Читать книгу Rainforest Asylum - Sara Ashencaen Crabtree - Страница 18

Having formulated my research focus the next step was to consider how to study the institution. After due consideration I decided to concentrate primarily on four wards: two acute and two long-stay wards. Of these four wards, two were allocated to female and two to male patients; the latter were used to provide comparison for the purposes of my study. The long-stay wards and the private wards were used for orientation and comparative purposes and, along with the occupational therapy department, were visited many times. This department provided some relief from the wards, where I gained some extremely useful insights into gender stereotyping and patient labour. Finally, other wards such as the forensic ward, Bunga Raya, a floral epithet for a ward exclusively for male offenders, attracted my interest as did, although to a lesser extent, the sick ward.

The acute wards, Female Ward 1 and Male Ward 1, and the long-stay wards, Female Ward 2 and Male Ward 2, were chosen on the basis of a combination of factors. The acute wards provided an interesting basis for comparison with the long-stay wards, in view of the fact that the selected long-stay wards were not exclusively but generally more likely to be the eventual destination of acute patients later perceived to be chronically afflicted. The daily routines, recreation and patient and staff interactions were livelier on the acute wards with the exception of the forensic ward. On the wards selected most of the patients enjoyed comparative youth compared with the remainder of the long-stay wards; and therefore, to generalise, were more likely to be able to communicate with me as opposed to wards where there were a greater number of elderly and mentally infirm patients.

Overt observation techniques provided the major part of the data I gathered in which I made no pretence to on-lookers to be there for any other purpose than that of observation. This strategy conformed closely with that described by Tim May (1999: 140) in which the ‘participant as observer’ role is a public one. This involves not only observation but also the development of working relationships with participants as informants for the study. Information duly gathered in this way proved sufficient to obtain good insights into particularly interesting phenomena, such as methods of control or the use of patient labour on the wards. This also enabled me to make an informed decision regarding which wards should eventually be selected for closer scrutiny, as well as drawing my attention to those individuals whom I felt I could approach and those who might represent a threat to the study, or more prosaically, to myself.

In the early days, however, my method of observation was closer to that of a ‘shotgun’ approach in which interesting people, events and activities were noted down with little discrimination and less understanding, in a small, handy notebook on site. As the study progressed my comprehension of events taking place around me increased and allowed me to target certain phenomena on the ward. Patient mealtimes, medication routines, bedtimes and awakenings were just some of the events I sought to observe at certain times of the day and night. I therefore made myself present for early morning breakfast rounds on the wards, and mid-morning snacks; present for soporific afternoons and patient siesta time, and occasionally kept a night-time vigil with the staff night shifts. These latter shifts proved to be the most sociable and companionable, with staff most amused by my persistence and supportive of my endurance. On these occasions I could rely on coffee and mee goring (fried noodles) to be liberally supplied to keep tired eyes open, including mine.

At first, I had felt grotesquely conspicuous on the wards and felt that staff in varying degrees were self-conscious when going about their everyday business under these artificial circumstances. After a considerable amount of time and personal discomfort had lapsed I eventually manage to achieve a certain level of invisibility where everyone, staff and patients alike, apparently ignored my presence albeit on brief occasions. These occasions were punctuated by activities in which individuals would regularly engage me in conversations. Over time my explanations that I wanted to see what it was like on the wards began to be accepted by participants with less suspicion as to my exact motives.

In this way, therefore my observations narrowed down over time from a broad sweep of noting everything and anything that caught my attention to a narrow, and hopefully, more acute focus (Bannister, 1999). Through the use of observation techniques employed in a comparative exercise, I found that data from observations both informed and synthesised my developing hypotheses in a rigorous and synergistic relationship (Burgess, 1995).

Observation strategies on the wards allowed me freedom to adjust to situations taking place and consequently I would often engage or be approached by patient and staff informants. In common with Shaffir’s (1991) experiences, most of these were informal conversations on a particular topic that I wanted to explore further. These interviews being ‘unstructured’ and ‘flexible’, informants often initiated the conversation from the outset (Lee, 1993). Here my interviewing strategy tended towards a deconstructive manoeuvre of attempting to uncover hierarchal distinctions through an appearance that was casual, with informal language and mannerisms, and generally trying to avoid with varying degrees of success the attitude and appearance of an orang puteh (White) lady visitor. Conversations with patients were fluid and spontaneous with participants joining in and departing from the discussion at hand as they pleased. This less formalised approach meant that patients chose the location to discuss matters and involved various settings. Occasionally we sat on stools under trees, or on the open veranda that most wards had, sometimes in the canteen or otherwise just sitting on beds inside the ward or in the rather bare recreation room. Some conversations took place in the occupational therapy department with patients chatting to me while they worked. Sometimes patients, usually men, would approach me to ask for a cigarette, which I did not have, or money, which I concealed, and then following this overture a discussion might be struck up. Similarly casual conversations with staff took place at the nursing station on wards, in private offices during tea breaks or while carrying out duties.

