566614 research-article2015
HPQ0010.1177/1359105314566614Journal of Health Psychologyvan Vuuren and Westerhof
Article
Identity as “knowing your place”: The narrative construction of space in a healthcare profession
Journal of Health Psychology 2015, Vol. 20(3) 326–337 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314566614 hpq.sagepub.com
Mark van Vuuren and Gerben J Westerhof
Abstract The construction of space in which a story takes place can have important consequences for the evaluation of health interventions. In this article, we explore the ways professionals narratively position themselves in a situation, treating identity literally as “knowing one’s place.” More specifically, we explore the spatial language health professionals use to describe their work. Using descriptions of professionals in a drug habilitation organization, we illustrate how they use route (i.e. an active tour through the space), survey (i.e. a stationary viewpoint from above), and gaze perspectives (i.e. a stable viewpoint onto a place) to explain the work situations they encounter. Each of these perspectives facilitates a different mode of evaluation in terms of distance, emotion, and identity. We propose opportunities for research and implications of the ways in which spaces and spatial perspectives set the scene in the narratives of healthcare professionals.
Keywords identity work, narrative, place, space
Introduction Health professionals always have to move between their own professional knowledge, attitudes, and methods on the one hand and the establishment of a good relationship with the clients they care for on the other hand. In other words, they need to balance between professional distance and relational proximity. Professional identities in the domain of healthcare thus hover around identifications with oneself as a skilled professional who belongs to a certain professional organization and identifications with clients who live in their own, non-professional world. As the balance between distance and proximity already suggest, professional identity construction can be expressed in terms of space. Identity, then, is “knowing one’s place” (Coldron
and Smith, 1999: 713). Given that stories get accomplished in spatio-temporal settings, it is striking that narrative studies tend to have focused on the role of time in stories rather than space. It is well-known that within stories “sequence is the source of sense” (Weick, 1995: 126) and that narrative studies addressed the development of plot lines over time (Brockmeier, 2000). Much less work has been done on the role of space. That is University of Twente, The Netherlands Corresponding author: Mark van Vuuren, Department of Communication, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. Email: [email protected]
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van Vuuren and Westerhof one reason why we will explore in this article how health professionals narrate the space between their professional involvement and their involvement in the world of the clients. We focus on the narrative construction of professional identities of a particular group of healthcare professionals: outreaching workers in addiction prevention. Their work provides a specific dilemma to the balance between professional distance and relational proximity as they have to reach out to youngsters at risk of addiction to alcohol or drugs in their world. As we focus on the description of space in narratives, we take our starting point by different perspectives that emerge in spatial descriptions. As extensive research work by Barbara Tversky and her colleagues (Taylor and Tversky, 1996; Tversky, 2003, 2004; Tversky and Hard, 2009) has shown, spatial descriptions can take three forms (i.e. survey, route, and gaze) in which the position of the speaker varies in relation to the space they describe. As an example, consider how you would describe the room in which you are reading this text. First, you could survey the room, in which you would describe the place from a stationary viewpoint from above. You would describe it as on a map or a model, from a certain height. Alternatively, if you would describe the space as a route, you would guide someone in a mental tour, describing each successive object or wall from your perspective. It would be as if you are walking through the room. Due to the continuously changing perspective of the narrative, what is “across” the room depends on the position we have on the route. The third option to describe your room would be to gaze from one position. This perspective would take one unchanging viewpoint from which you look onto the room. Imagine that you describe the room next to the one you are currently in from the view through the door. This combines the route and the survey, as you would not lead someone through that room, but you would not see it from the ceiling either, as in the survey description. Research in the area of spatial language also points out that space can be described in either literal or metaphorical ways. Literal space
refers to places one can go to (“So I arrived in Zwolle …”) and the meaning of the place refers to a location. Metaphorical spaces are descriptions in which the words make sense in another way than literally, for example, through similarity or comparison (“I was in heaven”). The exploration of similarities and differences between literal and metaphorical uses of spatial language is a rather technical research area (Graf, 2006). As the purpose of this project was to explore the ways space gets conceptualized by outreach workers, we notice literal and figurative references to space but do not treat them differently. While the literal and figurative references to space differ in certain ways, it is not the case that metaphorical space is harder to comprehend than references to literal space (Keysar, 1989). It is more important for the ease of processing whether a reference is conventional, frequent, and familiar or not than whether it refers to literal or non-literal space (Giora, 1997). In our case, the professionals themselves came up with their own spatial terms in several ways. Therefore, they provided us with language that was salient for themselves when describing their position. We believe it is important in this phase to focus on the communicative function of literal and metaphorical references to space than on the process by which they are comprehended (Wolff and Gentner, 2011). Therefore, rather than focusing on the metaphorical and literal uses of spatial language, we used Tversky’s distinction in survey, gaze, and route as sensitizing concepts for this project. While the literal and metaphorical references to space are not the primary focus of this study, the metaphorical description of space is an issue that appears in the context of Tversky’s work as well. People use spatial language not only to describe the physical space that surrounds us but also to describe non-spatial things in a metaphorical way (Taylor and Tversky, 1996). Spatial language is also used to construe one’s identity. In such cases, spatial language is used as a metaphor to convey abstract meanings. In this article, we explore the use of spatial language for the identity and relationship work of healthcare professionals. In the context of
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health psychology, identification with diseases happens through spatial positioning, for example, by stories that show identity-relevant positioning of patients versus their bodies. Todorova and Kotzeva (2006) report how Bulgarian women facing infertility separate their identities from their bodies in their stories: they split their “defective” body from their (“willing”) mind. Several mental disorders are also described as happening within their person, but something other than their selves (Weinberg, 1997). Similarly, spatial language is also used to construe one’s identity in interpersonal relations as has been put forward most systematically by positioning theory from a discursive perspective (Harré et al., 2009). Someone could psychologically distance himself from me because he considers me to be lower class. Here, language is not used to mediate between people and places, but constructs the relationship between them (Di Masso et al., 2013). In this article, we want to illustrate the ways in which healthcare professionals construct a professional identity through different uses of “space” within their narrative accounts of their professional practice. Similar to survey, route, and gaze, space can be seen in narratives in three different ways. First, space is the environment in which a professional health issue appears. This is the area of narrative geography, in which the context of a situation is described. One might compare this to a more or less detached description of the professional setting that one works in. This sets the stage on which the drama unfolds. Second, professionals make sense of this geography as they have a particular position within this context. They experience particular events in their everyday work life and narrate about them in terms of the settings, actors, acts, means, and goals. In their narratives, people describe the role they play on the stage. Third, professionals also make sense of their own position: they reflect on where they are and how this relates to their professional identity. Hereby, identity is constructed literally as “knowing one’s place” (Coldron and Smith, 1999: 713). The richness of narrative accounts thus provides a definition of space, a description of one’s position within that space as
well as an evaluation of that position. We believe that space—in these three ways—is often overlooked, yet really important for understanding people’s identity work through narratives. In this article, we illustrate the different kinds of spatial reasoning to the professional identity of a new group of healthcare professionals: outreaching workers in addiction prevention. Addiction prevention is an important goal in public health, given the long-term neurological and social implications of substance abuse and dependency. Youth is in particular at risk of developing abuse and dependency, yet is hard to reach and very reluctant to seek help. In recent years, addiction institutions introduced the role of outreach workers (cf. Ozechowski and Waldron, 2010) to engage in youth cultures to detect risk behaviors and guide youth toward professional help before their situation worsens. Several methods have been developed and applied for this purpose, including assertive community treatment, the gateway provider model, and motivational interviewing (Brown et al., 2005; Ozechowski and Waldron, 2010; Stiffman et al., 2004). Outreach workers are especially interesting in terms of studying their spatial positioning in their professional identities as they have to merge two different worlds: the world of youth and the world of professional healthcare. Besides this specific dilemma, new professions are generally interesting for narrative research as they ask for a lot of identity work, that is, the engagement of people in “forming, repairing, maintaining, strengthening or revising the constructions that are productive of a sense of coherence and distinctiveness” (Sveningsson and Alvesson, 2003: 1165). Through studying the accounts of place and positioning in accounts of work, research on health narratives could become more sensitive for contextual factors of identity work and evaluation (Van Vuuren et al., 2012). We carried out a secondary analysis of a project that was originally aimed at investigating the adequacy of the outreach activities of the outreach workers (Van der Wal, 2009). While a broad range of issues arose in this project, the aim of this study is to illustrate
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van Vuuren and Westerhof the three different ways in which outreach workers use spatial terms to describe their job and how narrative processes of identity construction are involved in these three different ways.
