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Individuals with severe mental illness have often been perceived by themselves and others as stigmatised and unable to make decisions about their lives. However, perceptions of mental illness and health care have experienced significant changes; as a result, community-, consumer- and recovery-based approaches have been developed. The aim of this article is to deepen our understanding about client participation as interactive and shifting positioning work. It examines how a client constructs him/herself as a decision-maker and how others support or hinder that position. The study is based on 25 mental health client interviews. Findings are reported in three sections that examine: (1) restricted participation; (2) supported participation; and (3) independent participation. It is argued that, when dealing with client participation in mental health, we need to focus on the subtle discursive practices by which clients perform positioning and are given positions. The findings provide a basis for discussing client participation as relational and interactive phenomena. Client participation is bound by client-practitioner interaction as well as by discursive practices. For the client to participate, he/she first needs to accomplish participant positioning, become an actor with a voice and be able to make decisions and choices. This is a crucial (but not easily accomplished) precondition of client participation.
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Nordic Social Work Research
ISSN: 2156-857X (Print) 2156-8588 (Online) Journal homepage:
Client participation in mental health: shifting
positions in decision-making
Suvi Raitakari, Sirpa Saario, Kirsi Juhila & Kirsi Günther
To cite this article: Suvi Raitakari, Sirpa Saario, Kirsi Juhila & Kirsi Günther (2015) Client
participation in mental health: shifting positions in decision-making, Nordic Social Work
Research, 5:1, 35-49, DOI: 10.1080/2156857X.2014.909875
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Published online: 22 Apr 2014.
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Client participation in mental health: shifting positions in
Suvi Raitakari*, Sirpa Saario, Kirsi Juhila and Kirsi Günther
School of Social Sciences and Humanities, University of Tampere, Tampere, Finland
Individuals with severe mental illness have often been perceived by themselves and
others as stigmatised and unable to make decisions about their lives. However, per-
ceptions of mental illness and health care have experienced signicant changes; as a
result, community-, consumer- and recovery-based approaches have been developed.
The aim of this article is to deepen our understanding about client participation as
interactive and shifting positioning work. It examines how a client constructs him/
herself as a decision-maker and how others support or hinder that position. The
study is based on 25 mental health client interviews. Findings are reported in three
sections that examine: (1) restricted participation; (2) supported participation; and
(3) independent participation. It is argued that, when dealing with client participation
in mental health, we need to focus on the subtle discursive practices by which cli-
ents perform positioning and are given positions. The ndings provide a basis for
discussing client participation as relational and interactive phenomena. Client partici-
pation is bound by clientpractitioner interaction as well as by discursive practices.
For the client to participate, he/she rst needs to accomplish participant positioning,
become an actor with a voice and be able to make decisions and choices. This is a
crucial (but not easily accomplished) precondition of client participation.
Keywords: mental health; client participation; positioning; decision-making;
Individuals with severe mental illness have often been perceived by themselves and
others as stigmatised, powerless and unable to make decisions about their lives
(Kopolov 1981; Bassman 1997; Hickey and Kipping 1998, 87; Cook and Jonikas
2002). This is largely a consequence of delivering psychiatric treatment in large institu-
tional settings and the dominance of the medical model of psychiatric treatment, which
has downplayed the clients agency and self-determination (Bassman 1997; Linhorst,
Eckert, and Hamilton 2005). However, understanding of mental illness and health care
has gone through signicant changes. Community-, consumer- and recovery-based
approaches have been developed, although traditional, paternalistic understanding still
exists (Lammers and Happell 2003). Currently, mental health clients
have more
possibilities to view themselves as active actors, as well as to be positioned as such by
other stakeholders.
An emphasis on clients participating in their own care and rehabilitation, and advo-
cating for more choices has arisen from a variety of directions (Pilgrim and Waldron
*Corresponding author. Email: suvi.raitakari@uta.
© 2014 Taylor & Francis
Nordic Social Work Research, 2015
Vol. 5, No. 1, 3549,
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1998; Drake, Deegan, and Rapp 2010). National policy documents and legislation have
globally articulated the importance of client participation. Clients, as well as welfare
and health professionals in various settings, have expressed positive attitudes towards
the principle of client participation (Cahill 1996; Collins et al. 2007b; Browne and
Hemsley 2008; Kvarnström 2011, 8; Kvarnström et al. 2012). The service user move-
ment has played a signicant role in highlighting client participation as a human rights
issue (e.g. Bassman 1997; Cook and Jonikas 2002). In Finland, client participation as
an objective in mental health has been articulated in the Ministry of Social Affairs and
Healths report (2009).
Through client participation mental health services are developed to be more con-
sumer led, responsive and exible for clientsneeds and wants. It has been argued that
client participation improves recovery outcomes, supports adherence to treatment and
promotes a healthy lifestyle (Hickey and Kipping 1998, 84; Lammers and Happell
2003). Client participation is also enhanced because clients, as active citizens, are con-
sidered to have the will, right and duty to be involved in their rehabilitation and deci-
sion-making processes (e.g. Adams and Drake 2006; Matthias et al. 2012). Client
participation is grounded in both the consumer model and democratic model. In the
rst model, clients are considered to be active, rational and capable of making informed
consumer choices. Beresford (2002,9698) and Pilgrim (2009,8689) argue that the
consumerist model is managerialist and treats clients as valuable service feedback giv-
ers in making service provision more effective and protable (Juhila et al. submitted).
In the latter model, participation is perceived in terms of involvement through collec-
tive and political action. Clientsinclusion, autonomy, independence and self-advocacy
are prioritised (Hickey and Kipping 1998; Beresford 2002; Cott 2004; Carr 2007;
Kvarnström 2011,18).
