Making the Clinic: Negotiating Illness,
Recovery, and Diagnosis in an Open
Psychiatric Unit in the Netherlands
Léonie A. J. Mol 5884780 leonie.anna.mol@gmail.com
University of Amsterdam (UvA) Supervisor: dr. Eileen M. Moyer Graduate School of Social Sciences Second reader: prof. dr. Ria Reis Social and Cultural Anthropology: Master’s thesis Third reader: dr. Anja J. Hiddinga Amsterdam, 6 January 2016
Amsterdam, January 2016
What is originality? To see something that does not yet bear a name, that cannot yet be named, although it is before everybody's eyes, as people are usually constituted, it is the name that makes a thing generally visible to them. — Original persons have also for the most part been the namers of things. (Nietzsche 2006:§261)1
This master’s thesis is the result of an intensive year of thinking, reading, and writing while I studied as a master’s student in Social and Cultural Anthropology at the University of Amsterdam (UvA). Thinking about psychiatry and psychiatric practice, as will hopefully become clear throughout the thesis, is something of the utmost importance in the years to come. This document is an attempt to pay attention to new developments in the treating of mental illnesses in Dutch society today. I hope it will trigger in readers questions, ideas, and disagreement.
I want to thank Eileen Moyer and Barbara Stringer for helping me preparing the research proposal and the documents necessary to obtain formal clearance to the clinic. I want to thank the psychiatrist, the semi-doctors and doctors in training of the clinic for introducing me to their patients and letting me take notes in their office. Last but not least, I want to thank Sam for staying calm while I suffered one of the many panic attacks that come along with writing a thesis.
Léonie Mol
1 “Was ist originalität? Etwas sehen, das noch keinen Namen trägt, noch nicht genannt werden kann, ob es gleich vor Aller Augen liegt. Wie die Menschen gewöhnlich sind, macht ihnen erst der Name eind Ding überhaupt sichtbar. – Die Originalen sind zumeist auch die Namengeber gewesen.”
Making the Clinic: Negotiating Illness, Recovery, and Diagnosis in an Open
Psychiatric Unit in the Netherlands
Summary Thesis: Making the Clinic: the Negotiation of Illness, Recovery, and Diagnosis in a
Psychiatric Ward ... 4
Introduction ... 5
Chapter One: “Nothing happens”: An Anthropological Unpacking of the Clinic as a Specifically Structured Domain ... 21
Chapter Two: Identity, Diagnosis, and Biosociality: Becoming a Patient ... 40
Chapter Three: Negotiating the Patient’s Emancipation: Shared Decision-making and its Implications ... 55
The Future of Clinical Care: A Care-ful Conclusion ... 72
Bibliography ... 72
Appendix I ... 93
Note: Without the bibliography, title page, index, and summary, this thesis is 30381 words; including the footnotes, it is 37259 words. Since a lot of footnotes contain translations of the quotes I used, I decided to mention both.
Summary Thesis: Making the Clinic: the Negotiation of Illness, Recovery, and Diagnosis in a Psychiatric Ward
Keywords: shared decision-making, clinical treatment, psychiatric care
This thesis analyzes the extent to which the psychiatric patient is viewed as an actively participating agent in his own recovery process and how this view of the patient can be linked to broader narratives on health and illness in the Netherlands. What does it mean to be mentally “ill”, and what does this tell us about shifting norms of care and psychiatric decision making in Dutch society today? Public mental health care has undergone significant changes over the past few years in the Netherlands. To highlight these issues, this ethnographic research focuses on one particular context: an open psychiatric clinic in which people who suffer from “severe psychiatric symptoms” are hospitalized. The analysis focuses on three themes: 1) how the clinic is described by health care workers and patients as a place where “nothing happens”, 2) how health care workers and patients identify patients as people diagnosed and in need of care and psychiatric treatment, and 3) how health care workers and patients negotiate a patient’s treatment. The analysis draws on material gathered during in-depth interviews with patients and health care workers, as well as observations of daily life in the clinic, including formal meetings between patients and health care workers. The thesis builds on Annemarie Mol’s theories related to the enactment of disease and the logic of care, as well as Carlos Novas and Nikolas Rose’s understanding of biosociality. Cheryl Mattingly’s analysis of clinical plots informed and helped to shape the narrative aspect of treatment.
Introduction
“Do you enjoy reading your paper?” Tom asks while sipping from his fourth cup of coffee this hour and continuing to rapidly type notes from an observation of a patient he has just made. Tom is the coordinating nurse of the clinic where I conduct my fieldwork and seems concerned about the progress of my research. I cannot help but notice how, from time to time, he looks in my direction with a puzzled expression from his office. Perhaps it’s more accurate to say “office”, since nurses sit behind a desk and indeed have their own coffee machine, but that is pretty much it. “We have broken all those offices and fish bowls we as nurses used to hide in, and we now work behind open desks, so we are more accessible to the patients,” another nurse explained to me.2 And this is at least partially true. As part of the effort to limit hierarchical relations between patients and staff, nurses no longer have a separate office or breakroom and while invisible boundaries still exist, patients do have the possibility of approaching nurses freely throughout the day. Many patients stop by to have a little chat or make some jokes – about the bad food, the weather, etc. — and today is no different. A predictable question comes up, asked now by a man wearing shabby old fake-Adidas pants, “I really don’t know where I put my pack of cigarettes last night… Can I borrow some money to buy new ones?”
Tom smiles before he replies. “But your mother brought you a whole pack of cigarettes yesterday!”
“I know, I know. I think I’ve lost them…”
Tom replies: “Well, that’s too bad. We agreed you could buy a new pack every three days, remember?” The man grunts in acknowledgement, then turns back towards his room. The sounds of his shuffling feet gradually fade.
Tom has just given his patients advice about their diet. Most of them have put on weight since coming to the clinic. While waiting in line before the scale, some of them give me and my newspaper a curious glance. “You know, you should work on that”, Tom tells a patient who has gained ten pounds. Observing these casual encounters in the common spaces also reveals a lot about communication dynamics and power relations, particularly the ways that patients are not so subtly encouraged to make specific health care choices, many of which, including those related to exercise regimes, diet, and smoking, may have little or no
consequences for their mental health. Often the goal seems to be to reiterate the importance of
making health-related decisions and taking an active role in achieving one’s own health.
