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Causal accounts as a consequential device in categorizing mental health and substance abuse problems

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Abstract

Professionals in human service work are at the centre of complicated client cases. The ways client cases are constructed and the problems explained form the basis for professionals' assessments, decisions, actions and interventions. In this article the ways professionals make sense of dual-diagnosis client cases are examined. Applying the concept of causal accounting, it is argued that 'theories of cause' are embedded in professional discourse and profoundly shape professionals' understandings of social and health problems, as well as of their own roles and responsibilities and of what interventions and outcomes are possible. The data consist of 48 tape-recorded weekly team meetings among professionals in a supported housing unit targeted for clients with both mental health and substance abuse problems. It was found that professionals reason about the relationship between these two problems in four different ways: (1) substance abuse causes or makes mental health problems worse; (2) substance abuse eases mental health problems; (3) mental health problems cause or make substance abuse worse; or (4) good mental health reduces substance abuse. Causal account research makes visible the ways professionals do institutional work by categorizing clients, accounting for responsibilities as well as assessing their work and clients' achievements according to moral expectations of a 'good'professional and a worthy client.
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This is a post-print version of the following article:
Raitakari Suvi, Günther Kirsi, Juhila Kirsi, Saario Sirpa (2013) Causal accounts as a
consequential device in categorizing mental health and substance abuse problems. Published
in Communication & Medicine 10 (3), 237-248.
Causal accounts as a consequential device in categorizing
mental health and substance abuse problems
Abstract
Professionals in human service work are at the centre of complicated client cases. The ways
client cases are constructed and the problems explained form the basis for professionals’
assessments, decisions, actions and interventions. In this article the ways professionals make
sense of dual diagnosis client cases are examined. Applying the concept of causal accounting
it is argued that ‘theories of cause’ are embedded in professional discourse and that they
profoundly shape professionals’ understanding of the social and health problems, their roles
and responsibilities and possible interventions and outcomes.
The data consist of 48 tape-recorded weekly team meetings among the professionals in a
supported housing unit targeted for clients with both mental health and substance abuse
problems. Four different ways to reason for the relations between these two problems are
found: (i) substance abuse causes or makes mental health problems worse; (ii) substance
abuse eases mental health problems; (iii) mental health problems cause or make substance
abuse worse; and (iv) good mental health reduces substance abuse. Causal account research
makes visible the ways professionals do institutional work by categorizing clients,
accounting for responsibilities as well as assessing their work and clients achievements
according to moral expectations of a ‘good’ professional and a worthy client.
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Keywords: causal accounting, client categorization, responsibilization, professional
discourse, mental health
1. Introduction
Professionals in human service work are at the centre of complicated client cases and social
problems. They try to ‘diagnose’ clients’ conditions in order to accomplish preferable
changes in clients’ situations, seen as problematic from the point of view of a particular
profession and helping institution. Accordingly, the negotiations of ‘what is the case and
what is causing it’, ‘who is responsible for what’ and ‘what ought to be done’ are the core of
professional practice and discourse, and are significantly consequential. The ways client
cases are constructed and the problems explained form the basis for professionals’
assessments, decisions, actions and interventions (Pithouse and Atkinson 1988; Taylor and
White 2000, 2006; Hall et al. 2003; Peräkylä and Vehviläinen 2003; Juhila and Raitakari
2010; Juhila et al. 2010.) In professional work as well as in everyday life, causal relations
are under constant negotiation and they can be questioned by alternative versions of cause-
and-effect relations; the client case may be approached in many different ways (Antaki 1988:
4; Edwards and Potter 1995; White 2002). Therefore it is important to delve into and
understand professional causal accounts and client categorizations more thoroughly.
However in this current evidence-based and cost-effectiveness era we are often more focused
on outcomes and costs than professionals’ reasoning, their ‘theories of cause’ (Bull and Shaw
1992; Saario 2014).
Professional reasoning and performance is especially demanding in cases where clients are
defined as having multiple and complex problems simultaneously such as both substance
abuse and mental health problems (Kavanagh et al. 2000). It is thus especially worth
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scrutinizing how professionals construct ‘a double trouble case’, and explain and account for
these cases in their everyday practices. In professional discourse and literature a concept of
dual diagnosis is often attached to the clients who are diagnosed as having both a psychiatric
illness (with psychotic characteristics) and a parallel severe substance addiction (Waal 1998;
Kavanagh et al. 2000; Schubert et al. 2009). We refer to these kinds of client cases when
using the term ‘double trouble’.
In this article we use causal accounting as an analytical concept. Bull and Shaw (1992) argue
that causal accounting is a deeply embedded but often neglected aspect in social work
practices. They state that it is essential to analyse causal accounting as part of client case talk
(Juhila et al. 2010; Keddell 2011). In this sense causal accounts are very useful devices for
professionals. Bull and Shaw (1992) label these ‘survival kits’. By giving causes and
explanations for example, referring to factors that are out of the professionals’ reach or
unchangeable professionals are able to justify things that go wrong, limits of their own
work, and insufficient effects from the interventions. Often the clients, other stakeholders or
external factors are constructed as the ones to be blamed for unwanted situations or
unreached outcomes (Pithouse and Atkinson 1988; Bull and Shaw 1992).