The article contributes to the ongoing discussion about client participation from the
point of view of the client. The aim is to deepen our understanding about client partici-
pation as an interactive and shifting positioning work in mental health. Based on earlier
research, our assumption is that decision-making encounters are crucial for client partic-
ipation (e.g. Hickey and Kipping 1998; Hall, Slembrouck, and Sarangi 2006,5370;
Matthias et al. 2012; Juhila et al. Submitted). We thereby ask, How do mental health
clients account for being actors in the decision-making encounters? To put it more pre-
cisely, we analyse small interview stories from the point of view of: (1) clients posi-
tioning themselves and others (e.g. doctors and nurses) and (2) others positioning the
clients. By applying the positioning theory developed in discursive psychology and nar-
rative research (Davies and Harré 1990; Harre and Van Langenhove 1991; Bamberg
1997; Wetherell 1998; Korobov 2001; Watson 2007), we reach for a more detailed
understanding of how client participation is displayed and realized in clientsaccounts
about decision-making encounters in mental health services. As discussed later, posi-
tioning is a relational concept that helps to capture the dynamic aspects of identifying
the self and others in interaction (Harre and Van Langenhove 1991, 1999; Ylijoki
2001, 245; Wetherell 2003). By examining the ways that clients talk and express them-
selves in interaction, we discovered certain difculties, constraints and prospects
embedded in the idea of client participation. Before describing the research setting and
data, we will clarify the different meanings associated with client participation in
mental health.
36 S. Raitakari et al.
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Researching client participation: classications, denitions and emphasizing
The history of participation is crowded with classications and typologies, beginning
with Arnsteins enduring and often cited ladder of participation(Arnstein 1969;
Beresford 2002). Commonly, client participation is understood in terms of individual or
collective participation and the degree or ladderof participation. At the individual
level, it is considered important that clients are provided with information and that they
are active in setting goals, dening support measures and making choices. At the col-
lective level, it is emphasized that clients should be involved in the planning, provid-
ing, assessing and researching services. (Hickey and Kipping 1998, 84; Pilgrim and
Waldron 1998; Lammers and Happell 2003; Beresford 2002,2009). In this article, cli-
ent participation is approached exclusively from the individual level, from the perspec-
tive of the clients participating in the decision-making concerning their own services
and treatment.
There have been many attempts to dene what participation represents at the indi-
vidual level (Cahill 1996; Hickey and Kipping 1998; Lammers and Happell 2003;
Collins et al. 2007b; Kvarnström et al. 2012). Aspirations to develop consumer-led
social and health services have given rise to the image of an informed, responsible,
individualistic and consumer-like client (e.g. Newman and Vidler 2006; Barczyk and
Lincove 2010). However, in Välimäkis(1998) interview study, long-term psychiatric
patients long for both intrapersonal and interpersonal self-determination. In intraper-
sonal self-determination the client makes choices and decisions, takes care of him/
herself, does something or refuses to do something. In interpersonal self-determination
the client does things together with others, is valued by others, and obtains help in
managing and making decisions. Additionally, patients interpreted the absence of self-
determination as a situation in which the individual is forced, or is not allowed, to do
something or in which certain rights are withheld (see also Woltmann and Whitley
2010). Client participation thus comprises power issues and negotiations of the clients
freedoms and abilities to act according to their will.
Client participation is extensively addressed in shared decision-making (SDM) stud-
ies that emphasize the importance of clientpractitioner interaction and communication.
Client participation is thereby understood to be bound by certain types of clientpracti-
tioner relationships. In the literature, different decision-making styles autonomous,
shared and patriarchal are commonly conceptualized and discussed (e.g. Charles,
Gafni, and Whelan 1999; Elwyn, Edward, and Kinnersley 1999; Adams and Drake
2006; Schauer et al. 2007; Simmons, Hetrick, and Jorm 2010; Woltmann and Whitley
2010; Matthias et al. 2012; for shared agency in social work see Hokkanen 2012).
Matthias et al. (2012, 306) summarize SDM in the following manner:
The most widely used denitions conceptualize SDM as an interactive process between at
least two parties (patient and provider) in which the sharing the information and opinions
occur, patients preferences and providers responsibilities are discussed, and both parties
agree on a course of action
As described, client participation at the individual level comprises many meanings
and intertwines with decision-making practices in mental health. In our analysis, we
examine client participation as positioning shifts in mental health client interview talk.
The approach applies research ndings that emphasize clientpractitioner interaction
and communication: client participation requires the client to take, or be given,
Nordic Social Work Research 37
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participants positioning in interaction (e.g. Collins et al. 2007a). As a consequence, it
is crucial to explore the ways that clients retrospectively construct themselves and oth-
ers as actors in decision-making encounters that they have previously participated in.
Setting and data collection
The current article is based on a research project
that examined rehabilitation courses
run by local NGO mental health organisations that target young adults with severe
mental health problems. The aim of the courses is to develop client-centred, systematic
and well-planned mental health rehabilitation approaches. A maximum of 10 voluntary
clients are selected for each course. During the course, different rehabilitation measures
and assessment tools are used and developed. For example, the clients are educated to
have better illness management skills and to overcome difculties in social interaction
with others in the community. Six social and health care professionals work on the
courses. The aim is to nd the necessary and best-tting support measures and services
for the clientsfuture recovery, in collaboration with many other stakeholders. The ser-
vices comprise housing and medical care, oating support, occupational rehabilitation,
self-help, leisure activities and user-led groups. During these negotiations, clients often
take the position of active participants; however, the professionals and stakeholders also
contributed signicantly. Many contextual features, such as a municipalitysnancial
resources and existing services, limit the type of support package negotiated in each
individual case.
