In Favour of Research Appropriate to its Subject Matter: Human Beings in the Context of Medical Care

Abstract: In this paper theoretical arguments and practical examples are presented in favour of research methods appropriate to their subject matter: the study and treatment of human beings in the context of medical care. The point of departure is a methodological one-sidedness in the areas of coping behaviour and psychotherapy. This one-sided exploration of the patient leads to a reduction of his or her humanity. As in the areas of coping behaviour and psychotherapy, the individual search for meaning plays a central role, the scientific neglect of its competency to construct viable models has especially negative consequences which are seen in both the unsatisfactory research findings and in the discontent of patients with their treatment. Studies of my own which have grown out of the research programme 'Subjective Theories' offer alternative possibilities for research that have a positive effect on the concrete treatment situation. Within the area of psychotherapy, an integration of various therapeutical procedures is presented which offsets the existing reductionist tendencies within individual schools and in so doing opens the way to an anthropologically appropriate non-reductionist therapeutic method.

Key words: assumed concepts of human being, chronic illness, compliance, coping behaviour, health beliefs, integration of methodologies, object-method-interaction, psychotherapy, qualitative research, subjective theories

What is the concept of human being, and what are the anthropological core assumptions that form the basis of our theories about human beings who are at the same time patients? The main focus of the research presented here is on the question of these assumed 'images of man' which, at least implicitly, provide the backdrop for the way the individual is studied and treated in medical and psychotherapeutical contexts. The reason for the choice of this topic is the lack of reflection on the relevance our assumed conceptions of human being for the choice and procedures and therefore for the perception of the patient as well. [1]

In respect to theory, this connection is discussed in light of object-method-interaction. The one-sidedness of mainstream research methodology is open to criticism on the basis of its anthropological core assumptions. The neglect of qualitative research leads to a one-sided perception of the patient in the areas of coping behaviour and psychotherapy. A reductionist view of this kind has in turn repercussions on the therapeutical technology that is derived from these research results. In the above-mentioned context of coping behaviour and psychotherapy, reductionist procedures have for the patient considerable consequences that are noticeable in his/her dissatisfaction and recourse to alternative methods of treatment. A further consequence of the one-sidedness of methodological preference can be seen in the limited range of fields of investigation that seem appropriate. Most often, the problems that receive investigatory energies are those that lend themselves to exploration within the ready framework of mainstream research methods. JÜTTEMANN (1983, 1992) speaks here of a principle of inversion which finds expression in an (again, one-sided) scientific conception of psychology. [2]

Taking this problematic situation as its starting point, the following will attempt to provide a more detailed account of research in the areas of coping behaviour and treatment of mental illnesses within the framework of psychotherapy. In these projects a conscious choice has been made in favour of a qualitative methodological approach that will allow for a differentiation between research methods. Within the context of the research program 'subjective theories' (GROEBEN, WAHL, SCHLEE & SCHEELE, 1988), the qualitative approach is implemented in the communicative validation phase. In the area of medical care, this hermeneutical approach leads to differentiation that shows both in the research procedure as well as in the research results. The change in the research procedure can be noted, for example, in the new, more active role of the patient in the research process. The patient, no longer a mere object of investigation, becomes the epistemological subject (GROEBEN & SCHEELE, 1977), whose individual perception no longer represents a deviation from the norm but takes on major significance for the research. The increased object-appropriateness of such methods can pave the way for new and important findings because the blind spots of previous research methods can be illuminated with them. Moreover, in the area of medical care, the implementation of qualitative research procedures leads also to a distinct change in the practical therapeutical relationship between the medical practitioner and the patient. Here, a hermeneutically oriented approach clearly complies with the wishes of many patients for treatment that takes greater consideration of their individuality. The patient is not reduced to his/her illness, but takes on an active role. The patient's own initiative is fostered. He or she is thus encouraged to contribute their capacity for self-management to the treatment process. These positive changes in research and treatment can be seen and utilised in both outpatient and inpatient settings as well as in the areas of rehabilitation and prevention. [3]

