The use of critical ethnography in managed mental health care settings.

How social workers in managed mental health care settings exercise their professional authority may have profound consequences for the provision of ethical and value-based services to vulnerable populations. Building upon Gidden's theory of structuration, this article describes the use of critical ethnography as a specific research methodology that may support social workers in the exercise of their authority. This article examines the historical roots of critical ethnography and provides a detailed examination of its underlying assumptions and research procedures. The article concludes with a case example of a critical ethnography conducted within a managed mental health care setting.

Keywords: critical ethnography, managed care, mental health, social work, professional authority

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Front-line social workers in managed mental health care contexts often experience cultural incongruence between management values and their own professional values. Among the most profound are those conflicts that exist between managerial and professional values (Furman, 2003; Scheid, 2003; Shapiro, 1995). Nonetheless, social workers may have opportunities to shape the procedures and practices of their managed mental health care organizations. This article will describe the utility of critical ethnography as a set of methods that may be used to assist social workers in becoming more consciously aware of how they take up their professional authority in managed mental health care contexts.

The revised code of ethics of the National Association of Social Workers (1999) stresses the professional obligation of social workers to incorporate the core values (i.e., service, social justice, dignity and worth of the person, importance of human relationships, integrity and competence) of Social work at all levels of practice, including their practice in organizations. The importance of upholding the core principles and values of social work practice is particularly crucial in today's managed mental health care settings. Indeed, the proliferation of for-profit managed care plans and the funneling of vulnerable individuals and groups into these plans has resulted in decreased quality care for persons with severe mental illness, including persons with fewer economic resources and those from marginalized racial and ethnic groups (Himelstein, Woolhandler, Hellander, & Wolfe, 1999; LaRoche & Turner, 2002; Mechanic, 2002, Mechanic, 1999, Mechanic & McAlpine, 1999; Sullivan, 1999).

Arguably, since its inception, social work has grappled with conflicts surrounding its professional identity. Indeed, as Cloward (1972) commented: "Among the various dilemmas confronting social workers, the most profound, although the least acknowledged or examined, is the conflict between our presumed role as helping agents and our bureaucratic role as agents of social control" [as cited by Racine (1984, p. 42)]. Perhaps nowhere is this conflict more evident than in managed mental health care settings, where social workers are increasingly replacing medical personnel as the more economical and hence preferred providers of mental health treatment (Cohen, 2003).

Despite these challenges, the current privatization of managed mental health care may provide social workers and other mental health professionals with opportunities to more proactively develop and create ethically-based programs and services geared to vulnerable populations. For example, effective case management and decision-making processes, roles that social workers typically assume in managed care settings, may be pivotal in ensuring quality services to consumers (Dobmeyer, McKee, Miler, & Wescott, 1990; Manning, Wells, and Benjamin, 1987; Rogers, Wells, Meredith, Sturm, & Burnham, 1993; Brady and Krizay, 1985). Therefore, the ways that social workers take up their organizational and professional authority in managed mental health care settings may have important consequences to consumers.

Authority has been defined in institutional contexts as "the given right to perform roles" (Kahn & Kram, 1994, p. 17). Historically, there have been at least two very different traditions or approaches to studying roles. The first is a structural view, espoused by traditional sociologists, most notably Talcott Parsons. A structural understanding of roles highlights its normative function, or the expectations that people come to expect from persons occupying particular statuses in the social structure.

Another approach to understanding roles emanates from a social-psychological perspective. This perspective focuses on the active processes involved in "making, taking and playing at roles" (Goffman, 1967). Within this tradition, roles are examined for their dynamic aspects, rather than their place in the social structure. Individuals are viewed as active in the process of taking up their roles.

Critical ethnography may well be suited for a study of how social workers take up their roles, both normatively and proactively, in managed mental health care settings. Specifically, critical ethnography may be used to examine how social work practices in managed mental health care contexts may serve to reproduce or maintain prevailing organizational structures and policies. Also, it may be used to discover how social work practice may change or recreate an organization's structures and policies.

