Lifestyle Interventions and Mental Illness, Article Critique Example

Abstract

This paper examines an article in the 2013 issue of the Journal of Advanced Nursing entitled “An ethnographic study of the incentives and barriers to lifestyle interventions for people with severe mental illness [SMI]” (Roberts and Bailey).  I begin with an introduction and rationale for the paper, then discuss the literature of the field; methodology; ethics; data-collection  strategies; data analysis; lessons learned; and then move to a general discussion of the article and its limitations as I see them. I end with some observations on the undiscussed role of smoking among schizophrenics and comments found in the scientific literature about it.

Keywords: e-cigarette, ethnography,  heuristic, intervention programs, midwifery, nursing, qualitative analysis, qualitative data, schizophrenia, semi-structured interview, thematic analysis, vaping.

Introduction and Rationale of the Paper

In Clara Barton’s time of the American Civil War,  nursing (and often doctoring) was mainly about ministering to the suffering by using one’s common sense — anyone with human sympathy and a strong stomach and a sharp knife could do it, if not necessarily for long (it finally exhausted the poet Walt Whitman during his own Civil War nursing work)  (Burns, 1989) (Jeffords). If anything, midwifery must have been more of a profession, founded as it was on repeated experience of essentially the same condition, if not grounded by scientific theory and method. But much has changed, both in theory and in practice. Nursing and midwifery is based solidly if not entirely on five-step research now, which can be summarized as follows: 1)  problem, purpose, hypothesis; 2) review of literature; 3) methodology; 4) results of data analysis; and 5) discussion of results (Summers, 1991).

Because nursing/midwifery is now so research-based, both professions have been increasingly about intervention and the monitoring that must precede and follow it. Nurses and midwives might almost be thought of as clinically trained social workers, in the sense that, within formally defined boundaries, they have what amounts to a license to intervene in the lives of others. Social workers have clients in the field (as do midwives), and nurses have patients in hospitals. Nurses and midwives, as data gatherers and front-line observers, often see the details and narrower patterns that physicians and academic researchers might and often do miss.

The Roberts and Bailey article discusses a study that is not itself an experiment, and no predictions were made as to outcomes. Instead, ethnographic data was gathered in a study attempting to discover the best way to manage future interventions in the lifestyles of the severely mentally ill. For this reason, it is an example of a contribution to heuristic, evidence-based clinical practices. The method of data-collection was qualitative, using the two standard methods of participant observation and in-depth interviews. Thus, the patients of the Roberts and Bailey study may not be, or have been, the biggest beneficiaries of the study itself. Like so much of the practice of Western medicine, a given patient’s treatment for a given condition may end up benefiting him little or none, instead benefiting future patients, as the conditions of many such patients today are compared and observed over time for future treatment. Data collected leads to experimentation, with predictions made, treatments developed, and results examined. Should the experiment fail, it may be repeated or another approach tried, depending on the potential of the condition to spread and whether developing a treatment will be economically worthwhile. Studies like this one may be considered exploratory steps.

Literature Review

An excellent literature review of the field of lifestyle intervention was published in 2010 (Cabassa, Ezell and Lewis-Fernandez, 2010). It can be considered current and comprehensive for the purposes of this paper, although the Roberts and Bailey study is not included, as it was not published until 2013. All twenty-three articles reviewed were written in English and published in the United States. (Roberts and Bailey studied patients in the United Kingdom.) The review did not limit itself to qualitative studies, including as it did group reports (like those of Roberts and Bailey) as well as “quasi-experimental studies, and randomized controlled trials.”

One difference or similarity is that the Cabassa study points out that “Persons from racial and ethnic minority groups were underrepresented, especially Hispanics and Asian Americans.” Roberts and Bailey do not mention race at all, not even as a cautionary point. Thus the matter of bonding or lack of it between subjects and staff, mentioned as being a key attribute by Roberts and Bailey, is left without a background detail that could be critical for some individuals. Also it should be remembered that the latter study is not about the benefits of particular treatments of lifestyle interventions for the mentally ill, but rather incentives and barriers to lifestyle interventions for such people. So the study is about the staff as much as it is about patients, and race is still often a marker of a person’s socioeconomic level. It can be assumed that the race and education of staff and patients will be a factor, at least in some cases. This problem presumably exists as well in the studies covered by Cabassa, et al. Regardless, Cabassa’s study concluded that “Lifestyle interventions adapted to persons with serious mental illness show promise in reducing weight loss and some risk factors for metabolic syndrome.” Roberts and Bailey concluded “[Our] study provides evidence about the incentives and barriers to lifestyle interventions from service users’ perspective, which should inform developments to improve the delivery of lifestyle interventions for this group.” So the study reviewed here is in basic agreement with related literature.