Proceeding from the epistemological subject model (GROEBEN & SCHEELE, 1977), which focuses on rationality, reflexivity and competency to act, the role of the patients' subjective theories is of special interest here. What are the theories, what are the models that patients have of themselves and their illnesses, and what are the effects of these subjective theories on the process of coping and on further treatment? The metatheoretical background of these queries is provided by the research program 'subjective theories' which was developed and elaborated by GROEBEN, WAHL, SCHLEE and SCHEELE (1988). The research program 'subjective theories' implements the above-mentioned human capacities consistently. In respect to methodology, this leads to a conscious choice of three-part methods for the investigation of subjective theories. Three-part measuring systems (cp. GIGERENZER, 1981) take the subject's model-building competency into account and thus allow for an individual survey of the patient's inner concepts. Such measuring systems have the outstanding feature of giving the patient/partner the possibility of presenting his/her conceptualisations in dialogue with the researcher. The phase of communicative validation in the research program 'subjective theories' (usually comprising two sessions) is designed toward this end. To begin with, the cognitive contents of the patient are made manifest in a half-standardised interview between the subject of research (the researcher) and the object of research (the patient). In a second sitting, the conceptualisations of the patient are then presented graphically in the form of a grid. At any given time during this procedure the patient has the possibility of contributing his or her view of the matter and of correcting any falsifications or misunderstandings on the part of the researcher that may have arisen. In contrast to many other methods used to survey the inner concepts of human beings, this method avoids the danger of the researcher presenting his own subjective theory about the patient's theory in place of the subjective theory of the patient. Following upon this phase of communicative validation in the research program 'subjective theories' is that of explanatory validation, in which individual derivations from the subjective theories of the patient are examined with empirical methods. In this way the question of the accuracy of the grid (the subjective theory of the patient) is examined. This two-phase structure of communicative and explanatory validation corresponds to the goal of integrating hermeneutical and empirical-social scientific procedures in the investigation of complex actions. [4]

While previous investigations within the research program 'subjective theories' (RPST) were focused on areas related to educational psychology, the content of my research concentration lies in the areas of medicine and psychotherapy. The latter fields, considered from a methodological perspective, also greatly restrict themselves to a two-part measuring procedure (cp. GIGERENZER, 1981). In these fields too, of course, it is recognised that the subjective view of the patient constitutes a relevant source of information for the investigation of his or her experience and behaviour. Nevertheless, in order to take stock of the inner concepts of the patients, these are most often asked to fill out a questionnaire in which certain constructs considered relevant by the researcher have been predetermined. Most of the time, this two-part procedure allows the patient only the possibility of selecting one from a number of predetermined alternative answers. The patient's individual model, his or her individual understanding of the illness, as well as his or her coping strategies—which from the view of the patient can be of major importance in respect to the action he or she takes—are neither considered nor are they included in the research process. This possibility arises first with the implementation of so-called three-part procedures (cp. GIGERENZER, 1981), like the structure-formation technique (SCHEELE & GROEBEN, 1988) and procedures derived from it. In an survey of patients suffering from chronic pancreatitis (inflammation of the pancreas), both (two-part) questionnaire procedures and (three-part) RPST methods were implemented in an investigation of locus of control orientation and then compared to one another (WAGNER, 1995a). The advantages and the disadvantages of both procedures were then worked out and set in relation to one another. On the whole, the methodological analysis of the subjective theories of the patients with the help of the structure-formation technique allows for a much more highly differentiated investigation of the individual coping strategies of the patients than is possible with the implementation of the questionnaire procedure. In addition, the results of the three-part method are more closely related to the everyday world of the patient and thus exhibit greater external validity. Furthermore, an important result of the RPST-conducted survey can be seen in the fact that the patients deal with their illnesses much more rationally than has been assumed among practitioners of the more standard treatment systems (WAGNER, 1998a). Interestingly enough, it is the very method of the differentiated investigation of the subjective theories of the patients that made this finding possible. [5]