Structuration and Social Practices

The exercise of authority by social workers in managed care settings may be conceptualized as occurring within a dynamic, historical, cultural, and interpersonal process of structuration (Giddens, 1993). Structuration theory posits that practice and structure form a transformational loop, with each influencing the other. According to structuration theory, social practices are influenced by the structures within which they occur, and, at the same time, contribute to the maintenance of those structures. However, feminists and other critics have charged that structuration theory emphasizes the deterministic nature of structure, rather than the transformational potential of human agency.

Giddens described structuration as "tie(ing) the structural integration or transformation of collectivities or organizations as systems to the social integration or transformation of interaction on the level of the life-world" (p. 131). The concept of structuration attempts to eliminate the distinction between action and structure and instead insists on the "interdependence of action and structure" (Campbell, 1996, p. 20).

According to Craig (1992), the concept of structuration gives "priority to social practices as opposed to actors and structures. The 'duality of structure' refers to the fact that structures are both produced by human action and are what Giddens called the medium of human action" (Craig, 1992, p. 43-44). In his theory of social practices, Giddens sought to retain the notion of praxis, defined as "the involvement of actors with the practical realization of interests, including the material transformation of nature through human activity" (Giddens, 1993, p. 53). Giddens [as quoted by Campbell (1996, p. 20)] defined action as "the causal interventions of corporeal beings in the on-going process of events-in-the world" (Giddens, 1993, p. 75; italics in original). The concept of structuration provides a theoretical basis upon which to conceptualize how critical ethnography may be used to assist social workers to better take up their professional authority in managed mental health care contexts.

The Utility of Critical Ethnography in Managed Care Contexts

Critical ethnography may be used to examine the ways that social workers in managed mental health care contexts may be constrained by organizational structures and policies (e.g., premature termination of services, pressures to follow specific treatment protocols, intrusions into professional and technical autonomy, lack of coordinated services, etc.) but, more importantly, it may also be used in the service of supporting social workers in the development of innovative and creative approaches that better meet the needs of clients. Thus, critical ethnography may be used in the service of achieving organizational 'praxis,' defined by Freire (1996) as "social action upon the world in order to transform it" (p. 36).

Critical ethnography has been described by Thomas (1993) as "the study of the process of domestication and social entrapment by which we are made content with our life conditions" (p. 7). Domestication refers to the ways that individuals' perceptions and behaviors are "tamed" by ideologies that "construct advance meanings and justifications for our actions and the actions of others" (p. 9). More importantly, critical ethnography seeks to resist reflexively processes of domestication and "unleash critiques" that expose "broader social processes of control, taming, power imbalance, and the symbolic mechanisms that impose one set of preferred meanings or behaviors over others" (p. 9). For example, critical ethnography can be useful to social workers in managed mental health care settings who may feel pressured to operate within a medical model approach and thus find themselves expected to provide mental health solutions to social welfare problems (Goldman & Morrisey, 1884).

Critical Ethnography versus Conventional Ethnography 

Critical ethnography is described as a "style of analysis and discourse embedded within conventional ethnography" (Thomas, 1993, p. 3), and thus shares several common fundamental strategies with it. These strategies include a "reliance on qualitative interpretation of data and core rules of ethnographic methods and analysis, an adherence to a symbolic interactionist paradigm, and a preference for developing 'grounded theory' (Glaser & Strauss, 1967)" (Thomas, 1993, p. 3).

However, critical ethnography differs from conventional ethnography in that it seeks to do more than just describe and interpret culture and cultural phenomenon. Critical ethnography seeks to change it. Specifically, critical ethnography seeks to make visible those covert structures of power and oppression that subtly and yet forcefully "construct and limit choices, confer legitimacy, and guide our daily routine" (Thomas, 1993, p. 6). Rather than remaining detached and neutral, critical ethnographers have a decidedly political agenda. They seek to unmask structures of social power and control. Thomas explains:

   Critical ethnography has a political purpose. It asks
   'what could be?'.... (It) refers to: ... the reflective
   process of choosing between conceptual alternatives
   and making value- laden judgments of meaning
   and method to challenge research, policy, and other
   forms of human activity (1993, p. 4).

