shaw, reflexivity and the acting subject.pdf
TRANSCRIPT
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THIS IS AN EARLIER VERSION OF A PAPER PUBLISHED IN QUALITATIVE
HEALTH RESEARCH ONLINE JULY 6TH, 2016
Reflexivity and the “acting subject”: Conceptualizing the unit of analysis in qualitative
health research
James A. Shaw, PT, PhD
Women’s College Hospital
Institute for Health System Solutions and Virtual Care
Author Note
Correspondence concerning this article should be addressed to James A. Shaw, 76
Grenville Street, Toronto, Ontario, Canada, M5S 1B2
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Abstract
The ways in which social scientists conceptualize the “reflexive” human subject has
important consequences for how we go about our research. Whether and how we
understand human subjects to be the authors of our own actions helps to structure what
we say about health, health care, and the many other topics addressed in qualitative health
research. In this article I critically discuss assumptions of human reflexivity that are built
into qualitative social science of health and medicine. I describe three alternative ways of
understanding reflexive thought and human action derived from the theoretical works of
Pierre Bourdieu, Bruno Latour, and George Lakoff and Mark Johnson, respectively. I
then apply these three different ways of thinking about reflexivity and the acting subject
to the analysis of an excerpt of participant observation data from a health services
research study of transitions from hospital to home, illuminating the different kinds of
analyses that arise from each perspective. I conclude with a call for social scientists to
commit to the search for better ways of understanding the human subject, resisting the
temptation to “settle” on theoretical statements that close down the path to more
sophisticated conceptualizations of human thought and action.
Word count: 7830
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Reflexivity and the “acting subject”: Conceptualizing the unit of analysis in
qualitative health research
Reflexivity has become a critical topic in discussions of qualitative research
methodology, consistently positioned as a key strategy to ensure the “good” application
of qualitative methods (Dowling, 2006; Finlay, 2002; Finlay & Gough, 2008; Koch &
Harrington, 1998). The practice of reflexivity as a strategy to ensure quality in qualitative
research has been discussed across paradigmatic positions (Pillow, 2003), and has been
proposed as one quality criteria that might transcend the epistemological and ontological
differences otherwise separating researchers into various paradigmatic “camps” (Ravenek
& Rudman, 2013). Despite the various ways of understanding and actualizing reflexivity
in the course of a qualitative study (Doucet, 2008), it has nonetheless become a standard
feature in the discourse of quality in qualitative research (Berger, 2015; Carter & Little,
2007; Mauthner & Doucet, 2003; Ravenek & Rudman, 2013).
In the interdisciplinary domain driving advances in qualitative methodology, a
concept such as reflexivity is bound to be problematic. This is not only because of the
different ways it can be taken up to inform the process of qualitative research, but
because of the distinctly different meanings of the term “reflexivity” in methodological
and philosophical/theoretical discussion (Archer, 2010). In relation to qualitative
methodology, reflexivity refers to a process by which we as researchers hold ourselves
accountable for the assumptions we enact when we do research; a process of justifying
why we are inquiring about people and the world in particular ways (Finlay, 2002; Seale,
1999). This is reflexivity as methodology or method, as process, as a practical step to
ensuring quality in qualitative research (Pillow, 2003).
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However, in relation to philosophy or social theory, “reflexivity” is not only
understood as a practice or method (Archer, 2009). In its more philosophical sense,
reflexivity refers to our beliefs about a special human capacity, a trait of human
conscious thought that we believe to exist; a human trait through which we structure our
life plans, solve our life problems, and go about making the mundane decisions of
everyday living (Archer, 2009; Giddens, 1991; Shaw & DeForge, 2014). Some say
reflexivity in this way is the defining characteristic of our current epoch of humanity (as
in “reflexive modernity”; (Beck, Giddens, & Lash, 1994)). This is a controversial
position (Archer, 2009), and so what we understand reflexivity to be and the power it has
over our actions is of high stakes. This kind of reflexivity is reflexivity in terms of what it
means to be human in our current age.
But just what is this reflexive thought? How is it possible? And most importantly
in discussions of quality in qualitative research, what role does it really play in bringing
about our actions as researchers, and the actions of our participants we study so closely?
As many of us have been taught in graduate school, the ways in which we answer
these questions are bound up with a complex set of other beliefs, situated within
particular traditions of philosophical and practical assumptions about the human body
and being (DeForge & Shaw, 2012; Denzin & Lincoln, 2011). Like a family tree, we can
trace the genetics of our beliefs about the human person back through their lineage in
order to better understand where they have come from, and thus better understand what
they mean for us as qualitative researchers. In this article I reflexively discuss how our
beliefs about the human person (Finlay & Gough, 2008), and the philosophical soil from
which those beliefs have grown, dictate particular ways of thinking about and doing
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qualitative research. Specifically I suggest that what we understand the human person to
be, how we conceptualize the “acting subject” has profound implications for the kinds of
claims we make in our research; for the kinds of analyses we do.
The ways in which our beliefs about human reflexivity pervade our research has
at least one further implication: By implicitly (and sometimes explicitly) telling people
that they exist in particular ways as particular kinds of entities through our research, we
encourage them to act according to those ways of understanding themselves. We help to
create particular kinds of acting subjects – we subjectify (Foucault, 1982; Miller & Rose,
2008). I suggest that we have to be careful about the assumptions of humanness that we
enact in our research, and therefore implicitly encourage people to believe about
themselves and others. My central claim is really that we always need more sophisticated
ways of understanding what it means to be a person – we can never stop looking for
them. We are never finished.
