INNOVATING MENTAL HEALTH CARE

Katia Dupret Søndergaard INNOVATING MENTAL HEALTH CARE - A CONFIGURATIVE CASE STUDY IN INTANGIBLE, INCOHERENT AND MULTIPLE EFFORTS Ph. D. Dissertation 2009 The Danish School of Education, Aarhus University

Innovating mental health care a configurative case study in intangible, incoherent and multiple efforts Katia Dupret Søndergaard

Innovating mental health care a configurative study in intangible, incoherent and multiple efforts Thesis submitted for PhD Department of Learning Research programme of Organisational learning The Danish School of Education Aarhus University Katia Dupret Søndergaard 18 September 2009

Acknowledgements The process of writing this thesis has been a long journey: Hard and lonely at times, and invigorating and refreshing at others. In spite the fact that only I can be held responsible for the final text, the process of researching a PhD. and being ready for the next step of continuous engagement with the text, with the empirical material and with the analysis has always been done in relation to other things and other people. I would like to thank them all. Primarily I would like to thank my children Aske and Mira for reminding me of the importance of playfulness and the connection to the world that is well beyond words. A special thanks to Nana Benjaminsen for showing up at a crucial time. Our connection made everything grow in our presence. Thank you for your sparkle. Thanks to Maria Duclos Lindstrøm, whom I admire for her humour and unconventionality, and for her ability to catch the ideas that I formulated at times like butterflies but did not have a net to catch them with myself. Thank you for making me able to re-open and improve the text once again in the final two weeks of my writing. Thank you to Will Medd, my coach and my dear friend. You told me the most important thing in the process of writing this thesis: Supervision is a luxury not a necessity. Thank you for making me write letters, and for providing answers when it was necessary and not providing answers when it was not. The reading group on cultural matters that developed along the way with Bjørn Schiermer Andersen, Anders Blok, Marie Bruvik Heinskou, Helene Rathner, Cecilie Juul Jørgensen, Camilla Balslev Nielsen, Nana Benjaminsen and Marie Duclos Lindstrøm opened the world of things and materialities and many other related academic discussions to me. Thank you for providing a supporting, nurturing, fun and intellectual challenging group that showed me that academia can be fun. Thank you for the luxurious and precise feedback from my supervisors Estrid Sørensen and Signe Vikkelsø. You engaged with my intellectual endeavours and knew where I was in the process and nurtured my confidence and trust that made me and the text develop and grow. Thank you for the valuable and enthusiastic support from my host supervisors during my stay at the Sociology Department at Lancaster University, UK, Vicky Singleton and John Law. And to Jules Knight for rendering all the logistics of that stay smooth. Paula Bialski, Anette Jerup, Jesper Olsen and Julian McHardy, Professor Elizabeth Shove, Maggie Mort, Monica Büscher, Bülent Diken and the rest of the staff and the post - graduates in the Sociology department for making my stay a fantastic intellectual and i

