Sue Cowan

When the business of sharing treatment decisions is not the same as shared decision making: A discourse analysis of decision sharing in general practice

Although shared decision making (SDM) in general practice continues to be promoted as a highly desirable means of conducting consultations it is rarely observed in practice. The aim of this study is to identify the discursive features and conversational strategies particular to the negotiation and sharing of treatment decisions in order to understand why SDM is not yet embedded into routine practice. Consultations from Scottish general practices were examined using discourse analysis. Two themes were identified as key components for when the doctor and the patient were intent on sharing decisions: the generation of patient involvement using first-person pronouns, and successful and unsuccessful patient requesting practices. This article identifies a number of conversational activities found to be successful in supporting doctors’ agendas and reducing their responsibility for decisions made. Doctor’s use of ‘partnership talk’ was found to minimize resistance and worked to invite consensus rather than involvement. The information from this study provides new insight into the consultation process by identifying how treatment decisions are arrived at through highlighting the complexities involved. Notably, shared decision making does not happen with the ease implied by current models and appears to work to maintain a biomedical ‘GP as expert’ approach rather than one in which the patient is truly involved in partnership. We suggest that further research on the impact of conversational activities is likely to benefit our understanding of shared decision making and hence training in and the practice of SDM.

Recovery in mental health policy: good strategy or bad rhetoric?

This article explores current positions on ‘recovery’ in Scottish mental health policy and the practical limitations of these positions from a rhetorical perspective. It is not our intention to conduct a formal policy analysis but rather to open up an argumentative space for thinking critically about recovery. In adopting a rhetorical perspective, we are concerned not with the quality of evidence in support of recovery per se, but with the quality of the arguments and the manner in which these have been produced, reproduced and promulgated to support recovery in terms of its adoption in policy and practice within the Scottish context. We sketch the background to the ‘case for’ recovery in Scotland by drawing upon key policy documents, referring to the public mental health focus in Scotlands mental health policy, and indicate how policy and practice on recovery have been evaluated in that context. We then explore the value of critical dialogue by exploring the potential limitations of the case for recovery by considering hope and the medical model as examples of themes in recovery policy and practice. In light of this analysis, we argue that while the policy and its implementation might be understood as a good strategy for addressing major issues in mental health, it is bad rhetoric to the extent that it limits argument, and therefore practical deliberation, about recovery. In conclusion, we discuss the implications of our argument for mental health practitioners, for whom a critical stance on health policy is a necessary resource.

Public arguments for and against the establishment of community mental health facilities: Implications for mental health practice

As the drive towards community care has increased in momentum, organisations involved in the establishment of community mental health facilities have encountered public opposition. It has been argued that this resistance is due to the attitudes held by the public towards people with mental health problems. This paper reports findings from a study of community attitudes towards mentally ill people. Discourse analysis was used to explore peoples views about this client group by examining the ways in which they were expressed in letters to the local press and in subsequent discussions and interviews, when arguing for or against a community mental health facility in their community. The findings demonstrate how participants formulate their arguments for and against the location of a new mental health facility in the neighbourhood around particular argumentative topics. Participants deployed a range of argumentative forms and rhetorical devices. The implications of these findings for mental health practice are discussed.

Understanding public opinion relating to the establishment of community mental health facilities: implications of a discourse analytic approach

This paper demonstrates a novel approach to investigating the problem of public opposition to community mental health facilities. With the move towards community care, organizations setting up mental health facilities have encountered public opposition. It has been argued that this is due, in part, to the attitudes held by the public towards mentally ill people. A knowledge and understanding of attitudes towards this client group therefore has the potential to be of practical use to policy makers and practitioners who have a responsibility to consult on, and implement, community care for mentally ill people. The survey approaches and hypothetical situations used in previous British studies of community attitudes towards mentally ill people have, however, failed to take account of the rhetorical richness and complexity of the attitudes likely to be expressed in real-life community care contexts. By contrast, the study reported in this paper used a discourse analytic approach to explore the views expressed about mentally ill people in a ‘hot situation’. Specifically, peoples views were explored in the contexts of the arguments they used to challenge or advocate a supported accommodation project for mentally ill people in their community. This paper examines some of these arguments and discusses the theoretical implications for traditional approaches to attitude research. In conclusion, the potential practical utility of the findings is considered. Copyright

The Essential Elements of a Risk Governance Framework for Current and Future Nanotechnologies

Societies worldwide are investing considerable resources into the safe development and use of nanomaterials. Although each of these protective efforts is crucial for governing the risks of nanomaterials, they are insufficient in isolation. What is missing is a more integrative governance approach that goes beyond legislation. Development of this approach must be evidence based and involve key stakeholders to ensure acceptance by end users. The challenge is to develop a framework that coordinates the variety of actors involved in nanotechnology and civil society to facilitate consideration of the complex issues that occur in this rapidly evolving research and development area. Here, we propose three sets of essential elements required to generate an effective risk governance framework for nanomaterials. (1) Advanced tools to facilitate risk-based decision making, including an assessment of the needs of users regarding risk assessment, mitigation, and transfer. (2) An integrated model of predicted human behavior and decision making concerning nanomaterial risks. (3) Legal and other (nano-specific and general) regulatory requirements to ensure compliance and to stimulate proactive approaches to safety. The implementation of such an approach should facilitate and motivate good practice for the various stakeholders to allow the safe and sustainable future development of nanotechnology.