In my new role as ethnographic researcher, I have already been sitting for a few days in the shared living room of the psychiatric unit. Because my research clearance requires me to engage only new patients, I have been mainly waiting and observing. But, as I soon found out, simply waiting for no particular purpose is something that does not exist in medical settings, at least not on the side of health care providers. If you are a doctor or a nurse, you are always busy and behind on your schedule, and if you are not, then newly arriving patients, fights in the unit, or people refusing to take their meds will quickly make you so. There are always a million things to do.
What does this mean for the anthropologist, the kind of researcher whose projects mostly consist of waiting, observing, taking notes, and then waiting again? Who is she, that young woman who apparently has all the time in the world?3 In this introduction, I will lay out my initial interest in this subject and reasons for conducting fieldwork in a psychiatric unit. I will then explain how I came to choose the themes around which this thesis is organized and briefly introduce my main theoretical concepts. Next I will reflect on how I negotiated access, an important feature of my research, not only because it is telling about the setting I was about to enter but also because to obtain access I had to integrate critical changes that shaped the outcome of my research. Finally, I will explain the methods I used and the theoretical implications of these methods.
Let us try to formulate an answer to the first question that came up: who is the anthropologist and what is she doing here? I am that strange young woman who is the only one who apparently has the time to sit, wait, write, and drink coffee. As a master’s student in social and cultural anthropology at the University of Amsterdam, I conducted fieldwork in an open clinic of a large psychiatric ward in a city in the north of the Netherlands. In Dutch society, public mental health care is organized within the GGZ (geestelijke gezondsheidszorg) and receives funding from the state.4 The clinic where I conducted research was part of “specialized” GGZ-services, meaning that patients need a referral from their GP and have been diagnosed
3 The “she” I refer to refers to myself, the woman sitting in the clinic. I do not intend to use it through the whole text. When I refer to myself, I will use the “I”. When I refer to “patient” or “health care worker” in general, I use “he”.
4 See http://www.ggznederland.nl/pagina/over-ggz-nederland and
http://www.ggzingeest.nl/thema/patientenvoorlichting/posters/verzekering-kosten-behandeling/ (both accessed October 8, 2015).
by a psychiatrist.5 It is an “open” clinic, meaning that patients are not tied to a fixed daily program and can, under certain conditions and restrictions, leave the clinic and choose their daily activities. They do so by negotiating their “freedoms” with their psychiatrist. An example of such a “freedom” is having two, four, or six hours per day “off”. Before leaving and when coming back people have to report their presence and absence to the nurses.
By chance, I had the opportunity to interview a psychiatrist for a methodology assignment early in 2015. This psychiatrist told me about how he tried to integrate his patient’s views in their treatment. He talked about shared explanatory models of a patient’s disease, and how the diagnosis and impact of the diagnosis was discussed throughout treatment. I was immediately interested in how this “open” clinic worked in practice and the ways medical staff actively involved patients in their treatment. A lot of changes have occurred in the organization of public mental health care, called GGZ in Dutch, over the last few years in the Netherlands. These changes, as well as the “new approach” this clinic promotes have hardly been studied in practice. Not only has the GGZ suffered funding cutbacks under the current government, but the focus of care and whose responsibility it is to take care of psychiatric patients have become topics open to debate. One example is the “ambulantorization” (ambulantisering) of mental health care (GGZ Nederland 2013: 20, 22; 2012:2). Ambulantorization means reducing the number of patients who receive residential care, and relocating health care “at home” instead of in a clinical setting. One of the main goals of the GGZ’s policy that is to be realized over the next few years is to reduce the number of clinical patients (GGZ Nederland 2013). This issue is being actively tackled by the current Dutch government.6 The ambulatory health care team, but also the police, schools, and employees are expected to contribute to the integration of (former) psychiatric patients in society. Shared decision-making in this context is seen as a tool to help make the patient aware of the role he is expected to play in his or her own recovery process and a crucial element embedded in the treatment trajectory meant to prepare patients to function in society more quickly (GGZ Nederland 2012:8-9).
In the clinic where I conducted my research, the ways these norms were instilled in patients seemed particularly interesting. Patients are actively integrated into their treatment and recovery process. They are both encouraged and expected to take an active and responsible role in making plans and carrying them out, since it is presumed that every patient
5 See http://invoeringbasisggz.nl/onderwerp/wat-is-gespecialiseerde-ggz (accessed December 8, 2015).
6See https://www.rijksoverheid.nl/onderwerpen/geestelijke-gezondheidszorg/inhoud/basis-ggz-en-gespecialiseerde-ggz (accessed November 17, 2015). For the changes of this policy in relation to the new DSM-5 and changes with regard to Dutch health insurance, see Zorginstituut 2014.
wants to get out as soon as possible. Individualized treatment plans emerge through a sort of collaborative process; the course of treatment is arrived at through shared decision-making. GGZ doesn’t try to trick their patients or patient’s family about miracle cures, but states their goals simply and directly:
Together we look for a shared explanatory model that will be used as the guiding principle for a successful plan for treatment and recovery. We aim at keeping our treatment as short as possible, in order to let someone recover in their everyday surroundings.7
Prior to beginning my fieldwork, I formulated some initial research ideas. Once I decided I wanted to conduct my fieldwork in the psychiatric unit, I realized I would need to get formal research and ethical clearance. This entailed obtaining formal permission from the director of the clinic, as well as the research committee of the clinic, and – because my research involved interviews with patients – the ethical committee. Since the medical staff of the clinic consciously presented itself as trying to work with a what they defined as a different, patient-centered approach, I chose to focus precisely on the involvement of the patient in his recovery process. My first questions concerned this idea of “shared decision-making” as both a theoretical concept and a practice.
In this thesis, I want to address several issues related to how the psychiatric patient is viewed, spoken to, and imagined as a participant in the recovery process. I want to sketch an image of how both health care workers and patients view treatment and how the patient is involved through shared decision-making, as well as discuss the clinic and its place in contemporary society. What does it mean to be considered psychiatrically “ill” today, and how are people taught to re-enter society after being a patient in a psychiatric institution? These are key questions in Dutch social life. These issues form part of the important narrative of mental illness today, how it is perceived and acted upon, not only by the people treating it, but also by “the world” outside of the clinic. Who is diagnosed with a psychiatric illness? When and where are people considered to be mentally ill? And what are they supposed to “do about it”? Psychiatric health care reflects the inclusiveness of the society we live in, defining borders of how people can and should behave and also shows the other side of the coin, namely, who is considered to be healthy enough to lead an autonomous, meaningful life. By
7
“Samen zoeken we naar een gedeeld verklaringsmodel, dat als leidraad dient voor een succesvol herstel- en behandelplan. We streven ernaar onze behandeling zo kort mogelijk te houden, zodat iemand zo snel als mogelijk in zijn of haar eigen leefomgeving verder kan herstellen.” (See http://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/kl-hlm/, accessed October 19, 2015). All the translations made from Dutch to English in this thesis are mine.
the end of March, I knew two things: I wanted to speak to health care workers as well as patients, to hear their ideas, which I wanted to relate to recent changes that occurred in the Dutch organization of public mental health care. And secondly, it was going to be a lot of work.
