Text A is titled “Making a good mental health diagnosis: Science, art and ethics”. Text B is titled “What really works in special and inclusive education: Using evidence-based teaching strategies”. Both titles foreground the texts’ interests in serving those with mental health conditions and disability/special needs, Text A through choosing psychiatric diagnoses and treatments in general practice, and Text B through choosing teaching strategies in education. Both titles are oxymoronic, suggesting contradictions in their terms. Text A seems to make the assumption that “a good diagnosis” can be established and described, yet counterbalances this normative singularity after the colon, by invoking the vast disciplines of science, art and ethics as essential to this act. While inclusive, the order of words in this list designs its own hierarchy, perhaps unsurprisingly putting science first. The breadth of knowledge and expertise required to make “a good diagnosis” is established from these first words, which are accompanied by a triumvirate diagram, like a three-leaf clover interchange. Science, art and ethics are here inextricably and harmoniously intertwined.
Text B’s title draws, apparently unironically, on the much critiqued (Biesta, 2007; Eisner, 2001/2017; Mockler, 2011; Zhao, 2017) education paradigm of “what works”, using the adverb “really” to emphasise the exceptional quality of its advice, yet applies this normative paradigm to a student cohort which is extremely diverse, and has historically been harmed by a medical or scientific approach (Brantlinger, 2009). For Lucinda, this title unintentionally intertextually invokes the voices of these critiques, and also, perhaps intentionally, the heft of the USA’s “What works” clearing house, a repository for specific solutions to generalised educational problems, based on scientific-style, quantitative evidence. In contrast to the complexity represented by the intertwined logo of Text A, Text B offers a linear and mathematical solution that is sustained throughout: evidence + teacher = outcomes.
Text B also chooses to use the contentious term “special” in its title and throughout, despite critique of this as a label risking the “assignment of children to categories of defectiveness” (Slee, 2013). It has also been called out for sustaining undemocratic separation, and for its “deep implication in matters of both racism and ableism” (Ferri & Connor, 2006). These critiques are not addressed anywhere in Text B.
As we read these texts, it emerges that these titles are representative of their respective text’s complexity (Text A), and internal contradictions (Text B). Text A reveals the irony of the “good” diagnosis by suggesting that sometimes, no diagnosis at all is preferable. Text B continues to claim to support diversity and yet simultaneously undermine it through the singularity of “what works”.
Openings of texts
Both texts open with an aspirational paragraph; they similarly aspire to quality of life for patients and students with mental health conditions, disability or special needs. Yet beyond this, they exhibit profound differences that upturn any assumptions that might be made about “clinical” medicine and “caring” education. Text A opens with the statement “PSYCHIATRIC DIAGNOSIS is difficult”, all bold red capital letters for the first two words (this is the journal’s style). The complexity of medical work is diagnosed as the problem here from the outset. Text B defines the underperformance of students with additional needs, and the underperformance of their teachers in relation to implementing evidence-based practice, as the problem to be resolved. This sets up contrasting interpersonal relationships between the authors and their professional audiences. Text A addresses allies. Text B addresses recalcitrants. These orientations have hierarchical power implications. Text A’s authors and audience are side by side. Text B’s authors are figuratively superior.
From the start, these texts address and attempt to call into being two kinds of professionals: “Good” doctors wrestling alongside each other with professional challenges and “bad” teachers who are not doing what they “could, and should [researchers’ emphasis]” do to close the “gap” between quantitative research findings and classroom practice. This spatial metaphor of the “gap” defines research and practice as separate, despite the rich educational tradition of praxis, or theoretically informed research in action (Freire, 1972). Evidence needs to be “integrated” into doctors’ practice yet teachers must “adopt” it entirely. Text B draws on the 2002 President’s Commission on Excellence in Special Education, which “bemoaned the lack of emphasis on aggressive intervention using research-based approaches”; teachers are implicitly chided for finding inspiration and support from their own experiences, or their colleagues, rather than “evidence”. The use of the word “aggressively” contrasts with the gentle and considered medical approach of Text A, and the medical authors’ sensitivity to patients. “Bemoaned” positions teachers as in deficit. The chief challenge in teachers implementing evidence-based practice is presented as their ignorance of it and incapacity to interpret it. An allusion is made to the fact that “much remains to be investigated”, suggesting the authors inhabit an imaginary in which every single aspect of education will one day have been studied by rigorous randomised controlled trials. These versions of practice and professionalism inhabit broader discursively realised and fundamentally different worlds; discourses of teacher fallibility are common in both academia and the media.