Causal accounting is also a device to make functional claims about clients’ characteristics
and responsibilities (Potter et al. 1993: 391; Edwards and Potter 1993, 1995: 91; Hall et al.
2006; Juhila et al. 2010). For example, if mental health problems are seen to be caused by
heavy drinking, the client becomes categorized as an ‘addict’ (not as a mentally ill person)
and the problems are seen as at least partly self-imposed. These kinds of conclusions about
the causes of social and health problems shape the ways professionals in turn perceive their
roles, tasks and responsibilities. This is why this article is focused on the following question:
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how are causal accounts displayed and used in client case talk when simultaneously
discussing mental health and substance abuse problems? More specifically, the aim is to
scrutinize how causal accounts do invoke client categorization and notions of responsibility
related to professional work done in a supported housing context?
2. Research on causal accounting and categorization: explaining the events and
portraying the client
The concept of accounts can be used in either a broad or a narrow sense (Buttny 1993; Buttny
and Morris 2001). In a broad sense, accounts are seen to be present in all everyday discourse,
such as in describing things and events (e.g. Antaki 1994). As Garfinkel (1967: 33) notes,
speakers routinely build into their talk accountable formulations that prepare rebuttals to
potential criticisms. Therefore, in professional client case talk, causal accounts are often built
in a manner that they give an impression of ‘good’ reasoning and work done in a given
situation. According to Potter and Wetherell (1987: 74), in a narrower sense accounts refer
to ‘explaining actions which are unusual, bizarre or in some way reprehensible’. Accounts
are understood as statements given when there is a gap between action and expectations
(Scott and Lyman 1968). The interest lies in how individuals account for cause-and-effect
relations in interaction and in situ (Eglin and Hester 2003; Juhila et al. 2010). By the term
cause-and-effect relation we do not thus refer to mechanistic causality, as in experimental
methods, but to individuals’ everyday rhetorical claims of cause-and-effect relations.
After Bull and Shaw (1992), professional talk and causal accounts have been explored, for
example in relation to risk talk (Keddell 2011), evaluation (Shaw and Shaw 1997), decision
making (Taylor and White 2006; Messmer and Hitzler 2011) and client and problem
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construction (Juhila et al. 2010; Keddell 2011). There is also a wide range of studies
concerning people’s beliefs and explanations about the causes of illnesses and illness
management (Kleinman et al. 1978; Furnham and Malik 1994; Gill 1998; Kendall 2003 et
al.; Gill and Maynard 2006; Lawton et al. 2007; Webb 2009; Saunders 2011). Accounts for
causes of illnesses and symptoms have also been studied in health care settings as they occur
in patientprofessional interaction (Gill 1998; Gill and Maynard 2006; Heritage and
Maynard 2006; Peräkylä 2006; Webb 2009). This line of research has shown firstly how
causal accounting is embedded in ways of making sense of illnesses and recovering from
them. Secondly it has demonstrated that causal accounting is bound to the institutional
contexts and tasks of interaction. As our analysis will reveal, in a supported housing context
causal accounts are done in regard to institutional rehabilitation and recovery expectations
and to the related ideas of ‘good’ and ethical mental health work and the roles of a ‘good’/
‘bad’ client and professional. Professionals also construct causal accounts in certain ways to
get acceptance and peer support from their co-workers (Pithouse and Atkinson 1988; Juhila
et al. 2010; Juhila and Raitakari 2010).
This study applies a discursive psychological way of reworking the attribution theory. The
approach argues that causal attributions should not merely be studied as cognitions (Antaki
1988; Potter et al. 1993; Edwards and Potter 1993, 1995, 2005; Potter and Edwards 2001).
As social actions, they are constructed and argued in social interaction where they have an
argumentative function (Edwards and Potter 1995; Potter et al. 1993; Taylor and White
2000). In institutional interaction causal accounts are made in order to get professional
institutional work done (Psathas 1999) such as justifying professionals’ actions and treatment
decisions. To get a better grip on how causal accounts are displayed and used in professional-
institutional talk to portray clients and allocate responsibilities we apply
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ethnomethodologically oriented categorization analysis, especially from the point of view of
how clients and professionals are categorized in institutional interaction (Hall et al. 2003,
2006 and 2014; Mäkitalo 2003; Juhila and Abrams 2011).