My ideas needed to be put into words, and the words needed to become sentences that made up a research protocol that was sufficiently neat and clear to convince the clinic’s ethical and research committees. I was planning to conduct fieldwork in my own country, but the rules and regulations I needed to follow and integrate in my project made me feel like I was lost in a far-away wilderness.
When I was given research clearance, I could start. To start meant “entering the field”, as anthropologists call it. But how exactly do you get there, and what do you do when you enter it? Textbooks for bachelor’s students in anthropology often describe the anthropologist as someone who was “just hanging out,” someone who is there, but without being noticed (Tracy 2013:78). The first day I entered the clinic, I was immediately approached by patients who asked me if I had been hospitalized as well. “Are you the new patient who is coming in today?” I had to explain I was not, and when they asked me if I was a new nurse or doctor in training I again said no. “But what are you then?” Yes, what was I? I doubt the statement “I am an anthropologist” ever enlightened anyone. I was that strange woman who apparently had the time to sit down, sip coffee, and take notes all the time. I was that strange woman “with a research protocol”, which, after the formal permissions had been granted, meant something else in the real world than on paper. “What do you mean, research protocol? Don’t you want to interview the patients from the closed ward as well?”
The clinic where I conducted my research is part of a larger psychiatric department in a general hospital. It is located next to a closed unit and a PAAZ (psychiatrische afdeling
algemeen ziekenhuis). There are seventeen private rooms, which are most often occupied.
Every patient is assigned a private room with a shower and toilet. In addition to the seventeen rooms there are also seven rooms that are not used. These are the rooms that, as of this year, are no longer available due to the cutbacks currently being implemented and the process of ambulatorization.
From the first day on, while I sat drinking cup after cup of coffee, pretending to read the paper, the nurses on duty seemed to be worried. “Do you think you will get enough data?” they kept asking. “You could also come back tomorrow. Today, nothing is happening!” I
would smile politely and pour myself another coffee. “Don’t worry”, I said, trying to comfort them as well as myself. It was only after many more cups of coffee I started really thinking about this; the way it kept recurring in my mind, it became like a mantra, or perhaps like the insistent mental phrases of an obsession. I wrote it in my notes: “nothing happens. They keep telling me nothing happens”. In the meantime, people were being weighed, given medication, coming to ask if they could leave for the afternoon. What did they mean when they said “nothing happened?” Was I being naive, thinking I saw things happening all the time? Or was “nothing happens” some secret code, popular among health care workers? Was this what happens in a psychiatric clinic — “nothing”? In interviews, doctors in training described the clinic as a place where “people have nothing to do, so they can get better”. “It’s like a summer camp. You don’t have to clean, to cook, you don’t have to go to the store”, as one of the doctors put it.8
I was also struck by how attached people became to the clinic or the people around them. Some patients developed a great sense of responsibility towards their fellow patients. What for me was a sterile building without Internet connection was for them “an oasis”. Often, these patients were so attached to the clinic they did not want to leave. The doctors called that “hospitalization”, which induced a state of “regression”, meaning patients over time became more and more dependent on living in the clinic.9 Doctors always wanted to make sure people left the clinic as soon as possible, since, as one doctor told me, “psychiatric care makes people who do not really need it more ill.”10
Fieldwork is not necessarily about finding a definitive answer to your initial question. Among other things, I learned that entering “the field” can be a strategic way of abandoning your research question, perhaps leading to other questions, or maybe, though this was not the case with me, to realizing you began with the wrong question or the wrong frame in the first place! As I sat reading my paper and taking notes, while reassuring Tom I surely would gather enough data about shared decision-making and how health care workers and patient negotiate a patient’s treatment, I was struck by a lot of different things, though perhaps to the patients and staff observing me sitting there, looking around, jotting down notes, I too appeared to be doing nothing, or at least nothing much. Most of all, fieldwork is about keeping your eyes
8 TR 2 July (1) 337-441.
9 I use hospitalization in italics when I refer to the Dutch word “hospitaliseren” which means “patients becoming too attached to the clinic”, as explained by the medical staff. When I use the English word hospitalization, I mean treatment taking place in a clinic or hospital.
open and trying not to get too desperate or dubious of the process when all those new questions pop up in your mind.
The longer I observed the more complicated the clinic seemed to become. I initially thought if people came there to be cured, it was good for them to focus fully on their recovery, and not have to bother about cooking their own meals or other daily tasks. I presumed that “nothing happens” was meant to create a soothing environment for patients. But how did patients themselves actually relate to the clinic? How did the clinic influence their identity? And what if they did not want to leave again? And what about this “psychiatry can also make you ill” story? After three months, I had many more questions than when I started.
Despite all the new questions, at the end of my three months of research, it was time to write my thesis. Drawing as much on the observations I conducted while seemingly “doing nothing”, as on my interview material, I decided to focus the thesis on three themes that touched upon central issues and phenomena I encountered during my fieldwork, which also shed light on the clinic as a specific place where patients and health care workers are constantly negotiating a person’s treatment, discussing and together shaping a narrative on illness and disease within a clinical environment.
In the Chapter One, “Nothing Happens”: An Anthropological Unpacking of the Clinic as a
Specifically Structured Domain, I critically review the clinic as a place where “nothing
happens”. What does this nothingness mean, for whom should it be beneficial, and when is this nothingness potentially harmful? I will approach the concept from several perspectives, starting with my first encounter. When the nurses worried I would not gather enough data, what did they mean by telling me that “nothing happened”? These words and their efforts to provide an ideal research environment are revealing, because they reflect not only how they viewed me, “the anthropologist”, but also suggest something about how they understand what occurs in a mental health facility, its place in Dutch society, and their professional roles in this enterprize. In the first place, it was probably very odd for them to meet someone who had the time to sit and observe, since, as I already mentioned, no one on the job in public mental health care has time for leisurely reading the paper and drinking coffee. I analyze how this “nothingness” is in fact an actively created, tightly organized environment which is supposed to be soothing for the patients. Far from the absence of something, I came to understand that this “nothingness” in fact results from a highly planned environment structured by various relationships, policies, social conventions, and institutional practices. Finally, I pay attention
to how time is experienced differently by health care workers and patients, and how this experience of time is constitutive of the patient’s experience of being ill.
