International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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642 C. Strike et al. / International Journal of Drug Policy 25 (2014) 640–649 relationship of self to self, to connect together questions of poli- tics and ethics. Foucault helps us think about how individuals are governed through their interactions with institutions like hospitals, and the ways they concede or resist, and what this says about larger political forces that extend beyond individuals, spaces, and places. Finally, Foucault invites us to think about conceptions of ethics that emerge within the constraints of governance, that is, how subjects stylise themselves in relation to the range of constraints and oppor- tunities around them. Or, in the current study, how people living with HIV who use drugs in hospitals are governed through poli- cies and procedures and conduct themselves; all of which serves to create a unique context. Overall, a Foucauldian approach invites a critical engagement with the study of health and place in a way that surfaces and interrogates power relations and forms of resistance in the shap- ing of a drug using context. In critical public health and addictions studies Foucault's work has been used to problematise the deliv- ery of harm reduction programs and addictions services (Fischer, Turnbull, Poland, & Haydon, 2004; Keane, 2009; P. Miller, 2001; Moore, 2004). Our subsequent analysis builds on this work by examining power and complexity in harm reduction in a hospi- tal setting. Cognisant of Foucault's (1978, p. 95) claim that "where there is power, there is resistance," we challenge the tendency to offer a solely negative reading of the operations of power. Indeed, most hospitals and other clinical spaces are easily constructed as panoptic and disciplinary, but this does little to advance our under- standing of how power circulates within their walls and what is produced and enabled. Following Conradson (2003, p. 510) we are interested in the way "socio-spatial environments may at times enable enhanced or more positive forms of human subjectivity" despite the presence of techniques for governing the individuals within. We now turn our attention to empirical data collected as part of an exploratory community-based research project. The setting Casey House Hospital, a sub-acute 13-bed speciality hospital, located in Toronto, Ontario, provides inpatient services to PLHIVs and implemented a harm reduction policy in 2008 to address drug and alcohol related issues among clients. Clients typically have multiple diagnoses, complicated medication regimes, and psycho-social challenges, and with an average length of stay of 45 to 60 days. Amongst admitted clients 87% have active men- tal health issues and 77% are poly-substance users (unpublished chart data). With little empirical research having been conducted on integrating harm reduction outside of community-based pro- gramming contexts at that time (Rachlis, Kerr, Montaner, & Wood, 2009), Casey House Hospital developed their approach through consultation with various stakeholders (management, clinicians, and clients) and in partnership with other organisations serving similar clients. The harm reduction implementation plan involved extensive training of staff and clinicians regarding harm reduction in general, the specifics of the Casey House Hospital policy, a weekly harm reduction discussion group hosted for clinicians to discuss successes and challenges, and distribution of a harm reduction brochure to clients. Methods This project developed following consultations with Casey House Hospital clients, staff and managers who identified the need to explore the impacts, positive and negative, of the imple- mentation of the harm reduction policy. These early consultations also revealed an interest in arts-based research methods amongst clients. After further consultation, we used photo-elicitation as the method to develop and answer our research questions amongst clients (Angus et al., 2009; Bagnoli, 2009; Fleury, Keller, & Perez, 2009; Lorenz, 2011; Oliffe & Bottorff, 2007; Radley & Taylor, 2003; Reinhardt et al., 2011). To recruit clients, a notice was posted in the hospital and also in the hospital newsletter and invited Casey House Hospital community members (i.e., current and former inpatients being seen by Casey House Hospital nurses in the com- munity) to call or approach the study coordinator about the study. After clients came forward, the coordinator explained the study, the consent procedure, answered questions and invited those interested. We asked participants to attend an orientation session where we discussed the objectives of the study; provided instructions regarding the use of the disposable camera; and where the basics of photographic composition (e.g., light, rule of thirds, content) were taught and discussed (Wang and Burris, 1997). At the end of the orientation session, participants were given the following instruction: Using the cameras provided to you, take a series of photos that show how you feel about or have experienced harm reduction as an inpatient or client at Casey House Hospital. You may also want to explore how you experience or feel about harm reduc- tion as a person living with HIV. These photos should relate to how you feel about drug use by Casey House Hospital clients and inpatients. After completing their assignment, participants were invited back for a one-on-one interview lasting 45 to 60 min to discuss their photographs in relation to their experience of harm reduction at Casey House Hospital (e.g., what can be seen in the photos, what is happening and why). Participants provided informed consent and were given a $15 CAD honorarium for the orientation session and $30 CAD for the one-on-one interview. Additionally, participants received a copy of all photos they had taken for this project. This project was part of a larger initiative to evaluate models of engage- ment and research methods suitable for people living with acute illness and receiving hospital care. With the agreement of the com- munity, it did not have the typical 'action' component where photos are exhibited for policy and decision-makers, and other members of the community are invited to attend. We did however host sep- arate exhibitions of the photographs for clients and managers and staff members. During the orientation session, we did not instruct the partici- pants to consider issues of space when taking photographs. Many of the photographs taken were used to represent aspects and/or the trajectory of health and well-being associated with Casey House Hospital and sometimes in direct reference to substance use (e.g., drug paraphernalia, drug dealer's feet, friends and partners) but not the socio-spatial issues related to the implementation of harm reduction. However, the centrality of socio-spatial issues in regard to the implementation of harm reduction at Casey House Hospi- tal surfaced during the first interviews. Most often socio-spatial issues were raised by the participants after they had selected and answered questions about their photos. For others, these issues were raised in between discussions of individual photos. While most photos did not attend to the socio-spatial issues we exam- ine below, one glaring exception was a photo of a bench used by a participant to literally show why and where drugs were consumed in proximity to the hospital (Fig. 1). With the exception of the bench photo, we made a deliberate decision to focus the analyses below on the interview transcript data. This decision is not unique within the corpus of photovoice and photo-elicitation studies. A 2010 system- atic review of photo voice in health research (Catalani and Minkler, 2010) revealed that while all projects involve the production of photographic images and discussion of these images, most typically

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