Background: The aim of this study was to compare illness concepts and coping strategies among native German cancer patients and those with a Turkish migration background. Methods: Guideline-based, semi-structured interviews were conducted with 11 German  and 11 Turkish  cancer patients. The transcripts were evaluated using a qualitative content analysis in accordance with Mayring. Results: We identified eight categories of illness concepts: stressful life events, environmental influences, the will of God, medical factors, fate, trauma, health behaviour, and psychological causes. German patients frequently attributed their illness to environmental influences, persistent stress, or medical factors, whereas Turkish patients blamed persistent stress, the will of God, or trauma. The last two categories are not found among German patients. We classified the coping strategies into 11 main categories: social support, activity, patient competence, fighting spirit/positive thinking, use of health services/alternative healing methods, lifestyle, emotional coping, cognitive coping, religious coping, spiritual coping, and culture-specific methods for patients of Turkish origin. For German patients, activities as well as social support played primary roles in coping. Turkish patients also often used social support. However, in contrast to the German patients, they are less active and use much more religious coping and culture-specific means. In addition, negative emotions occur more often when processing the illness than in the German patients. Conclusion: Common illness representations and coping strategies could be found for Turkish and German patients, but also specific ones for the respective group. It is particularly noticeable that German patients attach more importance to medical factors and try more actively to cope with the illness. For Turkish patients, cultural and religious factors play an important role, which should also be considered in treatment. Cancer is the second most frequent cause of death in Germany , and theIn the context of an illness, cultural influences should always be taken into account. This has been postulated for mental illnesses in many cases , but canWith regard to illness coping strategies, international studies demonstrate that Chinese cancer patients, for example, exclude their families from the illness process in order not to burden them . StudiesAccording to the Federal Statistical Office, migrants of Turkish origin make up the largest group of people with a migration background living in Germany, accounting for 2.8 million out of the total of 20.8 million . Due to The present study is a qualitative study. The data were obtained from guideline-based semi-structured interviews. The study was approved by the Ethics Committee of the Medical Faculty of Friedrich-Alexander University Erlangen-Nürnberg (file number: 232_14B). A written informed consent was obtained from each patient before the interview was conducted after a detailed explanation of the purpose and content of the study.Adult patients who were suffering from a malignant oncological illness at the time of the survey or who had suffered from this type of illness in the past (in adulthood) were interviewed. Half of the patients had a Turkish migration background; the other half were German citizens without a migration background. According to the Microcensus 2018, a migration background was defined as follows: “A person has a migration background if he or she or at least one parent does not possess German citizenship by birth.” . The patA total of 22 persons were interviewed: 11 German and 11 Turkish patients. Of the German patients, 8 were male and 3 were female. They were aged between 24 and 57 years, with an average age of 46 years. Among the Turkish subjects, 9 female and 2 male patients, aged between 24 and 77 years, participated. Their average age was 59 years. Subjects had gone through different educational paths and worked in different professions. The majority of the Turkish patients had only completed primary school. Among the German interviewees, attainment of the secondary school certificate was the most common. Overall, the German patients had a higher level of education. Further socio-demographic, migration-related, and clinical data are presented in Based on guidelines, socio-demographic, migration-related, and medical data were initially collected. Subsequently, questions were asked on several topics . For the present article, the topics “illness concepts” and “coping with illness” were selected. The question about the concepts of illness asked about the presumed cause of the illness. Five questions were used to examine how the illness was overcome, in which, among other things, the areas of emotions, family, and faith were examined in detail.In order to prevent the results from being biased by language barriers, the interviews with the patients of Turkish origin were conducted in Turkish (except for one person who had an excellent knowledge of German language). All interviews in the respective groups were conducted by the same person. Interviews with the German patients and the Turkish-born study participant with excellent language skills were conducted by the last author (E.M.), and interviews of the 10 Turkish respondents were conducted by a Turkish-born psychologist from the psycho-oncology team. The interview duration was between 25 and 140 min for the German study participants and between 15 and 90 min for the respondents of Turkish origin. The interviews were recorded on a tape recorder and transcribed. The transcribed Turkish interviews were translated into German by a professional translator or by a former Turkish-speaking staff member. All German transcripts were completely checked for correct transcription by the first author and corrected if necessary. Sequences of approximately 10 min from each Turkish interview were compared with the transcript by a Turkish-speaking staff member.The evaluation was carried out according to the qualitative content analysis scheme developed by Mayring . For thiWe identified a total of eight topics for the illness concepts, whereby the category “psychological causes” included several aspects. Differences could be observed regarding the frequency of reported illness beliefs between German and Turkish patients. There were also causes that were mentioned by only one of the two groups .The most frequent illness representation mentioned by the German patients was persistent stress.“Then someone once explained to me that this could perhaps also be time-related. I separated from my husband in 2011; he died in a bicycle accident on New Year’s Eve 2012, and then I got the illness in 2014.” (German Patient. 1).Toxins are another important attribution of causality for German patients. “Yes, maybe because I had started studying chemistry, and I might have inhaled something. Something harmful.” (German Patient. 5).Toxins played no role at all in the group of migrants. Medical factors were also mentioned by some German patients as illness concepts. These factors included previous infections, for example Ebstein Barr.Fate was also declared as a cause. All other less frequently mentioned illness beliefs can be found in If we look at the group of migrants, stressful life events were the most commonly reported individual explanation for cancer. Burdensome living conditions and stress were included under life events.“Yes, the family problems I have experienced were the trigger. I was badly treated by my family and through the stress my body developed this illness.” (Turkish Patient. 11).Traumatic experiences, which are described according to the ICD-10 as “a stressful event or situation of shorter or longer duration, with extraordinary threat or catastrophic proportions that would cause deep despair in almost everyone” , were trAspects important to the Germans, such as medical factors as well as fate, were barely described as causes by Turkish patients. In contrast to the German patients, however, there was a new category of causes in Turkish patients, namely, the will of God. It also represents a very important illness concept in the migrants.We identified eleven main categories, each with 2 to 10 different subcategories, as shown in Social support is defined as any form of help from the social environment of the patient. It can be differentiated between practical and emotional support.In both groups of patients, social support was found to play an important role and was often mentioned as an essential factor:“In coping, what helps me? Psychological support, conversations with friends, my family being there, so that helps me.” (German Patient. 7).What is different, however, is that among the Turkish patients, the neighbourhood was also included in the social environment.“Everyone supported me. We have nine families here—with me, ten families. They didn’t leave me alone in the evening, or at midday, or in the morning.” (Turkish Patient. 8).In addition, the type of support was also rather different between the groups. The friends and family of the German patients tended to focus on activating strategies, e.g., going for a walk or doing sports.Encouragement and praying were predominant among the Turkish patients:“Whenever I went for radiotherapy, I called everyone and asked them to pray for me. Because the mask was the hardest thing for me. If someone prayed, it went well. So, the next time, I said, ‘Let everyone pray for me’.” (Turkish Patient. 5).This category included physical activities, activities that are deliberately used for distraction, but also relaxation techniques or general rest and recreation. In addition, mental activities such as searching for information in books, on the internet, or through advice centres were also included.In both patient groups, although more frequently among German patients, it was emphasized that physical activities such as cycling, swimming, running, or Nordic walking played important roles in coping with the illness.“Yes, I also did a lot of sport in the autumn, i.e., moderate exercise.” (German Patient. 