Locating Critical Ethnography within Paradigms of Research

Guba and Lincoln (1995) offered a definition of a paradigm: "A paradigm may be viewed as a set of basic beliefs that deals with ultimate or first principles. It represents a worldview that defines, for its holder, the nature of the world and its parts" (p. 107). Critical ethnography may be distinguished from other research paradigms, such as positivist and post-positivist paradigms, on the basis of differences in ontology, epistemology, and methodology. Ontology refers to the nature of reality and how it is understood to exist, epistemology refers to the nature of knowledge or the "relationship between the knower or would-be-knower and what can be known" (p. 108), and methodology refers to how the inquirer goes about "finding out whatever he or she believes can be known" (p. 108). Illustrations of the differences among the three aforementioned paradigms of research along the dimensions of ontology, epistemology, and methodology will follow.

Positivism 

In the positivist paradigm, the ontological view of reality is that it is out there waiting to be apprehended and discovered. Within this paradigm, the epistemological assumption is that the researcher is capable of being neutral and objective. The belief is that research can be value-free and methodological procedures may be employed to reduce or eliminate bias in order to ensure the validity of data. The methodological assumption is that cause and effect relationships between variables are verified through experimental procedures and empirical tests.

Post-positivism

Within the post-positivist paradigm, the ontological assumption is that reality is believed to exist in an absolute form but cannot be understood positively or perfectly due to the fallibilities and imperfections of human processes of apprehension. Thus, the epistemological assumption is that the researcher's ability to be neutral and value-free is not seen as an absolute. Objectivity is considered an ideal to strive toward, even thought it can never be attained. Findings may be falsified, rather than verified. Research is typically conducted in naturalistic settings.

Critical Theory

In critical theory, reality is thought to be apprehendable, but what is taken as real is actually a "virtual or historical reality" (Guba & Lincoln, p. 110) shaped by "social, political, cultural, economic, ethnic, and gender factors, and then crystallized into a series of structures that are now taken as 'real'" (p. 110). There is no discrete distinction between researcher and researched, both are viewed as mutually influencing the other. The researcher cannot disavow or separate him or herself from underlying values or biases. The paradigm stresses dialogue and dialectical relationships between the researcher and research participants. The goal is to generate ways to transform consciousness and become more aware of the covert structures that influence consciousness.

Underlying Assumptions of Critical Ethnography

According to Thomas (1993), critical ethnography proceeds from the premise that "the structure and content of culture make life unnecessarily more nasty, brutish, and short for some people" (p. 33). Critical ethnography contends that "social constraints exist and research should be emancipatory and directed at those constraints ..." (p. 21). Emancipation refers to "the process of separation from constraining modes of thinking or acting that limit perception of and action toward realizing alternative possibilities" (p. 4). Critical ethnography seeks to identify those alternative possibilities and suggests ways that "we are able to change both our subjective interpretations and objective conditions" (p.18). The central premise of critical ethnography is that "one can be both scientific and critical, and that ethnographic description offers a powerful means of critiquing culture and the role of research within it" (p.vii).

Historical Roots of Critical Ethnography

Critical ethnography may be traced to both interpretive movements in anthropology and sociology and also to neo-Marxist and feminist social theory (Anderson, 1989). Interpretivists were concerned with redressing the over-determinism of positivist epistemologies by acknowledging the role of human agency and focusing on the native's point of view (Malinowski, 1922) and the importance of local knowledge (Geertz, 1973). Social life was viewed as consisting of meanings negotiated by individual actors engaged in social practices.

Neo-Marxist and critical feminists were concerned with the dialectical interplay between social constraints and human agency (Anderson, 1989). Critical feminists, in particular, underscored the importance of praxis or human agency and explicitly sought to "probe the lived realities of human actors and the conditions informing both the construction and possible transformation of these realities" (Dilorio, 1982, p. 22-23; as quoted by Anderson, 1989).

Critical ethnography was viewed as differing from both interpretivist and critical feminist ethnography in its assertion that "the perspectives of informants are necessarily permeated with meanings that sustain powerlessness and that people's conscious models exist to perpetuate, as much as to explain, social phenomena" (Anderson, 1989, p. 253). Anderson quoted Thompson (1981), who cautioned that research participants should not be "naively enthroned, but systematically and critically unveiled" (p. 143) thus stressing the importance of assisting participants in resisting and overcoming processes of "domestication."