In Chapter Two, Identity, Diagnosis and Biosociality: Becoming a Patient, I turn to a different aspect of life in the clinic. In this introduction I write about “patients” and “health care workers” as two separate groups, without questioning how these two groups are established or how they remain discursively separate. To a certain extent, this correctly represents “life in the clinic”. You have the people who work there, which is the staff, and the people who live there. The people who work there can leave without asking the psychiatrist’s permission; the people who live there cannot. How do these groups relate to each other, and what maintains them as distinct “groups”? How do the patients identify as patients, and how are they being identified by their health care workers as such? What do these questions tell us about how psychiatric diagnoses are intertwined with senses of belonging and identity? How is health seen and interpreted as constitutive of one’s identity? I use Nicholas Rose and Carlos Novas’ notion of biosociality to highlight the issues mentioned above (Rose and Novas 2003).
In Chapter Three, Negotiating Patient’s Emancipation: Shared Decision-making and its
Implications, I discuss questions about shared decision-making and address how health care
workers and patients operate with certain expectations and understandings they have of each other, and how these are forged through the therapeutic relationship. How do patient and health care workers negotiate a patient’s treatment, including duration, medicine, and daily activities? I make a distinction between the narratives presented by patients and health care workers offer in verbal accounts, and the practices I observed in encounters between patients and doctors. Chapter Three draws on theories that focus on the therapeutic encounter as a narrative event, while shared decision-making is a concept I borrow from medical science (Mattingly 1998a; 2000; 2005, Kleinman 1980; 1988, Benson and Kleinman 2006). In medical science, shared decision-making is explained by how patient and practitioner try to achieve a common understanding of treatment and a path for action (Broersen 2011; Elwyn et. al. 2012; Godolphin 2009). These concepts allow me to highlight and scrutinize shared decision-making as practiced in the clinic. How does a treatment emerge from this negotiation between two types of expertise? And how can we interpret these kinds of negotiations in light of how public mental health care is organized today? One psychiatrist in training captured the delicate relationship between a patient and a professional when he said, “you have the
knowledge, but they have got the experience”.11 These relationships develop through interviews and face to face discussions that can lead to profound consequences for a patient’s life. How does the practitioner respect the validity of the patient’s perspective in recounting his or her experience while still maintaining authority as the expert on that patient’s illness? And in turn, what is necessary to be perceived as a reliable expert in the eyes of the patient?
Ideas about patients’ responsibilities with regard to how one is taught to “manage” one’s disease are also related to the public image of how patients “should” behave, which is to say, they are deeply informed by societal norms, conventions, and policies. With this in mind, I will refer to how patients are imagined and described in the policy plans of the GGZ as well as how they are represented in three Dutch newspapers.12
Negotiating access, ethics, and my position in the field
Before conducting fieldwork in the psychiatric unit, I was assigned to a local supervisor, Barbara Stringer, who was able to help me to fill in the most important forms I needed to hand in to the research and the ethical committees. Barbara Stringer works for a department of the research committee of the GGZ. Both committees needed to grant me formal permission to approach patients, after having integrated certain suggestions and points in my research protocol. Thanks to her expertise and insider knowledge, Barbara was able to help me polish and refine my research proposal before presenting it to the responsible director of the psychiatric unit, the ethical committee and the research committee. Since the psychiatric unit where I wanted to conduct my fieldwork was a public institution, related to the Free University of Amsterdam (VU), I also had to obtain permission of the ethical committee of the medical department of the VU (VUmc), as well as from the responsible director of the GGZ (directeur behandelzaken) and the research department of the GGZ (commissie
wetenschappelijk onderzoek, abbreviated as CWO).13
11 TR 2 July (1) 105-106. 12
The three newspapers I refer to in my thesis are de Volkskrant, NRC Handelsblad and Trouw, considered to be the three “best” newspapers in the Netherlands (kwaliteitskranten).
13
In the Netherlands, there exist two types of formal permission that can be granted by an ethical committee: a WMO-verklaring and niet-WMO-verklaring. The term “WMO” refers to Wet medisch-wetenschappelijk onderzoek met mensen (Research involving human subjects) meaning the law concerning scientific research conducted with people (patients) in a medical setting. Since I intended to include four to six patients in my research, it was considered a niet-WMO-research. A larger research population would need a WMO-clearance (note this WMO is different than the Wmo discussed earlier). I needed to explain precisely how I wanted to gather my data and how I was going to approach patients, how I planned to anonymize and to guarantee study participants provided written informed consent. An informed consent form was given to patients along with an information letter in which I explained the topic and goal of my research. The responsible director decided which meetings between members of staff I could observe and which I could not. The ethical committee and the
If one has no contacts in the medical sector, or the help of someone who knows how institutions such as the GGZ function, it is practically impossible to gain access and “get in”. As Goffman put it regarding the total institution, psychiatric patients are carefully protected from “outsiders” (1968). Approaching the patients of a psychiatric unit thus proved to be a real challenge for me as an anthropology student. I learnt learned that if you are not occupying or in training for a medical profession, it is very hard to obtain clearance.
To get clearance, I had to integrate some changes in my research protocol. I could only approach patients after they had given verbal consent to their health care worker to be interviewed by me, for example. The ethical committee explicitly stated I should not approach patients directly. Another change I had to make was to approach only newly hospitalized patients in order to avoid what the committee termed as selection bias. From the day I was granted permission to approach patients, all the new patients were eligible to be interviewed after they had given consent. However, the fact they had just been hospitalized had profound consequences for my data collection. Some people had never before been in touch with the protocols and conventions of psychiatry and became suspicious, anxious, or fearful. They needed to be reassured and comforted, which made the focus of their treatment slightly different. “Panicking people in the middle of a crisis don’t want you to ask them what you should do”, as the clinic’s psychiatrist told me during an interview.14 This sometimes significantly changed the focus of my conversations. Since the patients I interviewed had just been hospitalized, their treatment had only just begun. This made it harder to focus on shared decision-making and their relationship with their therapist, since many had only spent a few hours or days in the clinic.
After having filled in forms, submitted official requests, which had been sent back again (“You didn’t know we update our protocols every six months?”), I had to wait. But as an anthropologist, you get used to all the waiting. What you do not get used to, at least I did not, is the stress you face when having to pass all the obstacles in order to convince the gatekeepers. Just when I started having nightmares about offices, protocols, and forms that again had been updated or changed without me noticing, the official clearance came through. There was light at the end of the tunnel. Now, I could start.
