In the twenty-first century the world faces the stark reality that’s far from any visions of an ideal world, accompanied by an epidemic of social inequality and global injustice. Many social and global issues such as the refugee crisis, climate injustice, racism, whitism, and terrorism are rooted in serious, untreated historical traumata. These traumata have been experienced by one or more members of a family, group, or community, and may have been passed down from one generation to the next through epigenetic factors. Phenomena of collective trauma can be described more understandably through its interpretation by the quantum social science of Wendt (2016). This interpretation provides a social pathology that offers methodological recommendations (methods of treatment) for social therapy. One potential example is the collective trauma integration process (CTIP) developed by Thomas Hübl . Healing Collective Trauma: a process for integrating our intergenerational and cultural wounds. Boulder: Sounds True.), which is a method to restore fragmentation by addressing and integrating individual, ancestral and collective trauma. This paper focuses on one methodological consideration for building a new culture through the integration of collective and intergenerational trauma, which is a framework based on collective trauma research in psychology, sociology, and quantum social science. Collective and intergenerational trauma is not only psychological phenomenon discussed in psychology and psychotherapy, but also social phenomenon researched in sociology and other social science. This phenomenon should be described from the perspectives of both methodological individualisms and collectivisms, and both psychological and social pathology. For this, we need more holistic interdisciplinary approaches which can disentangle the snarled collective and individual entity. One approach, which was originally developed for international relations in political science, is ‘quantum social science’. In this paper I use the quantum social science approach to describe the individual psychological and collective sociological pathology of collective and intergenerational trauma, and explore the functions and mechanisms of this phenomenon.This approach conforms to the theoretical assumptions of quantum social science of Alexander Wendt and collective trauma theory of Jeffrey Alexander and Thomas Hübl, who formulate their transformative scientific perspective as a means of coordinating our behavior to contribute to a more robust process of culture-building. This approach is organized in three sections: quantum social science approach (Sect. 2), its application for collective and intergenerational trauma (Sect. 3), and practical instruments for collective trauma integration (Sect. 4).The particle aspect is the individual aspect. Its characteristics are determinate. We can locate particles in space and time, we can focus on them and measure them. They are separate and relate mechanically. The wave aspect is indeterminate. It is a spread of possibilities located everywhere in space and time. We cannot pin waves down; they have no boundaries. Each wave overlaps and combines with all other waves (p. 109).According to Feynman , quantumRecently many physics and social science researchers who consider how concepts, methods, and understandings from quantum physics relate to societal issues are establishing ‘quantum social theory’. One such approach is Alexander Wendt´s quantum conscious hypothesis, which is briefly summarized below.Wendt  illustraThe core proposition for quantum social theory by Wendt can be summarized as follows: Due to ‘direct perception’ or ‘pure experience’ (measurement), an agent can be aware of affordance which is an action possibility formed by the relationship between an agent and its environment. This process of becoming aware of affordance – ‘intra-action’ between subject (agent of observation) and object (object of observation) – can bring out an agent´s Will, which is expressed in a speech act with perlocutionary force (quantum collapse). Wendt adopts quantum physics to establish a new social theory which is different from a classical worldview such as materialistic, deterministic, mechanistic and individualistic.As mentioned above, there is a long tradition of social theory, including Whitehead, who “was motivated by the quantum revolution to articulate a post-classical cosmology to display Newtonian cosmology” Allan, , p. 98. Wendt´s methodological approach is to draw out the epistemological lessons of quantum theory for social science by essentially trying to guess what the relevant complementary variables would be. In writing this paper, I am interested not only in analogies but also in the widely applicable psychological and sociological issues such as personal healing and societal transformation, cultural process, the nature and function of bodies, the nature of identities, and consciousness and the unconsciousness.There are some widely acknowledged researchers and authors who have contributed definitions of collective trauma, e.g. Volkan , Neal 1, AlexandFor Alexander , “culturWhen we think of historical trauma, we think about the painful and long-lasting consequences of war, imperialism, colonization, domination, subjugation, occupation, enslavement, interventionism, and hegemony. It is a force that often proliferates as a result of cultural, political, racial, ethnic, religious, gender and/or sexual extermination, suppression, or systemic intolerance. (p.67)Hübl  uses “inCultural, collective, intergenerational, or historical trauma have caused “a large group to face drastic losses, feel helpless and victimized by another group, and share a humiliating injury” Volkan, , p.8. A Victims (and their ancestors) of mass atrocities such as genocide and war choose, memorize, and narrate these atrocities as trauma, influencing their descendants emotionally, mentally, or somatically. Chosen trauma of historical events is transmitted intergenerationally  and affect subsequent generations . Chosen trauma that ancestors experienced has demonstrated social and psychological impacts on the current generation . The collective and individual symptoms which result from the unconscious influence of trauma are clearly evident in post-traumatized societies. The invisible entanglement between chosen trauma and narrative identity acts to reproduce post-traumatized, socio-cultural dysfunctions such as human rights abuses, lack of political transparency, economic instability, polarization, and political extremism, among other issues.The effects of collective trauma on the construction of meaning is not limited to the victim group that needs to reinvent itself and reconstruct all that was lost, but also impacts the perpetrator group which must redefine itself and construct a positive moral image in light of the atrocities it committed Particularly since 2015, Europe has seen an increase in refugees arriving from former European colonies like Syria, Afghanistan, and various African countries, fleeing from poverty, war, and terrorism perpetrated by groups such as ISIS in Syria, Al Qaida, and the Taliban in Afghanistan, and Boko Haram in Nigeria. Moreover, considerable scientific evidence supports a correlation between this surge in numbers and the escalating environmental degradation, consequences of climate change, and international tensions surrounding these regions. For example, Burke et al.  examinede Grimm, . The mose Grimm, . Victimse Grimm,  refers:TSo far as perpetration of our ancestors has not been atoned sincerely by them and their descendants, the descendants are possessed by historical unconsciousness and their behaviors have negative impacts on the descendants of historical victims consequently. In this way ancestor who were perpetrators become entangled with the historical unconsciousness of their descendants, and perpetration and victimization continue to repeat non-locally and timelessly.Culture influences its integral parts and institutions in which individuals are enculturated, acculturated, and interact with each other. In this socialization process, their cultural identity is constructed and protected by the transgenerational transmission of a mental representation of a traumatic historical event (chosen trauma) Volkan, . This trAydin  suggestsIt becomes a monster that haunts them unceasingly, a monstrum, something beyond normal human bounds that cannot be categorized and identified and persistently disrupts their mental order. It is inconceivable but, nevertheless, ever present. (p.131)If the unintegrated collective trauma is too big to digest, it damages consequently the resilience of a culture, which hinders further growth and flourishing. When the trauma cannot be integrated, it remains invisible and becomes an invisible shadow as part of the cultural identity of the victims and their descendants. According to Aydin , “they aIn the trauma field, large portions of energy are strongly dissociated and suppressed in shadow. Their energy resides in the dark lake, largely invisible to members of the society, even while the symptoms they produce are widely manifested throughout. The nervous system of the next generation is born