with students specifically describing the influence of burnout, introversion and anxiety on their management of uncertainty:I tend to be of a more anxious personality type. So, when I feel those emotions [related to uncertainty], I tend to think of them more as like my anxiety coming up…it's almost like I start to panic…I really want to get out of this situation…And my thoughts just basically start to go everywhere, in every direction. It doesn't make sense, it's very irrational…it's just a whole whirlwind of like, anxiety type emotions.” Violet, Year 3B, Group Interview.“sense of purpose facilitated UT by motivating them to navigate uncertainties:In contrast to negative impact of these personality factors, students described that possessing and fulfilling a I think having purpose definitely is a beneficial factor for…dealing with uncertainty… it reminds you of the bigger picture that if…you are feeling uncertain, your purpose reminds you …that you're really here for a bigger reason.” Nisha, Year 5D, Group Interview.“Students described finding their purpose in a variety of ways, including focusing on their career path in medicine, identifying the need to learn to care for their future patients, being helpful to their clinical team, acting in patients' best wishes, and maintaining their personal values within the context of healthcare. Purpose relating to personal values included discussion of social justice issues  and values rooted in religious beliefs, with these values often underscoring students' motivation to study medicine. Maintaining these values was described as being able to provide a sense of guidance and certainty for students despite the uncertainty surrounding them:I actually am having quite a bit of difficulty identifying moments or scenarios during which I felt certain. However, I do feel certain about my passion for women's health and my values rooted in intersectional feminism. I am grateful to have the opportunity to speak with women on a daily basis and be privileged enough to hear their stories and it was during those times of GP [general practice], when I was truly connecting with patients, that I felt the most certain… When I feel this way decision making is much easier and my overall confidence is increased.” Emily, Year 5D, Diary.“social comparison, or the process of thinking about others in relation to oneself as a means of making sense of one's current or future position  teaching behaviors, (b) placement inclusivity, and (c) healthcare professional cultures.Teaching behaviors were described as either facilitating or hindering students' UT depending on the educators' approach. Medical educators were identified by students as spanning the continuum of career stages from near-peer medical students to senior clinicians. Teaching behaviors described as facilitating UT included role-modeling UT, scaffolding knowledge (including selective didactic teaching), encouragement, constructive feedback, acceptance of mistakes and setting learning goals and expectations. For example, acceptance of mistakes seemed to facilitate UT by allowing students to distance themselves from negative emotions associated with uncertainty, and refocus their attention toward uncertainty as part of the learning process, whereas setting learning expectations provided students with a framework for managing learning uncertainties:I did have a clinical bedside tutor and in their first session with us…they were just like, ‘okay, I really want to set expectations of how I want this teaching to go… that this is a space where you can make mistakes… I want to figure out…what point in your journey you're at, because I'm a consultant and I'm so far from that now.' So, I think that's positive because it … gave us some certainty around expectations and also how to navigate the times when we were uncertain.” Leena, Year 3B, Group Interview.“Role-modeling UT was described through educators exposing their thought processes, dilemmas and failures [i.e. intellectual candor ] about u[The surgical registrar] was asking me why he wasn't cutting here … I said, ‘I didn't know' and he was like ‘…it's because there's a chance of cutting the inferior epigastric [artery] if you cut here…Ask me why I know that?' And I was like, in my head…'Oh, so you're going to tell me 'I knew this when I was a third year' or something', and he was like, 'Oh no, when I was reg somewhere else, I actually cut it and since then, I've made sure that I don't.' And so, I kind of felt like him offering that to me was actually like, look, I didn't know as well and I paid a price and that's why I'm teaching you this…I think for him to actually like reveal a personal flaw or maybe something like that was actually quite generous, but also made me feel like oh okay, everyone doesn't know things.” Cathy, Year 5D, Individual Interview.“Despite the many positive teaching behaviors described, students also experienced a variety of behaviors perceived as hindering their UT. These behaviors included singling out students from a group to answer questions, didactic teaching as a standalone pedagogical approach, acts of learner humiliation, false assumptions about students' prior learning, and inadequate supervision:One of the probably biggest factors [that impact uncertainty] is… supervision. So, the current rotation…it's a very busy rotation...I found…the busier the people in the team you're with, the less time they have to direct you in the right way. So, then you show up uncertain and if there's no one there to kind of guide you because they're extremely busy, that just…kind of snowballs it.” Christopher, Year 5D, Individual Interview.“When analyzing teaching behavior patterns according to the educator's career stage, we identified that positive behaviors were described in relation to teaching by near-peer medical students, junior doctors and senior doctors. However, teaching behaviors described as hindering UT were more typically described in relation to senior doctors. Students described the cognitive and social congruence  of near-I think, a…really big factor that has helped alleviate uncertainty for me have been my [year 5D student] mentors…I think just having these senior mentors…who know their way around and have been in our shoes really helps, and the fact that they're kind of closer in age and in…their journey to us compared to like, big consultants, really helps them like relate to us.” Linda, Year 3B, Group Interview.“Placement inclusivity encompassed whether students perceived their experiences as shared or isolated , and whether they felt included or excluded from their clinical team on placement . Inclusion and active involvement within a clinical team was described as facilitating UT, and could be achieved through simply addressing students by name and acknowledging their presence on ward rounds within the medical record:The HMO [house medical officer] would put my last name next to theirs in the patient notes, and would introduce me to the patient by name. It was such a simple thing to do but it made me immensely more comfortable in learning from them and asking questions – without feeling like a burden or like I was unwanted.” Ainsley, Year 3B, Diary.“burden” on their clinical team to discuss uncertainties.Conversely, exclusion from the clinical team included instances of students being ignored and/or actively excluded from typical placement opportunities such as ward rounds. This served to amplify students' uncertainty about learning on placement, as they felt they too much of a “health professional cultures more broadly described the customary behaviors of different health professional groups that students encountered. Specific cultural aspects described by students influencing UT were the hierarchies within medicine, and the tribalism between different healthcare professional microcultures. Medical students' perceived inferior hierarchical status within medicine could compound their uncertainties, wherein students described questioning their own knowledge or perceptions when these differed to that of a senior:Whereas placement inclusivity centered on the students' perceptions related to small teams of individuals encountered on placement, It's sort of come down to…me sort of like questioning people who are senior to me…There was another instance the other day where our [general surgery registrar] went into a patient's room and called the patient one name when it was a different name on the list… he went through the whole consult, telling this patient that … he had multiple [pulmonary embolisms]…he only noticed right at the end, that he was actually talking to the wrong patient…so I'm like, maybe I'm the one who's wrong… maybe it's the list…that's wrong, because obviously this the reg seems really confident.” Aarush, Year 5D, Group Interview.