We do flag that Text B, as a more commercially oriented product, must define a need for what it offers as a purchasable solution. The logics of production and consumption inform discourse, and the authors position themselves as saviours readily capable of “rectifying” deficiencies in teachers and students. They have what their audience does not (knowledge of scientific evidence), and of which teachers are notionally in need, in order to perform as “effective” or proper educators. In contrast, in Text A, effective doctors “recognise and acknowledge” the limitations of science, especially in regard to classification systems for mental illness and their associated evidence-based guidelines. They combine the “warp” of this important but inevitably flawed science with the “weft” of lived experience to form a clinical partnership with patients. Together they seek common understandings and make shared choices. This feminised weaving metaphor is in stark contrast to Text B, which demands teachers eschew experiential knowledge. Text A and B’s versions of practice and professionalism are epistemologically distant from each other.
Text B refers to “the body of evidence” in education as a static and clearly defined thing. Text A reminds readers of the ways psychiatric classifications have: (1) changed over time (for example, “hysteria”); (2) disappeared (“homosexuality”) or (3) emerged (“internet addiction”). Classifications and the concept of “disorder” itself are understood as socially constructed. The authors caution readers about the much-contested boundary between wellness and illness in psychiatry. For Andy this intertextually references the radical and influential work of RD Laing (1990) and his controversial notion that, in some desperate circumstances, “madness” makes more sense than wellness. It foregrounds how frequently comorbidities (multiple disorders) complicate choosing a “correct” course of action, and also how premature or incorrect diagnoses can harm.
Mistakes, in fact, are made through over-reliance on an evidence base that by nature excludes comorbidities in selecting trial participants. This is a distinct danger in education, too, that randomised controlled trials exclude participants with multiple special needs, yet Text B only once, in the introduction to the book, mentions in passing some apparently insignificant “problems” with the “body of evidence”. Text A realises that “shame and stigma” mean much is hidden. Text B assumes all can be readily known and revealed- the foundation of popular evidence-based programmes such as John Hattie’s Visible Learning (2008). Again, this epistemological difference materialises very different practice and professionalism, with doctors as empathetic listeners always open to learning more about their patients but aware full knowledge of others will never be achieved, and teachers as aggressive viewers who must see all, know all and, ultimately, control all.
Bodies of texts
The first pages of these two texts provide a further contrast. In Text A, one third of the first page describes Aditya, a 10-year-old boy from an immigrant family who is refusing to go to school. He is quoted describing his situation, his voice represented in the article through direct quotations and reported speech. His teacher’s perspectives are included, along with his mother’s concerns and suggested diagnosis for her son. Aditya’s story is a framing device, performing a textual metafunction creating cohesion for the article, and the authors return to him to personalise and humanise their discussion. No individual is named in Text B, and no voices of students, teachers or parents are included.
Instead in Text B, under the bolded heading ON THE WHOLE, STUDENTS WITH ADDITIONAL LEARNING NEEDS HAVE LOW LEVELS OF ACADEMIC ACHIEVEMENT, over 80% of the first page provides statistical data on the low academic achievement of students with additional needs, especially those with “mental retardation”. At this point, we step outside the dispassionate guise of discourse analysts and share that the authors’ use of this term creates a visceral shudder of deep unease for us. It is a phrase from our pasts, and we cannot detach ourselves from its countless iterations, in our childhoods, as a cruel insult. The authors, later in the chapter, attempt to justify their use of such terms because they appear in the body of evidence; the authors characterise such terms as merely “going against” their person-first sensibilities, but still appropriate.
