Chapter9 Double Ethics, Double Burden Professionalism, Activism, and Institutional Ethnography

Agnieszka Doll

Any foray into the field may lend a sense of betrayal.

—Adler and Adler (1997, 36)

In this chapter, drawing from my fieldwork, which examined the social organization of involuntary psychiatric admission procedures in Poland, I discuss the challenges that I encountered during my fieldwork, which was carried out in psychiatric hospitals and courts, and the ethical dilemmas that I experienced. To illustrate these dilemmas, I introduce the case of a young woman who was involuntarily hospitalized. As I followed her case, I witnessed both the breach of her substantive and procedural rights and her unsuccessful struggle to contest her emergency involuntary admission through legal means. Realizing that I had both the knowledge and the skills to potentially assist with her situation, I struggled with the ethics of whether and how I should intervene in her case. This emerged quite intensely in at least three moments: firstly, at the outset of her admission; secondly, at the district court proceedings; and thirdly, at her appeal hearing. Each moment resolved differently but left me with even more questions about institutional ethnography’s promise of merging activism and professionalism and highlighted the challenges in reconciling transformative research goals with impromptu intervention.

This chapter both attempts to make sense of the fieldwork experience and seeks to promote a broader discussion among institutional ethnographers on the implications of the researcher’s professional background for fieldwork practice.1 I argue that the researcher’s professional background is an integral element of a researcher’s bodily presence in the field. As the researcher’s dual positionality interacts dynamically with other factors during fieldwork, it both opens and forecloses possibilities for activism during research. Furthermore, while in some institutional ethnographic research designs, activism and the transformative goals of the project can be easily reconciled, in a project where a researcher takes the standpoint of “the oppressed” yet works mostly with the “experts” during the data collection phase, those two commitments can sometimes intersect in conflicting ways, raising questions about the possibility of reconciling transformative goals of institutional ethnography (IE) with impromptu interventions.

The chapter is organized into four sections. The first section explains my study’s context and its links to my professional legal practice. That section is followed by a discussion of Polish law on involuntary psychiatric admission. In the third section, I present the case of a young woman who was hospitalized during my fieldwork and struggled to have her legal rights protected. I also discuss the dilemmas and tensions that I faced as an institutional ethnographer with a professional background as I was considering intervention in her case. Lastly, I analyze those tensions in terms of double positionality as a researcher and professional and of fieldwork politics. I conclude with reflections on porous identities, ruling relations, and IE.

Locating My Institutional Ethnography on Emergency Psychiatric Admission in the Context of My Lawyering Work

This section of the chapter briefly discusses the emergence of my research project, designed as IE, to show its close link to my professional legal background and legal practice in criminal and mental health cases in Poland. My initial research aimed to explicate the social organization of women’s involuntary admissions to psychiatric hospitals on the grounds of mental illness and dangerousness. This involved looking at how women’s pathologies were produced through textually mediated practices and how broader social, legal, financial, and other relations organized those institutional practices. As I represented women in domestic violence and family cases, I observed not only pervasive gender stereotyping of how, for example, the victim of domestic violence should behave but also the adverse impact of any mental health diagnosis on the position of women in these cases. This professional experience led to my realization that while, in the short term, the medicalization of psychiatric intervention may bring some temporary relief for women located amid family conflicts (although I remain critical of the need to institutionalize in general), in the longer term, involuntary institutionalization does not serve women well. Psychiatric records and diagnoses tended to follow women on subsequent encounters with legal authorities, often with no legal purpose, but rather re-recreated narratives about those women as “bad” and “mad.” Often, these psychiatric files were attached to legal files upon the request of an opposing party, such as a partner accused of domestic violence or a party in a child custody case.2 Frustrated with a legal system that obscured the systemic inequalities that organized women’s lives and pathologized them as individuals, I decided to suspend my professional career and study overseas (in the United States and Canada) to equip myself to address the systems of power that contribute to the oppression of women by the law. Through an examination of everyday practices and processes, I hoped to learn how, within the context of the admission procedures, the accounts of mental health and behavioural pathologies in women were produced, so lawyers could gain new knowledge and tools on how to effectively challenge those psychiatric opinions or map the space where they could intervene effectively to provide alternative stories based on women’s experiential accounts. Hence, my research into the social organization of processes of involuntary admission of women clearly had an activist goal: to disrupt the metanarrative of the official and authoritative accounts of involuntarily hospitalized women as “mad and bad” and to improve institutional practices for women.

I chose IE as my method of inquiry because it focuses on exploring institutional practice and has the potential to inform social and institutional change (Smith 2005). This method of inquiry has been frequently utilized by researchers with professional backgrounds in social justice interested in addressing the operation of various policies that do not meet people’s actual needs (Bell 2001; Bisaillon and Rankin 2013; Miller 2005; Pence 2001; Rankin and Campbell 2006; Townsend 1998). Institutional ethnographers take seriously professionals’ concerns about institutions’ functioning and use their own professional experiences as starting points for further inquiry into how experiences and oppressive practices are socially organized (Smith 2005). Later, such knowledge can be taken up by those professionals to enact progressive social change on either an individual or a structural level (Campbell and Gregor 2008; Dobson 2001).

