Summary of the impact

This case study focuses upon discourse analytical research showing the importance of understanding communication activities in clinical settings, most particularly in mental health care and in transplantation medicine. The research described below has had an immediate impact upon educational and professional practice in medical settings in two European countries. The change that was engendered by the research can be seen both in educating clinicians in Poland as well as in changing communication practices of the British NHSBT.

Underpinning research

The case study draws on Critical Discourse Analytic (CDA) research into two areas of healthcare: discursive practices in the area of mental health and insights into the narratives of organ and tissue donation.

The research consists of a large multi-project investigation into the discursive practices of both service users and clinicians in the provision of psychiatric and psychological health care. It focuses on:

• the discursively constructed experience of mental illness (depression, ICD10: F31-32, and schizophrenia, ICD10: F20; Galasinski 2008 & 2010, respectively),
• the therapeutic process and other professional practices (Galasinski, 2008, 2011; Galasinski & Kozlowska, 2010, 2012)
• professional practice (Galasinski, 2012; Galasinski & Opalinski, 2012)

At its most general, this research shows that discourse analysis (and its critical strand, CDA), with its anchoring in a lexico-grammatical analysis of the data, can give clinicians a firmer empirical basis for their professional judgement. By providing insight into the linguistic form, CDA's microanalysis is based on phenomena (such as passive voice or nominalisation) which are independent of those who observe, analyse and interpret them. In such a way, qualitative discourse analytic research can help clinicians in understanding the complexities of the experience of mental illness; enhancing their sensitivity to the linguistic form of their patients' stories promotes deeper reflection thereon. Moreover, discourse analysis can offer more sophisticated answers to the questions of what it means to be a patient, to be mentally ill, to be in psychiatric care, and, in the process, it can build on a sound empirical basis to change and improve the care received by the most vulnerable. In the same way, examination of the discursive mechanisms underpinning the therapeutic process offers a better understanding thereof, which leads to its improvement.

The research flagged up a number of hitherto unexplored issues in the study of the discourses of mental health care. More specifically, it:

a. questioned the relevance of the so-called `depressed mood' in the clinical presentation of the depressive episode in men, adding empirically-based support to the calls for differentiating diagnostic criteria for depression for men and women;

b. suggested discursiveness (with the consequences of its performativity and anchorage in the local narrative context) of insight into schizophrenia;

c. showed a very weak `lived' understanding of clinical significance (a crucial concept in psychiatric diagnosis) amongst psychiatrists;

d. demonstrated significant weaknesses in psychometric testing, offering evidence both for poor understanding of a major test of gauging severity of depressive symptoms (the Beck Depression Inventory), and showing the negotiative nature of the discursive position of the questionnaire respondent;

e. showed a significant hiatus between how psychiatrists understand insight and the body of research into it.

The second and much newer avenue of the research focused upon in this case study is an analysis of narrated experiences of bereaved families refusing consent for transplantation of their deceased relatives' organs (Sque & Galasinski, 2013). This is the first text-orientated discourse analytic study of the transplantation experience. This research showed the importance of the insights offered by discourse analytic microanalysis in understanding the experience of transplantation. It produced results that were novel and potentially ground-breaking in the social science of transplantation medicine.

More specifically, the research offered a new understanding of the decision process involved in the refusal of organ and tissue donation. While the literature before the study assumed that families followed the wishes of their deceased relatives, and, later, that the refusal was based on the family's wish to keep their relative's body intact, the study questioned these assumptions. The analysis of the families' narratives showed that in fact those who take the decision are far more concerned with their own feelings about and perceptions of organ retrieval.

References to the research

All articles (apart from [5]) have been published in journals indexed by the Thomson Reuters' Journal Citation Reports and have impact factors which are significant for their fields. The novelty of the research reported on in [5] makes it a significant publication.

Details of the impact

The research has resulted in significant changes in professional education and training of clinical psychologists. The results of the research have been incorporated by the University of Social Sciences and Humanities, Warsaw into the training programme for specialisation in clinical psychology for clinicians in the Lower Silesia region of Poland (equivalent of the English programmes training for the Doctorate in Clinical Psychology). Modules focusing on exploring experiences of mental illness, insight, interview techniques and note-taking were introduced. The assumptions behind the research have also informed the latest recruitment strategy for new candidates for the programme. Considerably more weight was given to assessment of candidates focusing upon the narrated experiences of their patients. The reach of these changes is very significant - approximately 20% of all specialists in clinical psychology in Poland are now trained within the Programme.

The research has also been disseminated to professionals (psychologists and psychiatrists) as lectures and workshops in a number of venues in Poland, and most particularly:

• Psychiatric Clinical Hospital of the Wroclaw Medical University (October, 2009)
• Polish Psychiatric Association (October, 2009)
• General Psychiatric Hospital, Lubliniec (April, 2009).

The research has also been used by the NHSBT Consent Workshop (chaired by Emma Winstanley, National Referral Centre Manager, NHSBT, Speke), tasked with reviewing the consent process in terms of language, deceased donor family requirements and legislation. This resulted in improving the process of obtaining consent for organ and tissue donation in the United Kingdom. In particular, the impact consists in the panel's adoption of wide-ranging recommendations as to the language of consent documentation and leaflets. The recommendations were aimed at explicating and changing the discursive `structure of faith' behind the documentation to be used by the NHSBT. Most recommendations were adopted by the panel, directly impacting upon the form of the consent forms and leaflets for the bereaved families. Apart from this immediate impact, this activity is expected to have a long-term impact upon the level and quality of information received by the families being asked to give consent for retrieval of their relatives' organs and tissues, and in the process of the care for those involved in giving consent for organ and tissue retrieval.

The influence of these changes is far-reaching. 7,500 people are waiting for a transplant in the United Kingdom (1,000 die as a result of not receiving a transplant every year). Approximately 3,500 people die in circumstances where they can donate. The research described in this case study will have impact upon every request for consent for organ and tissue retrieval in the United Kingdom.

Sources to corroborate the impact

• Letter from Dr Justyna Ziolkowska, Co-ordinator of the Lower Silesia Programme for Specialisation in Clinical Psychology.
• Letter from Dr Piotr Baranowski, Consultant, Psychiatric Clinical Hospital of the Wroclaw Medical University, and the representative of the Polish Psychiatric Association in Wroclaw.
• Letter from Dr Artur Jedrzejewski, Deputy Director, General Psychiatric Hospital, Lubliniec.
• Letter from Ms Emma Winstanley, National Referral Centre Manager, NHSBT, Speke.