ChapterPDF Available

Clients Accounting for the Responsible Self in Interviews

Authors:
1
CHAPTER 5: CLIENTS ACCOUNTING FOR THE RESPONSIBLE
SELF IN INTERVIEWS
Suvi Raitakari and Kirsi Günther
Introduction
Nowadays, lively political and academic discussions revolve around the issue of personal and social
responsibilities (e.g. Passini 2011; Snelling 2012; Pearl and Lebowitz 2014). For example, the
discussions consider in what sense and to what extent (ill)-health and (bad) wellbeing are personal
choices and accomplishments (Giddens 1999; Wikler 2002; Brownell et al. 2010; Scott and Wilson
2011; Wiley et al. 2013). A common view is that individuals are primarily responsible for their
health and well-being and thus at least partly causing their adversities and problems (Robert et al.
2008; Lundell et al. 2013). Although public perceptions are not monolithic and this view of the
responsible self is widely criticised, it can still be said to represent a dominant cultural expectation
of agency in the Western world (Lyon-Callo 2000; Pearl and Lebowitz 2014).
The clients utilising employment, health, social and housing services and benefits are culturally
expected to account for being responsible and as “trying” despite the need of subsidies and support
services. However, individuals experiencing social exclusion are often in a difficult position due to
attempting to live up to the idea of a responsible self. Social exclusion erases and narrows
capabilities, resources and choices in life and can be defined as “what can happen when people or
areas suffer from a combination of linked problems such as unemployment, poor skills, low
incomes, unfair discrimination, poor housing, high crime, bad health, and family
breakdown” (Social Exclusion Unit 2004: 4; Cole et al. 2011: 13). These features are also well-
known social determinations of (mental) health problems (SDH) (Lundell et al. 2013: 1116; May et
al. 2013).
This is the accepted manuscript of the article, which has been published in Juhila K., Raitakari S., Hall C.
(eds.) Responsibilisation at the Margins of Welfare Services. London: Routledge, 2017. pp. 83–105
ISBN 978-1-138-92838-1. https://doi.org/10.4324/9781315681757
2
One root of the responsibility discussion is advanced liberalism that emphasises that people are to
help themselves and find ways to strengthen their capabilities to be self-governing individuals.
Personal responsibility and self-management are widely discussed in the govermentality literature
(Rose 1996; Scott and Wilson 2011; Solberg 2011; Chapter 2). Interestingly, self-management,
which implies empowerment and recovery, is at present strongly promoted in the (margins of)
welfare services (Davidson 2005; Scott and Wilson 2011; Chapter 3). For instance, self-
management has become a common approach in mental health work (Sterling et al. 2010) such as
where the client interview data examples of this chapter are located. Often, welfare workers support
the client’s responsibility and ability to manage his/her difficulties in life by conducting self-
management techniques such as making weekly programmes and schedules with the clients. Self-
management can be understood as the ability of individuals to get along with the symptoms as well
as the physical, psychosocial and lifestyle changes inherent in living with severe conditions (e.g. by
leaning to utilise different techniques and welfare services) (Johnston et al. 2008). Thus, it first and
foremost puts forward the notions of personal responsibility in line with advanced liberalism.
Our aim in this chapter is to reflect on issues related to personal and social responsibilities by
applying the concept of self-management, which we understand as being a mediator between macro
level discussions on responsibilities, professionals’ ideas of good recovery and grass-roots level
practices at the margins of the welfare services. The question addressed is as follows: how do
clients manage personal and social responsibilities in the process of recovery at the time of rising
expectations of self-management and the responsible self (self-responsibilisation)?
We begin by introducing discussions related to responsibility and self-management. Discourses of
responsibility can roughly be divided into two: those that emphasise personal responsibility as
essential in one’s agency and well-being (Brownell et al. 2010), and those that concentrate on social
responsibility i.e. that emphasise that others, institutions and collectives are crucial for ensuring an
individual’s wellbeing in society. Personal responsibility can especially be seen as a crucial element
of becoming the subject of one’s life (see Giddens 1999; McNamee and Gergen 1999; Kelty 2008;
Ballet et al. 2007), whilst social responsibility emphasises the subjects’ interconnected relations and
obligations: “the importance of connections between people, through their social commitments and
their embedding in social institutions” (Ballet et al. 2007: 186). Accordingly, personal and social
responsibility intersect with one another as a responsible self is not only expected to manage one’s
3
own life but also to be socially enlightened and to take care of the well-being of others too (Rose
1996; Lister 2015).
Then we continue by demonstrating via interview data examples how on the one hand clients at the
margins of welfare services account for (trying to) taking responsibility for themselves and others
and on the other hand resist this cultural expectation as impossible to live up to (in a current
situation). There exists a gap between cultural expectations and the resources and capabilities of
individuals (Scott and Lyman 1968). This gap is present in the interview talk as excuses,
justifications and explanations in regard to expectations to restore things back to “normal” in a
responsible way (see Chapter 4). In the analysis section we illustrate how clients reflect on the
discourses of responsibility and self-management. These discourses set norms for good and
respected individuals, and thus they offer “yardsticks” for the clients to assess their self-
management abilities and stages of recovery.
Discourses constructing the responsible self
Discourses of responsibility
As it is used today, ‘responsibility’ is an interestingly ambiguous or multi-layered
term. In one sense, someone who is responsible for an event can be said to be the
author of that event. This is the original sense of ‘responsible’, which links it with
causality or agency. Another meaning of responsibility is where we speak of someone
being responsible if he or she acts in an ethical or accountable manner. Responsibility
also however means obligation, or liability, and this is the most interesting sense to
counterpose with risk. (Giddens 1999: 8)
In line with the above quotation, Snelling’s (2012: 162) definition demonstrates the multi-faced
nature of responsibility. He represents three dimensional definition of responsibility: (i) a
responsible agent; (ii) having obligations (responsibilities); and (iii) being susceptible to being held
responsible (that is blamed if he fails to meet them)”. Responsibilities can, as in this chapter, be
approached as discursive accomplishments that are constantly redefined and revised in particular
contexts and social situations. This is what we mean by the term “discourses of responsibility”.
4
Responsibilities are expressed in relation to authorities and governance, and thus they imply
existing power relations, obligations and rules related to prefer behaviour and actions in current
society. Individuals possess rights and responsibilities with respect to each other, communities,
social institutions and authorities (Dean 2002; Flynn 2005; Ballet et al. 2007; Kelty 2008; Passini
2011: 282). As Trnka and Trundle (2014: 136) argue, “responsibility is a multivalent concept and
practice that is central to contemporary social life. Notions of responsibility are pervasive, visible in
forms of governance, emerging and enduring subjectivities, and collective relations in a wide range
of settings”. For example, being a welfare client implies particular responsibilities set by the welfare
professionals and institutions. Also, the status of being a human being in Western society distributes
responsibilities and rights to individuals according to human rights, religion and democracy. All in
all, discourses of responsibility govern and direct individual conduct. However, they comprise a
dispersed and conflicting totality that makes it possible for the individual to act upon the idea of the
responsible self in various ways in different personal, societal and interactional contexts. Discourses
of responsibility therefore enable and prompt agency in many ways, yet also restrict it.
Doheny (2007) deals with discourses of responsibility by presenting a liberal, republican,
communitarian and deliberative democratic version of responsibility. Liberal responsibility is
mostly about personal rights and responsibilities. It emphasises the importance of not abusing or
misusing the rights of a free individual, whereas republican and communitarian versions have more
to say about social responsibilities as civic virtues (see also Lister 2015). From a critical point of
view it can be argued that although republican and communitarian versions of responsibility
“explain that the citizen must internalize certain virtues if s/he is to behave responsibly, there is an
absence of detail on how the responsible citizen grapples with their actual responsibilities” (Doheny
2007: 408). The deliberative democratic version of responsibility, which is introduced as an
alternative and preferred version of responsibility, highlights that a fair distribution of
responsibilities requires ethical sensitiveness, reflective thinking and negotiations. It is also seen to
offer a relevant theoretical background to understand how people tackle responsibility issues in
their everyday life. Following the idea of responsibilities being negotiated and managed at the
grass-roots level, it has been for example studied how patient responsibility is constructed and
negotiated in hospital settings and “how these practices draw on discourses of medicine, care and
neo-liberalism” (Holen and Ahrenkiel 2011: 299). Similarly Beckmann (2013) studies lived
experiences of people living with HIV/AIDS in Tanzania, and how they account for acting
responsibly according to their condition, even though the biomedical authorities often see this
action as irresponsible.
