Reflexivity

Reflexivity has been described as turning a critical gaze towards oneself (Finlay, 2003). In qualitative research, the researcher is seen to play an important role in the construction of knowledge. Finlay illustrates this by stating:

As qualitative researchers, we now accept that the researcher is a central figure who actively constructs the collection, selection and interpretation of data. We appreciate that research is co-constituted - a joint product of the participants,

researcher and their relationship. We realise that meanings are negotiated within particular social contexts so that another researcher will unfold a different story. (Finlay, 2003, p. 5)

Given the researcher’s important role as a lens through which the data are constructed and interpreted, reflexivity allows the researcher’s influence to become transparent and act as a strength rather than a weakness (Finlay, 2003). It should be mentioned that my supervisors’ and co-authors’ disciplinary backgrounds will have impacted the design and interpretation of the studies presented here. Two of my supervisors, Prof Binder and Prof Sandal have academic and clinical experience in clinical psychology.

My third supervisor, Prof Diaz, has academic and clinical experience from migration and health and Family Medicine. The remaining co-authors had experience from social psychology, cross-cultural psychology, and medical anthropology. Similarly, this research was regularly presented to and influenced by a reference group, including stakeholders in the local municipality and GPs, some of which had Syrian and Somali refugee backgrounds. Their feedback during the design and interpretation phase are also likely to have influenced the studies presented here. Consequently, the studies are highly influenced by traditions and experiences from several disciplines and lived experiences beyond my own. As the first author, however, I will focus on my own reflections in the following section.

In line with Finlay’s view, Braun and Clarke’s reflexive thematic analysis approach sees researcher subjectivity as a resource. They argue that themes do not passively emerge but that the researcher is at the heart of the knowledge production (Braun &

Clarke, 2019). Therefore, it is highly important that the researcher engages in reflexivity to gain an insight into how their own view of the world may influence their work.

Our expectations about how things ought to be, or work, are based on what we previously have experienced. Consequently, my expectations of mental health and health care are heavily influenced by my own experiences with it. I grew up in Berlin,

Germany, around the turn of the millennium. While I did not personally encounter mental health services while growing up, and neither did many around me (at least not to my knowledge), I grew up with the belief that mental health was real and distinct from physical health. While there was some stigma attached to mental illness (not depression and anxiety disorders so much as psychotic disorders), I was aware of the existence and importance of psychologists, psychotherapists, and psychiatrists, perhaps moreso than others since I took a keen interest in abnormal psychology at a relatively early age. My surroundings imparted upon me the idea that mental health is important, and that mental illness is just that, an illness, that can be cured. I have since challenged my taken for granted beliefs around mental illness, having witnessed discussions within the field of critical psychiatry as well as having worked with clients with mental health problems. However, I feel that certain underlying assumptions remain. These include the idea that mental illness is something an individual is not to blame for, that some individuals can gain a lot from mental health interventions, that studying and better understanding mental health is valuable, and that mental health professionals are indispensable, including GPs, who often treat mild to moderate cases of mental health problems without referral to specialist services. These assumptions undoubtedly influenced the design of the current studies and study materials/methods, as well as my interpretation of both the qualitative and quantitative results.

The assumption that mental health exists underlies all papers in this thesis. Paper 1, for example, explored the experiences of GPs working with refugees suffering from mental health problems. More specifically, however, when considering this

underlying assumption, we are examining GPs’ experiences working with refugee patients whom GPs have deemed to suffer from mental health problems. I felt that this slight adjustment in nuance is important for the appropriate interpretation of the results.

Another element to reflect on in the context of this thesis is my status as an

immigrant, whose native language is not Norwegian. Gadamer claims that ‘language is the universal medium in which understanding occurs’ (Gadamer, 2013). An obstacle I faced during the qualitative interviews in paper 1 was my limited knowledge of the Norwegian language. I gave participants the choice to hold the interviews in Norwegian or English (or German, although nobody chose this option).

I felt that participants would be able to express themselves more precisely in the language in which they felt most comfortable and that their comfort was more important than my own, given that it was their narratives I was trying to gain insight into. Most participants chose to conduct the interviews in Norwegian, naturally.

While this filled me with some dread initially, I invited a Norwegian-speaking researcher to observe the first three interviews to ensure that the language barrier was not an obstacle for effective communication. We concluded that even with my limited knowledge of Norwegian, I was able to understand and transcribe the interviews accurately. I furthermore invited one of our Norwegian-speaking research assistants to compare the audio recordings of the interviews with my transcriptions to check for mistakes prior to conducting the analysis.

