Keywords

Good mental health is related to mental and psychological well-being. WHO’s work to improve the mental health of individuals and society at large includes the promotion of mental well-being, the prevention of mental disorders, the protection of human rights and the care of people affected by mental disorders. (WHO, October 2019)

Introduction

There is broad agreement in contemporary scientific discourse that the topic and focus of any research project determines the methodology used. If amounts, frequencies, and statistical relationships are of interest, quantitative methods are the methods of choice. However, if research focuses on structures of meaning, patterns of action, and associated processes, then the only option is to choose qualitative methods. In this context, traditional quality criteria of research derived from natural sciences like objectivity, validity, and reliability play a subordinate role. For qualitative research, instead, it is essential to define criteria linked to the respective research questions (see Flick, 2014; Strauss & Corbin, 1998; Strübing, Hirschauer, Ayaß, Krähnke, & Scheffer, 2018). Polemic discussions between scientists about what is “true” science should be a footnote of history (Kromrey, 2005). Nevertheless, it seems still important to emphasize the advantages and potentials of qualitative approaches in the field of social and health sciences (see e.g., Loewenthal & Avdi, 2018).

Classical approaches of qualitative research are often related to language and text, for example by conducting and analyzing interviews. In recent years, we witness two so-called turns: (1) a corporeal/body turn and (2) a visual turn. First, more attention is paid to the body as one particular field of research, as a theory category (e.g., within the context of conceptions of identity), as well as a tool to acquire knowledge about an area of research (Giardina & Donnelly, 2018; Gugutzer, 2006). Second, the importance and relevance of visual data is supported by an increasing significance of media in everyday life (Banks, 2001; Pauwels, 2000); Mey and Dietrich (2016), for example, transferred considerations and procedures of grounded theory onto visual data. In this book, Saara Jäntti, Kirsi Heimonen, Sari Kuuva, Karoliina Maanmieli, and Anu Rissanen present their research on Finnish people’s memories from mental hospitals; one of their foci is the body, in which experiences are metaphorically “engraved” (see Chap. 10). Another project, introduced by Penelope Kinney (Chap. 4), describes the method of “walking interviews”. Here as well, the body can be seen as a central tool of data collection and source of knowledge at the same time. Following the second development, Julianna Challenor, Eugenie Georgaca, Rebecca Aloneftis, Helena Curran, and Nobuhle Dlodlo (Chap. 6) present, besides other studies, a visual discourse analysis of childbirth images posted by postnatal women on Instagram. The example of giving birth as one primary affective lived experience shows that some realities “cannot or ought not to be reduced to discourse” (p. 107 in this book).

Nevertheless, in many other chapters of this book, the importance of word-based analysis is highlighted, reminding us that much meaning is communicated by language in social life, and this includes the construction of meaning around mental health.

The Tradition of Qualitative Research in Mental Health (QRMH) Conferences

Hosted by the Protestant University Berlin, Germany, the seventh Qualitative Research on Mental Health conference (QRMH7) took place in September 2018. These biennial conferencesFootnote 1 have grown from a modest beginning some fourteen years ago, being organized by a network of researchers. The 1st and 2nd Qualitative Research on Mental Health conferences were held 2006 and 2008 in Tampere, Finland, the 3rd and 4th followed 2010 and 2012 in Nottingham, UK, and the 5th and 6th in 2014 and 2016 in Chania, Greece. Successive events have attracted steadily growing international interest, both by novices as well as by experienced researchers. Contributors have come from a diversity of backgrounds: health and social care professionals, social scientists and health policy makers, mental health service users, and others, creating a space for lively and enriching discussions.

The QRMH conferences have developed in response to the wide acknowledgment that a fuller understanding of mental health difficulties, their origins, and their treatment entails a comprehensive range of epistemologies and research methodologies. As mentioned, qualitative methods offer essential insight into highly relevant mental health related topics, such as relationship issues, power, social exclusion, and other social phenomena, which quantitative approaches are typically not able to deliver. Therefore, they are an important complement to biomedical models and research methodologies, which can be considered as mainstream in mental health research these days. We agree with del Rio Carral and Tseliou (2019, p. 332) that “collective efforts are needed internationally to increase the participation of qualitative researchers” in a wide range of research areas, one of special importance being mental health themes. This awareness has been the motivation to engage in editing this book.