I conducted ethnographic fieldwork in Poland between August 2012 and February 2014. My research sites included psychiatric facilities, courts, lawyers’ offices, and emergency services. I interviewed judges, paramedics, psychiatrists, and administrators; had casual conversations with them; and observed their work. Aiming to illuminate how involuntary admission decisions are made and the material context of decision-makers’ work, I observed the daily routines of legal and medical professionals. For example, I participated in psychiatrists’ morning reports, observed their diagnostic work, listened to their discussions, and accompanied them in their other work activities (such as their lectures to medical students, seminar talks, and conferences). I spent a few hours a day in doctors’ offices, where I had the chance to engage in both casual conversations and formal interviews. Similarly, I accompanied judges on their trips to psychiatric facilities, attended hearings, and observed the production of case documents pertaining to emergency admissions. I paid particular attention to the exchanges between various professionals involved in a case or when a case was moved between different organizational sites. I also gathered various regulatory texts and a set of ex-patients’ medical and legal documents from courts and observed how they were used by medical and legal professionals during the admission process. Furthermore, I monitored a few individual involuntary admission cases from their outset to their conclusion to capture those exchanges, especially when the person was admitted against their will by an appellate court decision. There were several times I felt uneasy during my research; however, I found one case particularly troubling in terms of both institutional practices and my responses to those situations. The case of this young woman, whom I call Anna, sheds light on the challenges of navigating both professional and activist commitments. This conflict arises when one is conducting research with professionals involved in problematic practices while attempting to uphold the perspectives and rights of admittees.

Before I turn to that case, I will present a brief survey of the Polish mental health law on emergency involuntary admission, which provides an essential background for understanding Anna’s case and the emergence of my ethical dilemmas.

Polish Mental Health Law on Emergency Involuntary Admission

On January 22, 1995, the Mental Health Protection Act of 1994 (MHPA;3 particularly articles 23, 24, and 28) came into effect to regulate involuntary emergency admissions to psychiatric hospitals in Poland. The MHPA was the culmination of more than two decades of mental health reforms intended to humanize involuntary admission procedures and coercive treatment of persons deemed mentally ill (Zajaczkowska 2011). To address severe rights violations of patients in psychiatric facilities—abuses associated with a medical model in which psychiatrists exercised omnipotence over involuntary admissions—reformers in Poland (Dąbrowski and Kubicki 1994; Dąbrowski and Pietrzykowski 1997; Zajaczkowska 2011) and elsewhere implemented a rights-based legal framework grounded in the argument that “substantive improvements in a lot of the mentally disordered [would] follow from a recognition of their rights” (Rose 1986, 177).4

Accordingly, mental health reformers sought to enact stricter admission standards to prevent unnecessary admissions, including developing more comprehensive admission criteria than the single previous criterion of a need for treatment (Arrigo 1993; Collins 2009; Dallaire, Morin, and Cohen 2001). Specific solutions adopted in Poland included narrowing the grounds for an involuntary emergency admission by adding extra criteria that needed to be met, in conjunction with the diagnosis of a mental illness. These elements are called substantive grounds.

According to the MHPA, a person can be admitted involuntarily only if the person

1) is mentally ill and that person’s illness-related behaviour poses a threat to her own life or the life and health of others (article 23), or
2) exhibits a mental disturbance, and that person’s disturbance-related behaviour poses a threat to her own life or the life and health of others, yet it is unclear whether she is mentally ill (article 24),5 or
3) is mentally ill and not treating that person would cause a significant deterioration of her health (article 28, clause 1), or
4) is mentally ill and not capable of caring for her basic needs, and it is predicted that the treatment will improve that person’s health (article 28, clause 2).

The first two instances are called emergency admissions, and the admission decisions in these cases are made by psychiatrists and later reviewed for their legality by the courts. In the last two situations, admission decisions are made by a court.

Polish mental health reforms also resulted in procedural changes in the involuntary admission process. The MHPA imposed a strict timeline for decision-making and legal control, including a multi-level judicial control process, and granted admittees the right to participate in the procedure personally or through a legal representative. These elements are called procedural rights. The MHPA introduced a mixed medico-legal model into the involuntary admission procedure, wherein psychiatrists make the admission decisions but an independent judicial body assesses those decisions (articles 23 and 24). In Poland’s previous medical model regulating psychiatric admission, psychiatrists were the sole decision-makers (Zajaczkowska 2011). The significance of the mixed model is that not only does it impose a legal framework and control over psychiatrists’ decisions, but it also ratifies strict legal grounds for involuntary admissions (substantive rights) and increases guarantees of due process by the insertion of patients’ rights (procedural rights; Zajaczkowska 2011). These legal changes were to ensure that nobody would be confined unnecessarily and illegally. The MHPA also mandates the work undertaken by psychiatrists in stipulating and enforcing standards for emergency involuntary admission. For instance, upon a person’s arrival in a psychiatric facility, a psychiatrist needs to decide if that person should be admitted and on what grounds (MHPA articles 23, 24, or 28). Within forty-eight hours, the facility director is required to endorse the psychiatrist’s decision. Regardless of this endorsement, however, the director is obliged to notify the family court of the involuntary admission to the hospital (article 23, clauses 2–4). This sets in motion the procedure for judicial control over the legality of psychiatrist-issued admission decisions. These judicial control activities take place across organizational sites, as illustrated in figure 9.1.