The subject of a current research project is the influence of subjective theories on the course of rehabilitation among patients with chronic back pain. The background for this project is the unsatisfying state of research that sheds so little light on the connection between the objective results and the subjective suffering on the part of those affected (WAGNER & MEERTS, 2000). By means of a differentiated survey taken of the inner concepts of patients hospitalised in a rehab centre for chronic back pain, we have been able to acquire detailed information about the coping behaviour of the patients as well as the strengths and weaknesses of their prior treatment (WAGNER, MEERTS & LUEGER, 2000). The aim of this project is to optimise the rehabilitation of patients suffering from chronic back pain. [6]

Proceeding from anthropological core questions applied to the field of psychotherapy, metatheoretical and methodological questions will be investigated. What are the assumed images of human being that form the basis of the different schools of thought in psychological research and provide the framework of their various methodological procedures? On the basis of GROEBEN's scientific unities (GROEBEN, 1986), we have developed a metatheoretical model of the psychological schools of thought (WAGNER, 1995b). This model offers a foundation for the integration of different psychotherapeutical methods in the context of general psychotherapy (WAGNER & BECKER, 1999). One important aspect here is the critique of one-sided anthropological assumptions that form the basis of many psychotherapeutical schools of thought. In psychotherapy, the neglect of important anthropological factors has especially grave consequences. Especially in the context of psychotherapy should the patient be perceived in his or her entirety. The individual constructions of self and world of the suffering human are of enormous relevance for psychotherapeutical treatment. The inability of the therapist to perceive patients through any lenses other than those of his or her school of thought leads to patient dissatisfaction and feelings of insecurity that can, in turn, steer the patient in the direction of irrational psychotherapeutical movements (WAGNER, 2000). With the development of an integrative image of human being (WAGNER, 1999), the various images of human being can be brought together and thus allow the patient to be perceived, inasmuch as this is possible, in his or her entirety. In the foreground of these integrative images of human being, concrete derivations are presented for practical use. These relate to the choice of method and to the form of the therapist-patient relationship. The implementation of such technology leads to an anthropologically non-reductionist therapy. [7]

The goal of this research is to work out the reductionist view of the object of investigation ("patient") in the corresponding areas of treatment and to extend this view with the help of alternative, qualitative procedural methods. The prevailing mainstream research leads to a one-sided and incomplete perception of the patient which in turn culminates in one-sided research findings and reductionist treatment. By means of a differentiated survey and empirical examination of the inner concepts of the affected, it is possible to emphasise more clearly their capacities for reflection and competencies to act. By taking these abilities into consideration, the treatment is optimised and the contentment of the patient increased. Of course, this also leads to an improvement in compliance and in the relationship between the medical practitioner and the patient. The intensive dialogue with the patient made possible by the qualitative procedure leads indirectly to an exchange with patient self-help groups and self-management initiatives as well (e.g. WAGNER, 1996a, 1996b, 1998b). In this way, even a long-term mutual inspiration is possible between the researcher and the patient, between the "objective" and the "subjective" theories. [8]

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Study of Psychology at the University of Heidelberg, M.A. 1989. Involvement in various research projects in the fields of Theoretical Psychology, Clinical Psychology, Psychosomatics and Statistical Medicine. Ph.D., 1995. Consultant at the Institute for Psychotherapy and Medical Psychology at the University of Würzburg.

Research: Connection between qualitative and quantitative procedures in Medical Psychology and Psychotherapy centering on coping behaviour and Psychotherapy. Integration of psychotherapeutical schools of thought.

Practical experience: Treatment of patients with mental, psychosomatic, and somatic illnesses in an outpatient setting as well as in clinical counselling services for various clinics. Teaching therapist and supervisor.

Teaching duties: Teaching of students, medical doctors and M.A. psychologists in the areas of Medical Psychology, Psychosomatics and Psychotherapy.

Department of Psychotherapy and Medical Psychology at the University of Würzburg
Klinikstraße 3
D - 97070 Würzburg

Wagner, Rudolph Friedrich (2000). In Favour of Research Appropriate to its Subject Matter: Human Beings in the Context of Medical Care [8 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research], 1(2), Art. 27, http://nbn-resolving.de/urn:nbn:de:0114-fqs0002273.

Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

ISSN 1438-5627

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