The Transdisciplinary Field of Mental Health

In this book, and in line with the tradition of the QRMH conferences, mental health is referred to as a field of phenomena that requires multiperspectivity and a transdisciplinary stance to grasp the diversity of aspects contained in this concept. Moreover, even if health legislations (still) follow national policies, a field has been established within public health which tries to transcend national perspectives, “one that aimed to improve treatments, increase access to services, and reduce human rights abuses of people experiencing mental disorders” (Cohen, Patel, & Minas, 2014, p. 3). This global mental health approach grounds in the consensus, that neither pure biological, nor pure cultural processes are able to fully explain mental health conditions. We follow the above-mentioned premises, seeing mental health in a socio-ecological framework (Petersen, Barry, Lund, & Bhana, 2014), resulting from intrapersonal (genetic make-up, physical health, cognitions, emotions, skills, and behavior), proximal (interpersonal and immediate factors related to family, peer, school, and community), and distal factors (culture and policies, e.g., economic and environmental policies—representing national and the global level in terms of macrostructural factors).

According to Rutz (2001, cited in Coskun, 2017, p. 17), “the type of mental health services offered and how mentally ill people are treated and integrated into society is one of the most sensitive indicators of the level of democracy, pluralism, and tolerance in a society.” Starting from clients or patients and their concrete interaction with professionals, we have to incorporate mental health services in their intersectionality into our considerations (Wahlström, 2017). Moreover, we have to be aware of the influence of societal discourses regarding mental health and illness on individuals and social systems. These different phenomenological levels require a diversity of research approaches as “the context of where research is carried out, by whom, for what reason(s), from what position, with what aims, and in what manner are some of the, many, factors that affect its quality and usefulness” (Loewenthal & Avdi, 2017, p. 2).

Cultural and social practices co-construct how people understand mental health, be it as “service user,” “service provider,” or “decision-maker” (Coskun, 2017). Subsequently, research in this field has to be considered as cultural and social practice, too (Loewenthal & Avdi, 2017; Wahlström, 2017), providing the researcher(s) with responsibility and a certain amount of power. Self-reflexivity, which is essential in qualitative research, goes hand in hand with an emancipatory attitude, trying to enrich the social discourses on mental health with wisdom “from within” and “bottom-up,” instead of “top-down,” in its double sense: theory-driven as well as hierarchical.

Besides clarifications from a methodological standpoint, this task requires adequate methods with regard to the respective levels of analysis. That is why, among others, psychological, sociological, historical and linguistic disciplines, with their respective qualitative research approaches and specificities are needed to embrace the empirical complexity. Most often, this multiperspectivity cannot be achieved by one researcher alone, but needs collaboration. Chaps. 6–10 in Part II of this book illustrate how fruitful it can be to cooperate in studying one phenomenon, in its best case transcending disciplinary boundaries.

Mental Health as a Global Challenge

“Globally, it is estimated, that only 7% of health budgets are allocated to address mental health difficulties. Most investment is focused on long-term institutional care and psychiatric hospitals, resulting in a near total policy failure to promote mental health holistically for all. (…) Public policies continue to neglect the importance of the preconditions of poor mental health, such as violence, disempowerment, social exclusion and isolation and the breakdown of communities, systemic socioeconomic disadvantage and harmful conditions at work and in schools.(…) For any mental health system to be compliant with the right to health, the biomedical and psychosocial models and interventions must be appropriately balanced, avoiding the arbitrary assumption that biomedical interventions are more effective.” (United Nations, Human Rights Council; Report of the Special Rapporteur Dainius Puras, March 2017, p. 3ff)

