Constructing Care in the Community Together: A Discourse Analysis of Care Planning Meetings

Objectives: The Care Programme Approach (CPA) is the official framework for
care for adults with severe mental health problems in England. Research on
interactions in health settings have explored key concepts of patient-centred
care, shared decision-making and the biopsychosocial model. Discourse analysis
has been used to examine interactions in both health and mental health care.
However, research on the CPA has largely been based on service outcome
measures and interviews with service providers. This study aimed to explore
discursive constructions of service users' difficulties and therapeutic interventions
in CPA meetings and documentation in community mental health settings; how
potentially different viewpoints are negotiated; and the differences and similarities
between the meetings and documentation.
Method: Audiorecordings of six CPA meetings and their resultant CPA
documents were collected from a Community Mental Health Team and an Early
Intervention Service. A discourse analysis at the micro level, using a Discursive
Psychology framework, and at the macro level, using a Foucauldian Discourse
Analysis framework was conducted.
Results: An account of constructions of services users' difficulties, causes and
risk factors, care as medicine and care as managing the practicalities of everyday
living was produced. Rhetorical devices were used to create consensual
explanations of difficulties and decisions about medicine; tensions and
disagreements were not recorded in CPA documents. Discourses of a medical
model of difficulties were implicit and explicit in both teams, although discourses
of a biopsychosocial model were also apparent in the Early Intervention Service.
The complexity of participants negotiating discourses about the value of paid employment and discourses of illness were evidenced in all meetings.
Conclusions: Discourse analysis provided a useful means to explore CPA
meetings and documentation. The primacy of the medical model, even within
biopsychosocial accounts, and the goals of shared decision making within a
recovery framework are discussed and clinical, policy, and research implications
are explored.

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