into and raised within that field, which is invisible; its effects and structures become wired and are taken as “normal.” This traumatic-state conditioning makes it difficult for any person living within that community to realize a felt sense of its dark lake, even after such a native comes to cognitively recognize its existence. (p.92)This ‘monstrum’ is hidden in a dark lake which we can perceive as a shadow of culture, but cannot grasp and recognize by language. The language we’ve acquired in our socialization process is not adequate to describe it. Hübl  explainsThe ‘dark lake’ in which the ‘monstrum’ is hidden reappears with fears, expectations, fantasies and when “a chosen trauma is reactivated” and “time collapses occurs” Volkan, , p.10. ‘Without time collapse, the ‘dark lake’ remains invisible and unrecognizable. This ‘dark lake’ extends beyond our notions of space and time, occupying more than one position at any moment of time, like ocean waves that move along a stretch of beach. This wave movement overlaps with others and can occupy the same position at any moment of time. During the period of when the invisible ‘dark lake’ ensues, before the sense of time collapses, only the context in which the monstrum is hidden is recognizable – it is culture. Culture is localized objects that occupy a given location at each moment in time. The phenomena of the ‘dark lake’Entanglement and superposition are related and positioned in the matrix of victims, perpetrators, and ancestors Fig. .Fig. 1EnA group of people who were victimized by another group, for example in a genocide or a massacre, focuses on certain parts of this terrifying event which becomes their ‘chosen trauma’. The event has been transmitted as ‘chosen trauma’ intergenerationally from ancestors to descendants in this group. This transmission process occurs through identity politics which are manifested via political and societal power. The group operates in this manner to establish a stable foundation for their state and community. Descendants of victims are socialized under the influence of these identity politics and are identified with a specific cultural identity of the group. Individual cultural identity of each descendent becomes entangled with the chosen trauma of their ancestors (collective).However, on the other side the perpetrators of these victims experience a different process in the transmission of their perpetrations. The quality of these experiences can be interpreted as glorifying or they may forget their crimes. This process is typically enacted systematically in the form of identity politics inter-generationally from ancestors to descendants. The results are that descendants become unconscious of the perpetration committed by their ancestors. In this way, the historical unconsciousness  of descendants is entangled with the perpetration of their ancestors (collective).These two types of entanglements occur within the respective culture of each group. Culture is dynamic, and changes in its cultural process by providing an important context for entanglements. While culture is seen as “a consequence and a function of the social dimension of human life,” cultural process is “a consequence and an expression of human consciousness of the world and intentionality toward the world”  “the nature of the pain”; (2) “the nature of victim”, (3) “relation of the trauma victim to the wider audience”; (4) “attribution of responsibility” According to Thomas Hübl, one of the most effective approaches to collective trauma integration is the cultivation of coherence and resilience in groups, followed by a process of consciously turning towards and witnessing the emerging sharing of individual, ancestral, and collective trauma experiences. As people gather around a shared intention, they have more resources available and can integrate the pain, bit by bit, that could not be processed before. In this process they can sense the ‘dark lake’ as Hübl :When we Synchronizing and resourcingMeeting the landscapeBecoming a conduitListening to the fieldIntegrating and restoringTransforming and meta-learningThe ensuing release leads to mindset shifts and behavioral change—an increase in compassionate and collaborative ability, creativity and innovation and a decrease in isolation, polarization, and separation. Based on his experiences as a facilitator who has worked with thousands of people, Hübl developed the “Collective Trauma Integration Process (CTIP)” whose goal is to release and thereby integrate the trauma that is stored both within individuals and within groups of people who share a similar trauma pattern in their collective unconscious. According to Hübl , p.11 thThese six stages in the CTIP which takes place in a group of ca. 20–150 people guided by one or two facilitators might enable participants to break entanglements and the superposition to collapse through ‘redemptive measurement’ and ‘expressive measurement’  was originally proposed by Hübl and Ury  and was What is witnessed is expressed in language. Fierke and Mackay  call thiThese articulations express a form of wave-function collapse and a pattern of diffracted entanglement, by which the attributes of the system become visible or ‘seen’ as the vibrational frequencies surrounding a particular space, and the affect that arises from it, are transformed into language and thus became available for analysis. If language use is a measure of wave-function collapse, the language arising from a relational system becomes a measure of a non-linear historical trauma field. (p.458)Some researchers and trainers of collective trauma integration use a systemic constellation, which was developed by Bert Hellinger to disclose the hidden patterns unknowingly influencing thoughts, behaviors, and emotions in a system such as a family. Fierke and Mackay  report tThe communicative quality of expressive measurement should have illocutionary and perlocutionary force, with which wave-function superposition collapses In the collective trauma integration process (CTIP), two types of measurement – redemptive and expressive measurement – are enacted by participants in a group. Just as physical measurements such as length, weight, and speed require an apparatus, redemptive and expressive measurements are conducted by apparatuses too. In the context of CTIP, each participant can be understood as an apparatus of measurement that depends on other apparatuses in the group. This interdependence of apparatuses has been discussed as ‘agency of observation’ among many quantum physicists and philosophers, starting with Nils Bohr and Werner Heisenberg. In social contexts such as CTIP, and in framing this as a quantum discussion on the nature of apparatus, an apparatus of redemptive and expressive measurement is not limited to individual cognition, emotion, and sensation. The apparatus should be regarded as holistic collective performative action, a group of participants as an apparatus. For Barad , “apparaThe term ‘hidden fragmentation’ refers to the ‘dark lake.’ which is one existing potentiality of a superposition culture/dark lake. As the superposition culture/dark lake is visualized in Fig. In a culture constructed by invisible entanglements (when there is no conscious untangling) between collective/ancestors and individuals/descendants, we cannot have any reflexivity to respond to collective trauma, but we are also unaware of this absence of reflexivity, which is the nature of unconsciousness. The concept of reflexivity itself cannot work within a complex society that experiences global crises . The complexity of these crises involve numerous variables and impacts, but they all seem to be interrelated. They are especially related to the ubiquitous nature of climate change which is clearly embedded in and derived from our behavior in daily life Welzer, . In thisWithout perceiving the other half of reality we cannot discover a comprehensive, wholistic solution to complex problems, nor can we fully integrate our collective traumas. To see another half of reality we need special measurements and apparatuses which enable ‘diffraction’, which is defined in physics as the blending of waves (i.g. electron beam and neutron beam) around the corners through a slit into the region of geometrical shadow of the slit. Since Barad  applied In the CTIP, vocabulary from quantum social science can be used to enhance the experience of participants in their understanding of the process. Most importantly, the participants are enacting the language of quantum social science by embodying their diffractive and intra-active meanings. As they do this, the individuals (subject) and their collective traumata (object) can be enacted in a new way, as part of a new vision for culture. In this way, CTIP is one example of a quantum social science approach to collective trauma, highlighting the ways in which trauma can be rationalized, managed, and absorbed by a systematic process. The collective acknowledgement of collective trauma can then become starting point for the societal mobilization of healing mechanisms, through which society is equipped and empowered to draw strength, and finds new pathways to move towards a vision of culture rooted in collective healing.


