Knowledge in Policy

Embodied, Inscribed, Enacted

Freeman, Richard, Sturdy, Steve

• Publisher: Policy Press
• Year: 2015
• ISBN:
  9781447320975
• Edition: 1
• Topic: Politik & Internationale Beziehungen
• Subtopic: Öffentliche Ordnung

This important collection presents a radical reconception of the place of knowledge in contemporary policymaking in Europe, based not on assumptions about evidence, expertise or experience but on the different forms that knowledge takes. Knowledge is embodied in people, inscribed in documents and instruments, and enacted in specific circumstances. Empirical case studies of health and education policy in different national and international contexts demonstrate the essential interdependence of different forms and phases of knowledge. They illustrate the ways in which knowledge is mobilised and resisted, and draw attention to key problems in the processing and transformation of knowledge in policy work. This novel theoretical framework offers real benefits for policymakers, academics in public policy, public administration, management studies, sociology, education, public health and social work, and those with a practical interest in education and health and related fields of public policy.

Part One

Policy knowledge in space and time

TWO

Seeing knowledge in mental health in Scotland

Jennifer Smith-Merry

Introduction

The research I present here uses the embodied–inscribed–enacted framework to interrogate data gathered from a large qualitative research project that has sought to understand the way that knowledge functions in relation to Scottish mental health policy. This formed the first part of the work conducted by the Scottish health team under the KNOWandPOL project, which aimed to understand the different dimensions of knowledge use in relation to policymaking across Europe. My overarching interest in this chapter is on how the new framework might help to answer these questions and add to the analytic toolbox from which policy scholars draw.

In order to assess its utility, I applied the embodied–inscribed–enacted schema retrospectively to data already analysed in order to understand what new perspectives it could offer on the way knowledge functions across this particular policy sphere. The original analysis had been conducted before the framework had been devised and, as we shall see, that initial analysis was productive of further research questions. However, in pursuing that further research, it became apparent that the ideas about knowledge employed for the initial analysis were of limited utility for developing our more detailed case studies. It is therefore interesting to revisit those data to determine what new analytical approaches and insights the embodied–inscribed–enacted schema might open up. In doing so, I ask: how can this framework be applied to an existing set of data? What new insights can it add to previous attempts to understand this field? How might we redescribe the different kinds of knowledge that have come to shape this policy domain?

Scotland, mental health and policy: mapping the field

Previous research on mental health policy in Scotland has characterised it as a knowledge-based community with high levels of interaction between actors and a high degree of consensus over aims and approaches to improving mental health (Smith-Merry et al, 2008). As a policy field, mental health in Scotland underwent a radical reorganisation over a short period of time between 2000 and 2010. Drawing on major reviews of the system, new legislation and new policies for services and population mental health were launched: the Mental Health (Care and Treatment) (Scotland) Act 2003; and the government’s National programme for improving mental health and wellbeing, which began in 2003, and its policy statement Delivering for mental health (2006).¹ This happened in the context of a newly devolved Scottish government, just finding its feet and seeking to distinguish itself from England. The newly devolved government declared a focus on values of openness and inclusion, which aimed to open up government and include a multiplicity of voices in decision-making.

The extent to which a particularly Scottish ‘style’ of policymaking developed out of these circumstances has been debated in the academic literature (Cairney, 2008, 2011; McGarvey and Cairney, 2008; Keating, 2010); what we have found through the KNOWandPOL research was that much of what Scotland did in mental health appeared to be a function of old rivalries with England, which resulted in innovation aimed, among other things, at asserting Scottish difference (Smith-Merry, 2008; Smith-Merry et al, 2013). However, more generally, our research showed how, in this distinctive setting, the mobilisation and circulation of different kinds of knowledge was central, not just to the making of Scottish mental health policy, but to the way it was implemented through the active and knowledgeable participation of a wide range of actors.

The research for the KNOWandPOL project produced a large body of data derived from an initial ‘policy-mapping’ task and a series of in-depth case studies. The first ‘mapping’ phase of the project sought to understand the types of knowledge being used and produced in Scottish mental health policy and it is the data from this phase of the research that is drawn on for the substantive primary analysis in this chapter. The research in this phase drew on data from a set of 16 interviews with a range of key actors across the mental health sector in Scotland. The sampling of respondents was purposive, based on the roles that they filled in the mental health system, with the aim being to interview individuals working in key government and non-government positions throughout the sector. Our project advisory group identified potential respondents, who included representatives of service user groups.² All respondents we approached agreed to be interviewed.