1).“Sport is good for me, I always do sports. After rehabilitation, I do sports. I play sports twice a week.” (Turkish Patient. 10).The intensification of hobbies, such as art, motorcycling, or cooking, was also highly valued in both patient groups. However, the spectrum was somewhat broader overall among the German patients.Relaxation methods such as yoga, mindfulness, or progressive muscle relaxation were also predominantly mentioned by German patients.In terms of searching for information, both groups used books or information material from the hospital to read about the clinical picture as well as about treatment methods. However, the internet was only mentioned as a source in the German group.“I was doing research on the internet at that time and there was a seminar [Qi Gong for cancer patients] directly in the rehabilitation centre.” (German Patient. 2).The Turkish patients, on the other hand, also asked medically educated friends, which was not stated for the German patients.“[...] i.e., some friends who also studied medicine or were active in this field, and they were very supportive.” (Turkish Patient. 1).This section summarizes statements that involve the patient’s autonomy and assertiveness. Communication with medical staff was mentioned as a particularly important aspect, especially for German patients.“Yes. Because I want to understand that. And erhm, because I’m not a medical doctor, and if that’s too fast for me, particularly with technical terms, then I’ll just say, what does that mean for me translated? So, I ask them and write that down for me again.” (German Patient. 6).In contrast to the Turkish patients, the Germans stated, as a further strategy, that they also specifically told their acquaintances and colleagues about the illness, i.e., dealt with it openly.In addition, more German than Turkish patients reported that they have dealt openly with the consequences and continue to present themselves in public despite restrictions.Turkish patients were characterized by a high level of compliance and a great deal of trust in the attending physician.“If it weren’t for the doctors, I would be dead now. I had six months to live. It spread there, the doctor explained to me. If it weren’t for the doctors, I’d be gone now.” (Turkish Patient. 7).For German patients, autonomy and also the assertion of their own interests were important aspects in dealing with the illness.This refers to the will to actively approach and fight the illness or to think positively, taking emotional and cognitive aspects into account. In this category, no significant differences were observed between the two groups. Some German as well as Turkish patients reported strategies in the interviews that corresponded to a sense of the fighting spirit:“I think that really helped me enormously, the story that I didn’t give up.” (German Patient. 4).“But I have such a combative nature. It’s not because of the illness, it’s just... this is how I function in life.” (Turkish Patient. 1).This includes all health care services offered by the clinics or health insurance companies. On the one hand, this includes psychological support and self-help groups; on the other hand, it also includes medical services such as medications that make it easier to deal with the illness, , as well as medical rehabilitation, spa treatments, follow-up treatments, or gymnastics. Overall, the psychological offers and also the medical offers were used by both groups.“I have had complementary conversations with a psycho-oncologist in the psychotherapy unit in the cancer counselling center in Nuremberg.” (German Patient. 2).“I have seen doctors, therapies, and curers.” (Turkish Patient. 2).In terms of frequency, it is noticeable that German patients reported taking advantage of these services in greater numbers  and also used a broader range of health care services overall. For example, only German patients were found to have attended fatigue counselling sessions or anti-stress groups or used telephone counselling.An important point that concerns lifestyle is the change of diet. While Turkish patients tend to take additional vitamins, German patients try to change their previous diet, e.g., to avoid fast food or chemicals that might be in bottles made of polyethylene terephthalate.It was also pointed out several times in both groups that the perception of nature, be it during a walk or simply by looking at it, helps to distract oneself from the illness.It was even mentioned that one develops a new body consciousness, i.e., one perceives oneself and one’s body more consciously and respects it more.“... what my body is worth to me... so I had such respect for the body, how it regenerated itself.” (Turkish Patient. 1).Another difference is that only the German patients stated that they were increasingly doing themselves some good or indulging themselves.“Especially when I am sometimes not feeling well or I am not feeling so great, I take a shower and then turn on my music on my mobile phone. Then, my mood somehow lifts again. Or when I get dressed and put on my makeup.” (German Patient. 8).Furthermore, when asked about possible coping strategies, for many German patients, it was important to keep to a daily structure, and for some Turkish patients, it was important to adapt it to the new circumstances, for example, by allowing more breaks.“So, I get up and make myself a really nice breakfast and keep to a daily rhythm like that.” (German Patient. 6).“Or I also allowed myself to only be so active, but also in these... partly in these moments I withdrew, simply did nothing or did as much as I could—watched a film or did nothing at all, just looked out.” (Turkish Patient. 1).Finally, in particular, the German patients stated that they had gained an appreciation of life through the illness.This category includes both positive emotions, such as hopefulness, joy, and pride as well as negative emotions such as fear, depression, denial, and anger. Each patient was specifically asked about his/her emotional handling of the illness, and both positive and negative strategies were mentioned in both groups.Over the course of time, there were also some changes, and initial fears were transformed into confidence.“But then at some point, I discovered this rhythm for me, where the body... and then I also converted that into a positive thing, that I knew that the body would manage.” (Turkish Patient. 1).Another emotional coping strategy was acceptance.“There was nothing I could do about it anyway. It was there. … accepted. I said, ‘why waste energy’, because I didn’t have that much energy there. I was more focused on, ‘How do I get out of this thing? ’” (Turkish Patient. 1).“I took this for me, the illness is there, I took it, and I’m trying to make the best of it.” (German Pat. 11).Comparing the two groups of patients, it is striking that Turkish patients were more likely than German patients to experience negative emotional processes such as denial, repression, discomfort, anxiety, and depression.By cognitive coping we mean all strategies that have to do with perceptions and attitudes towards the illness. This includes, in particular, strategies such as fighting rumination, having plans/goals, decatastrophizing, rationalization, and relativization. These strategies were mentioned by both groups.“Because I say, I am still young, I want to live, I want to marry, I want children, I would like to go back to my beautiful work.” (German Patient. 7).Not thinking too much was also one of the cognitive coping strategies.However, in addition, the targeted use of specialist knowledge or the search for role models or examples was a cognitive coping strategy that was used by both patient groups.“And even then, through my profession, the knowledge of how one feels about chemotherapy, what the whole thing does to one.” (German Pat. 1).“I always wanted to know what are my chances, or I asked friends or ... girlfriends who had this illness, who had overcome breast cancer, what they did. So I picked out good examples for me.” (Turkish Pat. 1).Religious coping includes prayers, reading the Bible, or visiting a place of worship. Among Turkish patients, this category was one of the main categories; religious coping strategies played an important role for almost all patients. “But God‘s will will be done. If that is my destiny, then it will be so. I can’t make that determination. It’s up to God.” (Turkish Pat. 12).Only among the German patients were spiritual methods, such as mantras or singing bowl rituals, observed.“And I practice the [mantras] myself, too, but not like the Buddhists, not so extreme, but this thing helped me, too. This non-woman [monk in Buddhism] said that Buddhism wants all people to be happy, and if one chants this mantra over and over again, it has different meanings. Then, everything that contributes to my happiness comes into my life, for everyone involved.” (German Patient. 2).These include, for example, various Turkish customs or herbal remedies.However, many patients also said that they found a trip to Turkey particularly helpful for coping with the situation.“My husband said, go to Turkey for three months, switch off, it will do you good. You look at other people and say, I am clearly better off than them. It’s true. I was on the Black Sea coast.” (Turkish Patient. 