If the head and body are to be well,You need to begin by curing the soul.DialoguesPlato, prevention and delaying the onset gain enormous significance than combating after the onset. Natural therapy might be one of the best secrets of preventing emotional illness including dementia which is very often irreversible. It is the general lack of holistic approach in clinical practice that frustrates the patient and the caregivers as well, because mental illness is no longer viewed as an isolated case of neuropathological disarray. It has biological, psychological, emotional, social, economic, cultural, ethical, AND, spiritual dimensions, whose silent cries have been largely ignored thus far. Now, the paradigm is undergoing a welcome change (slowly but surely) with neuroscientists working in harmony with spiritualists evidenced by the emergence of Neurotheology.All emotional illness is basically unfinished business and unexpressed truth. For, truth has the power to heal, protect, guide, and inspire. The cardinal principle of psychotherapy is to help the patient become (more) truthful about his/her feelings. A psychotherapist may be elegantly described as a choreographer of emotions. A healthy and wise approach to mental illness would be the one based on honesty and truthful living which has a tremendous therapeutic impact. This preventive and healing aspect of natural therapy has been unfortunately obscured and almost drowned in the drone of (sometimes) premature pharmacological interventions. When we are dealing with potentially irreversible disorders, de” meaning “apart or away” and “mens” (genitive- mentis) meaning “mind”. A lonely sojourn of utter confusion and frustration for the patient, dementia has become a huge global problem.Manifesting as a set of symptoms representing a progressive decline in cognitive processes, dementia derives its name from the Latin root “Paranoid orientations tend to develop in demented people who have premorbid sensitive and suspicious nature. Existing personality traits are intensified by degenerative brain biochemistry and also the stress accompanying old age. It has been observed that elderly people with Alzheimer’s disease (AD) are usually unaware of their own cognitive deficits and hence do not attribute negative incidents to this cause.The sense of rejection, abandonment, helplessness and the deepening urgency to grab the fragments of slipping self-identity and self-worth are nearly palpable in many dementia patients. Minds which had once been beautiful, active and vibrantly alive gradually become blank and disconnected struggling endlessly and painfully to make sense of disjointed images. The shell of the mind closes in on its empty self.Dementia results in three principal kinds of loss: i. the loss of love, ii. the loss of control – intertwined with fear of rejection and making the person more vulnerable to loss of love, and iii. the loss of self esteem – including being embarrassed and being exposed as flawed.The magnitude of this disease is straining family and societal resources. The often associated problems of marked agitation, uncontrolled eating habits, inappropriate sexual behavior, senselessly repetitive behavior, unpredictable emotional outbursts, hoarding of useless objects, etc. in demented people can be enormously distressing to the caregivers, especially in the long run.AD patients with depression tend to develop extremely morbid preoccupations and delusions – hypochondriacal ideas about suffering from various dreadful diseases, for instance, often viewed as punishments for past sins. As a way of atonement, suicide is a possibility in such cases.Robertson (1982) aptly stated that “meaningful life can be prolonged if brain degeneration could be held at bay. But in broad terms, reasonable cerebral function is the key to the quality of survival in the elderly”.AD appears to be the product of not a single or even a limited array of specific causal factors. Often it is the consequence of an accumulation of risk factors – both environmental and genetic – that eventually exceed some clinical threshold when disease manifests.As the disease advances, caregivers are confronted not only with challenging management problems, but also with the “social death” of the patient as a person. It is weLiving in the present is perhaps all that a person with dementia can really experience as the condition advances, when past and future hold no meaning for him/her. Not compromising their basic dignity and not denying their value as humans, they need to be nurtured, empowered to respect themselves and encouraged to preserve whatever remains of their cognitive functions.The time has now come, as a means of shared humanity, to break the boundaries of ordinary reasoning and expand our empathic understanding of the essence of the person with dementia. It begins with unconditional acceptance, modulating the expectations, balancing and optimizing the influences of and interactions with the patient’s internal and external environment. Claire Biernacki states that while interpersonal care based on “Person centered model” is the order of the day which is likely to improve the quality of the patient’s day–today life, it is equally vital to maintain our awareness of advances in medical field that would enhance the clinical practice.In the changing paradigm of enhanced awareness about consciousness, a burgeoning idea is that the challenges we face as humans on earth are no longer regarded as meaningless suffering or random occurrences. They are viewed as life lessons consciously chosen during prebirth planning by our souls in order to evolve. Albeit aEmerging vistas indicate that the conventional medical world is on the threshold of recognizing the link between energy or spiritual dysfunction and illness. That survival strategies are passed along in our DNA has been shown by Evolutionary psychologists. CarolineNow it has been established that the body and its immune system possess tremendous healing potential. According to Dr. Zhi Gang Sha, “Lack of sufficient energy” is the root cause of degenerative diseases such as Alzheimer’s. The suggested healing remedy is to increase the energy density around the cells.Although people with dementia are generally regarded as having lost their minds, the beauty inherent in their spirit remains untainted and eternal. Statistics does not apply to human spirit – dementia or not.Here is a befitting tribute to the power of human spirit, envisaged as “Beautiful Soul” by the second author.I’m a beautiful soulLoving, eternal and wholeI’m a grateful smiling lightPeaceful, joyous and brightI’m an energetic tree,Balanced, blissful and freeI’m a lovely little flowerBlooming every hourI’m a daring bird, soaring highA non-judging observer, as life goes byI’m a mighty, humble mountainAnd the sprightly healing fountainI’m a passionate seaWilling and able to “BE”I’m Mother earth, ecstaticGrounded, dependable and authenticI’m the vast sky, awesomeCentered within the humdrumI’m a beautiful soulLoving, eternal and whole!


Preparation for heart transplant commonly includes booklets, instructional videos, personalized teaching sessions, and mentorship. This paper explores heart transplant recipients' thoughts on their preparation and support through the transplant process. Twenty-five interviews were audio-/videotaped capturing voice and body language and transcribed verbatim. Coding addressed language, bodily gesture, volume, and tone in keeping with our visual methodology. Recipients reported that only someone who had a transplant truly understands the experience. As participants face illness and life-altering experiences, maintaining a positive attitude and hope is essential to coping well. Healthcare professionals provide ongoing care and reassurance about recipients' medical status. Mentors, family members, and close friends play vital roles in supporting recipients. Participants reported that only heart transplant recipients understood the experience, the hope, and ultimately the suffering associated with living with another persons' heart. Attention needs to be focused not solely on the use of teaching modalities, but also on the development of innovative support networks. This will promote patient and caregiver engagement in self-management. Enhancing clinicians' knowledge of the existential aspects of transplantation will provide them with a nuanced understanding of the patients' experience, which will ultimately enhance their ability to better prepare and support patients and their caregivers. With heart transplantation comes well-documented medical and psychosocial challenges , 2. HealPatient and graft survival, transplant outcomes, and side effects , as wellIn the transplantation literature, “distress” refers to psychiatric diagnoses such as depression, anxiety, and psychosis –22. PsycChallenges are not limited to post-transplant experiences. Kop  highlighIn a study conducted by Haugh and Sayler , the teaPrior to discussing the study's methods, we outline the preparation potential transplant recipients currently undergo. At the Canadian academic teaching hospital where the research was conducted, patients being listed for heart transplant are prepared for the process in a variety of ways. The first conversation about heart transplantation occurs with a cardiologist. A nurse practitioner meets with them to provide information about what to expect while waiting for, and life after, transplant. Patients are also provided with a large educational manual and a videotape that explains the biomedical aspects of the transplant in lay terms. They then meet with a social worker to discuss medication regimens, their social support network, employment, insurance, and available financial supports. Each potential recipient is offered a transplant mentor to provide support outside the program although not all choose to have one . While tAn interdisciplinary team, composed of two advanced practice nurses, a cardiologist, a social worker, a sociologist, a psychiatrist, and a philosopher, engaged in a qualitative research study. The study is descriptive and exploratory. As per visual methodology, interviews of heart transplant recipients were digitally audio and video recorded . Our