Methodology

“Data collection was carried out through participant observations and semi-structured interviews with eight mental-health service users [six of them male] attending, or previously attended, a group-based lifestyle intervention. Interview data were collected between September 2008–April 2009 and observation data were collected between September–December 2009.”

The term semi-structured interview is a distinctive type of interview[1] used especially in the social sciences (Longhurst, 2010). It allows for a small sampling of people, typically with a behavior problem or characteristic in common. Whatever it is that links them together, it is serious or potentially serious enough to warrant study and solution or resolution. They are brought together in a relatively comfortable environment to talk, to share experiences, and be guided in a non-judgmental manner by a facilitator who has organized the meeting. According to Longhurst, the size of the group is usually between six and twelve, so the eight-person meeting described in the Roberts and Bailey paper fits the pattern.

Ethics

There is an entire literature review on the subject of the ethics of in-depth interviews, whether personal or group-based  (Allmark,et al., 2009). Themes discussed throughout the literature include privacy and confidentiality;  informed consent; harm (to both interviewer and interviewee, whether due to subject matter — such as bereavement — or interviewing subjects in dangerous settings); dual roles (being a nurse and a counselor, for example, and being drawn to one role over the other); over-involvement (seeking to protect the interviewee, becoming friends with that person, etc.); and “politics and power” (referring to how the interviewer can manipulate the interviewee, willingly or not). Roberts and Bailey report that all the standard ethical precautions were taken to protect the rights of everyone concerned.

Data Collection Strategies

Data collection strategies for academic studies are necessarily determined by the goal or purpose of each study. In the Roberts and Bailey study, the goal was to identify barriers and incentives to lifestyle interventions of the severely mentally ill — not so much the interventions themselves. More specifically, researchers were “especially interested in behaviours or activities indicating incentives or barriers to attendance,” of the interview sessions. So the barriers and incentives being discussed are entirely client-side — the researchers themselves presumably have their own barriers and incentives, not covered (at least directly) by this study. As noted earlier, the two principal methods — strategies — to data collection were overt participant observation and interviews, the latter being semi-structured.  The standard “nine dimensions of observation: space, objects, acts, activity, event, time, actors, goals, and feelings” provided the matrix by which the data would be organized for analysis. That data was hand-written during interviews, and later typed (probably into Word) and then imported into NVIVO8 thematic analysis software.  Each participant was interviewed once, one-on-one, over a seven-month period, from September 2008 – April 2009. They were recorded (probably electronically, but not covertly), transcribed, and also imported into NVIVO8. Patient quotations were anonymous.

Within the framework of group discussions (which took place from September – December 2009) there were standard operational strategies used to elicit relevant, accurate data: providing the right environment; maintaining an effective, non-judgmental facilitator style; building and maintaining group cohesion; and sharing information to facilitate two-way learning between facilitator and interviewees. The goal of this strategy was, as stated earlier, to learn the incentives and barriers to lifestyle-intervention programs. Analysis of the data was part of the overall strategy, summarized as follows: “Thematic analysis was performed as described by Braun and Clarke (2006)”, which I will now discuss.

Data Analysis

The Braun and Clarke study referred to above discusses “thematic analysis” in psychology. It admits that, at least at the time of its publication in 2006, that thematic analysis was a “poorly demarcated, rarely-acknowledged, yet widely-used qualitative analytic method within psychology” (V., 2006). Yet they argue that such analysis “offers an accessible and

theoretically-flexible approach to analysing qualitative data” both within psychology and beyond, a point at least partially confirmed by the Longhurst qualitative-study reference included in this paper (see “Key Methods in Geography”). The key point here is that the data is qualitative — basically subjective, at least much of the time — rather than purely statistical and quantitative. Although there probably would be plenty of quantitative data, it would likely play a support role in a fundamentally qualitative study.

