Sense-making and authorising in the organisation of mental health care

Abstract

This study narrates the organisation of mental health care via an ethnographic case study of a NHS Trust mental health directorate in England in the 1990s, during implementation of the Care Programme Approach (CPA). It seeks to understand how things are organised such that someone gets treated, by someone; in some way, and how far this mode of organisation commits people to courses of action and makes them accountable. Various stories are told - in different ways, using different theoretical frameworks, and pitched at different levels of analysis. The thesis deploys two 'ontological themes' to do this: sense-making and authorising. Sense-making refers to the processes of how people understand and act; authorising refers to the limits and stabilisation of sense-making, the fixing and legitimation of versions of the truth. The systems story of organisation narrates a gap between what was anticipated by government policy by introducing the CPA, and what happened, with regard to systems of care and forms of responsibility and accountability. 'The teamwork story narrates organising as accomplished through daily work practice. A ceremonial order in team meetings of primus inter pares results in different kinds of responsibility and accountability to that indicated in the CPA. The patienthood story narrates how people are transformed into objects of mental health work. Becoming a psychiatric patient is more diffuse than much labelling theory presumes. and is the product of specific forms of organisation. The thesis concludes by discussing the kind of organisation that allows for more or less authorised versions of what has been, and what should be, done. It suggests two ideal-typical forms of organisation, different kinds of 'structural context' within which organising may take place. The thesis produces two 'grand narratives' with regard to organisation: one, about the structure-process distinction; the other, about the evaluative nature of tales