social exchange. Thank you to Thomas and Susanna Marvedel and their children for hosting me in their fantastic Pipi-long-stocking house on the top of the hill. Thank you to all the Medds for making my stay away from my children, though very hard, at least bearable. Writing a thesis in a second language is a laborious process. It both opens and closes the access and engagement with the intellectual world. It closes it because discussions and arguments so often are curtailed due to lack of nuances and sharpness. It opens it because so many intellectual exchanges can occur across borders. I place my money on the cross-cultural exchanges and hope that with the help of Hazel Medd, who I thank for the important and careful work correcting my English, the nuances and sharpness have remained. Other people have helped me with the last proof-reading bits of the thesis. I am grateful for the assistance I have received from Stine Trentemøller and Katrine Lehmann Sivertsen. Finally, Jakob Fruensgaard saved the layout of the thesis from becoming an aesthetic disaster and Knud Holt Nielsen helped with the front page and the illustrations in the thesis. Thank you to Professor Dorte Marie Søndergaard for encouraging me, and believing in the project and for making it possible to be at the Educational Psychological Institute at the time. For the initial formulation of the project my thanks go to my former boss Birgitte Andersen for encouraging my marginal ideas, for seeing possibilities and for reading the political winds within mental health care. Thank you to the Head Manager in the Zealand Region and in the Storstrøm County at the time Dr. Med. Per Vendsborg, for supporting the fundraising initiatives I made to realize the project, for supporting the investigation in the county, and for the financial assistance he gave the project enabling it to become financially realistic. The thesis has been financed by three parties: The Danish University school of Education, the Ministry of Health and Internal Affairs and the Political committee in Stortrøm County. A special thank you to the people in the outreach team who, despite busy workloads, welcomed me and allowed me to follow their work. I know it felt fragile and vulnerable at times, I am grateful for the opportunity you gave me to obtain a glimpse into just how important a job you do. I would like to thank members of the reading group, Governing with subjects : Malou Juelskjær, Christa Amhøj, Hanne Knudsen, Helle Bjerg and Dorthe Staunæs. I have followed this group and it has followed me from the beginning of my PhD career. It has provided me with interesting discussions and nurtured my ambitions to think outside of the box. Further I would like to thank Steen Jessen for his sincerity and eagerness to nurture and challenge those ambitions. Thank you Dorthe Staunæs and Jette Kofoed for reading early drafts of my conference presentations and for the detailed editing work on one of my first articles based on analyses of the field material in this thesis. Thank you Tom Mathar and Yvonne Jansen for taking the initiative to invite me and ii

others from the prevention session at EASST 08, to write an anthology on preventive care practices and for taking upon yourself the heavy work of editing our drafts. The comments from the editing work have informed and improved several analyses in this thesis. Thank you Signe Vikkelsø and Randi Markussen, for valuable comments at my first work-in-progress seminar. Thank you to Professor Cathrine Hasse and Casper Bruun Jensen for reading my drafts and giving precise and supportive feedback at my second work-in-progress seminar. Thank you to my most recent roommates, Dorthe Staunæs, Malou Juelskjær and Hanne Knudsen. I apologize for my mental absences in the last months. Observing and chatting with you have given me the groundedness and a lot of insight into what it means to make an academic career. I still hope to be able to motivate you for ten minutes a day on the floor. Thanks to my family, and especially Ingrid Merchandani Rasmussen and Birgitte Kirsten Jensen together with their husbands, and my dear uncle Richard Saint Pol- Minier who have all been of invaluable support in the family when we were overwhelmed with work. Thank you for giving our children your love and nearness. Lastly, thanks to my dear husband Jacob Dupret Søndergaard, thank you for always giving me the crucial resistances, encouragements, love and loyalty. Frederiksberg, 18 September 2009 iii

List of publications relating to the thesis A number of publications and papers have been presented, submitted and accepted for publication in the process of writing this thesis: Søndergaard, Katia Dupret (2009). Intangible innovation processes in psychiatric practice A configurative case study. Submitted for peer reviewed Social Technology workshop in Amsterdam, October 2nd. Paper based on the analytical chapter on closed dialogue. Søndergaard, Katia Dupret (2009). Silence. Conference paper/workshop for Mental health and STS seminar, Lancaster University, GB. Paper based on drafts of silence collective dialogue analytical chapter. Søndergaard, Katia Dupret (2009). Configuring professional identity a way to renegotiate good care. Book chapter, forthcoming Dec., scientific anthology. In Thomas Mathar & Yvonne Jansen (eds). Health Promotion and Prevention Programmes in Practice. Transkript: Germany. Book chapter based on drafts from chapters on collective configuration and intensive configuration. Søndergaard, Katia Dupret (2009) Sammensmeltninger og konfrontationer i psykiatrien: teknologiers medkonstituering af nye subjektiveringsmuligheder for professionelle. Scientific article, forthcoming. In: Nordiske Udkast 2009 p. 1-22. Based on analyses from chapter on intensive configuration and multiple presences. Søndergaard, Katia Dupret (2008). Effects of No-strategies alternative resistances. Conference paper. Resistance, Power and Discourse, Manchester, spring 2008. Based on analyses not included in the thesis. Søndergaard, Katia Dupret. (2008). Renegotiating "best treatment practice" and professional subject positions. / p. 1-13. Conference paper: 4S/EASST conference "Acting with science, technology and medicine", Rotterdam, Holland, 20-23. Aug. Based on collective configuration, multiple presences. Søndergaard, Katia Dupret. (2007). Dancing Technology...Conference paper: Beyond Waltz - Dances between individuals and organisation (EGOS), nr. 23, Vienna, Austria, 5-7. juli 2007 (15 s.), peer reviewed. Based on drafts from chapters on analytical resources, and universal dialogue. iv