7).The third culture-specific aspect was the visiting of Turkish doctors, which made it easier for some Turkish patients to deal with their illness.The aim of the study was to analyse and compare the illness concepts and illness coping strategies of German and Turkish patients with cancer in order to draw conclusions for clinical care.In summary, similarities  but also clear differences could be identified. While German patients are often actively involved in the illness process, for Turkish patients, religious causes and coping strategies as well as culture-specific means are the main focus.The illness concept that was most frequently reported by both patient groups were stressful life events. Environmental influences such as toxins were also an important illness representation among the Germans, while many patients of Turkish origin attributed their illness to the will of God or to a trauma. These findings are partially consistent with results from other studies on illness beliefs of Turkish migrants in comparison with the autochthonous population. A possible explanation for these differences may be based on the concept of health locus of control that has been widely studied in recent decades. It reflects the individual beliefs in internal or external causes of health outcomes  . In a stEnvironmental influences or an unhealthy lifestyle, which, in international studies, were found to play major roles in the development of illness in Turkish patients ,38, wereBurdensome life events, such as conflicts or stress, were of primary importance for both groups in our investigation. In some of the Turkish patients, these burdens even fulfilled the criteria of a trauma. The fact that no traumas were named among the Germans could be related to the fact that German patients are in principle more open to psychological interventions  or are gRegarding coping strategies, it was generally observed that both groups mentioned numerous and very individual strategies, which we summarized by eleven categories. Social support played an important role for both groups. However, the extent was much greater among Turkish patients. The Turkish patients stated that their families took on important roles in everyday life, such as cooking, while the German patients tended to generally spend time together. It is due to the Turkish understanding of family that sick relatives should be completely cared for and possibly even nursed , whereasFranz et al.  also shoPatients with a higher socioeconomic status tended to avoid ineffective coping strategies ,45 and uIn contrast to Turkish patients, Germans were found to be more interested in alternative healing methods regarding the services of the health system. This could certainly also be related to their level of education or that the German patients named medical factors such as toxins or infections as the cause of their illness and therefore wanted less chemotherapy, for example. They are also less religiously influenced than the Turkish patients and therefore more open to different spiritual practices. An acceptance of the illness was found in both groups. For most Turkish patients in our sample, however, this seemed to be due to thinking it was God-given and unstoppable, whereas German patients saw it as a motivation to change their lives or to be more attentive to their own needs and to appreciate the life and enjoy the moment. Other studies have shown that Turkish patients also use other coping strategies, such as changing priorities in life, but are still guided by basic religious ideas such as “Shukran” (gratitude) . Psycho-The most important strength is that the present study is the first to compare illness concepts and illness coping strategies between German and Turkish cancer patients. Another strength is the fact that, in order to avoid a linguistic bias, the interviews with the Turkish patients were conducted in Turkish. However, the interviews were conducted by two different people, so despite a detailed discussion of the procedure, it cannot be excluded that the subjective interview style could have impaired the objectivity of the performance. For example, the Turkish interviews were shorter. Since there was only a small number of Turkish patients in the clinic, the samples of only 11 persons each are relatively small. Furthermore, the patients were not matched in terms of socio-demographic , medical, or life history  data prior to the study. Finally, as is the case with all retrospective studies, a memory bias cannot be ruled out. Future studies in larger, representative, and matched  patient samples are therefore necessary.The abovementioned results have clear clinical implications, especially for the treatment of Turkish patients. In addition to considering the language barrier, culture-specific aspects such as the handling of the body and the importance of religion and family should be taken into account. Migration does not mean that concepts and patterns of behaviour change fundamentally. Information and educational material should therefore always be available in Turkish for cancer survivors of Turkish origin, in particular, for first-generation migrants. In addition, the level of education should be taken into account and information should also be presented, e.g., through pictures. Health system services such as sports groups should specifically include groups for Turkish patients, and families should be involved in treatment at an early stage or should be considered as an important anchor when it comes to delivering difficult news. Although Turkish patients are very compliant, they should also be supported with their patient competence, as they do not always demand it, as German patients often do. Finally, individual concepts should also be asked about in all patient groups and integrated into the treatment plan, since, for example, psychological support for a traumatized patient contributes significantly to improving his/her ability to cope.In addition to the specific offers for patients, it is also important to sensitize the health professionals sufficiently for the cultural characteristics. Essential components of this cultural training are, on the one hand, advanced training courses on the topics of illness concepts and strategies, which in the best case are held by employees who belong to the respective culture. On the other hand, regular supervision and discussions in a multidisciplinary team can help to ensure that the patient and his/her cultural needs are considered in all areas of treatment.


Purpose: Healthy lifestyle interventions after breast cancer treatment have generally been studied in terms of weight-loss outcomes, which leaves a gap in our understanding of the phenomenological experience of such programs. Our knowledge of how or why women recovering from breast cancer engage or do not engage in these programs is limited. Thus, we aimed to share subjective experiences of lifestyle change within a 12-week group intervention entitled “Healthy Lifestyle Modification After Breast Cancer” (HLM-ABC).Methods: The present research entailed a multiple case study of four breast cancer survivors who participated in the HLM-ABC. Participants were interviewed longitudinally at four time-points: (1) pre-intervention; (2) mid-way intervention; (3) post-intervention, and (4) three-months post-intervention.Results: We analysed storytelling of participation in the HLM-ABC program to investigate participants’ unique and gradual endeavours towards living a healthier lifestyle. A qualitative, narrative analysis was applied to each participant’s set of interviews, which yielded two distinct story-telling patterns while participating in the HLM-ABC program: one “plot-driven” and one “character-driven”.Conclusions: These two narrative styles appeared to correspond with differing levels of intervention uptake and perceived success in the program. The implications of these narrative styles and their relationship to healthy lifestyle intervention are discussed. Due to the global surge in breast cancer (BC) survivorship  program addresses the need for a more integrative psychosocial lifestyle modification program  since or before their BC diagnosis. Participants were also asked to identify any other comorbidities such as ongoing physical or mental health conditions and were eligible if these health concerns were being managed.BC survivors who received treatment at the Odette Cancer Centre at Sunnybrook Health Sciences Centre in Toronto, Canada were recruited by healthcare providers if they were diagnosed with a primary BC (stages I–III), completed their treatment—including surgery, chemotherapy, and radiation within the last 5 years—irrespective of continued Herceptin or hormonal, pharmacological treatment. Prospective participants were asked by their providers whether they consented to be contacted by the research coordinator for a brief screening interview to confirm eligibility. The research coordinator assessed individual weight gain post-treatment and comorbid conditions. Participants were eligible if they self-reported a five pound or more weight increase after treatment, or had an overweight status  pre-treatment, (2) mid-way through treatment, (3) post-treatment, and (4) three-months post-treatment. The interviews were conducted in a semi-structured, iterative fashion in that the interview protocol was modified from one time point to the next in order to accommodate recurring narrative storylines and broader themes. Still, interview questions were treated as a guide, rather than mandatory questions, in order to have made room for a narrative-style interview where participants were given sufficient freedom to narrate as they wished , in seeking qualitative “integrity” to the phenomenon  and the whole (set of four interviews per participant) was integral to our research question of how BC survivors narrate and parcel together their experiences of participating in a healthy lifestyle intervention  plot-driven and (2) character-driven. Keeping in mind that the context of this narrative analysis is an intervention intended for healthy lifestyle change, the researchers defined a story “outcome” or “ending” as change in behavioural habits, notwithstanding other types of changes that may occur within an intervention, for example, personal growth or self-acceptance to name only a few. The distinction made between plot- and character-driven narratives is based on the following, primary criteria: Degree of linearity or non-linearity, and degree of agency and non-agency expressed. By linearity we mean a clear, beginning-middle-end structure. In the context of the HLM-ABC, the plot-driven narrative possesses a linear plotline with character agency and corresponded with the following features : satisfaction with the program, perceived change in oneself or one’s body, change processes that are evident