I eventually considered that my Norwegian language skills might even be an asset, allowing me to probe deeper into phrases and experiences I may have taken for granted in my native languages. For example, one of the participants mentioned that information from the patient came in ‘fragments’ or ‘bits and pieces’

(‘bruddstykker’). I asked the participant to explain what they meant, as I was not familiar with the term. They continued to explain that the patient did not enter the consultation and immediately state their name and age and explain their entire life story. Instead, the patient entered the consultation and focussed initially only on certain symptoms, such as restlessness, racing thoughts, lack of sleep. The participant then explained that the patients’ beliefs about the potential causes of these symptoms were only revealed after a few meetings. This clarification showed me that the

‘bruddstykker’ this GP was referring to, were in fact different types of information

that were being revealed as opposed to bits and pieces of, for example, symptom presentations. This allowed me to further reflect on the role of a trusting relationship between GP and patient, which may facilitate the sharing of important information. In this situation, my linguistic weakness became a strength, because I gained a deeper insight into the GP’s narrative.

In a similar vein, I became aware of my potential status as an outsider, not only as an immigrant with broken language skills, but within my role as a non-GP researcher. In research, an ‘insider’ shares the ‘characteristic, role, or experience under study with the participants’ (Dwyer & Buckle, 2009). However, the more I reflected on this, the more I found that I am both an insider and outsider in this research. While I am not a medical doctor, and therefore not strictly an insider, I am aware of some of the challenges of working in a clinical setting, as well as working with individuals from different cultural backgrounds. Before moving to Norway, I worked in the UK’s national health service as a psychological wellbeing practitioner with clients suffering from mild to moderate depression and anxiety disorders. I remember working with a client, who did not speak English as a first language. She decided against using an interpreter in our sessions, because she felt this would stand in the way of her being able share her experiences with me comfortably. The language barrier was a significant obstacle in our work. I noticed myself becoming frustrated and worrying about how to communicate with her let alone do any therapeutic work. This meant that our sessions often ran over time, and she eventually dropped out of treatment.

While these types of experiences have made me more sympathetic to some of the challenges GPs may face working with refugees, they also put me at risk of ‘being inherently biased, and too close to the culture to be curious enough to raise provocative questions’ (Merriam et al., 2001). Having reflected on this I made an active effort to see the GPs’ experiences as distinctly different from my past experiences.

On the other hand, I was also an outsider. Despite certain commonalities, the

interviews made me acutely aware of aspects the GPs and I did not have in common.

During one interview, the participant pointed out that I must know a lot about a certain mental health diagnosis if I work in psychology. While I was familiar with the diagnosis she mentioned, I later felt that I should have probed deeper into what the diagnosis meant to her.

It was vital to be aware of the effect my insider/outsider status might have on the interpretation of the data. However, ultimately, neither is more beneficial than the other, and ‘what an insider ‘sees’ and ‘understands’ will be different from, but as valid as what an outsider understands’ (Merriam et al., 2001).

Previous literature has often mentioned the important role of cultural context in our understanding of mental health. Therefore, I attempt to extend my reflections beyond personal reflexivity to cultural reflexivity. According to Aronowitz and colleagues:

The lens of cultural reflexivity is central to inquiries about how and why people act in certain ways and not others. (Aronowitz et al., 2015, p. 403) For example, while I did not interview Syrian refugees in paper 3, I still believe it is important to reflect on the potential power imbalance in this research. Despite using quantitative methods, which ideally aim to be limit researcher bias, I believe that research typically prioritizes the researcher’s voice over the participant’s voice. It is the researcher that is allowed to interpret the data and tell a story in the research paper, rarely the participant alone.

For example, in paper 3, while the help-seeking sources presented were based on previous literature, this literature was largely conducted in Europe and North America. Participants could choose one of the pre-suggested sources of help, or the choice ‘Other’. It is important that we are aware of the influences of our underlying assumptions that can permeate the earliest stages of research and therefore colour the entire research process. However, it is notable that participants indicated they were

relatively unlikely to seek help from an ‘Other’ category. This suggests that while we must be aware of how our choice of categories may have influenced our participants, it is possible that there was no significant omission in relevant sources of help.

Similarly, the idea that mental health exists and can be treated is an underlying assumption in the survey that would have put participants in a situation where they are required to respond despite a premise they may not necessarily agree with. While several participants indicated that they would not seek help for the experiences reported by the vignette character, it is unclear whether they see those experiences as poor mental health or something else entirely. Aarethun and colleagues’ paper (2021) gives some insight into this issue, suggesting that Syrian refugees recognized

symptoms of PTSD and depression and, in some cases, even named them as such.

However, they also add that PTSD, for example, was seen as a normal reaction to extreme situations and depression was often discussed in terms of feelings caused by social problems, and that individuals were hesitant to identify with the diagnoses of depression and PTSD even in cases where symptoms were recognized. I attempted to keep these insights in mind when interpreting data from paper 3, but think it is important to acknowledge that my voice as a researcher is likely to have trumped that of the participants.