Table of contents PART I - Introductions 1. Introduction 2 Initial trajectories 2 The research problem 5 An actor network approach to innovation 7 Invisible and intangible work 9 Research question 12 Care research and its adaptability with ANT/STS 13 Aims 18 Thesis outline 20 2. Style and Approach 25 From universal truths to local surprises 25 To be is to be related 27 Giving place to the world s multifariousness 28 Interest 29 3. Innovation in mental health care 33 Studies that raise methodological issues 34 Studies that innovate treatment 35 Technological innovations in mental health 38 Studies that use staff training as a means to innovate 40 Staff involvement 42 Leadership responsibilities in innovation 42 Studies that raise issues of what influences innovation 44 Unconventional approaches to innovation 46 Summing up innovation and mental health 47 4. Introducing the case study 50 Organisational framework 53 Description of the team 55 Type of activities and meetings in the team 56 Patient visits 58 Morning conferences 59 v

Team meetings 60 Meetings with other parties 61 The Open Dialogue approach 63 Summing up on Open Dialogue principles 65 The aspiration of Open Dialogue in the community team 66 Structuring the learning process 67 Summing up the introduction of the team s work 70 5. Analytical resources 71 Theoretical minimalism 71 Actor-Network Theory 73 Symmetry 74 Heterogeneous innovation processes - The principle of generalized symmetry 74 Gaining strength and stability 75 The hidden potential in generalized symmetry 77 The performative turn in Science and Technology studies 78 Performance 79 Actant 81 Figuration 83 From figurations to configurations 84 Configuring innovation 85 Summary of analytical resources 86 6. Methodology 88 Mistakenly looking for singular knowledge claims 88 How to avoid object reifying research? 90 Accessing the field 93 An ongoing renegotiation 93 Getting there 94 In the team 95 Cutting the mutual intervention - Anonymity and objectivity? 98 Absent actors 99 Collected material 101 Overview of types of data 101 Observation 102 Me - the fieldworker 102 On the use of video 103 Conversations and interviews 104 Method 107

Shadowing 107 Moving conversations 108 Slowing down to listen heterogenically 110 Tools of selection 112 Temporality of the material 113 Historical trails of reference 115 Surprise 116 Interactive emotional makeup 118 Summing up 123 Part II - Dialogues 7. Alternative dialogue 125 Introduction to cutting the connections 125 Mental health forms black boxed 125 Cutting forms from the alternative dialogue 128 Forms and diagnostics generalized 129 The diagnostic form configures the alternative 131 Validating the alternative to the medical world view 135 In the alternative configuration classifications are still taking place 137 Summing up the composition of an alternative dialogue 138 Conclusion - Invisibility 139 8. Universal dialogue 141 Introduction 141 Cutting connections to clinical evidence 142 Universality and fluidity 145 Universal values are added 147 Implications of fluidity and universality 148 Conclusion adaptability is both good and bad in innovation processes 150 9. Closed dialogue 151 Temporality composed through cutting connections 151 Cutting connections to the past 156 Cutting connections to the future 156 The heterogenic present 158 Conclusion a self-referring configuration 159