5
As discussed in this book, Miller and Rose (e.g. 2008) have approached personal responsibility as a
representation of an advanced liberal form of governance that is known for relying on and enabling
individual independence, empowerment and self-management (Rose 1996; Dean 2002; Chapter 2).
In other words, advanced liberal governance values self-disciplined, multi-skilled, entrepreneurial
and resilient individuals (Stasiulis and Bakan 2003: 22; Ilcan 2009: 211; Solberg 2011). As
Hazleden (2014: 422) sees it: “Contemporary understandings and classification of the self are
bound up with (neo)liberal political ideology and the rhetoric of choice, self-responsibility and
individual aspiration”. The advanced liberal understanding of personal responsibility is often
referred to as self-responsibilisation. This stresses personal choice and autonomy as the means
through which personal responsibility is accomplished – the responsibilities of the state are reduced,
and it is up to the individual to make the best out of the opportunities and to reach for the best
possible well-being. As Michailakis and Schirmer (2010: 931) put it, we have witnessed a “shift
from a collective responsibility of the welfare state towards individual responsibility”. Self-
responsibilisation focuses on the phenomenon of enfolding political expectations and aims at
personal subjectivities (Hazleden 2014: 433). Accordingly, individual agency is directed by
ongoing (self-)responsibilisation accounting processes (Clarke 2005).
Client responsibility and self-management
Personal responsibility is strongly addressed in client responsibility and self-management
approaches. Holding individuals accountable for their lifestyle choices and health is at the moment
both a general and topical, yet controversial, discussion in today’s society, which has a growing
awareness of health risks, the importance of prevention and the growing demands for more and
better treatments for less costs (Cappelen and Norheim 2005; Cayton 2006; Jallinoja et al. 2007;
Share and Strain 2008; Civaner and Arda 2008: 267; Michailakis and Schirmer 2010; Scott and
Wilson 2011). Civaner and Arda (2008: 264) have come up with the following list of patient
responsibilities: “promoting self-health, respect for the health and well-being of others, the
appropriate use of health care resources in the public sector, sharing relevant health information
with health care workers, considering carefully any advice offered by the health care worker, and
adhering to agreed treatment plans”. They classify patient responsibilities into four categories that
are “technical requirements, consumer obligations, responsibility for one’s own health, and
responsibilities to society at large (social responsibility)” (Civaner and Arda 2008: 264). Holen and
Ahrenkiel’s (2011) study shows that patient responsibility comprises aspects such as to have
6
morality, to possess proper will, to be compliant, display control and controllability, to be active
and, most importantly, to strive for self-sufficiency.
Self-management resonates with and has been incorporated into patient/client responsibility
discussions (Jallinoja et al. 2007: 244), and it was first applied in the welfare work context in the
medical rehabilitation and chronic disease literature (Sterling et al. 2010: 133). The approach is
based on and promotes the idea of a health consumer that is a responsible, choosing, life planning
and self-efficient actor (Scott and Wilson 2011: 43). Within this approach, the ideal client is one
who monitors and governs his/her condition with the help of appropriate expert knowledge and
support. It expects the client to perform responsibly also by pursuing healthy living and reducing
risks, following chosen care plans and medication and being a co-operative and active actor in the
health and social services (Lorig and Holman 2003; Sterling et al. 2010: 134). The expertise of
welfare workers is directed particularly to “individuals who lack the cognitive, emotional, practical
and ethical skills to take the personal responsibility for rational self-management” (Rose 1996:
348).
In the governmentality literature self-management programmes are named as “responsibility
projects” (see Chapter 2). Self-management can been interpreted to focus on “inquire about the
self”, which is also a bedrock of advanced liberalism governance, as the majority of its techniques
for tackling social problems “fall under the rubric of self-help and governing of the self” (Lyon-
Callo 2000: 335; see also Broom et al. 2014). Rose (1990) calls techniques that focus on the
transformation of subjectivity from powerlessness to active participation as “technologies of
citizenship” (Hazleden 2014: 423; see Chapter 6). Accordingly, the self-management approach is
said to be “social revolution, not against capitalism, racism, and gender inequality, but against the
order of the self and the way we govern ourselves” (Cruikshank 1996: 231 ref. Lyon-Callo 2000:
335).
In addition, the self-management approach implies empowerment and recovery (Davidson 2005;
Johnston et al. 2008; Sterling et al. 2010; Pulvirenti et al. 2014; Chapter 3). It is enhanced by
stating that when clients are actively involved in managing their conditions, better outcomes are
achieved. It is also seen as the client’s right to have an active role in finding solutions to health and
well-being problems. In other words, self-management permits clients to become participants in the
recovery process (Davidson 2005; Sterling et al. 2010; Chapter 3). The approach is applied as a
professional care ideology, as programmes and specific techniques to strengthen and empower
7
clients to overcome difficulties and improve their quality of life despite possible lifelong conditions.
In long-term conditions self-management is seen as a lifelong learning process and task that can be
accomplished and strengthened by mutual co-operation between clients and welfare workers.
Johnson et al. (2008: 5) state that “at the heart of each self-management approach is an empowered
patient with the skills and confidence to better manage chronic diseases and interact with the
primary health care system”. They also provide an enlightening definition of self-management that
emphasises empowerment and reciprocal relationship between clients and welfare workers:
Self-management refers to an individual’s ability to manage the symptoms, treatment,
physical, psychosocial, and lifestyle changes inherent in living with a chronic
condition. Self-management programmes seek to empower individuals to cope with
disease and live better quality lives with fewer restrictions from their illness by
developing self-efficacy, which is the level of confidence that an individual has in his
or her ability to succeed in dealing with their own chronic disease. It is important to
note the distinction between initiatives to build patient self-management and self-
management support. Self-management support requires a provider or health care
team to perform a certain set of tasks to create the self-efficacy necessary for a patient
to deal confidently with their own range of emotional, physical, and physiological
symptoms of their chronic disease. Self-management does not replace a health care
team, but rather, encourages a reciprocal relationship between patient and physician,
where self-management skills can be built and used at home, as well as in routine
health care system interactions. (Johnston et al. 2008: 5)
This definition links together personal and social responsibility as workers are constructed as the
ones enabling via reciprocal relationship a client to be self-efficient in the community. To grasp
how clients manage severe conditions in everyday bases, it is important to understand their
everyday challenges, ways of making sense of health, ill-health and their agency, as well as the
structural barriers that hinder their access to resources. Clients often are in a position where they
have no other alternatives than to balance the demands of the condition against those of everyday
life and to manage in one way or another with or without the support of welfare workers (see van
Houtum et al. 2015). Clients thus display personal responsibility, agency and means to manage
difficulties and risks, even though their actions might not always be approved by welfare workers.
The self-management approach is based on three presumptions that need to be addressed cautiously.
Firstly, individuals are seen as disempowered per se. Secondly, it is assumed that all individuals
8
want or have the resources to be empowered, to make life changes or self-manage their conditions
in a professionally preferred way (Pulvirenti et al. 2014). Thirdly, it is an individual client that is
worked on and targeted for interventions. A critical stance towards the self-management approach
and its presumptions makes it possible to resist the cultural expectation of the responsible self and
to recognise its limits and risks, such as victim blaming (see Chapter 2) - without denying the
positive consequences of the approach for clients’ agency and well-being.
Clients taking part in the life management programmes and techniques
Self-management programmes and specific techniques are at present commonly conducted in
welfare services to enhance the self-efficacy and personal skills of clients to govern health and
welfare difficulties in everyday settings (Lorig et al. 1994; Lorig and Holman 2003; Sterling et al.
2010; Cramm et al. 2015). It can be argued that the self-management approach currently represents
a preferred way to do mental health work and to understand client participation. In the following we
introduce shortly a few self-management programmes to demonstrate how they construct the client
as a responsible and active participant in service delivery and thus promote the cultural expectation
of the responsible self.
Different self-management programmes – for instance Care Programme Approach (CPA) (see
Chapter 7), Wellness Recovery Action Planning (WRAP) and Recovery Star – comprise techniques
such as education, care plans, time tables, advice-giving and directing, agreements, self-assessments
and follow ups to achieve recovery and better ability to function. WRAP is one of the mental health
self-management techniques developed by service users and rooted in the recovery movement. It is
widely applied especially in English speaking countries (Davidson 2005; Doughty et al. 2008; Scott
and Wilson 2011). Scott and Wilson (2011: 40) take a critical stance toward it and note: “The
WRAP is noteworthy for its construction of a health identity which is individualised,
responsibilised, and grounded in an ‘at risk’ subjectivity; success with this programme requires
development of an intensely focused health lifestyle”.
