"It's a Big Family Here." Becoming and Belonging in a Service Providing Employment-Related Support for People with Mental Health Problems: An Interpretative Phenomenological Analysis.

The impact of employment for individuals with mental health problems is complex. However, research suggests that when support is provided for accessing employment and gaining roles and skills that are valued by others, a positive effect can be seen on recovery. Employment-related support can take many forms and there is a need for further research into the experience of accessing different kinds of services. The current paper examines the lived experience of 11 people participating in a UK social enterprise providing work experience, training, and skills development for those with mental health problems. Although 'sheltered', the organisational ethos strongly emphasised service-user empowerment, co-production, equality with staff, provision of valued social roles and person-centred support. Phenomenological analysis revealed that participants valued a sense of belonging and authentic relationships within the service, whilst being given the opportunity to rediscover an identity that may have been lost because of their mental health problem. However, participants also discussed how, although the service improved their self-value, some feared the 'real world' outside of the service and were unsure whether they would be met with the same support. Tensions between field dominant approaches in supported employment and the experiences and values of the participants are explored. We argue that the findings highlight the importance of a nurturing working environment and the value for recovery of a range of meaningful roles, beyond competitive employment.

The Impact of the COVID-19 Pandemic on Those Supported in the Community with Long-Term Mental Health Problems: A Qualitative Analysis of Power, Threat, Meaning and Survival.

Research suggests that the COVID-19 pandemic has had a significant impact on those already living with mental health problems, though there is also evidence of resilience. However, to date there has been limited in-depth qualitative investigation. We interviewed 15 people living with long-term mental health problems who, before the pandemic, were being supported by third sector organisations, to explore how they experienced lockdowns and accessing services remotely. Template analysis was informed by the Power Threat Meaning Framework and suggested that participants experienced significant threats to their mental wellbeing and recovery which were exacerbated by current or previous powerlessness and inequality. Although participants described positive coping strategies, several described a return of unhelpful behaviours that had contributed to the original difficulties. The findings illustrate the wider contributions of social and economic context to mental health problems and the importance of ensuring that people do not feel abandoned and are proactively supported.

Self-conscious emotions and breastfeeding support: A focused synthesis of UK qualitative research.

Research on women's experiences of infant feeding and related moral discourse suggests that self-conscious emotions may be highly relevant to breastfeeding support interactions. However, the emotional impact of receiving support has not been fully explored. The aim of this review is to re-examine qualitative UK research on receiving breastfeeding support, in order to explore the role of self-conscious emotions and related appraisals in interactions with professional and peer supporters. From 2007 to 2020, 34 studies met criteria for inclusion. Using template analysis to identify findings relevant to self-conscious emotions, we focused on shame, guilt, embarrassment, humiliation and pride. Because of cultural aversion to direct discussion of self-conscious emotions, the template also identified thoughts about self-evaluation, perceptions of judgement and sense of exposure. Self-conscious emotions were explicitly mentioned in 25 papers, and related concerns were noted in all papers. Through thematic synthesis, three themes were identified, which suggested that (i) breastfeeding 'support' could present challenges to mothering identity and hence to emotional well-being; (ii) many women managed interactions in order to avoid or minimise uncomfortable self-conscious emotions; and (iii) those providing support for breastfeeding could facilitate women's emotion work by validating their mothering, or undermine this by invalidation, contributing to feelings of embarrassment, guilt or humiliation. Those supporting breastfeeding need good emotional 'antennae' if they are to ensure they also support transition to motherhood. This is the first study explicitly examining self-conscious emotions in breastfeeding support, and further research is needed to explore the emotional nuances of women's interactions with supporters.

Understanding process and context in breastfeeding support interventions: The potential of qualitative research.

Considerable effort has been made in recent years to gain a better understanding of the effectiveness of different interventions for supporting breastfeeding. However, research has tended to focus primarily on measuring outcomes and has paid comparatively little attention to the relational, organizational, and wider contextual processes that may impact delivery of an intervention. Supporting a woman with breastfeeding is an interpersonal encounter that may play out differently in different contexts, despite the apparently consistent aims and structure of an intervention. We consider the limitations of randomized controlled trials for building understanding of the ways in which different components of an intervention may impact breastfeeding women and how the messages conveyed through interactions with breastfeeding supporters might be received. We argue that qualitative methods are ideally suited to understanding psychosocial processes within breastfeeding interventions and have been underused. After briefly reviewing qualitative research to date into experiences of receiving and delivering breastfeeding support, we discuss the potential of theoretically informed qualitative methodologies to provide fuller understanding of intervention processes by focusing on three examples: phenomenology, ethnography, and discourse analysis. The paper concludes by noting some of the epistemological differences between the broadly positivist approach of trials and qualitative methodologies, and we suggest there is a need for further dialog as to how researchers might bridge these differences in order to develop a fuller and more holistic understanding of how best to support breastfeeding women.