In order to accomplish these goals, I will first highlight the connections between
the common analytic construct “attitudes” as used in health services research and a
Cartesian way of thinking about the human subject. This is intended to demonstrate the
implications of our beliefs about what constitutes “the human” and “reflexivity” for our
research and practice in health care. I will then outline three ways of conceptualizing the
human subject that are inspired by three different philosophical traditions, leading to
different understandings about what reflexivity is and whether and how it drives human
action. These perspectives include the “sociology of practice” of Pierre Bourdieu, the
“actor network theory” of Bruno Latour, and the “embodied cognition” of George Lakoff
and Mark Johnson. I will then apply these three different conceptualizations of the human
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subject to the analysis of a segment of data from a health services research study,
illustrating the different emphases of the analyses based on each perspective. I will
conclude with a call for social scientists to commit to the continual search for better ways
of understanding human thought and action, resisting the temptation to “settle” on
theoretical statements that close down the path to more sophisticated understandings of
reflexivity and the acting subject.
Cartesian Attitudes in Qualitative Research
This inquiry into different ways of conceptualizing reflexivity and the acting subject is in
part motivated by a reaction to the all-to-common reliance on common sense categories
of human psychology such as “attitudes”. Many qualitative studies purport to examine
attitudes regarding particular phenomena in various applied domains, and receive
substantial attention through publication in high impact scholarly journals. One
prominent example is qualitative research examining patient and health care provider
attitudes toward various issues in health care. A study published in 2003 in the Journal of
the American Medical Association, which reports on patients’ and doctors’ attitudes
about the reporting of medical errors, has been cited 706 times on Google Scholar as of
November 2015 (Gallagher, Waterman, Ebers, Fraser, & Levinson, 2003). This study has
presumably contributed to the general belief that attitudes about reporting medical errors
should be a dominant consideration in efforts to improve patient safety, distracting
attention away from the many contextual and organizational features of health care
environments that have since been shown to be essential to improving patient safety in
meaningful ways (National Incident Analysis Collaborating Parties, 2012).
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The problem with the prevalent focus on attitudes in qualitative inquiry is not in
the attitude construct itself, but in the lack of understanding of the broader philosophical
assumptions of humanness that accompany it (although there are many conceptual issues
with the attitude construct; see (Glasman & Albarracín, 2006) for a more thorough
discussion). Attitudes are understood to be discrete, binary summary evaluations of
phenomena encountered by humans in our everyday lives (Ajzen, 2001; Wallace,
Paulson, Lord, & Bond Jr, 2005). Social psychologists suggest that these summary
evaluations are stored in our brains and drawn upon to make binary judgments about our
experiences in terms such as “good-bad” or “like-dislike”, representing an essentially
dichotomous understanding of human judgment (Crano & Prislin, 2006; Ratanasiripong
& Chai, 2013).
This binary nature of attitudes, and their purported storage in the brain like
software on a computer, reflects a fundamentally Cartesian understanding of the human
subject. The belief that there is some essential distinction between the hardware of the
body and the software of the mind, in this case conceptualized as including something
called “attitudes”, implies the Cartesian distinction between mind and matter. Semin and
Smith suggest that social psychology, the discipline from which the attitude construct
arose, is “a field that still largely accepts traditional notions of internal representation and
computation” (Semin & Smith, 2002) (p. 385); these are distinctly Cartesian perspectives
on reflexivity and epistemology. However, the broader implications of this fundamentally
Cartesian view of human thought remain unarticulated and unexamined in much
qualitative research that draws on attitudes as a central focus.
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In his seminal 1989 essay, Kenneth Gergen explained some of the unintended
consequences of the Cartesian heritage that has grown to pervade the discipline of
psychology in general (Gergen, 1989). First acknowledging that “the field has
unwittingly fallen heir to a Cartesian world view in which a strong distinction is made
between a knowing subject and an object of knowledge” (p. 466), he explained how
crucial questions have been cut off from analytic attention. Most notably, he identified
the “disappearance of the social world” (p. 465) as a consequence of Cartesian,
cognitivist thinking, eliminating the possibility of understanding the relationships
between individual experience and social interaction. We see the same effect in
qualitative health research that draws on the Cartesian assumptions of attitudes and its
parent discipline (psychology) as a foundation. The consequence is the erosion of
meaningful inquiry into the ways in which people interact with their social contexts in the
production of activities in health care, enabling for example analyses of attitudes toward
patient safety at the expense of attention to the organizational and environmental realities
that lead to safer or more risky health care practices.
The purpose of these introductory comments is not to examine the attitude
construct and its Cartesian heritage in depth, but simply to point out the problems with
their uncritical application to qualitative research as a starting point. The Cartesian
perspective on reflexivity and what makes a human has been critiqued by generations of
philosophers (Gergen, 1989; Rorty, Williams, & Bromwich, 1980), and as qualitative
social scientists we should feel obliged to examine the support for and critiques of the
ideas we use in our research. We should recognize the kinds of assumptions of
humanness we perpetuate when we take “attitudes” as our analytic focus, reinforcing the
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common sense belief in the dichotomous separation between body and mind. Having
briefly introduced the links between the problematic use of common sense constructs
from psychology and a Cartesian philosophical heritage, I now turn to describing three
very different ways of thinking about what it is to be human that can be applied in
qualitative inquiry.
