Situating the design and use of institutional documents in psychotherapeutic discourse: Issues of usability, framing of power, and resistance to power

Institutionally-designed templates are tools that are commonly developed and used in medical and human service institutions as a form of accountability to outside regulators like insurance companies, managed care companies, and accreditation organizations. They are developed with the expressed purpose of guiding the work activity and documentation practices of professionals within those institutions. This is a clear example of Foucalt's first and second orders of discourse (1972). The rules and procedures that are contained in the templates themselves determine what can and can not be said or done within the institution. This specialized discourse also limits the occurrence of chance within discourse. It is, of course, important for an institution to focus on the work that the institution is created to do. Templates are heuristic documents that should help users keep a clear focus on the institutional work. However, since these documents have multiple audiences, it is important to ask if any of this focusing might pull the user away from the work that the user is doing in favor of some type of accountability focus.; The field of professional communications could benefit greatly from studying institutionally-designed templates. Among other things, research of this type could add to our present knowledge of: (1) Situated tool use in professional settings. (2) How written tools can be used to order and restrain discourse. (3) What elements shape the development and use of these tools at different points in history and in different areas of an institution and (4) How resistance to the institutional mandates affects the use of the tool and points to a trajectory of change.; This dissertation studies a particularly salient example of an institutionally-designed template as it traces the State of Michigan's attempts to mandate the values of self determination through the use of the person centered planning template (the institutionally-designed template). This work, then, traces the instantiation of the values of self determination and their transformation into the practice requirements of a large bureaucratic system. The values of self-determination, unfortunately, become reified to such an extent that the basic ideas are lost in the local use of the tool. The very elements of the tool that are meant to assure self determination for consumers, ends up defining and ordering the practice of planning in such a way that those elements interfere with the very process of consumer planning.; I believe that the combination of methods that I use in this dissertation is a powerful combination that could be used effectively by other researchers for the purposes mentioned above. I am proposing that in addition to adding to our understanding of variations of use, cognitive walkthrough interviews contain a certain linguistic frame structure that can be analyzed to look at moves that are contrary to expected moves. This micro-level analysis can highlight areas of imposed power and possible trajectories for changes in the tool. The compliment of activity system analysis, in turn, serves to contextualize at a macrolevel an understanding of the institutional development of any document over time and at particular points in time, including restrictions from outside of the institution. This situates possible change within the institution and the template itself.