The article is based on 25 client interviews, conducted by three researchers
(Günther, Saario and Raitakari) during eldwork at the rehabilitation courses (N= 6).
Every client (N= 36) was invited to participate in the study and 25 chose to do so.
Nineteen were men and six were women. Their age ranged from 18 to 35 years of age.
The majority of the young adults had become recently ill, and not everyone had a con-
rmed diagnosis. Some had experienced their rst psychotic experience and hospital
stay, and there was no certainty about the future prognosis of their condition. As a
result, some had very little experience of being a client in a mental health service. Cli-
ents signed informed consent forms before the interview. The voluntary nature of the
interview was stressed, as well as that it would have no impact on the assessments
made during the rehabilitation course. Participants were also informed about how the
interview material would be used and that it would be dealt with condentiality and
respect. It was also emphasized that participants could withdraw from the study at any
Interviews were loosely structured and the questions covered the following topics:
(1) the clientslife history, especially earlier contacts with the health and social care
system, as well as the locations at which they had lived or stayed while in care and
rehabilitation; (2) their current life situation and experiences during the rehabilitation
course; and (3) their future expectations and plans, as well as the expectations that
other stakeholders had towards their recovery. The interviews lasted between 30 and
90 min.
We approach interviews rstly as conversational data: clients do positioning in the
research interview context. Positioning is done and performed turn by turn in a particu-
lar interaction setting as a response to previous utterances and to full particular tasks,
such as blaming, justifying and making excuses. The interviewer also represents an
audience; that is, clients display their positioning to the interviewer. (Harre and Van
38 S. Raitakari et al.
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Langenhove 1991; Holstein and Gubrium 1995; Bamberg 1997; Korobov 2001, 2010;
Archakis and Angeliki 2005).
Secondly, we perceive the data to comprise small stories about the clientspast
decision-making encounters. Positioning is often done by extended accounts, explana-
tions and descriptions, i.e. by small stories. Small stories are produced in everyday and
institutional interaction, for example in workplace context (Watson 2007; Gubrium and
Holstein 2009). As Gubrium and Holstein state (1997, 146), small stories are short
accounts that emerge within or across turns at ordinary conversation, in interviews or
interrogation, in public documents, or in organisational records.
Accordingly, our interview data reveal the clientspositioning work, both in
research interview interaction and in decision-making encounters in mental health ser-
vices. This article will focus on these two contexts of positioning work.
Client participation as positioning oneself and others
Since we base our analysis on the concept of positioning, we approach client participa-
tion as a subtle, interactive, argumentative and contextual social action at the microlev-
el. The concept directs us to scrutinize particular discursive features and characteristics
in interview interaction that reveal how clients account for being actors during deci-
sion-making encounters. Before elaborating on how we proceeded with the analysis,
we will continue with a denition of positioning.
Previous studies about positioning examine identity construction in various settings
such as: young individuals legitimizing a subculture (Archakis and Angeliki 2005); devel-
oping a teachers identity (Watson 2007); self-identication as a caregiver (OConner
2007); the construction of kids and pupils in classroom interaction (Black 2004; Anderson
2009); considering a child as the novice and expert during family dinner interaction
(Perregaard 2010); taking a stance and arguing during a deliberation process (ODoherty
and Davidson 2010); and fashioning proper institutional and professional positioning in a
child welfare care conference (Hitzler 2011).
In positioning research, the concept of a roleis criticized for its emphasis on the
static, formal and ritualistic aspects of social reality. Unlike role, positioning refers to
the changing patterns of moral and contestable rules (rights), as well as to the obliga-
tions of speaking, acting and viewing social reality from a particular angle (Harre and
Van Langenhove 1991, 1999; Ylijoki 2001; Wetherell 2003). Positioning is a relational
concept; for example, if one positions oneself as knowledgeableand powerful, oth-
ers become positioned as less so. Positioning is an attempt to understand the dynamic
of social relationships: it helps us focus on the dynamic aspects of identifying the self
and others in interaction. As ODoherty and Davidson (2010, 224) argue:
It has been suggested [in discursive psychology] that individuals occupy a different subject
position at different times and draw on, construct, and shift between different subject posi-
tions in their everyday lives, and even in the course of particular conversations, dependent
on context and discursive purpose.
To summarize, positioning is a local and interactive discursive achievement, which is
constrained and made possible by the expectations and assumptions dened as relevant
by interlocutors.In interaction different positions are abandoned, reshaped and resisted.
It is through positioning and repositioning that social relations are maintained and
contested (Harre and Van Langenhove 1991). Positioning can be symmetrical or
Nordic Social Work Research 39
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asymmetrical (Davies and Harré 1990; Harre and VanLangenhove 1991). The kind of
self-positioning one is able to conduct has consequences as a particular positioning
makes it possible to talk and perceive the world in a certain way. In other words, posi-
tioning makes it possible to take more or less powerful stances in social interaction
(Davies and Harré 1990).
But how can ones positioning be recognized and known by others? In general, a
persons use of language and ways of acting reveal how he/she is positioning him/her-
self and others in a given situation. More precisely, positioning can be read from differ-
ent discursive hints and clues, such as from the categories, verbs, adjectives, pronouns,
modalities and moral commitments used in a conversation. The use of categories, cate-
gory-bound features and actions provide clues to positioning in action; the use of cate-
gories is bound to positioning and vice versa (Bamberg 1997; Korobov 2001, 2010;
Hitzler 2011). Positioning is a moral stance that includes expectations of ones rights,
restrictions, obligations and responsibilities to be an actor in interaction. Thus it can be
recognized from the moral order that exists within current discourse practice (Wetherell
1998). In our analysis we examine these different discursive positioning clues that are
embedded in small stories.