Alternatives to a Cartesian Understanding of the Human Subject
Many alternative ways of understanding the human subject have developed throughout
the 20th Century, motivated in part by a school of thought that Paul Ricoeur referred to as
the “school of suspicion” (Ricoeur, 1970). For Ricoeur, this school of thought is
represented most clearly by the common thread in the work of Friedrich Nietzsche, Karl
Marx, and Sigmund Freud: A deep suspicion of the very conscious understandings and
experiences on which our beliefs about human subjectivity are based. Each of these
theorists in their own way laid groundwork for future generations to take great issue with
the taken-for-granted beliefs about human consciousness and being that characterize
Cartesian philosophy and its consequences. The theoretical positions I address in this
article have, if only indirectly, inherited a philosophical legacy that acknowledges the
insights that are raised by this tradition. They respect the insights of these “masters of
suspicion”.
One key characteristic of the three theories I discuss is their distinct effort to
provide some resolution to the challenge of thinking about the relationship between the
individual and the collective in everyday life. Bringing the idea of the “collectivity” or
“the social” into the conversation already implies a shift in thinking about the “acting
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subject”. When we recognize the power of collectivities to impact our actions in some
way, we restrict the absolute freedom of the human subject that Descartes proposed. We
make room for the effects of the world around us on what we do everyday. Each of the
three theoretical positions I address below have done this somewhat differently,
providing a range of ways of thinking about how and why humans come to act as they do.
Bourdieu’s Sociology of Practice
The first theory I address is Pierre Bourdieu’s practice theory, because it offers perhaps
the clearest opposition to the social psychologist’s conceptualization of discrete,
individual categories called attitudes that drive behaviour. Bourdieu had a background in
philosophy (Bourdieu & Wacquant, 1992), and this contributed to his eagerness and
aptitude in stepping back from individual action to take a broader and more critical view
of the human subject. The first key point about Bourdieu’s sociology is that he
conceptualized human action as arising from and taking place within a particular field, a
metaphorical space in which the game of everyday life is played (Bourdieu, 1990). On his
view, we are born into a collection of intersecting fields, each with their structures of
hierarchy and obedience, histories of modes of interacting, and ways of understanding
enjoyment and taste (Bourdieu, 1984).
Bourdieu suggested that our relationship as a human body to these fields
structures the very mentalities and actions we call reflexive thought, the very ways in
which we might arrive at a concept called attitudes. The relationship between the body
and the world is a kind of bi-directional flow, a constant and continuous interplay
between the structures of the field and the structures of the body. Bourdieu called this an
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“homology” (Bourdieu, 1990). The relations of objects in the world around us are
incorporated into our body, they are “made body” to use Bourdieu’s phrase, instilled in us
as a collection of dispositions called habitus that make us act in the world in particular
ways.
For Bourdieu, it is habitus that drives our everyday actions and that really defines
the “acting subject”. Bourdieu described habitus as “systems of durable, transposable
dispositions, structured structures predisposed to function as structuring structures…”
(Bourdieu, 1990) (p. 54). This point highlights the bi-directional nature of habitus – it is a
set of dispositions that is structured by the world, shaped and created by the fields in
which we live our everyday lives. And at the same time, it then shapes how we act in,
recreate, and perceive those same structures. It goes both ways.
Bourdieu continued describing habitus, “… that is, as principles which generate
and organize practices and representations that can be objectively adapted to their
outcomes without presupposing a conscious aiming at ends…” (p. 54). This last comment
represents Bourdieu’s questioning of why we have to posit a Cartesian subject at all.
Habitus explains the relationship between the individual and the collective, the subject
and the field, in terms of what brings about human action. If we weren’t so saturated in
Cartesian ways of thinking about ourselves, we would never think of them as obvious or
natural. We are simply a habitus.
Bourdieu suggested that the ways of interacting in particular fields operate on
systems of capital – and that, actually, “it is impossible to account for the structure and
functioning of the social world unless one reintroduces capital in all its forms” (1986, p.
46). Bourdieu outlined different forms of capital, and in the 1986 essay from which this
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quotation comes, he suggested 3 forms: economic, cultural, and social (Bourdieu, 2011).
Bourdieu addressed the concept of capital to highlight how the relations between people
and objects in the fields from which our habitus is derived are not neutral. They are not
innocuous or arbitrary, but on the contrary, have implications for who gets to do what and
how in everyday life. They structure the system of “haves and have-nots” in which we
live.
Economic capital is perhaps the most intuitive of these three forms, because it’s
the one we tend to be most familiar with in capitalist democratic societies. Economic
capital is quite simply the amount of money in the bank, or the resources at our disposal
that can be traded in a market system. Cultural capital is somewhat more difficult to
define, because it can exist in a variety of ways. Cultural capital is what makes us
culturally desirable or indicates our cultural resources, such as educational qualifications,
or a great fashion sense, or an informed appreciation of art. Social capital represents the
resources available to us at any given time in the form of the actions and knowledge of
members of our social network: Those individuals with whom we have some actual or
potential relationship who can help us to achieve particular objectives in our everyday
lives.