The time frame for judicial control activities is also strictly prescribed and relatively short. Within forty-eight hours of the director’s notification, a district court judge from the family unit visits the admitted person for a preliminary assessment (MHPA article 45, clause 2). This preliminary assessment involves meetings between the judge and the admitted person and between the judge and that person’s lead psychiatrist. In my research sites, these meetings were held in psychiatric facilities. At this stage, the judge needs to determine whether the patient should be discharged immediately (if there are no grounds for the emergency involuntary admission) or whether the case should be sent for further adjudication by the court. My observations of the proceedings, along with my analysis of numerous case files, show that involuntarily admission cases are almost always sent for adjudication by a district court; the one exception is when the admitted person consents to the admission during that preliminary assessment by a district court judge. In such a case, the admission becomes voluntary, and the further procedure for judicial control is discontinued. Otherwise, a district court must hold the involuntary admission hearing within two weeks of the preliminary assessment (article 45, clause 1). Subsequently, if the district court finds the decision illegal, it recommends an immediate discharge of the concerned person from the psychiatric hospital. If the decision is found to be legal, the admitted person has a right to appeal, but appealing the admission decision is a lengthy procedure, and it may take up to a year for the court of appeals to issue its final verdict; therefore, the admitted person, by the time the appellate hearing is scheduled, might be already released.6 The appeals court can accept the appeal as valid or reject it and uphold the lower court’s decision. If the appellate court accepts the appeal on the basis that the emergency admission did not meet its legal grounds (article 23 or 24), it reverses the lower court’s decision and discharges the admitted person immediately. If the court of appeals accepts the appeal on the basis that there were procedural problems, it sends the case back to the lower court for re-adjudication. In such situations, the appeal court’s decision will not result in the immediate discharge of the concerned person.

Graphic depiction of activities comprising a judicial review of involuntary admission decisions and where they occur. Moving from left to right, the diagram shows that the first activity is a preliminary assessment, which takes place in a psychiatric hospital; the next activity is an involuntary admission hearing, which takes place in district court; and the last one is an appeal hearing, which takes place in appeal court. — Figure 9.1. Judicial control of the legality of psychiatrists’ decisions on emergency involuntary admissions.

With this brief explanation, now I turn attention to Anna’s emergency involuntary admission case, which sparked my ethical dilemma and tensions about whether I should intervene in her case and, if so, how to do it most effectively.

A Story of Anna’s Admission

About four months into my fieldwork, a young woman, “Anna,” was involuntarily admitted on emergency grounds (under article 23 of the MHPA) to the psychiatric hospital where I was conducting my research. The following morning, I learned about her admission when I attended the morning staff report and sat in a psychiatrist’s office where her case was discussed. Her case stirred intense reactions and discussion among the psychiatrists for at least two reasons. First, Anna was very vocal in contesting the legality of her admission, and second, her legal training provided her with the skills and knowledge to challenge the admission legally. Not only was she familiar with the substantive legal grounds for involuntary admission, but she also knew her procedural rights and was familiar with the network of human rights institutions that could potentially intercede in her case. For example, within the first few hours, she wrote a letter to the Human Rights Ombudsperson, asking them for assistance. Psychiatrists were aware that she would challenge the decision by an admitting psychiatrist by all available legal means. In a way, this was a unique situation because, from what I observed during my fieldwork, many patients were confused about what was happening to them, unfamiliar with their legal rights, and scared (for further discussion, see Doll 2017).

As I followed Anna’s case, I witnessed violations of her rights and her unsuccessful struggle to contest her involuntary admission. I will elaborate on both of those aspects below.

Violations of Anna’s Rights

There were at least three kinds of breaches of the legal provisions of the MHPA and Anna’s rights:

1. Violation of the MHPA substantive requirements for involuntary admission (the violation of substantive rights);
2. Deprivation of her right to representation (the violation of procedural rights); and
3. Deprivation of her right to participate in an involuntary admission hearing (a second procedural rights violation).

In terms of the first violation, from conversations among psychiatrists during the morning staff report and later continued in their offices, I learned that Anna was categorized as an emergency involuntary admission (based on article 23 of the MHPA) instead of a non-emergency one to facilitate her prompt admission and treatment. Yet what became quickly apparent was that she had been admitted because of an arrangement between her parents and one of the psychiatrists working in the facility, and not because she posed a direct threat to herself or others or could have been considered dangerous. Concerned about her well-being, her parents wanted her to get treatment, even against her will (I will expand on this topic below). Indeed, Anna’s parents had mounted two prior unsuccessful attempts to institutionalize her involuntarily. In those two instances, Anna had been able to avoid being admitted by physically escaping from the emergency ward where her parents had brought her. Knowing that Anna would legally contest her admission and the case would go under judicial review, the psychiatrists producing her medical documents put extra effort into constructing evidence of the danger she posed to herself and others. As per article 23 of the MHPA, they needed to demonstrate both that Anna was mentally ill and that her illness-related behaviour posed a threat to her own life or the life and health of others. I saw how Anna’s mental illness and, stemming from it, her perceived dangerousness were produced by psychiatrists. Psychiatrists had concerns about her mental health based on her drawings and sketches that her family had delivered and on Anna’s mother’s report suggesting that Anna had starved a dog. To construct a diagnosis of her mental illness, a certain narrative of Anna’s a-sociality was produced through accounts of her supposed transgression of gender norms, such as the expectation that women be social and friendly and that they neither express controversial opinions nor be openly critical of others. I also witnessed how Anna’s “dangerousness” was constructed in an interview with her mother, during which a psychiatrist led the mother through a set of specifically directed and suggestive questions. The psychiatrist asked the mother whether Anna had ever been physically violent—for example, by pushing or hitting her mother—or whether Anna had ever been verbally violent. Her mother explained that Anna had forced her mother aside to access the balcony; it happened only once, when the mother had blocked Anna from accessing the apartment balcony, ostensibly for Anna’s safety. This pushing event was recorded in the psychiatrist’s notes as an example of Anna’s violence and dangerousness, while the rest of her mother’s explanation, including the context of the encounter, was omitted. Psychiatrists also interpreted Anna’s vegan diet as evidence of her desire to harm herself, and it was used as another example of her danger, this time to herself (Doll 2017).