Categories store cultural knowledge and they work as sense-making devices in reasoning,
remembering and talking in interaction. Categories invoke assumptions about particular
features, characters and actions bound to them. Categories are bound to professional talk and
are often used in particular institutional tasks and ‘people-processing’ (Sacks 1992; Antaki
and Widdicombe 1998; Psathas 1999; Mäkitalo 2003; Juhila and Abrams 2011: 282). For
example, the ‘mental health case’ (illness category) and ‘drug abuser case’ (addiction,
behavioural problem category) enable professionals to make different causal explanations,
responsibility allocation and treatment options (Schubert et al. 2009; White 2002). By
combining the analyses of causal accounting and client categorization, it is possible to
produce knowledge about the institutionally relevant cause claims and client identities.
3. Setting and data
The setting of the study is a supported housing unit that offers community-based services for
people who have been assessed as having mental health and substance abuse problems (dual
diagnosis clients). More accurately, the study concerns professionals’ meeting talk and
interaction in the unit. The objective of the unit is to combine the professional knowledge
from the fields of mental health and substance abuse treatment and thus offer comprehensive
rehabilitation for people in ‘double trouble’ situations and support them to manage their
everyday life. Clients are defined as suffering from depression, a personality disorder or
psychotic condition and alcohol dependence and/or medicine abuse and/or drug abuse.
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The unit is located in a conventional high-rise housing estate, where 15 council flats have
been reserved for the unit’s clients at any one time. The unit functions as a meeting point for
both the clients and professionals. The clients visit the unit, and the professionals organise
group activity there as well as do home visits. The five professionals employed have previous
experience of both substance abuse work and mental health work.
Our data consist of 48 tape-recorded weekly team meetings among the professionals. The
average length of the meetings was 80 minutes. One of the researchers was present in the
meetings and took care of the recording. She was a silent participant who avoided
judgements, opinions and active participation in the discussions. However, there are a few
instances where the researcher asks questions or makes general remarks. Only the
professionals (and the researcher) from the unit are present; not the clients, managers,
supervisors or other professionals from other institutions. In the data there is one exceptional
meeting where three professionals from the local mental health outpatient clinic are present.
The meetings follow a uniform but informal agenda. They start with a discussion of general
issues related to the unit’s activity, timetables and the eligibility of potential new clients,
followed by the main part of the meeting, during which the professionals talk about the
situations with the current clients. Case talk about the current clients does not have a preset
agenda. It is initiated by the client’s key worker, but after the opening s/he assumes no special
authority in the course of the discussion. The purpose of this talk is to assess the clients’
progress, or lack of it, and to reflect on how the professionals have succeeded in helping the
clients or have failed to do so. These assessments are very often done by using mental health
and substance abuse talk.
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The approval for collecting the data in the unit was granted from the Board of Directors of
an NGO running the unit. The professionals and clients who participated in the study were
expressly told that participation was voluntary and confidential, and that they could withdraw
their consent at any stage. They were given written information about the person in charge,
the contact persons in the research team and an overall description of the research. Each
client completed a consent form before data collection commenced. The research complies
with ethical principles of research in the humanities and social and behavioural sciences, as
well as the Guidelines on Research Ethics by the Academy of Finland (2010).
4. Analysis and general findings: coding and scrutinising professional discourse
We approach causal accounting as a discursive device that the professionals use to present
‘double trouble’ client cases from particular points of view and to evoke particular client
categorizations, allocate responsibilities and justify actions (Bull and Shaw 1992; Hall et al.
2006). In practice, we conducted our analysis as follows. First, we identified all instances
where causal relations between mental health and substance abuse problems are explicitly
talked into being. In total there are 61 instances of this kind in the 48 tape-recorded team
meetings among the professionals. In the meetings, the relations between these two problems
are continuously touched on, but the professionals rarely state explicit causality between
them. As Perelman (1996) notes, cause-and-effect relations are usually treated in everyday
communication as common knowledge and thus they are not required to be explicated. What
is already known and shared by the participants need not be explained (Draper 1988: 29).
Thus, relations between mental health and substance abuse problems are common knowledge
for professionals and do not need to be discussed constantly. Nonetheless, there are instances
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where the professionals talk explicitly about cause-and-effect relationships between these
two problems. In this study we focus on these explicit instances.
Secondly, we coded the 61 instances into two main ways of formulating causal accounting:
1) Substance abuse explains mental health problems (50 instances)
1a. Substance abuse causes or makes mental health problems worse (38 instances)
1b. Substance abuse eases mental health problems (12 instances)
2) Mental health problems explain substance abuse (11 instances)
2a. Mental health problems cause or make substance abuse worse (9 instances)
2b. Good mental health reduces substance abuse (2 instances)
In the great majority of instances professionals construct causal relations so that substance
abuse (or giving it up) is a cause and has an effect on mental health difficulties in one way
or another. This accounting can be divided into two kinds of explanations: first (1a) substance
abuse is seen as a cause for mental health difficulties or a cause for making them worse. In
addition, professionals argue that substance abuse makes it more difficult for them to assess
a client’s ‘real’ mental state and for the client to recover from the mental difficulties.