Analyses: coding and reading discursive clues
We conducted our analysis as follows. At the rst stage, we coded the data by using
the ATLAS.ti programme on all the small stories where the clients identied themselves
as being active or passive actors during their rehabilitation. In addition, we coded the
episodes where the professionals were portrayed as those making the plans and deci-
sions, as well as the episodes where decision-making was described as a mutual accom-
plishment. In many small stories, clients depict decision-making as an episode where
they as well others have a stance and an opinion.
At the second stage, after reviewing the data and previous research literature, we
decided to report our ndings on three dimensions: (1) restricted participation; (2) sup-
ported participation; and (3) independent participation. These dimensions are based on
the dialogue between the data and SDM research literature (autonomous, shared and
patriarchal decision- making styles). The dimensions denote the participation discourses
that are made relevant in the data and in the research community (see the Researching
client participationsection). Subtle position shifts are performed and made possible
in situ by applying discourses and assumptions regarding participation. In every dimen-
sion, we illustrate the clients acts of positioning by careful reading of one data exam-
ple (the third stage in the analysis).Data examples are selected to represent different
but common ways of making mental health care decisions. Examples also illustrate the
rich variations in positioning work performed by the interviewer and interviewee. Ana-
lysing positioning work requires paying attention to the small but meaningful features
of the interaction. Accordingly, it is not possible to scrutinize a mass of data; however,
it is possible to concentrate on theoretically relevant illustrations (for similar research,
see Hall et al. 2003; Hall, Slembrouck, and Sarangi 2006; Hall et al. 2014). During this
detailed phase of analysis, we concentrate on discursive clues such as categories, verbs,
adjectives and pronouns embedded in the data examples. Throughout this analytical
process, the authors had four joint sessions where different analytical stages and rele-
vant interpretations of the data were discussed. Small stories tell us how clients remem-
ber and describe decision-making encounters during interview interaction. These
40 S. Raitakari et al.
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retrospective accounts comprise relevant meaning-making concerning the possibilities
and constraints of being a participant in mental health services.
Restricted participation
Harre and Van Langenhove (1991) write about deliberate and forced positioning. In
forced positioning, the initiative to position lies with somebody else rather than the per-
son involved. The force element can be mild, as in the interviewers open-ended ques-
tion in the following extract (what kind of experiences do you have at those meetings).
In interview interaction the interviewer often invites, expects, affects and directs the
interviewees positioning work. Accordingly, it is important to analyse the questions,
openings, initiatives and invitations to discuss a particular subject.
In the rst extract, the interviewer begins a discussion about the case conferences
held during the course. The interviewers objective is to discover the clients meaning-
making for participating in meetings. The interviewer assumes that clients participation
is related to the expression of opinions and to active participation in the case confer-
ences. In this context, the client tells a small story about decision-making related to
changes in medication.
Extract 1
I: what kinds of experiences do you have of those meetings (2)
C: well, theyre quite businesslike events
I: have you been able to state your opinion or
C: well, I have been (4) able to say something (.) but then (2) Ive also argued
against some things (2) I havent always agreed on everything
I: well (.) so what have you
C: well, about the medication a little bit (.) I would have wanted to change it but (.)
I: so
C: in the beginning, the practitioners said that we would change the medication to
tablet form but then they changed their opinion when the nurse and the doctor
came so
I: right (.) would you have wanted the (2) tablets
C: well, they did suggest it at rst, but then they changed their opinion
I: yeah (2) is it usually easy for you to state your own opinion or talk in the meet-
ings or (2)
C: well (1) I do get something said but then you dont remember to mention every
little thing (.) so you keep wondering about them afterwards.
The interviewer invites experience talk and thus shows that she is interested in the
clients meaning-making and point of view. In the opening question, the client is posi-
tioned as a teller and a person who has personal knowledge and experience. However,
the client does not respond by telling her feelings or inner thoughts, but makes a
neutral statement, distances herself and takes an evaluators position. By categorizing
case conferences as businesslike events, the client positions the other participants as
decorous persons confronting her in a businesslike manner.
The interviewer asks a more xed question and forcesthe client to reect on her
positioning as an opinion presenter in the meetings (have you been able to state your
opinion). This second question implies that in case conferences, the individual needs to
either have a powerful position or be given one in order to be able to express him/her-
self. It also assumes that it might be the case that the client is not given space to
express his/her views (if the space was well-dened, there would be no need to ask
Nordic Social Work Research 41
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about it). The question invokes complex positioning work. The client recounts that her
participation has been partial and restricted: she has only been allowed to say certain
things. On the other hand, she has resisted the positioning acts made by others. The cli-
ent positions the others as persons disagreeing with her. The misalignment between
actors is talked into being: it is stated that they have not always been like minded. This
account comprises extraordinarily long pauses (24 s), which may imply that the client
thinks carefully about what to say or is unsure how to express herself. The interviewer
responds by asking for more details about the issues that the participant has had
disagreements about.
In response, the client tells a small story about decision-making concerning medica-
tion changes. She is positioning herself as willing and wanting to make the change.