to the researcher, sense of hopefulness, and external conceptualizations of shifts or change . On the other hand, the character-driven narrative contained a non-linear plotline and lack of character agency and corresponded with features of: narrative foreclosure, a sense of hopelessness, stability of character, lack of perceived change in one’s health behaviour, narrative-interruptions in the participant’s account of their experience, and/or internal conceptualizations of mild or small shifts of change . At their core, plot-driven narratives were stories of movement and resolve, whereas character-driven narratives were stories of relative stagnancy, with self-identified behaviour change as our metric or marker of transformation.Two of the BC survivors, Louise and Felicia, seemed to narrate in a character-driven way that was less linear in its progression and focused on their personal characteristics over and above the task of lifestyle change. Melissa and Nicole, on the other hand, narrated in a plot-driven way where a clear beginning-middle-end structure was evident, generally resulting in perceived changes and healthy habit formation. Each style of story-telling is presented below and each woman’s case is categorized by narrative style. First, Louise and Felicia are presented as prototypical character-driven narratives, followed by those of Melissa and Nicole which are presented as prototypical plot-driven narratives.Louise’s narrative and self-characterization centred on defeat and hardship as a BC survivor. She maintained a “life is tough” attitude and stated that she has learned that tragedy follows her. Louise’s rare autoimmune disease and her genetic risk for cancer appeared in her narrative as a “continuous plotline.” In other words, Louise felt she had a grim, genetic destiny, which contributed to the “narrative foreclosure” Freeman,  present During her pre-treatment interview, she described a sense of hopelessness: “I’m just tired, exhausted, lazy, lacking motivation, and I also found out too that I have low iron, so that’s my excuse. Sometimes … I just get so down and I can’t, and I don’t do anything you know.”P1:I think I’m going to go eat something after this! [laughing]I:Oh boy.P1:I have kale juice, so you’re okayI:OkayP1:No, I do eat for comfort, absolutely I do.Further storying a sense of narrative foreclosure, Louise’s storytelling possessed a non-linear structure with some  “narrative arcs” or changes in her attitude or characterization over time. In other words, her story lacked a clear beginning-middle-end structure. For example, Louise would at times comment on a slight improvement, but then swiftly harken back to what appeared to be a fatalistic perspective. Midway through the intervention, Louise mentioned that she tended to eat when she felt bored and noticed that eating breakfast made her “less starving throughout the day,” yet denied learning new insights about her health behaviours or deriving benefit from the HLM-ABC. She would also move quickly between a more serious tone and a joking, lighter narration. When asked to recall any events or formative relationships that impacted her relationship to her body image, she spoke of a cousin who bullied her, calling her “fat and ugly.” Not only did Louise seem to internalize these harsh comments, earlier referring to herself as both of these things, but there appeared to be an express need to cope with these difficult memories related to her body, with food as a soother, as she recalled such during the interview. She stated directly to the interviewer:This response, an admission of emotional eating, was a rare moment of transparency from Louise. At times, she would reflect on her tendency to disengage from the interview itself or the HLM-ABC program when it felt too intense. Louise’s shifting between these contrary narrative stances, i.e., humour versus seriousness, never quite resolved or funnelled into a clear narration of change. In essence, while Louise openly acknowledged certain gains, these were quickly overridden by her detailing of circumstances that remained unchanged and unchangeable .Louise narrated a non-linear story of immutability in relation to lifestyle change, portraying herself as a passive protagonist who was sarcastic, “blunt” and “self-deprecating,” and who often cracked jokes about her “grim” situation. For instance, a self-description of “I am too heavy, too short, fat and ugly” was stated in a jocular way, alongside a perceived invitation for her audience (the interviewer) to laugh at this comment. So too did this brand of humour manifest during group sessions, when she joked with the other women about her favourite food: “cancer-causing hotdogs” and when she jested about whether she could bring a snack of potato chips to the next group session. The interviewer (SY) was admittedly responsive to Louise’s humour, laughing along with her when appropriate. However, an underlying tone of seriousness that came through at important moments was still noted. When for example, certain interview questions provoked more serious responses and Louise was forced to abandon her wry humour, she would express that she had reached her “mental limit.”Interestingly, by the end of the interview series, Louise declared that “food is not the boss of me” diverging from the “lazy” and passive self she mainly portrayed. The research authors saw subtle narrative transitions and arcs, and in brief spurts she abandoned her humour to reveal willingness to express more vulnerability, and thus hint at her underlying fear and pain. This change in self-awareness was perhaps Louise’s biggest change in characterization in the HLM-ABC; although she did not necessarily see these moments of insight as notable achievements, the researchers did.Um [long pause] I don’t know how to put this, I think it’s just when I have done group or you know individual therapy in the past, it’s clear that you are always yourself no matter where you go, um and that, and that there is kind of no magic, no magic bullet to change some of the things you struggle with.Felicia’s narrative progression, like Louise’s, focused around her identity as being stable rather than on change and progress. Upon starting the group, Felicia mentioned her main purpose for joining the HLM-ABC program was to maintain her health in order to be well for her daughter, and to reduce her risk of cancer recurrence. Her efforts seemed, however, to be thwarted by her persistent view of herself as an overweight individual often referencing her struggles with weight prior to cancer. As such, a narrative tone of hopelessness came through when she reflected on her participation in the program. Felicia’s narrative bore a strong resemblance to Louise’s in terms of the 'narrative foreclosure' implied in Louise’s use of phrases like “my default” (in relation to her lifestyle habits) and “historically I was a bad eater.” Felicia's language was suggestive of someone for whom a lack of satisfaction was part and parcel with her identity. For example, when asked in the mid-way interview if she experienced any new insights about herself and her body vis-à-vis healthy living, her reply illustrated her self-concept as fixed, and the futility of attempting to intervene:The richness and irony of Felicia’s “magic bullet” metaphor appears to be two-fold. Not only does it capture the current health trend of consuming blended drinks or “smoothies” (epitomized in North America by advertisements for the “Magic Bullet” kitchen appliance and the promises of well-being), and acknowledge that there is no immediate or effortless solution to weight reduction, but the word “bullet” itself harkens to the deep wounds of her cancer diagnosis that seem to have profoundly penetrated her view of self.The fixedness of weight and the narrative foreclosure expressed in Felicia’s story were, in her telling, connected to her family’s relationship with food. A “master” narrative  “top of mind.” She also spoke of adopting a more compassionate attitude towards herself, for instance, when she said in the post-treatment interview, “I find it easier to not beat myself up about making choices that are not so good, because it’s not just, it’s not just me [who is struggling].” Felicia’s guilt around her food choices waned when she witnessed the other women struggling to form and sustain new lifestyle habits as well.and a breast cancer survivor led to few narrative arcs and a non-linear progression throughout her HLM-ABC journey, which did not amount to a sense of satisfaction with the program. In one aspect, her narrative structure did have a defined beginning and middle (shift in thinking), but did not possess a clear end that would suggest she felt able to make tangible behavioural changes.Overall, Felicia’s sense of stagnancy and fixed identity as being overweight Melissa’s narrative followed a clear change trajectory in the form of a “voyage and return” story. She expressed in her interview series that she felt she was “not anywhere where I was before I had cancer” in reference to her physical health. She expressed what seemed to be a loss of control over her lifestyle choices after finishing her treatments and opted to partake in the HLM-ABC program in order to reclaim her pre-diagnosis self. The way she perceived herself before her breast cancer was as a healthy individual who felt satisfied in her body. She drew comfort from her regularly scheduled exercise classes and workout routine. However, post BC treatment, Melissa felt that she was at “ground zero.” She presented this plotline by stating that she could not return to her past habits and yet she lacked insight into why. Her participation was therefore centred around self-discovery and moving back to a recognizable self—which included being an individual with the ability to efficaciously control her weight.You know, I’m sort of struggling with that too, the idea of body image, because my body’s changed. Um and I probably struggled a bit more with that than the weight thing, because the weight thing I feel like if I just focus and get motivated in everything then I can just lose weight, but where my mastectomy and my reconstruction are concerned you know, I will always have these scars.In addition to struggling with motivation, Melissa commented on how her post-surgery body and the loss of her breast had impacted her self-esteem:felt in her body. This self-conceptualization was multi-dimensional and rich, adding a complex quality to her overall narrative. Melissa’s narrative was also characterized by a high level of self-awareness as was apparent in her pre-treatment interview:I know I can do it, I just somehow lack that motivation or I don’t know what it is and sometimes I question you know is it, you know, ‘Do I not want to do this?’ Like I want to do it, but do I not want to do it? Am I sabotaging myself [laughing] in my mind? I don’t know.Interestingly, Melissa’s perception of her alterable weight as distinct from her overall bodily sense, and fixed physical appearance, seemed to help her in overcoming some of the challenges to her body image. Specifically, the number on the scale representing her weight was not as important to her as the way she I have a lot of nice clothes that, you know, I want to wear. And I just saw something on TV and this girl is just wearing like a plain black turtleneck with skinny jeans and I’m like, “Wow, that was what I used to wear and I have that whole outfit upstairs but I can’t fit into those jeans so. You know and that kind of makes you feel sad, but it motivates me. It’s like, that’s what I want to do, I want to be able to just slip on a pair of jeans and t-shirt, because that’s more of how I was.Melissa appeared to engage in active meaning-making during her interview series. She was transparent about her inner dialogue and used metaphors and “thick descriptions” . Therefore, weight loss was not her main focus. Rather, Nicole sought out the HLM-ABC for social support and the companionship of other BC survivors. Her need for interpersonal contact and to feel accepted was driven by the abandonment she had felt by her friends during and after her treatment. As Nicole described it, her friends referred to her as no longer “normal”, making her feel stigmatized, as a diseased individual in their eyes. She stated that her friends treated her as if she were a completely different person after cancer. In her words, they “deserted me, they don’t call me, they don’t email me. They think I’m a cancer patient.” Despite these pronounced feelings of alienation, Nicole was committed to improving her health habits in order to stave off a cancer recurrence and to feel healthier on a day-to-day basis. Thus, although she joined the HLM-ABC to obtain social support, she also became invested in making health behaviour changes.I feel like a normal person attending the group. If not, I feel like a sick person. If I stay home for too long, only surrounded by my needy family members, I feel very bad. But then if I draw on some social activities like [the group] and then I feel like a normal person, too.For Nicole, feeling healthy was synonymous with feeling “normal.” It seemed there was a part of Nicole that internalized her friends’ perception of her as a “sick” individual. In the mid-way treatment interview, Nicole stated:I: That must be very difficult) … I feel not so bad about it, I just accept it as it is because some people lost their legs, some people lost their arm and some people lost important organs, but then I kind of say to myself ‘that’s no big deal.’ I just lost one side of the breast, I hope I can keep the other side healthy.I feel kind of bad because … I have [had a] mastectomy and I feel like I’m only half a woman now. So my image is not so good. So if I am at home I just dress in cancer clothing. But if I am going out to see other people, then I need to put on special clothing to pretend that I am a normal woman … .Nicole seemed to convey embarrassment about her body, which could have been related to her social withdrawal and feelings of isolation. Her narrative telling was complex and “double-edged” in that her self-portrayal as an isolated person seemed to jointly serve as a barrier to making health behaviour changes (keeping her away from others and disengaged) Nicole’s narrative is plot-driven in that she developed clear and tangible insights about herself and these were discussed in relation to her ability to make concrete behavioural changes. For example, Nicole gained awareness about what she termed the “mood-food relationship.” She explained that she is “easily affected by my mood. So if I can manage my stress, my anxiety, and my mood better, then I may actually master better eating habits.” In general, the latter half of Nicole’s interviews were narrated with positivity and hope for the future. Some of the benefits she spoke of included self-awareness, a motivating drive, “regaining balance” after setbacks or other sources of stress, “a positive attitude towards life after cancer,” and making plans to sustain her habits. For example, if her regular walking schedule was to be disrupted by weather, she would create a plan to walk inside in a mall. Consistent with one of the primary aims of the HLM-ABC program, Nicole reported that she was able to maintain her new habits. In her three-month post-treatment interview, Nicole stated, “I am good at sustaining the exercise program and I now formed good habits of exercise, which I enjoy and cannot do without it.” In essence, her new lifestyle changes helped her to narrate a positive story of finding her way, developing greater purpose, and building a newfound sense of security within herself.Four BC survivors were interviewed longitudinally, at four distinct times, to grasp a comprehensive understanding of their pathways of lifestyle change as they partook in a structured healthy lifestyle intervention. Despite the plentiful weight-loss outcome research in this area, there remains a gap in our knowledge of experiential and psychosocial barriers and facilitators to health behaviour change and weight modification after BC. The current research, by virtue of adopting a narrative analytic lens, elucidates the meaning and process of lifestyle change in the BC survivorship period.throughout the storyline as articulated by the women. Alternately, participant narratives were deemed by the researchers to be “character-driven” when they possessed predominant themes of non-change within the narrator’s sense of self, seemingly reflective of fixed character traits or states. That is to say, plot-driven narratives were associated with greater improvements as perceived by the participants, and character-driven narratives were associated with self-reported difficulty or resistance to grasping or applying the core habit-forming tenets of the HLM-ABC program. Being attuned to the participants’ process of storying their experiences revealed that that those women (Melissa & Nicole) who narrated plot-driven experiences seemed to report relative success and described changes in their lifestyles in the direction of healthier habits and greater self-compassion. In contrast, those whose stories were character-driven (Louise and Felicia) appeared to report relatively less success in the intervention and seemingly exhibited less motivation for change. In essence, plot-driven and character-driven narratives seemed to be connected to different change trajectories within the intervention.Participant’s storying was characterized as “plot-driven” when their narratives featured change Interestingly, we also found that in addition to being associated with poorer self-reported lifestyle change, character-driven narratives also appeared to be storied by women who experienced pre-morbid weight challenges. Louise and Felicia (who stated they struggled to maintain a stable weight before their cancer diagnosis) alluded to how their previous unsuccessful weight loss attempts or stories affected their degree of engagement and/or motivation in the HLM-ABC intervention. It is as though Louise and Felicia’s present narratives represent part of a larger series of similar historical experiences based on recurring plotlines characterized by stability and lack of resolve, contributing to a more resigned, helpless, or hopeless narrator tone. Comparatively, Melissa and Nicole, who did not report pre-morbid weight concerns or weight-loss difficulties, fared better in the program and were more successful in their application of the HLM-ABC principles, which was associated with more notable weight modification experiences . Seeing as previous experiences with weight loss informed these womens’ experiences to a heavier degree than anticipated by the researchers, the importance of assessing for an individual’s history of weight loss or prior behaviour modification successes may be indicated before formal, structured programs.Our findings relate to research conducted by Green et al.  who demoFurthermore, Corbett et al. , in theiA limitation of this study includes a lack of transferable study sample. The longitudinal multiple-interview structure among a smaller group of participants allowed for more in depth examination of each narrative case study Yin, , but canOverall, this study delves deeply into the idiosyncratic experiences of lifestyle modification among a group of BC survivors. With a narrative analysis approach- variation in experience, ranging from poor to successful lifestyle change- was elucidated. The women were able to articulate what was propelling them forward and what was holding them back, despite their shared mutual goals of weight maintenance and improved quality of life. The plot-driven and character-driven narratives represent potential sketches or profiles of individuals that healthcare providers may come across when aiding BC survivors with weight management or lifestyle change. This knowledge has the potential to inform providers about different styles of self-efficacy and personal beliefs surrounding weight loss and may shape the way in which they approach these clinical issues. This multiple-case study may also prompt researchers and clinicians to reflect on the value of moving away from general prescription of weight loss after cancer towards more holistic and individualized health conversations and recommendations in the survivorship period.