First encounters in the field
research committees also requested that I complete several official forms related to data storage and management.
After receiving permission, I was more or less left on my own to carry out the research according to my own wishes, with the presumption that I would stick to the approved protocol. The nurses and psychiatrists in the clinic, however, seemed to have no idea about my research protocol and did little to police my research. I had to make many decisions on my own when they told me something about a patient, or when they showed me how things were done in the clinic. I had to be very aware and careful to stick to the ethical guidelines agreed upon. This is not to suggest that the nurses or doctors did not have ethical standards concerning their patients — far from it. Rather, I mean to suggest that it is quite rare for a researcher to be in the clinic who is not also a psychiatrist or medical student. Perhaps this also helps to explain why I was treated as a member of staff by the health care workers. My insider status significantly shaped how my presence was perceived in the clinic by health care workers and patients, but it also indicates how one is, necessarily, put in a category. In the structured environment of the institution, everyone had a role, an assigned place, and there were explicit as well as implicit rules regarding behavior. In a medical clinic, one cannot avoid being part of a group. One is ill, or one is not: this was of fundamental importance for me, determining how I could approach people and how I was perceived, as well as providing an important insight about the structure and logic of the clinic.
Medical practice in theory differs significantly from medical practice as it is actually carried out and performed. For example, sometimes after I had observed a meeting between a psychiatrist in training and his patients, the patient would leave the room and the psychiatrist in training would discuss the conversation with me. Not only did this change me from “observer” to “assistant”, it also actively included me on the medical team. I was, in many ways, treated as a medical intern of the clinic. Perhaps because medical facilities don’t have an officially recognized place for an anthropologist, and I was clearly not a patient, my position and role elided somewhat with that of the medical professionals. Since the clinic is part of a public institution offering mental health care, medical students who are required to do their psychiatry internship are sometimes also present in the clinic, “assisting” while learning to think and to act like medical professionals. But unlike me, medical interns were allowed to observe and participate in every meeting and gathering between patients and health care workers as part of their training. They can, and should, assist to as many meetings as possible in order to become good doctors. Of course, I was not there to become a good doctor; I was there observing how doctors think “good doctors” should behave, how they teach those in training to assume similar roles, and what this treatment looks and feels like in an actual clinical situation.
How did the patients understand and approach me? During my methods class, a fellow student said, “you are an attractive young woman. How are you going to deal with people falling in love with you or thinking you’re their best friend?” I laughed. I am a young woman indeed, but I did not think that was a sufficient reason to have such worries. But within the psychiatric unit, all social interactions and interactions are colored by the environment, and that environment is quite different than a university, a public space, or a bar. The clinic’s psychiatrist warned me, for instance, that there would be “troubled men” who had been “locked up for weeks, without seeing any woman except for the nurses”. Indeed, the question “When are we finally going for drinks, Ms.the anthropologist,” continued to pop up during my three months of research. I turned down such offers, but it shows an important aspect of fieldwork: you can never plan what happens, nor how people will react to your presence. Others asked why I did not have the same duties as the medical intern. During the fieldwork, there were approximately as many men as women hospitalized and I interviewed two male and two female patients. There are no statistics about the clinic in particular: in the Netherlands, the amount of women receiving psychiatric care tends to be slightly higher than the amount of men. However, the difference is quite small.15
Methods
The material presented in this thesis draws on ethnographic research conducted over a three-month period in a psychiatric out-patient clinic. Ethnographic methods included focused observations of everyday therapeutic and non-therapeutic practices in the clinic, as well as in-depth interviewing of patients and staff. I conducted seventeen interviews and one focus group. The goal was to try to grasp the clinic as a phenomenon in its totality (Green and Thorogood 2006:132-133, Tracy 2013:40, 65, Hardon et. al., 2001:224, Hylland Eriksen & Sivert Nielsen, 2013:52).16
In the first section of this introduction, I characterized myself, “the anthropologist,” as someone drinking coffee, “doing nothing” in the clinic. In this section, I explain what I did when the nurses thought I was “wasting my time” or “just waiting”. Here I’m helped by the work of many excellent professional anthropologists. In Improvising Medicine: An African
15 In the latest official report, the number of men and women receiving psychiatric care is around equal, with a slightly larger amount of women (GGZ Nederland 2009:23).
16 Branislow Malinowski (1884-1942) is considered to be one of the fathers of modern anthropology. Participant observation refers to his method of actively immersing oneself into the field, trying to grasp the everyday life and practices of what it means “being part of” the setting or culture one wants to explore. This stands in sharp contrast with the formal interviews and ways of conducting ethnography before Malinowski. The researcher should learn the language of his informants, and not only focus on answering his specific question (“no fact is too trivial to be recorded”) (Hylland Eriksen & Sivert Nielsen 2013:52).
Oncology Ward in an Emerging Cancer Epidemic, Julie Livingston describes her daily
activities as an anthropologist doing research in a cancer ward in Botswana. She calls her research method “hospital-based ethnography”, which is a combination of data gathering through interviewing, observing, waiting and… assisting, since Livingston was frequently asked to help the nurses or doctor out while conducting a surgery or treating a patient (2012:26-27). “In order to understand how biomedicine is contextualized”, Livingston writes, “it helps to spend time in its core institutions, hospitals” (2012:25). Livingston’s book shows an important feature of those who carry out research in a medical setting: when you observe and wait, you are considered to be wasting your time. Secondly, you are often treated as an “assistant”, who can help the doctors and nurses when needed.
“Grasping the clinic” or, “trying to understand the clinic” for me meant traveling there from early June until late August, spending three or four hours a day observing the nurses and patients, and the doctors in their working room. To the medical staff, observing and taking notes is seen as “waiting” (for another interview, or a new patient) and interpreted as “doing nothing”, though apparently a different kind of ‘nothing’ than what they say ordinarily occurs in the clinic. Instead, this “doing nothing” and “waiting” seem more closely related to the fear of wasting time (that is, productive time), as the Swedish anthropologists Billy Ehn and Orvar Löfgren discuss in The Secret World of Doing Nothing (2010:27).