The right to mental health as a universal right is a regulating idea according to Kant, as humankind might never reach this aim. As with all regulating ideas of humanity, the challenge is not to surrender in front of the task, but to the contrary, to show perseverance in approaching this goal. In this context, Di Nicola (2019) refers to a “slow psychiatry”; from his point of view, a redefined social psychiatry is needed, which is phenomenological (instead of technocratic), is emic (experience-near), creates thick descriptions, is heuristic (instead of developing algorithms), accumulates knowledge (instead of emphasizing the pragmatic impact), focuses on comprehension (instead on mastery), and which is methodologically pluralistic. His position is clear: “The vaunted biopsychosocial (BPS) approach, offering an integration of three domains, became a convenient cover for psychopharmacology and neuroscience research to appear inclusive, yet in practice, as DSM‑IV chairman Allen Frances later observed, BPS became “bio‑bio‑bio”.” (ibid., p. 9). Also Janice Sargent and Angela Abela (Chap. 2) point out that “psychiatric diagnosis do not explain aetiology, prognosis and treatment but merely classify them” (p. 19 in this book). By asking research questions like “Where do psychiatrists locate themselves on the continuum between the biology-only perception of schizophrenia and its recovery and the biopsychosocial perspective of the disorder and its recovery?” and “how are such perceptions in turn manifested in their clinical practice?” (p. 20), we can trace psychiatrists’ habitus and their influence on their professional work, as done in Sargent and Abela’s research on the island of Malta. As shown in their study, “despite all participants holding a medical view of schizophrenia, those who focused more on the disease and its medical treatment as opposed to viewing the person as a whole and incorporate diverse interventions, appeared to develop a more pessimistic view of recovery in schizophrenia” (p. 28). Obviously, as mental health treatment is always provided through interaction (even if it is merely medication), a more pessimistic view is in danger of creating negative effects on the therapeutic relationship and consequently, on the patient himself/herself. However, we also need to widen the perspective: “The mental health system in which psychiatrists operate seems to greatly influence their decisions when it comes to treating individuals diagnosed with schizophrenia. Although the mental health act (2012) states that treatment should primarily take place in the community, the participants [of the study; i.e. psychiatrists] claimed that community support is lacking, (….) and the mental health system in Malta is still hospital-based” (p. 29). This is confirmed by the number of beds in psychiatric hospitals.Footnote 2 At the same time, multidisciplinary teams and a structure of community treatment are lacking. Taken these factors together, we see that even if some of the psychiatrists wished to adopt a different, less trauma-inducing and more recovery-oriented treatment, they might fail due to the deficiency of resources. Here, there is no other option than to change the system of intervention from medical to political.

Giving Voice—The Inside and Outside

What it means to be a “service user” shows itself in different ways, depending on whether it relates to one’s own experience, an experience we witness or an experience accessed second or third-hand—researchers are mostly in the latter position. As Carla Willig states, “suffering is not a passive state but a project in which the person is actively engaged” (p. 98 in this book). How can we approach this suffering in an ethically appropriate way? In her chapter, Penelope Kinney presents a participant-focused data collection method, which is compatible with different epistemological backgrounds; here, in the center of attention is not the researcher with his/her (scientific) worldview, but the subject of inquiry. Kinney learned as an occupational therapist within forensic psychiatric services, that “living with major mental illness often affects a person’s ability to hold spontaneous conversation” (p. 65). Researching this specific group of patients, she reflects: “A person may sit passively during traditional qualitative talking interviews, waiting for guidance on how to answer questions. I looked to find if there was another option that would allow the client participants to engage in a way that was familiar to them, and would not put undue pressure on them to speak continuously. I came across the walking interview.” This description shows, how the researcher tries to adapt her method of inquiry to the group and the topic she wants to study—“walking alongside a participant in a familiar environment the researcher can gain insight into a sense of alienation or connection the participant has with their community. Because the researcher is observing the participant while also interviewing them, it is possible to gather information about how the mental health client interacts with both their physical and social environment” (p. 80). By connecting oneself with the usual environment of the interviewee, the researcher might get an idea and a feeling from “inside,” how this situation affects the everyday life of the interviewed person. That means of course exposing oneself to the researched world, becoming ethnographic, for grasping the researched topic in a more complete, both rational and sensual way—at least to a certain extent.