Methods Participants All 20 outreach workers from “Rehabion,” [the pseudonym for] a Dutch institute for addiction care, were interviewed. These are 12 women and 8 men who worked in different cities where Rehabion is active. The participants were recruited through the program leaders. The researcher approached all outreach workers individually for interviews and all 20 agreed to participate.
Interviews All interviews were conducted by a Master’s student in psychology. The interview consisted of three parts. The first part served to get acquainted with the specific function of the participant as well as his or her educational background. The second part considered the professional identity of the outreach workers: how did the worker develop professionally, what knowledge, competences, attitudes, and behaviors did he or she acquire that are necessary for their current functioning as outreach workers, and what organizational conditions need to be fulfilled to be a successful outreach worker. The third part consisted of a topic list that was used to discuss the definition and evaluation of outreaching work by the participant. In this article, we focused on the second and third parts of the interviews. The questions used in this part were open-ended questions that allowed the participants to elaborate on their own views and experiences. Each open question also had a number of further probing questions that served to standardize the collected interview material. The interviews were transcribed literally, but did not include prosodic features such as pauses and intonation.
Analysis The primary analysis was focused on a description of outreaching work by the participants themselves. A coding scheme was developed that focused on themes like goals, tasks, attitudes, competencies, methods, and evaluations of outreach work (Van der Wal, 2009). For the secondary analysis reported in this article, we focused on the spatial metaphor in the interviews. Although the interview questions did not probe a specific narrative structure, participants did tell stories about their outreach work and often used spatial metaphors. We first focused on the construction of space within the narratives (e.g. the discursive constructions of landscapes, distances, borders, order, locations, relative positions) and the spatial language the participants used. We read all interview transcripts and marked all uses of spatial language (e.g. references to locations, traveling, distances, movement through space (“went to,” “arrived”), place (“in,” “at”), and territory). In the next phase, we structured the texts according to the position the narrator takes while telling the story. This position defined the spatial language of survey (observer as an outsider, describing a scene as a non-participant), route (involved person moving in the scene), and gaze perspectives (involved person, standing at a fixed place to reflect on the position they are in). We then grouped all texts from all interviews according to these three uses of spatial metaphors. As we were not interested in individual differences or in the frequency with which specific spatial terms occurred for this article, but only in illustrating how outreach workers position themselves in spatial terms, we combined the texts of individual participants in what might be called a collective narrative. Overlapping parts of the texts that showed common meaning were deleted, whereas differences in the texts were seen as individual additions to the overall story. The analyses were not conducted by separate researchers but jointly by the authors of this article. In line with the main aim to illustrate the use of space in narratives, it was thus not our goal to calculate
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measures of inter-coder reliability, but to improve intersubjectivity by consensus. In the results section, we use the resulting collective story, structured by the three spatial positions, while representing citations of different individual participants.
Results Survey: description of the scenery Generally, an interview starts with a description of the context. In terms of space, the narrator takes the position of an outsider to describe the scenery in which the drama takes place. Outreach workers use frames of “distance” and “obstacles” to describe the complex environment they face. The picture that emerges of the narrative geography is one of a gap between two worlds. The two worlds of Rehabion and youth cultures are separated from each other, leaving a distance to cross. This distance can be taken literally, as the physical distance between the places where teenagers are and the place where they are supposed to meet with Rehabion. As one of the outreach workers said, Well, just look where we are located. When I’ve had the first couple of meetings at school, let’s say in [name city], and then they have to go to this place. At once you [the youngsters] need to bike your way through the weather for five kilometers. Guess what happens to the program? You know, that just does not work.
Significantly, this physical space is translated in a metaphorical “threshold.” As one of the outreach workers states: “Look, these youngsters are demotivated, so when you heighten the threshold by saying that they have to come to this place, that they have to take the bus while they have no money, then they won’t come.” Apart from the literal distance, there is a metaphorical distance between the different worlds of experience of health professionals and youth culture. In this metaphorical sense, what happens in the space between Rehabion and the teenagers is framed in terms of the complications that come with attempts to overcome that
distance. First, the scenery is cluttered with obstacles (“thresholds”) that teenagers experience when they imagine moving toward Rehabion. This hinders a smooth closure of the gap from a teenager perspective. This threshold needs to be overcome or lowered before teenagers will seek professional help from Rehabion. Second, compared to the creativity and inventiveness needed to cross the obstacle, standard procedures for getting in contact with substance abusers is too much of a “clearly mapped out well-trodden path.” They lead to nowhere, as they are too static and do not meet the needs of typical youth cultures. Any formal institution has a reputation in youth communities, and Rehabion is no exception, which leads to perceived distance and walking away: “I’ve heard quite often that if you use the word Rehabion, that youngsters walk away or become inhibited.” Overcoming the distance is complicated by an obstacle, “a high threshold” teenagers (are said to) experience when considering to ask Rehabion for help with their substance abuse. In order to bridge the gap, there is a need to put efforts in either lowering the threshold or enabling teenagers to step over it: “teenagers experience a very high threshold when they consider knocking on the door of any institution.” For the purpose of this article, it is important to note that the narrators easily switch between accounts of metaphorical distance and physical distance from this survey perspective. The identification of the place is described in terms of a narrative geography, as if the narrator takes a God’s eye view on the situation. The language used is a way of storying one’s work as an outreach worker, including use of words like them, you, teenagers, and youth in general. The scene is set, ready, and awaiting someone who comes up with a solution.
Route: storying particular events After setting the scene in terms of distance, gaps, and obstacles, it is a reasonable continuation of the narrative to talk about the need for a bridge. And here, the outreach workers enter the scene: the careful mapping out of the
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van Vuuren and Westerhof situation enables them to identify themselves in terms of bridge-builders. Without a gap, a bridge becomes obsolete. They are the threshold-lowerers, of a threshold that has been put in place right before. Now, with the positioning of both parties far away from each other, the mission of the outreach worker becomes extremely relevant: to position himself or herself between the two parties and trying to bring them together. The starting point for the solution is that Rehabion does not wait until someone comes to them, but that professional workers reach out on behalf of Rehabion. One has to overcome the physical distance first to find ways in which the psychological distance can be reduced. The first step is to literally move out of the Rehabion office to the places where the teenagers are: “It is as simple as that. You head for a youth gathering, just take a look around, chatting a bit, and you’ll see where it ends.” With the explorative nature of the first moves, the narrative changes perspective from a distant survey to a route, a more involved and moving story. These moves are indeed described from a route perspective, leading to an exciting, adventurous narrative, where the open-endedness of the process strongly contrasts to the institutional setting. Several accounts describe the route: You need to be willing to walk into their world. In essence, that’s what you do with outreach work. Rather than inviting them into your world, your office, your organization, where you know it all, remain in charge. You have to have the guts to enter their world. And just experience it, and see what happens.