The courses professionals are categorized as turncoats. First, they take the initiative
and suggest the medication change but then, during the case conference, they do not
stand behind their suggestion. The doctor and nurse are portrayed in such a way that,
by their very presence, they can change decisions. Conversely, it can be interpreted that
the client is categorized by others as a disagreeing participant and one who is not in a
position to make medication changes on her own. The interviewer reinforces the cli-
ents positioning as a wanting and choice-making actor by returning to the question of
what the client herself wants (would you have wanted the tablets). Interestingly, the cli-
ent does not reect again on what she wants but returns to how the courses profession-
als changed their positioning from taking the initiative to going along with the doctors
and nurses perspective (they did suggest it at rst, but then they changed their
The interviewer moves the discussion to a more general level when she asks again
if it is usually easy for the client to express her opinion or talk in the case conferences.
The client categorizes herself as someone able to partially express opinions in the meet-
ings but has difculties remembering what is worth mentioning in case conference
In the extract, we can perceive how subtle positioning shifts are constantly under
modication, reection and reconstruction. These shifts can be identied based on short
wordings and small clues in language use. As further interpretation, it can be argued
that the positioning work is accomplished in the following manner: the client is posi-
tioned as wanting, willing, resisting and betrayed. The others are positioned by the cli-
ent as businesslike, taking the initiative, suggestion makers, turncoats and as the nal
decision-makers. In turn, the client is positioned by the others as a knowledgeable teller
who is resistant towards the current medical care. The client participates but is not in
the position to make decisions concerning her medication. She expresses opinions, but
decisions are made by others. Similarly, the client is given space to express her experi-
ences during the research interview but she does not take, nor is she given, the position
to form questions or prompt for performing particular self-positioning (or positioning
of others) regarding the structure of the interview.
Supported participation
In the interviews, the clients were often asked how the illness affects their current
everyday life. By asking this question, clients are positioned as ill and forcedto
reect on the potential everyday restrictions and difculties that illness engenders. Dur-
ing the discussion, and before the next extract, the client stated that depression and
headaches are the most severe hindrances in his everyday life. The interviewer shows
42 S. Raitakari et al.
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concern when asking the opening question (how has that been treated here or have
you been able to discuss it).The question directs the client to reect on actions taken
and decisions made concerning his health difculties; especially if he has been active
in raising the problem himself.
Extract 2
I: yes (.) how has that been treated here or have you been able to discuss it
C: my headaches
I: and depression, both.
C: regarding depression, we tackled it two weeks ago approximately, a bit over two
I: yes (.) did they [the professionals] notice it here or did you talk about it yourself
C: well I (.) we kind of did it together so (.) I discussed it with [practitioners name]
a little (.)
I: yes
C: about my status (.) and then about getting medication for the depression
I: yes.
C: so now I have Cipralex for it
I: hows that been
C: well (.) I guess its starting to work now but I think I will still (.) Ill ask the doc-
tor for more medication
I: yes (.) yes
C: if I could get something to give me energy
I: yes
C: so I would have energy and, like, feel something
I: yes (.) right
The client cheques that he is expected to talk about the handling of the headache (my
headaches[?]) The interviewer gives him the option to talk about both the headache
and depression. The client makes the choice to extend the telling about the handling of
the depression. He tells how professionals were alerted to his depression about two
weeks ago. The form wedoes not express precisely who actually started to handle
the clients condition, but we may assume it refers to the client and courses profession-
als. It implies joint conduct (we tackled it two weeks ago). The interviewer asks the
clarifying question (did they [the professionals] notice it here or did you talk about it
yourself or) directing the attention to actors and activities taken. The clients small story
about joint play compresses the meanings related to supported participation: issues are
raised, discussed, decided upon and done together. In supported participation, a client
positions him/herself as a collaborator, as is done in the extract (we kind of did it
together so (.) I discussed it with [practitioners name] a little). The client and the pro-
fessional decide together that it is helpful to nd out whether it is possible to obtain
medication for the depression. In this small story, the depression medication simply
arises: the decision-making process is not opened up, but the end result shows that the
doctor made the medication decision in line with the clients and courses professional
perceptions of the condition. The client categorizes himself as able to approach the doc-
tor actively (Ill ask the doctor for more) and as one trying to move away from a
strengthless to an energetic position. He is hoping for a positioning shift.
To summarize, in this small story the client is positioning himself as not coping
and as an individual that mentions concerns and makes requests to the professionals.
The others are categorized by the client as co-partners and allies, especially the doctor
Nordic Social Work Research 43
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who is categorized as having the power to advocate his matters and nd solutions (it is
worth asking the doctor). It is not that clear how the others are positioning the client.
However, when reading the underlying assumptions, the client is categorized by the
others as ill and in need of support to participate in decision-making and taking care of
his matters during the course. He is not set to a position where he would be able to
make the diagnoses and the treatment decision himself. The interviewer supports the
clients storytelling: there are minimal responses (yes) expressing agreement and
encouraging the client to continue the telling. However, the client is not encouraged to
tell just any small story: the interviewer is actively pursuing accounts about the clients
and others actions and leeway in decision-making.
