The Goldilocks Paradox: Constructions of Readiness for Therapy on Adult Acute Wards

The aim of this thesis is to explore how clinicians working in adult acute settings construct their understandings of readiness for therapy, utilising a Foucauldian discourse analysis (FDA).
The first part presents a critical review of the literature considering the multifarious discursive constructions of readiness for therapy. These are considered in relation to the differing therapeutic approaches, illustrating the socio-historical construction of this concept. Constructions of readiness for therapy are also considered in relation to the lack of research and treatment development in inpatient acute settings and the inherent implications for this absence: primarily lack of provision of, or access to, therapy.
The analysis is then presented, employing semi-structured interviews to explore how five clinical psychologists and five psychiatrists conceptualise the construct of readiness for therapy in their work in acute inpatient psychiatric settings. Transcripts were analysed using an FDA.
The thesis adopts a critical realist social constructionist epistemological position in order to facilitate the exploration of readiness for therapy as a construct both at the level of discourse in the text and at a wider institutional level. This position also enables consideration of contextual and social factors and their implications for subjectivity.
The analysis demonstrated that clinicians constructed their understandings of readiness for therapy in three main ways. They constructed readiness for therapy in relation to the requirement for a particular ‘ideal’ therapeutic subject constituted through processes of subjectification. They constructed ‘unreadiness’ for therapy as a tool to support their position as ‘expert’ through disciplining practices of surveillance and coding. Finally they constructed broader service contexts - service structures, regulatory guidance and therapy itself - as barriers to their ability to provide therapy in this setting; thus facilitating their subject-positioning as ‘ethical’ practitioners.
As a consequence of these discursive constructions it is therefore very unlikely that patients in these settings would fulfil criteria necessary for them to be considered ‘ready’ for therapy and to thus have access to therapy.
This thesis recommends utilising the Power Threat Meaning framework (Johnstone & Boyle, 2018) to enable dominant biomedical discourses to be challenged in facilitating differing constructions of readiness for therapy, more suited to the context of inpatient acute settings. The lack of and need for research in this clinical area is acknowledged. Recommendations are made that therapeutic approaches should be pragmatic and flexible in their attempts to meet the needs of the patients admitted to inpatient acute wards.