At other times, interviews were more formal when I wanted to discuss a range of issues based on a semi-structured interview guide that I had prepared earlier. The only criteria used for these interviews with patients were that they were willing to talk to me and fit enough to be interviewed; and here I relied on advice from the ward staff on the patient’s state of health and lucidity. Semi-structured interviews with patients, as opposed to informal discussions, took place in the treatment room at the end of the wards. This room was separated from the main ward by a grill gate and was about the only private place that could be allocated to me. Nonetheless, interviews were often inadvertently interrupted by the nursing staff, cleaners or other patients who wandered in. Interviews would then be momentarily suspended if possible, before continuing. Semi-structured interviews were conducted at various intervals with selected members of staff, including medical officers, nursing staff and allied personnel, such as occupational therapists and the two social workers, as well as former members of staff. Normally these interviews required careful planning due to medical schedules and outpatient appointments, therefore they were usually tape-recorded and supplemented by extensive note taking during the interview process itself.

Semi-structured interviews with patients were usually taped with their consent. The open use of a tape recorder in informal situations was eventually seen to be too intrusive for general conversations after I detected that, in particular, members of staff felt uncomfortable and inhibited by the idea. Furthermore, I had the impression that the tape recorder was distracting for patients, as well as intrusive, and tended to curtail spontaneous disclosures. Reliance on an increasingly elastic memory for informal conversations meant the flow of conversation was not interrupted; and a more relaxed and confiding atmosphere could be created. Hastily but discreetly written up notes in shorthand on small notebooks usually took place in secluded corners of the ward following these valuable sessions, as like the patients I was not able to enjoy freedom of movement due to ward ‘lock-up’ procedures.

Although I had initially hoped to engage a wide range of respondents, in reality some were considerably more responsive than others. Opportunities to talk to both patients and staff were seized more on the basis of luck than design, commensurate with Burgess’ definition of ‘opportunistic sampling’ (1995: 55).

Amongst the patient population my key informants were nearly all women; male patients tended to shy away from contact or at any rate often seemed less likely to respond to my questions with relevant information. On the face of it this is in keeping with the rapport Ann Oakley discovers in her research activities through the democratisation of the interviewing process, premised on the notion of shared commonalities, of which she writes:

The women were reacting to my own evident wish for a relatively intimate and non-hierarchical relationship (Oakley, 1984: 47).

However, I lacked the basic common grounds that Oakley held; she was a British mother, interviewing British mothers. Whereas I was a foreign woman who had never been admitted to a psychiatric hospital and was attempting to develop a rapport with women and men, many of whom had spent years of their lives being processed by the Malaysian psychiatric services. Yet, despite Daphne Patai’s (1991) critique of pseudo-identification, I remain convinced on my part that empathy of sorts was created during these times, albeit fractured with misunderstandings, cultural, social and sexual dissonances. Female patients in particular were often very friendly and even affectionate to varying degrees. I was subjected to a lot of gentle physical contact, and complimented, while at least one woman attempted to develop greater intimacy with me through sexual overtures.

The enveloping, cordial, affectionate and sometimes cloying atmosphere on the female wards was not replicated on the male wards. Rachel Forrester-Jones (1995) in reference to Ann Oakley, discusses the problem of creating reciprocal relationships with informants of the opposite sex to the researcher. Here, as Bailey (1996) notes, heterosexual and gender issues permeate the platonic boundaries of the relationship. Attempts at reciprocity are jeopardised by unshared gender expectations and politics, where women researchers may face the possibility of unwanted sexual advances from male participants. Accordingly, Estroff discusses the difficulties of negotiating relationships with male psychiatric informants whose social unfamiliarity with women creates a potential for painful misunderstandings.

Being female helped and hurt. Over half of the subjects were men. My gender served as an entrée to contacting them and eliciting some interest, but it created tensions as well. Many had never had a female friend, that is, a symmetrical, platonic, heterosexual relationship. This led to some confusion of their part when their sexual advances offended me, and to reluctance on my part in entertaining situations with them that might be misconstrued. It was often inappropriate to participate with the group as the only female, and as a sexually inaccessible one, at that (Estroff, 1985: xvii).