The onset of critical ethnography in education is dated to the emergence of the "new sociology" in Britian (Anderson, 1989). During that time, in the 1970's, both Britain and the United States "saw the cross-fertilization of sociological phenomenology (particularly the works of Berger & Luckmann, 1967; Garfinkel, 1967; and Schutz, 1964) and Marxian social analysis" (Anderson, 1989, p. 255).

Among early critical ethnographers, Anderson (1989) noted a tension between an emphasis on the structural versus the phenomenological, with some favoring an emphasis on the structural (Sharp & Green, 1975), and others favoring an emphasis on agency (Willis, 1977). According to Anderson, (1989), early British critical ethnographers sought to maintain a balance between both Marxian conceptions of social structure and phenomenological concerns with human agency.

He further explained that American critical ethnographers "viewed ethnographic methods as a way out of what many saw as structural overdeterminism," (p. 256) which occurs when researchers are more concerned with issues of social reproduction, rather than resistance. Anderson stated: "American critical ethnographers ... turned to theories of social production that view the process of social and cultural reproduction as one filled with complex forms of resistance and accommodation" (p. 256).

Anderson offered what he characterized as a "persistent criticism" of educational critical theory, in its tendency toward social critique, rather than the development of "a theory of action that educational practitioners can draw upon to develop a "counter-hegemonic" practice in which dominant structures of classroom and organizational meaning are challenged" (p. 257). More recent efforts to empower research respondents through a process of "consientizacao" (Freire, 1996), which, as Anderson explains, "makes humans subjects rather than object of history," comprise efforts to assist critical researcher in the development of counter-hegemonic research practices. These practices include the use of oral history methods (Wexler, 1987), informant accounts and narratives (Gilbert & Abell, 1983; Meichler, 1986), and collaborative research endeavors (Freire, 1996; Mies, 1983; Aronowitz & Girouz, 1985; Wexler, 1987).

Thus, within the historical evolution of critical ethnography, the reciprocal relationship between structure and practice has been stressed, with researchers and theoreticians differing on whether to focus on the restraining and delimiting forces of structure, or the potential liberating effects of human agency. Thomas' (1993) conceptualization of critical ethnography and the research procedures that underpin it seeks to both acknowledge the "domesticating" effects of structure while seeking also to identify and support the potential transformational nature of human agency or praxis. In order to accomplish this dual task, the researcher must be open to scrutinizing the ways that he or she is indoctrinated into normative ways of thinking and acting, utilize research methods that seek to identify how research respondents may be similarly indoctrinated, while, at the same time, identifying areas in which human agency or praxis is actually taking place. Most importantly, the research procedures of critical ethnography are themselves designed to be praxial, or capable of creating transformative action and change.

Research Procedures of Critical Ethnography

Thomas (1993) proposed several data collection and analytic procedures that adhere to the underlying premises of his conceptualization of critical ethnography. First, to ensure accuracy and avoid processes of 'domestication,' the researcher must always scrutinize interview and observational data for imposition of the researcher's values. That is, the researcher must search for any instances of asking leading questions or prompts that do not emanate from the actual collected data. "It is as important to analyze interviewer's style of questioning and interjected responses as it is to interpret the responses themselves, because the interviewer's prompts can predetermine informants' discourses" (p. 39). Moreover, the researcher's questions must be examined for the extent to which they may be reproducing inadvertently prevailing organizational structures and attitudes.

Second, when interviewing participants, it is important to look for anomalies--contradictory answers, defying observed reality, cover-ups or gaps--in the data elicited. This is a way of getting underneath conventional responses to questions that may serve the purpose of impression-management and accessing a deeper level of meaning. By getting below the surface, the researcher may be able to identify areas of resistance and agency. Thomas suggested that interviewers need to be flexible and ready to ad-lib or reframe questions in order to get below the surface.

Third, Thomas proposed using a process of 'defamiliarization' to "look for non-literal meanings of our data texts" (p. 43). Defamiliarization is a way of distancing ourselves from the taken-for-granted aspect of what we see and allowing us to view what we have seen more critically. We take the collection of observations, anecdotes, impressions, documents, and other symbolic representations of the culture we studied that seem depressingly mundane and common, and we reframe them into something new ... The researcher decodes the ways that the symbols of culture create asymmetrical power relations, constraining ideology, beliefs, norms, and other forces that unequally distribute social rewards, keep some people disadvantaged to the advantage of others, and block fuller participation or understanding of our social environs (p. 43).