Recovery Star is a holistic and personalised outcome measurement tool. It is based on the idea that
both the worker and the client assess, rate and discuss the client’s progress in self-management and
recovery. The tool directs clients to plan, quantify and reflect on their progress, as well as welfare
professionals and organisations to capture performance and outcome results (Onifade 2011; Tickle
et al. 2013). Ten dimensions (see Dickens et al. 2012) are assessed: “managing mental health;
9
physical health and self-care, living skills, social networks, work, relationships, addictive behavior,
responsibilities, identity and self-esteem and trust and hope” (Tickle et al. 2013: 195). Furthermore,
Recovery Star is based on the idea of a “ladder of change” that demonstrates steps in the recovery
journey from “being stuck to accepting help, then on to believing that things can change, thereafter
to learning new skills/approaches to maintain recovery and finally to self-reliance” (Onifade 2011).
As WRAP, Recovery Star aims to construct and facilitate transformation from a passive self driven
by external forces to a reflexive self that is proactively and responsibly managing the circumstances
and difficulties in life.
The clients, whose interview talk we analyse in this chapter, have participated in a variety of more
or less strict self-management programmes. They have been clients of several health and social
services, having lived in supported housing and rehabilitation course settings or independently with
the support of floating support services. Accordingly, our presumption is that they have confronted
and experienced a range of “re-responsibilisation” techniques such as monitoring pre-symptoms and
well-being, making weekly schedules, taking part in self-care groups, practicing social and
everyday living skills and receiving advice concerning healthy living, medication and preferred
behaviour. Thus, it is important to scrutinise how such “re-responsibilized”, and in many ways
socially excluded, individuals account for personal and social responsibility.
Clients accounting for causes and responsibilities in interview talk
To live a life at all is to confront conditions that are nettlesome, disappointing,
irritating, and downright devastating. The problem then is not that we confront the
problematic but, rather, how we respond. Perhaps the chief riposte is to seek
restoration: We strive ascertain cause and with cause in place, gain rationale for
action. With responsibility assign, we sense responsibilities for admonishment,
correction, coercion, punishment, and so on (McNamee and Gergen 1999: 3).
Responsibility is a central concept within human life and thus also for an ethnomethodologically
informed research approach (see Chapter 4) where it is seen as linked to accountability in social
interaction. Following this approach, the subsequent analysis examines negotiations of
responsibilities “in action”. We ask, to what extent and in what ways do the clients (and
interviewers) orient to the discourses of responsibility and self-management approach in interview
interaction.
10
The illustrative examples are chosen from a data corpus of 44 (32 Finnish and 12 English) client
interviews which have been conducted in four different settings: 1) a supported housing and floating
support service for people with mental health and substance abuse problems (Finland); 2) a floating
support service for people with mental health problems (UK); 3) a project offering housing and
social skills training for young adults with diagnosed schizophrenia (Finland); and 4) an outpatient
clinic for people with severe drug abuse problems (Finland). All these services are run by non-
governmental organisations (NGOs) (see Chapter 4). The services deploy a variety of self-
management programmes and techniques to promote individual recovery and coping in everyday
life. For example, the clients commonly practice travelling by public transportation and everyday
living skills such as cooking and cleaning. An essential activity is also giving information about
mental difficulties and substance abuse problems and advising how to manage them.
The structure of the thematic interview was the same in England and Finland. The interview
proceeded temporarily: the themes addressed the past, present and future hopes of clients. The
themes covered the clients’ background, previous and present accommodation and contacts with the
social and health services. In addition, direct questions were asked about agency, personal and
social responsibility and client-centredness.
Responsibilities are often touched upon by both participants in the interviews: by the interviewer
when putting forwards questions in a frame of responsibility and self-management and thus inviting
the client to account their own responsibilities and those of others. As seen from the examples, the
interviewer directs interviews by asking questions that imply particular presumptions concerning
the client roles and responsibilities in the recovery process. However, the main emphasis in the
analysis is on the responses and accounting practices of clients (not on the expressions of the
interviewers).
In the analysis we apply analytical concepts such as causal accounting and resistance (see Chapter
4). In a broad sense, accounts are seen to be present in all everyday communication (e.g. Buttny
1993; Antaki 1994). In accounting, speakers address issues of agency and responsibility (Edwards
and Potter 1993: 25). As Garfinkel (1967: 33) notes, speakers routinely build into their talk
accounts rebuttals to potential criticisms (see Raitakari et al. 2013). For example, in interview talk
clients often explain their action and answer questions in a way that implies that they are aware that
11
they are potentially judged as “not responsible” and “not trying”. As Matarese and Caswell (2014:
46) state, “accounts are common responses to questions prompting an explanation”.
When we apply a narrower sub-concept of accounting – causal accounting – the interest lies in how
individuals account for causes and construct cause-and-effect relations when making sense of their
actions and the situation at hand (Bull and Shaw 1992; Juhila et al. 2010). By “cause-and-effect
relation”, we do not refer to mechanistic causality, as in experimental methods, but to individuals’
everyday rhetorical claims of cause-and-effect (Bull and Shaw 1992; Raitakari et al. 2013).
Applying Bull and Shaw’s (1992) ideas on causal accounting we scrutinise the clients’ “theories of
cause” and how they construct relations between causes, agency and responsibilities regarding their
own situations and behaviour. In a variety of ways, the clients claim causal relations between the
following issues: What is causing their conditions and difficulties? What can be done to ease the
suffering? Who ought to be active and responsible in solving problems?
By giving causes, justifications and explanations – for example, by referring to factors that are out
of one’s reach, control or are unchangeable – individuals define the scope of their responsibilities
and account for not being able to be the expected responsible self. In the client interview talk causal
accounts are often built in a manner that creates an image of a good client who is trying his/her best
in a demanding situation to live according to self-management expectations. However, the clients
construct also causal accounts that imply resistance towards and resigning from the self-
management approach.
The analysis section proceeds in the following way: in the first part, we analyse data examples that
illustrate accounts for trying to be the responsible self. We notice that the clients express a lot their
wish to be more self-sufficient, independent and active in life, but at the same time there are things
that make it impossible for them. We refer to this kind of talk when using the term “trying to be the
responsible self”. We chose, named and organised the data examples according to different factors
that the clients construct as mainly their responsibility. In the second part, we examine such data
examples that illustrate resistance towards personal responsibility. This resisting talk produces
causal accounts for not being able to be responsible for one’s life (for now) or act responsibly (in a
particular situation). It also makes it possible for the client to question the profound justification of
(re)-responsibilisation. Accordingly, we have named the last data examples according to the reasons
constructed as explanations and justifications of why the client is not capable of taking the position
12
of the responsible self. Hence, the analysis in a general sense demonstrates how discourses of
responsibility and self-management are reflected among clients at the margins of welfare services.
Responsible self: Accounting for trying
Responsible for…
Our first impression of the data was that it comprises a large amount of professional self-
management vocabularies, as well as causal accounts that explain why it is difficult for the clients
to live up to the expectation of the responsible self as much as they would like to. These causal
accounts also imply attributes of responsibility and blame. The clients describe their struggles with
ordinary everyday matters and limited resources, yet also their abilities to manage symptoms and to
estimate their shifting ability to function. Whilst doing this, they simultaneously allocate
responsibilities to themselves and others; for example, welfare workers.
... managing care contacts, monitoring oneself and seeking help
The first example is client interview data from England. The client is living in her own flat with the
support of a floating support service. She is in her fifties and has special needs related to substance
abuse and severe psychotic level mental health problems. The interview is held in a supporting
housing and floating support service’s office. The data excerpt is from an interview section
concerning support services and professional networks taking part in the client’s treatment.
Extract 1
1. INTERVIEWER: What is important for your own wellbeing?
2. CLIENT: Making sure that I’m drug free and alcohol free, that’s the most important one.
Making sure that I have three teams, Support Service, my advocate and my psychiatrist and my
social worker is. Making sure they’re there so I can trust them. So, that if I do start to feel
unwell I have somebody that I can phone up, you know, and get in touch with. Instead of
leaving it and leaving it, and getting worse, you know, to the point where I want to hurt myself.
I don’t want to have to get to that point any more.