Making use of expertise: a qualitative analysis of the experience of breastfeeding support for first-time mothers.

There is now a body of research evaluating breastfeeding interventions and exploring mothers' and health professionals' views on effective and ineffective breastfeeding support. However, this literature leaves relatively unexplored a number of questions about how breastfeeding women experience and make sense of their relationships with those trained to provide breastfeeding support. The present study collected qualitative data from 22 breastfeeding first-time mothers in the United Kingdom on their experiences of, and orientation towards, relationships with maternity care professionals and other breastfeeding advisors. The data were obtained from interviews and audio-diaries at two time points during the first 5 weeks post-partum. We discuss a key theme within the data of 'Making use of expertise' and three subthemes that capture the way in which the women's orientation towards those assumed to have breastfeeding expertise varied according to whether the women (1) adopted a position of consulting experts vs. one of deferring to feeding authorities; (2) experienced difficulty interpreting their own and their baby's bodies; and (3) experienced the expertise of health workers as empowering or disempowering. Although sometimes mothers felt empowered by aligning themselves with the scientific approach and 'normalising gaze' of health care professionals, at other times this gaze could be experienced as objectifying and diminishing. The merits and limitations of a person-centred approach to breastfeeding support are discussed in relation to using breastfeeding expertise in an empowering rather than disempowering way.

Maintaining the 'good maternal body': expressing milk as a way of negotiating the demands and dilemmas of early infant feeding.

AIM: To report a descriptive study of early infant feeding experiences focusing on ACCOUNTS OF WOMEN WHO EXPRESSED MILK EXTENSIVELY IN THE FIRST FEW WEEKS POSTPARTUM. BACKGROUND: Relatively little is known about the reasons for expressing milk following healthy term births. Evidence indicates it is an increasingly common practice during early infant feeding in Westernized countries. A more comprehensive understanding of this practice will help midwives and nurses assist mothers negotiate early feeding challenges. DESIGN: Qualitative data were collected in two phases in the first few weeks postpartum. METHOD: Audio-diary and semi-structured interview data from seven British women who extensively expressed milk in the first month postpartum were analysed. These data were drawn from a larger qualitative longitudinal study which took place in 2006-2007. Themes, discursive constructions and discourses are identified through the use of a feminist informed analysis. FINDINGS: The practice of expressing was employed as a solution to managing the competing demands and dilemmas of early breastfeeding and ensuring the continued provision of breast milk, thereby deflecting potential accusations of poor mothering. In addition, the practice may afford a degree of freedom to new mothers. CONCLUSIONS: The need to maintain the 'good maternal body' can account for the motivation to express milk, although there may be reasons to be cautious about promoting expression as a solution to breastfeeding difficulties. Education for health professionals, which emphasizes the complexities and contradictions of mothering and which challenges prescriptive notions of 'good mothering' could better support new mothers in their feeding 'choices'.

'It should be the most natural thing in the world': exploring first-time mothers' breastfeeding difficulties in the UK using audio-diaries and interviews.

Breastfeeding is a practice which is promoted and scrutinized in the UK and internationally. In this paper, we use interpretative phenomenological analysis to explore the experiences of eight British first-time mothers who struggled with breastfeeding in the early post-partum period. Participants kept audio-diary accounts of their infant feeding experiences across a 7-day period immediately following the birth of their infant and took part in related semi-structured interviews a few days after completion of the diary. The overarching theme identified was of a tension between the participants' lived, embodied experience of struggling to breastfeed and the cultural construction of breastfeeding as 'natural' and trouble-free. Participants reported particular difficulties interpreting the pain they experienced during feeds and their emerging maternal identities were threatened, often fluctuating considerably from feed to feed. We discuss some of the implications for breastfeeding promotion and argue for greater awareness and understanding of breastfeeding difficulties so that breastfeeding women are less likely to interpret these as a personal shortcoming in a manner which disempowers them. We also advocate the need to address proximal and distal influences around the breastfeeding dyad and, in particular, to consider the broader cultural context in the UK where breastfeeding is routinely promoted yet often constructed as a shameful act if performed in the public arena.