During the first weeks of my research, I chose to sit in the shared living room, so that I could both observe the patients and the nurses. However, as many anthropologists have discovered before me, locating and negotiating one’s space can sometimes pose quite serious challenges for the anthropological researcher. I had to deal with the suspicion I created by sitting and observing, taking notes and fake-reading in order to disguise I was taking notes of everything that happened around me. I often felt compelled to read something in order to give the nurses the idea I “had something to do”, because if I was just taking notes, they would keep approaching me, encouraging me to do observations in the closed clinic, which was next door and not part of my research. During the second part of my research, I decided to spend more time in the doctors’ office, not only because the nurses’ obsession with my (possible) lack of data made me nervous, but also because the doctors had a separate office, in which they could talk privately about their patients. I was curious to know what happened behind this closed door. And so we went back and forth in this curious dance where I would take notes of them doing their work, carrying out their activities; then, they would interrupt me, and urge me to go somewhere else, which would be more “interesting” and “useful”. Since doing my work (observing them) seemed to make the nurses uncomfortable, I did my best to
scribble my notes as surreptitiously as possible, and keep my gaze a furtive as I could. Did the patients ever feel similarly discomfited while under observation, and did the nurses ever connect their own apparent feelings with those of the patients? I never asked them, since I only noticed this dynamic much later, on reflection. But in retrospect, I see there was a powerful undercurrent of tension that informed our different ways of “doing nothing”.
I started my interviews with the health care workers in June; when ethical clearance was granted at the end of July I started interviewing patients. Usually, I started my day with a coffee and a little chat with one of the nurses or doctors, asking them how their day had begun and if any interesting events had occurred during the night. Then, I would conduct an interview or two, and go to the doctors’ office to ask them if new patients had come in. In the event new patients had been hospitalized, I would ask the doctors to give the patients my informational letter and informed consent form. If they consented to being approached for an interview, I would then try my luck and ask them when they had time to be interviewed. One of the strange things about this protocol was that often I would have already met the patient in the hallway of the relatively small clinic before any official forms had been signed; but for the sake of the protocol I decided to let the doctors hand the patients the official letter and form. Before, between, or after interviewing, or just to talk, I would sit in the living room with the patients or chat with the doctors in their office.
I did not only gather data through fake-reading the newspaper, although it did offer a good way for me to blend into the surroundings. Also, some patients would talk to me about what they had read in the newspaper that day or the day before, or ask to borrow it. The newspaper became my secret ally in trying to go unnoticed, but yet remain accessible enough. While fake-reading I was also watching, thinking, asking questions in my mind. “Doing nothing” meant trying to observe and disguise, without explicitly wanting to do so, my presence as an observer. “Doing nothing” meant listening to the doctors conversation, joking with the doctor about her new boyfriend, chatting with the nurses about their daily struggles with the patients. Most of all, “doing nothing” meant scrutinizing the environment and practices while the medical team focused on how I would gather enough information from the patients.
Analysis
In my research, language was of utmost importance. Not only because I gathered most of my data through linguistic means – interviews, observations in the form of written field notes, and closely listening to encounters between doctors and patients, but also because the discipline I
analyzed, that of psychiatry, relies for a large part on discursive practices. A lot of psychiatric therapy is about talking: “…talking is extremely important and it helps”, as Simon, the responsible psychiatrist of the unit, put it.17 Talking to your patients, but also to the patient’s family and among colleagues is something that is crucial to the psychiatrist’s occupation. Nurses and doctors called each other by their first name and emphasized I should do as well. The medical team also uses each other’s first names while talking with and to their patients. This is an important detail, since it tells a lot about how patients are approached. Therefore, in this thesis I refer to the medical staff and patients with a coded first name, just as they asked me to call them during the fieldwork.
In my analysis, I approach language as a performative tool, which actively shapes our social environment and experiences of this environment. By this, I mean language is not a purely referential vehicle that serves to convey information. Within the field of anthropology conversation analysis has proven a useful method for analyzing the doctor-patient encounter (Maynard & Heritage 2005:431). The patient-doctor interaction is interpreted as a collaborative event (ibid: 429). Medical discourse and practice takes place within a certain “genre” of discourse (Good 1994, Wilce 2009). In other words, what someone “can” say, is closely linked to what one can “do”.18 A patient can tell his doctor what he ate for breakfast or how he feels about his relationship with his wife. But if the psychiatrist would start a therapy session by a long whining monologue about his annoying girlfriend or what his children did last weekend, this would change the whole setting and context. Language is not only about talking, but also about doing and acting (Gee 2011:2).
This view on language as an act or performance opens up possibilities for rethinking the patient-practitioner relationship. “Narrative” is a theoretical concept, referring to the emergence of (more or less) coherent story lines, but it is also a methodological tool, which can be used to analyze the spoken and written language encountered during research. If language is not purely referential, what happens in the clinic is more than the transference of inner state and circulation of information. Patients participate in the debate and discourse, by contributing to their own diagnosis. “Talking” is not merely describing, it is also doing something and not least of all creating reality. This holds not only for my interviewees or interactions between patient and practitioner, but also for the interactions between my
17 “En dan blijkt, dat praten ongenadig belangrijk is, en helpt” (TR June 20 245). 18
See also speech act theory and the concept of “authorized” language (Austin 1955; Bourdieu 1975). Both Austin in semantics and Bourdieu, later, in sociology have theorized how the function language fulfills is linked to what language one is authorized to speak. What we say is also something we “do”: Austin calls this language as action a “speech act”. A successful speech act meets the conditions of felicity, i.e. corresponds to the speaker’s social status, the context and situation in which it is uttered (ibid.).
informants and me. I was always the anthropologist, never the doctor, never the patient. This does not only mean I simply “did not understand” what was going on, finding myself in a fundamentally different position. I think it also meant I was, for example, in a better position to “…figure out what they [your informants] think they are up to” (Geertz 1974:29), in no small part because I was the only one who had the time to take notes and drink coffee.