The deprivation of Anna’s procedural rights began as soon as the day after her admission, when she requested a legal aid lawyer. She made this request verbally to her lead doctor, who noted it briefly in her patient file. However, in Poland, in all non-criminal cases (to which involuntary admission cases also belong), only a court has the legal authority to appoint a legal aid lawyer for those who request such. Thus, for Anna to get a lawyer, her request needed to be brought to a judge’s attention—yet the psychiatrist failed to pass Anna’s request along when the judge came for the pre-assessment meeting in her case. Nor did the judge see the note about the request in Anna’s patient file when skimming through her medical documents during the preliminary assessment meeting. Although the request for a lawyer does not automatically result in the appointment, it is still a patient’s right to have such a request reviewed by a judge. This is especially important in cases involving psychiatric patients. Since 2010, the Supreme Court of Poland, in interpreting the provision on representation in involuntary admission cases (article 48 of the MHPA), has even suggested that people undergoing admission are unable to represent themselves due to their mental health or their confinement in closed wards, and they should have a lawyer mandatorily appointed (for example, Poland Supreme Court 2012). Although Polish law is not precedent based, the Supreme Court’s interpretation informs how lower courts should apply certain legal provisions. However, this did not happen in Anna’s admission case, and nor was a lawyer appointed for her mandatorily. She only received the lawyer later at the appeal hearing when she resubmitted her request in written form.

In terms of the second instance of procedural rights deprivation, this one relates to her absence from the involuntary admission hearing held at the district court. As I mentioned before, giving the admitted person an opportunity to be heard was to be one of the core advancements enacted by mental health reforms and the MHPA. After Anna learned of the date and time of her involuntary admission hearing, she requested that her doctor allow her to participate in that hearing. The doctor did not see any medical concerns preventing Anna from participating; moreover, the doctor phoned to inform the court that Anna had requested to be transported there. However, because of the significant distance between the hospital and the district court and the security restrictions imposed on involuntarily admitted persons, they require secure transportation to the courthouse if they want to participate in their involuntary admission hearings. Although the MHPA institutionalized the right of an individual to attend their hearings, this was not practiced in my research sites. Neither the court nor the hospital considered ensuring transportation for these patients to be their responsibility. Moreover, district court judges did not see the patient’s presence in court as essential in involuntary admission hearings (Doll 2017). Indeed, in assessing the legality of involuntary admission, judges relied heavily on documents produced by the admitting psychiatrist and the judge visiting the hospital for the pre-hearing meeting and on the opinion of a so-called independent psychiatric expert.7 As a result, on the hearing day, Anna was ready and waiting to be taken to court to defend her rights in person in front of the district court judge, but she was not allowed to do so. She was never taken to the courthouse, and the hearing proceeded in Anna’s absence. The notation in the court file was that Anna had been informed about the date and time of the hearing but did not come to attend (Doll 2017).

These short vignettes show how various rights violations emerged in different forms, as the case of an involuntary admission that I traced moved through various stages of admission and judicial control. In the rest of this chapter, I discuss how ethical challenges manifested themselves for me in these contexts and how various constellations of power relations during my fieldwork opened some opportunities for my intervention while closing others.

Ethical Dilemma and My Advocacy for Anna

Compelled by my commitment to social justice, and following the standpoint grounded in the interests of the involuntarily admitted persons, I wanted to act and advocate for Anna’s rights—yet I realized how constrained I was in my ability to do so in various ways. At the initial stage of her admission, I felt that my ability to advocate for her rights was limited. Thus, in response to the breach of her substantive rights at the initial stage of her admission, I decided to intervene only by asking psychiatrists questions to raise doubt about the nature of the symptoms of her “illness” and present a potential alternative interpretation of her behaviour. I wanted to show how both her symptoms (such as her lack of interaction and socialization with members of the small-town community) and her actions could be interpreted differently if put in the broader context of her life trajectory (she had been educated internationally and was pursuing a graduate degree in France, and thus she might not see members of the community as intellectual companions; plus their values and priorities might have differed from hers).