10. Intensive dialogue 161 Performing space 161 Is a circle of chairs providing trust and security? 162 Performing a circle of chairs 164 The effects of the circle of chairs 165 Extending mutable immobility to the circle of chairs 167 Intensity 168 Conclusion of the performance of the purified circle of chairs 170 Part III - Negotiations 11. Multiple presences 173 Introduction 173 Disrupting the round 174 Conclusion Inserting managerial responsibilities 177 12. Adding together the psychiatric doctrine and humaneness 179 Open Dialogue borrowing from the medical world view 179 Do innovations necessitate contradictions? 182 Extension rather than cutting connections 183 Conclusion Collectivity and hierarchical trails united without tension 185 13. Fragmenting diagnostic recruitment procedures 187 Introduction 187 The researcher is connecting continuity and continuity 187 The researcher asks an odd question 188 Conclusion on fragmenting existing practices 195 14. Silent work 196 Introduction 196 The how of silences 197 What kind of silence? 197 Silences as a configurating actor 198 The silence of the passive collectivity 201 The witnessing silence 202

The silence of the ontological shift 203 Collective silence 204 Configuring silence and expectations 206 Configuring silence and emotions 209 Conclusion: Silences are important to acknowledge innovative work 214 Part VI - Conclusion Conclusion: Intangibility in innovative mental health care practices 217 Configurations 218 To change or to disappear Innovation processes are hard work 222 (In)-visibility, politics and mental health care Reforming mental health care 224 Propositions 226 References 230 Appendix: Ethical considerations 244 English abstract 247 Dansk sammendrag 254

Part I - Introductions This thesis investigates innovation processes in mental health care through the lens of micro situations analyses from an Actor-Network theoretical position. 1

1. Introduction Initial trajectories When I was working in the research unit of the psychiatric department of Southern Denmark part of my job was to make contact with psychiatric personnel both through my teaching and through qualitative interviews in order to establish their reasons for leaving their jobs. Through these interactions in these interviews I discovered a strong sense of frustration in the personnel as they described their motivations and reasons for being in the mental health care profession and why they left. They expressed that they were trying to make a difference to the lives of the patients and in some respects this, in practice, had become difficult for them. This sense of frustration has been the motivating puzzle for writing this thesis. The frustration per se, however, is not what I am going to investigate. Rather, I am puzzled and want to understand what this frustration is an expression of in the everyday practices of the mental health care and how the wish to make a difference is translated into these everyday practices. Loaded with this initial drive towards finding out how the personnel themselves tried to surmount their frustration, I started to look for how they might formulate approaches that would take away this frustration in their work. This search led me to an article in a social psychiatric journal about the treatment approach Open Dialogue. It was written by a head nurse in charge of a ward that tried to renew its practices around this approach. When reading this article I found a link to the staff members search for a solution to the problem of how to reintroduce meaningfulness into their working practices. I wanted to investigate how they found out which practices should be changed and, indeed, how practices could be changed. I was intrigued to investigate what kind of practices psychiatric professionals would find that would be making a difference. The Open Dialogue approach presented in the article was formulated as proposing an approach that offers this. My curiosity had now shifted from trying to understand what promoted the frustration of the personnel in mental health care to wanting to investigate how mental health care staff aspired to make their practices different in order to surmount this frustration. Many initiatives have been made nation- and worldwide to make treatment better. The Open Dialogue approach is one such initiative. The reason why my investigative trajectory ended with this approach is due to a number of juxtaposed interests and incidents. Firstly, in brief, the Open Dialogue approach is proposed as an alternative that improves the treatment and, more importantly, makes the approach to the patient better. This formulation of offering itself as an alternative is also linked to a broader 2