The relevance of the Braun and Clarke study to Roberts and Bailey may best be seen in its statement that “Qualitative analytic methods can be roughly divided into two camps.” In the first, “one recipe guides analysis”, meaning that data is interpreted by the researcher’s theoretical approach, whether it is “conversation analysis”, “interpretative phenomenological analysis”, or whatever. But in the second camp “. . .  there are methods that are essentially independent of theory and epistemology, and can be applied across a range of theoretical and epistemological approaches” and for this reason is thought of as a “realist/experiential” method. In other words, just roll up your sleeves and get the data: record the interviews, guide the discussions, code the data in NVIV08 and see what patterns and hidden facts you and your colleagues can find. If it is the first study of its kind within your field, you would want to cast a wider rather than a narrower net. One question is whether, lacking the theoretical rigor of the first camp, researchers would over- or under-rely on software coding of possible themes within the data; but this is probably as much dependent on each researcher, or each researcher’s lead investigator (who may do the coding) as the type of qualitative method.

Lessons Learned: Results of Data Analysis

What was learned? Probably the most important thing learned was surely known beforehand simply by virtue of meeting the participants: that obesity plays a big part in the lives of  many mentally ill and disabled people. In this study, it is reported to have affected all of the participants. They don’t eat right; their antipsychotic medications may interfere with maintaining a normal and healthy appetite (or even health itself, especially if combined with other drugs); they don’t exercise enough (the reason for that lack of exercise being one of the target barriers of future intervention programs); and schizophrenics — seven of the eight participates were diagnosed as schizophrenics —  are known to smoke heavily as a self-limiting form of self-medication. (Nicotine spurs the production of a neurotransmitter that acts as a “stop light”, regulating signals among the hundred billion neurons in the human brain) (Zelkowitz, 2008).

Each of the subjects was weighed (individually, in a separate room) after removing their shoes, excess clothing, and emptying their pockets. The prospect of this was a big barrier for some of the participants — no one wanted to be the heaviest. (Although that information was probably not made public, participants may have initially thought it would be). Others liked it or were at least less intimidated by the prospect of it. All of them regarded a weight-loss program as a powerful incentive for attending. Since participants evidently engaged in at least some group exercise, in reading the study, one gets the feeling that it was principally a kind of Jenny Craig program for the mentally ill — a good thing to have.

In all, five themes were identified as incentives and barriers to attendance: weight measurement (fear vs. benefits of monitoring); apprehensiveness about meeting new people with problems like their own (principally obesity and mental illness); negative attitudes of healthcare staff; dealing with new persons of authority in their lives; knowledge or lack of it regarding specific benefits for attending.

Discussion

The discussion section is probably the most interesting part of the study. (One might even read it first.) One learns something new right off: “The desire to lose weight was the single most important motivator for attending a lifestyle intervention.” Although the article does not say so, I think that is something most people probably would not be aware of. One does not automatically associate a mental illness like schizophrenia with obesity because many people encounter schizophrenics as homeless people on the streets. Such no-med individuals are less likely to be obese, dependent as they are on rations of basic Red Cross–style shelter food and the necessity to gather their belongs come daybreak and walk the streets. In any case, weight loss was the leading and perhaps only important incentive to attend a lifestyle intervention program, although the desire for social interaction was also important for some, as was the fear of it — another barrier.