To prove the youth that they understand them, they contrast the office world and the life world of youth in their approach: “They also like it when you serve soft drinks, not only coffee and tea. Simple things.” Again, references to concrete places and the metaphorical distance are blurred in the accounts, as overcoming physical space is aligned with psychological interpersonal proximity: Yes, teenagers experience a very high threshold when they consider knocking on the door of any
institution. So you are in a safe environment, from the teenager’s point of view. It is important to be in a place that belongs to the teenager and where he feels safe. Sometimes it can be motivating to make an appointment during their last lesson at school. You negotiate. Show them that it is not so bad to talk a bit. Show them that Rehabion is pretty normal.
The bridge of empathy that outreach workers build between Rehabion and youth is a matter of understanding. The route is described as encounters, with lively and emotionally laden particular events. One of the outreach workers describes a case in which she built this bridge by stressing that she understands her: This girl had an eating disorder. A lot of substance abuse. She has come out in a rash, left her home. So she was deemed to, you know, on a ten-point suicide scale, she rated herself a nine [out of ten]. Aggressive. But [Rehabion] never succeeded in getting her in. […] And I said to her: “I understand why you are so angry.” She was amazed. “Yeah, really, you are telling this whole story, and I think, well, if that all happened to me and someone would do that to me, I could have battered them up too, maybe. I admire you for coming this far.” Well, bring in the tissues!
This process of showing that you understand and surprise the teenagers is pictured as “moving into their territory.” This is safer for the teenagers: You’re in their domain, they set the rules, and they’re in control. The threshold for a little talk is low. […] When you behave like a guest, they may get a sense of equals. You’re having a say in the conversation, but you are on their territory.
This is the route perspective in their narratives, in which the outreach worker is taking the first step to bridge the gap. Their role as bridgebuilder provides them with a sense of identity. “To go places where they hang around. If you make contact, you are less frightening as a Rehabion employee.” The stereotypical caricature of going into rehab is not motivating for engaging in activities that could close the gap:
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Because everywhere a rather mysterious idea dominates what treatment at Rehabion looks like. Everyone thinks in terms of ‘junkies’ and ‘addicts’, and ‘I don’t want to belong there’.” The depiction of the walk described by the outreach workers is not only discouraging from the perspective of teenagers. The emotions of the professionals when they described their experiences could be quite disheartening as well. They saw the route, went into action, but the expectations differ: “We actually expect that teenagers having issues come to the office, or that they are in the picture, start the conversation [themselves], having contact.” It is like what was meant as a guided tour fails because the visitors do not walk as they are expected. A major step is expected from the youth. But this is a bridge too far for them: There are no teenagers who will easily say, “I have a problem and I need help.” Even if that is the case, a lot of them do not know which path takes them into rehab. In that regard, we need to clear the fog.
The narrative processes in describing a route take other dynamics for identity work than those for a survey: there are more signs of personal involvement and the stories are more emotionally laden. The language use includes more references to I and we, and from this perspective, professionals provide vivid descriptions of specific events.
Gaze: reflecting on your place to gain identity The action focus of the route is an engaging narrative in which people describe their experiences. But on several occasions, the narrator stops to reflect, and [in terms of spatial language perspectives] gazes on the situation they perceive. After framing the scenery in terms of a constellation of elements, positioned toward each other in space, in a problematic way, the narrators had positioned themselves in this space. By reflecting on this positioning on the map, they gain identities.
This reflection can be seen when the motion in the stories (during the route) disappears and they gaze from a certain point to their situation. As they reflect on their position, they review it in terms of the places they earlier construed. Both their experiences of problems and solutions are described in terms of distance and proximity, as they learn what to do. And one aspect of learning is that it is not only a cognitive and social experience, but also an identity experience. Who we are, what we are able to do, and what we will be, based on what we learn, are constantly challenged when we attend learning situations. (Ligorio, 2010: 97, emphasis added)
The route through the scenery provides an identity experience which is explicated while taking an evaluative gaze on the scene. This is the perspective from where identity conclusions are drawn. Again, the problems they encounter are described in terms of gaps: “You’re coasting along, and think ‘Help, what am I supposed to do?’ No methods, no tools from the organization.” They literally describe their position as onlookers: “Look, we work in a grey zone and that means that some guidelines are not clear.” But the difference they make in reducing the gap is a satisfying view: For most of the teenagers, if there would have been no outreaching work, then they would not have come in. And then it can be expected, you don’t know of course, but then the abuse probably would have increased, or the problems would have worsened.
The characteristics of the place they constructed also influence their description of the solutions they provide, illustrating how the importance of place and distance remain central to the story. Describing what it takes to become an outreach worker, they state that you will have to deal with this distance: “You need to relate to their world of experience. […] And at the same time it is important to guard your professionalism in that contact. I think that for
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van Vuuren and Westerhof outreaching work the aspects of distance and proximity are crucial.” The reflective question of where they position themselves in the picture unveiled an important identity issue: Do they belong to Rehabion (and its core business) or not? First, some outreach workers refer to outreach workers as pioneers outside Rehabion. Especially when Rehabion is a synonym for “care” or “treatment,” they are only canvassers. A recurring definition of outreach work summarizes this, referring to oneself as guidance (not “guide”): “I am low-threshold guidance towards care.” In that case, the boundaries between the organization and their target group remain intact. The organization is the place where “real care” or “treatment” starts, and outreach workers “only” bring them in. This positioning echoes the “gap”-metaphor, in which outreach workers go out, look for the teenagers, and accompany them on the journey toward Rehabion. Other references are made to outreach workers as essential part of the organization, referring to their healthcare intervention as a Rehabion without walls. Where they are, Rehabion is. They are “Rehabion’s face.” While the first conceptualization relates to the gap-as-adistance metaphor, this second conceptualization refers to the lowering of thresholds and removal of obstacles. As part of Rehabion, they try to “catch” teenagers. There is no standard procedure for this (in contrast to the well-trodden path metaphor in the initial depiction of the scene): I sometimes compare it with fishing. You’re angling with six rods in a youth center, and well, sometimes you end up having a nice contact with a youngster. Then you see how they nibble your lure, you know, and then you try to reel them in. And you really need to take the time for that. Don’t expect to have had the intake after the first meeting, and you’ve cracked the code of the teenager’s problems. It might take some time before you understand what’s going on.
These conceptualizations position the outreach worker different in the space between Rehabion and youth. The narrators reflect on the situation by taking a step back (but remain in the field, otherwise they would take a survey perspective
again). Especially in the case where the outreach profession is treated as something less than “care,” it unveils a negative consequence of their position. While trying hard to bring two life worlds together, the outreach worker ultimately belongs nowhere. This leads to the experience of loneliness. Reflecting on their position, outreach workers sometimes feel as if they are merely canvassers for Rehabion. They have to bring them “in,” but remain outside themselves. At the same time, the outreach workers feel they cannot be full members of youth cultures. They are there for a reason, and although invited, they remain guests. Therefore, while they engage between both worlds, they feel that each side considers the outreach worker as part of the other group (and not theirs). Contact with the other groups is a threshold for the both sides to really see outreach workers as one of their own. By positioning themselves in between two worlds, they may end up in no man’s land. The reflection of the gaze perspective combines an evaluative stance like a survey, but with the involvement and proximity of the route. The gaze turns out to be the type of narration in which the typical process of identity formation takes place.