Interestingly, professionals also assess that, in some instances, giving up substances may at
first increase mental distress so the risk of relapses and setbacks is high.
The second explanation (1b) comprises a juxtaposing way of constructing the causal relations
between substance abuse and mental health difficulties. Professionals might state that a client
is using substances, because it eases his/her mental health difficulties (like hearing voices,
fears and anxiety). It is noteworthy to point out that in these instances professionals are
usually looking at the situation from the client’s point of view; they try to understand why
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she/he is using substances or has a hard time in giving them up. They are trying to find out
the client’s own rationale in the ‘double trouble’ situation. They are not actually arguing that
substance abuse itself would have positive effects on the situation in the long run, although
it may give momentary relief for the client. Both using substances and giving them up can
be justified by the claim that it eases mental health difficulties, but professional discourse is
strongly based on the latter causal explanation.
In much fewer instances professionals construct causal relations so that mental health
difficulties (or recovery from them) have an effect on substance abuse in one way or the other
(the second type of causal accounting). Following the explanation 2a, this way of reasoning
is used when explaining a client’s substance abuse and setbacks in rehabilitation.
Professionals state that a difficult mental state, or for example a fragile personality, causes
and increases substance abuse or the risk of it. Whereas, explanation 2b comprises instances
in which the client’s need for mental health treatment is justified with the argument that good
mental health treatment has an impact on the substance abuse problem and helps to get it
under better control. Good mental health is thus seen to prevent substance abuse problems.
By coding causal accounts we were able to perceive more precisely how the relations
between mental health and substance abuse problems are constructed in professional
discourse. We moved on to analyse how causal accounting is displayed and used in these
instances. We examined how clients and mental health and substance abuse problems are
categorized, and how the moral implications of who is held responsible for the ‘double
trouble’ situations are connected to these categorizations (third phase in the analysis)
(Bergmann 1998; Dillon 2011; Stokoe 2003). In Bergmann’s (1998: 287, 291) words: “Moral
work can be done through the selection of categories” and “the whole enterprise of people-
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processing in institutions rests on assessments and decisions about people’s normality and
moral accountability”.
The following extracts from the meetings are selected to represent the variety of causal
accounts (1a2b) displayed in the data. The actual names of the clients have been changed
to fictitious ones. All references to localities and services that might risk the anonymity of
the persons involved have been removed. The original language of the meetings is Finnish,
but the excerpts have been translated into English for the purposes of this article. We aim to
present the original meanings of the accounts and the ways they are talked into being as
accurately as possible. The original Finnish language excerpts and the explanations of the
transcription symbols are found in the appendix.
5. Substance abuse causes mental health problems
Our first extract is from the case talk where the professionals are first unsure how to proceed
with the client, how to produce ‘good’ support practices or client outcomes. The client is
perceived as acting in an unwanted way, and this needs to be explained by a causal account.
Professional (P1) is making sense of the troubling situation by remembering how the client’s
stay in the unit started. Researcher (R) ensures that the utterance was about the beginning of
the client’s housing period and thus prompts P1 to continue. Another professional (P2) in the
end of the extract expresses understanding and defines the client case as ῾difficult’.
Extract 1
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P1: Had once used in [detox unit] (.) when he moved here (.) after a week he bought Subutex
(.) injected it and was (.) in psychosis in [name of hospital] like tw was it one week or maybe
two (.) so that’s how his residence started
R: So that was the start
P1: Yes that was the start (.) and the ‘honeymoon’ was all of five days long (2) and then he
was at it just two weeks after (.) that he met this [woman’s name] and bought benzos off her
(.) this is what he said (.) or was given benzos by this [woman’s name] who’d been clean for
ten years (.) former junkie (.) so that’s the way
R: Yes, that’s how it [detox unit] holds up
P1: And now this (.) I just don’t know
P2: It is difficult
In the extract causal accounting is used to describe that the client had bought Subutex,
injected it and was then in psychosis. P1 constructs Subutex as the cause for psychosis and
the cause-and-effect relation between the drug use and mental health disorder is thus created
in a straightforward manner. He does not explain why the client has shifted from the short
‘honeymoon’ to purchasing drugs and relapsing. In a subtle manner, the professional portrays
the client as having failed in rehabilitation due to using drugs, having broken the
‘rehabilitation agreement’ and the rules of the unit. Accordingly, P1’s account can be further
interpreted as indicating that the client has undermined the rehabilitation outcomes by
causing the relapse with his own action.
P1 categorizes the client as a sedative misuser and as a person who buys or gets drugs from
other addicts. The categorization is consequential from the point of view of client
responsibility. If you yourself buy drugs, you can be held responsible for your actions, but if
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you are given drugs, you can be seen more or less as a victim, or as one who has been
tempted. The case formulation is done in a way that it supports the argument that despite the
placement in a rehabilitation unit and the professionals’ good endeavours, the client is still
an addict. P1 describes how the client behaves like an addict, and no other explanation is
expected from the co-workers: the ‘addict’ category itself explains the difficulties
professionals encounter in their work. Furthermore, it can be argued that the causal relation
is constructed in such a way that it makes it possible for the professional to position himself
as one not accountable for things going wrong and the recovery not proceeding.