Shame as a social phenomenon: a critical analysis of the concept of dispositional shame.

An increased clinical interest in shame has been reflected in the growing number of research studies in this area. However, clinically orientated empirical investigation has mostly been restricted to the investigation of individual differences in dispositional shame. This study reviews recent work on dispositional shame but then argues that the primacy of this construct has been problematic in a number of ways. Most importantly, the notion of shame as a context-free intrapsychic variable has distracted clinical researchers from investigating the management and repair of experiences of shame and shameful identities and has made the social constitution of shame less visible. Several suggestions are made for alternative ways in which susceptibility to shame could be conceptualized, which consider how shame might arise in certain contexts and as a product of particular social encounters. For example, persistent difficulties with shame may relate to the salience of stigmatizing discourses within a particular social context, the roles or subject positions available to an individual, the establishment of a repertoire of context-relevant shame avoidance strategies and the personal meaning of shamefulness.

Managing shame: an interpersonal perspective.

Experiences of shame are often difficult to manage, not least because of their interpersonal implications. However, limited research attention has been paid to the management and repair of shame, and in particular to the role that social factors may play in this. We aimed to explore these issues by obtaining 50 written first-person accounts of experiences of managing difficult episodes of shame from a cross section of students and employees at a British university. These participant-generated narrative accounts were supplemented by written answers to open-ended questions. Via a contextual constructionist thematic analysis, three overarching themes were identified: The centrality of others' evaluations of the self; Repositioning the self vis-à-vis others, and Being disabled by shame. Discussion focuses on the first two of these themes which together suggest that because the participants saw their shame as produced in interaction with others, effective management and repair of shame depended not just on a changed view of the self but on a repositioning of the self in relation to others. This analysis therefore suggests that repair of shame may often need to be mutually negotiated and as such provides support for theoretical approaches to shame which emphasize the centrality of others' actual or perceived judgements of the self.

Socially sensitive lactation: exploring the social context of breastfeeding.

Many women report difficulties with breastfeeding and do not maintain the practice for as long as intended. Although psychologists and other researchers have explored some of the difficulties they experience, fuller exploration of the relational contexts in which breastfeeding takes place is warranted to enable more in-depth analysis of the challenges these pose for breastfeeding women. This article is based on qualitative data collected from 22 first-time breastfeeding mothers through two phases of interviews and audio-diaries which explored how the participants experienced their relationships with significant others and the wider social context of breastfeeding in the first five weeks postpartum. Using a thematic analysis informed by symbolic interactionism, we develop the overarching theme of 'Practising socially sensitive lactation' which captures how participants felt the need to manage tensions between breastfeeding and their perceptions of the needs, expectations and comfort of others. We argue that breastfeeding remains a problematic social act, despite its agreed importance for child health. While acknowledging the limitations of our sample and analytic approach, we suggest ways in which perinatal and public health interventions can take more effective account of the social challenges of breastfeeding in order to facilitate the health and psychological well-being of mothers and their infants.

Expressing yourself: a feminist analysis of talk around expressing breast milk.

Recent feminist analyses, particularly from those working within a poststructuralist framework, have highlighted a number of historically located and contradictory socio-cultural constructions and practices which women are faced with when negotiating infant feeding, especially breastfeeding, within contemporary western contexts. However, there has been little explicit analysis of the practice of expressing breast milk. The aim of this article is to explore the embodied practice of expressing breast milk. This is done by analysing, from a feminist poststructuralist perspective, discourse surrounding expressing breast milk in sixteen first time mothers' accounts of early infant feeding. Participants were recruited from a hospital in the South Midlands of England. The data are drawn from the first phase of a larger longitudinal study, during which mothers kept an audio diary about their breastfeeding experiences for seven days following discharge from hospital, and then took part in a follow-up interview. Key themes identified are expressing breast milk as (i) a way of managing pain whilst still feeding breast milk; (ii) a solution to the inefficiencies of the maternal body; (iii) enhancing or disrupting the 'bonding process'; (iv) a way of managing feeding in public; and (v) a way to negotiate some independence and manage the demands of breastfeeding. Links between these and broader historical and socio-cultural constructions and practices are discussed. This analysis expands current feminist theorising around how women actively create the 'good maternal body'. As constructed by the participants, expressing breast milk appears to be largely a way of aligning subjectivity with cultural ideologies of motherhood. Moreover, breastfeeding discourses and practices available to mothers are not limitless and processes of power restrict the possibilities for women in relation to infant feeding.