I was aware of the limited space for challenging Anna’s mental illness as a justified ground for her involuntary admission due to the predominance of the hegemonic biomedical model of mental illness and the interpretation of her actions according to it. Thus, my attempt to involve psychiatrists in the discussion did not have significant traction as the biomedical model of mental illness was upheld uncritically by professionals with whom I interacted. Furthermore, I was unsettled by my decision not to intervene directly by drawing attention to her request for representation even though such intervention could cause harm to my research participants—such as the professionals managing her case as well as putting me in breach of research confidentiality. It was still disheartening to watch her longing for help and not provide it. New space for intervention opened later as her case moved to appeal court. I decided to approach this space strategically. Before her case reached the appeal court, I felt that I could not intervene in Anna’s request for a lawyer without violating the standard of confidentiality that I guaranteed to my research participants, specifically psychiatrists, who told me about Anna’s request.

Yet even without a lawyer, given her legal training, I foresaw that Anna would have more of a chance to make her points if only she would be given an opportunity to present her case to the district court during the hearing. In fact, during my fieldwork activities, I learned about one successful case in which the court adjudicated that admission was illegal after hearing facts presented directly by an admittee. Thus, I put my efforts into ensuring that she could appear in the district court. On purpose, I went early to the psychiatric facility and later to the courthouse on the day of the hearing. In the courthouse, I engaged in a casual conversation with a judge, during which I mentioned that Anna was waiting in the psychiatric facility to come to the courthouse. I also ensured that I was at the hearing and waited for a few hours for it, hoping to put tacit pressure on the court by my persistence in attending this hearing and learning its results, although I was discouraged by court staff from doing so. Unfortunately, I was neither successful in making the judge consider Anna’s appearance in the court nor given a chance to observe the hearing, as in Anna’s absence, it was moved in camera, meaning that the judge decided the case in their office.

The most successful intervention came about unexpectedly at the court of appeals. After Anna sent a written request directly to the district court, she was eventually granted a legal aid lawyer to represent her in the appeal. Just before the appeal hearing (to which Anna did not come despite having been discharged from the facility by her treating psychiatrist), in a brief conversation, I was able to direct Anna’s lawyer’s attention to the fact that she had not received legal representation in the previous stage of the procedure (and this was the recommendation of the Supreme Court and practice encouraged by the appeal court). He understood the clue and was able to incorporate the argument about the breach of her procedural right (the right to representation) into the oral submission during the appeal (the announcement of the decision was deferred for some time). Anna’s appeal was successful, and the case was sent back to the lower court. Yet here I was troubled, knowing how limited the scope and effectiveness of my intervention would be. By the time the appeal hearing came up, Anna had already been discharged from the hospital for months—not because she was able to mobilize the means to challenge her decision’s legality, but because she began to comply with the treatment recommendations of her doctors. Reopening the hearing at the lower court meant that she would be required to partake in something that she might want to forget about. In fact, I saw in court files that she stopped accepting court correspondence about her case.

I left my field sites feeling that I had betrayed my moral and ethical standing as both a lawyer and a researcher, given my limited intervention in the early stages of her admission case and later intervention at the appeal court, which might have carried adverse emotional effects for her. By acting “safely” and guardedly, worrying about the impact of my bolder interventions on my institutional access, I felt that I betrayed the people whose interests motivated my research. I started to question IE’s promise of merging activism and professionalism and institutional ethnographers’ capacity to reconcile a project’s transformative goals with impromptu interventions within a fieldwork context.

Two Facets of My Dilemma: Social Relations of Professionalism and of Fieldwork

Grasping these dilemmas’ complexity was an emotionally and intellectually challenging undertaking—one that took several months to come to grips with. It was like peeling layers of an onion, uncovering the many elements that both constrained my ability to intervene and determined my choice of strategies for specific interventions. Initially, I thought the conflict was between my professional and research ethics, but with time, I realized the situation was much more complex. I came to understand that the social relations of professional standards and ethics interacted dynamically with other influences—such as my specific research design and fieldwork politics (Bisaillon and Rankin 2013)—to discipline my capacity for action.

I address the social relations that I see disciplined my capacity for action, and eventually my intervention strategies, by grouping them into two sections. First, I discuss restraints in terms of professionalism, reflecting on my research and legal professional relations, precisely values and standards binding me in these capacities and restricting my capacity to intervene. Second, I address restraints imposed on me by the “politics of fieldwork,” where the tension between working with professionals who contributed to the observed rights violations and the adoption of the standpoint of those subjected to those violations surfaced with great intensity.

The Lawyer as Institutional Ethnographer: Social Relations of Professionalism

Belonging to professional communities granted me certain privileges in the context of my fieldwork. Due to my professional credentials as a researcher and my previous work-based connections as a lawyer, I was able to gain entrance to research sites in psychiatric facilities and restricted spaces in courts, such as judges’ chambers, often closed to others. I was afforded considerable trust and credibility and gained “insider” status from the outset. Once I secured access, I established good working relationships with both legal and medical professionals. The facility director granted me extensive access to files and records, and I was welcomed into professional spaces where everyday work occurred. Professionals working in the hospital and courts took me into their confidence; many even felt comfortable expressing their opinions, frustrations, and concerns about their work and the admission procedure. Through this open access to data, I learned the details of Anna’s case.