Integrated information theory (IIT) asserts that both the level and the quality of consciousness can be explained by the ability of physical systems to integrate information. Although the scientific content and empirical prospects of IIT have attracted interest, this paper focuses on another aspect of IIT, its unique theoretical structure, which relates the phenomenological axioms with the ontological postulates. In particular, the relationship between the exclusion axiom and the exclusion postulate is unclear. Moreover, the exclusion postulate leads to a serious problem in IIT: the quale underdetermination problem. Therefore, in this paper, I will explore answers to the following three questions: (1) how does the exclusion axiom lead to the exclusion postulate? (2) How does the exclusion postulate cause the qualia underdetermination problem? (3) Is there a solution to this problem? I will provide proposals and arguments for each question. If successful, IIT can be confirmed with respect to, not only its theoretical foundation, but also its practical application. Integrated information theory (IIT) states that the brain generates conscious experience by virtue of its capacity to integrate information. Identifying consciousness with integrated information, IIT attempts to explain both the levels and the qualities of experience in a mathematical manner. Levels of consciousness can be quantitatively measured by the values of Φ. Qualities of consciousness can be geometrically represented in a multidimensional space termed the concept space ,2,3. Frophenomenological axioms. These axioms describe a number of the fundamental properties of consciousness. The second is termed ontological postulates, describing how physical systems should be in order to produce consciousness. These postulates are implemented by mathematical models and technical concepts in IIT. Compared with other hypotheses in the field, this ‘axiomatic approach’ to consciousness is truly distinctive of IIT [IIT intends to explain neural data regarding consciousness in a unified manner. It also predicts that artificial consciousness is possible: “[T]o the extent that a mechanism is capable of generating integrated information, no matter whether it is organic or not, … and independent of its ability to report, it will have consciousness” . Althouge of IIT . InteresWith regard to the specific modeling of IIT, one of the postulates causes a serious problem. The exclusion postulate holds that the maximally integrated cause and effect (MICE) repertoire must be chosen as ‘quale sensu stricto’ , and others should be excluded. Although ‘MICE’ is also known as a concept, to avoid possible terminological confusion, I will use the term ‘MICE’ only   how does the exclusion axiom lead to the exclusion postulate? (2) How does the exclusion postulate cause the problem of underdetermined qualia? Finally, (3) is there a solution to this problem? As the exclusion postulate is closely related to the exclusion axiom, in order to assess the qualia underdetermination problem, one should start by examining the relationship between the exclusion axiom and the postulate. First, one possible method of inducing the exclusion postulate from the exclusion axiom will be suggested . Second,IIT has many interesting and even seemingly problematic predictions, such as sophisticated panpsychism, the possibility of zombie systems, fading and dancing qualia, and the paradox of certainty ,14,15,16However, it appears that the theoretical structure of IIT receives relatively little attention. IIT, at least its current version, starts with a number of axioms and postulates: five phenomenological axioms regarding consciousness and five ontological postulates regarding the physical substrates of consciousness. Technically, with the exception of the first two postulates, existence and composition, the postulates are divided into two levels: a level of mechanisms and a level of systems of mechanisms. This axiomatic approach is clearly unique. To the best of my knowledge, no scientific theories of consciousness follow such an approach.induce or derive the postulates regarding the physical mechanisms of consciousness from the axioms regarding consciousness  ” ach experience excludes all others–at any given time there is only one experience having its full content, rather than a superposition of multiple partial experiences; each experience has definite borders–certain things can be experienced and others cannot”  p. 3). . Max. ThCompared with cases of information and integration, however, it is not clear as to whether the exclusion postulate can be plausibly or intuitively derived from the exclusion axiom. The problem is that the exclusivity of experience does not appear to require the exclusive, unique integrated information generated by mechanisms. Even when a mechanism produces multiple pieces of integrated information and excludes nothing, it remains possible for experience to be exclusive and not superposed. This contrasts with cases of information or integration. For instance, in order for experience to be informative, the mechanisms contributing to experience must produce information. If the mechanisms do not produce information, there seems to be no explanation as to why experience is informative. However, if experience is fundamentally integrated and a mechanism contributes to experience, it seems necessary that a mechanism integrates information. Producing integrated information appears to be the only explanation as to why experience is essentially irreducible to its independent parts. In these cases, we can plausibly or naturally infer the information or integration postulate from the corresponding axioms. Nonetheless, in the case of exclusion, this inference seems less plausible. How the exclusion axiom leads to the exclusion postulate or how the exclusion of non-maximal integrated information explains the exclusivity of experience is not clear.One may note that IIT has already provided a reason for the exclusion postulate. It appears that the central rationale is derived from “a principle of causal parsimony, or a causal version of Occam’s razor, roughly saying ‘do not unnecessarily multiply causes’”   Experience is exclusive (the exclusion axiom).(2) If a mechanism contributes to experience by specifying multiple irreducible cause–effect repertoires, then it contributes to one or several experiences.(3) If a mechanism contributes to one experience by specifying multiple irreducible cause–effect repertoires, then the experience cannot be exclusive.(4) If a mechanism contributes to several experiences by specifying multiple irreducible repertoires, then those experiences cannot be exclusive.(5) A mechanism contributes to experience by specifying a unique irreducible cause–effect repertoire.(6) A unique irreducible cause–effect repertoire specified by a mechanism must be maximally irreducible. That is, it must be MICE.(7) A mechanism can contribute to experience only by specifying MICE (the exclusion postulate).Premise (1) is the exclusion axiom. Premise (2) is logically apparent. If Premise (6) is true, then we have the exclusion postulate as a conclusion. The crucial part is the inference from Premise (3) to Premise (6). Below, I will explain each premise in turn.According to Premise (3), an experience cannot be exclusive when a mechanism contributing to the experience specifies multiple irreducible cause–effect repertoires. If a mechanism contributes to one experience by specifying multiple irreducible cause–effect repertoires, the mechanism would contribute to the experience multiple times simultaneously. Because the mechanism’s contribution to the experience would be reflected by a certain part of the experience, the natural consequence is that the part of the experience is somehow superposed. For instance, suppose that a mechanism contributes to Mary’s visual experience by specifying two irreducible cause–effect repertoires. As the two repertoires are different, each contributes to her visual experience in different ways. One repertoire may contribute to Mary’s phenomenal visual field by producing a red quale. Another may contribute to her visual field by generating a blue quale. As a result, somewhere in Mary’s phenomenal visual field, the red quale and blue quale will overlap. That is, Mary’s visual experience should be partially superposed. This partial superposition in experience by overlapping qualia violates the exclusion axiom. Therefore, when a mechanism contributes to a single experience by specifying multiple irreducible cause–effect repertoires, the experience cannot be exclusive.Some may argue that two different irreducible cause–effect repertoires may not produce two different qualia. Rather, it seems possible that two repertoires conjointly generate a single quale. In the case mentioned above, for example, two repertoires can generate one quale, which may be a purple quale or a neither-red-nor-blue quale. While this scenario appears to be feasible at first glance, there is a good reason to believe that it cannot be the case. In the framework of IIT, specifying two different irreducible cause–effect repertoires means producing two different pieces of integrated cause–effect information. If two irreducible cause–effect repertoires somehow produce one quale, the two pieces of integrated information must be ‘merged’ into one. In IIT, the only means by which this merging could occur is integration. Thus, in order to generate a single quale by specifying two repertoires, a mechanism must produce two pieces of integrated information and integrate them once again. The problem is that integrating integrated information cannot occur via a single mechanism. According to IIT, integration of information occurs among multiple different mechanisms, not within a single mechanism. “Clearly, for integrated information to be high, a system must be