Interviews were in-depth, ranged from 25 to 90 minutes in length and were semi-structured. The questions guiding the research focused on the knowledge held and produced by the respondent in their work, and how they interacted with others in terms of this knowledge. We asked:

•What knowledge do you draw on in the work of your organisation?

•What knowledge outputs has your organisation produced, or been involved in the production of, over the past two years?

•What areas of knowledge production does your organisation prioritise?

•Does your organisation have particular relationships with others in terms of knowledge production?

•Does the work of your organisation specifically use knowledge produced by international organisations or bodies?

Interviews were transcribed and the data was entered into NVivo, where it was hand-coded.

In analysing the interview data, I attempted to categorise the data according to function and purpose. The initial analysis used codes that were derived inductively from the data, and that were grouped according to actor, theme and knowledge. I brought the codes for knowledge together and separated them into similar ‘types’ of knowledge based on their function, behaviour and situation. To these groups of codes, I gave a descriptive category. In writing up this data, the categories were separated into either ‘knowledge inputs’ or ‘knowledge outputs’ – knowledge used and created by the mental health system (Smith et al, 2007). The knowledge categories we ended up using for this stage of the analysis were:

•Official/formal: knowledge that is from official sources or is formalised in some way. The format of these sources is often bound by codes that dictate how they are devised and what sorts of data they contain. They included training, literature reviews, commissioned research, academic work, primary research, evaluation, official letters and emails, official policies, guidance or legislation, and international work. There were 18 instances of this data included as ‘knowledge inputs’ in the interviews and 36 as outputs.

•Processual/oral: knowledge that is transmitted orally through meetings, consultation, reference groups, events, committee membership, teaching, theatre performances, seminars, networking roadshows, workshops, speeches, conferences and training. Here, knowledge is created, transformed and transmitted through the process of meeting and talking. There were 10 instances of this knowledge included as ‘inputs’ in the interview data and 47 as outputs.

•Regulatory: knowledge that comes from regulatory tools such as benchmarking, codes of practice and regulatory tool development. There was only one instance of this type of knowledge listed as a knowledge input and four instances of regulatory knowledge as an output.

•Informal/experiential: knowledge that could be described as tacit, informal or experiential. It is knowledge that does not come from a codified or formalised source and cannot be tested for objective validity. In this category, I included feedback, expertise, practical experience, personal experience, service user knowledge, institutional knowledge, monitoring, briefings, advice and secondment. There were 20 instances of this type of knowledge discussed as knowledge inputs in the interviews and 15 as knowledge outputs.

•Public education: knowledge that was used to promote public mental health within the community. In this category were included media work, magazines, television advertisements, leaflets and websites. There were 11 instances of this type of knowledge included as an output, but none as an input.

As will be apparent from reviewing this list, the knowledge categories that emerged inductively from our initial analysis were somewhat heterogeneous. While I set out to classify knowledge into functional categories, only some of the categories were actually functional in any clear sense, while others were more about the epistemic or social organisation of the knowledge (eg official/formal), and others conflated function with a kind of behaviour (processual/oral). Given the preliminary and exploratory aims of this part of the research, this was not a problem at the time. On the contrary, it was invaluable in helping us to understand the dimensions of the mental health policy field, including what forums and processes were particularly important for the creation and mobilisation of knowledge. Among other things, it alerted us to the importance of user groups and their interpenetration with other policy actors. For example, we were able to identify that much of the knowledge creation in the system took place not through the production of official policy documents or guidelines, but through individuals speaking with one another in meetings: this was a system where the spoken word held more sway than formal documents.

The mapping exercise also enabled us to identify a series of case studies that structured the remainder of the KNOWandPOL project work, and through which we were able to explore further the overarching research aim of understanding knowledge in policy. In particular, the knowledge classification we developed for the preliminary phase of the project alerted us to the importance of consultation in building policy impetus, of a practice- and service-user-led social movement in shaping recovery policy, and of international meetings for sustaining domestic policy. Our first case study accordingly used ethnographic observation, interviews and documentary analysis to examine the consultation processes for a new population mental health strategy; our second and third case studies used interviews and documentary analysis to examine, respectively, the emergence and implementation of recovery as a value guiding policy and practice, and the use of targets, indicators and measurement in mental health policy. A final case study looked to Scotland’s relationship with the World Health Organization Europe (WHO Europe) in the field of mental health, to determine the way knowledge was used in this context.

