Tor-Johan Ekeland

Metasynthesis and Bricolage: An Artistic Exercise of Creating a Collage of Meaning

During the past decades, new approaches to synthesizing qualitative data have been developed. However, this methodology continues to face significant philosophical and practical challenges. By reviewing the literature on this topic, our overall aim in this article is to explore the systematic and creative research processes involved in the act of metasynthesizing. By investigating synthesizing processes borrowed from two studies, we discuss matters of transparency and transferability in relation to how multiple qualitative studies are interpreted and transformed into one narrative. We propose concepts such as bricolage, metaphor, playfulness, and abduction as ideas that might enhance understanding of the importance of combinations of scientific and artistic approaches to the way the synthesizer “puzzles together” an interpretive account of qualitative studies. This study can benefit researchers by increasing their awareness of the artistic processes involved in qualitative analysis and metasynthesis to expand the domain and methods of their fields.

What constitutes competence? That depends on the task

General practitioners (GPs) are trained for and mandated to provide continuous healthcare to the general, unselected population in a low-threshold, local setting. This presumes as a paramount precondition that the doctor is competent as a medical helper of a large variety of people of all ages attending for an increasing variety of health-related problems or complaints. The central question as regards competence is this: How does the doctor conceptualize and understand the “entity” that enters the GPs office? If one identifies the subject matter of medicine as diseases, carried by (more or less) average patients, then adequate medical competence involves knowledge about diseases. Thus, the wider characteristics of the diseased persons become of secondary significance. Such a framework attributes to diseases the status of essences, affecting people in the same manner, and consequently representing the core entities in medical knowledge production. This view accords with the biomedical framework of human bodies and their functions being the sum of biological mechanisms that can be unambiguously classified, and to which group-based data can be applied to explain dysfunctional states and achieve therapeutic success. If, however, one perceives that what enters the GPs office is persons, who are or feel diseased, in other words “are not at ease with themselves”, quite a different competence is demanded. Then, knowledge of the person becomes key in a double sense: first, to enable the doctor to understand how personhood in general, and this person in particular, is affected by being diseased [1]; and, even more crucially, to make the doctor capable of “reading” the present dysfunctional state as an impact on this persons embodied life [2]. The significance of knowing about a persons lifetime experiences to understand the manifestation of current or chronic sickness has been ever more solidly documented during the last two decades of multidisciplinary research [3]. According to Eric Cassell, a person is “an embodied, purposeful, thinking, feeling, emotional, reflective, relational human individual always in action, (and) responsive to meaning. Virtually all of a persons actions – volitional, habitual, instinctual, or automatic – are based on meanings” [4]. Engaging with a diseased person in an adequate manner demands, consequently, the ability to accrue an understanding of this persons unique biographical and relational context, in other words, a historical, socio-cultural, and linguistic competence. This demand precludes predefined labelling of a persons ailment in general and of reports on complex malfunction in particular. However, both clinical practice and research are currently hampered by the fact that phenomena like complex malfunction, typically termed co- or multimorbidity, are ill defined. This is a consequence of the biomedical concept of the nature of human beings and human bodies, failing to account for the fact that humans are situated beings and, as such, embedded in systems of symbols and of socio-culturally established values [5]. This complexity was recently exemplified in a study of how Nordic GPs perform detached diagnostic labelling of patients. It was based on simulated, video-recorded consultations with a common denominator: a simulated patient presenting so-called subjective health complaints (SHC) to a GP [6]. Such a presumably objective approach to human beings may in itself represent an ethically questionable reduction of both doctors and patients for several reasons [7]. First, the premise is a framework defining the subject matter of the medical encounter to be diseases or symptoms and not persons who experience illness. Second, it is questionable whether concordance in choice of labels is a potential hallmark for system quality, especially when the matter at hand is poorly defined. Third, aiming at labelling instead of understanding means failure to fulfil the central prerequisite for proper treatment. Finally, a detached method, prohibiting a mutual relationship, allows for limited insight. The studys predictable result, a considerable heterogeneity of labels, elegantly demonstrates that the construction called SHC lacks an adequate theoretical basis, and that SHC cannot be classified in a valid and reproducible manner based on the biomedical aspect alone. This fact points to the fallibility of health politics anchored in diagnostically based statistics. It also underscores the need for re-conceptualizing human beings from a medical perspective. Human beings are embodied beings, living their lives incorporated as lived bodies. Consequently, the biomedical framework of the de-contextualized and depersonalized biological body, devoid of history and meaning, is of limited validity. Fortunately, researchers in a broad array of disciplines are currently accumulating knowledge demonstrating the impact of a persons experience on that persons body – and health [8]. In other words: the lived body, a phenomenology-derived concept subverting the mind/body dualism that still haunts biomedicine at its core, is entering into medical awareness [9]. General practitioners in the Nordic countries and, it is hoped, worldwide, may be the medical professionals who will most eagerly embrace this knowledge because it validates what most of them already know through their own accumulated professional and personal experience: human bodies are lived bodies, and lived life and health are indivisible.

Discourses of service user involvement in meeting places in Norwegian community mental health care: a discourse analysis of staff accounts

Abstract In previous research, meeting places have been favourably addressed by service users, but they have also been contested as exclusionary. In this participatory explorative study, we sought to perform a contextual analysis of meeting places in Norway based on a discourse analysis of three focus group discussions with 15 staff members. We asked the following question: how do meeting-place employees discuss their concrete and abstract encounters with service users and their experiences? We focused on service user involvement, which was largely analysed as neoliberal consultation and responsibilisation. Service users were positioned as resisting responsibility trickling down and defending staffed meeting places. Social democratic discourse was identified in the gaps of neoliberal discourse, which is noteworthy given that Norway is a social democracy. This relates to global concerns about displacements of democracy. We suggest that meeting places appear to hold the potential for staff and service users to collaborate more democratically.