connected in such a way that information is generated by causal interactions among rather than within its parts”  (pp. 220Premise (4) states that experience cannot be exclusive when a mechanism contributes to multiple experiences by specifying multiple irreducible cause–effect repertoires. I argued in the previous paragraph that when a mechanism contributes to one experience by specifying multiple repertoires, such an experience must be partially superposed. Accordingly, one may consider whether a mechanism contributes to several experiences. For example, suppose that Mary’s visual field is divided into two color experiences. The right half of her visual field is filled with blue, and the left half is filled with red. One mechanism contributes to both visual fields by specifying two repertoires, as before. In this case, the mechanism contributes to Mary’s two visual fields simultaneously, specifying one repertoire for the blue-right field and another repertoire for the red-left field. Then, Mary’s two visual fields would be partially superposed in that they share a physical substrate. To illustrate this point, consider the case wherein the same neuronal group contributes to two experiences: a visual experience of colors and an auditory experience of sounds. What is naturally expected is synesthesia, i.e., hearing colors or seeing sounds. That is, if both visual and auditory experiences partially share their physical substrates, the two experiences will overlap. This can be generalized regardless of the sensory modality. If the physical substrates of Mary’s blue-right field and red-left field are partially overlapped, the two visual fields themselves must be partially overlapped. Again, this is a violation of the exclusion axiom. Even when a mechanism contributes to multiple experiences by specifying multiple irreducible cause–effect repertoires, those experiences cannot be exclusive.Premise (5) states that a mechanism contributes to experience by specifying a unique irreducible cause–effect repertoire. The inference from Premise (4) to (5) is apparent. Experience must be exclusive according to Premise (1). However, Premise (4) states that if a mechanism contributes to multiple experiences by specifying multiple irreducible cause–effect repertoires, experience cannot be exclusive. Hence, one must conclude that once a mechanism contributes to experience, it must do so only by specifying a unique irreducible cause–effect repertoire.Premise (6) argues that the unique irreducible cause–effect repertoire that contributes to experience must be maximally irreducible. We already have discussed the arguments supporting this claim. Irreducible cause repertoires represent irreducible sets of possible causes, and one of the grounding features of IIT is that to exist as a whole is to make differences that are irreducible to the parts of the whole. Only the most irreducible set of causes makes the most irreducible differences in a mechanism. No causal work is left for the less irreducible ones such that they can be said not to exist. Only the most irreducible one can be said to exist. One can treat effect repertoires in the same manner. If a mechanism must have a unique irreducible cause–effect repertoire to contribute to experience and only MICE can exist, the unique irreducible cause–effect repertoire must be MICE.To recapitulate, the argument from Premise (3) to (6) is driven by reductio ad absurdum: if the exclusion postulate is incorrect, the exclusion axiom cannot be true, and the axiom must be true. Therefore, the postulate also should be true. If a mechanism contributes to experience by specifying multiple irreducible cause–effect repertoires, the experience cannot be exclusive. When multiple maximally irreducible repertoires contribute to a single phenomenological content of conscious experience, the content must be superposed. Even when multiple maximally irreducible repertoires contribute to multiple phenomenological qualities of experience, those qualities must overlap. Either way, experience must defy the exclusion axioms. Henceforth, if the exclusion axiom is maintained, the maximally irreducible cause–effect repertoires contributing to experience must be unique. Hence, the exclusion postulate must be true.In the previous section, I argued that we have good reason to believe that a unique irreducible cause–effect repertoire must be MICE. That is, being unique entails being maximally irreducible. Does the reverse hold? Apparently, it does not. Although being unique entails being maximally irreducible, there is no guarantee that maximum irreducibility entails uniqueness. That is, MICEs can be non-unique, and several can exist. A unique irreducible cause–effect repertoire must be the one that is MICE. However, MICE need not be unique at all. Furthermore, this asymmetry raises a serious problem in the framework of IIT 3.0, known as the qualia underdetermination problem.max, must be dependent on MICE. In IIT, Φmax represents the level of consciousness. Further, MICE is represented as points in the multidimensional space termed the concept space that constitute a ‘constellation’ referred to as the maximally integrated conceptual structure (MICS) [MICE involves almost all features of IIT. First, conceptual information (CI) is calculated as the Earth’s mover distance (EMD) between the maximum entropy distributions and MICE . Integrae (MICS) . IIT 3.0max, and MICS change depending on which MICE one selects, when MICE is underdetermined, so are the CI, Φ, Φmax, and MICS. If MICE is underdetermined, both Φmax and the shape of the MICS also are underdetermined. Moreover, when multiple MICEs are calculated, one cannot know which MICE is the genuine quale sensu stricto nor which MICS is the real quale sensu lato. In the framework of IIT, these underdeterminations directly imply practical limitations: how can we measure the levels of consciousness? How can we geometrically describe the qualities of consciousness? Once MICE is underdetermined, theoretically as well as practically, everything is underdetermined. The qualia underdetermination problem shakes IIT to the ground.Accordingly, the possibility of non-unique MICEs immediately provokes serious problems in all respects mentioned above. First and foremost, it affects theoretically central concepts in IIT: how can we know which MICE is the genuine one? How can we select one MICE to represent the real quality of our consciousness? Given that the CI, Φ, Φmax, and MICS. This case describes how MICE, or qualia, can be multiplied when implementing IIT.Krohn and Ostwald provide a good example of underdetermined qualia . FocusinTo the best of my knowledge, only two solutions to the qualia underdetermination problem have been proposed. Both concern the dimensionality of repertoires, but each takes the opposite stance. First, Oizumi et al. introduced the highest dimensionality criterion . They arMIP(S) > 0, its subsets R have lower or at most equal ϕMIP, and its supersets T have lower ϕMIP: ϕMIP(R) ≤ ϕMIP(S) > ϕMIP (T), for all R ∈ S and all T ∈ S. If there are multiple maximal CER(S) each with the same scope, then at any given time only one is realized as a concept, although which one is indeterminate [If several CER(S) yield the same max, one takes the CER(S) of largest scope (accounting for the most), where ϕerminate   each with the same scope,” such that the genuine MICE is “indeterminate” .In contrast, Krohn and Ostwald argue for the exact opposite criterion . They suSelecting the lowest-dimensional MICE, however, is essentially a limited solution to the qualia underdetermination problem. Krohn and Ostwald themselves demonstrated that their own criterion cannot solve this problem. Even when the criterion with the lowest dimensionality is applied, among the three equivalently maximally irreducible cause repertoires, only one can be eliminated. The other two irreducible cause repertoires are equal to one another and therefore remain underdetermined  (p. 15).Overall, while underdetermined qualia raise a serious problem in IIT, no satisfying solution has been provided. The qualia underdetermination problem occurs when there are multiple MICEs. It affects IIT conceptually as well as practically. The current version of IIT nonetheless has no criterion for selecting one MICE as the genuine quale. The suggested solutions focus on the dimensionality of repertoires. Initially, the criterion with the highest dimensionality was suggested, but this strategy was found to be inadequate. However, the criterion with the lowest dimensionality also cannot cover all possible cases of multiple MICEs, even when it is supplemented by the most shaping criterion. It is highly desirable to find a sensible formal criterion for the selection of MICE.The failure of previous attempts strongly suggests that accounting for dimensionality or adding further criteria cannot be the solution to the qualia underdetermination problem. It appears that a more principled and a priori approach is required. Merely excluding some MICEs and preserving others would not help. It is tempting to identify a means by which the problem can be prevented. That is, one may attempt to dissolve the qualia underdetermination problem rather than solve it. In the next section, I shall propose a novel criterion and argue that the qualia underdetermination problem can be prevented.My suggestion starts by focusing on the notion of integrated information. What does it mean for a mechanism to produce integrated information? Integrated information is information generated by the whole mechanism over and above its parts. When a mechanism generates integrated information, it is “irreducible with the respect of information”  (p. 8) (t, specifies two MICEs under two purviews: ABt/ABt–1/ and ABt/CDt−1. Under both purviews, the φ produced by ABt is 3. Because both past purviews are sufficient to yield the same MICE, this situation can be considered to be a sort of causal overdetermination, the case where there are two or more sufficient causes. One partitions the first purview into ABt/t−1 and t/ABt−1 