Qualitative Health Psychology

Theories and Methods

Michael Murray, Kerry Chamberlain, Michael Murray, Kerry Chamberlain

• Publisher: SAGE Publications Ltd
• Year: 1999
• Print ISBN: 9780761956617, 9780761956600
• eBook ISBN: 9781446234976
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

`This book constitutes a valuable resource for postgraduate students and researchers. Most.... of the chapters succeed in providing a clear and comprehensive introduction to the various approaches and/or methods, thus enabling the reader to make an informed decision about whether or not they wish to pursue the topic further. The book as a whole is also very well referenced and this makes it a source of essential information for students and researchers with an interest in qualitative health psychology? - Health Psychology Update

This book explains the role of qualitative research within health psychology. Theories and methods from a qualitative perspective are highly varied but, in general, differ from the positivist approach which is concerned with quantifying the individual risk factors presumed to cause health and illness behaviour. This book shows clearly how a qualitative approach offers a better understanding of the experience of illness while locating it in its broader social context.

Providing a detailed examination of these issues, the book is organized into three sections - the first considers some of the main theoretical perspectives underlying qualitative research in health psychology including discourse analysis and narrative as well as the social context and embodiment of health and illness; the second examines some of the practical issues involved in conducting qualitative research with different populations, such as children and the terminally ill; and the final section considers a range of analytic issues and specific analytic approaches such as grounded theory and action research, and the evaluation of qualitative methods.

Part I

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Constructing Health and Illness Through Language

1

Health Psychology and Qualitative Research

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Michael Murray and Kerry Chamberlain

Over the past thirty years, since its formal inception, health psychology has grown rapidly in popularity as evidenced by the numerous textbooks and journals dedicated to the subject, and by the size and growth of specialized societies and conferences. One problem faced by a discipline which is young and experiencing such rapid growth is that there is a tendency to adopt the standards and methods of more established disciplines as a means of gaining respectability and status within the wider scientific community. This rush for respectability can curtail debate about the relevance and legitimacy of the more dominant theoretical and methodological frameworks. Fortunately, health psychology has arrived on the scene at a time of intense debate about the nature of psychology and of science. This debate provides an opportunity to consider and reflect on the foundations of the discipline.

The purpose of this book is to contribute to that debate through an examination of the role of qualitative research within health psychology. The contributions in the book are not limited to a discussion of methods but inevitably consider broader epistemological issues. To provide a framework for this discussion it is useful to begin by considering the epistemological foundations of psychology as a discipline and the implications of the current challenges for health psychology.

Psychology as a Science

Psychology has been characterized as an archetypal quantitative science. Born in the heyday of nineteenth-century positivism it has maintained a fascination with (supposed) objective measurement and the identification of statistical associations between (so-called) psychological variables (see Danziger and Dzinas, 1997). Quantitative methods have provided a unifying feature for what was a rather diverse set of psychological perspectives. The concern for measurement and experimentation served to distinguish psychology from philosophy, religion and other attempts to explore the human psyche, such as psychoanalysis (Smith, 1997). It was through the adoption of the paraphernalia of the natural sciences, such as the laboratory and its associated equipment and white coats, that psychology paraded its self-awarded scientific status. Indeed, it could be argued that this concern for quantification reflected a certain anxiety or insecurity about the legitimacy of its position within the broader pantheon of sciences. Much research effort was expended in revising and improving psychological measurement and experimental procedures. Danziger (1990: 5), in his history of the development of psychology, suggests that ‘these preoccupations with the purity of method frequently deteriorate to a kind of method fetishism or “methodolatory”’. Researchers who deviated from the strict methodological guidelines were dismissed as unscientific.

Not only was this ‘scientistic’ psychology (see for example Richardson and Fowers, 1997) concerned with measurement of psychological variables and the establishment of universal laws of human behaviour but it also sought to establish an applied science which could demonstrate its legitimacy and value. Rose (1996, 1997) has described how psychology justified its expansion through the advance of its applications to predict and control human behaviour. In the early days of psychology this interest in social engineering was most apparent in the concern with mental measurement and the close interweaving with eugenics. Later, the emphasis shifted to the measurement of other psychological constructs such as personality and attitudes. Such knowledge could then be used to promote the smoother working of society without critiquing its underlying ideology. Admittedly, psychology was not alone in this endeavour. As Fox and Prilleltensky (1997: 265) noted, ‘the natural and social sciences have been obsessed with instrumental values of control and domination at the expense of emancipatory values such as justice, mutuality, and autonomy’.

Throughout its development, therefore, psychology has held fast to the belief that its quantitative methods gave it access to the psychological world, that the application of these ‘objective’ methods by the detached scientist would reveal the fundamental laws which were presumed to underlie human endeavour (Danziger, 1990), and that the use of these laws could contribute to the creation of a better world. The model of natural science was adopted as the natural model for any science, and psychology certainly considered itself to be a science.