Discussion The aim of this article is to explore the importance of space, place, and position in evaluative healthcare narratives. Following the proposition that these perspectives could be used to explore identity narratives, several reflective issues arise. We used the case of outreach workers to illustrate how they used survey, route, and gaze perspectives on space to construct their professional field (in the survey), describe some particular events (as a route), and construct their identities (with a gaze). Of course, the playing field of the outreach workers is more complex than this. But their narratives do show how people construct a narrative place using spatial language. This case provided us with the opportunity to illustrate how perspectives generally used for navigation (Tversky, 2005) can
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also be applied to navigate professional identity work, including gaps, obstacles, well-trodden paths, dead-end roads, bridges, and a carefully crafted position for the professional. Ultimately, the hard work pays off when substance abusing teenagers find their way into treatment. The survey perspective is generally used at the beginning of the story, to “set the scene” and give an overview of the situation before the professional enters. The narrator takes a distant position from the scene, often described in relatively neutral terms. They are outsiders, able to draw a static map. They tell about a situation that develops, but they remain uninvolved themselves. Then, the situation changes when they describe themselves as actors in the developing narrative, changing the perspective to a route. They take part in the action and describe their experiences in the situations they encounter. By taking an active role, they no longer describe the place, but become part of it. The description of the place is no longer a neutral exploration of a field, but it defines the boundaries within which the professional takes his or her place. Arrangement of practices provides a script. “In acting out this script, organizational agents position themselves and others above/ under it, inside/outside, and before/after” (Vásquez and Cooren, 2013: 42). Therefore, in the case of the outreach workers, one could say that we use space as a “mental map” in the literal sense. Finally, there is the possibility of the gaze perspective, in which they describe themselves as being in the narrative space, but reflecting on the situations. There are still a lot of verbs used, but in contrast to the route, they are not actions (cf. Taylor and Tversky, 1996: 375–376). Like using spatial language to describe a place as if they look from a doorway (Tversky, 2004), the gazing professional takes a more observing perspective but remains within the situation. Here, identity is derived from knowing one’s place. The conceptualization of the scene they entered leaves its traces in the rest of the accounts. It is therefore important to note that the stage and the role define each other. On the one hand, this frame game means describing a
place that makes “your own role most prominent, and where you are seen to shine because you are the hero” (Taylor and Van Every, 2011: 63). Therefore, the place can be conceptualized with the goal of one’s own role in mind. On the other hand, the fit between the stage and one’s position within it is crucial for one’s own “belief in the part one is playing” (Goffman, 1997: 95). Therefore, as Taylor and Van Every (2011) explain, people play bot on the game (defining the situation to meet their needs) as well as in the game (their needs are defined by the situation). This is illustrated by the fact that the problems they encountered in the process of reaching out were defined in terms of the problems they already identified—which led to their appearance on the scene in the first place. The outreach workers saw a gap between Rehabion and substance abusing youngsters. Reflections on the new order showed then that they position themselves in between those two—but not really belonging to either one of them. The case of the outreach workers illustrates different ways of positioning the outreach worker in the space between organization and youth culture. This hinted at different conceptualizations of outreach: Some outreach workers consider themselves as shifting the boundaries of the organization (bringing the organization to the people, working as a “hospital without walls,” engaging in “Meddle care,” with the outreach worker as an “outpost of Rehabion”), while others saw themselves as moving beyond the boundaries of the organization (in which the outreach worker goes “out” of the organization, in order to pull them in and hand them over to the organization for “real care”). This process is not restricted to the case of outreach workers. McCann et al. (2013) showed in an ethnographic study of emergency ambulance personnel that the tension exists between “taking healthcare to the patient” and “transportation to definitive care” (p. 769). It may be a broader issue of healthcare management for organizations who need to hit the street, reach out, or pick up people. When the core business of the organization is within the walls of a building, the professionals moving out of that
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van Vuuren and Westerhof specific concrete location may have to relocate their identities too. This is a nuanced picture, in which the hero evaporates and a realistic scene of hard work, loneliness, craving for backup, and continuous flexibility are in sight. Apart from the awareness of the different perspectives people take to describe spaces and the perspectives they take in describing them, our findings suggest potential future research questions. First of all, it would be exciting to study the role of spatial language in other occupations. In line with our analyses, it can be fruitful to see how identity gets accomplished through locating oneself in a certain space, and how a place fuels occupational identity work (Larson and Pearson, 2012). Alternatively, the lack of clarity about one’s identity could also be phrased in terms of space. In narratives of priests, for example, Kreiner et al. (2006) described how individuals in this very demanding profession with a strong occupational identity looked for space for their personal identity: where is the “me” among the “we”? (p. 1031). Another area for future research would be to explore different types of references to space. We used Tversky’s concepts of survey, gaze, and route as sensitizing concepts, but another question could be to distinguish more systematically between literal and metaphorical references to space. An interesting area could be to explore the emotional side of space. Citron and Goldberg (2014) studied the role of emotions in metaphorical and literal expressions. Their findings that particular brain areas (i.e. the amygdala and the anterior portion of the hippocampus) were more active when metaphorical sentences were used indicate that conventional metaphorical expressions are more emotionally evocative than literal expressions. For narrative accounts of identity and place, the role of emotions could be explored deeper through comparing literal and metaphorical references to space. Finally, our findings may have an important methodological implication for future research in narrative health psychology. Taking different spatial perspectives into account may enrich evaluation studies on health practices and interventions. Existing studies often use a survey perspective when it comes to the quality of
healthcare. They ask for general evaluations and descriptions of the scenery of a specific practice or intervention. Such a survey perspective suggests distance, whereas a route narrative indicates active involvement. Especially when one wonders about the emotions that arise when confronted with a situation, it seems helpful to take a guided tour as the emotions are where the action is. Route narratives could thus have a meaningful contribution to understand how specific practices and interventions work for particular individuals and how care can be improved to work even better (Ubels, 2011). Gaze narratives may be important for healthcare as well. Explicating identity issues—as in a gaze—means to be aware of one’s perspective on one’s position within society, one’s interactions with others, and one’s interpretations of experiences (Gee, 2000; Geijsel and Meijers, 2005). It takes place in “a social nexus involving the complex interplay of practitioner, organizational practices and settings, professional associations, knowledge and society” (Brown and Phua, 2011: 86). A reflection on one’s position may thus provide further evidence of how professionals and their clients and patients position themselves within certain healthcare practices. Gaze narratives may provide more insight into what is at stake for different stakeholders in terms of identity management. They may thereby contribute to better understandings of how certain health practices and interventions relate to this identity work. We propose that healthcare practices can be best addressed by shifting between survey, route, and gaze perspectives. The starting point is to see how a survey perspective provides a narrative geography, a route perspective inspires the sharing of particular stories, and the gaze perspective points attention to the identity consequences of the narrative. In all, the dynamics within and between the different perspectives can enable the exploration of unknown territory of one’s identity. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
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HPQ0010.1177/1359105314566614Journal of Health Psychologyvan Vuuren and Westerhof
Article
Identity as “knowing your place”: The narrative construction of space in a healthcare profession
Journal of Health Psychology 2015, Vol. 20(3) 326–337 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314566614 hpq.sagepub.com
Mark van Vuuren and Gerben J Westerhof
Abstract The construction of space in which a story takes place can have important consequences for the evaluation of health interventions. In this article, we explore the ways professionals narratively position themselves in a situation, treating identity literally as “knowing one’s place.” More specifically, we explore the spatial language health professionals use to describe their work. Using descriptions of professionals in a drug habilitation organization, we illustrate how they use route (i.e. an active tour through the space), survey (i.e. a stationary viewpoint from above), and gaze perspectives (i.e. a stable viewpoint onto a place) to explain the work situations they encounter. Each of these perspectives facilitates a different mode of evaluation in terms of distance, emotion, and identity. We propose opportunities for research and implications of the ways in which spaces and spatial perspectives set the scene in the narratives of healthcare professionals.
