The line of argument regarding the constructions of depot administration as
‘punishment’, ‘beneficial to treatment’ and related ‘claims of expertise’ is one formed around the notion of agency. Pivotally, how users deal with notions of agency in accounts of administration mechanisms, and how constructions ‘work’ to solve the problem of agency. The problem of agency relates to the difficulties facing users whose administration mechanism have been changed from tablets to depot, in an attempt by their service provision team to ensure adherence with regimens. Through the
formulation of ‘depot medication as punishment’ that was narrated in the previous accounts, it was seen how users drew upon formal knowledge of medication related to the mechanisms of action service providers engage in when faced with a user who ceases to comply with their medication regimen. Users were positioning themselves as ‘wrong’ for their non-adherence, and this ‘error’ lead to the punishment of depot injection. The issue then becomes one of agency, and more specifically how users construct a notion of agency in an account that appears devoid of any potentiality of agentic actions.
Through the delicate oscillation between the discourses of punishment, treatment and self-expertise seen in this chapter it is argued that an intricate notion of agency is worked through, despite the surface difficulties. This exists in addition to the delicate separations of adherence and compulsion, and expertise from authority. Separating adherence from compulsion is one mechanism through which users can manage the problem of orienting to formal knowledge whilst negotiating the position of non-
technical expert. The separation of expertise from authority allows a sense of autonomy to be constructed through defending against the authority figure (i.e. psychiatrist) being
in total control. If expertise is represented as existing elsewhere (i.e. laboratory in the case of Rick), then users are not constructed as being totally controlled by their service provision team.
The relation between the discourses of punishment and beneficial treatment appears at surface level to be a simple one. It could be argued that users construct the depot administration as beneficial to treatment as a way of providing an alternative
representation than its existence as punishment. By constructing it as beneficial they can narrate an account of themselves as actually receiving appropriate valuable medication now, although they had to be ‘punished’ to get to this position. This construction serves two purposes. Firstly, it allows for their current state to not just be shrouded in negative terms, as in ‘punishment’, and secondly it enables a sense of agency to be constructed regarding the administration mechanism.
In the case of ‘punishment’, the narrating of an alternative account to punishment is an important one as the positions available to users to construct their current states are limited. Briefly, the importance of being able to narrate a positive account is vital for users so as to position themselves away from the previous negative experiences of the past. Thus to be able to construct depot medication as currently positive – in that it allows for a proper medication regimen to be enacted – is valuable to users through the positioning it enables away from the initial punishment construction first narrated.
This element of agency constructed here emerges through the way that users narrate the change in administration mechanism as instigated by their own actions. Whilst in the first instance it may seem that the construction of punishment emerging from an initial act of non-adherence only serves to frame users in negative terms - as ‘wrong’ in some way - it is argued here that this is actually part of a complex construction of agency narrated by the users. What it allows, is for their current state of receiving proper medication in an adherent manner to be actually in part due to their initial actions in the first place. As we have seen in the extracts of Henry and Beatrice, both framed their initial non-adherence as due to a problem with their particular medication regimen at the time; for Henry he could not perceive any element of efficacy in the medication, and for Beatrice the medication was causing a lot of pain in her legs. Thus, by narrating this account of initial agency users can actually assume some control over their current
regimen – which as we have seen is framed as positive – which serves as an important function of self agency. Within the narrow range of subject positions available a
construction of agency is still enacted. Indeed, given the lack of positions available and the apparent element of power exerted by mainstream psychiatric practice over users, it can be seen how important this sense of agency becomes. In the face of adversity users are still able to enact some complex notion of agentic behaviour, by representing the change in administration mechanism as due to them rather than as an act entirely in the control of their service provision team. Given the privileged position of service
providers with regard to administering medication regimens, the problem of agency is overcome to a certain extent through constructions of responsibility for changes in administration mechanisms.
Another strand of this complex agentic construction can also be seen to emerge from the formulation of expertise that was seen earlier. The claims to self-expertise appear to be doing the ‘business’ of developing an adequate sense of agency through some control over the current medication regimen to be narrated. This is similar to the previous agentic construction as it relates to the issue of alterations to medication regimens and administration mechanisms. In the extract of Mark, it can be seen how a construction of agency is developed through the account he provides of the issue of changes to his medication. In stating that his service provision team have considered changing his administration mechanism from depot to tablets he first raises the issue of control over his medication – through the construction that his service provision team have the power to consider and effect changes to his medication. However, far from passively allowing this element of control to be constructed as existing entirely in the domain of his provision team, Mark actually constructs a notion of control over his medication himself. He does this by stating that he has communicated to his provision team his unease regarding their consideration of a change in administration mechanism. He accounts for this as being due to his belief that a chance exists that if he is provided with the control over his medication – an option in overall control of provision team – he could engage in suicidal behaviour as he has in the past. Given his realisation that this is an option – and one that Mark does not want to occur – he utilises some sense of control over his medication in attempting to ensure that control is not going to be placed in his hands. This is interesting as it constructs a level of control for Mark at an overarching level – that of administration mechanism – whilst resisting the option of
control at the everyday level of managing actual tablet administration. Mark’s claims to self expertise enable him to be seen to be in some sense in control of his administration regimen as he is the one who has acted to ensure that it remains in the form of depot injection. This exists even though common sense tells us that actual control over his administration mechanism would surely lie entirely within the domain of the provision team, especially given a history of suicide attempts.
A similar construction is seen in the interview with Sarah where she narrates an
account in which the issue of medication change is discussed along with the role of her service provision team in considering a change. Sarah states her provision team
communicated to her their consideration of a gradual reduction of her medication with the possibility of cessation, and she voices her concerns regarding this. Her concerns focus around the possibility of hallucinations re-emerging should medication cease. Similarly to the extract of Mark, common sense tells us that any consideration of medication cessation would only occur in accordance with the professional opinion of service providers that psychotic symptoms would not return. Indeed, across the corpus of users in this study the possibility of a cessation of medication was only raised twice, so it can be seen how unusual this is. Sarah, however, is not narrating an account of passive adherence with any proposed change, but rather is constructing control as existing to a degree in her hands, as she can express her misgivings. Now whether these concerns are listened to or indeed would actually change the decision making process of the provision team is not really the issue here. Rather it is the ways in which users rhetorically work to construct agency as a possibility for them, and the resultant beneficial position of being seen to be in some way in control of one’s administration mechanism. Indeed the issues of agency occur throughout the accounts of users.