Independent participation
In the interviews, the clients were asked to reect on their presuppositions about the
course and how the decisions were made that they would attend the course. How the
clients were informed about the course, what they knew about it beforehand and how
they recalled that the decision-making processes were interpreted as indicators of client
Extract 3
I: what did you think about this [name of the course] beforehand (.) what was like
your idea beforehand
C: that I wouldnt come here (.) I will only come here to see what its like but Im
not going to come here at all
I: so you thought yourself that you wouldnt want to come here
C: I already decided that I wouldnt come here (.) that I would only come see what
its like (.) then I (.) decided (.) that I would come here after all
I: so you yourself (.) was it your own decision or
C: its my own interest in this (.) because I (.) came here thinking that Im not inter-
ested Im not going to come here but then
I: yes
C: when I saw the place and I noticed that you have your own room here (.) and I
can bring my own stuff, then I started to get interested and (.) then I just decided
that I have to come here
I: thats wonderful (2) do you remember the rst days (.) what happened he- (.)
what was it like when you came
The interviewer is interested in the clients thoughts and assumptions, and thus is posi-
tioning him as a ponderer (what did you think about). In his response, the client
explains how he had a negative stance towards coming to the course; he is not coming
to the course by any means, he will just come to get to know the place. The client is
positioning himself as a strong actor who knows, has opinions and is able to make
decisions by himself. Interestingly the interviewer repeats her doubtful question three
times (you thought yourself, so you yourself,was it your own decision [?]) and so ques-
tions if it was totally the clients own choice and decision and yet the client repeats the
answer three times. He sticks to the small story about an independent actor who is able
to make choices and decisions, make up and change his mind, and do things according
to his own interests.
In summary, there is a major position shift taking place. At rst the client is defen-
sive and reluctant but curious about the course. In the end, after having made positive
observations, he was ready to decide that he must go to the course. It is possible to
44 S. Raitakari et al.
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interpret the clients position as a consumer that makes informed and individual service
choices. The others are absent, not inuencing the clients decision-making or position-
ing him in any way. Only the interviewer strongly questions the categorization of the
independent actor. This example makes use of, and illustrates, the discourse of client
participation in individualistic and consumer-like decision-making.
When researching client participation in mental health and social work, we need to con-
sider the subtle discursive practices by which clients are doing positioning and are
given positions. Our ndings provide a basis for further discussion on client participa-
tion as a relational and interactive phenomenon. The ndings illuminate both: client
participation in research interview and in mental health decision-making. The theoreti-
cal classications and typologies grasp well the ideals and cultural discourses of client
participation. While they conceptualize what client participation should or should not
be like, they do not show how it is displayed in everyday interaction. In social work
and mental health settings, self (client) and other (professionals) positioning is a
dynamic and local accomplishment, although at the same time, institutionally and polit-
ically shaped and directed (e.g. Hall et al. 2003; Hall, Slembrouck, and Sarangi 2006;
Hitzler 2011; Juhila and Abrams 2011). As Juhila and Abrams (2011, 287) point out,
asymmetry is characteristic of social work settings. According to institutional tasks
and agendas, professionals are in a position of asking, caring, activating, controlling,
and providing advice. Yet, as shown in this article, it is important to scrutinize how
clients produce positions for professionals and themselves. This comprises valuable
information, since there is a tendency in the literature and in practice to emphasize the
most powerful positioning work, i.e. how professionals and institutional practices
produce particular client positions and categorizations (e.g. Hall et al. 2003; Juhila and
Abrams 2011; Mäkitalo 2013).
The concept of positioning provides possibilities for the more power-focused inter-
pretations of interactional data that are done in the article. Client participation inevita-
bly includes power issues (Breeze and Repper 1998; Bennetts, Cross, and Bloomer
2011). The possibilities available for a client to participate are commonly restricted by
a lack of institutional resources, negative attitudes toward client agencies, prejudices,
asymmetry and professional-led approaches to work and communication (Carr 2007;
Fischer and Neale 2008; Bennetts, Cross, and Bloomer 2011). We nevertheless wanted
to highlight the realization of client participation, i.e. client resistance, joint play, client
choice and independent decision-making in clientprofessional encounters. Organiza-
tions place professionals in powerful positions and expect them to full the ambitions
of organizational and governmental policies. Yet professionals can still use their discre-
tion in situ and decide how responsive they are, and to what extent they can promote a
clients right to own his/her case, and take a strong position in the decision-making pro-
cess (Hjörne, Juhila, and van Nijnatten 2010).
The complexity of client participation lies in the tension between autonomy and
dependency. The non-participatory position is sometimes a necessity and may produce
security or be in some other manner useful to the client (Elwyn, Edward, and Kinnersley
1999; Cardol, De Jong, and Ward 2002, 971; Schauer et al. 2007; Fischer and Neale
2008; Scheyett et al. 2009). In addition, clients have different interests and expectations
about their possibilities and abilities to participate (Hickey and Kipping 1998; Välimäki
1998; Lammers and Happell 2003, 387; Fischer and Neale 2008). Accordingly, client
Nordic Social Work Research 45
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participation, and mental health and social work in general, require reciprocity, communi-
cation skills and the ability to overcome difculties in communication (Kvarnström et al.
2012; Sommerseth and Dysvik 2012). If we really want to strengthen the mental health
clientspositioning as decision- and choice-makers within the welfare system and society,
it is paramount that we listen to their small stories. Client participation is about hearing
and understanding what the clients say, how they say it (often in a subtle manner) and
why they say it. It is also about professionals positioning themselves in a tting,
dialogical way in accordance with that information.
The article is written in the research project Responsibilization of professionals and service users
in mental health practices (20112016)funded by Finnish Academy and University of Tampere.
1. We chose the term clientrather than service useror consumerbecause in the Finnish
context, clientis commonly used and more neutral than consumer. In Finnish, client
refers equally to individuals who do business, for example in a shop, in a lawyersofce or
in a mental health clinic. Another option would have been to use the term course participant.
2. The authors and the non-governmental organizations (NGOs) in the project have a long his-
tory of research cooperation. Negotiations regarding researchers gaining access to the rehabil-
itation courses began at the early stage, when suitable research funding was conrmed. The
decision to apply for funding was jointly made. Each stakeholder was aware of the role of
the researcher in the eld, which included participating in course activities, informing partici-
pants about the research, recruiting clients and practitioners to take part in the interviews,
and conducting the interviews and clientpractitioners encounter recordings.