“In healthcare tribalism, the differing beliefs and values held by different healthcare professional groups  also served to compound students' uncertainty about learning within the relatively unstructured clinical placement context:Our tutor has also given instructions such as ‘don't ask the nurses as they overprotect their patients', which makes it more difficult when no doctors seem to be free or around for us to speak to.” Linda, Year 3B, Diary.“vulnerable” patient and student groups thus had to contend with navigating the compounded uncertainties of institutions and culture constructed by and for those with greater privileges:Concerningly, a culture perpetuating the discrimination of minority and marginalized people was described by some students, with this influencing some students' UT. Descriptions included students' observations of healthcare professional-patient interactions, as well as students' own experiences as subjects of discrimination. These “It's mostly been sort of an issue of racism…that I've experienced…Sticking up for myself …[is] something that definitely I do not feel comfortable doing, that I definitely feel uncertain about doing in the hospital environment…There was an instance on the wards the other day that a patient was… unintentionally kind of racist...and the reg played it off…I kind of had to just bite my lip and not say anything…there's even been instances where… I've been called sort of racist terms by staff in the hospital as well…it doesn't feel nice not being able to stand up for yourself in the hospital environment.” Aarush, Year 5D, Group Interview.“A culture of social inclusion facilitating UT  was not identified within the data.Academic factors pertained to moderators enacted at the level of medical school programs and their administration. Moderators described by students included (a) assessment, (b) orientation and (c) faculty communication.assessment on UT was divisive for students. Some students described assessments as facilitating UT by providing structure to guide them through learning uncertainties, whereas others felt the objective nature of assessments impeded their ability to engage with the uncertainties of clinical medicine. Indeed, the lack of summative assessments in Year 5D was described by some students as facilitating engagement with clinical uncertainty:The influence of Without the stress of exams looming over our heads…I think I am finally enjoying the “art of medicine” (where previously I would hyper focus on the “science of medicine” because exams). This year, I have found that I better embrace the ambiguous [and] uncertain situations as I am less driven to be learning just for the sake of an assessment.” Chara, Year 5D, Diary.“orientation to clinical placements appeared to vary between clinical sites. When formal placement orientation was provided, this was described as reducing the perceptions of uncertainty related to learning within unfamiliar placement contexts, and facilitating capacity to manage uncertainties related to learning clinical medicine:Provision of an What [our placement administrator] tried to do is… give us a tour of the [emergency department] to like help orientate us and little things like that have taken away a little bit of the uncertainty…And they sent a whole document at the start of the rotation talking about the different roles of the different areas and what the roster is. And they really helped to take away a lot of the uncertainty and so now it's…I think it's just the right amount of uncertainty now… where you feel like you have that space to grow and that space to learn.” Olivia, Year 5D, Group Interview.“When formal orientations were omitted, some students described initiating their own peer-to-peer orientations, including handover document development and communication via group messaging applications. This self-directed approach to orientation also appeared to facilitate UT, as students managed their placement uncertainties by sourcing information from peers who had previously completed the same placement.communication from those in the faculty , and whether this was perceived as supportive of students, served to moderate their UT. This sub-theme was particularly described within the context of pandemic-related impacts to placements. Knowing that they were supported by the faculty seemed to facilitate students' UT, even in the face of significant and enduring uncertainties. A cornerstone indicative of support was frequent communication interpreted as conveying the primacy of students' educational interests:Students described that the style of To have faculty support and to know that they had our backs despite all the uncertainty was very reassuring, even as I understood that the situation was very fluid. This encouraged me and allowed me to feel supported and reassured on an academic level, and ultimately gave me enough peace to make difficult decisions.” Patrick, Year 5D, Diary.“By contrast, infrequent, untimely and conflicting communication from faculty was perceived as unsupportive of students, and could magnify students' uncertainties about possible disruptions to learning and assessments. This was especially the case when communication from faculty differed from messages students received from other health professional staff working at students' placement sites:There is a lot of confusion, in the sense that directives we as students are receiving are quite mixed. [The university] has standardized it recently, so that the clinical school you are associated with dictates things, however, the head nurse, the consultant, registrar and other staff that you work with do provide directives…[that]…can be mixed.” Ali, Year 5D, Diary.“reframing” uncertain scenarios by taking the focus away from negative associations with uncertainty, and instead focusing on ways in which uncertainty could be beneficial:Although the primary role for the research diaries was to explore clinical students' experiences of uncertainty, the way in which participants described their experiences suggested that the reflective process was, itself, moderating UT. The role of reflection as a moderator was further supported by students through their interview responses. Reflections appeared to influence students' perceptions about past uncertainties, as well as future uncertain scenarios. Dominant reflections described by students involved “I kind of enjoyed being able to write out the diary entries. It's sort of forced me to look back on things and look back on what I've gained…from a rotation, or what I haven't gained and need to carry into the next rotation…So… I thought it's actually been beneficial for me as well to be able to reflect on that uncertainty and really think about it in, you know, in terms of uncertainty as opposed to just failings.” Pallavi, Year 5D, Individual interview.“The predominant way in which students reflected on uncertainty was in terms of identifying learning opportunities facilitated by uncertainty. Students recognized that although uncertainty could be uncomfortable, it was inherent to learning and the practice of medicine:Uncertainty is quintessential to our learning now, as it pushes us to learn and find out things. I mean, the only way to learn is to not know, and I want to be both comfortable in not knowing, while still wanting to reduce the amount of things I don't know.” Harrison, Year 3B, Diary.