criticism of psychiatry in general that in line with the anti-psychiatric movement of the 70s, to an increasing degree, has been criticised for being objectifying and reductive and therefore only taking into account isolated aspects of the patients lives (e.g. Foucault, 1973/1979; Illich, 1976; Scheper-Hughes & Lock, 1987) or for creating whole new conceptualizations of the individual that cut out substantial parts of how one is to understand the whole human being (e.g. Rose, 2007). Further, psychiatric governmentally funded services have been criticised for mixing matters of economic and neo-liberal arguments, framed in terms of individual choice, with understandings of care practices (Mol, 2008). Or for an increasing focus on managerial monitoring strategies rather than focusing on quality in the treatment (Rankin & Campbell, 2006) as represented in the so-called neo-liberal era of the health field in general and the mental health field in particular. The Open Dialogue approach adds to this criticism by proposing a mental health care that is based on dialogue rather than standardisations and a decision making process in treatment that is taken collectively with the patient and his or her relatives. Secondly, the Open Dialogue approach resonates with initiatives focusing on qualitative values that are found in many places in the Danish health care system in general. For example the initiatives formulating value guidelines of respect and autonomy towards the patient found in the national code of conduct for adult psychiatric services in Denmark (Lindhardt & Christensen, 2005) and this is therefore a good initial example to answer how making a difference is taken up specifically in this approach. Thirdly, the county that facilitated the formulation of, and part of the funding for, this research project had taken different steps to encounter the Open Dialogue approach. This is also the reason why I discovered that an outreach team 1 in Southern Zealand, Denmark had actually started the process of introducing Open Dialogue in their daily practices. Approaching this outreach team with my initial questions and a project outline, the team members explained to me that the introduction of the Open Dialogue approach was an attempt to make a difference in the mental health field. To them Open Dialogue provides an approach that makes mental health care practices more respectful towards the patients and therefore more meaningful to themselves as staff members. In that sense I was given a fantastic opportunity: I was offered the possibility of following this outreach team in their struggles to introduce a treatment approach that offered a 1 Further explanation of the outreach team is given in chapter 4 introducing the case. 3

potential solution to their expressed frustration. For the team, Open Dialogue offers the ethical values that they feel are absent in their existing working routines. The team members expression of absence of ethical values in the traditionally organized psychiatric setup links to what has already been raised as a critical issue in the anti-psychiatric movement in the 1960s (Laing, 2001/1960) 2 that was briefly mentioned above. In the Open Dialogue approach the team members find respect, listening, dialogue and inclusion. To the team members these ethical values should, ideally, come before anything else in psychiatric treatment. Due to prioritizing these values, other more traditionally prevalent issues such as; professional knowledge on psychiatry, hierarchical positions, patient journals, nationally conducted questionnaires and surveys or diagnostics are constructed as secondary or absent in many of my investigations of the practices in this team. But the story does not end with the innovative efforts. In retrospect something else happened as well. The practice of the Open Dialogue approach disappeared during and after my field work. This was not something that was clear during my field work. However there were signs; during my stay with the team, the team members started to look for other jobs, and resigned. Afterwards, I learned that no managerial decision was taken to keep on trying to apply the principles of Open Dialogue after the disappearance of the people who had introduced it in the first place. In spite of the interesting possibility to pursue this disappearance I have remained loyal to the ethnographic study that was conducted in the first place. The analytical focus is thus not primarily to post-rationalize the cause of events. As such the material at hand had the focus of how the effort to introduce something new was done. The ethnographic material was collected at a certain time and this temporality has to a large extend been kept in the analyses. Also, I do not have the information at hand to explain its disappearance fully. Therefore, the focus remains on how to understand the efforts of something that was initially formulated as being an important contribution to meaningful changes within mental health care practices. Thus, what will be my matter of concern in this text is to investigate how innovating mental health care is a matter of continuous, negotiating efforts. 2 The movement was most clearly formulated in the 1960s, where the psychiatrists David Cooper and Ronald D. Laing were among its supporters. The term was invented by Cooper in 1967. Laing and Cooper argued for example that schizophrenia is not an objective phenomenon, but an interpretation of the traditional psychiatry and making part of its scholastic diagnosis. Psychotic symptoms are considered as normal reactions in a sick society. The distinction between practitioner and patient was to be dissolved and it was important to go through the mental crisis rather than disrupting it as in traditional psychiatry. 4