3. The transcription symbols are as follows: C = client, I = interviewer, [ ] = additions made by
the authors, (1.5) = a number in round brackets measures a pause in seconds. The transcrip-
tion is done in a manner that it shows the rhythm and content of the talk. The style of talk is
transformed a bit closer to standard language to make extracts easier to read.
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... Yhteinen päätöksenteko edellyttää näin ollen kummaltakin osapuolelta kykyä rakentaa vuorovaikutuksessa itselleen positio aktiivisena toimijana (ks. Raitakari, Saario, Juhila & Günther, 2015). ...
Full-text available
Osallisuus ja yhteinen päätöksenteko mielenterveyskuntoutuksessa Tutkimuksessa tarkastellaan yhteisen päätöksenteon rakentumista mielenterveyskuntoutujien ja heidän oh-jaajiensa välisessä vuorovaikutuksessa Klubitalo-toiminnan kontekstissa. Huomiomme kohdistuu keinoihin, joilla ohjaajat säätelevät mielenterveyskuntoutujien osallisuutta tekeillä oleviin päätöksiin pyrkien yhtäältä 1) edistämään vuorovaikutuksen osallistujien tasavertaisia osallistumisen mahdollisuuksia ja toisaalta 2) varmistamaan, että vuorovaikutuksessa saadaan ylipäätään jonkinlaisia päätöksiä tehdyksi. Aineistona on 30 videotallennettua ryhmätapaamista, joita on analysoitu keskustelunanalyysin menetelmällä. Tarkasteltavat ohjaajien vuorovaikutuskäytänteet ilmenevät päätöksentekosekvenssien eri vaiheissa. Analyysimme havain-nollistaa, kuinka ohjaajat voivat käynnistää päätöksentekosekvenssin käsittelemällä jälkikäteen ehdotuksina sellaisiakin kuntoutujien vuoroja, jotka eivät tällaisina tulleet alun perin käsitellyiksi. Tilanteissa, joissa oh-jaajien omat ehdotukset eivät saa kuntoutujilta vastakaikua, ohjaajat saattavat itse edistää päätöksenteko-sekvenssiä muistuttamalla kuntoutujia tiedollisesta pääsystä ehdotusta koskevaan tietoon tai kalastelemalla samanmielisyyden ja sitoutumisen ilmaisuja ehdotettuun asiaan. Tällä tavoin ohjaajat ottavat enemmän vastuuta vuorovaikutuksen etenemisestä ja päätösten syntymisestä kuin kuntoutujat. Vaikka ohjaajien toi-minnalle voidaan esittää monia pedagogisia perusteita, ne muodostuvat jännitteisiksi suhteessa Klubitalo-toiminnan taustalla vaikuttavaan kuntoutusideologiaan, jossa aidosti yhteinen päätöksenteko on keskeistä.
... It has also been exploited to study autobiographical SMITH illness narratives, showing how a narrator's self can be positioned via archetypal 'quest stories' (Frank, 1995) or how Twitter accounts of depression position tellers and audiences in conformity with the narrative genres of testimony and confession (Koteyko & Atanasova, 2018). As recent mental health care reforms have turned their back on paternalistic care models in favour of community-or consumer-based approaches, positioning theory has been applied to test the extent to which normative expectations about, for instance, shared decision-making are reflected in discursive practice (Raitakari, Saario, Juhila, & Günther, 2015) or whether partnership models of care construct users willing to engage with services (Chase, Zinken, Costall, Watts, & Priebe, 2010). The role of carers has been studied from the point of view of informal carers in interaction with health professionals (Gilbert, Ussher, Perz, Hobbs, & Kirsten, 2010) and from the point of view of professional carers (healthcare assistants) identifying with patients to challenge their marginalised status within hospitals and care homes (Scales, Bailey, Middleton, & Schneider, 2017). ...
This paper uses subject positioning theory to explore how conflicts between autonomy and protection are managed in the justification of controversial care arrangements for patients with mental/neurological illness. Its basic argument is twofold: firstly, to justify or propose care arrangements at strategic or contentious moments, actors position illness as an actant and make it present in talk‐in‐interaction, exploiting alignments and misalignments between the there and then of reported events and the above and beyond of shared societal discourses to say what matters and what's to be done here and now; secondly, the introduction of authoritative voices from elsewhere involves imbricating narrative and routine sequences in order to prioritise different subjectivities. Dilemmas opposing autonomy and protection may seem less intractable if we adopt a corresponding perspective interplay between narrative and routine situational readings.
Client participation is one of the social work’s central ideals, yet several studies have illustrated the challenges around including client perspectives in decision-making and action-planning procedures in institutional settings. The present study explores how social workers can help clients form and expresses their views to influence decisions about how to proceed in their case. We use a discourse analysis methodology focused on naturally occurring interactions in meetings in which a client initiative has consequences for the decisions made. Our analysis illustrates a process where the social worker assists the client in taking the initiative to form and express their views about how to proceed in the case followed by joint exploration, adjustment and concretisation of the client’s initiative into an institutional referral. This account casts participation in conversation as more than the acceptance or implementation of clients’ ideas or requests. Rather, participation in this setting is a negotiated activity that entails supporting clients in developing thoughts and ideas about how to achieve their long-term goals within the available framework of institutional resources. The analysis offers concrete implications for practice, as the single case illustrates interactional practices involved in facilitating client participation within a welfare-to-work context.