It is notable, however, that the exploration of these case studies did not, on the whole, draw further on the categories used in the initial mapping exercise. In practice, when we came to look more closely at how knowledge works in policy, our original categories proved too static to be useful, and we had to employ other categories or theories of knowledge – usually on an ad hoc basis – to capture the dynamics of the policy processes we studied. This was before the schema of embodied–inscribed–enacted knowledge was properly articulated. Had we had that scheme to hand when we conducted our case studies, would it have helped to facilitate our analysis, or to throw light on aspects of the case studies we previously overlooked? In the next section, I reflect on the new perspectives that a re-categorisation of our data using the embodied–inscribed–enacted framework adds.

Types of knowledge: re-analysing our data

In order to re-categorise our original data using the new framework, I merged inputs and outputs as I found this categorisation to be unnecessary. All the knowledge types referred to in the original interviews then fitted easily into the new schema:

•Embodied knowledge: within the embodied category, I included personal knowledge of international examples, consultation, secondment, personal experience, practical experience, expertise, feedback, advice and representation. There were 30 instances of this knowledge referred to in the interviews.

•Inscribed knowledge: within the inscribed category, I included reviews, academic papers, reports, evaluation, letters, newsletters, awards, emails, written guides, DVDs, benchmarking, research, tool development, codes of practice, briefings, websites, leaflets, television advertisements and magazines. Respondents made reference to 70 instances of this kind of knowledge.

•Enacted knowledge: within the enacted category, I included events, committee participation, teaching, meetings, theatre performances, seminars, roadshows, workshops, speeches, conferences, training, media work, monitoring and networking. There were 62 instances of this knowledge referred to in the interviews.

This re-categorisation showed a policy community where embodied, inscribed and enacted knowledge types are all represented: each is discussed in detail in the following.

Embodied knowledge

“So if you are going to have a breakdown, have one [here], not [there].” (Towards a Mentally Flourishing Scotland [TAMFS] consultation, field note, 19 February 2008)

“Locally, what has worked well with Choose Life has been trying to plant a seed and let it grow – men’s groups, men’s mental health stuff is going on but is not joined up. We need to allow a network to develop around [population mental health work].” (TAMFS consultation, field note, 19 February 2008)

“We have no formal means of prioritisation, but if requests come in for work to be done, then it would be taken to the board and our host organisation for discussions about whether it was felt that it was a valuable and appropriate thing to be involved in.” (Interview, 8 June 2007)

Each of these quotations deals with embodied knowledge – knowledge held in the bodies and minds of, in this case, service users, practitioners and advocacy workers. I have categorised embodied knowledge as including that gained through experience: as the preceding examples illustrate, in the case of the empirical research, embodied knowledge was comprised mainly of the personal experiences of service users and the practice-based experience of policymakers and practitioners. Embodied knowledge would typically be used to weigh up alternatives for action or to negotiate policy networks to influence change. It would also be used to draw attention to an area through recounting the negative impacts current processes have on individuals.

Looking at our case studies, our work on recovery demonstrated an important place for embodied knowledge in the development of recovery policy and practice (Sturdy et al, 2012; Smith-Merry and Sturdy, 2013). Recovery is generally described as the idea that individuals can expect a fulfilling life despite a diagnosis of mental ill-health, and is conceptualised as a personal process or journey that individuals are involved in to this end (Frese et al, 2009; see also Scottish Government, 2010³). Recovery has become a significant value shaping the operation of services for mental health in Scotland and is highlighted as a policy goal for both services and population health strategies (see, eg, the mental health services policy document Delivering for mental health [2006] and the Mental health strategy for Scotland 2012–2015 [2012]⁴). Our research found that embodied knowledge was used extensively in order to spread the concept of recovery through the policy, practice and service user community in Scotland. This is suggested by the following quotations:

Audrey described her experiences of being diagnosed and treated and the effects that her medication had on her ability to work and to study. She came to feel that she no longer wanted to live under the shadow of medication. She felt she had been ‘written off’ and was depressed – ‘who wouldn’t be?’ Being part of self-help groups and the Hearing Voices Network was a liberating experience and the start of a journey towards recovery. (Scottish Development Centre for Mental Health, 2002, p 5)

“People from the Hearing Voices Network started talking about their experience of using services, how everything about their life had become symptomatic and diagnosis was reflected – they only lived throug...