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The factor tree

 

The factor tree

Hilde Ham

[A tree with bitter fruits. The development of an observation protocol for researching situations involving self-injurious behaviour.]

Schipper has studied self-injurious behaviour in people with learning disabilities for a very long time (in a pilot study 1987-89, he still referred to them as deeply mentally retarded. This subject is a rather emotionally charged one for the family and relations of such people and for many professional carers. After all, who can bear to witness someone beating themselves in blind rage, sticking a ballpoint pen up their nose until the blood flows, hitting holes in their head or biting off their lips? Many of those involved in daily nursing care will initially have ambivalent feelings about the protocol. They may shout for joy at seeing this thorough, exploratory and practice-oriented research. At last there is an attempt to provide them with something to hold on to in their daily work as a professional carer and when attempting to reduce self-injurious behaviour. On the other hand, it is also a confrontation, forcing them to look at this behaviour in an even more focussed and systematic way.

The situation context is the focus

The term ‘situation context’ used consistently by Schipper appears to be an example of tautology. The situation is the one in which self-injurious behaviour takes place; in other words, the context. So, why was this term chosen?

As I had expected, chapter 1 contains a definition, prevalence, clarification models and theories. In the definition of self-injurious behaviour, Schipper uses a double negative: self-injurious behaviour is the not unintentional, consciously or unconsciously motivated infliction of bodily damage or pain on oneself. Does he mean ‘intentional’ when he says ‘not unintentional’? The use of a double negative in a definition is not exactly elegant.

Schipper’s main objection to the many movements, theories, clarification models and research projects is that the causes of this self-injurious behaviour are sought in the clients themselves. According to him, the ‘situation context’ is ignored or regarded as a given. I believe, however, that there is much more a question of subtle differences in aims and accents. After all, external factors are most certainly noticed by theoreticians and researchers, as Schipper himself has written, but then very superficially and not really explicitly. If one applies a biological-psychiatric model, random (spastic) movements that inflict wounds by chance can, under certain social influences (reactions and reinforcement from others), turn into intentional behaviour. Heijkoop (1978) and Cohn (1979), too, included interactions between group leaders and clients in their research results. Furthermore, King et al. (1978) mentioned organisational inconstancy and staff turnover as factors to explain this behaviour, while Schwartz (1967) described behavioural patterns as being the result of configurations: the stabilisation of a combination of behavioural patterns in a patient and the response of the carer. It is certainly not the case that other authors completely ignore the significance of the situation context. However, Schipper in his small-scale investigation does place more emphasis than others on the situation context, situation characteristics and situation factors. The last of these are illustrated in a factor tree on p 51 of his book. Factors identified in the course of observation are somehow associated with self-injurious behaviour. The title of the book alludes to the Factor tree, which produces bitter fruits.

Symbolic Interactionism

The sociological approach that Schipper chose continues further with the theme of Symbolic Interactionism. This has a number of consequences for methodological principles. In other words it is essential:

  • to study symbols in use and their meanings, and also the behaviour in practice;

  • to involve and investigate those in the immediate environment

  • for the researcher to remain as open as possible in his/her attitude

  • for the researcher to perform ‘role-taking’;

  • to have a preference for participatory observation.

Role-taking means that a qualitative researcher has to be able to perceive the world of the Other Person from the perspective of this Other Person. But can an observer/researcher take on the role of a person with serious or extremely serious learning disabilities? In this particular sort of research, is it either useful or essential to participate in ‘role-taking’? To what extent can we understand the behaviour within this target group? After all, this type of behaviour is very difficult for outsiders to understand. We can only make attempts to reconstruct it, as Schipper himself indicated later on in his research.

Participatory observation does not cover all the necessary aspects. This type of research is not about participatory observation involving long-term participation in the daily activities of the subjects, but rather about non-participant observation: a direct form of observing behaviour, the researcher not being actively involved in the group activities (Hutjes and Van Buuren, 1996, p 209). Moreover, the period of observation was not extensive, varying between just 2.45 and 23.10 hours. Schipper also wrote that the observer did his best to remain both passive and detached. Various appendices contain examples of the forms used: forms for recording observations with notes made on the spot, overview of observation times, behaviour measurement outline for group leaders etc. who were on duty at the time.