The research problem These initial trajectories and connections between several points of interests and people with a focus on wanting to change mental health care pointed my research in the direction of investigating how this change is aspired to be obtained and how it is done in practice. The introduction of the Open Dialogue approach is one such attempt at introducing a new good care practice to renew and innovate the psychiatric system. To renew and innovate something new needs support. The protagonists of what is argued to be innovated must try to convince others to relate to the new project. To get Aramis past the paper phase into the prototype phase, you have to get a whole list of things interested in the project. (Latour, 1996a, p. 57). The innovation requires acceptance, participation, time, resources, resolution of eventual conflicts, and other direct or indirect ways of showing support for the initiative. The efforts to persuade others may be difficult and long-lasting. The research problem which the thesis investigates will be to investigate how such an innovation process travels into an already established practice of psychiatric care. Innovation in classical terms is thought of as an effort by one or more individuals to create economic profit through a qualitative change (Schumpeter 1934 in Darsø, 2001, p. 93). Likewise most models of innovation originally integrated an economic aspect as Schumpeter was an economist. However, innovation models have gained greater scope and flexibility. Innovation can be a new product, a new production process, a new form of organisation or management, and a new form of marketing or general market behaviour (Darsø, 2001, p. 94). One way of trying to include the process element in innovation rather than only the end product is formulated by Van de Ven & Poole (1995): a good process model of innovation development does more than simply define its component events; it strings them together in a particular temporal order and sequence to explain how and why innovations unfold over time. (Van de Ven & Poole, 1995, p. 163) This approach seems to acknowledge that innovation is not only about the end product. However, it also keeps a strictly linear and causal line of explanation. It suggests that innovation is about an accumulative cause of events that added together will bring the end product. Even though it might be that the end product of an innovation process is rational, it does not mean that the innovation process in itself is that too. Innovation processes include both the irrational and the relational aspects of the creation process. And both elements are important to explore in order to understand its creativity and ways of coming into being. The mental health field has also been the subject of innovation studies. To mention but 5

a few: (Addington, 2009; Amiel, 2001; Arthur & Lalande, 2009; Arya & Callaly, 2005; Barton, Johnson, & Price, 2009; Bertrand, 2009; Bodenheimer, Lorig, Holman, & Grumbach, 2002; Broom, 2005; Cummins, Curtis, Diez-Roux, & MacIntyre, 2007; Magnabosco, 2006; Massatti, Sweeney, Panzano, & Roth, 2008; Mazzei, 2007; McKenzie, 2001; McLaughlin, 2003; Mercer, 2007; Nabitz, Jansen, van der Voet, & van den Brink, 2009; Nicolini, 2006; Overstreet, Casel, Saunders, & Armstrong, 2001; Paige, Julie, Debra, Nonie, & et, 2005; Panzano & Roth, 2006; Parr, 2008; Perrin, 2000; Praill & Baldwin, 1988; Pringle, 2009; Quatrano & And, 1975; Roberts, 1982; Rosenheck, 2001; Ruzek & Rosen, 2009; Scott & Du Plessis, 2008; Strosahl, Hayes, Wilson, & Gifford, 2005; Sznelwar, Silva, & Mascia, 2008; Timmermans & Berg, 2003; Timpka, Bang, Delbanco, & Walker, 2007; Winnick, Werum, & Pavalko, 2000; G. Aarons, D. Sommerfeld, D. Hecht, J. Silovsky, & M. Chaffin, 2009). Innovation within the field of mental health has been concerned with everything from improving treatment, to introducing new computer technology, to using sports, to training staff members and measuring different types of outputs. I will give an overview of the research themes and approaches in the chapter on innovation and mental health. Briefly, I have found that the approaches that apply innovation to mental health to a great extent resemble and apply slightly amended versions of the definition of innovation presented above. This body of research often reports on studies that have a clear criteria of measurement: what is to be measured and how, and the output: what is to be improved. Thus, most studies that I have come across operate with an approach to innovation processes as something that is linear, accumulative and causal. With linear, I mean linear in time, with accumulative I mean if the working practices are adding something it adds to the productivity, efficiency, knowledge and the value of the work and third by causal I mean that it is often assumed that when influencing working practices with, for example, training staff in a new technology, the causal outcome will be more knowledge in the new technology. In contrast to this reading of the field of innovation and mental health I do not produce neither linear, accumulative nor causal research. I aim to further add three dimensions to this body of research of innovation in mental health. These are multiplicity, heterogeneity and intangibility. These are terms that have a theoretical heritage, and they will be explained in the following. In order to grasp the multiplicity, when speaking of innovation processes and efforts in the outreach team I do it with reference to the readings of STS and ANT rather than to innovation models specifically. In those readings the irrational but also the material aspect becomes important when investigating innovation processes. As such it has to interest both people and things (Latour, 1996) and the question of added value is therefore not only defined by supply and demand or by management or some other human actor, but by a collective interest. I will come back to this in chapter 2 on the 6