Moreover, Thomas contended that researchers must constantly and rigorously examine how their values and beliefs affect "data gathering, analysis, and subsequent display of data to an audience" (p. 46). Thomas explained that "through reflection, an act of repeated thinking about our project, we become self-aware of the process and consequences of knowledge production" (Thomas, 1993, p. 46). Also, the language we use to communicate our data to our audience must always be examined to identify "traditions, norms, institutions, artifacts and other characteristics of culture that provide access into the netherworld of mundane life to unblock alternative metaphors and meanings" (p. 45-46). According to Thomas, two main questions guide critical reflexivity. First, how does one's ideology influence the work? Second, how does the research challenge injustice and what are the implications for action?

Critical Reflexivity

Anderson (1989) contended that a consideration of reflexivity is not new to critical ethnography and has been a central topic in any discussion of ethnographic methods and procedures. Historically, reflexivity has included a consideration of the relationship between theory and data (Glaser & Strauss, 1967), as well as a reflection on the effects of the researcher's presence on the data collected (Hammersley & Atkinson 1983; Lincoln & Guba, 1985).

However, in critical ethnography, the role of reflexivity may also be expanded to include a consideration of the dialectical relationship between structural/historical forces and human agency (Anderson, 1989). Anderson summarized reflexivity in critical ethnography as including a consideration of the dialectical process among "(a) the researcher's constructs, (b) the informants' commonsense constructs, (c) the research data, (d) the researcher's ideological biases, and (e) the structural and historical forces that informed the social construction under study" (p. 254-255).

Critical Ethnography: A Case Example

Between the spring of 2002 and the summer of 2004, this author conducted a critical ethnography within a large health maintenance organization (Bransford, 2006). The purpose of this critical ethnography was to examine the practice of authority--personal, professional, and organizational--by individual social workers in a managed mental health care organization. The study focused on 17 individual social workers in two outpatient mental health centers of a large, northeastern health maintenance organization (HMO), and identified and critically examined the historical and cultural precedents, contexts and conditions (e.g., organizational, interpersonal, and intrapersonal) that facilitated or inhibited their exercise of authority. A theoretically-based, underlying assumption of the study was that the practice of authority by social workers in managed mental health care settings may provide a legitimate basis upon which they may strive to create organizations that more effectively support the ethical principles and values of professional social work practice.

Methods of Data Collection and Analysis

Methods of data analysis included a combination of participant observation, document analysis, in-depth interviews, and focus groups. A focus group was convened at each of the two study sites to review preliminary findings and to solicit the input of participants in a process of refining and clarifying conceptual propositions derived from data analysis. Additionally, the focus groups provided an opportunity for social work participants to "use critical knowledge for social change" (Thomas, 1993, p. 4).

The interviews with staff members were both informal and formal. The informal interviews were designed to provide anecdotal material and "off the cuff' observations of the uses of authority in the exercise of group and organizational tasks in the two study sites. The formal interviews included open-ended, semi-structured questions that asked individual respondents to provide examples of their subjective experiences of exercising their authority in work contexts. Interpersonal processes between interviewer and interviewee were examined to provide further illumination about how authorization was conferred or not conferred by both participants to the interview. When respondents allowed, the interviews were audio-taped, transcribed and examined for historic and cultural precedents, contexts and conditions surrounding processes of authorization and de-authorization.

Organizational texts (meeting minutes, memos, and other presentations and representations of organizational life) were examined to identify "how people are constrained by the constructions they build and inherit from the past" (Denzin 1992, p. 23), and to understand how people may liberate themselves from these constraints (Freire, 1996) and perform "social action upon the world in order to transform it" (p. 36). Analysis of organizational texts assisted in the generation of interview questions and in providing contextual data (e.g., historical, organizational, structural) relevant to processes of authorization and de-authorization.