Interviews and document analysis (reports) complemented data collection in addition to observation. Schipper explained meticulously which choices he made and when. He explained, for example, why he decided to do qualitative research and not to use video equipment. His argument for not using video recordings summons up several questions and is open to question. He believes that video recordings disturb the routine more strongly than live observations. However, this is questionable now there is advanced equipment available (e.g. the concealed cameras used in the Big Brother TV programmes). Moreover, if the observer acts as a wallflower, this can be just as disturbing as making video recordings, or perhaps more so.

I am still in the dark as to what the observation protocol actually is. It can be requested from the author (p 82). I sent a request but have not yet received any response.

Wester as teacher

The book devotes plenty of attention to the problem, the theoretical framework, the selection of research units, the procedures for collecting data, validity and reliability checks and the methods of analysis. In this, Schipper is a faithful follower and/or pupil of Wester, one of his supervisors who, using Kwalon 30, showed the ins and outs of how important a method section, member checks, replication, triangulation and peer debriefing are. Schipper is also honest (in a very pleasing manner; one I especially appreciate) about all the problems he came across: people taking part were not well prepared; lists were not always filled in consistently; very few cases; insufficient time.

The ultimate aim of the research

An initial cheer for the Observation Protocol for self-injurious behaviour can subsequently die away as it becomes clear that it is extremely labour-intensive in its use. One needs to invest at least ten days in each client and perhaps even longer. This can cause the long-term aim of this practical research – reducing or ending self-injurious behaviour – to come under pressure. However, one cannot deny that Schipper has put self-injurious behaviour back on the map with his research.

Literatuur

Cohn, N. (1979). Psychopathologische, psychodynamische en communicatieve aspecten van automutilatief gedrag. In: Tijdschrift voor Psychiatrie, 21, p. 287 – 301.

Heijkoop, Jacques C.M. (1978). Zelfverwonding: een Wanhoopsdaad? In: Tijdschrift voor Zwakzinnigheid, Autisme en Andere Ontwikkelingsstoornissen, 15, p. 59 – 70.

Hutjes, J.M. en J.A. van Buuren (1996). De gevalsstudie. Strategie van kwalitatief onderzoek. Meppel: Boom.

King, Roy D., Norma V. Raynes en Jack Tizard (1978). Patterns of Residential Care, Routledge and Kegan Paul: London.

Schwartz, M. (1967). Patient Demands in a Mental Hospital Context. In: S. Kirson Weinberg, (red.), The Sociology of Mental Disorders. Londen: Staples press.

Wester F. (2005) De methodeparagraaf in rapportages over kwalitatief onderzoek, KWALON 30, 3 (10), p. 8 – 14.

Reply

Dear Hilde Ham

Thank you for your positive review of my thesis. I would like to respond to your objections, some of which were in fact discussed by the Advisory Commission for the project.

Firstly, a couple of language issues. We used the concept of ‘situation context’ because this was the most suitable description for what we meant. The context of a certain type of behaviour comprises more than just the situation itself; it can also be the behavioural context, a comprehensive behavioural pattern of which self-injurious behaviour is just one aspect. The concept of ‘situation’ turned out in practice to evoke associations with the client’s life in general rather than specific events linked to the behaviour in question. Incidentally, the term ‘situation context’ was not clear to everyone and obviously needed to be further defined; on the other hand, we were unfortunately unable to discover a better term.

And then the phrase ‘not unintentional’ in the definition of self-injurious behaviour. We deliberately chose this phrase, thus following the consensus definition of self-injurious behaviour used in a Delphi study (Bernard and Haveman, 1994). This definition excludes unintentional, random movements that result in injury, but the term ‘intentional’ has an annoying undertone of what lawyers refer to as ‘after careful consideration’ – a conscious, purposeful action. In some cases, this will certainly be true, but not every time. This double negative (you are right; it is not exactly elegant) was therefore the most adequate term, as far as we were concerned.

As far as the definition of ‘participatory observation’ is concerned, we used a broad definition as coined by Denzin (1978) who defined it a field strategy that combines document analysis, interviews, direct participation and observation and introspection. It is the opposite of the more distant, standard form of monitoring. So, I have to agree with you that this is not really participatory observation in the strictest sense.