The Place of Health Psychology

Health psychology, as a recent development, has predominantly followed the methods of mainstream psychology. The debate about epistemology that has occurred recently within some branches of psychology, in particular social and feminist psychology (for example, Gergen, 1985; Hollway, 1989), has been rather muted within health psychology. There are several reasons for this, not least being its close attachment to medical science. Medicine is an immensely powerful profession in the western world, where its standards and perspectives are broadly promoted and accepted as truth. Biomedicine is pervaded with the rhetoric of discoveries and cures. Working within the medical establishment, health psychologists have tended to follow the ‘predict and control’ tenets of positivist science that are dominant there. These were wedded to the methodology of physiology on the one hand and of epidemiology on the other, such that in many senses health psychology could be characterized as a blend of psychophysiology and behavioural epidemiology. The former had a particular interest in the physiological processes underlying such psychological constructs as stress, while the latter had a particular interest in topics such as psychological predictors of healthy and unhealthy behaviours. This new form of behavioural medicine was attractive to many physicians not least because it enabled them to extend their authority over other areas of human existence (Kugelmann, 1997).

Health psychology largely adopted an accommodative stance in relation to biomedicine rather than one which seriously critiqued the legitimacy of the medical model. The easiest way to do this was to introduce a new psychological dimension into the basic biomedical framework but otherwise to leave the edifice untouched. This accommodation resulted in a shift from a biomedical to a more inclusive biopsychosocial model. However, Ogden (1997) has examined this supposed challenge to biomedicine and found it to be more rhetoric than reality. She argues that, in spite of the rhetoric to the contrary, the practices of health psychology continue to privilege biological aetiology over psychological causation, serve to promote mind/body separation and interaction rather than the view of an integrated individual, and also serve to separate the bodily from the social. Modern biomedicine directs its gaze at the individual body (Foucault, 1973), and health psychology has merely extended that gaze to include the mind, defined in terms of psychological variables, with social processes often ignored or ‘controlled for’ in statistical analyses aimed at producing general laws.

Although health psychologists often worked as members of interdisciplinary teams, the team members all accepted the basic quantitative tenets. Each member was assumed to have specific expertise in the measurement of certain types of variables. It was expected that, in the same way as medical scientists could measure relevant aspects of particular bodily parts and functions, so health psychologists could measure the psychological variables which were relevant and held to be pre-existent and distanced from the researcher. The possibility of objectively identifying and measuring these psychological constructs was taken for granted, although there were some concerns as to how validly and reliably this could be achieved. Admittedly, this perspective on science was common throughout psychology. As Danziger and Dzinas (1997: 46) argued, throughout psychology there is ‘a fairly wide-spread, though implicit and unexamined, belief that any psychologically relevant part of reality was already pre-structured in the form of distinct variables, and that psychological research techniques merely held up a mirror to the structure’. Psychological variables were assumed to exist in reality rather than being constructed by the psychological observer. Such a view allowed health psychology to be located within and integrated into a biomedical framework.

However, concerns about the adequacy of natural science as a model for psychology have led to increasing criticism of the use of quantitative methods within health psychology. For example, the experiment, the cornerstone of classical psychology, was critiqued because it ignores both process and context. Danziger (1990: 116) described the experiment as an artificial construction ‘in which individuals are stripped of their identity and their historical existence to become vehicles for the operation of totally abstract laws of behaviour’. A similar argument could be levelled against the unquestioned acceptance of clinical trials by health psychologists in that they ignore the social nature of the experimental procedure (Farr, 1978) and its socio-historical context. Similarly, Ibanez (1991: 195) critiqued positivist social psychology on these grounds arguing that ‘the neglect of historicity, and, consequently, the negation of the always concrete and singular nature of the social, obliged this research strategy to empty the investigated phenomena of all their social content’. Within health psychology this ahistoricism is reflected in the search for general laws and the ignoring of social and cultural variability of health and illness (Landrine and Klonoff, 1992). This debate about the adequacy of natural science methods also had broader implications.

Challenges to Positivism

The past ten or so years has witnessed a rising critique of the legitimacy and adequacy of quantitative methods within psychology. In view of the centrality of measurement to psychology, this critique, which was initially methodological, also began to question the epistemological foundations of the discipline (for example Hollway, 1989). Whereas the positivist paradigm assumed that empirical methods gave it access to an objective reality, critics were not so sure. Shotter (1986: 95) in his review of empirical methods summarized the contrasting viewpoints as follows:

We now realise that what the empirical and behavioural sciences call data are not simply given us in the phenomena we study, but are theory-laden, i.e. they only appear to us as the facts they are in terms of a theory constructed by us. Instead of being called data they could more correctly be called capta (Laing, 1967, pp. 52–53) for, rather than being simply given us by Nature, we in fact take them out of a constantly changing flux of events.