These three forms of capital imbue the relationship between habitus and field with
particular kinds of meanings. They represent the resources that different actors have at
their disposal to act in particular kinds of ways, and to garner the further accumulation of
resources. “It takes money to make money”, as the wall street saying goes. For Bourdieu,
understanding the “acting subject” isn’t just about how habitus structures what we do and
what we think, but about how capital itself plays a role in structuring the habitus that is
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the root of our actions in the world. The very reflexivity we so often think of as
characterizing our humanness is itself structured by this system of capital. This is
fundamental to Bourdeusian accounts of the acting subject and the social world.
Latour’s Actor Network Theory
Next I address Latour’s Actor Network Theory (ANT), in part because it is a way of
thinking about the analysis of social phenomena that is a direct reaction to what he calls
“critical sociology”; this “critical sociology” is a category that Bourdieu’s theory of
practice fits squarely within. The big issue that Latour has with “critical sociology” is its
usual reliance on a concept of the social as a thing unto itself. He claims that sociologists
have been “hypostatizing” the social, making a distinct ontological thing out of what is
really just an adjective, a description of a bunch of other things (Latour, 2005); it is just a
phrase used to designate the many relationships between objects in the world. I think
Dorothy Smith actually described this best when she referred to the same sociological
analyses that Latour is critiquing as relying on a “blob ontology” (Smith, 2005), one that
treats the social like a blob hanging over individuals. This sounds like a similar
conceptual mistake to positing attitudes hanging over a brain (although of course
Bourdieusian scholars passionately clarify that this is not how they conceptualize “the
social”; see (Crossley, 2003)).
Latour moved away from the constructs “social structure” or “the social”,
suggesting they provide a false certainty about the nature of the human subject and the
causes of human action. He explicitly wanted to “shift from a certainty about action to an
uncertainty about action” (2005, p. 60). He fully embraced a shift away from traditional
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notions of the human subject, leveling the impact of human agency way down to size.
Latour understood, with most social scientists, that human action is in some way
constituted by something like “the collective”, but he wanted to spell out exactly what
that is and exactly how it happens in particular situations. In order to do this, Latour
suggested, we need to consider everything – all of the colours, objects, distances,
lightings, surfaces, spaces, etc. that represent the most proximal influential steps in a
very, very long causal chain. He wanted to take that social blob and break it down
molecule by molecule.
ANT has become well known primarily as a perspective that gives agency, or
“causal force” to inanimate objects, like how the specific screen or piece of paper on
which you are reading causes you to understand these words in a particular way. But of
course Latour’s theory is much more than just that. Latour clarified,
ANT is not the empty claim that objects do things ‘instead’ of human actors: it
simply says that no science of the social can even begin if the question of who and
what participates in the action is not first of all thoroughly explored, even though
it might mean letting elements in which, for lack of a better term, we would call
non-humans. (2005, p. 72)
I understand Latour’s perspective as suggesting that the extent to which some category
called “the social” may be understood as impacting human action is simply the extent to
which the objects in our immediate surroundings bring that effect into being. The social
is not some blob above our heads, but is simply the impact of the objects (including
people) that immediately surround us.
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Latour continued, “In addition to ‘determining’ and serving as a ‘backdrop for
human action’, things might authorize, allow, afford, encourage, permit, suggest,
influence, block, render possible, forbid, and so on” (2005, p. 72). So Latour made the
impact of “non-human” objects equal to the impact of human agency in bringing about
human action. This obviously implies a drastic overhaul of the concept of human agency.
In fact, it moves completely away from discussing human agency as a concept unto itself.
On this view, agency and the human subject are so radically constructed by the world
around us, that it doesn’t really mean anything to talk about human actors as a special,
distinct category anymore. Instead, we need to talk about “actor-networks”, because all
actors are simply links in a chain of other actors, both human and non-human. According
to Latour, this is how we should understand the constitution of the human subject and
human action in the world. Reflexivity is nowhere to be found.
Embodied Cognition: George Lakoff and Mark Johnson
I now turn to discuss the work of George Lakoff, a cognitive linguist, and Mark Johnson,
a philosopher. The two of them have written a few books together exploring the
intersections of cognitive science, neuroscience, and philosophy, addressing topics that
include self, morality, rationality, and metaphor. The purpose of their ongoing intellectual
project has been in part to reconcile what insights might be gained from the conventional
sciences with those gained from philosophical inquiry about what it means to be human.
Lakoff and Johnson are proponents of an “embodied mind” (Lakoff & Johnson,
1999), suggesting that all human thought and action are based on a relatively simple
system of metaphor that is fundamentally built upon our bodies; it relies upon our
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existence as embodied beings. The only reason we experience thinking and acting and
reflecting the way we do is because of the evolutionary status of our bodies. On this view,
despite our common sense beliefs to the contrary, even our most abstract rational thought
is in some way metaphorically referring to our body’s spatial and experiential dimensions
(Lakoff, 1995). Reason itself relies on the experiences of the body.
Following Lakoff and Johnson’s approach to explaining this abstract idea, a few
examples might help to illustrate the point:
When someone expresses “caring” they are “warm”, like the bodily warmth of a
parent’s embrace.
When someone is mean to us they are “cold”, they give us the “cold shoulder”.
This metaphor reflects the primary and fundamentally embodied experience of heat and
cold. Our very ideas of caring and meanness are metaphorically built upon our more
primary experiences of heat and cold. Another example:
When we are feeling good we are feeling “up”, we are “uplifted”, we are in a
“light mood”.