A special mode of doing ethnography, i.e., autoethnography, is constructing a position of being both object and subject of the research, as done by Carla Willig in this book (Chap. 5). Her research aim is “to shed light on the lived experience of cancer in contemporary Western culture” to “understand the nature and quality of the distress that can be generated by a cancer diagnosis” (p. 84). She points out, that “subjective experience is, at least in part, mediated and shaped by available discursive resources” and the active engagement with these resources is a way to create meaning for this experience (ibid.). This is also the starting point of the above-mentioned study by Challenor et al. (Chap. 6) named “Listening to what is not said.” The authors exchange the foreground with the background: using different discourse analytic approaches, they are concerned with “in whose interest it might be that certain discourses or discursive repertoires are not heard” (p. 105, italics by M.B.) and “what function is served by the absence of alternative ways of speaking, thinking and doing” (p. 106). This creates an extraordinary position of the respective research, as the analysis not only gives voice to the researched (be it oneself or someone else) but shows also, that adopted discourses are always only one option of making sense of one’s experience. Other, alternative discourses are marginalized or even excluded and these exclusions follow certain functions: the not-listened-to becomes a self-disciplining not-said, thus stabilizing existing power structures.

Power Issues and Ethical Considerations

Mariya Lorke, Carolin Schwegler, and Saskia Jünger show and explain in Chap. 7, how differently people make sense of being confronted with health risks; what does it mean to “be at risk” for a person, either to develop dementia (in their chapter: study 1) or psychosis (study 2)? The authors state: the “probabilistic form of medical risk factors leaves the individual unclear concerning their relative effect, and without certainty about the future. Notwithstanding this, the ‘power of definition’ with respect to health risks predominantly lies with professionals, i.e. scientists or health professionals, implying that there is one appropriate way of understanding and interpreting risk-related information, and transforming it into health-promoting behaviour” (p. 137 in this book).

As mentioned, reflexivity is a central concept and tool in qualitative research. Seeing research itself as social practice, qualitative research is usually more concerned with power issues than traditional quantitative approaches following a biomedical perspective. In addition to the analysis of the research interviews from both studies, Chap. 7 also presents ethical considerations around how to do research with vulnerable groups; intervision might be a format of choice to keep reflection on the research process ongoing, with positive outcomes both for the researched individuals and for the research goal.

Accumulating Knowledge

Two chapters in this book (Chaps. 3 and 5) use and explain their work with metasynthesis of existing qualitative research, “Due to its commitment to a detailed exploration of meanings, qualitative research tends to use data from relatively small numbers of participants. This means that it can be difficult to draw wider conclusions from an individual piece of research. Metasynthesis is a methodology that provides us with an opportunity to integrate findings from several qualitative studies to produce a conceptually more robust account of the meaning and significance of an experiential phenomenon than would have been possible on the basis of a single qualitative study alone” (Willig, p. 96 in this book). Krivzov et al. explicate: “While being comparable with the better-known quantitative meta-analysis, metasynthesis can and should go beyond the mere question of treatment efficacy, which is often the focus of quantitative meta-analysis. Instead, metasynthesis can address more complex process-related questions” (p. 38). In their chapter, Juri Krivzov, Dewi Hannon, and Reitske Meganck refer to the Single Case Archive (www.singlecasearchive.com), an online database bringing together over 3000 psychotherapy case studies, collected by an international team of researchers (for more information see Chap. 3). This database is a unique opportunity for conducting metasyntheses, especially on process themes, as case studies have the advantage of reporting on therapy processes in naturalistic settings. Krivzov et al. invite us to witness sophisticated methodological innovations like the creation of timelines of therapeutic events.

Understanding Systems on Different Levels and Feeding Knowledge Back

The concrete interaction between the so-called service users and practitioners might be the level of concern in discursive research; we can frame the construction of this interactional arrangement as the therapeutic system in a narrower sense (see Chap. 8). As mentioned above, process research in naturalistic settings requires innovative methods. In their study on systemic couple therapies, Borcsa and Janusz implement Interpersonal Process Recall, also known as Stimulated Recall Interviews. “IPR/SRI has been developed as a method of reviewing a video recording to recall thoughts and feelings that occurred during the time of the recording. Hence, with regard to psychotherapy research, IPR as an interview approach was designed to access a therapy participant’s experiences as close as possible to the moment of the original interaction” (p. 172 in this book). The aim of the presented analysis is to study the mutual dynamic between the couple therapists’ references to their professional practice and to their personal experiences during the interview. To achieve this aim, two methodological approaches are employed: dialogical analysis to investigate the distinction between the therapist’s professional and personal selves, and the narrative storytelling approach in order to describe the therapist’s positioning in terms of his or her discursive identities being displayed in the IPR/SR interview.