At the beginning of the extract, the interviewer asks what is important for the client in sustaining
her wellbeing (turn 1). In the response the client constructs herself personally responsible for
making sure that I’m drug free and alcohol free being”. Her duty is “making sureabout a variety
of things: a substance-free life, support services, a trustworthy worker and her ability to act if things
13
are getting worse, you know, to the point where I want to hurt myself”. In her response the client
portrays herself as a strong and empowered agent in the sense that she manages her condition and
professional network, monitors wellbeing, makes requests for support and allocates appropriate
responsibility to the welfare workers. Causal accounts are presented when the client argues that she
is required to be active in order to sustain good condition and support relations. Conversely, she
constructs her possible passivity as a cause that leads to a worsening of things. The client wants to
be the responsible self that takes care and does not hurt herself. However, success in this is bound to
her ability to be proactive and keeping the welfare workers committed to helping her. In her
response, the client displays herself as an active actor who is responsible for arranging her own
care. She positions herself as the central person whose role is to inform, coordinate and make
demands on welfare workers concerning her health and safety. The responsibility to manage the
condition is constructed as shared between the client and welfare workers; responsibilities are based
on reciprocal client-workers relationship. In order for the client to act responsibly, the welfare
workers carry an obligation to be available and responsive to the client’s needs.
In general, such client talk reflects the ideals of the personal responsibility and self-management
approach. The self is constructed as active, reflexive, monitoring and responsible for the condition
getting better or worse. Accordingly, the client associates with personal responsibility and self-
management vocabularies, and this makes it possible for her to display strong and empowered
agency. However, the client’s ability to be personally responsible is bound to the welfare workers’
social responsibility to be liable and available to care for the client.
… being an independent and well-functioning client
The following data example is from a client interview conducted in the Finnish project offering
housing and social skills training for young adults with diagnosed schizophrenia. The client is in his
thirties and has a severe mental health problem, which make coping in everyday life demanding.
The interview is held in the project’s office. The excerpt is from the end of the interview where the
client’s wishes for the future are being discussed.
Extract 2
1. INTERVIEWER: Well. You can choose yourself. Thinking about something so extensive as
the future. What would you?
2. CLIENT: Hope for?
14
3. INTERVIEWER: Hope for?
4. CLIENT: Well. Functional capacity, to be able to do those things that I used to do, which I
was interested in. Difficult.
5. INTERVIEWER: Functional capacity is a fairly broad too and it comprises so many issues.
6. CLIENT: Yeah, and I also want this, what would I call it? It's a bit difficult to describe.
Functional capacity and what else. This kind of, like having a tolerable life somehow. So I
wouldn't have to suffer so damn much. That kind of thing.
7. INTERVIEWER: Well. That's something already.
8. CLIENT: Well. Anyway, functional capacity and coping in life. I could get started with that.
And managing symptoms. I mean, they're mostly the same things as here ((project’s name)).
9. INTERVIEWER: Indeed. Yeah, you do have plenty to hope for there.
10. CLIENT: To be able to finally become independent despite everything. Not be so dependent
on so many things just because you're so broken.
11. INTERVIEWER: Do you think that becoming independent would be about having less
contact with these treatment places, or?
12. CLIENT: I mean just in general, to have enough money, the apartment would be in decent
shape, financial issues would be handled on time and accurately without any changes to
payment terms or due dates and things like that. It also requires that I should get this chaos
out of my head somehow.
The extract begins with the interviewer's inquiry concerning the client’s future expectations (turn
1). The client first clarifies that the question is really about his wishes (turn 2). Then he responds by
using professional self-management language: functional capacity and coping in life. I could get
started with that. And managing symptoms. I mean, they're mostly the same things as here
((project’s name)) (turn 8). In this turn the client explicitly makes a reference to the project that is
underway that can be regarded as a specific self-management programme. The client hopes for the
same things that have been discussed in the project. He uses causal accounting when arguing that
the limited ability to function is restricting him from doing things that he has previously done and
that would interest him (turn 4). Poor ability to function is thus constructed as a cause and a
justification of a passive self.
The client continues by constructing himself as trying to be eventually more independent and less
dependent despite everything (turn 10). The client justifies his current dependency by defining
himself as incomplete you're so broken”. An “incomplete” self cannot be independent and thus is
constructed as the cause of the client being dependent. The client expresses dependency negatively:
he values independency and wants to abandon dependency although he has restrictions.
Independence is culturally a highly appreciated attribute of the responsible self, and it is also for the
client, too. The interviewer presents a clarifying question concerning what independency actually
means for the client, and suggests that it might mean having less intense relations with the treatment
institutions (in this way aligning with the idea of independence being a valued attribute, turn 11).
15
However, the client talks into being a more overall self-management based understanding of
independency. He stresses the following issues: “to have enough money, the apartment would be in
decent shape, financial issues would be handled on time and accurately without any changes to
payment terms or due dates and things like that”. These resonate with the expectations related to the
responsible self (turn 12). The client thus recognises improved self-management as his future
recovery aim, yet also constructs a major obstacle in achieving it: “It also requires that I should get
this chaos out of my head somehow”. The client utilises the passive tense. Hence, from the
utterance, it is possible to read what the client is displaying as his aim and what the difficulty is in
reaching it, but it is not possible to read how and who would be able to undo the difficulty; the
chaos. The utterance is constructed as a causal account: the mental chaos is seen as causing the
dependency, and consequently to achieve independency, the chaos first needs to be solved. The
client talk is unclear about allocating personal and social responsibility: someone needs to act on the
chaos, but it is unclear who and by what means.
In sum, the “wish talk” reflects and uses personal responsibility and self-management vocabularies
to set recovery aims and visions for the future. The client would want in the future to be self-
sufficient and a more active agent, and thus he allies himself with the responsible self at the ideal
level. The self-management approach provides a “yardstick” for the client for preferred agency and
a vision of a better, more independent future. However, in this example, it does not give means to
construct an empowered self that would know how to overcome the barriers in the way of a
preferred agency, or who could be helpful in the struggles against dependency. Accordingly, the
(mental) chaos is constructed as a force and agent on its own, not managed by the client’s
endeavours, and it is thus not a question of personal or social responsibility.
Resisting self: Accounting for limited responsibility
Limited responsibility due to …
Next we examine how the clients resist the expectations of personal responsibility and self-
management. When the clients formulate resisting accounts, they display their limited abilities and
strengths as causes and explanations of why they cannot (try to) live independently without support.
The examples illustrate the resistance towards the expectation of personal and social responsibility,
the responsible self.
16
... severe conditions and limited strengths
This example demonstrates a resisting self in a situation where the client’s energy and ability to
function are limited. The client is from the Finnish floating support service for people with mental
health problems. The client is in his twenties. He suffers from severe mental health problems and
ADHD. The interview is conducted in the client’s apartment. The extract is from an interview
section where client-centreness is discussed.
Extract 3
1. INTERVIEWER: If you think about, do you have some wishes that you would like to
present to the physician, for example, or, what should they take into consideration in your
treatment or. How should they change their actions?
2. CLIENT: I haven't come up with anything new. Sometimes I feel like there has been too
much happening here. I should be doing things all the time, like sorting out and taking care
of things and vocational rehabilitation activities and everything. I don't seem to have enough
strength for it.
3. INTERVIEWER: What is your role in rehabilitation? What should you do in order to
maintain your condition?
4. CLIENT: Well, to live as regularly as possible, regularly, and have a healthy life style. I
haven't come up with ((anything else)). I'm just trying to make things work in every way I
can, to avoid having excessive stress which would make my condition worse.
The extract begins with the interviewer's question concerning the client's wishes for treatment. The
question is also formulated to find out the client’s view on the welfare workers’ roles, possibilities
and responsibilities to aid him in managing his condition: is there anything that welfare workers
should change in their conduct to be more supportive for the client (turn 1). The client does not
come up with any straightforward requests for the welfare workers despite sometimes I feel like
there has been too much happening here.The client’s response can be interpreted to mean that the
welfare workers are considered partly responsible for arranging too many things for the client to do.
However, the client does not explicitly blame them but his limited resources: “I don't seem to have
enough strength for it.” (turn 2). The client interprets his limited strength as a main problem and the
one to be blamed. He constructs a cause-and-effect relationship between the feeling of “too much”
and a lack of energy. If he had more strength, things would be easier to conduct. Hence, the lack of
energy works as an explanation and justification for the client’s difficulties to fulfil the tasks related
to a responsible self operating in society and “doing recovery”. The client explains that he is
17
struggling to perform the expected tasks at the margins of welfare services, and thus there is the risk
that the responsible self is too great a demand in his current situation (turn 2).