When we are feeling bad we are “down in the dumps”, we are “heavy”, the world
is “weighing on us”.
This example suggests that the ideas of mood or affective status are built upon our
body postures. The more primary experience of a strong, tall posture structures the ways
in which we attribute meaning to our moods and emotions. According to Lakoff and
Johnson (Lakoff & Johnson, 1980, 1999), we could increase the complexity of our
metaphor examples all the way up to the most abstract reflexive thought. For them, all the
processes of reflexivity and subjectivity that we have come to attribute to an
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ontologically special human mind are really just the opposite – they are the function of an
ontologically unremarkable human body (Lakoff & Johnson, 1999).
While these are just two examples, the point is that all language, and therefore all
reasoning and morality, are fundamentally based on metaphors derived over time from
our status as embodied beings. As Richard Rorty says, language is just a collection of
dead metaphors that originate from our bodily experience in the world (Rorty et al.,
1980). And we go about our everyday lives on the basis of meaning that is derived from
these bodily metaphors.
One very important implication of this view, according to Lakoff and Johnson
(1999), is that these more primary metaphors are continuously at work whenever humans
think or act in the world. They are literally at work in our bodies, in parallel neural
pathways that operate while we engage in abstract thought. These metaphors are active at
an unconscious level during all thought and action. Lakoff and Johnson (1999) describe
this as follows:
Our unconscious [metaphorical] system functions like a "hidden hand" that shapes
how we conceptualize all aspects of our experience. This hidden hand gives form
to the metaphysics that is built into our ordinary conceptual systems. It creates the
entities that inhabit the cognitive unconscious – abstract entities like friendships,
bargains, failures, and lies – that we use in ordinary unconscious reasoning. It thus
shapes how we automatically and unconsciously comprehend what we experience.
It constitutes our unreflective common sense. (p. 74, emphasis added)
This already structured way of understanding the world that operates apart from our
conscious awareness reflects how the collective human past functions in the thoughts and
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actions that characterize humanness. We are not free to think and act however we want in
a Cartesian sense, because the very ways in which we do these things are fundamentally,
ontologically dictated by the body and its situation in the world.
One important implication of this view is that even our most detached, objective
reasoning is intricately interrelated with the more fundamental feelings and emotions we
experience. When we are happy and at ease the kinds of rationality we think with are
different from when we are upset and on edge. I am sure we can all think of stupid
decisions we made when we were angry, that a later self regretted and considered
irrational. This is a perfect demonstration of how emotion itself structures what we call
rational thought. Our everyday distinction between these two categories of experience is
again based upon a taken-for-granted Cartesianism that pervades our culture.
Transitions from Hospital to Home: An Empirical Example
In order to help clarify how these different understandings of reflexivity and the human
subject might be brought to bear on a qualitative study, I am going to present a data
excerpt from a health services research study and explore what each theoretical approach
might have to say about the data. The study itself explored transitions from hospital to
home for older people living with complex needs in a large urban hospital setting in
London, United Kingdom. This particular excerpt is part of a longer observation of a
community-based meeting in which a group of professionals were discussing the care of
a particular patient. The important point for our purposes is not about the broader context
of the study, but about how these different perspectives identify different elements as
being most important in the example.
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In this particular meeting, the clinical team was discussing the plan for Mrs. V (all
participant names are pseudonyms). She had complex mental and physical health issues,
and had been showing up to the emergency department every week for the past few
months. She had longstanding anxiety issues and at the time was experiencing a Urinary
tract infection (UTI). The health care team was debating whether she could be managed
at home or should be placed in a long-term care facility.
The participants in this data excerpt are as follows: First is Dr. Porter, or Samuel
as he is referred to in the excerpt, a psychologist who works at the hospital primarily with
older people, and represents the hospital’s interests in the meeting. Next is Julia, a senior
mental health nurse with lots of experience in community care. Then is Dr. Aitkin, a
geriatrician at the hospital; and last is Sarah, a young social worker.
Dr. Porter says in an assertive tone, “Yes, the UTI is clouding the picture, but I
really think the infection is a consequence of the anxiety and the broader situation,
not the cause.” Julia very quickly replies to Dr. Porter’s comment, “you’re right,
Samuel [Dr. Porter’s first name], we need to establish a baseline to understand
why these deviations are occurring. But we also need to act in her best interests,
especially now that she doesn’t have capacity. I think we need to ask if a package
of care can sustain her at home.” Julia’s expression is calm and she speaks with a
calm, non-confrontational tone. Dr. Aitkin raises his naturally loud voice, and
with a frustrated chuckle loudly says, “No!” [He had already voiced this opinion a
number of times]. He shakes his head and looks down at the notes in front of him.
Sara then joins the debate from against the back wall, leaning forward on her seat
and agreeing with Julia: “we need to at least attempt to manage her at home-” Dr.
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Aitkin interrupted again, saying in a loud and urgent tone “but even with 24 hour
care at home, she’s still going to call the ambulance!” Sara then repeated, quietly
now and with less conviction, “we should still try to manage her at home.”
Now, what is going on here? Why did this exchange transpire in exactly this way? And
with what consequences? How we answer these questions depends on our beliefs about
the acting subject, so we will now take a look at how the three theories discussed in this
article might address them.