While my professional status as a researcher and legal professional opened important doors for me, it also imposed significant limits. As a researcher, I was bound by the research ethics and protocols approved by the Research Ethics Board at my home university (Human Research Ethics Board 2012). I guaranteed that the information I acquired through formal interviews, informal conversations, and observations of participants’ work would be confidential. I emphasized guarantees of confidentiality when I was recruiting professionals for my study and when I was engaging in research with them. We mutually agreed to the confidentiality measures by signing informed consent documents. I guaranteed I would use the data only for academic and professional publications and policy recommendations. Accordingly, my potential interventions could only be grounded in the information that would not risk confidentiality or affect my participants’ professional status. As a researcher, I was reminded (even by my doctoral supervisors) that I should restrain myself from such action and focus on documenting the abuses as evidence that could be used to inform changes in policy and practice. My fieldwork had, after all, not been proposed under an activist research design. This imposed a specific limitation on my ability to disclose to a judge Anna’s request for a lawyer, as this information was obtained from my psychiatric professional informants. I was freer to disclose that Anna was waiting to be transported to the courtroom because I was able to observe it first-hand. Lastly, when the case reached the appellate stage, I could use my fieldwork knowledge of what arguments had been successful in involuntary admission appeals to intervene without breaching research ethics and confidentiality. I suggested to Anna’s legal aid lawyer that they consider the Supreme Court’s decision that had recommended legal aid representation for detainees at all stages of the judicial control procedure and check when Anna was provided with legal aid. Thinking through this suggestion, he arrived to the argument that Anna was not represented properly in the previous stages of the adjudication process.

In addition to research ethics, as a legal professional and a member of the Polish bar, I was bound by professional, ethical standards set for lawyers, specified in the Polish “Bar Law” (1982) and Polish “Code of Ethics and Professional Conduct for Advocates” (1998). According to these regulations, a lawyer in Poland can provide legal assistance only when formally appointed. This means they can only advise or advocate on someone’s behalf upon receiving a power of attorney from that person or their relatives. Also, to provide legal representation, a lawyer needs to be a practicing member of the local bar. When I entered my graduate studies, I had suspended my legal career and became a non-practicing member of a regional bar, which imposed an additional barrier to my engagement in Anna’s case. Yet at the same time, in Poland, admission to the bar is perceived as a vocation and a calling to co-work with other legal agencies to defend the rule of law and protect human and civil rights (“Bar Law” 1982). Thus, it was not only because of my professional affiliation that I felt conflicted with my inability to advocate for Anna directly but also because of the professional values that I had internalized as a member of the attorney community and my personal commitment to social justice. For these reasons, I was inclined to engage in an impromptu, informal action to fulfill my professional legal commitment—yet the very same professional standards, with their formal requirements, prevented me from acting or even advising based on my professional legal knowledge of Anna’s case. Being aware of these formal limitations to my direct professional legal involvement, I needed to channel my advocacy commitment through informal conversations with practitioners, where they would serve as mere suggestions. I was aware that, otherwise, my intervention in Anna’s case could breach provisions for legal representation in Poland and the ethics set for lawyers by the regional bar association.

I realized how social relations of professionalism organize how we position ourselves in activist ethnographic fieldwork and the strategies we develop to meet our social justice goals. Thus, in the institutional ethnographic project, a more dynamic approach to the researcher’s professional background and experience is needed, one that moves beyond seeing the importance of professional background and experience only in the initial phase of IE, when the researcher maps the disjuncture in the functioning of institutions, to treating them as an integral element shaping the “politics of fieldwork” (Bisaillon and Rankin 2013). This new approach can help account for power relations that may materialize during the fieldwork, of which relations stemming from one’s professional background and commitments are important. Furthermore, taking seriously challenges that emerge because of one’s professional background may help researchers with a dual professional commitment to prepare for fieldwork and consider in advance spaces for advocacy intervention.

“Fieldwork Politics”: Challenges to Advocacy

In the usual design of an IE project, a researcher begins their study by working with a group of people whose experiential knowledge is the starting point for the inquiry. After mapping the problematic in institutional practices through interviews with those standpoint informants, and potentially also through the observation of their work/life realities, the researcher proceeds to explore the organization of institutional processes and practices and, more broadly, of the coordination of ruling relations and how this problematic arises out of coordinated ruling regimes and specific power constellations. Accordingly, in this design, the researcher only works with experts and authorities (also called extra-local informants) at the later stage of the project. In this stage, the data collected is through interviews, and the researcher does not usually spend a substantive amount of time with extra-local informants. My own research design departed from this. While my study took a standpoint of institutionalized women (and I carried out the study in their interests), I adopted what could be called a “jump-in” research design. DeVault and McCoy (2006, 22) note that in this kind of design, the researcher “jumps right into the examination of organizational work sites” and specifically investigates “organizational work processes and the activities of people who perform them.” Additionally, they point out that this type of IE focuses on ruling relations. The researcher proceeds with “the detailed examination of administrative and professional work processes,” exploring specifically “how they are carried out, how they are discursively shaped, and how they organize other settings” (22). Accordingly, I collected data at multiple sites of emergency services, psychiatric facilities, and various levels of courts. There, I spent a significant amount of time observing work processes, carrying out interviews and informal conversations, and participating in professional training, conferences, workshops, and so on. I interacted predominately with medical and legal professionals involved in involuntary admission during my data collection.