In this study I examined the positions Finnish frontline workers constructed for their long-term unemployed clients through the employability discourse. The data consisted of 34 telephone interviews with rehabilitation counsellors working as part of a multi-sectoral team aiming to enhance the employability of unemployed jobseekers who face multiple barriers to attaining a job. In my analysis I identified four main positions: motivated, resistant, unfortunate and blameworthy. Within all of these positions, the responsibility related to employability enhancement was scrutinized. My analysis revealed that frontline workers position themselves as responsible or not responsible for enhancing their long-term unemployed clients’ employability depending on how employability or lack of it is constructed and a long-term unemployed individual positioned.
Full-text available
Kokemusasiantuntijuus hyödyttää palvelujärjestelmää ja sen asiakkaita sekä kokemusasiantuntijoina työskenteleviä, joilla katsotaan olevan kaksoisrooli sekä asiakkaina ja palveluiden käyttäjinä että oma-ehtoisina toimijoina. Artikkelissa kysytään, miten kokemusasiantuntijat asemoivat itsensä päihde- ja mielenterveyspalveluiden hyödyntäminä asiakkaina suhteessa palvelujärjestelmään, sen palveluksessa oleviin ammattilaisiin sekä päihde- ja mielenterveyskuntoutujiin. Tutkimuksessa haastateltiin ko-kemusasiantuntijoita, jotka toimivat kokemusasiantuntijoina erilaisissa tehtävissä päihde- ja mie-lenterveysasiakkaiden tukena ja ammattilaisten rinnalla. Aineiston analyysi kytkeytyy sosiologisen kulttuurintutkimuksen tapaan lähestyä tutkimuskohdetta kulttuurisena ilmiönä. Tutkimus esittää, että kokemusasiantuntijoiden asema on ristiriitainen yhtäältä asiakkaan kuntoutumista vahvistavina päihde- ja mielenterveyspalveluiden toimijoina ja toisaalta hallinnon harjoittaman osallistamispoli-tiikan välineinä.
This paper examines recovery from intimate partner violence and mental health problems through the perspective of experiential expertise (EE). The aim is to investigate the formation of EE in the context of empowerment-oriented recovery in non-governmental organisations (NGOs). This triangulated study includes both quantitative and qualitative data. The quantitative part was acquired through a survey on people with personal experience of mental health problems (N = 133) and the qualitative part was collected from a development project including sixty female victims of intimate partner violence and nine professionals who worked with the women. First, the data were analysed separately through statistical analysis and hermeneutic close reading. Second, a triangulated synthesis was made. There are three types of EE: individual, group and organised. These provide a basis for personal and social empowerment. EE consists of emotional and influential ways of acting, which enable renewed action as well as the reformation of a self-image. Our findings indicate that the relation between EE and recovery is reciprocal and mutually beneficial. We argue that especially group and organised EE should be integrated more firmly into social work practices, preventive social policy and structural social work.
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Analysis of language and discourse in social sciences has become increasingly popular over the past thirty years. Only very recently has it been applied to the study of social work, despite the fact that communication and language are central to social work practice. This book looks at how social workers, their clients and other professionals categorise and manage the problems of social work in ways which are rendered understandable, accountable and which justify professional intervention. Features include: •studies of key practice areas in social work, such as interviews, case conferences, home visits •analysis of the language and construction used in typical case studies of everyday social work practice •exploration of the ways in which professionals can examine their own practice and uncover the discursive, narrative and rhetorical methods that they use. The purpose of this engaging study is to increase awareness of language and discourse in order to help develop better practice in social work. It is essential reading for professionals in social work, child welfare and the human services and will be a valuable contribution to the study of professional language and communication.
With communication and relationships at the core of social work, this book reveals the way it is foremost a practice that becomes reality in dialogue, illuminating some of the profession's key dilemmas. Applied discourse studies illustrate the importance of talk and interaction in the construction of everyday and institutional life. This book provides a detailed review and illustration of the contribution of discourse approaches and studies on professional interaction to social work. Concentrating on how social workers carry out their work in everyday organisational encounters with service users and colleagues, each chapter uses case studies analysing real-life social work interactions to explore a concept that has relevance both in discursive studies and in social work. The book thus demonstrates what detailed discursive studies on interaction can add to professional social work theories and discussions. Chapters on categorization, accountability, boundary work, narrative, advice-giving, resistance, delicacy and reported speech, review the literature and discuss how the concept has been developed and how it can be applied to social work. The book encourages professional reflection and the development of rigorous research methods, making it particularly appropriate for postgraduate and post-qualifying study in social work where participants are encouraged to examine their own professional practice. It is also essential reading for social work academics and researchers interested in language, communication and relationship-based work and in the study of professional practices more generally. © 2014 selection and editorial material, Christopher Hall, Kirsi juhila, Maureen Matarese and Carolus van Nijnatten. All rights reserved.
This paper reports on empirical research exploring and describing the variations in service users' conceptions of service user participation (SUP), specifically in interprofessional practice. The social work practices in which front line workers were using interprofessional teamwork were explored at three Swedish welfare institutions. Service users included individuals with chronic pain disorders, obesity conditions or in need of short-term placement in elder care facilities. The qualitative study design was informed by a phenomenographical approach and conducted as semi-structured individual interviews with twenty-two service users. The main findings suggest five qualitative variations of service user's conceptions of SUP: (i) information transmission; (ii) choices and decisions among resources; (iii) comfortable relationship and communication; (iv) interaction for increased understanding; and (v) conditions for service user participation. The findings highlight the importance for the interprofessional team of social workers and other professionals to recognise the various ways of experiencing SUP by service users. The findings thereby support the possibilities to understand and to take into consideration the individual service user's conceptions of SUP in interprofessional practice.