Citizen minds,citizen bodies: the citizenship experience and the government of mentally ill persons

The concept of citizenship is becoming more and more prominent in specific fields, such as psychiatry/mental health, where it is constituted as a solution to the issues of exclusion, discrimination, and poverty often endured by the mentally ill. We argue that such discourse of citizenship represents a break in the history of psychiatry and constitutes a powerful strategy to counter the effects of equally powerful psychiatric labelling. However, we call into question the emancipatory promise of a citizenship agenda. Foucault's concept of governmentality is helpful in understanding the production of the citizen subject, its location within the ‘art of government’, as well as the ethical and political implications of citizenship in the context of mental health.     

Evading and embracing normality: estrangement and ambivalence in the accounts of methamphetamine consumers

While much has been made of the governmentality evinced in drug policy, its effects on people who use drugs have received less attention. Scholars who have investigated these effects commonly focus on the views and experiences of individuals receiving treatment for their drug use, often reporting an explicit desire among individuals in treatment for a return to a normal, healthy life. Many authors trace this desire to the normalisation inherent in drug policy, and the governmentality involved in the delivery of drug treatment more directly. This article adds to these discussions by shifting focus from the experience of individuals in treatment to those out of treatment settings. In so doing, we aim to develop a more nuanced understanding of how heavy drug users negotiate power, governmentality and the modulations of health and illness in the course of everyday life. We ground our discussion in qualitative research conducted in Melbourne, Australia, with 31 current methamphetamine consumers. We argue that regular methamphetamine consumption involves a complex and ambivalent relationship with the ideas of health and normal life, imposing as well as reflecting a form of estrangement between its consumers and mainstream (or normal) society. This ambivalence has important implications for the delivery of health and social services among methamphetamine consumers, insofar as the restoration of normal health and the reintegration of former drug users into mainstream society are typical health service goals. We address some of these policy implications by way of conclusion.     

The demise of repetitive strain injury in sceptical governing rationalities of workplace managers

In the mid-1990s, RSI (repetitive strain injury) loomed as an occupational health epidemic in industrialised countries. A decade later, the problem appears to have faded away, but there has been little explanation for how this problem might have diminished. This paper offers an explanation for the decline of RSI in the social relations of workplaces, in the pragmatic, day-to-day governance of occupational health by workplace managers. Using the conceptual lens of governmentality theory, this study examined how workplace managers conceptualised, rationalised and responded to RSI in their work organisations. Open-ended interviews were conducted with 35 managers at four Ontario newspaper workplaces. This paper describes managers as guided by a discourse of scepticism about the legitimacy of RSI complaints. This discourse was 'practised' in different ways at each newspaper in varied RSI-management strategies, but each strategy privileged ideas about RSI being problematic in certain types of workers rather than in types of physical work environments. This conceptualisation of RSI splintered, subordinated and collapsed the problem within a broad human resources framework. This paper suggests that the 'taming' of RSI might have occurred in the context of micro-political, workplace-level shifts in the conceptualisation and management of RSI as an occupational health problem.     

Rational choice(s)? Rethinking decision‐making on breast cancer risk and screening mammography

Women who refrain from undergoing breast cancer screening are believed to be uninformed about risks and usually labeled as irrational. Our purpose in writing this paper is to challenge the traditional notion of rational behaviour, illustrating with qualitative data that people's rationality is influenced by their socio-cultural and political identities. We explore three major themes: (1) cultural explanations regarding intention to use screening mammography (2) (dis)trust in science and expert opinion, and (3) self-responsibility and self-surveillance in caring for one's body. Understanding that women rely on different risk discourses to make decisions about their health should aide researchers, health professionals, and the community in better understanding alternative ways of conceptualizing people's health-related behaviours when they do not coincide with health authorities recommendations.     

Exploring the dynamics of power: a Foucauldian analysis of care planning in learning disabilities services

This paper draws upon a study completed in 2000 that focused upon health and welfare provision for people with learning disabilities in one English county. This study drew upon the theoretical insights of Michel Foucault to provide an analysis of the micro politics of care planning. This involved the analysis of text from two sources: the academic literature and interview material gained from a number of professionals working in health and welfare services for people with learning disabilities. Drawing upon this research material, the first part of this paper briefly explores the relationship between policy, professional practice and the people who are the subjects of that practice. The discussion then moves on to consider Foucault's five methodological precautions and the way power produces a localised web of activity that identifies specific targets for management. In this process power draws into the web a range of informal and formal practices that initially lie outside of the web. The discourse produced through the activity surrounding care planning provides the evidence of this flow of power. This discourse then takes on the status of science (truth), which reproduces this activity.     

Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

This paper explores how current 'patient safety' reforms offer to change the regulation of medicine. Drawing on existing literature, it is argued that this policy agenda represents a new frontier in medical/managerial relations, introducing a disciplinary expertise within the health service that provides managers with the knowledge and legitimacy to survey and scrutinise medical performance, made real through procedures for incident reporting and root-cause analysis. The extent of regulatory change is investigated, drawing on an ethnographic case study of one hospital. It is shown that, as with other organisational and managerial reforms, doctors are resisting managerial prerogatives through seeking to subvert and 'capture' components of reform. I describe this as 'adaptive regulation' to account for how doctors seek to maintain their regulatory monopoly and limit managerial encroachment. It is speculated, however, that this process could signal the future 'modernisation' of medical professionalism where emerging managerial discourses, within the wider context of public sector reform, are increasingly internalised with medical practice and culture. This leads to new and rearticulated forms of self-surveillance, self-management or 'governmentality', ultimately negating the need for external groups to explicitly manage or regulate professional practice.     

Creating the socially marginalised youth smoker: the role of tobacco control

We discuss how the tobacco control discourse on youth smoking in Canada appears to be producing and constituting socially marginalised smokers. We analyse material from a study on social inequalities in Canadian youth smoking. Individual interviews were conducted in 2007 and 2008 with tobacco control practitioners specialising in youth smoking prevention in British Columbia and Quebec. We found that the discourse on youth smoking is creating a set of divisive practices, separating youths who have a capacity for self‐control from those who do not, youths who are able to make responsible decisions from those who are not – with these distinctions often framed as a function of social class. Youths who smoke were not described simply as persons who smoke cigarettes but as individuals who, through their economic and social marginalisation, are biologically fated and behaviourally inclined to be smokers. This ‘smokers’ risk’ discourse obscures the social structural conditions under which people smoke and reproduces the biological and behavioural reductionism of biomedicine. The collision of risk and class in the discourse on poor youth who smoke may not only be doubly burdening but may intensify social inequalities in youth smoking by forming subcultures of resistance and risk‐taking.     

Impersonal trust and professional authority: exploring the dynamics

AIM: The aim of the study was to explore the relationship between impersonal trust, governmentality and professional activity through an analysis of professional discourse. BACKGROUND: This study emerged from an earlier paper that described a four-dimensional model based on Luhmann's definition of trust as "reducing complexity and managing expectations". Linking trust with the Foucauldian notion of governmentality develops this further. Governmentality raises the question of how professional authority is constituted through the practice of nurses and other health and welfare professionals. METHOD: Discourse analysis was used to explore the text from two genres--academic literature and interview material (n = 17)--in the context of community residential services for people with learning disabilities. Findings. The study provided evidence to support claims that trust is produced through impersonal systems. Trust is contested in a dynamic process where there are gains and losses. Professionals in organisations actively promote trust, often through systems of distrust. The study also built on the four-dimensional model of impersonal trust--trust, mistrust, abuse and hope--and re-conceptualized the trust-hope dimension. CONCLUSION: There are theoretical links between governmentality and trust. Similarly, in order to understand trust nurses need to understand the dynamic nature of the systems in which they operate. The proposition that trust could frustrate hope adds an element of controversy to the discussion of hope in the nursing literature.     

‘Because I’ve been extremely careful’: HIV seroconversion,responsibility, citizenship and the neo-liberal drug-using subject

In this article, we examine how injection drug users who do not attribute their HIV infection to engaging in HIV risk behaviours take up and critique discourses of individual responsibility and citizenship relating to HIV risk and HIV prevention. We draw on data from a study in Vancouver, Canada (2006–2009) in which we interviewed individuals living with HIV who had a history of injection drug use. In this paper, we focus on six cases studies of participants who did not attribute their HIV infection to engaging in HIV risk behaviours. We found that in striving to present themselves as responsible HIV citizens who did not engage in HIV risk behaviours, these participants drew on individually focused HIV prevention discourses. By identifying themselves in these ways, they were able to present themselves as ‘deserving’ HIV citizens and avoid the blame associated with being HIV positive. However, in rejecting the view that they and their risk behaviours were to blame for their HIV infection and by developing an explanation that drew on broader social, structural and historical factors, these individuals were developing a tentative critique of focus on individual responsibility in HIV transmission as opposed to dangers of infection arising from the socio-economic environment. By framing the risk of infection in environmental rather than individual risk-behaviour terms, these individuals redistributed responsibility to reflect the social-structural realities of their lives. In this article, we reflect on the implications of these findings for public health measures such as risk prevention messages. We argue that it is important that such messages are not restricted to individual risk prevention but also include a focus of broader shared responsibilities of HIV.