“Reflections on uncertainty also discussed identifying personal growth and increasing the capacity to take appropriate steps in the face of future uncertainty. Students described that contending with uncertainties developed their confidence and resilience within healthcare contexts:I think I have become more resilient throughout the year… So, when I was bit uncertain about things, or felt a bit kind of insecure in a moment, I would kind of regroup, think and just continue on, or come up with a plan B.” Natalie, Year 3B, Individual Interview.“There was, however, a darker side to reflection described by some students, including rumination and a sense of regret. Ruminating on uncertainty involved a persistence or amplification of negative responses to uncertainty that students recalled feeling in the moment of uncertainty:I feel like sometimes my uncertainty gets, like, amplified because I have a tendency to like, overthink things, like after the situation and like, ruminate about things. So, yeah, in some ways, I feel like it, I've become more uncertain, like the further it becomes from [the uncertain situation].” Victoria, Year 5D, Group Interview.“Students who described regret on reflection seemed to perceive their uncertainty in terms of inadequacies or subpar performance in a learning encounter. Unlike positive reflections, this regret was not countered with a sense that the uncertain experience could be of benefit in some way:I definitely beat myself up a bit if the outcome isn't necessarily good, because all you can think is I should have done better. I knew the answer to that, or I know what I should have done in that scenario. Why do I know that now? Why didn't I think about that 5 minutes ago? All those sorts of feelings.” Raimon, Year 3B, Individual Interview.“These negative reflections were less typically described by students, with the dominant pattern we identified being that reflective learning facilitated UT. Furthermore, this facilitation could occur despite recalling negative responses  experienced at the time of students' initial uncertainty.individual factors, sociocultural factors, academic factors, and reflective learning. Our findings both refine and extend the Hillen et al.  could hinder UT, effectively trumping previous experience gained. Thus, describing experience only in black-and-white quantifiable terms is likely insufficient to fully understand this moderator, as our research suggests that the nature of these experiences additionally influences UT.Amongst our identified moderators and their subthemes, many were described as having a variable influence on students' UT, either facilitating or hindering UT depending on specific student perceptions and contexts. This differs from existing research that typically only describes moderators in terms of being associated with one or the other of higher or lower measured UT. For example, prior research typically describes experience as a moderator in terms of quantifiable experience gained (e.g. number of years in practice), and demonstrated inconsistent results regarding whether UT increased or decreased with experience . In our personal characteristic influencing students' UT, or act as a set point around which moderators are able to exert an influence. Critically, however, our data supports the notion that students perceive that their UT can be moderated with the assistance of medical educators and educational institutions.Although our research supports UT as a modifiable state, questions do remain regarding the possibility of a trait level component to UT (i.e. a relatively stable and consistent pattern of response to uncertainty over time). Inherent differences in UT traits between individuals could explain the differing perceptions students had about some moderators (e.g. assessment), and why some students tended to ruminate upon reflection. In this way, trait level UT could be conceptualized as an additional reflective learning appears to have the potential to powerfully influence clinical students' UT in a manner that may help counter other moderators with a negative influence. For example, engaging with reflective learning may benefit clinical students who perceive negative experiences related to uncertainty, allowing these to be reframed into learning opportunities. The clinical students in our study valued the repeated, formative nature of the reflective diary entries, the flexibility to choose their reflective medium, and the ability to reflect on and share their experiences through interviews. More generally within medical education, reflective learning is known to assist in developing skills for lifelong self-regulated learning, and for managing the complexities of practice .Although our study was conducted within the context of clinical years students, many of our suggestions may also be helpful for preclinical students, especially where moderators may allow early years students to build skills in preparation for the uncertainties of clinical placements . For example, think-aloud protocols could be used to deeply explore students' experiences of uncertainty as they engage with uncertainty stimuli, and learning analytics could provide data approximating students' actual responses to uncertainty. Further research is also needed to explore UT moderators in a wider range of medical education settings , and develop assessment strategies that balance evaluation of learning medical knowledge, with skills for managing the uncertainties of clinical practice.Key strengths of our study that helped ensure the rigor of our work include our attention to information power  and the Given the inherent ambiguity, complexity and indeterminacy of healthcare, managing uncertainty remains a critical attribute for medical graduates , 4. Our michelle.lazarus@monash.edu.The datasets presented in this article are not readily available because the raw data cannot be shared outside the authorship team due to ethical restrictions. Sharing of de-identified data sets supporting coding and analysis may be shared in limited circumstances and depending on compliance with ethical approvals. Requests to access the datasets should be directed to This study involving human participants was reviewed and approved by the Monash University Human Research Ethics Committee (MUHREC). The participants provided their written informed consent to participate in this study.Funding for this study was obtained by ML. Participants were recruited by GS and ML. All data were collected and present article was drafted by GS. All authors contributed to the design of the study, analysis, interpretation of data, critically reviewed and edited subsequent drafts of the article, and gave their approval for the publication of the final version.This research was funded by a Faculty of Medicine Nursing and Health Sciences Learning and Teaching Grant.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Legal automatismencompasses a whole range of more complex actions,….where the accused has no capacity ongrounds of…involuntariness.’Definitions of automatism abound – legal and clinical. In Bratty versus Attorney Generalfor Northern Ireland, 1963 , Lord Denning defined automatism as ‘an act which isdone by the muscles without any control by the mind such as a spasm, a reflex action or aconvulsion; or an act done by a person who is not conscious of what he is doing such as anact done while suffering from concussion or while sleepwalking.’ More recently, in R. versusColey (2013) (EWCA 223), the England and Wales Appeal Court gave this definition: ‘Theessence of it is that the movements or actions of the defendant at the material time werewholly involuntary. The better expression is complete destruction of voluntary control …Examples which have been given in the past include the driver attacked by a swarm of bees ora man under hypnosis. ‘Involuntary’ is not the same as ‘irrational’; indeed it needs to besharply distinguished from it.’ Rumbold and Wasik defined automatism as ‘an involuntary piece of behaviour over which an individual hasno control. The behaviour itself is usually inappropriate to the circumstances, and may beout of character for the individual. It can be complex, coordinated and apparentlypurposeful and directed, though lacking in judgement. Afterwards, the individual may have norecollection, or only partial and confused memory for his actions.’ Bourget et al. and Yeo both argued that involuntariness and lack of control are much more important featuresof automatism than the precise level of consciousness (or lack of it). Kopelman adopted an essentially pragmatic, descriptive definition, which was ‘an abrupt changein behaviour in the absence of conscious awareness or memory formation associated withcertain, specific clinical disorders.’ These included epilepsy, parasomnias, hypoglycaemiaand head injuries .Clinically, the presence of amnesia is a necessary, but not sufficient, condition forautomatism. Fenwick proposed that an association between epilepsy and violent behaviour required (i) thediagnosis of epilepsy by at least one neurologist with special competence in epilepsy; (ii)epileptic automatisms documented by the history and closed-circuit television andelectroencephologram (EEG) monitoring; (iii) the presence of aggression and simultaneousictal EEG changes demonstrated by video EEG; (iv) aggressive acts characteristic of theindividual's habitual seizures; and (v) the offence should be part of the seizure in thejudgement of the attesting neurologist Similar criteria have been proposed for establishingan association between post-ictal confusion and violent offending. In practice, documentation of automatisms by closed-circuit television and EEGmonitoring, or aggression with simultaneous changes demonstrated on EEG/video EEG, areusually unavailable in prison inmates. As a result, the diagnosis usually has to be made onthe basis of the history, available EEG evidence, and on ‘the balance of probabilities.’Various more specific criteria have been proposed for particular clinical conditions. Forexample, Delgado-Escueta et al. have specified criteria for the diagnosis of confusional arousals or sleepwalking,when associated with violence. For example, in a confusional arousal: (i) The subject musthave been asleep for a sufficient length of time to reach deep sleep (stage 3 or 4); (ii)The stimulus must be sufficient to induce an awakening; (iii) The abnormal behaviour muststart immediately on arousal; and (iv) Usually the episode is short, a matter of a fewminutes, but may be lengthened if alcohol is implicated. Where parasomnia is claimed toaccount for abnormal behaviour on (for example) an aircraft precipitated by alcohol and/ormedication (as in some recent cases), there should be evidence of previous parasomnia and/orabnormal arousals on polysomnography. The problem, as the law stands, is that an externallyprecipitated (‘sane’) automatism does not require expert opinion.Similarly, in parasomnias, Ebrahim and FenwickWhile Scottish law is similar to English law in this matter, there appears to beconsiderable variability across international jurisdictions. In 2008, the U.S. State ofIndiana Court of Appeal ruled (Roger J.Schlatter v. State of Indiana): ‘Automatism isbehavior performed in a state of mental unconsciousness apparently occurring without will,purpose, or reasoned intention … a person … capable of action … not conscious of what he/sheis doing. Automatism manifests itself in a range of conduct, including somnambulism,hypnotic states, fugue, metabolic disorders, epilepsy and other convulsions, or reflexes.’Thus, this definition incorporates both metabolic and psychological disorders. In Canada,automatism from somnambulism or epilepsy results in a person being found ‘not criminallyresponsible because of mental disorder.’ He/she then has to be reviewed within 90 days withregard to determining an appropriate psychiatric ‘disposal’. In this, epileptic automatismsor parasomnias are treated the same as psychoses, delirium tremens, dissociative states,battered women's syndrome and panic reactions, but differently from self-induced alcoholicintoxication. Similarly, in Sweden and Denmark, a neurological or psychiatric findingaffects ‘disposal’ or sentencing. proposed a new defence of ‘not criminally responsible by reason of a recognisedmedical condition,’ which might be a mental or physical disorder. For this to apply, thedefendant must ‘wholly’ lack the relevant criminal capacity because of a lack of control,lack of understanding that the act was wrong, or inability to form a rational judgement.This defence would not be available if the lack of capacity were self-inflicted, as inalcohol or substance intoxication. ‘Sane automatism’ would be reserved for those rare caseswhere the behaviour was not the result of a medical condition – for example, a reflexaction. This would bring the law in England and Wales more into line with that in Canada,except that the burden of proof  would be onthe prosecution, unlike Canada (where it is on the defence). This defence would be available both in Crown Court and in Magistrates’ Courts, andpossible ‘disposals’ would range from a hospital order to an absolute discharge.In England and Wales, the Law Commission1315 a matter on which there are important differences across internationaljurisdictions. Such verdicts are rare in England and Wales, with very occasional exceptions.For example, in the case of R. versus T, 1990 (Crim LR 256), T had been raped 3 days beforeparticipating in an armed robbery: the Crown Court ruled that the defence of non-insaneautomatism was available as a consequence of a dissociative state and PTSD, although thejury rejected this defence and convicted her. In the case of R. versus Roach, 2001 (EWCACrim 3217), the Court of Appeal ruled that ‘automatism of psychogenic type’, secondary topersonality disorder and the combination of alcohol and medications, should have been put tothe jury. Such cases appear to be more common in Australia, where evidence of dissociationhas led to ‘some questionable acquittals’. The Canadian Supreme Court ruled that claims of ‘psychological blow automatism’required ‘an extremely shocking trigger … to establish that a normal person might havereacted to the trigger by entering an automatistic state …’. Nevertheless, commonplaceissues such as ‘a traumatic marriage breakdown’ have been accepted as ‘sane automatism’ inAustralia and ‘insane automatism’ in Canada.What remains unresolved is the place of ‘psychological blow automatism’ or ‘dissociativeautomatism,’ Yeo and McSherry have all argued that a lack of volition/control, rather than the level ofconsciousness, is the critical factor in determining ‘automatism’, with McSherry positing a continuum across volitional, dissociative and automatic behaviours. Butthere is, surely, a qualitative difference between those disorders in which voluntary actionis ‘wholly’ disrupted by a disturbance of consciousness  and those in which volition is merely compromised in the absenceof any disturbance of consciousness ?Bourget et al.). Problems arise because, in many jurisdictions, the notion of ‘diminishedresponsibility/competency’ is limited to homicide cases. If ‘diminished responsibility’ wereto apply to other offences, the temptation to broaden the concept of ‘automatism’ to includepsychological shock or ‘blow’ would no longer exist.Some of the inconsistencies which have arisen, both within and between differentjurisdictions, result from the failure to make this important distinction. The concept ofmedical ‘automatism’ should be reserved for those cases in which volition is disrupted as adirect result of a disturbance of conscious awareness  those neurologicalconditions in which volition is traduced by a disturbance of consciousness and (ii) thosepsychiatric disorders in which volition is merely compromised in the absence of anydisruption of conscious awareness. While giving the impression of deftly bypassing thisissue, the proposed reforms may, in fact, compound the difficulties that courts willface.