The interviewer's second question explicitly addresses personal responsibility and self-management
in recovery. It also puts forward a presumption that managing mental health requires one to actively
do things (turn 3). This may trigger the clients to respond by using vocabularies of self-management
and by constructing recovery as a matter of a particular way of living. He contends that he ought “to
live as regularly as possible, regularly, and have a healthy life style.” In addition, the client
explains that he has discovered the importance of avoiding too much stress. In the causal account
the stress is perceived as a cause of the possible worsening of the condition. In other words,
sustaining good condition would require circumstances favourable for a life without stress.
In this example, personal responsibility and self-management have been displayed as demanding
activities that would require strong agency and strengths from the client. The client outlines a
balance between trying to fulfil the tasks (of the welfare services) and the risk of becoming too
stressed. Personal responsibility and self-management does not appear as empowering “I talk” or
hopeful “wish talk” but as “pressing talk” of things being understood as “too much” and possibly
worsening the client’s condition. Instead of reaching for more self-management techniques, things
to do to manage everyday life, the client tries to avoid increasing activities in life. In this sense, the
client talk formulates a critical stance towards the ever growing demands of personal responsibility
and self-management, and it emphasises that they can in some situations work against the liberating
aim of becoming an empowered and healthy individual.
... illegitimate/ unrealistic expectations
The fourth example is from the supported housing service for people with mental health problems.
The client is in his thirties and has severe mental health problems. The interview was held in the
client’s apartment. The data excerpt is from an interview section concerning the client’s arrival at
the supported housing services.
Extract 4
1. INTERVIEWER: So, if we just talk a bit about your present life here in ((supported housing
services for people with mental health problems)). So, what do you do with the staff, do you
have conversations?
2. CLIENT: Now that I’m moving out not so much.
18
3. INTERVIEWER: Oh that’s right.
4. CLIENT: When I first moved in, yeah.
5. INTERVIEWER: You had then.
6. CLIENT: Yeah. When I moved in yeah, and it’s only because I was getting better, better I
should say, that it lessened off a little bit I should say. Check up on me. See if my room was
tidy and that. My room’s never tidy. My kitchen is. I’ll wash the pots right, and I’ll do that,
and I actually quite enjoy doing that right. But my front room is just, it’s like a bomb’s gone
off and I don’t know why.
7. INTERVIEWER: So, they come and say to you could you please?
8. CLIENT: Yeah. And I don’t do anything. Eventually I’ll look at it and think I need to go in
the bed now.
9. INTERVIEWER: So, how about discussions then?
10. CLIENT: Telling a depressed person to do something is really a bad idea.
The extract begins with the interviewer’s question that implies the presumption that using the
service comprises encounters and discussions with the workers (turn 1). The client’s response
constructs the intensity of the client-worker interaction to be bound to the client’s well-being and
progress in recovery: “it’s only because I was getting better, better I should say, that it lessened off
a little bit (turn 6).The phrase is a causal account in the sense that “getting better” is seen as a
cause for a lessening of the support relationship. It also constructs what the welfare workers do (are
responsible for) as part of the support relationship: “Check up on me. See if my room was tidy” (turn
6).These activities can be interpreted as worker-led management techniques that have elements of
control, ensuring and taking responsibility for the client’s coping. The next question-answer
sequence (turns 7 and 8) reveals the assumption that the client is directed to eventually internalise
the importance of having a tidy room and work for it by himself. The client expresses how he is not
acting accordingly with this expectation of self-managing and personally responsible client: My
room’s never tidy.” (turn 6), “I don’t do anything. Eventually I’ll look at it and think I need to go in
the bed now(turn 8).The account is a factual statement: it does not indicate that untidiness is a
problem for the client or that he would try to change his behaviour in the future. It can be
interpreted as resistance towards higher cleanness standards, more active agency and self-
management requirements.
The interviewer goes back to the assumption that a support relationship should include
conversations (turn 9). The client responds in an ambiguous way by saying that “Telling a
depressed person to do something is really a bad idea”, which implies that telling someone what to
do is not an appropriate technique to approach a person that lacks energy and is depressed (turn 10).
The account can thus be read as resistance towards such a support relationship that is based on
“telling” or advice giving. The turn creates a potential causal account: because the client is “a
19
depressed person”, the room is never tidy. Being a depressed person is then put forward as an
explanation and justification for the client’s passive behaviour. The causal account is constructed in
a way that the situation appears as self-evident, fixed and unchangeable. The account proposes a
“fatalistic talk” that there is no means to change a depressed person, and consequently no one is to
blame for or seen as being accountable for the passive self. It is just a common fact.
… discriminating society
The last example examines social responsibility and society as a context where socially excluded
individuals try to manage their lives. The interview interaction does not follow the ordinary pattern
of question-answer sequences as the client both asks the questions and answers them. He uses the
question sheet that the interviewer gives to him. In this way, it is easier for the client to stay focused
and handle the interview situation. The client was in his thirties and had many special needs related
to drug abuse, homelessness, severe mental health conditions and ADHD. The interview was
conducted in a Finnish outpatient clinic for people with severe drug abuse problems.
Extract 5
1. CLIENT: Yeah. Yes. Who is responsible for your well-being and recovery? I am, and
probably the party treating me. At least on some level. They’re responsible for what the
treatment is. They’re responsible for that at least. I can’t really say. How do you see the
responsibility or impact of the society regarding your coping or the fact that things haven’t
always been easy? The society sucks, it tries to put all people into the same category. But
when this one person, I’m a Lego piece and I don’t belong to that big Lego series. So, I’m
flawed and I’m thrown away into the trash can. I’m just a mere nuisance from an elitist point
of view.
2. INTERVIEWER: That was a really great analysis. One of the greatest I’ve ever heard.
The extract begins with the question that the client reads from the question sheet Who is
responsible for your well-being and recovery? (turn 1), which triggers the client to distribute
responsibility between himself and those involved in his care. The client recognises himself
personally responsible “Ì am” and welfare workers as partly responsible for the content of the
treatment: what the treatment isis defined as the scope of the welfare workers’ responsibility.
The utterance reflects the thought that it is the welfare workers that decide the quantity and quality
of treatment services. The client goes on to the next interview question that addresses society’s
impact on the client’s recovery (turn 1). The question gets the client to describe critically how in
society it is attempted to put everyone into the same category and thus not allowing unfitting “Lego
pieces” that do not belong to the “big Lego series”. This metaphor can be understood to mean that
20
individuals are grouped into those who are fit for society and those who are not; the outcasts. In
addition, it refers to stigmatising, blaming and discriminating societal powers which are beyond the
client’s control but which do have an influence on his wellbeing. The client displays how he does
not have influence or personal responsibility in society; he is just thrown away by others. The
metaphor portrays the client as being “faulty” and “waste” that society does not care for: I’m
flawed and I’m thrown away into the trash can. I’m just a mere nuisance from an elitist point of
view” (turn 1).
In sum, the data example demonstrates a “drifting talk”. It is a description of circumstances that
oppress and exploit the self and make self-managing thus difficult. The self is oppressed by powers
out of its control and given a degrading position in society. The self is faced with external forces
that it is not capable of (or responsible for) taming or turning for the better. The client constructs
himself without an entitlement to agency and thus is at the mercy of others’ (discriminating) action.
In turn, welfare workers are seen as being only responsible for treatment services. In the example,
no-one is seen as capable of making a totally inclusive “Lego series” or of taking wider social
responsibility: the socially excluded individual’s personal responsibility is narrowed to “drifting”
and to being an object of the actions of others.
Conclusion and discussions
Today much is talked about self-responsibility. Individuals are expected to actively manage their
own health and make responsible lifestyle decisions (Roberts 2006; Broom et al. 2014). They are
supposed to work on themselves and seek expertise knowledge in order to learn skills and self-
management techniques for better well-being and health (Scott and Wilson 2011; MacGregor and
Wathen 2014; Chapter 2). In this chapter, we have scrutinised how the clients talk about personal
and social responsibility in the process of recovery at the time of rising expectation of self-
management and the responsible self (self-responsibilisation). We have illustrated how “theories of
causes” are influential and essential in how people construct and distribute responsibility, blame and
agency – and thus important matters to examine. Cause construction points to the ones responsible
for (exceptional) occasions and life situations (e.g. Pearl and Lebowitz 2014).