6. Substance abuse eases mental health problems
In the following extract the professional gives a report on a home visit she had made earlier.
She had discussed with the client that support was not helpful, even if a home visit was made
every day, but that the client should learn to manage better by himself and take more
responsibility of his coping.
Extract 2
P1: Yes so you’d always have some sort of safety net there (.) one should learn to cope on
one’s own and (.) and well we thought about the way yesterday like when (.) like what to do
when you feel anxious and bad and you want to get something [drugs or medicine] so what
will you do at that point and (.) how will you act differently so you don’t go along with it (.)
so yes (.) yes Antti is giving us quite a lot of work but (.) Antti visits us every day now since
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it’s daily that we give him his med– (.) he collects each day’s medications from us and (.)
we’ve agreed with Antti that he comes (.) well Tuesdays it’s the gym and then (.)
Wednesdays the football (.) and we talked a bit about the relaxation and walk on Friday but
yes Antti comes round every day (.) we’re keeping an eye on him now to see how he appears
Causal accounting is used when arguing that difficult feelings increase the risk of the client
relapsing: by using drugs he is looking for relief from mental stress. Mental health problems
are interpreted as the primary problem and drug use as a way to ‘cure’ the anxious symptoms.
The client is categorized as a mental health client who is tempted to misuse medicine and
drugs.
Another causal account is made when it is assumed that exercise and daily visits to a support
centre would ease the client’s bad feelings and hence decrease his desire for drugs. On the
one hand, the client is accorded responsibility for learning to cope better on his own and
finding the means to live a sober life. On the other hand, the professionals are categorized as
responsible for offering the client counselling, support and activity options. The causal
accounting in this extract indicates that the professionals have means to promote a desired
outcome (abstaining from substance abuse) and that they have been active doing all they can.
In other words, if the client relapses, it will be because he chooses not to take advantage of
the professional support that is available. Once again, causal accounting is used to present
professional work in a positive light.
7. Mental health problems cause substance abuse
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In the meeting from where the next extract is taken, the professionals are assessing a client’s
ability to function; how heavy medication and a positive attitude towards medication affect
coping in everyday life. The professionals’ aim is to reduce the medication, and this has been
earlier talked about with the client and his doctor. Now the professionals continue reflecting
on the client case by describing the client’s substance use history and what medication means
to him.
Extract 3
P2: Has used an awful lot of stuff (.) hasn’t he?
P1: He has had some experiments
P3: Or mostly pills and codeine
P1: And then he’s forged prescriptions for others (.) a right little pharmacist he’s been
((joint laughter))
P3: He’s really so easily led
R: Yes so right now he’s like (.) now he’s like inst– (.) within normal practices
P1: You know he’s so fragile somehow (.) his psyche is sort of constructed (.) he constructs
his psyche somehow on the medications (.) with the benzos (.) I mean he’s just like this (.)
shaking
P3: Yeah
P1: He’s somehow terribly fragile
P3: He is a problematic case I mean that (.) I think we ought to go so (.) carefully in so many
respects (.) like what (.) er I wrote here (.) about getting more exercise (.) if he really could
do that then that would automatically (.) calm him down a bit
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By referring to such activities as having “used an awful lot of stuff”, “had some experiments”
and “forged prescriptions”, the client is categorized as a medication abuser. The actions are
in turn explained with the attribute of being ‘easily led’ which is constructed as a cause for
the client’s unusual and reprehensible actions. This way of accounting reduces the client’s
responsibility. An ‘easily led’ person is easy for others to exploit, and because of this the
client has probably been in a position where he has not been able to make completely free
choices.
P1 continues constructing the relations between the client’s psyche and medication. The
client category is associated with the attributes ‘fragile’ and ‘shaking’. The psyche and
medication are constructed as deeply interwoven. Thus a fragile psyche is named as one
cause of the behaviour of the drug user.
The client is categorized as a problematic case, which requires the professionals to proceed
carefully, reflect on their own actions and not to ‘push’ the client too much. Causal
accounting is done in such a way that the client is primarily a ‘mental health’ case and only
secondarily a ‘drug abuser’ case. The categorization of a ‘fragile mental health client’
justifies the recommended measures to help the client to calm down (mental objective and
outcome). In addition, causal accounting enables professionals to approach the client case
with understanding. In sum, it can be read that they position themselves as understanding,
‘knowing’ and reflecting professionals and that the client’s problems will be addressed if he
follows their advice.
8. Good mental health reduces substance abuse
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In the meeting the presentation that P2 has been listening to previously brings up the issue
of whether the substance abuse or the mental health problem ought to be treated first. The
extract shows how the causal accounts are under negotiation in the meeting interaction. The
extract is from the exceptional meeting: there are three professionals from the local mental
health outpatient clinic present. The task of the meeting is to go through and assess the client
cases shared by the two institutions.