Keywords identity work, narrative, place, space
Introduction Health professionals always have to move between their own professional knowledge, attitudes, and methods on the one hand and the establishment of a good relationship with the clients they care for on the other hand. In other words, they need to balance between professional distance and relational proximity. Professional identities in the domain of healthcare thus hover around identifications with oneself as a skilled professional who belongs to a certain professional organization and identifications with clients who live in their own, non-professional world. As the balance between distance and proximity already suggest, professional identity construction can be expressed in terms of space. Identity, then, is “knowing one’s place” (Coldron
and Smith, 1999: 713). Given that stories get accomplished in spatio-temporal settings, it is striking that narrative studies tend to have focused on the role of time in stories rather than space. It is well-known that within stories “sequence is the source of sense” (Weick, 1995: 126) and that narrative studies addressed the development of plot lines over time (Brockmeier, 2000). Much less work has been done on the role of space. That is University of Twente, The Netherlands Corresponding author: Mark van Vuuren, Department of Communication, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands. Email: [email protected]
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van Vuuren and Westerhof one reason why we will explore in this article how health professionals narrate the space between their professional involvement and their involvement in the world of the clients. We focus on the narrative construction of professional identities of a particular group of healthcare professionals: outreaching workers in addiction prevention. Their work provides a specific dilemma to the balance between professional distance and relational proximity as they have to reach out to youngsters at risk of addiction to alcohol or drugs in their world. As we focus on the description of space in narratives, we take our starting point by different perspectives that emerge in spatial descriptions. As extensive research work by Barbara Tversky and her colleagues (Taylor and Tversky, 1996; Tversky, 2003, 2004; Tversky and Hard, 2009) has shown, spatial descriptions can take three forms (i.e. survey, route, and gaze) in which the position of the speaker varies in relation to the space they describe. As an example, consider how you would describe the room in which you are reading this text. First, you could survey the room, in which you would describe the place from a stationary viewpoint from above. You would describe it as on a map or a model, from a certain height. Alternatively, if you would describe the space as a route, you would guide someone in a mental tour, describing each successive object or wall from your perspective. It would be as if you are walking through the room. Due to the continuously changing perspective of the narrative, what is “across” the room depends on the position we have on the route. The third option to describe your room would be to gaze from one position. This perspective would take one unchanging viewpoint from which you look onto the room. Imagine that you describe the room next to the one you are currently in from the view through the door. This combines the route and the survey, as you would not lead someone through that room, but you would not see it from the ceiling either, as in the survey description. Research in the area of spatial language also points out that space can be described in either literal or metaphorical ways. Literal space
refers to places one can go to (“So I arrived in Zwolle …”) and the meaning of the place refers to a location. Metaphorical spaces are descriptions in which the words make sense in another way than literally, for example, through similarity or comparison (“I was in heaven”). The exploration of similarities and differences between literal and metaphorical uses of spatial language is a rather technical research area (Graf, 2006). As the purpose of this project was to explore the ways space gets conceptualized by outreach workers, we notice literal and figurative references to space but do not treat them differently. While the literal and figurative references to space differ in certain ways, it is not the case that metaphorical space is harder to comprehend than references to literal space (Keysar, 1989). It is more important for the ease of processing whether a reference is conventional, frequent, and familiar or not than whether it refers to literal or non-literal space (Giora, 1997). In our case, the professionals themselves came up with their own spatial terms in several ways. Therefore, they provided us with language that was salient for themselves when describing their position. We believe it is important in this phase to focus on the communicative function of literal and metaphorical references to space than on the process by which they are comprehended (Wolff and Gentner, 2011). Therefore, rather than focusing on the metaphorical and literal uses of spatial language, we used Tversky’s distinction in survey, gaze, and route as sensitizing concepts for this project. While the literal and metaphorical references to space are not the primary focus of this study, the metaphorical description of space is an issue that appears in the context of Tversky’s work as well. People use spatial language not only to describe the physical space that surrounds us but also to describe non-spatial things in a metaphorical way (Taylor and Tversky, 1996). Spatial language is also used to construe one’s identity. In such cases, spatial language is used as a metaphor to convey abstract meanings. In this article, we explore the use of spatial language for the identity and relationship work of healthcare professionals. In the context of
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health psychology, identification with diseases happens through spatial positioning, for example, by stories that show identity-relevant positioning of patients versus their bodies. Todorova and Kotzeva (2006) report how Bulgarian women facing infertility separate their identities from their bodies in their stories: they split their “defective” body from their (“willing”) mind. Several mental disorders are also described as happening within their person, but something other than their selves (Weinberg, 1997). Similarly, spatial language is also used to construe one’s identity in interpersonal relations as has been put forward most systematically by positioning theory from a discursive perspective (Harré et al., 2009). Someone could psychologically distance himself from me because he considers me to be lower class. Here, language is not used to mediate between people and places, but constructs the relationship between them (Di Masso et al., 2013). In this article, we want to illustrate the ways in which healthcare professionals construct a professional identity through different uses of “space” within their narrative accounts of their professional practice. Similar to survey, route, and gaze, space can be seen in narratives in three different ways. First, space is the environment in which a professional health issue appears. This is the area of narrative geography, in which the context of a situation is described. One might compare this to a more or less detached description of the professional setting that one works in. This sets the stage on which the drama unfolds. Second, professionals make sense of this geography as they have a particular position within this context. They experience particular events in their everyday work life and narrate about them in terms of the settings, actors, acts, means, and goals. In their narratives, people describe the role they play on the stage. Third, professionals also make sense of their own position: they reflect on where they are and how this relates to their professional identity. Hereby, identity is constructed literally as “knowing one’s place” (Coldron and Smith, 1999: 713). The richness of narrative accounts thus provides a definition of space, a description of one’s position within that space as
well as an evaluation of that position. We believe that space—in these three ways—is often overlooked, yet really important for understanding people’s identity work through narratives. In this article, we illustrate the different kinds of spatial reasoning to the professional identity of a new group of healthcare professionals: outreaching workers in addiction prevention. Addiction prevention is an important goal in public health, given the long-term neurological and social implications of substance abuse and dependency. Youth is in particular at risk of developing abuse and dependency, yet is hard to reach and very reluctant to seek help. In recent years, addiction institutions introduced the role of outreach workers (cf. Ozechowski and Waldron, 2010) to engage in youth cultures to detect risk behaviors and guide youth toward professional help before their situation worsens. Several methods have been developed and applied for this purpose, including assertive community treatment, the gateway provider model, and motivational interviewing (Brown et al., 2005; Ozechowski and Waldron, 2010; Stiffman et al., 2004). Outreach workers are especially interesting in terms of studying their spatial positioning in their professional identities as they have to merge two different worlds: the world of youth and the world of professional healthcare. Besides this specific dilemma, new professions are generally interesting for narrative research as they ask for a lot of identity work, that is, the engagement of people in “forming, repairing, maintaining, strengthening or revising the constructions that are productive of a sense of coherence and distinctiveness” (Sveningsson and Alvesson, 2003: 1165). Through studying the accounts of place and positioning in accounts of work, research on health narratives could become more sensitive for contextual factors of identity work and evaluation (Van Vuuren et al., 2012). We carried out a secondary analysis of a project that was originally aimed at investigating the adequacy of the outreach activities of the outreach workers (Van der Wal, 2009). While a broad range of issues arose in this project, the aim of this study is to illustrate
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van Vuuren and Westerhof the three different ways in which outreach workers use spatial terms to describe their job and how narrative processes of identity construction are involved in these three different ways.