We have demonstrated how the clients at the margins of welfare services on the one hand (try to)
live up to the ideal of the responsible self and on the other hand resist this cultural expectation as
impossible or unreasonable. They (and interviewers) reflect responsibilities by utilising client
21
responsibility and the self-management vocabularies. Then they use professional concepts that
resonate with the management of health, well-being and life. Self-management vocabularies allow
empowering “I talk” and future-oriented, hopeful “wish talk”. Clients construct their agency
frequently in a way that reflects the ideal individual presented in the era of advanced liberal
governance. In other words, they express that they try to be self-sufficient, independent and active
in life despite barriers, and it is the “I” that needs to be, and can be, the one that makes the required
life changes (see also Chapter 6).
Self-management vocabularies point to the deficiencies of individuals that are to be worked on.
Thus, it can be interpreted that they trigger “pressing talk” in which recovery activities become
constructed as “too much” and a burden according to the client’s present strengths and abilities. The
self becomes constructed as “insufficient” and “faulty”. The way of talk can be seen as the client’s
linguistic device to resist personal responsibility by stating that limited resources are causing
passive agency and a need for the support of others. The self-responsibility is a too demanding
expectation in a powerless situation and if “you're so broken”.
However, the clients also detach themselves from the self-management approach and personal
responsibility by producing resisting “fatalistic talk” that displays their situation as such that there is
no means (and no sense) to try to change things for the better or to ease their troubles. Similarly,
“drifting talk” positions the client as powerless and oppressed and thus without the ability to be a
personally responsible actor. We conclude that for the clients at the margins of welfare services
managing responsibilities “in action” is a demanding, context-bound and multi-dimensional
accomplishment. They are struggling to both be the responsible self with limited resources and to
detach themselves from this expectation.
Although self-management techniques support clients to manage their everyday lives and offer
objectives for more active agency in health and illness, they do not necessarily eliminate the clients’
need for support. Personal responsibility is talked into being and reflected in relation to social
responsibility. In other words, the clients bring forward that in order to take responsibility from
themselves they need to have sufficient resources and others such as welfare workers to support and
value them. This underscores the relevance to examine further the causal relation constructed
between supportive relationships and self-management as has been already done by previous
research (Dashiff 2003; Cramm et al. 2015).
22
Many scholars have claimed that personal and social responsibility are intertwined, related and
relational concepts (McNamee and Gergen 1999; Brownell et al. 2010; Naumova 2014; Trnka and
Trundle 2014). Personal responsibility requires social responsibility: social recourses, social
support, genuine options in life and reciprocal relations in the community (Brownell et al. 2010).
Trnka and Trundle (2014:137) approach the distinction between personal and social responsibility
by arguing that responsibilisation contains multiple meanings and needs to be approached not only
within an individual neoliberal discourse, but “through the lenses of care relations and social
contract ideologies”. Similarly, Passini (2011: 284) argues that “the claiming of rights and a sense
of duty should always involve the recognition of a responsibility – to oneself as well as to others”.
Our individual agency is dependent on the actions of others and on our status in the community.
There are times that we are able to care for ourselves and others, whilst at other times we might be
powerless, helpless and without means to live a meaningful life due to long-term illnesses and
adversities.
The clients’ talk about recovery and self-responsibility reflects the cultural and moral understanding
of what a valued citizen and lifestyle means (Broom et al. 2014; Keddie 2016). We agree with
Broom et al. (2014: 527), that a cultural norm of duty is to be taken as the core morality implicated
in the drive for good health, and that it is also present in advanced liberal governing of the self (see
also Brownell et al. 2010). Without denying that self-management may promote empowered selves,
it can also turn out to be “cruel optimism” for those who do not have the resources or possibilities to
achieve positive recovery outcomes by setting them in the position of the ones that fail. MacGregor
and Wathen (2014) stress the risk that social determinants are ignored at the political level and
“those who cannot manage their own health may fall further behind”.
At the time of rising expectations of self-management clients both try to fulfil the criteria of the
responsible self and detach themselves from it. They identify the risk of failures in recovery and the
assumed gaps in their life between expectations and actions. Hence, it is critical to not only work on
individual conduct but also on the cause-and-effect relation in play and “relational re-
responsibilisation”. The relevant questions are: how is valued and “sufficiently” responsible agency
culturally constructed? Whose responsibility it is to promote and support this agency? The
responsible self is a reciprocal, social, relational and negotiable construction and is thus a collective
accomplishment.
23
References:
Antaki, C. (1994) Explaining and Arguing: The social organization of accounts, London: Sage.
Ballet, J., Dubois, J-L. and Mahieu, F.-R. (2007) ‘Responsibility for each other's freedom: agency
as the source of collective capability’, Journal of Human Development, 8(2): 185–201.
Beckmann, N. (2013) ‘Responding to medical crises: AIDS treatment, responsibilisation and the
logic of choice’, Anthropology & Medicine, 20(2): 160–174.
Broom, A., Meurk, C., Adams, J. and Sibbritt, D. (2014) ‘My health, my responsibility?
Complementary medicine and self (health) care’, Journal of Sociology, 50(4): 515–530.
Brownell, K.D, Kersh, R., Ludwig, D.S, Post, R.C., Puhl, R.M., Schwartz, M.B. and Willett, W.C.
(2010) ‘Personal responsibility and obesity: a constructive approach to a controversial issue’,
Health Affairs, 29(3): 379–87.
Bull, R. and Shaw, I. (1992) ‘Constructing causal accounts in social work’, Sociology, 26(4): 635–
649.
Buttny, R. (1993) Social Accountability in Communication, London: Sage.
Cappelen, A.W. and Norheim O.F. (2005) ‘Responsibility in health care: a liberal egalitarian
approach’, Journal of Medical Ethics, 31(8): 476–480.
Cayton, H. (2006) ‘The flat-pack patient? Creating health together’, Patient Education and
Counseling, 62(3): 288–290.
Civaner, M. and Arda, B. (2008) ‘Do patients have responsibilities in a free market system? A
personal perspective’, Nursing Ethics, 15(2): 263–273.
Clarke, J. (2005) ‘New labour citizens: activated, empowered, responsibilized, abandoned?’,
Critical Social Policy, 25(4): 447–463.
Cramm, J., Murray, N. and Anna, P. (2015) ‘Chronically ill patients' self-management abilities to
maintain overall well-being: what is needed to take the next step in the primary care setting?’, BMC
Family Practice, 16(1):1–8.
Cruikshank, B. (1996) ‘Revolutions within: self-government and self-esteem’, in A. Barry, T.
Osborne and N. Rose (eds) Foucault and Political Reason: Liberalism, neo-liberalism and
rationalities of government (pp. 231–252), Chicago: University of Chicago Press.
Dashiff, C.J. (2003) ‘Self- and dependent-care responsibility of adolescents with IDDM and their
parents’, Journal of Family Nursing, 9(2): 166–183.
Davidson, L. (2005) ‘Recovery, self management and the expert patient: changing the culture of
mental health from a UK perspective’, Journal of Mental Health, 14(1): 25–35.
Doheny, S. (2007) ‘Responsibility and the deliberative citizen: theorizing the acceptance of
individual and citizenship responsibilities’, Citizenship Studies, 11(4): 405–420.
Dean, M. (2002) ‘Liberal government and authoritarianism’, Economy and Society, 31(1): 37–61.
24
Dickens, G., Weleminsky, J., Onifade, Y. and Sugarman, P. (2012) ‘Recovery Star: validating user
recovery’, The Psychiatrist, 36: 45–50, doi: 10.1192/pb.bp.111.034264
Doughty, C., Tse, S., Duncan, N. and McIntyre, l. (2008) ‘The Wellness Recovery Action Plan
(WRAP): workshop evaluation’, Australasian Psychiatry, 16(6): 450–456.
Edwards, D. and Potter, J. (1993) ‘Language and causation: a discursive action model of description
and attribution’, Psychological Review, 100 (1): 23–41.
Flynn, D. (2005) ‘What's wrong with rights? Rethinking human rights and responsibilities’,
Australian Social Work, 58(3): 244–256.
Garfinkel, H. (1967) Studies in Ethnomethodology, Cambridge: Polity Press.
Giddens, A. (1999) ‘Risk and responsibility’, The Modern Law Review, 62(1): 1–10.
Hazleden, B (2014) ‘Whose fault is it? Exoneration and allocation of personal responsibility in
relationship manual’, Journal of Sociology, 50(4): 422–436.