The use of video recordings was the subject of many discussions. Video has many undisputed advantages; it is possible to study events at one’s leisure and it provides material for letting other people (including the users) take a look. However, there are also distinct disadvantages. Firstly, the cameras were, in those days, rather large and it was quite a performance to produce good recordings. More importantly, however, is that videos are mainly suitable for studying just the behaviour and the reactions that take place at a particular place. The wider context is literally not in the picture, and noises are often difficult to interpret. You also run the danger of obtaining so much information that you become overwhelmed by it. This is what Fred Wester himself experienced. This is why we decided not to use video. Nowadays, I would probably consider using it in some situations – to film people eating, for example. This takes place at one spot, the interactions are close at hand and so much happens in a short time that it is impossible to report it live.

Role-playing is certainly difficult, especially (but not only) in the case of severely mentally handicapped people. In fact, we assumed that they also define situations according to their own experience of life, allocate a meaning and then match their behaviour accordingly. This can sometimes turn out to be self-injurious behaviour. Thus, in order to be able to understand that behaviour, you cannot avoid attempting to reconstruct a situation definition. In some cases, that provided added value because it became possible to cluster together a number of diverse situations (from the point of view of the client) under one heading. For example, one client (Kees in the book) always had problems with the presence of a broom in the living room, but that did not by any means lead to self-injurious behaviour in all cases. It only occurred when sweeping (he knew it was a temporary hindrance) stopped, but he himself was prevented from taking the broom back to its rightful place. Self-injurious behaviour occurred specifically in situations having those characteristics that were first recorded on the basis of actual observations, and then subsequently interpreted according to Kees’ point of view. It was this interpretation that allowed diverse situations to be brought together under one heading.

And then other models for clarifying self-injurious behaviour: our objection was not that they completely ignored the situation context of this behaviour, but rather that they were either limited to a specific facet of the situation context or that they localised the essence of the problem in the clients themselves. Few other researchers have focussed attention on the situation context, as we did.

If the problem is sought in the clients themselves, the solution has to be sought there as well – as medication or behaviour therapy. However, if the self-injurious behaviour is somehow linked with the situation context, and the results of our research suggest this is likely, it means that the situation context is the one which usually needs to be tackled. If this aspect is ignored, the real problem will not be solved in most cases. And this happens frequently.

Finally, the problem that the observation protocol we developed was rather labour-intensive. That is indisputably the case and it was certainly a real problem, but we are talking here about an extremely complex behavioural problem in people who are difficult to gauge and who do not have the means to explain to others what motivates them or concerns them. Thus, this can only be determined by observing behaviour. Self-injurious behaviour often turns out to be incurable or only temporarily curable, even though all sorts of treatments have been tried out over a period of years. And it is precisely this self-injurious behaviour that affects the quality of life of these people very considerably.

Of course I appreciate that those who take decisions in institutions often have to weigh up the financial effects. However, I believe we have a duty to these people to do everything possible to solve the problem and to invest in a method that could provide new insights and lead to a breakthrough for the carers. They have to deal with self-injurious behaviour and yet are unable to provide suitable treatment.

Best regards

Wim Schipper

Literatuur

Bernard, S. en M.J. Haveman (1994). Zelfverwondend gedrag bij verstandelijk gehandicapten. Verslag van het Delphi-onderzoek. RU Limburg.

Denzin , Norman K. (1978). The Research Act. A Theoretical Introduction to Sociological Methods . McGraw Hill, New York.

Reply

Dear Wim Schipper,

Thank you very much for your comprehensive response to my review. It is good to hear that you deliberated so painstakingly with others before making your final choices with regard to such things as the use of terminology or video equipment.

I am in total agreement with you that, when dealing with this extremely vulnerable and dependent group in our society, it is advisable to place the emphasis on showing humanity and providing quality of life. The balance sometimes leans towards bureaucracy, money matters, ‘care minutes’, protocols and macro-economic principles. However, these clients do not fit into standard procedures and approaches. They require research and customised care! There could be an interesting task here for managers, pressure groups and researchers to generate funding for further research.

Best regards,

Hilde Ham