visMembers of our unique interdisciplinary research team have extensive formal training in conducting qualitative research. We bring together professors, scholars, and senior scientists in both the field of medicine and social sciences who all bring unique expertise and contributions to this research project. Informed by the work of Christian Heath and Sarah Pink who are both well known for their use of visual methodology, our team designed our unique visual methodology. We conducted pilot interviews to test our methodology, specifically our analysis process. We have published a number of papers that demonstrate how we have used video in concert with in-depth interviewing and field notes , 43, 44.The study was approved by the Research Ethics Board (no. 07-0822-BE) and took place in a heart transplant program of a large metropolitan hospital in the southern portion of an eastern province in Canada. All individuals who met inclusion criteria were consecutively approached by a transplant nurse not affiliated with the study. This was done so that potential study participants had the opportunity to decline to take part in the study and not feel obligated to the investigators. When a potential participant showed interest in the study, a research associate discussed the study in detail and obtained informed consent. Thirty-six patients were approached, 6 declined to participate, and 3 did not follow through after they signed the consent. Sample size was in keeping with similar qualitative research studies and recruitment was stopped when we reached theoretical saturation.Each patient provided written, informed consent prior to participation. The study included 27 post heart transplant patients, 2 videos were technically compromised (audio recording failure) which yielded 25 analyzable videos , range 18–72; mean time since transplant 4.1 yrs (±2.4); 20 White, 2 Black, 5 South Asian). Participants were at least 18 years old, 1–10 years post-transplant, English speaking, and medically stable. Regardless of the time elapsed since transplantation, anecdotal and clinical involvement with transplant recipients tells us that they are able to communicate their experiences with immediacy and clarity. We accept as true that memory is a process, and as such, all participant responses reflect their embodied experiences and enriched and informed our findings accordingly.n = 19). A few chose hospital based conference or “sitting” rooms that were distinct from the clinic area (n = 8). Each interview was audio and videotaped to capture voice and body language concurrently. All participants received instructions on how to switch off the recording equipment at any time. The camera was purposely visible and static to film the embodied interaction of the interviewer and participant, a practice consistent with standard contemporary visual methods  think you know what we went through, but you do not (PTx10).” The difficulty for him in communicating this was apparent in his low and flat tone of voice as he nervously twirled his fingers and avoided eye contact.A thirty-year-old woman, who was interviewed in a room close to the heart transplant clinic area, slouched down in her chair while she said “… I do not like to tell people unless they've been through something similar, because the truth is that you cannot really understand unless you've been through the same thing… (PTx13).” She seemed to have reconciled herself to the idea that other people just would not understand, and she had told few people about her ordeal. A fifty-six-year-old man, who was interviewed in his home, sat crossed legged on a couch with closed posture. In a very monotone voice he spoke about what he would say to a potential recipient as follows: “… look, if you are really in a bad way, here is my phone number, here is my email…. I know exactly what you are going through, I know how bad it gets, you cannot surprise me, just phone… (PTx12)Maintaining their positive attitude after transplant was reportedly very important for 13 (52%) of the recipients. Their statements included endorsements of not being told about potential transplant-related complications or personal struggles and receiving only encouraging words. A fifty-four-year-old woman, who was interviewed at a large table in a dimly lit kitchen, said with a very worried look on her face “Well, you have to encourage this person… never tell them… Oh, my God, you know, tomorrow you are going to be worse, never say that to the person who went through a nightmare… never discourage people (PTx15).” As the inflection in her voice rose, in an effort to make her point clear, she wrapped her arms around her body, as if comforting herself while sharing her difficult story. Nervously giggling, a man, who had spoken previously in his interview of the emotional difficulty of going through a heart transplant, said that if he were to speak to another patient, he would say “Do not worry about it, everything is going to be fine… I would tell him that he is going to feel good after. He is going to feel better than before… (PTx17).” As he completed his statement, he leaned forward with open arms to enforce that although his experience was difficult, he would only share positive outcomes with other potential recipient.Thirteen (52%) recipients commented that HCPs had provided the needed reassurance about their ongoing medical status and continuity between the transplant clinic and their home. A fifty-six-year-old man who was seven years post-transplant stated “my support system, I would have to say, are the transplant nurse coordinators because if ever there is a problem I could just call them, and they do phone back… I just feel very protected and well taken care of… whenever I had questions, all I needed to do was call, and they were answered (PTx12).” At this point in his interview, the participant relaxed his posture and seemed to speak more freely about his experience. Another male participant stated that “… they [HCP] are there if you need them, but like I say, first couple of years you really depend on them, you feel so much better going there [hospital]…. The transplant team is really extraordinary. I do not know how they do it… (PTx10).” He made this statement with a clear assertive voice and repeated it more than once. Another young man reported “My support system, I would have to say it's [Advanced Practice Nurses' names], because if ever there is a problem, you know, I can just call them… I think in the whole that I just feel very, uhm, protected and well taken care off from there [hospital], so whenever I have problems… questions, all I needed to do was call… (PTx22).” He represented this in a very matter of fact fashion, as if the answer was obvious.Family members and close friends were reported by 5 (20%) recipients to have been an important part of their lives throughout the transplant experience. Sitting very composed with crossed legs, a male interviewee flatly said “[wife's name] was there all the time, right with me, and there were a couple of really good friends who just made sure I was OK… (PTx12).” He spoke as if his answers had been scripted, using a very monotonous tone of voice and a very controlled body posture. A physically fit looking man who sat at a table stated “I think they [recipients] need to have somebody around because the days are long… they need to have somebody around that can, you know, they can gab with and hang out with, so you do not have all that time to think (PTx14).” A woman, sitting in a large, well-appointed living room stated “There are lots of people in my life who have been really great trying to help me out. But mostly my husband, he has been a saint, a saint…. I honestly do not know how somebody could get through it alone. If I had not had my husband, I would not have made it. You just… you cannot. It is so hard to do alone (PTx24).” She delivered her message with a lot of emphasis and certainty; there was conviction in her voice. She continued by saying “… you just have to be there for them [transplant recipients]. I would imagine that driving people around would be all part of it, and being with them. Some of it is you need them there to do stuff for you, another is to… commiserate with you (PTx24).”The transplant program offers every patient the opportunity to connect with a mentor, who is a transplant recipient. When participants were asked how to best support transplant recipients, 10 (40%) spontaneously spoke of this mentorship program. Six of those 10 recipients reported having elected to be mentored and described it as a supportive experience. The 4 participants, who had declined having a mentor, retrospectively thought being a mentee would have been beneficial. A frail looking older married woman, sitting at her kitchen table, said how helpful it had been “… because you always wonder what it is going to be like after the transplant, and seeing someone by your bedside that has already had a heart transplant… just saying everything is going to be fine… (PTx9).” As she said the words “everything is going to be fine,” her body changed from being slouched forward with arms crossed and she became more engaged by using expressive gestures and increasing the tone and inflection of her voice. A retired man, who reported during his interview that the support of mentors was vital in his recovery, nervously chuckled as he said “I did hear a lot of people saying that they did not have much support as far as mentors… it's a big thing [transplant], it's too bad…. I think the mentor thing is really good (PTx10).” Another man appeared content and comfortable sitting in his living room stated, “They set you up with a buddy system…. We met up and had a chat… its nice to see somebody that's had a transplant… I do not think anybody said too much negative, the only thing is I think they all, after a few years, forget the sort of bit of trauma you go through… (PTx11).” He leaned comfortably back in his chair, crossing his hands in his lap.Many participants speak about the difficulty of living with a transplanted heart. They stressed that most “others” do not understand what recipients go through and that only someone who has a heart transplant truly understands the experience. Similar findings have been