The practical challenges of working with professional informants while maintaining the “oppressed” standpoint have already been noted by Bisaillon and Rankin (2013) in their post-study reflection on fieldwork challenges. They show how fieldwork politics were challenging to navigate because of the disjuncture between the standpoint grounded in the experimental knowledge they adopted and the “official” knowledge that extra-local informants represented. They argue that the politics embedded in a standpoint position shape ethnographic fieldwork and pose various challenges, which can even threaten the research process. While I was able to gain access to these research sites due to my “belonging” to the professional community and my previous professional and personal relationships within the medical and judicial systems, my access was precarious and only secured after a lengthy process of institutional approvals by multiple levels of courts, supervisors from psychiatric wards, and governing bodies. It took me from June to December 2013 to obtain all these approvals. Thus, as much as I wanted to engage in the most expansive advocacy for Anna I could, I also needed to carefully consider how to do it most effectively and without foreclosing possibilities for future data collection and research that aimed to illuminate socially and legally troublesome practices during the admission process and to subsequently map space for organizational transformation. While there are several examples of institutional studies where researchers who were practitioners were able to successfully reconcile their professional duties with their researcher standing, due to my research design, this negotiation was incredibly challenging for me, to the extent that I felt it could threaten the future of my data collection. For example, in his doctoral research, Craig Dale (2013), a critical care nurse specializing in mouth care and a researcher in a clinical critical care setting, supported other critical care nurses, his standpoint informants, in their patient care. Similarly, Megan Welsh Carroll (in this volume) studied the social organization of re-entry and, during her fieldwork, assisted women in filing papers for social assistance and used her social work experience to help these women navigate other bureaucratic hurdles.

Yet I was able to use my professional knowledge of legal procedures, along with insights gained through my research, to strategically assess what kind of interventions I should undertake and assess their potential for success. For example, I became aware that advocating for legal representation would contradict the judiciary’s focus on procedural efficiency. Lower court judges often told me about significant workloads, for which they are accountable to the chief justice of their court division. From an interview with a chief of the family and youth division of a regional court, I learned that the successful performance of a judge is understood as their ability to quickly adjudicate cases, ensure minimal delay, and show few overdue cases in the monthly report, sent by the chief of each department to the minister of justice (unpublished data, May 7, 2013). Furthermore, the district court judges are made responsible for enacting financial discipline for their courts and sections (Doll 2017). The district court judges were clearly aware of the financial consequences of their decisions to grant legal aid for their court’s budget (“Decree of October 22, 2015 of the Ministry of Justice”). Responding to my question about her practice of the Supreme Court of Poland’s promotion of extensive scope of legal aid assistance in involuntary admission cases, one district court judge stated, “If I appoint an advocate to every single case, the Chief Justice will not be happy about it” (district court judge, unpublished data, February 22, 2013). At the same time, the appellate court tended to adhere to the Supreme Court’s recommendation on access to legal aid lawyers for admittees. This affected my decisions around strategizing my interventions in Anna’s case and what interventions I could enact pragmatically.

As becomes clear, my professional background and knowledge interacted with other factors during the fieldwork in a dynamic way; at various times, they both opened and foreclosed different constellations of possibilities for activist actions during research. My experience coincides with observations made by Marie Campbell (2006) about activism from the “inside” of agencies. She reflects that finding oneself “arrayed on the opposite side of issues from those with the power” (88) carries numerous implications. Because of the power differences and the fact that their understanding is superseded under the official one (representing a different set of priorities), the activist “must find ways of impressing on the opposition the importance of their view and the course of action it requires” (88). This involves looking strategically at a problem, including what elements to focus on and what course of action will maximize effects. As Campbell (2006) further indicates, challenges can prompt a good analysis that reveals functioning institutions. Thus, beyond my direct intervention, I hope that my chapter can also be useful in this way.

Porous Identities, Ruling Relations, and Institutional Ethnography

My experience illuminates some specific ethical and practical challenges that researchers with other professional credentials or training might face while pursuing ethnographic fieldwork—in this case, the difficulty in navigating fieldwork as a researcher with legal skills in situations where I witnessed abuses that I felt obliged to challenge as both a researcher and a lawyer. Even though I was committed to social justice in both of my roles, I found it difficult to realize my obligations in practice because my actions were constrained by professional ethical standards, conflicting priorities, the formalism of legal procedures, and the structures of my research sites. This caused me significant emotional distress. Researchers coming from human services have recognized that there are dilemmas that “are especially likely to occur when researchers who are also practitioners recognize the need to acknowledge relevant multiple responsibilities and sensitivities” (Bell and Nutt 2012, 77; see also Miller et al. 2012). When the researcher is accountable institutionally or morally to different sets of professional standards and, even more so, when these conflict with loyalty to subjects for whom the research is being pursued, the researcher may experience these ethical standards as a double burden. This double burden can articulate itself, as was the case in my research, in questions about how to “‘manage’ all these responsibilities in practice, in ways that all parties would consider ‘ethical’” (Bell and Nutt 2012, 76).