Extract 4
P1: What was the subject of that presentation?
P2: Well it was exactly double diagnosis (.) I have the themes of the sheets over there (.) so
(.) yeah (.) well if you don’t in a way (.) if you speak only about the psychiatric diagnosis (.)
the other diagnosis is not touched upon and you use the word relapse well this won’t get you
far (.) you get the revolving door syndrome (.) hospital outpatient care hospital
outpatient care hospital outpatient care and it goes on (.) distant future (.) nobody does
anything really if you don’t touch upon another diagnosis (.) you know it has to be cut off
P3: Yeah but (.) yeah (.) it is like this in a way but then again it isn’t (.) these are not (.) these
are not like really exclusive
P2: No
P3: Then again we know that with good psychiatric care you can (.)
P2: Erm
P3: Treat the [substance abuse] problem then
P2: Well yeah
P3: Like we kind of have those examples as well (.) this reminds me of one drug addict
P2: Yeah
P3: (--) The kind who (.) in my view (.) once the psychotic features are somehow managed
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to be put under control (.) so it will remain (.) the substance abuse for example will also
remain under control better like that
P4: Also the anxiety is now under control
P2: Yes
P4: (--) Some meaningful activities during the daytime (.) and it starts to back off that (--)
P2:Yeah
P3:Yeah
P2 argues strongly that in ‘double trouble’ cases no progress is achieved if just the psychiatric
diagnoses are concentrated on and other diagnoses are not dealt with as well. He constructs
a causal account in which bypassing the substance abuse problems causes the revolving door
effect: the client goes back and forth between the outpatient and institutional care without
real progress in rehabilitation.
Interestingly, P3 (from a mental health outpatient clinic) only partly agrees with this line of
reasoning and brings up the point that mental health and substance abuse treatment do not
exclude one another and that the rehabilitation process may also proceed successfully in the
opposite causal order. In the interaction, the client example serves as ‘evidence’ of the
existence of a questionable causal relation: after the psychosis was better under control, the
drug use was also more controllable. The client is categorized as a ‘success story’ and as an
example of effective mental health work. P4 (also from a mental health outpatient clinic)
adds details to this successful client formulation and it is possible to make an interpretation
that the support measures and the achievement of a better mental state have caused reduced
drug use. The professionals use the passive voice, thereby not stating who or what is
responsible for this change for the better. In sum, in the inter-organizational interaction,
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professionals utilize causal accounting in order to argue for preferred treatment models and
to construct mental health work as an effective practice also in treating substance abuse
problems.
9. Conclusion
Nowadays social and health care professionals are directed to pay specific attention to
performance, cost-effectiveness and outcome indicators. Regarding the duration of client
cases, quick solutions and interventions are favoured (Saario 2014; Taylor and White 2000).
Human service work is more and more outcome oriented and it is not fashionable to
concentrate on professional ‘theories of cause’. However, in this article we have argued that
‘theories of cause’ are embedded in professional discourse and that they profoundly shape
professionals’ understanding of the social and health problems, their roles and
responsibilities and possible interventions and outcomes.
Causal accounting is a crucial discursive device in professional interaction and discourse to
‘make a case’: it enables sense making of client cases where thing are going ‘wrong’, the
client is not proceeding in a direction or behaving as expected by the professionals (Antaki
1998). In mental health and substance abuse work professionals are actually often dealing
with a circular argument; substance abuse affects mental health and mental health affects
substance abuse. However, for the professionals in the supported housing context the first
explanation is the most essential. An interesting question is: why is that the case? It can be
posited that mental health difficulties are more familiar to the professionals and easier for
them to handle than substance abuse relapses. If this is the case, then the substance abuse
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breaks the institutional (mental health) rehabilitation routines and recovery processes; it is
‘news’ and calls for reflecting on the cause-and-effect relations in ‘double trouble’ cases.
The professionals have to decide in their everyday work whether to encounter a client
primarily as a mental health case or a substance abuse case. The ‘mental health client’
(illness) category is bound to different causal explanations, responsibility expectations and
treatment options than the ‘drug abuser’ (addiction, behavioural problem) category (Schubert
et al. 2009). Additionally, cause constructions direct how the professionals perceive their
roles, responsibilities and opportunities to make a change in ‘difficult’ client cases. The
causal accounts that the professionals assign to clients’ actions/diagnoses/perceived needs
are based on a particular view of themselves as particular ‘providers’ and ‘experts’ as well
as their clients as ‘recovering’ and ‘ill persons’ (Smith 1987; Griffiths 2001; Dillon 2011).