reported by Sadala and Stolf . Our effSuffering is the unspeakable, as opposed to what can be spoken; it is what remains concealed, impossible to reveal; it remains in darkness, eluding illumination; and it is dread, beyond what is tangible even if hurtful. Suffering is loss, present or anticipated, and loss is another instance of no thing, and absence…. Suffering resists definition because it is the reality of what is not.To this end, the interviews captured the very body showing everything the mind suffers: crying, moaning, lacking affect, dropping their tone of voice, speaking monotonously, stooped shoulders, head dropped forward, avoiding eye contact and legs crossed. In this paper, the notion of suffering captures participants' affective experience of sadness or unpleasantness. Heath [If suffering is “unspeakable,” it explicates why more than half of the study participants felt only someone who has walked, lived, and suffered in their shoes could understand their plight . It alsoHope was described as an essential component in dealing well with illness and life-altering experiences. Wiles et al.  performeParticipants identified three major sources of support: their transplant team, family and friends, and transplant mentors. These findings are in keeping with reports from Sadala and Stolf . When coParticipants reported that health care professionals provided “instrumental support” to transplant recipients through ongoing assessment of health status and guidance in their self-management of care. In doing such the HCPs also provided emotional support to individuals. Participants were able to review their concerns with transplant professionals during clinic visits as well as through a sophisticated patient management telephone system, providing them not only with access to resources, but also with ongoing reinforcement to be able to manage their own care. This type of support provided transplant recipients with strategies to ultimately enhance their competence taking on the onerous tasks of self-management. Such tasks include managing their medications, medical challenges, and adapting to their altered life with a transplanted organ.For some transplant recipients, the mentor/mentee relationship has continued throughout the transplant trajectory. The ability for transplant recipients to connect with individuals, who have experienced a similar process, provides an opportunity for the provision of “emotional support.” The mentor/mentee relationship offers a unique connection between transplant recipients that creates a sense of belonging. King et al.  describeThe presence and availability of family and friends provided great comfort to some transplant recipients. Assistance with day to day responsibilities and having others around even if they are “just being there” are both sources of comfort and support . Study pParticipants, although ethnically and socioeconomically diverse, were all recruited from a single academic health care setting. They were recruited consecutively as they attended routine follow-up clinics to minimize bias. Our study population represents sex, ethnic, and social demographic groups that are comparable to our larger urban transplant program population. Both interviewers are researchers with this study, actively participating in all aspects of the research process, and are the main authors of this manuscript. Although all study participants were asked the same questions, in keeping with conventions of semistructured interviews, the discourse of the interview was not directed by the interviewer, allowing the conversation to evolve spontaneously. Consequently, not all participants spoke of the same topics, limiting the ability to draw conclusions about participants who did not report on certain themes.Participants felt that few people understood what they were going through and that only someone who has had a heart transplant truly understood the experience, the suffering, the hope, and a second chance at life. If Frank is correct, because of the unspeakable nature of suffering, key issues of the transplant experience remain hidden from the HCP and most researchers. Visual methods provide a portal to more comprehensively engage with the notion of suffering. They might allow researchers and ultimately HCPs to understand and hence acknowledge heart transplant recipients concerns, thereby giving their experiences legitimacy. Also, knowledge of the existential aspects of organ transplantation will provide HCPs with a nuanced understanding of the patients' transplant experience. This will allow them to better prepare and support patients through the transplant process, and ultimately promote patient and caregiver self-management.In our research, we found that despite others inability to truly understand the transplant experience, ongoing relationships with family, friends, and healthcare providers were none-the-less fundamental in the provision of continuous support. In an effort to build stronger support networks, we also need to look at innovative ways to educate individuals who will be providing support for transplant recipients. Written teaching materials and instructional videos should not be the exclusive recipient preparation modalities because interpersonal relationships and interactions, including the mentorship program, were considered more helpful and supportive. Strong efficacious mentorship programs need to be developed and evaluated, recipient support networks need to be encouraged, clinicians' knowledge of the existential aspects of organ transplantation need to be enhanced.


Outcomes for colorectal cancer patients vary significantly. Compared to other countries, Australia has a good record with patient outcomes, yet there is little information available on the referral pathway. This paper explores the views of Australian patients and their experiences of referral for colorectal cancer treatment following diagnosis; the aim was to improve our understanding of the referral pathway and guide the development of future interventions.A purposive sampling strategy was used, recruiting 29 patients representing urban and rural areas from 3 Australian states who participated in 4 focus groups. Seven patients provided individual interviews to supplement the data. Recordings were transcribed verbatim, data was coded with NVivo software and analysed thematically before deductive analysis.Four aspects of the referral process were identified by patients, namely detection/diagnosis, referral for initial treatment/specialist care, the roles of the GP/specialist, and the patient’s perceived involvement in the process. The referral process was characterised by a lack of patient involvement, with few examples of shared decision-making and few examples of limited choice. However, patients did not always feel they had the knowledge to make informed decisions. Information exchange was highly valued by patients when it occurred, and it increased their satisfaction with the process. Other factors mediating care included the use of the public versus private health system, the quality of information exchange , continuity of care between GP and specialist, and the extent of information provision when patients moved between specialist and GP care.Patients described poor GP continuity, ad hoc organisational systems and limited information exchange, at both interpersonal and inter-organisational levels, all leading to sub-optimal care. Implementation of a system of information feedback to GPs and engagement with them might improve information exchange for patients, enabling them to be more involved in improved referral outcomes. Colorectal cancer (CRC) is a more commonly occurring cancer in Australia and represents a significant and growing health burden -4. EffecBeing informed of the diagnosis is, in itself distressing and although healthcare systems in Australia do well in comparison to other countries in terms of survival , improveReferral is the process of directing a patient to access care, informing the carer, and assuming an on-going role in that care. Medical referrals for CRC in Australia are most frequently made to surgeons, followed by gastroenterologists and oncologists  and whilCRC patients report poor co-ordination between primary and secondary care and consider that this deficiency compromises the referral process . A patiePatients typically value rapid diagnosis , and polThis study aimed to explore Australian patients’ perspectives of the referral pathway when they first receive the diagnosis of CRC, and to describe their expectations regarding referral to specialist services in order to improve the patient pathway.The study used a conceptual framework of the care pathway from diagnosis to follow-up  to guidePurposive sampling was used to ensure a diverse range of views. The purposive sampling technique involved contacting health care professionals and patient advocates in existing health care organisations. Purposive sampling was used to ensure inclusion of a range of patients by age, gender, geography , and type of health care (public/private). Patients were recruited from support groups and by hospital staff, in person and via telephone, in both public and private hospitals in 3 Australian states , South Australia (SA) and Queensland (Qld)). No data was available on those who chose not to participate. The University of New South Wales (UNSW) Human Research Ethics Committee approved the study (HC08065).Focus groups were conducted to encourage participants to discuss with their peers factors influencing their referral . It was Data was coded using NVivo software . The anaCodes were reviewed for duplication and clarity and emergent themes were added to the coding framework to ensure completeness. The themes were then checked and verified, and differences in the accuracy or completeness of themes were resolved by discussion among the authors . A constant comparison method was used to improve the internal consistency of codes. Other methods used to improve the reliability and validity of coding included a measure of word repetitions; further, the data were examined to identify missing information, metaphors, similes, and analogies. An assessment of connectors , and of unmarked text was also completed. A 20 % sample of the coding was cross-checked by a second researcher (MH). Themes were supported by direct quotes from patients in the focus groups and from individual interviews. Patients’ comments were identified with an individual number and as having public or private health insurance where appropriate.Twenty-nine patients participated in four focus groups. Seven additional individual interviews supplemented the sample. In total there were 22 female and 14 male participants  were considered by patients to be problematic. Patients in the public system usually had longer waiting times. Some patients considered it too costly to go outside the public system for referral.Two or three days later I was with a specialist … and a week later I was in the hospital for the colonoscopy and a week later I was on the operating table … It was very fast” – NSW, group, female 1 [Private].