Thus, institutional ethnographers must engage with research ethics and the “double responsibility” of a researcher who is also a practitioner belonging to academic and professional communities (Doll 2017). There are two reasons for doing so: first, these are integral realities in the lives of researchers with other professional credentials, and second, it is through analyzing the organization of ethical dilemmas that we gain valuable insight into the ruling regimes that activists and politically engaged scholars aim to challenge. IE is attractive to researchers with professional backgrounds, as it assists them in understanding their workplace worlds and the problems that arise therein. Yet in IE, a researcher’s professional background, with all the experience and knowledge it involves, is seen only as a terra incognita from which to launch an inquiry. My fieldwork experience and subsequent analysis problematize this selective attention, prevalent among institutional ethnographers, to researchers’ professional backgrounds. I documented that a researcher’s professional background is an essential element of their presence in the field, carrying methodological and ethical significance for the research practice. The professional background creates “conditions and restraints under which [research] is produced” (Mauthner and Doucet 2003, 424). One does not stop being a professional when one becomes a researcher. As a mode of inquiry, IE needs more discussion about the pragmatics of working in the field. This could offer novice researchers hands-on strategies for navigating the various challenges, including ethical ones, they may encounter during their fieldwork (Bisaillon and Rankin 2013; Grahame and Grahame 2009).

By treating a professional background as an element of the researcher’s field presence that contributes to certain experiences of ethical dilemmas, we can approach this background and experience analytically. By analyzing the organization of institutional ethnographic research processes and the ethical dilemmas that may emerge in the fieldwork context, we can gain valuable insight into governing relations (Nichols 2016). I initially saw my roles as a researcher and a professional as being in conflict. A closer analysis of my dilemmas, however, revealed that institutional ethical standards reinforced my standing as an agent of certain institutions in both roles, and that compromised my standing as an ad hoc advocate of the rights of the committed person (Doll 2017). It is essential to recognize that ethical standards are not neutral. Hussey (2012, 13) points out that a “person’s ‘ethics,’ ‘morals,’ or ‘politics’ don’t just come from anywhere.” Serving “as a mechanism for endorsement and quality assurance,” Tummons (2014, 419) asserts that professional standards are connected to broader social and legal relations. In my roles, I internalized this kind of professional accountability, whether toward my university or the bar association. My professional ethical commitments forced me to discipline my activist involvement even though this conflicted with my moral and political standing. Acting upon my professional commitments, I sacrificed my ability to help Anna the way I would have wanted, even though I had the knowledge and skills to do so.

Although I could not intervene in Anna’s case to the extent and in the manner that I wanted to, I nevertheless ended up with significant research findings on institutional practices that significantly undermine the rights of involuntarily admitted persons. The matter of legal representation, the tensions I felt, and my capacity to intervene in these regards are important to consider, as they speak to the broader social organization of involuntary admission procedures. While institutional priorities constructed limits to my activist involvement, more importantly, they also suppressed the interests of people involuntarily placed in psychiatric facilities. I realized that ethics is a socially organized work of academic and legal professionals that can interfere with the ethics of caring for people in research. Furthermore, the analysis of my ethical dilemma illuminated how the interests of involuntarily committed people “are being marginalized in routine organizational action” (Campbell 2006, 91). By taking seriously my ethical dilemma and challenges surrounding my intervention in Anna’s case, I hope that my research has contributed to a better understanding of the potential structural and ethical limitations (as organized by ruling relations) of advocacy-motivated research in the context of legal and psychiatric systems.

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1 Since the chapter was written and accepted, an important discussion about the social relations of professionalism concerning IE researchers with a professional background (topics considered in my chapter) has also been undertaken by other IE scholars. See Luken and Vaughan (2023), Campbell (2023), and Ridzi (2023).

2 See Megan Welsh Carroll in this volume (chapter 8) for a similar reflection on “the travel” of the criminal record across organizational sites as women discharged from prisons navigate their re-entry into society.

3 Translations of Polish statutes and their titles are mine unless otherwise noted.

4 Mentally disordered is an old-fashioned term, used commonly when Rose’s article was published.

5 The Polish language uses gendered nouns. The noun “person” is a female noun, and therefore it is accompanied by the pronoun and a possessive determiner “she/her” while referring to all genders.

6 A patient might be released while an appeal is in process, for instance, if their psychiatric team deems them well enough or when the statutory time for involuntary hospitalization expires. The latter circumstance is applicable to involuntary hospitalization based on article 24 of the MHPA, where the MHPA limits such detention to a maximum of ten days. During my fieldwork, I also found out that the psychiatric team may release a person when the insurance coverage for an assigned diagnosis expires.

7 Such valuation of psychiatric experts’ reports or facts presented by psychiatrists and devaluation of the voices of detainees are not unique to the Polish courts that I observed in my study. For example, in the 2017 report Operating in Darkness: B.C.’s Mental Health Act Detention System (Johnston 2017), similar biases were reported in the operation of review panels. Regarding the matter of independent experts in Poland, my data show that experts who prepare these opinions are employed typically in the same ward to which the person is admitted. Given that in the research sites where I conducted my study, wards were rather small, with a limited number of doctors employed, and that these doctors shared offices, the degree to which their opinion was an independent expert opinion could be contested. I observed that some cases were widely discussed among professionals, and every new admission was discussed during a routine morning report, which all doctors, student residents, and a head nurse should and tended to attend (Doll 2017).

10. Objectivity Regimes: Challenges for Activist Research in the Academy