Same diagnosis, different lives. A qualitative study of adults with severe mental illness, in treatment and education

This study focuses on how adults diagnosed with severe and persistent mental illnesses experience their lives and relationships and their own engagement in these relations in two different environmental conditions. Participants include 14 patients in psychiatric treatment in Norway and 15 students at schools for adults with mental illnesses in Denmark. All participants were diagnosed with severe mental disorders persisting for a minimum of two years and with pronounced impact on daily living. Data were collected through qualitative interviews on two occasions 6–8 months apart for most participants. The findings and interpretations showed that the two groups of informants described their lives quite differently. Patients described a focus on receiving treatment for their disease, few stable and mutual relations, and a generally low quality of life, whereas students described a focus on social relations, interests and personal growth. Students also described a higher quality of life, little loneliness and greater satisfaction with life. This suggests that the main problem for many patients struggling with persistent and severe mental illness might not be the illness itself, but a lack of environmental conditions supporting personal development.

The Knowledge Concealed in Users’ Narratives, Valuing Clients’ Experiences as Coherent Knowledge in Their Own Right

Objective. As the history of psychiatry has been written, users have told their stories and often presented pictures incompatible with the professional or official versions. We ask if such a gap still exists and what the ethical as well as epistemological implications may be. Study Design. The design is based on a hermeneutic-phenomenological approach, with a qualitative content analysis of the narratives. Data Sources. The paper draws on user narratives written after the year 2000, describing positive and negative experiences with the mental health services. Extraction Methods. Among 972 users answering a questionnaire, 492 also answered the open questions and wrote one or two stories. We received 715 stories. 610 contained enough information to be included in this narrative analysis. Principal Findings. The stories are coherent, containing traditional narrative plots, but reports about miscommunication, rejection, lack of responsiveness, and humiliation are numerous. Conclusions. The picture drawn from this material has ethical as well as epistemological implications and motivates reflections upon theoretical and practical consequences when users’ experiences do not influence professional knowledge to a larger degree.

Not talking about illness at meeting places in Norwegian community mental health care: A discourse analysis of silence concerning illness-talk:

Research on the topic of not talking about psychosocial hardships describes the presence of ‘house rules’ against illness-talk in common areas in ‘meeting places’ (‘day centres’) in community mental health care. The aim of this article was to explore the complexity of not talking about psychosocial hardships (‘silence’) in meeting places in Norwegian community mental health care. The research team consisted of first-hand and academic knowers of community mental health care (participatory research team). We performed two series of focus group discussions with service users and staff of meeting places. The focus group interviews were analysed within a discourse analytic framework, and five discursive constructions were identified: (1) biomedical colonization of illness-talk, (2) restricted access for biomedical psychiatry and problem-talk in the common spaces of meeting places, (3) censorship of service users’ civil and human rights to freedom of speech, (4) protection from exploitation and burdens and (5) silent knowledge of the peer community. Based on the analysis, we suggest that not talking about illness (silence) entails a complexity ranging from under-privileging implications to promoting the interests of people who ‘use’ meeting places. For instance, restricting biomedical psychiatry may imply the unintended implication of further silencing service users, while silently shared understandings of hardships among peers may imply resistance against demands to speak to legitimize one’s situation. The discussion illuminates dilemmas related to silence that require critical reflexive discussions and continuous negotiations among service users, staff and policymakers in community mental health care.

Evidence-based practice in social work: perceptions and attitudes among Norwegian social workers

ABSTRACT Although the concept of evidence-based practice (EBP) eludes precise definition, it is used as a trademark label to ensure that practice is based on science and thereby effective and of high quality. Proponents of EBP have proposed that both education and practice in social work should be transformed according to the principle of EBP. They attribute critical opposition to EBP to a lack of knowledge of what EBP is. In this article, we endeavour to clarify the concept and present results from a survey among social workers (N = 2060) from Norway. The survey results show that although many have heard of the concept, few have precise knowledge about it. However, the more educated social workers are (master’s level), the clearer their opinions, both critical and non-critical. The results are discussed in relation to neo-liberal governance and development of social work.

How can context and discourse affect teachers’ and mental health professionals’ interactions with adults with mental illness?

ABSTRACT Patients with severe mental illness may have needs different from those of patients with more limited illnesses and might benefit from other types of intervention than traditional treatment. We interviewed health care professionals from two open, short-term psychiatric wards and teachers from two schools for adults with psychiatric diagnoses. The focus was to explore how differences in contextual factors such as time, tasks, and organizational demands might affect the actions and attitudes of health care professionals and teachers, as well as the potential consequences for patients and students. Data were collected through qualitative interviews. Participants included 14 health care professionals and 14 teachers. The informants worked with patients and students with similar diagnoses and illness durations. All interviews were conducted during the informants’ work time. Findings and interpretations showed that both teachers and health care professionals were engaged in their work and in the wellbeing of students and patients. However, they described marked differences in practice, including the amount of time spent with students/patients, the organization of their work, main tasks, amount of control over their tasks, and social structure. These differences seemed to affect relationships with students/patients, attitudes toward students/patients, norms and values, and opportunities for patient empowerment. Our findings suggest that while existing psychiatric health care might be appropriate for limited short-term problems such as single-episode depression, a model with a supportive environment, based on stable relations and possibility for learning, may improve personal development and mental health for persons with severe mental illness and disturbances in self-experience.