iii Discourse Analysis

DA is a methodology that subscribes to the social constructionist belief that language is not unambiguous and descriptive, but an active tool that

constructs versions of social reality and that the way people talk, tells us something about what they are using the tool of language for, such as

disclaiming, persuading, justifying and excusing, rather than using words as a representation of a cognitive structure, as in IPA (Willig, 2015). However, DA also fits with a critical realist position through which it is argued that the nature of people, institutions and power relations flow from an overarching

ideological context, rather than from individuals’ attitudes and motivations (Parker, 1992). DA is concerned in studying the meaning and meaning making where it occurs, in language. Not because this is considered to

provide a direct relation to universal truths, but because it is through language that meaning making and action taking are constructed or contested in the social world (Dunn & Neumann, 2016). Discourses provide a framework for understanding the world, within which they represent the constructed “regimes of truth” and “knowledge” and how these open and close opportunities for action (Willig, 2015; Dunn & Neumann, 2016). It is considered that

“discourses make intelligible some of the ways of being in and acting towards the world and operationalising a particular “regime of truth” while excluding other possible modes of identity and action” (Miliken, 1999; cited in Dunn & Neumann, 2016) and therefore acts to both enable and constrain.

Culture is a way of collectively “knowing” in a social world (Bruner, 1993). This shared knowledge constructs a set of everyday practices (Scriber & Cole, 1981). Key to culture is the construction of shared meaning which acts as a lens through which we see the world (Jahoda, 1992). Dominant discourses and narratives act to form this lens, and so to understand the social

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construction of a phenomenon it is important to investigate those dominant discourses that construct that shared meaning. The concept of culture

represents something that is deeply socially ingrained and difficult to change, and is akin to the regimes of truth and lived ideologies of DA11_{. It has further}

been cited as a factor in a number of inquiries investigating serious incidents in health care (Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013; DoH, 2012) and other industries in which lives depend on the actions of others in control, such as aviation (Haddon-Cave, 2009).

The aims of this research are concerned with the discourse, social context and available ways of constructing challenging behaviour and acting in response to this. It is of note that although FDA is concerned with language and the role that language plays in social and psychological life (Willig, 2008), its focus goes beyond the immediate interpersonal context of language. FDA’s concern sits with the “regimes of truth” and the relationship between available discourses, and how this facilitates and limits what can be said and known (Parker, 1992). It is argued that as we confront social structures, particularly where there is unintentional resistance to change, there is a need to reflect on why the existence of alternative discourses does not necessarily equate to alternative social practices (Parker, 1992). Such discourses have ideological effects, and reproduce and maintain power relations (Parker, 1992).

In the context of inpatient mental health services, discourses exist in a variety of texts, such as talk, training, resources, books, medical notes and care plans. Parker (1992) proposes that much of the time, people are not aware of the discourses that form the architecture of our society, as such “it is not possible to say we create a society, rather we must either reproduce or transform it” (Parker, 1992 p. 37). Deconstruction of lived ideologies through recognition and reflection on the existing discourses, from a critical realist perspective has the potential to lead to prospects of change (Parker, 1992).It was therefore considered that DA was the most appropriate method to

address the research question of what are nurses’ discourses of challenging behaviour in inpatient mental health services?.

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Broadly speaking, there are two main schools of DA; discursive psychology (DP) and Foucauldian discourse analysis (FDA). These two types of DA are explored below.

Discursive Psychology

DP is concerned with the performative qualities of discourse, in particular “what are participants doing with their talk?” (Willig, 2015). DP prioritises the fluidity and variability of language as the primary site for meaning making (Stokoe & Wiggins, 2005; Willig, 2015). It takes a social constructionist stance where questions about “reality” are put to one side to consider how they are talked into being (Willig, 2008). The DP approach is interested in

understanding the local interaction of talk and is not typically concerned with wider socio-cultural discourses (Willig, 2008; 2015).

Foucauldian Discourse Analysis

FDA was developed from the principles and writings of philosopher Michel Foucault. It is concerned with the way in which language constructs versions of reality that then become rationalised and legitimised (Parker, 1997). It is concerned with the broader socio-cultural discursive resources and power and is interested in the discourses people draw on to talk about a subject and the implications that these have (Willig, 2015). It assumes that although mediated socio-culturally through language, meanings to some degree are durable and standardised (Willig, 2008). These socio-cultural accounts are powerful and can enable or disable the available ways to construct versions of events and ways of acting (Willig, 2008). The term “subject position” refers to the location of people into certain positions through the way that they are talked about, or talk about themselves (Willig, 2008). The freedom to position oneself is reliant on access to power (Parker, 1992).

In FDA, power and language are considered inseparable (Willig, 2008; Dunn & Neumann, 2016). The availability of dominant discourses support and

validate some positions but marginalise others, producing understandings that over time become taken for granted and treated as “common sense” and “truth” (Alvesson & Karreman, 2000; Dunn & Neumann, 2016).

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Foucault (1969, trans. 2002) wrote about howthe things that must be questioned are those that appear most immediately and arepresented in a certain manner. He considered how as closer inspection of these “truths” occurs, the difficulties they pose become apparent. He reflected that every discourse rests not only on what has already been said, but also on the unsaid.

Therefore, Discourse Analysis, taking a mixed approach weighted towards FDA, was the most suitable methodology to explore the research question: What are the discourses drawn on by inpatient mental health nurses in talking about challenging behaviour and its management.

Combining DP and FDA

Whilst DP has criticised FDA for failing to take seriously certain aspects of language, such as the power negotiations during an ongoing interaction, FDA has argued that DP is reductionist (Alvesson & Karreman, 2000). It has been proposed that a combination of the two approaches is best practice for DA (Alvesson & Karreman, 2000). Therefore, this is the approach that has been taken for the analysis. Steps set out for both DP and FDA in Willig (2015) were combined and followed, in the analysis of the data, with a stronger focus on FDA12_.

Existing Research

DA has been used to explore other psychiatric interventions, such as electroconvulsive therapy (ECT) (Johnstone & Frith, 2005) and how

professionals talk about psychiatric diagnoses (Harper, 1994; 1995; O’Key, 2014). Johnstone and Frith (2005) conducted a discourse analysis of an influential paper presenting service-users’ experiences of ECT. They identified that where service-users refused to participate in the study or were critical of ECT, they were constructed as hostile, uncooperative, ignorant and

unreliable. In contrast, those who reported neutral or positive experiences were constructed as passive, compliant and unquestioning. The authors concluded that this DA deconstructs the paper’s conclusions that ECT is

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helpful and not frightening and might serve to purpose the original authors’ own interests.

Benson, et al. (2003) have previously found that staff and service-users both presented themselves as “good people” and the “victim” in talk about incidents of violence and aggression, but staff drew on discourses of blame and

personality whilst service-users drew on discourses of injustice in explaining the incidents. A number of studies have shown how dominant clinical

practices are enabled and maintained through language (Harper, 1995; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995). Holmes and Murray (2011) conducted a DA study of documents regarding behavioural modification programmes in a Canadian secure hospital and found that they were more reflective of what staff valued and needed rather than service- users.

Hamilton and Manias (2006) reviewed ethnographic and discourse analytic research of mental health nurses’ use of language in acute inpatient settings. They reviewed studies that analysed spoken language and documentation. Identifying that discourses of moral judgement, common sense, objectification and empathy were drawn on. The authors also identified that there was a dominance of biomedical language and discourses of the organisation and bureaucracy. However, this research did not focus on the discourses drawn on in talking about challenging behaviour or nursing interventions.