such that the mechanism ABt−1 is eliminated. Here, it is important to note that this elimination is not done to calculate how much integrated cause–effect information is generated by ABt. The operation of elimination is not performed from the past of the external observer. Rather, it is performed to eliminate the past purview intrinsically. Usually in IIT, one should partition a purview when she needs to calculate integrated information produced from a mechanism as an external observer. In this case, elements outside of the purview in question are marginalized. In the example, however, one may partition the purview ABt/ABt−1 into its past and present, ABt and ABt−1, in order to find out whether ABt−1 makes any difference to ABt. Thus, no marginalization is needed. Hypothetically, this is a possible operation. From the perspective of the current system ABCDt, however, this elimination does not affect in any way the irreducible and intrinsic existence of ABt. Even when ABt−1 is eliminated, there is still the other purview ABt/CDt−1, and under this purview, ABt would specify the maximally irreducible cause repertoire and produce the same φ value. Regardless of whether or not ABt−1 exists, from the perspective of ABCDt, ABt as a whole would still be in its state.Hence, what if a certain mechanism specifies multiple MICEs under different purviews? For the sake of argument, let us focus on maximally irreducible cause repertoires. Suppose that a system consists of the four elements A, B, C, and D. One current mechanism, ABt−1 have no effect on ABt as a whole from the intrinsic perspective of the system. The crucial point is that according to IIT, to exist is to cause differences. “IIT’s information postulate is based on the intuition that, for something to exist, it must make a difference” [t−1 is eliminated, no intrinsic differences arise. This implies that the states of ABt–1 cannot make any intrinsic difference in ABCDt. Therefore, the states of ABt−1 cannot exist from the intrinsic perspective of ABCDt. This means that the repertoires specified by ABt under the purview of ABt/ABt−1 cannot represent anything that intrinsically exists. In short, the maximally irreducible cause repertoire fails to be a repertoire of something that exists intrinsically.If this is the case, states of ABt−1, into ABt/t−1 and t/CDt−1. Then, while the past mechanism CDt−1 is eliminated, from the intrinsic perspective of ABCDt, this would not cause any difference with regard to the irreducible and intrinsic existence of ABt due to the purview ABt/ABt−1. Under this purview, ABt would generate φ = 3. This implies there is no difference in ABt as a whole from the intrinsic perspective of ABCDt. ABt would still be in its state both irreducibly and intrinsically. This absence of difference-making indicates that the states of CDt−1 fail to exist from the perspective of ABCDt. Again, under the purview of ABt/CDt−1, the maximally irreducible cause repertoires specified by ABt cannot represent something that intrinsically exists.With regard to the other purview, the situation is the same. Suppose that one partitions the other purview, ABt/CDIf the above analysis is correct, when two or more maximally irreducible cause repertoires are specified by a mechanism, all of them fail to represent something that intrinsically exists. In IIT, the repertoires are probability distributions over past or future states of a certain subset of elements that exist intrinsically. Once multiple maximally irreducible cause repertoires are given, however, the possible states represented by the repertoire cannot be said to exist from the perspective of the system itself. All maximally irreducible cause repertoires fail to be repertoires at all. It is easy to see that the same applies with multiple maximally irreducible effect repertoires. When there are multiple maximally irreducible effect repertoires, these repertoires cannot be said to represent possible effects that exist from the intrinsic perspective of the system. Therefore, when there are non-unique MICEs, paradoxically, all MICEs fail to be repertoires.The argument thus far suggests a new criterion for the qualia underdetermination problem: given the argument, when there are multiple MICEs, which MICE is the genuine one? The answer is that none of them can be the genuine MICE. The rationale for this answer is that none of the multiple MICEs can be cause or effect repertoires. All multiple MICEs fail to represent something that makes any intrinsic difference in the system. Conversely, for a MICE to be the genuine MICE, it must represent something that makes a difference from the intrinsic perspective of the system. Thus, one could say that only a MICE representing the states of a mechanism that make differences from the perspective of a system itself can be the genuine MICE; i.e., it is the real quale. This criterion deserves to be called the difference-making criterion. According to this criterion, the qualia underdetermination problem does not occur, as there cannot be multiple MICEs in the first place. As soon as there are multiple MICEs, all such MICEs will be excluded as non-repertoires. As mentioned at the end of the previous section, the difference-making criterion does not solve the qualia underdetermination problem. Rather, it dissolves or prevents the problem.If all multiple MICEs cannot be the real quale, then what should be selected? I believe that one should find ‘the next big thing’ of irreducible cause–effect repertoires. When multiple maximally irreducible cause–effect repertoires are excluded, there would be a cause–effect repertoire that is less irreducible than the maximally irreducible repertoire but more irreducible than others. This next maximally irreducible cause–effect repertoire can be a proper candidate for the genuine MICE. Nonetheless, what if there are multiple next maximally irreducible cause–effect repertoires? For the reasons provided earlier, the multiple ‘next big things’ should be excluded and the lesser irreducible one should be selected as the genuine MICE. Overall, one can exclude all multiple MICEs until she identifies the unique MICE. In this sense, the procedure of identifying the genuine MICE described in this section does not allow the qualia underdetermination problem.MAX.Of course, there are various possibilities that require further investigation. For instance, while all of the examples in this paper implicitly assume deterministic systems under ideal conditions, it is nonetheless possible that under actual conditions, noise and/or spontaneous fluctuations from the external environments of mechanisms may resolve underdetermined qualia. There can also be ‘a top down criterion’: even when there are multiple MICEs, how they contribute to a large phi can differ. Then, one may discern one that contributes to the maximum or minimum among the alternative values of ΦTo summarize, the qualia underdetermination problem can be prevented by adopting a novel criterion for the genuine MICE, in this case the difference-making criterion. Under the difference-making criterion, there cannot be multiple MICEs, as once there are multiple MICEs, none can be repertoires. The only means left is to select the unique MICE. In this sense, the qualia cannot be underdetermined; they must always be uniquely determined.While several conceptual and technical limitations have been raised against IIT, to date IIT appears to be one of the leading theories in the field of consciousness studies. Its bold approach to consciousness, which directly identifies experience with regard to MICS, has attracted the attention of researchers from diverse fields. It is true that the explanatory and predictive power of IIT mainly derives from its articulated mathematical model and applicability. The current version of IIT, IIT 3.0, not only explains a wide range of empirical data in an integrative manner but also provides interesting and testable predictions regarding many interesting issues in the science of consciousness. However, the uniqueness of the theoretical structure of IIT has received relatively less attention. The relationship between phenomenological axioms and ontological postulates deserves a deeper analysis. In this paper, focusing on the link from the exclusion axiom to the exclusion postulate, I have provided one possible means by which to understand how the phenomenology of exclusion constrains the ontology of exclusion.max, and MICS concepts. Practically, it prevents us from determining which Φmax is the real level of consciousness and which MICS shape represents the quality of consciousness. A couple of solutions to the qualia underdetermination problem have been suggested, but none were successful in excluding all possible cases of multiple MICEs. To prevent or dissolve the qualia underdetermination problem, I have argued for the difference-making criterion, which does not allow multiple MICEs.Further, there is a delightful and disturbing problem that originates from the exclusion postulate. Although the postulate enforces that only MICE can be the real quale, when multiple MICEs are specified by a mechanism, IIT cannot determine which is the genuine MICE. Even the most recent version of IIT, IIT 3.0, is affected by this qualia underdetermination problem. Conceptually, the underdetermination of qualia affects other central concepts of IIT, including the Φ, ΦThe arguments for the novel criterion are derived from a thorough reading of the fundamental ideas and intuitions in IIT. Therefore, unless there are conceptually radical changes in IIT, the proposals developed in this paper could be applied not only to the current version, but also to any version of IIT. The core concepts of IIT, specifically integrated information and existence, are essentially related to the notions of irreducibility, intrinsicality, and difference-making. Regardless of the detailed differences in the versions or formalisms, any theoretical reading of IIT must consider these notions more seriously. This strict interpretation may shed some light on the inherent problems of IIT.