A psychoanalytic approach to data collection and analysis
This chapter outlines the psychoanalytically informed methods used to collect and analyse data in a study of staff and patient relationships in a public mental health service. In relationships we experience strong and powerful affects that influence likes, dislikes and the quality of interactions. When we experience strong feelings of love or hate in an interaction there is an attempt to rationalise what is occurring. Conscious rationalisation invariably attributes the reaction to the social situation, the overt relationship to another. Psychoanalysis’s concept of transference exposes the unconscious source, purpose and potential of these powerful affects. Conducting psychoanalytic research is challenging as the data sought after relates to unconscious processes, hidden aspects of human experience. Data for the study referred to in this chapter was collected by non-participant observation, opportunistic conversations and formal interviews informed by psychoanalytic methods. The aim of this chapter is to increase the readers understanding of the application of psychoanalytic theory and practice as tools that extend beyond conventional approaches to social research. Institutions have a homogeneous nature and the study design outlined in this chapter offers a possible template to explore other social institutions.
The three learning points for the reader in this chapter are:
- • Understanding how to conduct non-participant observation in psychoanalytic research;
- • Understanding the key elements of psychoanalytically informed interview techniques;
- • Understanding how to approach psychoanalytically informed data analysis.
Overview of the research study
The study site was a contemporary Irish mental health service which featured in the media as an exemplifier of the organisation of mental health care around an institutional structure (Connelly, 1980; Gilsenan, 2005). The constituting nature of an institution influences the dynamic between individuals suggesting that change is unlikely to occur without recognition of the impact of the unconscious (Lyth, 1988). Change was imposed on the service at intervals of seven and two years prior to the study with the introduction of new mental health legislation and policy (Health Service Executive, 2006; Mental Health Act, 2001).The aim of the research was to investigate the unconscious dynamic of transference and to make recommendations in relation to how recognition and management of transference may have positive outcomes for service occupants.
Transference has a structuring effect on relationships and is generally understood as the attribution of the qualities of a significant person from the past onto a person in the present, sometimes without taking unconscious elements into account (Skelton, 2006). We experience transference in immediate reactions of liking or disliking someone we have never met before, in the experience of falling in love at first sight, in our reaction to others. Love therefore is of interest to psychoanalysts because it allows us to understand the mechanism of transference (Lacan, 1994).
When a persons mental health is compromised we see aspects of their relationship style that we would not notice otherwise (Freud, 1917/2001a). If a persons self-preservation instincts are challenged, they will act opportunistically, looking for another to give them a sense of safety, security, love and belongingness. Not surprisingly anyone entering mental health care may direct their feelings at those that express an interest in them, giving transference a positive quality. However, many staff and patients experience a reversal into the opposite, that is, hostile or negative feelings. Positive transference is normally identified with love whereas negative transference is never identified with hate. Instead we normally employ the term ambivalence. Lacan (1994) suggests that positive transference is when you have a soft spot for the subject and that negative transference is when you have to keep an eye on him. Keeping an eye on or observing the patient, in particular patients that may harm themselves or others, is a concern for staff whose practice is founded in observation and categorisation (Foucault, 1961/2006). Additionally patients observe and categorise staff for whom they may develop positive or negative feelings. Patients want to be loved by the staff and staff can be overwhelmed by this (Lyth, 1988). Health care delivery takes place within a relationship that carries expectations that differ from other social relationships. It should aim to be a therapeutic professional relationship placing responsibility on staff to acknowledge and address subjectivity.
Two settings were used for data collection: the acute admission unit and a day hospital. All site visits, following permission to conduct the study, were treated as data collection opportunities. Multiple data sources are commonly used in studies to reflect a total situation. Therefore the researcher was guided by four ethnographic data sources outlined by Taylor (1994) and used in combination with a psychoanalytic approach:
- • Data was collected from interviews, conversations, observations and documents;
- • Behaviour was observed in everyday context rather than experimental conditions;
- • An unstructured approach was adopted to data gathering in the early stages, to allow key issues to emerge during analysis;
- • An in-depth study of one or two situations, in this case staff/patient and staff/staff interactions was made.
