Place, Need and Precarity in UK Mental Health Care: An Ethnography of Access

In this thesis, I investigate the co-production of “place” and “need” in voluntary sector mental health care, in order to re-think and breathe new life into the problem of access to services. The research draws on ethnographic fieldwork from 2016-2018 at three psychotherapy centres providing different specialised services in London. I describe how, in these places, the visibility of the “vulnerable migrant” client group, and notions of culturally specific need, reflects a global—but perhaps temporary— “turn” to migration. I attend to the everyday practices of care providers working to “fill gaps” in mainstream service provision, and tell fragments of client stories about moments of access at each site. Drawing on data generated from interviews, observations and a creative method, I describe practices around the sociomaterial thresholds and doors to each service: waiting, accessing, assessing, gate keeping, and including or excluding. Part One, on “Place,” makes visible a paradox, whereby the work to create and maintain inclusive places for people who may not “belong” elsewhere in the mental health system, (re)produces the precarity of both people and places, positioned “always almost on the outside.” Part Two, on “Need,” extends this inquiry into boundary work and precarity, showing how working against mainstream classifications of need created possibilities but came at a cost. To produce eligibility and access to care, providers made mental health need legible through laborious negotiation between funders, their internal values and interests, and wider matters of concern. The ordering of these two parts builds the argument, grounded in theories of relationality and milieu, that places are not merely inert “context” but are generative of certain forms of need. The chapters in this thesis move away from seeing care providers as “solutions” to “unmet need,” opening up new problem spaces around the practice of doing need differently

“Ready for What?”: Timing and Speculation in Alzheimer’s Disease Drug Development

“Readiness cohorts” are an innovation in clinical trial design to tackle the scarcity of time and people in drug studies. This has emerged in response to the challenges of recruiting the “right” research participants at the “right time” in the context of precision medicine. In this paper, we consider how the achievement of “readiness” aligns temporalities, biologies, and market processes of pharmaceutical innovation: how the promise of “willing bodies” in research emerges in relation to intertwined economic and biological time imperatives. Drawing on long-term engagement with the field of Alzheimer’s disease prevention and interviews with researchers from academia and the pharmaceutical industry, we describe the discursive construction and practical arrangement of readiness. This paper contributes to understandings of temporal specificity, or “timing,” within prevention research and casts critical light on the way this specificity—the threshold for “trial readiness”—relates to an opaque and highly speculative drug development pipeline. Extending the study of biomedical potential, as that which holds promise but may not yet exist, we consider how absences operate in adaptive trials. By highlighting these absences (“ready for what?”), we outline an opportunity for socio-ethical research to intervene in the speculative gaps of drug development.</jats:p