“Reasonably urgent colonoscopy, that will be four weeks to do the colonoscopy” – SA, group, female 2 [public].“Would you have it done privately?’ and I said ‘No … it’d cost me a bomb’.” – Qld, rural group, female 4 [public].“‘Patients identified sources of dissatisfaction as poor continuity of care for themselves and individual GPs, especially where this was a cause of slower referral. Early and rapid referral was associated with greater patient satisfaction with their GP’s care.the patient waited] Two weeks to see a doctor so I went and pleaded my case and saw a [different] doctor … within a week. She wouldn’t even look at it” – Qld, rural group, male 7 [private].“[Communication between patient and surgeon and the quality of information provided were important in determining patient satisfaction with treatment. These factors also influenced how confidently patients made decisions about which treatment to accept. Poor communication was associated with poor satisfaction with treatment.So at every step [e.g. at consultation with colonoscopist] it seemed the information about me had never got through” – SA, group, female 2 [public].“I suppose I worried about it … then I was explained all the statistics[by the surgeon] – you know, I was given a lot of information.” – NSW, urban group, male 4 [private].“Continuity and consistency of care were impaired by lack of communication and difficulty in accessing secondary care services. Perceived lack of communication between the specialist and GP hindered the GP’s ability to effect a referral.I still haven’t got an appointment [e.g. a consultation with a colonoscopist /surgeon ], and at no time did it occur to me that I should have been ringing Royal Brisbane directly. I thought I had to go through her [the GP]” – Qld, urban group, female 8 [private].“Throughout the treatment process, patients felt that surgeons and GPs had distinct roles. Patients saw surgeons as conducting follow-up, answering questions, and providing information. Patients’ descriptions of the GP’s role varied, and included medication management, management of psychosocial issues, and provision of treatment advice.I was always under the care of the oncologist afterwards … if it was not of an urgent nature he’d just say ‘go and see your GP’, you know, which is OK.” – NSW, urban group, male 4 [public].“Some patients directly contradicted each other in the range of services they were referred to, especially regarding allied health.Who were you referred to? - Interviewer.Nobody – NSW, urban group, female 1 [private].Dietician, psychologist -– NSW, urban group, male 4 [private].Nobody else really - – NSW, urban group, male 6 [private].Patients stated that it was more often the GP who made the choice as to whom they were referred. Some patients felt that, although theoretically they had some level of choice , in reality, they had little involvement in decision-making. They lacked opportunities to contribute to the decision-making process. Importantly, patients felt that they lacked the information required to make an informed decision.Had little choice of who I saw and where I went. GP made those decisions. We didn’t discuss it.” – Qld, individual interview, female [public].“GPs rarely discussed the variables and considerations taken into account in making the decision regarding whom to refer to. The only example was from a rural patient:He [GP] said, ‘Well there’s a chap in town but I don’t think … you know, I think it’s a bit above [the local surgeon’s experience] and you probably need more intensive care … somebody who simply specialises’… I’m sure he had to mention the local bloke.” – Qld, rural group, male 2 [public].“Positive experiences were associated with information exchange between GP and patient during treatment and planning the involvement of other members of a multidisciplinary team. Information exchange was a specific strategy identified by patients to improve care. Anticipatory and preparatory information was perceived to be crucial to effective care and good outcomes.It’s lovely to be so included … when they had decided to be aggressive … the radiologist, the oncologist all these people … the stoma therapist … saying ‘Look, you’re going to have to do this, and you’re probably going to have a bag’ … anyhow I’m quite convinced that if I hadn’t have gone down that road … I’d be dead” – Qld, rural group, male 2 [public].“There needs to be multidiscipline routine care … where they actually have a team conference and talk about the patient as the, the centre, of the care” – SA, group, female 2 [public].“The referral pathway for CRC diagnosis and treatment is complex. Initial decisions on this pathway can make a difference to outcomes for patients in this study. The study explored CRC patients’ perspectives of the referral pathway during diagnosis, their expectations regarding referral to specialist services, their experiences of existing services, and the need for services. Patient awareness of a change in symptoms   was an iThe Anderson Total Patient Delay Model developed by Walter identifies events, processes, intervals and other contributing factors as important influences on the diagnostic interval . Our finPatients often stated that they lacked an opportunity to contribute to the decision-making process, and lacked the information necessary to make well-informed decisions. This negatively influenced their treatment experience. Good communication between all parties was related to a feeling of patient satisfaction with the experience of referral, and to the ease with which patients made decisions about their treatment. It is possible to overcome barriers to access and gaps in quality, through the use of strategies such as engagement of community members and “peer navigators” within the health system, and active GP support of patients throughout the total interval, which was particularly useful for rural patients in this study and elsewhere ,29.The steps within the referral pathway are affected by contributing factors. The relationship with the GP was considered important by patients in this study, as has been reported in comparable studies, in that continuity and good communication skills influence timely diagnosis and the subsequent referral pathway .Patients stated that during the diagnostic interval, healthcare provider and system factors such as better continuity of care with GPs and access to private health insurance facilitated ‘early’ and ‘appropriate’ referral. Patients who had been managed in the public system reported less satisfaction with the care provided, largely because of delays and poor communication. Waiting times in the public health system were an issue for most patients in this study. Patients reported that their GPs had been able to influence the speed of the referral . However, GPs needed the capacity to overcome barriers within the public health system.This study drew on patients’ experiences in three Australian states covering rural and urban areas across the public and private patient populations. The sample included patients attending public and private hospitals, support groups and consumer advocacy groups. The under-representation of males in the study is a reflection of the greater use of primary care by female patients and the reluctance of men to reflect on their experience with cancer. The results therefore reflect the views of patients who used these services. It is possible that such participants had atypical expectations and experiences. The study had little information from specific sub-groups in the Australian population such as those from Indigenous and culturally/linguistically diverse backgrounds. Although there was a high level of consistency and agreement amongst the patients regarding factors influencing the patient, doctor and system interval, the findings may not be generalisable to all patients.In summary, patients perceived that a poor quality relationship with their GP, poor continuity, limited information exchange both at interpersonal and at inter-organisational level, all contributed to sub-optimal care. Continuity and good information transfer were mediators of the perceived quality of the patient experience of referral, the period following diagnosis, and beyond. Referral from general practice is the main pathway to specialist services in Australia. Outcomes vary for patients however it is not known to what extent patients believe GP and organisational systems contribute to care. This paper describes poor GP continuity and limited information exchange all leading to sub-optimal care in the patients’ experience. Greater involvement through shared decision making, choice and information exchange all influence the perception of improved outcomes for patients.Further research is needed to explore the continuity of involvement GPs with the care of patients across the cancer journey and their communication with medical specialists and specialist services. The sharing of audit information with both patients and GPs may help to ensure a more systematic approach within the treatment pathway. Quality improvement systems are needed in both public and private health services to ensure that patients experience a predictable and timely pathway to quality care.The implication of these findings for GPs is that it is desirable to ensure continuity and engagement with their CRC patients who are