Latour’s Actor Network Theory
First I discuss an ANT perspective on the observation, for reasons that will be explained
when I turn to Bourdieu’s perspective next. We should recall that ANT wants to
thoroughly consider who and what participates in the action (Latour, 2005). This is an
observation of a particular moment in time, but the “actor-networks” responsible for
producing this exchange need not necessarily all be here in this room at this time.
Think about Sara – as the social worker assigned to this case, she has been to Mrs.
V’s house. For Sara, it is off-kilter welcome mats, half-finished bottles of wine, stale
milk, mixed medications on the kitchen table, unopened telephone bills and the smell of
stale urine that leads to her suggestion the team has not really made a comprehensive
effort to manage Mrs. V at home. And it is Julia’s voice ringing in Sara’s ears, the voice
of the community standing up to the hospital that calls Sara’s words forth. It can be done.
It is these objects of an unmanaged home environment and the materiality of support
from a team member that brings Sara’s words forth.
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It is more than that though – it is the concerned tone in the voice of her social
work manager about this months long term care expenditures, the white walls of painted
institutional brick in the long term care residence, the sporadic cries of remembered terror
from the next room, the smell of microwaved mushy peas, and the uniform, yellowing
housecoats of publicly-funded institutional care that leads her to suggest the team tries
better to manage Mrs. A at home. These things all form an actor-network, coming to a
head at this moment that we observe in the meeting about Mrs. A’s future.
And what about Dr. Aitkin - he basically lives within the hospital walls. He knows
the hospital. For Dr. Aitkin, it is the wheeled cart full of patient record binders stacked
higher every day, the ward clerk asking for updated discharge dates, the misplaced
stethoscope left at a busy bedside that should be around his neck, the security guards
glaring at him after restraining a distraught patient, the unanswered emails from the
psychiatry department, and the Director of Care’s voice nagging him about this one
patient’s multiple readmissions that lead Dr. Aitkin to advocate for an institutional
admission. For Dr. Aitkin, the actor-network doesn’t include any links that recommend
continuing to manage this patient at home. For him, Mrs. V needs institutional care.
So for ANT, the issue of reflexivity among the participants themselves never
really comes up. It is about understanding how and why these objects and people have
brought about the participants’ actions in particular ways. The implications of this view
are focused attention to the conditions in which exchanges such as this one take place – it
is not about changing the rational thought processes or attitudes of the people involved. It
is about changing some of the many actants in the relevant actor-networks to produce
22
more respectful, more productive inter-professional discussion. To understand the human
subject, we need to look away from the human subject.
Bourdieu’s Sociology of Practce
Now we move on to a Bourdeusian account of this interpersonal exchange. I think it is
helpful to discuss Bourdieu second because Bourdieu would take issue with the analysis
provided by ANT. It seems to leave something out. What about power? What about
capital? Why does Sara lose her enthusiasm here; why is that allowed to happen?
Bourdieu would highlight the links between the habitus of these participants and
their respective fields, pointing to the differences in capital that characterizes each one.
Dr. A’s habitus is built upon an upper class lifestyle, on masculinity, on extensive
education, expensive wine, a global network of colleagues, and well-spoken English. He
has accumulated a great deal of capital that is embedded within his habitus. This habitus
drives his actions at this meeting – his aggressive tone, his eagerness to interrupt the
conversation, his disbelief at the suggestion Mrs. A should be managed at home. These
actions are a function of his connections to fields that imbue him with power, and
characterize the extensive amounts of capital he has within this particular field of health
and social care. They are not discrete, conscious actions, but part of a habitual disposition
that flows from his relationships with particular fields.
Sara, on the other hand, is a social worker. She is a woman, and a young woman
at that. She has been socialized into a middle-class lifestyle, with middle class tastes, who
has seen and experienced enough about marginalization to understand its meaning in the
life of Mrs. V. She belongs to the field of social services, a much less respected and
23
powerful field than that of medicine. Her position within the fields to which she belongs
does not imbue her with a great deal of capital, yet she is nonetheless compelled to stand
up for her position, even if somewhat timidly, here in this meeting. The meeting is in the
community, not in the hospital – it’s on her home turf. She treads carefully down the path
created by Julia’s comments, already standing up for the perspective of social care. Her
habitus spontaneously agrees with Julia, and expends what capital it has available to
repeat her claim: “we should still try to manage her at home.”
Again for Bourdieu, these actions are not constituted by a reflexively thinking
subject free to act in any which way. The structures of the field from which each actor
comes play out through their habitus, intersect in a sort of competition of capital. Here
and now, in this situation, whose capital will win out? The hospital and medicine? Or the
home and social care? On this view, efforts to promote more respectful, inter-professional
work require a better balance of capital. They require changes to the institutional fields
that structure the dispositions of the practitioners involved in this meeting. Only then can
all voices be heard and considered.
Lakoff and Johnson’s Embodied Cognition
Finally we move on to our last reading, the embodied cognitive theory of Lakoff and
Johnson. Now, while this theory does make room for the influence of something like “the
collective”, it does so in a very different way from either Latour or Bourdieu. As I
suggested earlier, it locates the influence of the collective via our shared evolutionary
structure of cognition and action. We all evolved in this way and we all think and act in
24
this way. There are unconscious processes driving our actions that none of us recognize
in day-to-day life.