In our dataset, causal accounting is often used to create the category pair of ‘a skilful
professional who is coping and trying’ and ‘a fragile or difficult client who is in risk of failing
and who is not trying’. Hence the professionals are able to display their work and
performance in a favourable light in both successful and unsuccessful client cases and get
understanding from the co-workers. Causal accounting is a device for assessing the client
case either in an understanding way or in a critical, blaming way. The consequences of the
case formulation for the client can be either positive or negative: the professionals’ case
formulations can match the client’s own understanding of the situation well and lead to
shared decision-making, alliance, support and the services that s/he needs. But the
professionals’ and clients views may just as well differ on ‘what the case at hand is’, and
this often causes difficulties in the client-practitioner relationship, even the client’s exclusion
from the services. (see also Juhila et al. 2014a and 2014b.) In current research and practice,
21
shared understanding, client involvement and decision-making are stressed as pivotal to
effective and ethical treatment and rehabilitation (e.g. Matthias et al. 2012; Raitakari et al.
forthcoming). Accordingly, it is reasonable for the professionals to take time and try to
negotiate shared understanding of relevant cause-and-effect relationships both among
themselves and with the clients before making treatment suggestions.
Causal accounting is an especially essential device in making claims about morality and
responsibility. Causal accounting embeds attributions of responsibility and blame (Bull and
Shaw 1992: 641; Potter et al. 1993: 391). The core distinction is whether causal factors are
judged to be in or out of one’s control (Lawton et al. 2007). In case talk, professionals
constantly assess whether the clients are capable of taking responsibility for their actions and
what their own responsibilities are in each individual case, as well as applying the criteria of
‘good’ and ‘bad’ clients/citizens (Juhila 2003; White 2003; Kolind et al. 2009: 275276).
Accordingly, causal accounting research informs and deepens the current political, academic
and professional discussion on responsibilization (e.g. Share and Strain 2008; Roy 2008;
Michailakis and Schirmer 2010). In professional practice, it is crucial to be sensitive and
reflect more on the ways of making arguments on who or what is responsible for causing the
current welfare, health and social problems, and why.
Appendix 1
The transcription symbols used in the article are:
(--) = missing words (impossible to hear from the recording)
(.) = pause
((laughter)) = a comment added by the transcriber
22
P1, P2, etc. = professionals (for the reasons of anonymity the same number does
not refer to same professionals in different excerpts)
R = researcher
[ ] = information added by the transcriber
Appendix 2
Data extracts in original Finnish language
Extract 1
P1: Kerran oli käyttäny [hoitokodissa] (.) ku hän tähän muutti (.) viikon päästä osti Subutexia (.) laitto
suoneen ja oli (.) psykoosis [sairaalan nimi] sitte ka- oliks se viikon vai kaksko se oli (.) se lähti siitä
se asuminen
R: Se oli se alotus
P1: Se oli se alotus (.) siinä ei kuherruskuukaut kestäny ku viis päivää (2) sitte hän menikö kaks
viikkoo (.) hän tapas jonku [naisen nimi] ja osti siltä bentsoja näin hän sano (.) tai sai bentsoja [naisen
nimi] joka oli ollu kymmenen vuotta raittiina (.) entinen narkkari (.) että tällainen
R: Näin ne kantaa
P1: Nyt sitte tämä (.) et en mä tiedä
23
P2: Vaikeeta on
Extract 2
P1: Niin ois joku turvaverkko siinä aina (.) ku pitäs iteki niinku oppia pärjäämään ja (.) ja niinku
mietittiin niitä keinoja sitte eilen että ku (.) että mitä tehdä kun tulee ahdistus ja paha olo ja tekee
mieli ainetta niin et mitä siinä kohtaa sitten teet ja (.) toimit toisin etkä lähde mukaan siihen että kyllä
(.) kyllä siinä työmaata on tossa Antissa mutta (.) Antti käy ny joka päivä ku joka päivä annetaan
lääk- (.) päivän lääkkeet hakee täältä ja (.) Antin kans on sovittu että se tulee (.) no tiistaisin kuntosali
ja sit (.) keskiviikkona tää futis (.)ja sit oli puhetta siitä perjantain rentoutuksesta ja kävelystä mut et
joka päivä Antti tässä käy (.) me pidetään sitä nyt silmällä et miltä se vaikuttaa ja
Extract 3
P2: hirveesti aineita käyttäny eiks ollu?
P1: On sil jotain kokeilui ollu
P3: Tai lähinnä pilleriä ja kodeiinia ja
P1: Ja sit se on väärentäny reseptejä muille (.) se on tämmönen pikkuapteekkari ollu
((naurahdus yhteen ääneen))
P3: Kyllä se on niin helposti johdateltavissa
R: Niin et se on niinku (.) nyt se on niinku lait- normaali käytännöissä
P1: Se on niin heiveröinen (.) jotenki sen psyyke on niinku rakennettu (.) se rakentaa sen psyykensä
jotenki niitten lääkkeitten varaan (.) niitten bentsojen että sehän on aivan näin (.) tärisee
P3: Niin on
P1: Se on jotenki hirveän hauras
24
P3: Se on ongelmallinen tapaus niinku siis (.) pitäs niin monelta kantilta osata mun mielestä lähestyä
(.) varovasti että mitä (.) tuota mä panin tohon (.)että siihen liikunnan lisäämiseen (.) jos se tosiaan
rupeis tekemään sitä niin sehän automaattisesti (.) rauhottas sitä jonkin verran
Extract 4
P1: Mikä se luennon aihe oli?