Although we do not have the space to review these debates in detail, they have implications for how we should seek to make progress in health psychology, especially in relation to considerations of what is available knowledge and how it can be accessed. Shotter’s argument above encapsulates the dilemma arising from the appeal to data as ‘facts’. The rise of social constructionsist ideas emphasized that ‘reality’ was more appropriately regarded as constructed in interaction between researcher and researched. The researcher was not, and could not be, value free, and facts as well as theory were necessarily value-laden. The ‘subjects’ of research were equally involved in this construction through the interaction of their expectations and activities with those of the researcher. Beyond this, it was argued, any piece of research was constrained to be a construction determined by the possibilities and limitations of the physical, social and historical context in which it was conducted. If this is the case, it is obviously impossible for the researcher to adopt a value-free neutral perspective and for the phenomenon under investigation to be separated from the context in which it is investigated. This presents a radically different view of the research enterprise from the one taken for granted by the positivist position. Instead of seeking accurate measurement of hypothetically related variables and assessing their relationship statistically, these alternative approaches seek detailed complex interpretations of specifically socially and historically located phenomena. As Smith, Harré and Van Langenhove (1995a) have argued, this involves a shift from measurement to understanding, from causation to meaning, and from statistical analysis to interpretation.

One of the central arguments in this critique has been concerned with the significance of language in the construction of reality. The rise of social constructionist ideas within psychology has emphasized the role of language in shaping or even creating reality (Gergen, 1985). This emphasis, and especially discursive approaches premised on it, has provided the basis for some new methods adopted recently within health psychology (for example, Stainton Rogers, 1996; Middleton, 1996). Adopting a discursive approach abandons the notion of traditional psychological variables and views them as changeable constructions, historically and socially located and serving particular functions. The discursive approach argues that psychological ‘entities’ such as cognitions and personality traits are not fundamental, but can be analysed as constructions to reveal why they came to be construed in a particular way by a particular group at a particular time. As Yardley (1997: 6) states, ‘rather than allowing the psychosocial realm to be analysed in biomedical terms, discursive critics of the biopsychosocial model argue that we should reinterpret the biomedical realm from a psychological and socio-cultural viewpoint’.

One argument against privileging language in this way is that it denies or precludes the material dimension of life, that realm where so much of health and illness may be seen to reside. The so-called ‘death and furniture’ arguments (see Potter, 1996: 7) have often frustrated social constructionists who accept that while phenomena may be socially constructed in discourse this does not mean that discourse is everything (Greenwood, 1989). In the current debate surrounding embodiment, psychologists are beginning to explore further the relationship between discourse and physicality (for example, Stam, 1996) and how materialist and sociolinguistic aspects of health and illness are intertwined (for example, Yardley, 1997).

These critiques give rise to a number of concerns which specifically relate to qualitative research practice. If researchers construct their interpretations, this opens the possibility that they must choose what to interpret from amongst the detail and ambiguity of their data, and this choice will inevitably be influenced by their presuppositions and values. Their theories, therefore, can never be complete and will always be partial and value-laden. However, they can be reflective about their interpretations and offer a commentary on their position and socio-historical location in relation to the phenomena being researched. As St Maurice (1993) notes, this collapses the distinction between theory and data, and reveals how theory is a function of the way the researcher understands the world and views the data. Reflexivity offers a window on the context in which methods and theories are constructed.

The idea that our understandings are constructions also problematizes some traditional quantitative research issues such as generalizability, reliability and validity. Qualitative researchers have responded to these issues in a number of ways, from devising alternative understandings through to dismissing them as irrelevant to qualitative research. This book does not (with some specific exceptions) seek to discuss these issues explicitly, but they do form a backdrop and framework for the various chapters of the book. For instance, several of the contributors draw on the analysis of multiple paradigms offered by Guba and Lincoln (1994) as a convenient frame for providing some order to these debates, but other contributors would contest this account. Whatever claims one may make for or about qualitative research, there are always alternative views and opinions to be found. Indeed, as Becker (1993: 228) has noted, ‘it is always possible to criticise how things are done if you are a different person at a different time with a different purpose’.

We have focused on constructivist challenges here because they are currently the strongest within psychology. In doing so we have not considered the debates around post-structuralist and post-modernist views which are beginning to emerge more frequently within the discipline, although minimally as yet within health psychology. We have also over...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Notes on Contributors
• Part I Constructing Health and Illness Through Language
• Part II Conversing About Health and Illness
• Part III Transforming Talk into Text
• Name Index
• Subject Index