Focus groups were convened to provide respondents who participated in the individual interviews with an opportunity to discuss and develop critiques of propositions that emerged from the analysis of data. This kind of "member checking" was used to corroborate and/or disconfirm the interpretation of observational and interview data and to encourage respondents to take up their authority in the service of data analysis. Study participants were asked to reflect on how the experience of participating in the study affected their experience and use of authority in organizational contexts. Moreover, the use of focus groups provided additional opportunities to observe authorization and de-authorization processes occurring among participants, and to note discrepancies between focus group data and data from participant observation and individual interviews (Morgan, 1997).

Methods of data analysis were consistent with those proposed by Thomas (1993) and included de-familiarization, searching for anomalies, and the use of critical reflexive practices. The analysis was thickened through the use of field notes, memos, and through constant referral to both grounded and extant theory. The ongoing processes of data collection, analysis, and reflexivity were used to inform and enrich each part of the process, such as interviewing organization members and critically analyzing the relationship of the researcher to the setting. Moreover, the joint processes of observation and participation are the hallmarks of praxis--critical reflection and purposeful action.

Results

Several salient authorization processes were identified that could be used to assist social workers with better taking up their professional authority in managed mental health care settings.

These authorization processes included identification with clients' struggles and needs; staying within the boundaries of one's work role; degrees of freedom from organizational acculturation; internalized role models; age and experience; turning point and last straw experiences; and having time and space to think through and process ideas. Virtually all of the respondents across all systems of analysis identified supportive and collaborative relationships with others as conducive to a successful exercise of professional authority

De-authorizing processes included repercussions for speaking up, fear of conflict, concern about losing organizational privileges, overt and covert collusive practices occurring between management and workers, and subtle degrees of power among psychiatrists, psychologists and social workers. Gender, class, age and race were mitigating factors in the ability of social workers to exercise their authority. Subversive practices, such as extending sessions beyond their prescribed limits or reclassifying psychotherapeutic groups as psycho-educational groups to avoid the institution of co-pays or session limits, were identified as comprising covert efforts to exercise professional authority in a managed mental health care organization.

Moreover, a number of respondents reported, both within individual interviews and in the focus groups, that they felt better able to engage in organizational change strategies as a result of their participation in the research process. For example, within individual interviews, respondents were asked to identify and analyze episodes of authorization and de-authorization in organizational contexts and thus were enabled to discover strategies for organizational change.

Conclusion

This article has defined and described critical ethnography as a research methodology that may be used by social work researchers in managed mental health care settings to make those settings more amenable to the underlying values of social work practice. The analytic procedures of critical ethnography seek to make visible those organizational structures and policies that may constrain workers from exercising their professional authority in managed care contexts, such as organizational imperatives that classify individuals into diagnostic categories rather than develop programs and services that promote social justice or change. The goal of these procedures is to identify ways that workers may more consciously take action to change those organizational structures and policies that impede the provision of quality services to consumers. Researchers could use these findings to help shape social work policy, practice, and education.

In addition to social work researchers conducting critical ethnographies that adhere to the rigors of formal research, line social workers in these settings could utilize some of the analytic procedures of critical ethnography as heuristic tools in their organizational practices. For example, workers could carefully examine their ways of both interviewing and conceptualizing their clients' difficulties in living for imposition of personal and cultural assumptions and biases. They could also examine their own reflective processes for anomalies or contradictory answers in order to avoid ubiquitous human tendencies toward self-deception and to penetrate to a deeper level of understanding. This could be done through reflexive processes occurring before, during and after therapeutic sessions, and also in reaction to meetings, memos, documents, and other organizational texts and artifacts.

Workers could adapt procedures of de-familiarization into their clinical work. Thus, they could critique their work with clients for the extent to which they are actually meeting their clients' needs, rather than simply conforming to a strictly medical model approach. Also, by critically examining their organizational practices, social workers could assess whether they are exercising methods of social control or advocacy in their work with consumers.

The fact that managed mental health care delivery systems are increasingly used to treat vulnerable populations previously served by human service organizations makes crucial the need for social work researchers to utilize critical methodologies that don't seek simply to understand managed care policies and social work practices, but also seek to change them. Critical ethnography offers a set of methods that aim to fulfill that purpose.

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