In mental health services, recovery constitutes a guiding principle that is endorsed in professional medical guidelines and has become central to mental health policies across the world. However, for many clinicians, it can be a challenge to effectively embed recovery concepts into professionally directed treatment of disease without distortion, and ostensibly away from what matters to those who use the services. We discuss the evolving and multifaceted concept of ‘recovery’, including illness narratives to frame our discussion. We demonstrate how integration between a person-directed management of illness and a professionally directed treatment of disease can converge, resulting in positive outcomes for people with mental illness. Increasingly, patient-led research has been challenging traditional professional perceptions on the trajectory and outcomes of mental illness. . Many people may not fully recover from mental health problems, but can discover how to cope with their condition. Evidence has also highlighted that recovery, and many of the processes involved in it, can happen across a period – in many cases, outside of formal medical environments. In this editorial, we summarise and discuss contemporary aspects of recovery, including the co-concept of ‘illness narratives’. We argue that although recovery can be a contested topic with differing views, it is also ubiquitous, and its meanings are not always fully incorporated into truly co-produced models. Models that put patients’ narratives at the core could perform as a connecting mechanism that provides a process to take account of ‘personalisation’, which is likely to create a better fit with individual context, structure and the complex diverse realities of recovery-oriented practice and routinely provided interventions.1 Anthony's work remains highly influential (and cited) to definitions of recovery, stressing that ‘recovery is what people with disabilities do, recovery is a truly unifying human experience’.1 He also asserts that recovery, is ‘multi-dimensional, defying simplistic measurement’.1 Other perspectives on recovery have been explored: Slade has divided these into two forms, with clinical recovery being defined as symptom changes viewed by the clinician,2 and ‘personal recovery’ being defined as what the individual narrates and understands in a meaningful way.2People outside of the formal health settings understand recovery in terms of their individual, specific and personal perceptions. Accordingly Anthony has shown that illness can hinder a person's perception of a productive life and undermine their process of recovery.3 Patient movements have dominated the concept of recovery since the mid-1970s,4 and currently there has been criticism of professionals that look to be trying to ‘mainstream’ recovery concepts to their advantage.6What is strikingly obvious here is that recovery is being presented in a distinct and separated pattern. This separation appears to be divided by the focus and the lens through which it is viewed. It is questionable whether this separation is helpful both clinically and furthering the discourse on recovery itself. The separation pushes apart the idea that ‘professionally directed’ treatment and ‘person-directed’ treatment can converge; indeed, the spirit of recovery would challenge the language of this – ‘directed’ inferring ‘being done to a person’ and would call for it to be more fitfully replaced by ‘perspective’. McWade also reinforces our view that this concept of recovery can be defined in such a way that allows freedom to converge medical expertise and affords patients the autonomy in their individual journey to recovery.7 to attempts to define, standardise or measure the conceptual framework,9 alongside histories10 and empirical studies.12 Recovery-orientated practice guidelines exist for service provision,18 including an emerging critique19 resting on personal recovery,22 recovery-oriented services,29 in addition to provider competencies.36 Despite the accumulation of research produced to support or isolate contested elements of recovery, disagreement and criticism remains over the definitions of recovery and on whether recovery has to be survivor-led or a policy directive.37There has been a significant amount of research and published work attempting to support each of the individual recovery concepts, but little has been done on the positive outcomes of converging the constructs. Recovery research ranges from personal accounts22 to incorporate accepted components of recovery.38 This, however, has only led to further compound the idea of mainstreaming of recovery.37 Amid this accumulation of criticisms, Braslow has shown that ‘recovery is everywhere’ despite including an array of perspectives.5 Since the 1990s, the concept of recovery in mental health domain has affected both the person experiencing mental health difficulties and the clinicians.37 A conceptual framework that acknowledges recovery36 has been produced by Leamy et al, highlighting five main approaches in their CHIME framework: Connectedness, Hope – optimism, Identity, Meaning – purpose, and Empowerment.38 However, CHIME has not been without its critics. Bird et al carried out a validation study applying thematic analysis of data from CHIME, using focus groups with those with diagnosed schizophrenia, bipolar disorder and depression.36 They demonstrated that the CHIME framework was both valid and appropriate for use, but highlighted areas that were not included, such as ‘a desire for practical support, issues around diagnosis and medication, and scepticism about the concept of recovery’.39 As noted, evaluating recovery is an inherently complex concept,40 challenging the essence of creating ‘reliable measures of individual recovery’39 and the construct validity of this. Andresen et al suggest that if the said concept of recovery is entirely individual,41 contrary to ‘what can it be normed and as might be expected for a concept in which symptom reduction is not paramount’, then ‘correlations with customary clinical outcome measures may possibly be poor and convergent validity low’.42Narrative and systematic forms of syntheses and reviews have tested tools43 in the operational aspects, emphasised in popular guidelines, discourse, policies and research. Pilgrim aptly suggested that recovery is a polyvalent concept.43 However, this does not translate easily to those who may wish to activate the recovery construct for better patient outcomes and improved service delivery. Quiet so, Braslow has argued that recovery remains an ‘unquestioned overarching principle and popularly known to include a melange of beliefs, values that materialized because of the intellectual and social movements’.5Given all of this diversity of recovery principles, it is perhaps not surprising to find professionals misunderstanding and confused40 – could complement and augment professional knowledge.44 However, this requires a substantial shift in the clinical lens, incorporating ‘lay types of knowledge’, such as a person's own understandings of dealing with illness, including social functioning.44 Suitably, Davidson and Roe conceptualise that meaningful illness narratives are a gift exchange, providing meaning, emotive steadiness, narration and collective experience.40To further link back to the discussion on the concept of converging the person-directed management of illness and professionally directed treatment, we recognise, similar to Davidson and Roe, that an anthropological model – one situated upon ‘principles of reciprocity’ that concerns itself more with the integration of healthcare45 although we may be seeing some welcomed change with this, and COVID-19 may offer an interesting corollary, with the emphasis of ‘long-COVID’ care moving toward wellness and self-management of long-term chronic difficulties. Pilgrim has pointed out that the root basis of patients’ adverse perceptions can be based on pathology, making clinicians appear as ‘chemotherapists with a prescription pad’.45Biological aspects have often been viewed by patients as both coercive and impersonal,46 The Care Programme Approach (CPA) necessitates that health and social needs are comprehensively assessed and reviewed with individuals with serious mental illness, with a ‘philosophy of recovery and to foster personalised care’.49In the UK, the National Institute for Health and Care Excellence explicitly calls for care plans to be jointly drawn up between individuals and their clinician, with shared decision-making and agreed dates to review its progress.50 there remains a general lack of data exploring actual practice in the community, and even less that is focused on in-patient care.51 The Healthcare Commission in the UK assessed in-patient performance across 554 wards in 69 National Health Service (NHS) Trusts. About 40% were rated as ‘weak’ when it came to including patients and carers; astonishingly, half of care plans had no evidence of recording patients’ views, and about a third made no mention as to whether there