The concrete interaction between any service user and professional is at all times embedded in an institutional situation. Fiorella Bucci, Rosa Maria Paniccia, Felice Bisogni, Stefano Pirrotta, Francesca Romana Dolcetti, Giulia Marchetti, and Katia Romelli make us acquainted with Emotional Textual Analysis (ETA). Chapter 9 describes ETA as a psychoanalytically informed method of text and discourse analysis, “to enable psychological research and intervention with social groups, institutions and organizations” (p. 201), aiming at researching the culture of the institution in question (in the authors’ first study being a school, in the second study a healthcare organization providing services for adult disability). Focusing on emotions expressed in language, ETA states that they are a fundamental organizer of relationships, i.e., also in the relationship between clients and practitioners. The chapter transcends the structure of this book in two ways: ETA understands itself explicitly as an intervention-research tool, informing concrete training activities with staff as well as clients. Further, it is a mixed-method, as statistics are used in a second step of analysis (for further details, see Chap. 9).

Jäntti et al. (Chap. 10) draw our attention to the socio-historical aspects of mental health, giving us insight into Finnish psychiatric practice from 1930 onwards, which at that time was heavily based on psychiatric hospitals and institutionalization. The multidisciplinary research group comprising of a language and communication scientist, an art historian and cognitive scientist, an artist-researcher, a poetry therapy instructor and psychiatric nurse as well as two academics in history and ethnology, investigated how experiences in mental asylums are remembered today, analyzing writings by patients, relatives, personnel, and their children. This work gives us an extraordinary insight into the fruitfulness of a multidisciplinary approach, an approach which furthermore becomes interventive by creating artistic events and discussions with the audience following their research.

All this research sheds light on the social construction of mental health phenomena on the micro-interactional and macro-institutional level and makes us aware that historical change is possible and needed, locally and globally.

The Book Structure

The book structure follows the two main formats, which were included at the QRMH7 conference: individual presentations on the one hand and symposia on the other. All chapters refer to concrete research questions and present their respective results.

Part I of this book is dedicated to specific research studies, submitted as individual papers to the conference—they mirror different levels of academic work, some originating in Master theses, others conducted by Ph.D. candidates, yet others by experienced academics. Some of the chapters deriving from these presentations are more focused on data collection; others put their emphasis more on data analysis (for a detailed methodological reflection on the chapters of this book, see concluding Chap. 11).

The chapters in Part II are resulting from symposia where researchers had united beforehand for a larger cooperative research project, working on these projects in their respective home countries like Lorke et al. in Germany (Chap. 7) or Bucci et al. in Italy (Chap. 9) or Jäntti et al. in Finland (Chap. 10). Another group of papers has their commonalities in using similar research methods or methodologies, but in different studies: Challenor et al. (Chap. 6) present three different studies with the unifying feature of using discourse analytic approaches. Maria Borcsa has been working with Stimulated Recall Interviews in a couple therapy research project in Germany, while independently, Bernadetta Janusz has been using the same method in couple therapy research in Poland. In Chap. 8, they join their perspectives.

Recent individual, collaborative, or institutional endeavors mirror an increasing interest in studying mental health phenomena from more than one perspective and furthermore, bringing together existing qualitative research, as is done in metasynthesis. In view of that, the chapters in Part II of this book demonstrate clearly, how the combination of more than one methodological perspective can enrich data collection and analysis.

Hence, the uniqueness of this book is that it explicates innovative qualitative research methods, i.e., in terms of both data collection and analysis, and at the same time increases our insight into the mental health field by presenting the results of respective studies from different countries. Overall, the studies originate from Belgium, Finland, Germany, Italy, Malta, New Zealand, Poland, and the United Kingdom, raising our awareness of the mental health field within diverse cultural and discursive, organizational and institutional as well as legislative contexts. Each study is grounded in a defined epistemology; the area of interest informs the chosen methodological approach. Following the tradition of qualitative research as an intervention in science and society by giving voice to minorities like vulnerable populations, most chapters seek to promote social justice and empowerment. The position of the researcher in the research is reflected on and is mirrored also in the style in which the chapter is written (e.g., from an I-perspective); we as editors have promoted this diversity and refrained from requesting standardization.