Holen, M. and Ahrenkiel, A. (2011) ‘‘After all, you should rather want to be at home’:
responsibility as a means to patient involvement in the Danish health system’, Journal of Social
Work Practice: Psychotherapeutic approaches in health, welfare and the community, 25(3): 297–
310.
Ilcan, S. (2009) ‘Privatizing responsibility: public sector reform under neoliberal government’,
Canadian Review of Sociology, 46(3): 207–234.
Jallinoja, P., Absetz, P., Kuronen, R., Nissinen, A., Talja, M., Uutela, A. and Patja, K. (2007) ‘The
dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians
and nurses’, Scandinavian Journal of Primary Health Care, 25(4): 244–249.
Johnston, S., Liddy, C., Ives, S.M. and Soto, E. (2008) Literature Review on Chronic Disease Self-
Management, retrieved December 10 2015 from
https://www.livinghealthychamplain.ca/documents/pages/ReviewChronicDisease.pdf.
Juhila, K., Hall, C. and Raitakari, S. (2010) ‘Accounting for the clients' troublesome behaviour in a
supported housing unit: blames, excuses and responsibility in professionals' talk’, Journal of Social
Work, 10(1): 59–79.
Keddie, A. (2015) ‘New modalities of state power: neoliberal responsibilisation and the work of
academy chains’, International Journal of Inclusive Education, 19(11): 1190–1205.
Kelty, C.M. (2008) Responsibility: McKeon and Ricoeur. Anthropology of the contemporary
research collaboratory, Working Paper #12, retrieved December 10 2015 from
http://kelty.org/or/papers/Kelty-Mckeon-Ricoeur-WP12.pdf.
Lister, M. (2015) ‘Citizens, doing it for themselves? The Big Society and government through
community’, Parliamentary Affairs, 68(2): 352–370.
Lorig, K. and Holman, H.R. (2003) ‘Self management education: history, definition, outcomes, and
mechanisms’, Annals of Behavioral Medicine, 26(1): 1–7.
25
Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalex, V. and Minor, M. (1994) Living a Healthy
Life with Chronic Conditions, Palo Alto: Bull Publishing Company.
Lundell, H., Niederdeppe, J. and Clarke, C. (2013) ’Public views about health causation,
attributions of responsibility, and inequality’, Journal of Health Communication, 18(9): 1116–1130.
Lyon-Callo, V. (2000) ‘Medicalizing homelessness: the production of self-blame and self-
governing within homeless shelters’, Medical Anthropology Quarterly, 14(3): 328–345.
MacGregor, J.C.D. and Wathen, C.N. (2014) ‘’My health is not a job’: a qualitative exploration of
personal health management and imperatives of the ‘‘new public health’’, BMC Public Health,
14(1): 726–735.
Matarese, M. and Caswell, D. (2014) ‘Accountability’, in C. Hall, K. Juhila, M. Matarese and C.
Van Nijnatten (eds) Analysing Social Work Communication: Discourse in practice (pp. 44–60),
London: Routledge.
May, J., Carey, T.A. and Curry, R. (2013) ‘Social determinants of health: whose responsibility?’,
Australian Journal of Rural Health, 21(3): 139–140.
McNamee, S. and Gergen, K.J. (1999) Relational Responsibility: Resources for sustainable
dialogue, London: Sage.
Michailakis, D. and Schirmer, W. (2010) ‘Agents of their health? How the Swedish welfare state
introduces expectations of individual responsibility’, Sociology of Health and Illness, 32(6): 930–
947.
Miller, P. and Rose, N. (2008) Governing the Present: Administering economic, social and
personal life, Cambridge: Polity Press.
Naumova, E.N. (2014) ‘A cautionary note for population health: disproportionate emphasis on
personal responsibility for health and wellbeing’, Journal of Public Health Policy, 35(3): 397–400.
Onifade, Y. (2011) ‘The mental health recovery star’, Mental Health and Social Inclusion, 15(2):
78–87.
Passini, S. (2011) ‘Individual responsibilities and moral inclusion in an age of rights’, Culture &
Psychology, 17(3): 281–296.
Pearl, R.L. and Lebowitz, M.S. (2014) ‘Beyond personal responsibility: effects of causal
attributions for overweight and obesity on weight-related beliefs, stigma, and policy support’,
Psychology & Health, 29(10): 1176–1191.
Pulvirenti, M., McMillan, J. and Lawn, S. (2014) ‘Empowerment, patient centered care and self-
management’, Health Expectations, 17(3): 303–310.
Raitakari, S., Günther, K., Juhila, K. and Saario, S. (2013) ‘Causal accounts as a consequential
device in categorizing mental health and substance abuse problems’, Communication & Medicine,
10(3): 237–248.
26
Robert, S.A., Booske, B.C., Rigby, E., and Rohan, A.M. (2008) ‘Public views on determinants of
health, interventions to improve health, and priorities for government’, Wisconsin Medical Journal,
107(3): 124–130.
Roberts, C. (2006) ‘“What can I do to help myself?”Somatic individuality and contemporary
hormonal bodies’, Science Studies, 19(2): 54–76.
Rose, N. (1990) Governing the Soul: The shaping of the private self, London: Routledge.
Rose, N. (1996) ‘The death of the social? Re-figuring the territory of government’, Economy and
society, 25(3): 327–356.
Scott, M. and Lyman, S. (1968) ‘Accounts’, American Sociological Review, 33(1): 46–62.
Scott, A. and Wilson, L. (2011) ‘Valued identities and deficit identities: Wellness Recovery Action
Planning and self- management in mental health’, Nursing Inquiry, 18(1): 40–49.
Share, M. and Strain, M. (2008) ‘Making schools and young people responsible: a critical analysis
of Ireland's obesity strategy’, Health & Social Care in the Community, 16(3): 234–243.
Snelling, P.C. (2012) ‘Saying something interesting about responsibility for health’, Nursing
Philosophy, 13(3): 161–178.
Social Exclusion Unit (2004) Tackling Social Exclusion: Taking stock and looking to the future,
emerging findings, London: Office of the Deputy Prime Minister.
Solberg, J. (2011) ‘Accepted and resisted: the client’s responsibility for making proposals in
activation encounters’, Text & Talk, 31(6): 733–752.
Stasiulis, D. and Bakan, A. (2003) Negotiating Citizenship: Migrant women in Canada and the
global system, New York: Palgrave MacMillan.
Sterling, E.W., von Esenwein, S.A., Tucker, S., Fricks, L. and Druss, B.G. (2010) ‘Integrating
wellness, recovery, and self-management for mental health consumers’, Community Mental Health
Journal, 46(2): 130–138.
Tickle, A., Cheung, N. and Walker, C. (2013) ‘Professionals’ perceptions of the Mental Health
Recovery Star’, Mental Health Review Journal, 18(4): 194–203.
Trnka, S. and Trundle, C. (2014) ‘Competing responsibilities: moving beyond neoliberal
responsibilisation’, Anthropological Forum: A Journal of Social Anthropology and Comparative
Sociology, 24(2): 136–153.
van Houtum, L., Rijken, M. and Groenewegen, P. (2015) ‘Do everyday problems of people with
chronic illness interfere with their disease management?’, BMC Public Health, 15(1): 1–9.
Wikler, D. (2002) ‘Personal and social responsibility for health’, Ethics & International Affairs,
16(2): 47–56.
Wiley, L.F., Berman, M.L. and Blanke, D. (2013) ‘Who's your nanny?: Choice, paternalism and
public health in the age of personal responsibility’,Journal of Law, Medicine & Ethics, Supplement
41: 88–91.
... Saerlig interaksjon i jobbsentre, arbeidsformidling og jobbtrening har vaert studert, i både dansk (Olesen, 2001;Asmuß, 2007;Eskelinen et al., 2010;Caswell et al., 2013;Danneris & Dall, 2017), svensk (Mäkitalo & Säljö, 2002;Mäkitalo, 2003) og norsk kontekst (Svennevig, 2001). I finsk kontekst er interaksjon mellom sosialarbeidere og brukere med rusproblemer/psykisk uhelse studert (Juhila, 2003;Juhila et al., 2010;Raitakari & Günther, 2017). Også møter relatert til økonomiske ytelser er studert i en svensk kontekst (Flinkfelt, 2017;Linell & Fredin, 1995). ...