P2: No se oli nimenomaan kaksoisdiagnoosi (.) mul on ne kalvon aiheet tuolla (.) niin tuota (.) kyllä
(.) kyllä jos ei siihen sillä tavalla (.) puhutaan vaan psykiatrisesta diagnoosista (.)jätetään toinen
diagnoosi käsittelemättä ja puhutaan sanalla retkahdus (.) niin ei siitä päästä puusta pit-, siinä tulee
[pyöröovi]syndrooma (.) sairaala avohoito sairaala avohoito sairaala avohoito ja se jatkuu
(.) hamaan tulevaisuuteen (.) kukaan ei tee siitä sen kummemmin mitään jos ei siihen toiseen
diagnoosiin päästä kiinni (.) kyllä se poikki täytyy [saada]
P3: Niin mutta (.) niin (.) näin se on tavallaan mutta sitten ei (.) nä ei oo (.) niinku ihan poissulkevia
P2: Ei
P3: Toisaalta tiedetään (.) hyvällä psykiatrisella hoidolla voidaan sitä päihde
P2: Mm
P3: Ongelmaakin hoitaa sitten
P2: No kyllä
N1: Että niinku meillä on niitäkin esimerkkejä (.) tulee ihan mieleen täs yks huumeidenkäyttäjä
P2: Joo
P3: (--) Tavallaan semmoinen joka mun mielestä (.) kun se psykoottisuus on saatu niinku jotenkin
kuriin (.) niin se pysyy se päihde-, huume-, huumekäyttö esimerkiksi kurissa paremmin että se
P4: Myös ahdistus on paremmin kurissa
P2: Kyllä
25
P4: (--) Jotain mielekästä päivätoimintaa niin se (.) tukee
P2: Joo
Acknowledgements
This article originates from the research project titled Responsibilization of Professionals
and Service Users in Mental Health Practices (20112016), funded by Finnish Academy
and University of Tampere.
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IntroductionFindingsThe role of self in the onset of diabetesAttributing blame: contextualising responsibility and controlDiscussionAcknowledgementsNoteReferences
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The Montreal Massacre: A Story of Membership Categorization Analysis adopts an ethnomethodological viewpoint to analyze how the murder of women by a lone gunman at the Ecole Polytechnique in Montreal was presented to the public via media publication over a two-week period in 1989. All that the public came to know and understand of the murders, the murderer, and the victims was constituted in the description and commentaries produced by the media. What the murders became, therefore, was an expression of the methods used to describe and evaluate them, and central to these methods was membership category analysis - the human practice of perceiving people, places, and events as "members" of "categories," and to use these to explain actions. This is evident in the various versions comprising the overall story of the Massacre: it was a crime; it was a tragedy; it was a horror story. The killer's story is also based on his own categorial analysis (he said his victims were "feminists"). The media commentators formulated the significance of the murders in categorial terms: it implicated a wider problem, that of violence against women, and thus the reasons for the murders were shown to be categorial matters. As a contribution to sociology, and as a demonstration of the significance of ethnomethodology for understanding social life, the book reveals the methodical and particularly categorial character of how sense is made of events such as this and how such methodical and categorial resources are central to human interaction.
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In the literature on medical consultations, there are two strikingly different ways of thinking about the relation between doctors and patients. One emphasizes the doctor’s authority, while the other, often programmatically, emphasizes the patient’s knowledgeability and his or her participation in the diagnostic procedure and the decisions about the treatment. Writers who have emphasized the doctor’s authority include, most notably, Talcott Parsons (1951), Eliot Freidson (1970b), and Andrew Abbott (1988). They point out that doctors possess technical and scientific knowledges that enable them to diagnose illnesses, and society has warranted them with the license to decide about medication and sick leave, and to perform surgical and other therapeutic procedures. The patient does not have such knowledge and licenses. Therefore, the relation between the doctor and the patient is necessarily characterized by the doctor’s authority. However, there are other writers-for example, in medical anthropology (Stimson and Webb 1975; Kleinman 1980; Helman 1992) and on fields of research closely related to medical practice (e.g.; Pendleton 1983; Tuckett et al. 1985; Lipkin et al. 1995), who maintain that the patient, as well as the doctor, has ideas about the nature, the origin and the possible remedies of the patient’s ailment. The consultation could and should be an encounter between two differently but equally resourceful agents where they negotiate diagnosis and treatment. In an ideal case, the parties’ views will merge.