navigating the broader cancer care system and beyond. Given outcomes vary according to the patients’ place of residence and clinician variables, the findings regarding the importance of the patients relationship with their GP has significant implications for care coordination and psychosocial care across the total interval . This maEthics approval was provided by the UNSW Human Research Ethics Committee.1. What was your relationship like with your GP before you were first diagnosed with CRC?Prompts:i. Assessment/diagnosisii. Communication2. How was your diagnosis communicated?Prompts:i. Level of information/understandingii. Follow-up/next step3. What do you think are the priorities for health care professionals in referring patients after they are newly diagnosed with CRC?Prompts:i. Communicationii. Access (appointment times)iii. Proximityiv. Follow-up4. What treatment options were discussed after diagnosis?Prompts:i. Expectationsii. Effectivenessiii. Accessibilityiv. Cost5. How was the specialist to whom you were referred chosen?Prompts:i. What was your influence over the referral decision?ii. Was your GP involved?iii. Was there a directory of CRC specialists available?6. How did the referring doctor communicate with the specialist service?Prompts:i. Letterii. Emailiii. Faxiv. Phonev. In person7. What was your experience when you first attended the specialist appointment?8. How was the communication between the specialist service and the GP?Prompts:i. When first seenii. During your treatmentiii. Follow-up9. Did you see your GP while you were receiving specialist cancer treatment?Prompts:i. What for?ii. What role did your GP have?iii. What did you think about this?10. What were your expectations after treatment?Prompts:i. Feedbackii. Informationiii. Accessiv. Subsequent referral (Who was involved?)11. How was the communication back to your GP and/or referring doctor?Prompts:i. Did your GP know about all your treatment/prescriptions?ii. The next step12. What were your experiences after treatment?Prompts:i. Communication to family/carerii. Symptom managementiii. Informationiv. Accessv. Subsequent referralE.g. Support network13. What are your preferences regarding referral, looking back?Prompts:i. Looking back, did your expectations match your experience?ii. What methods would be best to meet your referral needs? iii. What types of referral issues and barriers does your health area encounter ?iv. Are there specific resources you feel you should have in your community for cancer care, but don’t currently have?14. Final comments* Anything that we’ve missed? – Partner/carer involvement* Anything you would like to add?CRC: Colorectal cancer; GP: General practitioner; NSW: New South Wales, Australia; SA: South Australia, Australia; Qld: Queensland, Australia; UNSW: University of New South Wales.The authors declare that they have no competing interests.SP helped conceive the study, carried out the studies, participated in the focus groups and drafted the manuscript. MH helped conceive the study, assisted with the data analysis and drafted the manuscript. LC participated in the focus groups and helped to draft the manuscript. JB helped conceive the study, participated in the focus groups and helped to draft the manuscript. CV helped conceive the study, participated in its design and co-ordination, and helped to draft the manuscript. AS helped conceive the study, participated in its design and co-ordination, and helped to draft the manuscript. All authors read and approved the final manuscript.Dianne L O’Connell: Cancer Research Division, Cancer Council NSW, David Goldsbury: Cancer Research Division, Cancer Council NSW, Michael B Barton: Collaboration for Cancer Outcomes Research & Evaluation, Liverpool Health Service, Liverpool, NSW, Ian Olver: Cancer Council Australia, NSW, David Weller: School of Clinical Sciences and Community Health, University of Edinburgh, Scotland.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/124/prepub


When foraging for information, attention is guided toward the unknown. When foraging for reward, attention is guided toward high reward values, allowing decision-making to proceed by accept-or-reject decisions on the currently attended option. According to this account, attention can be regarded as a low-cost alternative to moving around and physically interacting with the environment—“teleforaging”—before a decision is made to interact physically with the world. To track the timecourse of attention, we asked participants to seek out and acquire information about two gambles by directing their gaze, before choosing one of them. Participants often made multiple refixations on items before making a decision. Their eye movements revealed that early in the trial, attention was guided toward information, i.e., toward locations that reduced uncertainty about value. In contrast, late in the trial, attention was guided by expected value of the options. At the end of the decision period, participants were generally attending to the item they eventually chose. We suggest that attentional foraging shifts from an uncertainty-driven to a reward-driven mode during the evolution of a decision, permitting decisions to be made by an engage-or-search strategy.What is the purpose of attention? One avenue of research has led to the proposal that attention might be crucial for gathering information about the environment, while other lines of study have demonstrated how attention may play a role in guiding behavior to rewarded options. Many experiments that study attention require participants to make a decision based on information acquired discretely at one point in time. In real-world situations, however, we are usually not presented with information about which option to select in such a manner. Rather we must initially search for information, weighing up reward values of options before we commit to a decision. Here, we propose that attention plays a role in both foraging for information  Recent studies have suggested that visual attention might play a role both in acquiring information and searching for reward. Several groups have demonstrated that reward can guide attention  before coming to a decision  might be beneficial; whereas when attention determines which information is gathered, then attending to uncertainty might be beneficial  or moving to the other location (“search”). From this perspective, any progressive reduction of uncertainty by guiding attention can be viewed as “foraging for information.”In such a model, when we are free to search for information, attention would be considered to be driven at each fixation whether information is sufficient to support choosing of the attended option, or not. Critically, over the course of each individual fixation, we might expect the amount of information being acquired to decrease  of an attentional shift should become small Figure  as less information carries salience, but as more information is acquired, reward value should become salient. The allocation of attention during a decision is initially uncertainty-driven, but as information is “consumed,” and EV estimates become more precise, EV itself guides attention, culminating in choice of the attended option. Such dynamic changes in attentional guidance could resolve a longstanding rift in the attention literature, between those that demonstrate attention to uncertainty, vs. those showing that reward guides attention.An alternative way of putting this hypothesis is that under conditions of uncertainty, forage for information from a limited set of risk and reward data for as long as they like before they make their decision. By tracking their eye movements we can obtain a measure of where, how and in what order attention is deployed over time prior to a decision. Participants viewed two gambles, on the left and right of the screen, each of which was characterized by a probability and a monetary stake, displayed numerically on a vertical axis .After choosing, they either won or lost the stake of the chosen gamble, with the specified probability of winning. Thus, choosing a probability greater than 50% was likely to win the stake, whereas below 50% was likely to lose money. A range of expected values and risks were chosen for each gamble. One gamble was always more risky than the other, but could have a higher or lower e Figure . This alprobability of winning vs. losing (denoted with a “%” suffix) and a monetary stake (denoted with a “£” prefix). Both the probability and stake associated with a gamble were presented separately, one above the other (location randomized). Participants selected their preferred gamble by a keypress. After selection, a sound indicating win/lose was played over a loudspeaker, and the “bank balance” was displayed centrally, which was either incremented or decremented by the chosen stake. We recruited 17 participants from an advert, mean age 41. Research was conducted with informed consent, and was approved by the Imperial College Research Ethics Committee.In our task, participants had to make a choice between two gambles, but were given unlimited time to come to a decision. The gambles were presented on the left and right hand sides of the screen and participants freely viewed a display with four numbers, two on either side of the screen, to acquire information about the two gambles. Each gamble was given a Stimuli were displayed in Matlab and PsychToolbox on a CRT at 1024 × 768 pixels, 100 Hz. Participants had to fixate a central cross before the start of each trial. Numbers were displayed in the four quadrants of the display, at an eccentricity of 10°, with size 0.5°. Probabilities were indicated with a “%” suffix, and monetary stakes were indicated with a “£” prefix Figure . In orde“colour-coded,” such that probabilities were in one color, and stakes in another, with the code being consistent for each participant . Participants were informed of these color contingencies before the experiment. Thus, in the color-coded trials, they could know whether each location contained a probability or a stake, in advance of fixating it. This allowed us to examine whether participants could utilize such prior knowledge to strategically fixate items of the same “dimension” (stake or