In the case of Dr. A and Sara, embodied cognition would direct our attention to
the kinds of rationality being used in this meeting and how that rationality is based upon
more fundamental, emotive processes. The emotional tone is clearly high in this meeting,
and people feel strongly about their different positions. The important term there is feel –
they feel strongly, they do not think strongly. Both sides of this debate, the hospital and
social care, have pressures to accomplish particular things. The pressure to accomplish
those things are linked with feelings of self-preservation, of a sense of identity, a sense of
success or failure. The underlying drive to achieve these things, to maintain a sense of
equilibrium in everyday life leads to their feelings of anxiety that structure their
arguments in this exchange.
For Dr. A, the pressure to prevent yet another readmission is tied up with his
reputation as an intelligent, brave, successful clinician. He must get Mrs. V off his plate.
He feels anxious to do so. For Sara, the pressure to cut costs in social services and her
perceived moral obligation to at least give Mrs. V a fair chance at home structure her
anxiety and felt motivation. She is anxious too.
After all the arguments have been made and the rationality has run out, they
finally resort to this: Dr. A interrupting and raising his voice, and Sara simply repeating
her claim. There is no more reasoning to be had, simply a demonstration of the emotions
that really underlie this exchange.
For embodied cognition, the purpose might be to understand how these embodied
feelings structure the metaphorical reflexive processes, the rationalities, through which
25
the decision-making process occurs in this meeting. The goal would be to produce
positive feelings, a feeling of cohesiveness and purpose among this group, such that those
emotions drive a respectful discussion. An anxious, desperate tone would be avoided at
all costs. That will not lead to an effective transition plan.
Discussion and Conclusion
The theoretical positions discussed in this article have raised very different ways of
thinking about the special human trait we call “reflexivity”. The Actor Network Theory
of Latour avoids reflexivity altogether, the practice theory of Bourdieu highlights its
construction by interwoven systems of capital, and the embodied cognition of Lakoff and
Johnson locates reflexive thought in a system of bodily metaphors. Each of the three
perspectives displaces the ultimate importance of reflexive thought by offering
explanations of the processes by which it arises in collective, historical, social life. The
influence of the collective on how we think, on reflexivity itself, is emphasized.
Although reflexivity has been addressed critically in discussions of social science
methodology (Davies et al., 2004; Pillow, 2003), it remains a central focus of teaching
and writing about quality in qualitative research (Ravenek & Rudman, 2013). The
perspectives addressed in this article provide an implicit critique of qualitative
researchers’ faith in reflexivity as a strategy to guarantee the sound application of theory
and method in the course of a qualitative study. If the very ways in which we weigh
conceptual options, trace the steps in a line of logic, or imagine the significance of a
particular finding are in some way dictated by the fields that help to structure our habitus
26
(to use a Bourdeusian example), how much should we be investing in our own reflexive
process?
And yet, Bourdieu and his collaborator Wacquant themselves called for
reflexivity in social science as a means to bring the activity of our habitus and the
structures of the fields in which we live to our notice (Bourdieu & Wacquant, 1992).
They suggested that only through critical processes of reflexivity are scholars able to
identify the ways in which our own modes of thinking are constructed. Such reflexive
processes are really the foundation on which this article has been built – if reflexivity is
useless, than so has been this comparative intellectual effort.
Reflexivity might not be a panacea for reflection and action in the world, but
drawing on our own experiences of reflexive thought, it certainly seems consequential for
what we do and think every day. In this way reflexivity is neither the sole means to
conquer our social environments or a mere handmaiden to the discourses that surround
us; it is something in between. Archer (2010) described this as follows:
Structures exist, they impinge upon people by shaping their action contexts, but
they do not work by pushes and pulls upon passive agents. The reception of such
influences by active agents is therefore indispensable to understanding and
explaining the eventual outcomes, which are mediated through their reflexivity.
(p. 12)
Exactly how the influences of the social world, or “the collective” as I have referred to it
here, interact with our mental processes and habitual actions is far from being well
understood. Despite this recognition, there are those who feel they already have it right.
As Archer (2010) explained, those who side with a purely monadic individualist view of
27
the human subject on one end of the spectrum, and those who side with a purely cultural
determinist perspective on the other, will not be interested in exploring reflexivity any
further. Fortunately, the majority of scholars fall somewhere in between.
The space between the two poles of beliefs about reflexivity is the rich ground on
which the applications of theory to qualitative methodology and our relational reflection
on our assumptions can be challenged, advanced, and grown. If this article accomplishes
nothing else, I hope it encourages qualitative researchers to remain in this space,
acknowledging that we should never feel we have arrived at a final solution to the
questions of reflexivity and the acting subject. As theory and research continue in
unanticipated directions, surely we will find new and better ways of conceptualizing our
own reflexive processes by which we create those concepts in the first place. This
continued effort to refine our ways of thinking about and practicing reflexivity, and the
concurrent effort to revisit the ways in which we subjectify our participants, is central to
our commitment to analyzing and enhancing health and medicine through intelligent
applications of social science.
28
References
Ajzen, I. (2001). Nature and operation of attitudes. Annual review of psychology, 52(1), 27-58.