The primary data collection methods used were non-participant observation and psychoanalytically informed interviews. With the former, data was gathered on the observable relationships between staff and patients by watching and listening to their interactions. All data collection in the form of non-participant observation, development of field notes, informal opportunistic conversations and formal audio-recorded interviews took place on-site. Off-site field notes and researcher reflections were reviewed and expanded upon and audio recordings were transcribed and analysed. Quiet presence and free-floating attention, techniques of psychoanalysis, featured as guiding principles for the researchers conduct. Quiet presence and free-floating attention involve “‘overall’ listening to what is being said as opposed to trying to catch every word”. It also refers to “going with” the participant and not trying to keep them on a particular theme. This allows for noting of “non-verbal and paralinguistic aspects of communication”, while also noting your own “thoughts, feelings and body sensations” (Burnard, 1992/2013, p. 89).
To capture the total situation participants were observed in the real life context of services during normal office hours. Overt observations (n = 52) were conducted in general ward areas, corridors, hallways, sitting rooms, dining room, bedrooms, meeting rooms, therapy rooms and offices. Written consent was obtained from participants for formal interviews. It was anticipated that up to 20 formal interviews and opportunistic conversations were required to support the other data sources, in keeping with sample sizes obtained for similar studies (Bion, 1961/2004; Estroff, 1985; Lyth, 1988; Scheper-Hughes, 1979).The anticipated sample size was flexible allowing for data saturation and deemed appropriate for a qualitative study, as well as the subgroups of participants (McLeod, 2011). Data saturation is a point where the researcher is satisfied that no new information will be obtained from collecting further data. This determines the sample size in qualitative research as it indicates that sufficient data has been collected for a detailed analysis. The observation period allowed for the recording of 156 opportunistic conversations and ongoing analysis of this data and the field notes supported data from ten formal interviews.
Participants for formal interviews were identified based on the desire to get a picture of the total situation, the literature reviewed and field observations. Care was taken to ensure that I observed and listened to all grades of staff and patients occupying the study site. Group psychoanalytic literature (Bion, 1961/2004; De Board, 1978/2006; Freud, 1914/2001b), indicated the need to interview participants with limited as well as extensive experience of services in order to gain access to personalised yet contextualised accounts. All requests for patient participation were made through staff, as agreed when negotiating ethical permission, while staff were approached directly. Formal interviews were conducted in rooms designated for that purpose. In line with best practice participants were given a participants information sheet and asked for written consent. To maintain consistency in data management formal interviews were recorded electronically, transferred to the researcher’s password protected computer, identified by a set of codes, listened to repeatedly and transcribed onto field notes templates.
Psychoanalytic research, like ethnographic research, utilises multiple data sources such as participants’ speech and actions, observations of social and cultural structures, examination of the products of a group or culture, therefore making it an examination of a total situation (Bion, 1961/2004; De Board, 1978/2006; Diamond, 1993; Fotaki, 2010; Lacan, 1994; Lyth, 1988; Vanheule, 2003).The data was subjected to a psychoanalytic investigation with reference to the speech and actions of participants. The study did not involve the psychoanalysis of subjects. Instead it viewed the data through a lens informed by a specific aspect of psychoanalysis, Lacan’s discourse theory, which describes social bonds constructed by discourse, desire and social interaction (see Lacan, 1969/2007). The researcher looked for the actions of the unconscious in these sources as it is observable in our discourse and our social bonds and is particularly evident in anxiety, proving situations making critical incidents a rich source of relevant data.
Findings indicated that transference was unacknowledged and unmanaged in the study setting. Services were found to be constructed around a bureaucratic patriarchal structure supporting staff power and unconsciously generating jouissance. Findings also suggested that health care legislation limits patient access to meaningful therapeutic relationships. Services fail patients and staff by not incorporating knowledge of the importance of primary relationships founded on love but incommensurable with orthodox science. To achieve constructive consistent change, extensive staff retraining, education and support were recommended.