Our friends over at the Mental Elf are asking what qualitative research has ever done for us? For those who don't know what I'm talking about there are two basic kinds of research methodology in science: quantitative research and qualitative research. Quantitative research is what most people would think of as 'research'. Basically it is about having a question (called a hypothesis) and getting data to answer it. An example might be asking yourself if food served in burger joints is saltier than food served at vegetarian restaurants. To do this you would go around town eating at all these different restaurants and recording how much salt they put in their food. When you finish stuffing your face and writing in your notebook you would have a table with restaurants and salt content. If you got all the data, you know for sure whether on average food is saltier in burger joints or not.
Qualitative research does not do that - it is more like a focus group. You ask people about their opinion or their experience from their point of view. Your data is not recorded in numbers (ounces of salt) but in words. You try to record what people say exactly and then you try to extract some themes from the things they are saying. This is useful in coming up with the right questions to then go and do quantitative research on. The problem is that of late a lot of medical scientific publications do not publish this type of research and they assign it a low priority. In an open letter 76 senior academics have recently asked the British Medical Journal to rethink the fact that they now say no to qualitative papers because they think they are of low priority.
Echoing this the Mental Elf has organised an expert webinar to discuss the issue on 13th April. The organisers are asking a few questions and I wanted to answer the first one 'what is the most important “landmark” qualitative research study in mental health?'
There are many, including the one commissioned by the American government to produce guidelines for services that wanted to promote recovery. The project, which started in 1999, was called 'What Helps and What Hinders Recovery Project'. While that one gets an honourable mention I like these two:
- Davidson L, Hoge MA, Godleski L, et al. Hospital or community living? Examining consumer perspectives on deinstitutionalization. Psychiatr Rehabil J. 1996;19:49-58.
- Davidson L, Hoge MA, Merrill M, et al. The experiences of long-stay inpatients returning to the community. Psychiatry: Interpersonal and Biological Processes. 1995;58:122-132.
I like them because they challenged our assumptions and they made me rethink, back when I was a junior doctor, all the policies we had (and continue to have) about patients undergoing long-term hospitalisation in mental health hospitals. The wisdom to this day is that people prefer to live in the community and be less dependent on help from others and therefore there is a huge drive to discharge them.
These two papers explored the experiences of a group of such patients whose long-stay wards were closing down and they had to be relocated to community placements. When researchers interviewed them after the resettlement they found out that from the point of view of patients their life had not changed all that much - still a lot of empty hours filled with despair. In fact they found out that complains of loneliness and lack of access to medical/clinical care were worse.
This motivated some rethinking (at least in Canada) and instigated some quantitative research that otherwise would not have happened. I think the findings of these papers are still largely ignored at the peril of people with severe mental health problems. Unfortunately, the hypothesis that a lack of access to medical care is a bad outcome of discharging people from long-stay hospitals has proven to be true. Adults with serious mental illnesses living in the community have a reduced life expectancy compared to similarly unwell people receiving care in long-stay hospitals. We need to ensure better access to medical care and better access to meaningful social connection if we want to truly help people with serious mental health problems live successfully in the community.