Archer, M. S. (2009). Conversations about reflexivity: Routledge. Beck, U., Giddens, A., & Lash, S. (1994). Reflexive modernization: Politics, tradition
and aesthetics in the modern social order: Stanford University Press. Berger, R. (2015). Now I see it, now I don’t: researcher’s position and reflexivity in
qualitative research. Qualitative Research, 15(2), 219-234. Bourdieu, P. (1984). A social critique of the judgement of taste. Traducido del francés
por R. Nice. Londres, Routledge. Bourdieu, P. (1990). The logic of practice: Stanford University Press. Bourdieu, P. (2011). The forms of capital.(1986). Cultural theory: An anthology, 81-
93. Bourdieu, P., & Wacquant, L. J. (1992). An invitation to reflexive sociology: University
of Chicago press. Carter, S. M., & Little, M. (2007). Justifying knowledge, justifying method, taking
action: Epistemologies, methodologies, and methods in qualitative research. Qualitative health research, 17(10), 1316-1328.
Crano, W. D., & Prislin, R. (2006). Attitudes and persuasion. Annu. Rev. Psychol., 57, 345-374.
Crossley, N. (2003). From reproduction to transformation social movement fields and the radical habitus. Theory, Culture & Society, 20(6), 43-68.
Davies, B., Browne, J., Gannon, S., Honan, E., Laws, C., Mueller-Rockstroh, B., & Petersen, E. B. (2004). The ambivalent practices of reflexivity. Qualitative inquiry, 10(3), 360-389.
DeForge, R., & Shaw, J. (2012). Back‐and fore‐grounding ontology: exploring the linkages between critical realism, pragmatism, and methodologies in health & rehabilitation sciences. Nursing inquiry, 19(1), 83-95.
Denzin, N. K., & Lincoln, Y. S. (2011). The SAGE handbook of qualitative research: Sage.
Doucet, A. (2008). “From her side of the gossamer wall (s)”: reflexivity and relational knowing. Qualitative Sociology, 31(1), 73-87.
Dowling, M. (2006). Approaches to reflexivity in qualitative research. Nurse researcher, 13(3), 7-21.
Finlay, L. (2002). “Outing” the researcher: The provenance, process, and practice of reflexivity. Qualitative health research, 12(4), 531-545.
Finlay, L., & Gough, B. (2008). Reflexivity: A practical guide for researchers in health and social sciences: John Wiley & Sons.
Foucault, M. (1982). The subject and power. Critical inquiry, 777-795. Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003).
Patients' and physicians' attitudes regarding the disclosure of medical errors. Jama, 289(8), 1001-1007.
Gergen, K. J. (1989). Social psychology and the wrong revolution. European Journal of Social Psychology, 19(5), 463-484.
29
Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age: Stanford University Press.
Glasman, L. R., & Albarracín, D. (2006). Forming attitudes that predict future behavior: a meta-analysis of the attitude-behavior relation. Psychological bulletin, 132(5), 778.
Koch, T., & Harrington, A. (1998). Reconceptualizing rigour: the case for reflexivity. Journal of advanced nursing, 28(4), 882-890.
Lakoff, G. (1995). Metaphor, morality, and politics, or, why conservatives have left liberals in the dust. Social Research, 177-213.
Lakoff, G., & Johnson, M. (1980). Conceptual metaphor in everyday language. The journal of Philosophy, 453-486.
Lakoff, G., & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to western thought: Basic books.
Latour, B. (2005). Reassembling the social-an introduction to actor-network-theory. Reassembling the Social-An Introduction to Actor-Network-Theory, by Bruno Latour, pp. 316. Foreword by Bruno Latour. Oxford University Press, Sep 2005. ISBN-10: 0199256047. ISBN-13: 9780199256044, 1.
Mauthner, N. S., & Doucet, A. (2003). Reflexive accounts and accounts of reflexivity in qualitative data analysis. Sociology, 37(3), 413-431.
Miller, P., & Rose, N. (2008). Governing the present: Administering economic, social and personal life: Polity.
Pillow, W. (2003). Confession, catharsis, or cure? Rethinking the uses of reflexivity as methodological power in qualitative research. International Journal of Qualitative Studies in Education, 16(2), 175-196.
Ratanasiripong, N. T., & Chai, K. T. (2013). A Concept Analysis of Attitude toward Getting Vaccinated against Human Papillomavirus. Nursing research and practice, 2013.
Ravenek, M. J., & Rudman, D. L. (2013). Bridging conceptions of quality in moments of qualitative research. International Journal of Qualitative Methods, 12, 436-456.
Ricoeur, P. (1970). Freud and philosophy (D. Savage, Trans.). New Haven, CT: YUP. Rorty, R., Williams, M., & Bromwich, D. (1980). Philosophy and the Mirror of Nature
(Vol. 401): Cambridge Univ Press. Semin, G. R., & Smith, E. R. (2002). Interfaces of social psychology with situated and
embodied cognition. Cognitive Systems Research, 3(3), 385-396. Shaw, J. A., & DeForge, R. T. (2014). Qualitative Inquiry and the Debate Between
Hermeneutics and Critical Theory. Qualitative health research, 24(11), 1567-1580.
Smith, D. E. (2005). Institutional ethnography: A sociology for people: Rowman Altamira.
Wallace, D. S., Paulson, R. M., Lord, C. G., & Bond Jr, C. F. (2005). Which Behaviors Do Attitudes Predict? Meta-Analyzing the Effects of Social Pressure and Perceived Difficulty. Review of general psychology, 9(3), 214.