Learning from the study of trajectories

Trajectories paperHere’s a post about research, which draws on the paper Complex caring trajectories in community mental health: contingencies, divisions of labor and care coordination which I authored with Davina Allen.

One of the things I’m interested in is the study of ‘trajectories’. With colleagues, the US sociologist Anselm Strauss wrote about these in the book Social Organization of Medical Work. Most people will be familiar with the idea of illnesses ‘running their course’. To this everyday concept Strauss and his collaborators added a whole lot more, introducing the term ‘trajectory’ to refer:

…not only to the physiological unfolding of a patient’s disease but to the total organization of work done over that course, plus the impact on those involved with that work and its organization (Strauss et al. 1985: 8).

Trajectories are dynamic and often unpredictable, not least because they involve people. They are also vulnerable to being tilted by what Strauss et al term ‘contingencies’. Contingencies can have origins in the health and illness experience. So, a trajectory can (for example) veer off in a new direction because of an acute exacerbation of a chronic illness. But trajectories can additionally be shaped by contingencies which have organisational origins. These can relate to the biographies of workers, and to features of the system such as the availability of resources.

Trajectories can be studied. In my PhD I borrowed the design and methods used by Davina Allen, Lesley Griffiths and Patricia Lyne in their study of stroke care, and used these to understand the trajectories of people using community mental health services. In each of two contrasting parts of Wales I recruited three people currently using secondary mental health services. Each became the starting point for a detailed, small-scale, trajectory case study. Over a period of months I followed each person’s unfolding experiences, and the organisation of work surrounding. Using snowball sampling I mapped the network of (paid and unpaid) people providing care to each, and interviewed those identified in this way about their work. I observed care planning meetings, home visits, and read each service user participant’s National Health Service (NHS) records.

Community Mental Health JournalIn the publication for Community Mental Health Journal to which this post relates, Davina and I drew on these data to show how trajectories unfolding in the mental health field are shaped. We offered instances of trajectories being tilted by mental health crises, but also by key professionals leaving their posts and by a lack of resources within the larger system.

We then used data to reveal actual divisions of labour, in a way which has not (to the best of my knowledge) been done before  in the mental health context. By mapping the networks of care surrounding each user participant we were able to learn about work being done by all sorts of people, including many who (I suspect) are rarely thought of as making significant contributions at all. We wrote about the work of community pharmacists, support workers, lay carers and indeed the work of service users themselves.

Having laid all this out we closed by pointing to the importance of what Strauss et al called ‘articulation work’. This is the work associated with the management of trajectories, through mechanisms such as care coordination. Mental health workers in the UK know all about this through things like the care programme approach (CPA).

The detail of this paper you can read for yourself, with the link at the top of this post taking you to our author’s copy of the manuscript as stored on Cardiff University’s ORCA repository. This, word-for-word, is the same as the version of the article which is currently in press here.

For those interested in the paper’s back story, just to note that when it came to selecting a journal I was keen not to submit to a nursing publication. I have no problem with nursing journals per se, but this ‘trajectories’ paper was (and is) aimed at a wider readership. Community Mental Health Journal is based in the US, and publishes papers on, well, community mental health. And that fitted well with the intended audience. This said, one of the anonymous reviewers of the submitted manuscript had things to say about the language used, reminding us that the journal to which we had submitted is read by mental health practitioners and academics and not, primarily, by sociologists. Attending to the review meant some rewriting to improve accessibility. I’ll leave future readers to judge for themselves whether we succeeded.


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