Transcript Using ethnography to study the ‘black box’ of a complex

Addressing the “how does it
work?” question in complex
mental health intervention
John Aggergaard Larsen
European Institute of Health and Medical Sciences
University of Surrey
[email protected]
BSA Sociology of Mental Health Study Group
Rethinking the Boundaries
30 June 2005, Nottingham
Aims of paper
• Outline the limitation of traditional outcomefocused intervention studies in mental health
• Argue the value of qualitative research on
complex mental health interventions
• Argue the value of applying sociological and
anthropological theory to examine the workings
and effects of complex mental health
interventions
• Example: person-centred ethnographic study of
early intervention in psychosis service
The traditional outcome-focused
research design
• The randomised controlled trial (RCT) as the
‘gold standard’ – use of control group to
demonstrate effects of new/other intervention:
‘does it work better or worse?’
• Other factors kept constant – study of ‘pure
effect’ (ideal: a drug)
• Focus on outcome – dependent on valid
variables and reliable measurements.
• Assumption that interventions are following
guidelines/protocol (that the intervention element
is constant and unproblematic or controllable).
The challenge of
complex interventions
• Recognition in mental health that medical
treatment needs to be supplemented with
therapeutic intervention and social support –
integrated ‘biopsychosocial’ treatment.
• In complex interventions it is difficult to isolate
the treatment/intervention effect – the difficulty of
identifying the ‘active ingredient’.
• The theoretical understanding of complex
interventions’ efficacy is often poorly developed.
• Complex interventions are difficult to control and
standardise – they are ‘messy’ and dependent
on a variety of professional, personal, social,
cultural, institutional and cost variables.
The problem of the ‘black box’
• It is problematic to treat a complex intervention
as a ‘black box’ of therapeutic effect – the
intervention is not ‘one thing’.
• It is insufficient to rely on guidelines and ‘check
list’ protocols to control and standardise the
intervention.
• Assuming a ‘black box’ ignores the important
question: ‘how does the intervention work and
bring about treatment effects?’
Complex interventions and
qualitative methodology
• Necessary to look in detail at how the
intervention is provided and how patients/clients
benefit – utilising qualitative methods (Campbell
et al. 2000; MRC 2000).
• Taking an explorative and theory-generating
approach to identify and understand the
workings within the ‘black box’ – define relevant
variables and processes.
• (The qualitative findings can (later) be applied in
a large-scale quantitative study to look at issues
of prevalence and regional variation.)
Ethnography in the study of
complex interventions
• Ethnography allows the researcher to take a
holistic, flexible and explorative approach to the
field of study (Sharkey & Larsen 2005).
• The ethnographer is actively present in the
intervention by using him-/herself as a research
tool and taking a socially visible membership
role (Adler & Adler 1987).
• Ethnography seeks to identify:
– sociocultural processes in specific settings and
– the perspectives and activities of individuals/agents
Example: studying early
intervention in psychosis
• Outcome studies suggest that integrated
‘biopsychosocial’ treatment and support
following first episode psychosis improves
recovery and mental health prognosis
(Birchwood et al. 1998; McGorry & Young 2003).
• Early Intervention in Psychosis (EIP) services
are a NHS policy priority (DoH 2000).
• 50 services are being established nation-wide –
3-years intervention.
• Clinical guidelines seek to direct and
standardise the interventions (DoH 2001).
Questions of working and effect
• How do EIP services bring about the positive
outcomes – what is the ‘active ingredient’?
• How does the intervention influence clients’
experiences and perspectives?
• How do variations in EIP service delivery and
staff-client interaction influence clients’ social
roles and trajectories?
• What does variations in clients’ attitudes,
perceptions and their social backgrounds mean
to the effectiveness of the intervention?
• What does ‘recovery’ mean following first
episode psychosis?
Person-centred ethnographic study
of Danish EIP service, 1998-2000
• Accessed through role as project evaluator of
experimental project, while PhD student in
Sheffield (Larsen 2002).
• Participant observation in day-to-day work of the
service, therapeutic settings and staff meetings.
• Repeated interviews with 15 clients over a two
and a half year period and participatory
approach: creative-expressive project group
producing a book with six stories.
Some findings
• Becoming mentally ill represented an existential
crisis that was life-disrupting and involved a
sense of ‘ontological insecurity’ (Larsen 2005).
• The psychotic experiences were disturbing and
some engaged in creative meaning-making
activity, drawing on systems of explanation from
the cultural repertoire (Larsen 2004).
• Through ‘psychoeducation’ and cognitive
therapy the intervention provided scientific and
psychological-mechanistic theories that provided
a ‘symbolic myth’ for processes of ‘symbolic
healing’ (Larsen, under review).
Proposed multi-site study in the UK
• A comparative multi-site ethnographic study of
UK EIP services based on participant
observation in service interventions and
longitudinal engagement with clients (key
informants and creative-expressive project
work).
• Improve understanding of:
– The sociocultural therapeutic workings of EIP services
– The trajectories of clients given individual and social
circumstances
– Theoretical understanding of ‘recovery’
In conclusion
• The need for qualitative (ethnographic) methods
when studying complex interventions.
• Sociological and anthropological theory can
contribute to understanding the sociocultural
therapeutic effect of complex interventions.
• Comparative design required to examine how
client trajectories relate to differences in service
delivery and client circumstances.
• Strategic collaboration with mental health
service providers and involve large-scale
quantitative studies to identify prevalence and
regional variation.
References
Adler, P. A., & Adler, P. (1987) Membership roles in field research. Newbury Park, CA:
Sage.
Birchwood M, Todd P, Jackson C (1998) ‘Early intervention in psychosis: the critical
period hypothesis’, British Journal of Psychiatry 172: 53-159.
Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L., Sandercock, P., Spiegelhalter,
D., & Tyrer, P. (2000) Framework for design and evaluation of complex interventions
to improve health. British Medical Journal, 321, 694-6.
Department of Health (2000) NHS Plan. A Plan for Investment. A Plan for Reform,
http://www.doh.gov.uk/nhsplan/nhsplan.pdf
Department of Health (2001) The Mental Health Policy Implementation Guide,
http://www.doh.gov.uk/pdfs/mentalhealthimpgraphics.pdf
Larsen, J. A. (2002) Experiences with early intervention in schizophrenia: an
ethnographic study of assertive community treatment in Denmark. PhD Thesis.
Department of Sociological Studies, University of Sheffield.
Larsen, J. A. (2004) Finding meaning in first episode psychosis: experience, agency and
the cultural repertoire. Medical Anthropology Quarterly, 18(4), 447-471.
Larsen, J. A. (2005) Becoming mentally ill: existential crisis and the social negotiation of
identity. In V. Steffen, R. Jenkins, & H. Jessen (Eds.), Managing uncertainty:
ethnographic studies of illness, risk and the struggle for control (pp.197-223).
Copenhagen: Museum Tusculanum Press.
McGorry, P. D., & Yung, A. R. (2003) Early intervention in psychosis: an overdue reform.
Australian and New Zealand Journal of Psychiatry, 37(4), 393-398.
Medical Research Council (2000) A framework for development and evaluation of RCTs
for complex interventions to improve health, http://www.mrc.ac.uk/pdf-mrc_cpr.pdf
Sharkey, S., & Larsen, J. A. (2005) Ethnographic exploration: participation and meaning
in everyday life. In I. Holloway (Ed.), Qualitative methods in health research, pp. 168190. Maidenhead: Open University Press.