My understanding of narrative is part of a debate about (the possible) correspondence of language and experience, as Cheryl Mattingly writes (2005:22). Like Mattingly, I position myself in the debate as anthropologist who critically reviews and analyzes language and narrative; however, I refuse to abandon the conviction that “any referential [relationship] between story and experience” might be possible (2005:22-23). I fully subscribe to her statement that far from “estranging”, giving attention to narrative and “the linguistic turn” in anthropology is precisely about everyday life and practice (2005:18), not in the least because how psychiatric practices relate to larger narratives and stories about health, illness and recovery “as we know it”. Looking at how language is performed in psychiatric practices and the ways society talks about these practices and policies is another important way of “making the familiar strange”, which seems to me one of the major tasks of anthropology.19 And that is something I would at least want to try, not just for the sake of defamiliarization per se, but rather, to enlarge one’s perspective and interpretation. In the clinic, alongside my usual newspapers, I would also read Edward Said. Reflecting on language and how reading can teach us about other subjectivities, he wrote eloquently on the power of narrative to illuminate so much about the world. In Orientalism, Said proposes the following interpretation of narrative, which seems to be an important and beautiful task for anthropological research as well:
Narrative asserts the power of men to be born, develop, and die, the tendency of institutions and actualities to change, the likelihood that modernity and contemporaneity will finally overtake “classical” civilizations; above all, it asserts that the domination of reality by vision is no more than a will to power, a will to truth and interpretation, and not an objective condition of history. (Said 1979:240)
19“Making the familiar strange” is originally a literary technique, theorized by the Russian formalists in the nineteenth century (see Schklovsky 1918). The Russian formalists originally saw art and literature as the most suitable techniques for defamiliarization, using the power of language and narrative. Writing as a tool to open up perspectives and gaining insights is also a method used in anthropological research (see Sunstein and Chiseri-Strater 2011).
Chapter One: “Nothing happens”: An Anthropological Unpacking of the Clinic as a Specifically Structured Domain”
Another day at the clinic
As I start to read an article on the front page of the newspaper for the fifth time, I realize I might have to turn the page in order not to raise more suspicion than I already have after sitting in the clinic for ten minutes or so. A female patient, with heavy dreads in her hair and golden teeth, approaches the table where I am sitting. “Are you new here?” I explain I am not, but that I am working here as “an intern” (which is technically correct, since all research conducted at the GGZ must be carried out by people officially contracted by the organization). “Oh, a new intern! That’s cool! Can you help me to make some coffee?” the woman with the dreads asks. Over the next half hour or so, she keeps asking me all kinds of things: “Can you please check if I closed the can correctly? Do you think I placed this chair right or should we put it more to the left? Do you think we should move these plants? I don’t want any fake flowers near me.” I help her to do several things and then say I have to do some reading. She sighs and puts on the television, after having sorted out all the fake plants and having put them on a table near the window.
While I continue fake-reading the paper, patients wait in line to be weighed by Tom. “You know, Pete, you really have put on weight”, Tom says. Tom is one of the coordinating nurses in charge of managing the open clinic today. He is in his early thirties, has bright blue eyes and seems cheery all the time. “You shouldn’t eat so much!” Pete laughs and answers: “Well, it’s just because you won’t let me go to the gym! And the fitness instructor was ill last week! It’s not my fault there’s nothing to do in here.” When Pete has disappeared in the corridor, a meager man approaches with eyes fixed on the ground. He mumbles when Tom says he seriously has to watch his weight. “Almost fifteen pounds!”
The woman with the dreads looks up from the TV. “Tom… I found an earring or something last week. In fact… no I think it’s part of a piercing. D’you think it belongs to Jezebel?”
“It might. But Jezebel… She’s been transferred to the closed unit again, hasn’t she?” “Ah, the closed unit…”20 The woman with the dreads sighs, walks back to the TV. “Hey, lady!” Tom calls. “Didn’t you forget something? Your meds?” The woman laughs, her
20 The closed unit is the psychiatric ward next to the “open” one, where patients are being treated in a more restricted setting. Patients hospitalized in the closed unit form often a “direct danger” for their environment and have often been brought in by the police. People who “go back” to the closed unit often suffer a setback in their
gold teeth flash in the sunlight coming in through the window. “Yes, the meds, you bet I didn’t forget them! How many pills you givin’ me today, eh?”
After having given the woman her pills, which she takes in a small closet where the nurses gather, one of their HQ’s in the building, Tom sits next to me. “You know, I’m really sorry to tell you but… that woman I told you about, the new intake that we planned for today? Well, she’s not coming. She suffers from a compulsive eating disorder, psychotic episodes and depression, so it would have been so interesting for you to be there. I’m sorry. I believe no one is coming in today. I’m really sorry for you nothing is happening.”
In this chapter, I will unpack the notion of “nothingness”. Who said nothing was happening and about which kinds of situations was this said? I will reflect on the concept from different angles and start with my first encounter — with the concerned nurses. Nothingness serves multiple purposes in the clinic, not least contributing to a calm atmosphere for patients, which many find soothing. I discuss the possible positive and negative aspects of this soothing nothingness. Finally, I lay out several ways in which temporality is experienced in the clinic.
“I’m really sorry for you that nothing is happening in here.”
When I first heard this phrase, I was waiting for an interview. At first, I did not notice it. I thought of it as an apology in disguise; because of an unexpected intake, I had to wait forty minutes. These forty minutes actually gave me the possibility to observe the woman in dreads trying to pour herself a cup of coffee, asking me to help her. Amused and fascinated, I looked around. But this same phrase kept returning; when I had been sitting around in Tom’s sight, fake reading the paper for a few hours: “Don’t you want to go the closed unit? How are you going to get data? No, tell me!” After a few weeks explaining that I really did have time to conduct three months of fieldwork, and that I really did not mind doing an interview “tomorrow instead of today” (“But… I can’t imagine how many times you have to come here! All that travel-time you must have!” one nurse exclaimed), I still could not convince the nurses that sitting there and drinking coffee was not a complete waste of my time.
In the beginning of my research, my presence and behavior often induced a lot of questions. Patients thought I was a new patient, and if I said I was not, they thought I was the new medical intern. I have explained this as a feature of what I call “the logic of the clinic”, which presupposes that everyone there is “healthy” or “ill” and in need of care. There are no recovery process or have displayed violent behavior or refused repeatedly to take their medication. For more information, see http://www.ggzingeest.nl/hulp-nodig/aanbod/haarlem/klg-hlm/ (accessed October 7, 2015).
unassigned roles. The population in a psychiatric unit is made up of two distinct groups: the people who are treated, and the people who treat. In my thesis, I designate both groups by referring to “patients” and “health care workers”.
Furthermore, my presence and behavior rose quite a lot of suspicion. If, apparently, you have time to sit and observe and take notes and talk about supposedly insignificant things with people, what exactly are you doing? My honest answer was that I was conducting research on the collaboration between health care workers and patients, “shared decision-making” being far too theoretical for most people I met in the clinic. But if I was conducting research, why couldn’t I assist to nor observe all meetings between staff members, I was asked, and why wasn’t I conducting interviews with patients from the closed ward or was I just not interested? Then I had to explain that because I was not a medical professional I could not be easily admitted to the closed wards, or more confidential meetings with patients, which didn’t always clarify matters, especially for patients. “You keep talking about a research protocol… but I just want to show you something about medication!” My protocol was precisely about who could show me what about anything, As an anthropologist, I was quick to realize that the world-on-paper is something wholly different than the world-in-practice. A research protocol is indeed just a protocol and not the research, but this did not mean I could forget it altogether.