Methods Participants All 20 outreach workers from “Rehabion,” [the pseudonym for] a Dutch institute for addiction care, were interviewed. These are 12 women and 8 men who worked in different cities where Rehabion is active. The participants were recruited through the program leaders. The researcher approached all outreach workers individually for interviews and all 20 agreed to participate.
Interviews All interviews were conducted by a Master’s student in psychology. The interview consisted of three parts. The first part served to get acquainted with the specific function of the participant as well as his or her educational background. The second part considered the professional identity of the outreach workers: how did the worker develop professionally, what knowledge, competences, attitudes, and behaviors did he or she acquire that are necessary for their current functioning as outreach workers, and what organizational conditions need to be fulfilled to be a successful outreach worker. The third part consisted of a topic list that was used to discuss the definition and evaluation of outreaching work by the participant. In this article, we focused on the second and third parts of the interviews. The questions used in this part were open-ended questions that allowed the participants to elaborate on their own views and experiences. Each open question also had a number of further probing questions that served to standardize the collected interview material. The interviews were transcribed literally, but did not include prosodic features such as pauses and intonation.
Analysis The primary analysis was focused on a description of outreaching work by the participants themselves. A coding scheme was developed that focused on themes like goals, tasks, attitudes, competencies, methods, and evaluations of outreach work (Van der Wal, 2009). For the secondary analysis reported in this article, we focused on the spatial metaphor in the interviews. Although the interview questions did not probe a specific narrative structure, participants did tell stories about their outreach work and often used spatial metaphors. We first focused on the construction of space within the narratives (e.g. the discursive constructions of landscapes, distances, borders, order, locations, relative positions) and the spatial language the participants used. We read all interview transcripts and marked all uses of spatial language (e.g. references to locations, traveling, distances, movement through space (“went to,” “arrived”), place (“in,” “at”), and territory). In the next phase, we structured the texts according to the position the narrator takes while telling the story. This position defined the spatial language of survey (observer as an outsider, describing a scene as a non-participant), route (involved person moving in the scene), and gaze perspectives (involved person, standing at a fixed place to reflect on the position they are in). We then grouped all texts from all interviews according to these three uses of spatial metaphors. As we were not interested in individual differences or in the frequency with which specific spatial terms occurred for this article, but only in illustrating how outreach workers position themselves in spatial terms, we combined the texts of individual participants in what might be called a collective narrative. Overlapping parts of the texts that showed common meaning were deleted, whereas differences in the texts were seen as individual additions to the overall story. The analyses were not conducted by separate researchers but jointly by the authors of this article. In line with the main aim to illustrate the use of space in narratives, it was thus not our goal to calculate
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measures of inter-coder reliability, but to improve intersubjectivity by consensus. In the results section, we use the resulting collective story, structured by the three spatial positions, while representing citations of different individual participants.
Results Survey: description of the scenery Generally, an interview starts with a description of the context. In terms of space, the narrator takes the position of an outsider to describe the scenery in which the drama takes place. Outreach workers use frames of “distance” and “obstacles” to describe the complex environment they face. The picture that emerges of the narrative geography is one of a gap between two worlds. The two worlds of Rehabion and youth cultures are separated from each other, leaving a distance to cross. This distance can be taken literally, as the physical distance between the places where teenagers are and the place where they are supposed to meet with Rehabion. As one of the outreach workers said, Well, just look where we are located. When I’ve had the first couple of meetings at school, let’s say in [name city], and then they have to go to this place. At once you [the youngsters] need to bike your way through the weather for five kilometers. Guess what happens to the program? You know, that just does not work.
Significantly, this physical space is translated in a metaphorical “threshold.” As one of the outreach workers states: “Look, these youngsters are demotivated, so when you heighten the threshold by saying that they have to come to this place, that they have to take the bus while they have no money, then they won’t come.” Apart from the literal distance, there is a metaphorical distance between the different worlds of experience of health professionals and youth culture. In this metaphorical sense, what happens in the space between Rehabion and the teenagers is framed in terms of the complications that come with attempts to overcome that
distance. First, the scenery is cluttered with obstacles (“thresholds”) that teenagers experience when they imagine moving toward Rehabion. This hinders a smooth closure of the gap from a teenager perspective. This threshold needs to be overcome or lowered before teenagers will seek professional help from Rehabion. Second, compared to the creativity and inventiveness needed to cross the obstacle, standard procedures for getting in contact with substance abusers is too much of a “clearly mapped out well-trodden path.” They lead to nowhere, as they are too static and do not meet the needs of typical youth cultures. Any formal institution has a reputation in youth communities, and Rehabion is no exception, which leads to perceived distance and walking away: “I’ve heard quite often that if you use the word Rehabion, that youngsters walk away or become inhibited.” Overcoming the distance is complicated by an obstacle, “a high threshold” teenagers (are said to) experience when considering to ask Rehabion for help with their substance abuse. In order to bridge the gap, there is a need to put efforts in either lowering the threshold or enabling teenagers to step over it: “teenagers experience a very high threshold when they consider knocking on the door of any institution.” For the purpose of this article, it is important to note that the narrators easily switch between accounts of metaphorical distance and physical distance from this survey perspective. The identification of the place is described in terms of a narrative geography, as if the narrator takes a God’s eye view on the situation. The language used is a way of storying one’s work as an outreach worker, including use of words like them, you, teenagers, and youth in general. The scene is set, ready, and awaiting someone who comes up with a solution.
Route: storying particular events After setting the scene in terms of distance, gaps, and obstacles, it is a reasonable continuation of the narrative to talk about the need for a bridge. And here, the outreach workers enter the scene: the careful mapping out of the
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van Vuuren and Westerhof situation enables them to identify themselves in terms of bridge-builders. Without a gap, a bridge becomes obsolete. They are the threshold-lowerers, of a threshold that has been put in place right before. Now, with the positioning of both parties far away from each other, the mission of the outreach worker becomes extremely relevant: to position himself or herself between the two parties and trying to bring them together. The starting point for the solution is that Rehabion does not wait until someone comes to them, but that professional workers reach out on behalf of Rehabion. One has to overcome the physical distance first to find ways in which the psychological distance can be reduced. The first step is to literally move out of the Rehabion office to the places where the teenagers are: “It is as simple as that. You head for a youth gathering, just take a look around, chatting a bit, and you’ll see where it ends.” With the explorative nature of the first moves, the narrative changes perspective from a distant survey to a route, a more involved and moving story. These moves are indeed described from a route perspective, leading to an exciting, adventurous narrative, where the open-endedness of the process strongly contrasts to the institutional setting. Several accounts describe the route: You need to be willing to walk into their world. In essence, that’s what you do with outreach work. Rather than inviting them into your world, your office, your organization, where you know it all, remain in charge. You have to have the guts to enter their world. And just experience it, and see what happens.