scientific approach. An actor network approach to innovation At its broadest, most general level, this thesis, thus, investigates innovation practices in mental health care. But it is not about innovation in general. Neither is it about overall organisational innovations. Rather, I investigate how a newly introduced mental health treatment approach is attempted to be put into action by a specific group of personnel. It is the struggles of the personnel of the team and their experiences and the destiny of their newly introduced practice that is to be the focus of the thesis. Actor-Network Theory (ANT) and Science and Technology Studies (STS) have dealt extensively with processes of innovation in socio-technical and technical-scientific systems. To mention but a few:(e.g Bruun Jensen, Lauritsen, & Olesen, 2007; Callon, 1986; Callon & Latour, 1981; Laet & Mol, 2000; Langstrup Nielsen, 2005; Latour, 1987a, 1991/2006, 1993/1984, 1996a, 2005; Latour & Woolgar, 1986/1979; Law & Moser, 1999/2003; Law & Singleton, 2005; Mol, 2002; Mol & Law, 1994; Pols, 2005, 2006; Svenningsen, 2003; Sørensen, 2005). Their field of investigation is vast; from the disappearance of scallops, to artificial insemination, to technologies in class rooms, to Zimbabwean water pumps, to electronic patient records, to the development of aircrafts and subway trains etc. This extensive research in innovation processes is therefore my first reason for choosing ANT and STS as the theoretical and analytical sources of inspiration for this thesis. STS and ANT research do not only have a vast empirical field of coverage. STS and ANT are not closed theoretical paradigms. They are constantly relating to and negotiating with other theoretical and disciplinary fields and finding inspiration in anthropology, cultural studies, feminist theory, history, information studies, communication and media studies, informatics, educational studies, philosophy, social psychology and sociology. However STS and ANT researchers are strict in their use of specific overall meta-theoretical principles. These shared principles will be elaborated in chapter 5 on analytical resources where ANT is also described as an important constituting contributor to my investigations and part of the broader field of STS. But briefly, for the purpose of introducing my positioning here in the introduction, I divide my inspiration within this scientific field between two sources. These two sources of inspiration are usually named: Traditional ANT (e.g. Callon, 1986; Latour & Woolgar, 1986/1979) and Post-ANT or a Post-Human position (e.g. Bruun Jensen, 2005; Gad, 2005, 2009). The traditional principles of ANT inform the thesis with the principle of generalized symmetry which implies that both humans and non-humans potentially make a difference to the construction of practice. Traditional ANT also initiated the idea that 7