was a carer involved. A further third had input from the patients’ community care coordinators only some or none of the time.52Despite their imbedding in contemporary British mental healthcare,53 They found substantial variations among sites for results on therapeutic relationships and participant groups in their study, related to the experiences of care planning and understandings of recovery and personalisation.53 Consequently, carers expressed varying levels of input, and despite risk assessments being part of central clinical concerns, they were rarely discussed with patients.54Work by Simpson et al examined the views and experiences of stakeholders involved in community mental healthcare, investigating factors related to the provision of personalised, collaborative, recovery-focused care.55 and staff accounts of routine collaboration contrasted with patient accounts and care plan reviews. They also found that personalisation was not a common phrase, but care was often delivered in an individualised way.55 McWade has argued that this endorses that perspective of failure of co-opting or mainstreaming the ‘thing’ that is recovery.3Patients valued therapeutic relationships with care coordinators and others, and saw these as central to recovery. However, in another study by the same team, the staff, patient and carer interviews revealed gaps between shared aspirations and realities,56 Conversely, ‘illness problems’ are the principal difficulties that symptoms and disability create in lives, and ‘illness behaviour’ then consists of initiating treatment .57 There is an overdue lack of understanding placed on the notion that there is a pre-existing underlying relationship between the person and their illness. Albeit in separation of formal treatment environments, this occurs in the way individuals perceive their difficulties, the type of help they envisage, and the approach they are willing to engage with for formal treatments; it includes making contact with clinicians and entering into a contract with services for future treatment.‘Illness management’ can be understood as an approach to support patients with a diagnosis to engage with clinicians, to reduce patient susceptibility to the disease.58 We propose that Kleinman's illness narratives model has proved influential in this regard, remarking how the practitioner has also been socialised into a distinct collective experience of sickness. It is true that clinicians are trained to capture the essence of illness by using concepts that delineate disease. For instance the use of expressions such as relapse, recurrence, remission and recovery.59 In this way, the symptom profile is used to transform the patient's illness (in a form of recasting of illness in accordance with the theories of disorder) into a disease formation.57 The absence of an ongoing intervention other than that relationship can be perceived by care managers as a need for premature discharge from services, for fear of creating dependency. However, some who use services desire an ongoing relationship, which commonly matters more than interventions, and this aspect can be missing in some recovery narratives. The construct of so-called ‘palliative psychiatric care’ is informative in this regard.60 Further, moral experience is central to Kleinman's model of illness narratives, incorporating constructs of ideal virtues of the practitioner61 and so opening up ‘illness narratives’ to create patient ‘storylines’, which brings to life inanimate parts of practices, policies and discourses.63 Hajer suggests that storylines are ‘narratives on social reality’, which combine elements from many different domains and ‘provide actors with a set of symbolic references that suggest a common understanding’.64 Albeit critically, Kleinman also envisaged that partnership is vital and is susceptible to change over time, with caregiving perceived as a construct focused more on ‘doing good for others in their world’ and projecting that ‘as earnest and naïve as it sounds, it is what medicine is really about’.65For the purpose of this editorial, a critical discussion cannot be complete without including a focus on clinicians understandings. Hitherto, psychiatric models have perhaps viewed the concepts of recovery from mental illness in a similar style to how clinicians have viewed physical illnesses.66 There is a recurring critique of recovery presented as the ‘next best thing’,67 and a mere form of symbolism, undermining ‘authentic alliances’68 donning recovery in a sense to reduce effective support.69 Service cuts have been associated with the manner in which services and health systems manage future demand for mental healthcare, allied to the economic cutbacks planned for financial savings.71 Consequently, recovery concepts used in this method risk being used, or at least perceived, as indicative of justification to reduce services or their ability to provide timely input.Despite the common understandings, it should be noted that some patients remain suspicious of the recovery concept because it is potentially intolerant of those who do not change, and so it may remain, in their eyes, a source of oppression used against them.40 the importance clinical recovery2 and personal recovery are touted in guidelines for key clinicians.76 The significance of tackling personal recovery, in conjunction with more standard concepts of clinical recovery,2 is currently endorsed in guidance for all key professions.76 Whether it as a model or framework, a movement or a guiding ethos, recovery is now ‘the hegemonic guiding principle of public mental health policy’.5 The social sciences have already reworked treating disease as a process of medical micro-encounters,77 and to the idea that ‘disease problems’ can occur within an individual's circumstances of everyday life.76 It is evident that researchers, clinicians and services alike may require a more complex approach to personal narratives and construction of meaning if individual recovery is to be more clearly understood.78In the majority of English-speaking countries79 not merely because they interfere with professional knowledge, but because they have the power to strengthen the capabilities of individuals to bring forth personal goals and generate a sense of identity,17 a fusion, a convergence to create a mechanism of acceptability, of both person-directed management of illness and professionally directed treatment of disease, or, in essence, shared understandings of recovery and shared decision-making toward that outcome. Roberts and Hollins have also encouraged that medicine ought to discern that ‘disease understandings’ are embedded in patients’ experiences and their daily lives, and are considerably tied to a person's social history.71 This necessitates clinicians to move from a tradition of ‘paternalistic attitudes’ of helping or being the expert, to create meaningful alliances.80 Likewise, Lawton et al described an approach to illness experiences that recognises a dynamic interplay between ‘survivor’ and the healthcare system, whereby one affects the other,77 suggesting that medical encounters merely comprise a relatively insignificant portion of most patients’ lives . Accordingly, the medical support to patients’ ‘sense-making’ tends, in reality, to be exhausted by the conditions and encounters met in the extra-medical social world.81Psychiatric treatment historically conceptualised primarily based on a disease model could have the potential to impede the long-term treatment and assessment of those with chronic difficulties and illness. Linked to this assertion, Voronka has indicated that narratives can be utilised and shaped as a ‘gap-mending’ strategy,81 Peer support is increasingly recognised and implemented within NHS services, with roles in the UK typically at band 4/5; indeed, the Health Education England publication ‘Stepping Forward to 2021: The Mental Health Workforce Plan in England’ advocates even greater expansion of this.82 Nevertheless, there has equally been a call and need to deliver care in ways that have just not been possible in traditional teams. A potentially very fruitful and positive development in this regard has been the growth of recovery colleges, driven by strong patient engagement and roles, often at odds with, or at blurred boundaries to mainstream NHS services. Accordingly, central to improving outcomes for individuals, services should involve providing services that are ‘person-centred, strengths-based and recovery-focused’.74 To enable the interpretation of the recovery approach into practice, there is a necessity to involving illness narratives as a mechanism to personalise treatment and care so that it can be operated and assessed within medical and research environments.25Recognising and embracing recovery concepts enhances care and the therapeutic experience for professionals and patients. The possible ‘recursivity’ between services and perceptions is relevant to understanding the way in which those with mental health problems might engage with care services.


