‘GETTING TO YES’ IN MENTAL HEALTH SERVICE ONE DOOR ACCESS MEETINGS: A DISCURSIVE ANALYSIS OF DECISION-MAKING PRACTICES

This study uses Conversation Analysis and Discursive Psychology to examine discursive practices of decision-making, specifically interactional displays of persuasion, resistance and authority to show how interactants navigate to decision-points. The dataset comprises 28 audio recordings of a particular kind of Adult Mental Health Service meeting in a health board in NHS Scotland – the One Door Access meeting. In these meetings referrals (requests for mental health service input) are discussed and decisions are made as to which discipline(s) within the Community Mental Health Team will be providing intervention. Analysis highlighted the differentiation of unproblematic acceptances of work from those where displays of persuasion, resistance or authority shifts are evident. Unproblematic acceptances are characterised by speakers providing their agreement directly following the reading of the referral. By contrast, displays of persuasion, resistance and authority shift are deployed to move work towards a particular discipline (or away from one’s own). First, and in contrast with Social Cognitivist Psychology (SCP) theories of persuasion which centre on attitude change as an internal process dependent on characteristics of source, target, message and environment, the thesis shows how persuasion is live within interaction and is enhanced by the use of categorisation (to depict patients positively or invoke empathy) and by the use of affiliative practices to keep speakers on topic and aid progressivity. Second, it focuses on resistant practices in situ, illustrating granular details of resistant practices not fully explored within mainstream SCP. Analysis contrasts resistance between meeting participants and that shown towards referrals generated by individuals outwith the meeting. Third, and contrasting with SCP theory on authority as a fixed and stable attribute, this thesis finds that both deontic and epistemic authority shift on a turn-by-turn basis centering on ‘who knows more’ and upon relative identities and alliances made salient during interaction – the focus is on switches between the use of personal pronouns ‘I’ and ‘we’ and on the use of the modal constructs ‘could’ and ‘should’ along with the directive ‘let’s’. Aside from contributing to discursive literature on persuasion, resistance and authority this thesis enhances previous work on activity shifts, progressivity and uses of identity and categorisation. Issues apparent from previous CMHT studies are illuminated, including role boundaries/role blurring/role clarity, power asymmetries and workload disparity. Regarding NHS working, further research is indicated in terms of different leadership styles in similar NHS meetings. Analysis also highlights the potential for inequitable treatment of referrals dependent on their source.