While the roles for patients and staff were familiar and largely naturalized or assumed by everyone, the role and activities of the anthropologist seemed curious, slightly suspect, and largely inexplicable. I was sometimes approached as if I was in the same position as a medical intern who came do “learn and observe”. As an anthropological researcher (“But what is that? And what does the “medical” in medical anthropology mean?” people would continue ask), I was by definition not allowed to participate in the activities of the medical team. It was not part of my training to learn to prescribe medication or make a diagnosis. However, when doctors discussed an encounter they had just had with a patient, they actively positioned me in the medical team. Technically speaking, I was an intern doing research for my thesis. Since I was not coming there as a patient, I could not be fully be seen as “ill”. Sometimes, I was treated more like an assistant than an observer, when a psychiatrist discussed an encounter with a patient with me. This made me a kind of unofficial assistant, since, unlike the “real” medical intern who came in when I had been “hanging out” for a month, I was not allowed to observe all meetings for privacy reasons. I was not an unofficial assistant, nor was I a patient. But I had things in common with both categories, and spoke to both groups. Though I was
accommodated by the clinic and welcomed by some more than others, in the logic of the institution, I never really had a place.
When Tom said for the third time during a morning I was in the clinic to observe that he was so sorry nothing happened, and that all this must be very boring for me, I was surprised; I had just been watching the patients being weighed and reprimanded for becoming “too heavy” or even “too fat”. I was being tested by the woman with dreads, who tried to change me into her personal assistant. Patients were walking in to get their medication, made jokes with the other nurses at work. Nothing happens? How so?
Clearly, the health care workers had an idea of what would be an interesting research setting for me. They never explained it to me with so many words, but it quickly became clear that doing research, in their eyes, was certainly not observing and writing and sitting in a chair, while they were doing “their jobs as usual”. On the contrary, “doing research” seemed to mean for them that I should be in the lookout for all the strangest things. “Doing research” from their perspective, meant assisting to a new intake where someone was being hospitalized with a set of symptoms I had never seen before. For the medically trained staff, research also was linked to experiences that had nothing do with analyzing daily practices. Research was taking surveys, testing the effect of several types of drugs. Doing research involved laboratories, new ideas on medical and psychiatric treatment. “Doing research” was, actually, everything but trying to discover a set of daily routines. When Tom told me that nothing happened, just after he had called in half a dozen patients to take their pills or clean the kitchen, that meant things were going “as usual”. Partly, this is why my absence made people wonder: I was not looking for anything in particular, nor was I focusing on extreme situations. I wanted to see what happened when people said nothing happened. And, it turned out, a lot was going on.
Take, for example, the weighing of the patient. Working as a nurse meant, among other things, monitoring the patients’ weight. If they put on too much weight and too fast, the nurse made them aware of this “unhealthy” development and, ideally, encouraged them to watch their weight. Another important aspect of the nurses’ daily job was to make people take their medication. The clinic where I was doing research on an open psychiatric unit, which means medication should only be taken with the patient’s consent.21 “Giving a patient his medication” meant more than just handing someone his pills. People needed to be informed
21 This freedom was relative, in the sense that if a patient was perceived as potentially dangerous because he did not take his medication, he would be transferred to the closed unit were people can be given forced medical treatment.
about the pills, or convinced to take them and sometimes took a lot of time.22 The prescribing is done by the doctors, but the nurses have to make sure people receive and take their medication during the day.23 One of the nurses, Nelly, reflects on this during one of my interviews as following:
“And… eh, what plays a role during the whole shift is the taking in of medication. There are fixed hours to do that, and we expect people to get their medication themselves. But… I think around 75% of the patients do so, and one quarter do not, and well then you have to search for… to stimulate people to take it, or on the other hand… there are also people who want medication too soon, all kinds of tranquillizing medication, and then you should restrain them. So that is a recurrent theme, taking medicine, that plays a role during the whole shift… and giving people an explanation about their medication.”24
Nelly emphasizes the role of the nurse as the caregiver who should provide the right information about medication. Nurses must stimulate people to take their medication, or “restrain” them if they want too much medication too soon. As the interview continued, she reflected on the role of the health care worker indeed as someone who should inform the patients, and take note of how the patient experiences his treatment, but still on a fundamental different level than the patient;
“Well I… it’s funny if you… if you talk about… what you think about the patient’s responsibility… [points at my information table that lies before her on the table.] eh… I think that, I think that’s a very funny… eh a funny phrasing, because I think often the division of roles very often still is like eh… like we know everything.”
“Yes?”
“Like we know everything that’s good for someone. And ehm… that we try to motivate the people, to do things. And by doing so eh… I think you also make the patients feel not so much responsibility for their own recovery process.”25
22 TR 2 July (3) 129-134, TR 30 June 209-212. All (new) medications are supervised and prescribed by the psychiatrist, but the distribution of medication is the job of the nurses (TR 22 June 270-276, 526-534).
23 TR 7 July 45 50-52.
24 “Eh… eh… wat eigenlijk gedurende de dienst ook de hele tijd terugkomt is de medicatie-inname. Daar zijn vaste momenten voor, en we verwachten dat mensen dat zelf komen halen. Maar… ik denk dat dat ongeveer driekwart van de mensen doet en dan één kwart niet, en dan moet je daar ook op [Ja.] zoeken, stimuleren om dat te nemen, of juist dat de andere kant… er zijn mensen die medicatie te snel willen [Ja.], allerlei dempende medicatie, en dan moet je dat afremmen. Dus dat is zeg maar een thema [Ja.], medicatie verstrekken, wat gedurende de hele dienst… uitleg daarover, dat dat een rol speelt.” (TR 7 July 45-50)
25 “Nou ik… Het is wel grappig als je… [Ja?] als je die zin noemt van… wat je vindt wat de verantwoordelijkheid van de patiënt (staat in de informatiebrief die op tafel ligt, wijst ernaar) [O ja.] eh… [Ja.]… ik vind dat, ik vind dat een hele grappige… g… een hele grappige zin, omdat ik denk… dat de rolverdeling toch heel vaak nog zo is… eh… eh, dat wij de allesweters zijn.”
“Ja?”