We also show that architecture is increasingly global, with decreased interest in local and/or national issues and the growing prevalence of English as a publication language. Finally, this academic focus is manifested in references cited by architectural papers with the gradual substitution of professional and artistic oriented knowledge, for scientific approaches tied to engineering and technology.According to recent literature on “architecture” as a discipline, practical knowledge relevant to its process of making has decreased in importance in favor of a more academic approach. Using data derived from Ulrich’s Periodical Directory and Clarivate Analytics’s Web of Science, this paper suggests providing empirical evidence supporting of such shift, as revealed by an overview of the dissemination practices in architecture scholarly production between 1980 and 2015. Our results support that architecture is becoming increasingly  Standing midway between arts and applied sciences, architecture is not easily definable unambiguously, as it encompasses both the abstract and the tangible. Architectural research combines several disciplines from arts (aesthetic judgment), engineering , practice  and even social sciences . While architecture, as an institutionalized academic discipline, needs to be distinguished from its associated professional activities, both technical-oriented architecture and academic architecture are taught in universities, influencing the nature of scholarly research.The Discipline of Architecture  single interest magazines […], and to most literary magazines”;“Trade”, which refers to the “business publications targeted to readers in […] employment or commerce: industrial or manufacturing; merchandizing or trade; institutional; and professional”; and“Academic/Scholarly”, which corresponds to refereed journals identified through “a process combining publisher self-reporting about individual titles and independent Ulrich’s editorial research”.A total of 1,915 records were recovered, of which 1,354 were kept after removing duplicates. The content types “Consumer”, “Trade”, “Academic/Scholarly” led to the retrieval of 257, 549 and 548 journal records respectively. This dataset provided bibliographical information on each journal, including editing country, founding and terminating (if applies) dates, audiences, and language. The aforementioned duplicates of magazines  were removed from the data and renaming and/or fusion of journals and magazines were respected as far as possible.Observatoire des Sciences et des Technologies (OST) in a relational database format. This database includes the three main WoS indexes, that is the Science Citation Index Expanded, the Social Science Citation Index and the Arts & Humanities Citation Index. In accordance with the criteria established in bibliometric analysis, specific publication types only were taken into consideration, namely research articles, notes, and reviews. A total of 71,448 articles published in 79 distinct journals were found. Although architecture is considered as an interdisciplinary field with important ties to arts, engineering, urban planning, etc., the Arts & Humanities Citation Index contains a specific subcategory labelled “Architecture”. According to Clarivate Analytics, this category “covers resources that are concerned with the study of art and science of buildings, particularly the design and construction of habitable structures”. It also includes: “resources on architectural history, landscape architecture as well as urban and country planning and design” [We retrieved from Clarivate Analytics’ Web of Science (WoS) all articles published from 1980 to 2015 in the subject area “Architecture”. As the Web version of the WoS is not well suited for advanced bibliometric studies, the analyses presented in this work were based on WoS data provided by the  design” .Architectural Digest or L’architecture d’aujourd’hui. “The fact that they are included in the ISI suggests there are no rigorous transparent quality criteria in place that govern the ISI’s Art & Humanities Citation Index” [As underlined by Van der Hoeven, WoS’s “Architecture” subcategory not only includes peer-reviewed academic journals but also trade and commercial journals such as n Index” . Since jTo observe the evolution of the architecture publications’ characteristics, we have divided the dataset in two segments for some analyses: 1980–1997 and 1998–2015. This division allows a better comparison between the first and second halves of the studied period.Comité national d’évaluation de la recherche, the WoS database has several limitations including a limited coverage, the exclusion of certain types of documents (such as books that are widespread in literature on architecture), changes in the journal titles, a classification of the journals by disciplines, non-discrimination of different individual authors with identical names, distribution of the work among authors without reflecting their proportional contribution and non-detection of negative or erroneous citations [As noted by the French itations , 19, 20.itations . JournalAn analysis of the data retrieved from Ulrich’s shows that when considering only journals with a clear year of founding, the overall number of journals and magazines dedicated to architecture has increased between 1980 and 2015  lose their prevalence at the international level, other English-speaking countries such as the United Kingdom and Australia are increasing their share of world papers.The dominant place of US scholars in architecture papers is confirmed in Despite the decline of US papers, English remained dominant and grew in importance throughout the years . In contThe results from this analysis should, however, be interpreted with caution as the Clarivate Analytics’ WoS tends to favor the English language, a bias already pointed out by many investigators. As a result, non-English-speaking authors, institutions, publishers, or countries are likely to be underrepresented . DespiteTroiani et al. observed that scholarly research in arts and humanities is “carried out by lone individuals, each acting independently, often raising questions rather than answering them, and, in architecture’s case, often testing architecture’s boundaries to ask what architecture might be” . Such a In addition to mostly being the result of individual authors, publications in humanities, including architecture, tend to include fewer references compared to publications in other fields. Hammarfelt considers most humanities as a “rural field”, where there is low dependence on colleagues, less communication between the researchers, less publication channels, and thus fewer citations. Thus, “the social and intellectual organization of the humanities is the main reason to why citation-based approaches are less applicable in these fields” .Articles published in trade journals and in consumer magazines do not usually contain a reference list, as this is not standard practice in these types of publications. The data presented in The disciplines to which scholarly papers in architecture are referring are presented in The data presented above suggests that publications on architecture are increasingly becoming academic. This is demonstrated by the growing proportion of articles and journals intended for a scholarly rather than professionals (trade), or grand public (consumer) audience. The overall number of journals and magazines dedicated to architecture belonging to the type scholarly/academic, trade, and consumer is growing every year testifying that their readership does not dramatically decrease. According to our body of study, academic/scholarly journals have, however, become the dominant type of publication in this field, outnumbering professional journals (trade) and the magazines intended for consumers. Trade and consumer papers seem to have lost their prevalent position and thus are relegated to a secondary position in the diffusion of architecture-related information, in favor of journals labelled as academic/scholarly.The number of papers is not representative of the overall academic and scholarly production of articles in architecture as the WoS considers documents published in journals; which does not cover all of the communication channels used by the scholar community. In fact, it is well documented that authors in applied sciences, social sciences, behavioral sciences and humanities, tend to use other means of communication including books or multidisciplinary scholarly journals , 10, 24.lingua franca in sciences, national languages are more common in humanities due in part to the strong local or regional orientation of this field and the nature of the objects to be studied [Although English is considered the  studied . This be studied . The cho studied . So, desThe observed gradual growth in the overall number of references per paper may also suggest the academization of architectural research. Because architecture as a discipline does not have its own research methods, it must refer to other fields , thus exOur analysis attempts to provide empirical evidence of an academization of the field of architecture, thus confirming Piotrowski and Robinson’s observations . However