To prove the youth that they understand them, they contrast the office world and the life world of youth in their approach: “They also like it when you serve soft drinks, not only coffee and tea. Simple things.” Again, references to concrete places and the metaphorical distance are blurred in the accounts, as overcoming physical space is aligned with psychological interpersonal proximity: Yes, teenagers experience a very high threshold when they consider knocking on the door of any
institution. So you are in a safe environment, from the teenager’s point of view. It is important to be in a place that belongs to the teenager and where he feels safe. Sometimes it can be motivating to make an appointment during their last lesson at school. You negotiate. Show them that it is not so bad to talk a bit. Show them that Rehabion is pretty normal.
The bridge of empathy that outreach workers build between Rehabion and youth is a matter of understanding. The route is described as encounters, with lively and emotionally laden particular events. One of the outreach workers describes a case in which she built this bridge by stressing that she understands her: This girl had an eating disorder. A lot of substance abuse. She has come out in a rash, left her home. So she was deemed to, you know, on a ten-point suicide scale, she rated herself a nine [out of ten]. Aggressive. But [Rehabion] never succeeded in getting her in. […] And I said to her: “I understand why you are so angry.” She was amazed. “Yeah, really, you are telling this whole story, and I think, well, if that all happened to me and someone would do that to me, I could have battered them up too, maybe. I admire you for coming this far.” Well, bring in the tissues!
This process of showing that you understand and surprise the teenagers is pictured as “moving into their territory.” This is safer for the teenagers: You’re in their domain, they set the rules, and they’re in control. The threshold for a little talk is low. […] When you behave like a guest, they may get a sense of equals. You’re having a say in the conversation, but you are on their territory.
This is the route perspective in their narratives, in which the outreach worker is taking the first step to bridge the gap. Their role as bridgebuilder provides them with a sense of identity. “To go places where they hang around. If you make contact, you are less frightening as a Rehabion employee.” The stereotypical caricature of going into rehab is not motivating for engaging in activities that could close the gap:
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Because everywhere a rather mysterious idea dominates what treatment at Rehabion looks like. Everyone thinks in terms of ‘junkies’ and ‘addicts’, and ‘I don’t want to belong there’.” The depiction of the walk described by the outreach workers is not only discouraging from the perspective of teenagers. The emotions of the professionals when they described their experiences could be quite disheartening as well. They saw the route, went into action, but the expectations differ: “We actually expect that teenagers having issues come to the office, or that they are in the picture, start the conversation [themselves], having contact.” It is like what was meant as a guided tour fails because the visitors do not walk as they are expected. A major step is expected from the youth. But this is a bridge too far for them: There are no teenagers who will easily say, “I have a problem and I need help.” Even if that is the case, a lot of them do not know which path takes them into rehab. In that regard, we need to clear the fog.
The narrative processes in describing a route take other dynamics for identity work than those for a survey: there are more signs of personal involvement and the stories are more emotionally laden. The language use includes more references to I and we, and from this perspective, professionals provide vivid descriptions of specific events.
Gaze: reflecting on your place to gain identity The action focus of the route is an engaging narrative in which people describe their experiences. But on several occasions, the narrator stops to reflect, and [in terms of spatial language perspectives] gazes on the situation they perceive. After framing the scenery in terms of a constellation of elements, positioned toward each other in space, in a problematic way, the narrators had positioned themselves in this space. By reflecting on this positioning on the map, they gain identities.
This reflection can be seen when the motion in the stories (during the route) disappears and they gaze from a certain point to their situation. As they reflect on their position, they review it in terms of the places they earlier construed. Both their experiences of problems and solutions are described in terms of distance and proximity, as they learn what to do. And one aspect of learning is that it is not only a cognitive and social experience, but also an identity experience. Who we are, what we are able to do, and what we will be, based on what we learn, are constantly challenged when we attend learning situations. (Ligorio, 2010: 97, emphasis added)
The route through the scenery provides an identity experience which is explicated while taking an evaluative gaze on the scene. This is the perspective from where identity conclusions are drawn. Again, the problems they encounter are described in terms of gaps: “You’re coasting along, and think ‘Help, what am I supposed to do?’ No methods, no tools from the organization.” They literally describe their position as onlookers: “Look, we work in a grey zone and that means that some guidelines are not clear.” But the difference they make in reducing the gap is a satisfying view: For most of the teenagers, if there would have been no outreaching work, then they would not have come in. And then it can be expected, you don’t know of course, but then the abuse probably would have increased, or the problems would have worsened.
The characteristics of the place they constructed also influence their description of the solutions they provide, illustrating how the importance of place and distance remain central to the story. Describing what it takes to become an outreach worker, they state that you will have to deal with this distance: “You need to relate to their world of experience. […] And at the same time it is important to guard your professionalism in that contact. I think that for
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van Vuuren and Westerhof outreaching work the aspects of distance and proximity are crucial.” The reflective question of where they position themselves in the picture unveiled an important identity issue: Do they belong to Rehabion (and its core business) or not? First, some outreach workers refer to outreach workers as pioneers outside Rehabion. Especially when Rehabion is a synonym for “care” or “treatment,” they are only canvassers. A recurring definition of outreach work summarizes this, referring to oneself as guidance (not “guide”): “I am low-threshold guidance towards care.” In that case, the boundaries between the organization and their target group remain intact. The organization is the place where “real care” or “treatment” starts, and outreach workers “only” bring them in. This positioning echoes the “gap”-metaphor, in which outreach workers go out, look for the teenagers, and accompany them on the journey toward Rehabion. Other references are made to outreach workers as essential part of the organization, referring to their healthcare intervention as a Rehabion without walls. Where they are, Rehabion is. They are “Rehabion’s face.” While the first conceptualization relates to the gap-as-adistance metaphor, this second conceptualization refers to the lowering of thresholds and removal of obstacles. As part of Rehabion, they try to “catch” teenagers. There is no standard procedure for this (in contrast to the well-trodden path metaphor in the initial depiction of the scene): I sometimes compare it with fishing. You’re angling with six rods in a youth center, and well, sometimes you end up having a nice contact with a youngster. Then you see how they nibble your lure, you know, and then you try to reel them in. And you really need to take the time for that. Don’t expect to have had the intake after the first meeting, and you’ve cracked the code of the teenager’s problems. It might take some time before you understand what’s going on.
These conceptualizations position the outreach worker different in the space between Rehabion and youth. The narrators reflect on the situation by taking a step back (but remain in the field, otherwise they would take a survey perspective
again). Especially in the case where the outreach profession is treated as something less than “care,” it unveils a negative consequence of their position. While trying hard to bring two life worlds together, the outreach worker ultimately belongs nowhere. This leads to the experience of loneliness. Reflecting on their position, outreach workers sometimes feel as if they are merely canvassers for Rehabion. They have to bring them “in,” but remain outside themselves. At the same time, the outreach workers feel they cannot be full members of youth cultures. They are there for a reason, and although invited, they remain guests. Therefore, while they engage between both worlds, they feel that each side considers the outreach worker as part of the other group (and not theirs). Contact with the other groups is a threshold for the both sides to really see outreach workers as one of their own. By positioning themselves in between two worlds, they may end up in no man’s land. The reflection of the gaze perspective combines an evaluative stance like a survey, but with the involvement and proximity of the route. The gaze turns out to be the type of narration in which the typical process of identity formation takes place.