Limitations and Conclusions

There is no way of knowing (it is not said in the paper itself), whether some or all of the individuals in the study were institutionalized. I think this is a crucial point and its absence from the study is puzzling, although it might have been meant to be taken for granted. Even so, the implications for a study like this is unmistakable. If they (one was diagnosed with a personality disorder instead of clinical schizophrenia), it is possible that the present study may be a way of creating interventions within the context of a given institutional home for such patients. Or it may be a way of getting them out of their daily environment for a day once a week or month. (The schedule for this studied group of participants was once a week for ten weeks.) Or it might evolve into both — probably the most likely outcome. But here one problem or possible problem arises. The study itself points out: “Negative views expressed by healthcare professionals were considered highly discouraging, supporting previous findings . . . Participants wanted healthcare professionals to be knowledgeable to provide appropriate lifestyle advice and information,” which we may take as being an interpretation of their original words, which were no doubt less scholarly in words and tone.  In any case, staff attitude is important if not critical, which leads me to conclude that the most successful lifestyle interventions for this kind of “clinical group” will be located outside their normal day-to-day environment. Adding to this complication was the age-range of the subjects: 24–66 years and the gender ratio of six males to three females, although the authors state that the age range of both sexes was good.

One matter did jump out at me, which I will end this paper with. As I mentioned, schizophrenics smoke to self-medicate, and the process is self-limiting (both as to dose and unsubsidized, pocketbook expense). The authors state that “Our evidence suggests that efforts to motivate people with SMI through rewards and financial incentives are unlikely to be effective or sustainable. Financial incentives for smoking cessation in the general population do not improve outcomes long-term. We therefore suggest focusing efforts on other incentives, such as social networking and the learning needs for this clinical group.”

It may be that the authors were unaware of the link between schizophrenia and smoking, but I think they may have simply chosen to ignore it. It may be that the phrase “learning needs for this clinical group” includes educating and training schizophrenics in the use of nicotine patches or, more recently, e?cigarettes. On the other hand, others apparently want schizophrenics to stop smoking without reference to nicotine’s apparent benefit  (Harding, 2014). This is a point worth dwelling on because it indicates to me a kind of disconnect among the community of clinicians involved with schizophrenics.

Consider that Harding, in the reference above, quotes Dr. Eden Evins, of Massachusetts General Hospital in Boston, as follows: “The gene that codes for the alpha-7 nicotinic receptor has been tied to schizophrenia and, recently, to bipolar disorder.” But another study says “Nicotine, a low-potency agonist at the alpha7 receptor, has some positive effects on neurophysiological and neurocognitive deficits associated with schizophrenia” (Olincy, 2006). What seems to have been forgotten is that when people quit smoking they generally gain weight. My conclusion is that e-cigarettes will increasingly be used by schizophrenics.

References

Allmark, P., Boote, J., Chambers, E., Clarke, A., McDonnell, A., Thompson, A., & Tod, A. (2009). Ethical issues in the use of in-depth interviews: literature . Research Ethics Review, 48-54.

Burns, K. (Director). (1989). The Civil War [Motion Picture].

Cabassa, L. J., Ezell, J. M., & Lewis-Fernandez, R. (2010). Lifestyle Interventions for Adults With Serious Mental Illness: A Systematic Literature Review. Psychiatric Services, 774-782.

Harding, A. (2014). Extended Smoking Cessation Treatment May Help Schizophrenia, Bipolar Patients. Retrieved from PsychCongress Network: http://www.psychcongress.com/article/extended-smoking-cessation-treatment-may-help-schizophrenia-bipolar-patients-14787

Jeffords, C. (n.d.). Doctors, Healers, and Health: The State of Medicine in the Old West. Retrieved from Ancestory.com: http://freepages.genealogy.rootsweb.ancestry.com/~poindexterfamily/ChristinesPages/Doctors.html

Longhurst, R. (2010). Semi-structured Interviews and Focus Groups. In N. Clifford, S. French, & G. Valentine, Key Methods in Geography (pp. 103-116). London: Sage.

Olincy, A. (2006). Proof-of-concept trial of an alpha7 nicotinic agonist in schizophrenia. Arch Gen Psychiatry, 630-8.

Roberts, S. H., & Bailey, J. E. (2013). An ethnographic study of the incentives and barriers to lifestyle. Journal of Advanced Nursing, 69(11), 2514-2524.

Summers, S. (1991). Defining components of the research process needed to conduct and critique studies. Journal of post anesthesia nurses, 50-55.

V., B. V. (2006). Using thematic analysis in. Qualitative Research in Psychology, 77-101.

Zelkowitz, R. (2008, October 14). Why Schizophrenics Smoke. Science Now.

[1] Interviews may also be formally structured and unstructured.