In recent years, there has been something of an explosion of interest in those artworksand installations that directly foreground the bodily senses. Often referred to asproprioceptive (or prop.) art, the question to be addressed in this narrative historicalreview is how it should be defined, and why has it become so popular? A contrast is drawnwith examples of sculpture and/or tactile art. The entertainment/experiential element ofsuch works cannot be denied, especially in an era where funding in the arts sector is sooften linked to footfall. At the same time, however, a number of the works appear to beabout little more than entertainment/amusement. One might wonder why such “edutainment”should be placed in the art gallery rather than, say, in a museum of science or illusion.Nevertheless, in the best cases, the foregrounding, or removal, of bodily sensations thatproprioceptive artworks deliver can potentially help to connect people in an increasinglydigital, online, mostly audiovisual, and hence in some sense disembodied contemporaryexistence. These issues are discussed in the context of the works of Carsten Höller, aprolific German installation and object artist. There has been a rapid growth of interest in what has come to be known as “proprioceptiveart” in recent decades. In this narrative historical review, I want to take a closer look ata number of those artworks that somehow directly stimulate the bodily senses, and considervarious issues with the definition, conceptualization, and relative merit of proprioceptiveart. I also want to address the question of why the interest in such works, many of whichfall under the broad umbrella term of “relational aesthetics” , has gro thermoception, nociception, proprioception  senses. At the same time, however, I will exclude any artworks that onlystimulate the bodily senses indirectly, including the perception of dance amongst those whoare dancers themselves e.g., .2 This At the time, any artist who was able to elicit this response from their viewers wouldonce have been considered to be at the top of their game. Relevant here, Broadly speaking, the indirect route to stimulation of the bodily (interoceptive) sensesperhaps ought to include the early Dutch still life with fruit paintings. The artist'sintention in such cases was often to try and induce their viewers to salivate by renderingthe glistening surface of the cut lemon as vividly as possible see .3 At tAccording to the definition of proprioceptive art put forward here, the stimulation of thebodily senses should be somehow integral to the artist's work/intention. It is necessary toinclude this point in order to exclude those immersive artworks that stimulate the bodilysenses, but where that stimulation would seem to have been incidental to the artist'soverall aims and objectives. For instance, your author experienced one such example ofindirect  bodily awareness on a recent trip to the Art Fuseexhibit at Artechouse in New York . The worFulcrum (1987). According to  This approach was captured more than a century ago at Oxford's Picture Gallery in theBodleian Library that read: “Touch what you like with the eyes, but do not see with thefingers” .Although the sculpture is typically considered a primarily visual art form nowadays, it isworth noting how some artists have intended for their works to be experienced through touch.Just take, for instance, Brancusi's sculpture for the blind from the opening decades of the20th century . In thishttp://www.rosalyndriscoll.com/pages.php?which_page=book_introduction; seealso More recently, the North American artist, Rosalyn The above works would all seem to represent examples of what might be called tactile art.Importantly, the full appreciation of these works may well require the viewer's activebodily engagement. That said, in contrast to the works of proprioceptive art that will bediscussed below, the focus in such cases is very much on the feel of the object itself,rather than on bodily sensations/experience. It may be said that the aesthetic pleasure insuch works would appear to result either from the “aesthetic aha” , as in t artworks deliberately engage proprioception, kinesthesis see . Meanwhiite)see ; p. 32: However, before taking a closer look at some of Höller's works, it should be stressed thatthis artist is by no means unique in attempting to foreground the experience of the bodilysenses see . WhileEMany of Höller's works were brought together for his Experience exhibition held in New York, to mixeAccording to the critic, One of the points to note here concerns the fundamentally multisensory nature of theexperience of such fairground rides/attractions. Indeed, it is interesting to note how manywriters have drawn attention to the sensory overload that is typically associated with thefairground/theme park phantasmagoria ,the artist has been quoted as saying that “Subjective personal experience in science is ano-no” in .8 It sed e.g., . Strattoed e.g., . Meanwhied e.g.,  classic ed e.g.,  is alsoed e.g., .Upside-DownGoggles, 1991–2001) is actually based on a psychological investigation that wasitself originally built entirely around the subjective report of the authors/scientistsconcerned. That being said, one can also turn things around, and note how the experimentalresearch on which the artworks are loosely based, built as they are on the introspectivereports of participants involved may also help to explain the pleasure resulting from thebrain's attempt to integrate the sometimes-incongruent multisensory cues. Similarly, thesensory hallucinations that have often been documented in laboratory studies of sensorydeprivation , or as part of public understanding ofscience-type “edutainment” .One challenge to considering at least certain works as prop art comes from pursuing theKantian suggesti Here, it is perhaps worth returning to Höller's Mirror Carousel (2005), which, assome have noted, turns maddeningly slowly. On the one hand, this slowing down of the actionhelps to distinguish this example of bodily sensation from the white-knuckle excitement ofmany theme park rides . Here, it may be helpful to consider JerroldLevinson's , 2002 de Once again, though, if one looks at the long history of sensory deprivation researchthen it very soon becomes clear that the researchers working in this area have also longbeen interested in subjective reports of those who are sensorially deprived, be it in aflotation tank  would have us believe. Taken together, then, the direct proprioceptiveartworks would appear to either foreground bodily awareness , as in SThere has undoubtedly been a rapid growth of interest in proprioceptive (prop) art inrecent years, even if few of the artists themselves necessarily choose to use terms such as“proprioception” and “prop. art,” nor do they necessarily even directly refer to thestimulation of the bodily senses. There are likely a number of reasons for this growinginterest in engaging the bodily senses: First, it is clear that the rise of the “experienceeconomy” e.g., ,1999, aOn the other hand, the growing popularity of proprioceptive artworks/installations mightalso be contextualized in terms of the “shock of the modern” . Here, i They might also be seen as fitting in within our growing awareness of the senses moregenerally ( and increasingly to audiovisual life in the digital world or Metaverse (Pursuing this idea still further, a number of the artistic works discussed in this reviewmight perhaps be seen as a reengagement of, or reconnection to, the immediate bodily senses.11 Theenerally . Indeed,enerally . One migenerally , that emenerally 12 and etaverse .13