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This chapter begins by exploring discontent with currently dominant situational logics and associated directional tendencies within mental health services, before identifying countervailing logics, tendencies and forms of resistance. It then goes on to consider how the latter might inform the development of alternative ‘thick’ social-relational approaches (social perspectives) in this setting, and the collective agents and particular forms of agency through which these might be realised.

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This concluding chapter will begin by briefly reviewing the theoretical orientation of the book and its core arguments. Having done so, it will consider the sociopolitical implications of these arguments for policy and practice within the mental health system, the wider welfare state and beyond.

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This second individual case study chapter discusses the intervention of workers from Southville Community Mental Health Team (CMHT) and the local mental health inpatient unit with a service user, Alistair, and his wife and informal carer, Felicity. The chapter explores the different constructions of Alistair’s mental health needs elaborated by his consultant psychiatrist, his care coordinator/social worker, Felicity and Alistair. The implications of transitions between ‘stable’ and ‘acute’ phases for the way in which practitioners understand and respond to this service user’s experiences of mental distress are explored.

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This introductory chapter offers a brief overview of the theoretical orientation of the book. It also introduces its core argument. This is that mental health services are action environments, which offer either enablements to or constraints on the articulation of models of mental distress (as ideational frameworks) and their enactment in the form of practices within the mental health services setting. Consequently, a satisfactory account of models must consider both the forms of knowledge and the situated contexts within which they may (or may not) manifest. The aim of the book, therefore, is to examine this interface between knowledge, practices and structural environments and understand the effects of their interaction and interplay.

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This chapter provides historical and policy context for the fieldwork chapters that follow. It begins by arguing that models of mental distress cannot be understood in isolation from the activities and action environments of which they form a part. Therefore, to develop a more contextually situated account of these forms of knowledge, the chapter proposes a sociohistorical framework for understanding key phases in the development of policies and systems of mental health provision. These four ‘conjunctural settlements’ begin with the 19th-century asylum, followed by the biomedical hospital system, then community care in the 20th century, and finally contemporary neoliberal provision. Prominent ways of understanding and responding to mental distress associated with each settlement are introduced.

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This chapter presents findings from the second phase of data collection. Between the first and second phases, there were three key areas of policy reform and service transformation. These were: the austerity-related cuts in funding; welfare reform; and the service-line management (SLM) reorganisation of team structures and service delivery within the Trust. This chapter examines these processes and their effects within the new Rehabilitation and Recovery Team (RRT) structure arising from SLM that replaced the Community Mental Health Team (CMHT). The particular focus is how service provision became more short term and the managerial culture more punitive, as well as the additional impacts of austerity and welfare reform.

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The last chapter introduced a number of service users and practitioners, and described relational casework during what practitioners called a ‘stable phase’. This and the next chapter extend this exploration of CMHT work through a focus on interactions with service users considered to be ‘in crisis’. This chapter is about a service user called Manu and his experiences with Southville CMHT and within inpatient services. The chapter illustrates how a defensive institutional culture around risk management generates tendencies towards what is called ‘custodial paternalism’. The chapter also examines how this tends to marginalise considerations on the effects of racialised inequalities.

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This chapter gives a more granular picture of forms of agency from above and from below in the context of the neoliberal reform of mental health services. There are three parts to the chapter. First, mental health nurse and trade union activist Roger offers an overview of the shifting landscape of relations between trade unions and senior managers from the latter stages of the community care era up until the Rehabilitation and Recovery Team (RRT) restructure. Second, the disciplining and victimisation of team manager Evelyn provides a case study of intensified processes of managerial control during this period. The third section then examines how Roger, Evelyn and other practitioners responded to these organisational reforms and shifting frontiers of control.

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