Article
Full-text available
Background Being chronically ill is a continuous process of balancing the demands of the illness and the demands of everyday life. Understanding how everyday life affects self-management might help to provide better professional support. However, little attention has been paid to the influence of everyday life on self-management. The purpose of this study is to examine to what extent problems in everyday life interfere with the self-management behaviour of people with chronic illness, i.e. their ability to manage their illness. Methods To estimate the effects of having everyday problems on self-management, cross-sectional linear regression analyses with propensity score matching were conducted. Data was used from 1731 patients with chronic disease(s) who participated in a nationwide Dutch panel-study. Results One third of people with chronic illness encounter basic (e.g. financial, housing, employment) or social (e.g. partner, children, sexual or leisure) problems in their daily life. Younger people, people with poor health and people with physical limitations are more likely to have everyday problems. Experiencing basic problems is related to less active coping behaviour, while experiencing social problems is related to lower levels of symptom management and less active coping behaviour. Discussion The extent of everyday problems interfering with self-management of people with chronic illness depends on the type of everyday problems encountered, as well as on the type of self-management activities at stake. Conclusions Healthcare providers should pay attention to the life context of people with chronic illness during consultations, as patients’ ability to manage their illness is related to it.
Article
Full-text available
Background: Although widespread problems in patient-professional interaction and insufficient support of patients' self-management abilities have been recognized, research investigating the relationships among care quality, productive interaction, and self-management abilities to maintain overall well-being is lacking. Furthermore, studies have revealed differences in these characteristics among certain groups (e.g., less-educated and older patients). This longitudinal study thus aimed to identify relationships among background characteristics, quality of care, productivity of patient-professional interaction, and self-management abilities to maintain overall well-being in chronically ill patients participating in 18 Dutch disease management programs. Methods: This longitudinal study included patients participating in 18 Dutch disease management programs. Surveys were administered in 2011 (T1; n = 2191 (out of 4693), 47 % response rate) and 2012 (T2: n = 1722 (out of 4350), 40 % response rate). A total of 1279 patients completed questionnaires at both timepoints (T1 and T2) (27 % response rate). Self-management abilities to maintain well-being were measured using the short (18-item) version of the Self-Management Ability Scale (SMAS-S), patients' perceptions of the productivity of interactions with health care professionals were assessed with the relational coordination instrument and the short (11-item) version of the Patient Assessment of Chronic Illness Care (PACIC-S) was used to assess patients' perceptions of the quality of chronic care delivery. Results: Perceived and objective quality of care and the productivity of patient-professional interaction were found to be related to patients' self-management abilities to maintain overall well-being. These abilities were related negatively to and significantly predicted by low educational level, single status, and older age, despite the mediating role of productive interaction in their relationship with patients' perceptions of care quality. Conclusions: These findings suggest that patient-professional interaction is not yet sufficiently productive to successfully protect against the deterioration of self-management abilities in some groups of chronically ill patients, although such interaction and high-quality care are important factors in such protection. Improvement of the quality of chronic care delivery should thus always be accompanied by investment in high-quality communication and patient-professional relationships.
Article
Full-text available
This paper draws on interview data gathered as part of a broader study around issues of equity and schooling. It features the voices of the Executive Director and four Head Teachers from one of England's top performing academy chains, ‘CONNECT’. The notion of neoliberal responsibilisation is drawn on to examine, first, the ways in which Head Teachers describe their work and, second, the chain's expectations of them as CONNECT leaders. Responsibilisation of the self was apparent in Head Teachers' construction of themselves as ideal neoliberal workers - performing and enterprising subjects who readily accept the business principles and results-orientation of their ‘data-driven’ environment. Responsibilising of Head Teachers by the organisation was evident in the rigorous ‘non-negotiable’ standards and accountabilities at CONNECT that they were expected to comply with. These non-negotiables cultivated and rewarded Head Teachers’ entrepreneurial identity of achievement motivation. The paper illustrates how such neoliberal responsibilisation is both a crucial and highly troubling element in the work of academy chains as new modalities of state power.
Article
Full-text available
In line with Norwegian welfare policies, clients in vocational rehabilitation encounters are responsibilized to take an active part in the planning of measures that will qualify them for suitable work. In situ, among other things, this is actualized by the counselor's open what-question, eliciting the client to propose appropriate actions. The article analyzes two cases where a long-term education is proposed in the answer-slot, which, due to its contingent acceptability, is a very ambiguous interactional enterprise. The analysis demonstrates by means of ethnomethodological conversation analysis how clients might proceed when they deal with the eliciting question. In the first case the client complies with the allocated responsibility of reporting plans/ideas and formulates a proposal easily heard as an answer to the request. The second instance demonstrates a less aligned approach where the client by “proposal-implying tellings” takes steps to transform proposal making into a more open-ended activity. It is argued that the second approach, relying on the counselor's active co-participation, represents a more distributed responsibility, and to the client, a less troublesome way for introducing and discussing a contingent proposal.
Article
Today health consumers and citizens are repeatedly asked to actively manage their own bodies and those of their families in order to maximize health outcomes. This contemporary demand can be theorized as a form of somatic individualisation: a subjectification process establishing new and ever-closer relations between bodies and selves. Somatic individuality, according to Novas and Rose (2000), involves citizens and health consumers in ever-increasing levels of responsibility for bodily care and consequent practices of prudence and caution about physical futures. This paper critically examines the concept of somatic individuality, asking both how these forms of “responsibilisation” are intertwined with normative gendering processes, and if there is a disjuncture between rhetorics of responsibility and patients’ experiences in medical clinics. Two case studies of contemporary hormonal bodies are analysed: discourses describing the effects of endocrine disrupting chemicals; and discourses of menopausal women’s use of hormone replacement therapy.
Book
The literature on governmentality has had a major impact across the social sciences over the past decade, and much of this has drawn upon the pioneering work by Peter Miller and Nikolas Rose. This volume will bring together key papers from their work for the first time, including those that set out the basic frameworks, concepts and ethos of this approach to the analysis of political power and the state, and others that analyse specific domains of the conduct of conduct, from marketing to accountancy, and from the psychological management of organizations to the government of economic life. Bringing together empirical papers on the government of economic, social and personal life, the volume demonstrates clearly the importance of analysing these as conjoint phenomena rather than separate domains, and questions some cherished boundaries between disciplines and topic areas. Linking programmes and strategies for the administration of these different domains with the formation of subjectivities and the transformation of ethics, the papers cast a new light on some of the leading issues in contemporary social science modernity, democracy, reflexivity and individualisation. This volume will be indispensable for all those, from whatever discipline in the social sciences, who have an interest in the concepts and methods necessary for critical empirical analysis of power relations in our present.
Article
Since its launch, David Cameron's flagship Big Society agenda has attracted hostility and incomprehension in roughly equal measure. An important criticism of the Big Society is that it contains a rather confused view of motivations. In attempting to correct an overmighty state, the Big Society urges involvement in different ways: through market mechanisms (where profit is the prompt to action), increasingly, through ‘nudges’ and, finally, citizen exhortation (where civic duty is the motivation). These represent, I argue, dissonant views of the individual and what motivates them, with the former two representing ‘anti-political’ positions, as they discourage debate, contestation and authorship. Yet, placing it in a longer line of initiatives aimed at prompting greater levels of citizen engagement and responsibility, I argue that the Big Society represents the most recent iteration of a process that has a much longer heritage in British politics. Governments from the late 1970s onwards have sought to mobilise citizens to take on ever greater responsibilities. From this perspective, attempts to mobilise citizens, particularly through incentives and nudges, should be seen less as prompts to civic participation and more as diverse governance techniques to prompt self-government and responsibilisation.
Article
People are increasingly compelled to take responsibility for their health and illness trajectories. The existing literature on what may be termed self-care points to the ways that public health initiatives have instigated the transfer of governance onto the individual through campaigns promoting physical activity and diet among other things. Meanwhile, cultural trends may have been enhanced and/or transformed by the increased prominence of complementary and alternative medicine (CAM) which often include a focus on self-determination and self-responsibility for achieving health and wellbeing. This article examines women's contemporary self-care practices and the logics underpinning their approaches to health, illness and healing. Our findings show that although these women were often positive about the prospects of being autonomous decision-makers, their search for alternatives and practices of self (health) care can be problematic in certain cases and may be viewed as reproducing neoliberal forms of governance and their derivative inequalities.
Article
It is often argued that self-help books negate citizenship and the public sphere by promoting a hyper-responsibility in which individuals are rendered entirely responsible for their own life experiences, without reference to social relations. This article argues that discourses of responsibility in self-help literature are more complex and ambiguous, and that this is in part due to the widespread influence of codependency theory, and in part due to tensions within liberal-democratic political ideologies.