probability) when looking between options.Fifty percent of the trials were During the decision period, an Eyelink 1000 Hz infrared eye tracker allowed us to follow the sequence in which numbers were fixated over the decision period. Participants then made a choice by pressing a left or right key with the index or middle finger of their right hand. When the choice was made, an auditory tone of high or low pitch indicated whether participants had won or lost, and after 1500 ms the running total  amount won was displayed in the center of the screen for 1 s. Participants had to fixate a central cross for 500 ms prior to the start of the next trial. Participants completed two 64-trial blocks over 30 min and were paid based on their winnings.We analyzed fixations in the period from display onset to choice keypress. We removed blinks and discarded fixations shorter than 50 ms and fixations off the display items. The item fixated at any time was determined with an 8° radius. Blinks accounted on average for 2.4% of decision time, and off-item fixations accounted for 3.8% of the decision time. Dwell times were calculated as the time between arriving at an item, and arriving at the next item.EV) and a risk (R). Here, risk is defined as variance or uncertainty in the outcome:S is stake and P is probability of winning. Note that the factor 2P − 1 incorporates the possibility of both winning and losing the stake. Probabilities under 50% yield a negative EV. From Equation (1), we can see that a gamble with a 50% probability of winning or losing has EV = 0. At the start of a trial, both P and S are uncertain, but after acquiring information, they will be more precisely known. Therefore, we can consider both S and P as random variables that must be estimated by the brain.The probability and stake for each gamble gives an expected value  expectation of reward, because they could either win or lose it.Of note, Next, we can calculate gamble risk, defined as variance of reward value:EV)—i.e., after seeing a £90 stake, the risk estimate is high, since the outcome value is highly variable: +£90 or −£90.According to this equation, a probability of 50% carries the highest risk because the outcome is most uncertain, and as probabilities get closer to 0 or 100%, the outcome is more predictable, so risk falls. Notably, the expectation of risk also changes when we learn a stake  was then randomized by adding a uniformly distributed integer from −10 to +10. This gave a set of trials which had a spectrum from similar EVs to different EVs, and high to low EVs. Similarly, risks ranged from high to low, with the difference in risks ranging from 20 to 70. The risky gamble's stake was between 57 and 77, and the safe stake was 10–30.On each trial, one of the two gambles had a high risk, and the other had a low risk Figure . Values During the decision period, we traced the order of acquisition of information  = 2.18, p = 0.045]. The gamble's probability had no effect on dwell time (p = 0.38). Thus, at the start of a trial, gaze—and by inference, attention—appeared initially to be attracted by higher risk (since stake determines the variance in outcome) but not by higher EV.Mean dwell time on each acquisition was 762 ms and this decreased systematically over the course of a trial Figure . In thisEV gamble on 69% of trials overall. This occurred more often on “easy” trials—i.e., when the EV-difference between choices was large . The higher EV was chosen less often when the risk difference was large . Participants took less time to choose between the options when EVs were similar and large. There were strong biases for participants to choose the first option they fixated (p < 0.001) or the last item fixated , even when informative color coding (see Methods and below) was present. Logistic regression revealed that preference was governed primarily by EV difference but was also influenced by final fixations , irrespective of whether the probabilities and stakes were horizontally or diagonally aligned. The advantage of color-coding was also evidenced by shorter durations of acquisitions (736 vs. 836 ms for the first acquisition).Choice reaction times were significantly faster when color-coding was present . Thus, participants preferentially refixated items that had not been seen recently. The effect can be equally explained by foraging or inhibition of return.At each fixation, we calculated the recency with which each display item was previously seen—i.e., how many items ago it was last fixated. On acquisitions that were refixations, the recency of the t(16) > 2.8, p < 0.01 at serial positions 3, 4, 5, and 6], just as might be predicted from a foraging perspective. This finding suggests that once viewed, an item cannot hold attention for as long.Refixations were shorter than acquisitions at unvisited locations even when they occurred at the same serial position in the trial .Information seeking only partly predicts the first two shifts of attention. For subsequent fixations, however, it is more effective. We can follow the acquisition sequence that participants made, iteratively applying Bayesian updating Equations (5)–(9). At each fixation, we calculated the online estimate of the option EV? Early acquisitions were equally likely to go to the lower or higher EV option, whereas later acquisitions (7th and 8th) tended toward the higher EV option . Thus, value had a stronger pull later in the decision period.What was the timecourse of the attentional pull of initially fixated item , we aligned each trial's acquisition series to the end of the sequence, such that all the final, penultimate etc. acquisitions were grouped. Again, the effect of EV increased monotonically through the trial, to the final saccade which had a 62% chance of going to the higher EV. The final saccade correlated with choice on 80% of trials , and EVoption(i) is the estimated reward EV of the corresponding option. The coefficient α(t) might begin at 1, and decrease to zero through a trial, weighting first information then value.over the three possible shifts of attention. Here both low, than when they are both high . They also made more acquisitions when the difference in expected values of the two gambles was small  = 8.96, p = 0.0086]. This would be consistent with estimated distributions of value getting progressively sharper, or more accurate, with more information: sharper posterior distributions are required in order to distinguish between options with similar EVs, as predicted by diffusion and rise-to-threshold models  = 5.53, p = 0.023)  before choosing. Participants made more acquisitions when the expected values of the gambles were l Figure , i.e., h) Figure .do make more refixations when the probability difference is small, but the extra refixations are not specifically directed to the probabilities  may not be constant through the decision period; in particular, it might be low for the initial acquisitions, which would also explain the longer initial fixations  would decrease over time (Sutton, In calculating whether participants fixated the most informative location, we took σ as constant. That is, we did not include the effect of fixation durations or decay, which would involve making assumptions about the information acquisition rate and forgetting rate. In particular, we did not fit any parameters to individual participants' performance. Information acquisition rate and forgetting rate may well vary from person to person (Colzato et al.,  Sutton, . In our Finally, throughout our analysis, we have made two assumptions: saccades are a relatively direct index of how attention is directed, and attention is focused rather than divided. Attention dissociates from eye movements in experimental conditions of enforced fixation (Juan et al., Attention influences the decision process in a number of ways. Selecting stimulus features boosts their contribution in the stochastic progression of an ongoing decision process (Roe et al., Sampling theories make predictions about how we acquire information from the options available before a choice (Stewart et al., EV and choice (Figure It seems counterintuitive, however, to choose an option that is not being attended. Indeed participants generally choose the option they were last attending to unless that option is much worse than the other one (Shimojo et al., e Figure . The dece Figure , which iBut can we also explain the bias for choosing the initially-fixated option Figure ? InformaThe foraging view of decisions suggests that as information is “depleted from the environment”—or rather, the precision of our internal estimates approaches that of the environment—information salience no longer drives attention. At this point attention becomes driven by the estimated values. This makes two strong neurophysiological predictions. First, reward signals should propagate from stimulus-value regions early in a trial, to attentional regions later in the trial. Thus, one prediction might be that value-sensitive brain regions, such as OFC (Padoa-Schioppa and Assad, explicit representation of the uncertainty signal (Fiorillo et al., Second, in order to support information foraging, the most uncertain items in a display must compete for attention. Neural signals proportional to the lack of information or uncertainty should compete spatially, weighted by expectations of what information is available in the environment. Importantly, such competition would require not simply representation of a probability density, but rather an EV on the guidance of attention. We found that attention was initially drawn to uncertainty, and specifically depended on how the numbers seen determined uncertainty about EV. Toward the end of the trial, attention was drawn toward the higher EV, and eventually predicted choice. This suggests that attention is drawn by information-salience early in trials, and by reward-salience later in trials. We hypothesize that this reflects that choices are in fact made by a foraging mechanism of successively rejecting or accepting the currently attended option—a process which converges on the highest valued option.We used a freely-viewed choice between two gambles to examine the effects of risk and 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.