Discussion The aim of this article is to explore the importance of space, place, and position in evaluative healthcare narratives. Following the proposition that these perspectives could be used to explore identity narratives, several reflective issues arise. We used the case of outreach workers to illustrate how they used survey, route, and gaze perspectives on space to construct their professional field (in the survey), describe some particular events (as a route), and construct their identities (with a gaze). Of course, the playing field of the outreach workers is more complex than this. But their narratives do show how people construct a narrative place using spatial language. This case provided us with the opportunity to illustrate how perspectives generally used for navigation (Tversky, 2005) can
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also be applied to navigate professional identity work, including gaps, obstacles, well-trodden paths, dead-end roads, bridges, and a carefully crafted position for the professional. Ultimately, the hard work pays off when substance abusing teenagers find their way into treatment. The survey perspective is generally used at the beginning of the story, to “set the scene” and give an overview of the situation before the professional enters. The narrator takes a distant position from the scene, often described in relatively neutral terms. They are outsiders, able to draw a static map. They tell about a situation that develops, but they remain uninvolved themselves. Then, the situation changes when they describe themselves as actors in the developing narrative, changing the perspective to a route. They take part in the action and describe their experiences in the situations they encounter. By taking an active role, they no longer describe the place, but become part of it. The description of the place is no longer a neutral exploration of a field, but it defines the boundaries within which the professional takes his or her place. Arrangement of practices provides a script. “In acting out this script, organizational agents position themselves and others above/ under it, inside/outside, and before/after” (Vásquez and Cooren, 2013: 42). Therefore, in the case of the outreach workers, one could say that we use space as a “mental map” in the literal sense. Finally, there is the possibility of the gaze perspective, in which they describe themselves as being in the narrative space, but reflecting on the situations. There are still a lot of verbs used, but in contrast to the route, they are not actions (cf. Taylor and Tversky, 1996: 375–376). Like using spatial language to describe a place as if they look from a doorway (Tversky, 2004), the gazing professional takes a more observing perspective but remains within the situation. Here, identity is derived from knowing one’s place. The conceptualization of the scene they entered leaves its traces in the rest of the accounts. It is therefore important to note that the stage and the role define each other. On the one hand, this frame game means describing a
place that makes “your own role most prominent, and where you are seen to shine because you are the hero” (Taylor and Van Every, 2011: 63). Therefore, the place can be conceptualized with the goal of one’s own role in mind. On the other hand, the fit between the stage and one’s position within it is crucial for one’s own “belief in the part one is playing” (Goffman, 1997: 95). Therefore, as Taylor and Van Every (2011) explain, people play bot on the game (defining the situation to meet their needs) as well as in the game (their needs are defined by the situation). This is illustrated by the fact that the problems they encountered in the process of reaching out were defined in terms of the problems they already identified—which led to their appearance on the scene in the first place. The outreach workers saw a gap between Rehabion and substance abusing youngsters. Reflections on the new order showed then that they position themselves in between those two—but not really belonging to either one of them. The case of the outreach workers illustrates different ways of positioning the outreach worker in the space between organization and youth culture. This hinted at different conceptualizations of outreach: Some outreach workers consider themselves as shifting the boundaries of the organization (bringing the organization to the people, working as a “hospital without walls,” engaging in “Meddle care,” with the outreach worker as an “outpost of Rehabion”), while others saw themselves as moving beyond the boundaries of the organization (in which the outreach worker goes “out” of the organization, in order to pull them in and hand them over to the organization for “real care”). This process is not restricted to the case of outreach workers. McCann et al. (2013) showed in an ethnographic study of emergency ambulance personnel that the tension exists between “taking healthcare to the patient” and “transportation to definitive care” (p. 769). It may be a broader issue of healthcare management for organizations who need to hit the street, reach out, or pick up people. When the core business of the organization is within the walls of a building, the professionals moving out of that
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van Vuuren and Westerhof specific concrete location may have to relocate their identities too. This is a nuanced picture, in which the hero evaporates and a realistic scene of hard work, loneliness, craving for backup, and continuous flexibility are in sight. Apart from the awareness of the different perspectives people take to describe spaces and the perspectives they take in describing them, our findings suggest potential future research questions. First of all, it would be exciting to study the role of spatial language in other occupations. In line with our analyses, it can be fruitful to see how identity gets accomplished through locating oneself in a certain space, and how a place fuels occupational identity work (Larson and Pearson, 2012). Alternatively, the lack of clarity about one’s identity could also be phrased in terms of space. In narratives of priests, for example, Kreiner et al. (2006) described how individuals in this very demanding profession with a strong occupational identity looked for space for their personal identity: where is the “me” among the “we”? (p. 1031). Another area for future research would be to explore different types of references to space. We used Tversky’s concepts of survey, gaze, and route as sensitizing concepts, but another question could be to distinguish more systematically between literal and metaphorical references to space. An interesting area could be to explore the emotional side of space. Citron and Goldberg (2014) studied the role of emotions in metaphorical and literal expressions. Their findings that particular brain areas (i.e. the amygdala and the anterior portion of the hippocampus) were more active when metaphorical sentences were used indicate that conventional metaphorical expressions are more emotionally evocative than literal expressions. For narrative accounts of identity and place, the role of emotions could be explored deeper through comparing literal and metaphorical references to space. Finally, our findings may have an important methodological implication for future research in narrative health psychology. Taking different spatial perspectives into account may enrich evaluation studies on health practices and interventions. Existing studies often use a survey perspective when it comes to the quality of
healthcare. They ask for general evaluations and descriptions of the scenery of a specific practice or intervention. Such a survey perspective suggests distance, whereas a route narrative indicates active involvement. Especially when one wonders about the emotions that arise when confronted with a situation, it seems helpful to take a guided tour as the emotions are where the action is. Route narratives could thus have a meaningful contribution to understand how specific practices and interventions work for particular individuals and how care can be improved to work even better (Ubels, 2011). Gaze narratives may be important for healthcare as well. Explicating identity issues—as in a gaze—means to be aware of one’s perspective on one’s position within society, one’s interactions with others, and one’s interpretations of experiences (Gee, 2000; Geijsel and Meijers, 2005). It takes place in “a social nexus involving the complex interplay of practitioner, organizational practices and settings, professional associations, knowledge and society” (Brown and Phua, 2011: 86). A reflection on one’s position may thus provide further evidence of how professionals and their clients and patients position themselves within certain healthcare practices. Gaze narratives may provide more insight into what is at stake for different stakeholders in terms of identity management. They may thereby contribute to better understandings of how certain health practices and interventions relate to this identity work. We propose that healthcare practices can be best addressed by shifting between survey, route, and gaze perspectives. The starting point is to see how a survey perspective provides a narrative geography, a route perspective inspires the sharing of particular stories, and the gaze perspective points attention to the identity consequences of the narrative. In all, the dynamics within and between the different perspectives can enable the exploration of unknown territory of one’s identity. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
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