Unlike Estroff’s case, my contact with male patients did not take place in the social context of the community, but with only one exception, took place on the ward and for the most part in full sight of other patients and staff. Nevertheless, it was awkward and embarrassing to be the regularly subjected to so much inquisitive, blatant or wistful and forlorn attention from male patients, such as dealing with those who persisted in calling, flirting and chatting to me through the bars of the locked section. I was of course very aware that I was ultimately free to stay or go and they were confined, bored and excited by any break in the tedium, which by my presence I had caused. By persisting in staying on the ward, as fieldwork demanded, I was aware that I was also guilty of encouraging and exacerbating this mortifying sexual attention in an atmosphere of palpable, claustrophobic voyeurism. This verged, as Gearing (1995) found in relation to her own study, on sexual harassment. Furthermore, evasive strategies could not be properly mobilised, such as the feigned dignified, and casual indifference of a woman passing a building site, as this directly conflicted with the research guise of keen-eyed vigilance to detail. For the most part therefore, I tried to encourage relationships with male patients that were polite, friendly and neutral, in an atmosphere where physical contact and verbal intimacy were subtly discouraged. Obviously, there were exceptions to the rule, whereby some of my relationships with male patients were mutually respectful with no hint of a sexual overture on any occasion.

Contact with staff provided a fascinating contrast, in that, as stated, while female nursing staff were often reticent, their male counterparts - the ‘medical assistants’ - on the male wards were much more willing to disclose information to me than the female nursing staff and could be, when they chose to be, cheerful, amusing and friendly in their interactions with me. Such was the peculiar and intriguing balance in that in general women patients and male nursing staff were by far the most helpful and friendly towards me, whilst male patients and female nursing staff were often distant, close-lipped and occasionally overtly suspicious of me. As others have noted, women as researchers are seen as more harmless (and usually less socially important) than male researchers by male participants and therefore as less likely to use information in a damaging way (Gurney, 1991; Warren, 1988).

Any perceived lack of status on the grounds of gender may therefore have worked against forming a good rapport with female staff, in that there were few incentives for them to overcome the insider/outsider power dichotomy in an environment of closed ranks. Furthermore, Taylor (1991) points out that in his own research in a male-dominated setting rapport with informants was built upon a foundation of male solidarity, socialising activities and initiation ceremonies, something from which I was culturally barred in my own research with men and which did not materialise with women members of staff. Yet a few friendships were developed between myself and female members of staff, where one nurse occasionally pressed on me bottles of homemade tuak (rice wine), which at first I thought I was expected to pay for and only later realised were spontaneous gifts.

The conditioning of women to cautiously observe the boundaries between the sexes will continue to mediate relations in a research encounter. These will qualify the nature and depth of disclosures by informants as well as altering the agenda of what can be discussed in comparative safety for informants and researchers alike. I was, for example, very interested in learning more about the sexuality of male patients but this proved to be a problematic area for inquiry, and one where responses from male staff and patients were unsatisfactory, superficial and laden with implications. Lesbianism, however, was a subject that could be discussed with women, once relationships of comparative trust had been satisfactorily built. Reciprocity therefore is heavily dependent on gender relations in the field and consequently influences the quality of disclosures from informants. Like Forrester-Jones (1995) I feel that a male co-worker would have been able to elicit information from male informants that was to some degree inaccessible to me as a woman researcher in the field.

In his ethnographic account of psychiatric patients in Australia, Barrett (1996) makes full use of medical records and attends team meetings to augment information on informants. However, at an early stage of research I decided that I would not request access to patients’ medical records although did note verbal information on patients from staff. My reasons were partially practical and partially ideological. Medical notes were kept on the ward and staff consultations of them took place in plain sight of patients, so that it was not possible to avoid being seen reading them. Any such activity would have been conspicuous and instantly noted by patients, and I feared that this therefore might interfere in forming relationships of trust with patients. Furthermore, I felt that these could probably contribute little in the way of understanding interactions in the hospital; my interest was located in everyday events and the perceptions of informants, rather than in turgid medical information, which could largely provide me only with details of admissions, discharges and medication. Finally, I also felt strongly that this was a transgression of privacy, to which my status as researcher could not really entitle me. This position was justified when patients prefaced their interviews by asking me if I had read their medical notes. I felt that my reassurance that I had not read them created a more confiding environment in which to seek personal disclosures from patients, who might otherwise see me as a sort of member of staff, or some such similar type of authority, although this of course did nevertheless happen.

Despite my good intentions however, I had not bargained for the frequent invitations by staff to read the notes. The nurses and medical assistants often seemed to feel the need to fit me into some type of legitimate medical role and offered me the records on numerous occasions, sometimes opening them at certain pages and putting them in front of me, which made it difficult to refuse a quick perusal. This bears comparison with Burgess’s (1995) research experiences in a school setting, where he describes a similar need by staff to try and neutralise him through assimilation into the professional corps he was in part studying. Similarly therefore the invitation of medical notes not only legitimised my presence but also my research, which otherwise probably seemed a nebulous and unscientific way of going about things. The notes offered concrete and valid information in the eyes of staff, as opposed to the naïve and no doubt foolish questions I asked. My insistence on sitting with and talking to patients was commented on, to reiterate, with levity, incomprehension, or thinly veiled hostility.