We find this language unacceptable and feel concerned that it may be presented to and modelled for pre-service teachers. Such terms also highlight potential problems with the research being drawn upon, with its definitions, classifications and intentions. Returning to the section as a whole, this deficit construction of learners, via the language of “low”, and its bulk in the text, contrast with the way social actors are represented in Text A; genericisation and specification, whether people are assimilated into groups or treated as individuals, and whether they are quantified as statistics, are important representational choices authors make (van Leeuwen, 1996).
We acknowledge that inclusive educators face difficulties in wishing to expose barriers to success while avoiding portraying students as victims. Ye the cumulative effect of the statistics here and the language used, with their effects inextricably interwoven, create a weight of dismal deficit: “low” (used six times); “little”; “concern”; “gap”; “insufficient”; “disproportionate”; “exclusion”; “paucity”; “diagnosis”; “disadvantage”; “risk”; “poverty”; “less”; “problems”; “drop out”; “unemployed” and “underemployed”.
Text A relies on story. Text B draws conclusions from quantitative data, not story. This creates different implied interpersonal relationships between doctors and patients, teachers and students, described as follows. Doctors, in Text A, are oriented towards patients, to context and to multiple voices telling different stories. Teachers, in Text B, are oriented towards data’s monologic story, told only in the voice of an archaic version of quantitative science. Doctors’ impetus, in Text A, is to listen. Teachers, in Text B, is to fix. While Text A’s doctors draw on knowledge that is ever changing, socially constructed, unstable, evolving and always open to challenge from patients’ stories, Text B’s teachers implement knowledge as tool, unchanged over time, even in its language. Medicine, in Text A, reports that an “objective” problem-based approach is demonstrated to be “particularly damaging” to some individuals. Education, in Text B, does not mention this. Here we reflexively note the way our own language can readily construct these two articles as accurately representative of their fields, when further research would need to be done to establish this.
Another striking contrast in the ways doctors and patients, and teachers and students are represented is in terms of their agency. One way this can be determined is through their presence in the text, the ways they are grammatically constructed as active within sentences and both the kinds and number of verbs. In reading with attention to active verbs, identifying, counting and listing them, we found that doctors’ actions in Text A are largely but not entirely about perception and interpretation (“understand”, “consider”, decide”, “believe”). Eleven of the 40 active verbs representing actions carried out by doctors are interpersonally oriented (“ask”, “understand”, “discuss”, “negotiate”). Teachers’ actions, in Text B, are largely but not entirely instrumental (“plan”, “implement”, “evaluate”, “increase”). Only three of 44 teachers’ active verbs are oriented towards dialogue (for example, “help”).
The modality of the verbs (on a continuum from definite to possible, as represented by the words “must” and “might”) used throughout each text is also of interest, suggesting doctors are working out what to do, as part of their professional role, while teachers are busy doing what they “must”. This also suggests the orientation of the authors to their audience, as peers or in positions of greater power and seniority. Most powerful of all, however, was an observation related to patients and students and the number of active verbs overall, pertaining to their actions. Text A contains 47, while Text B contains 26. In portraying and constituting practice, patients are much more present and active in Text A than students in Text B. This invites us to question whether attention to patients and patient involvement in evidence-based medical practice is more important than attention to students and student involvement in education. If so, this is in line with our perception that in Text A, evidence-based practice is a partnership between doctors and patients, In Text B, it is an individualised, performative response to perceived inadequacies in professional behaviour and student achievement.
Text B tells teachers that the authors “know what works”, assumes that teachers are “unsure” of effective strategies, and “frustrated by ideas that turn out to be fads and fancies”; teachers are thereby constructed as in deficit, en masse. While Text A also wants to provide support in good practice, this is constructed as a challenging and complex process, the pitfalls of which are present for all, including the authors. In Text A, four boxes complement the main text to demonstrate this complexity. The first box (notionally the “science” of the title) describes in detail the ten stages in making a diagnosis, including attention to developmental and family history, social situation and comorbidities. The second (the “art” of the title) describes developing a formulation, a theory about illness developed over time with the patient and including biological, psychological, socio-cultural and spiritual factors. These are all considered vital to finding reasons for illness and genuinely beneficial, feasible therapies. The third questions objectivity and describes how socioeconomic status and ethnicity of patients influence apparently objective decision making by doctors (practice and professionalism incorporating reflexivity and criticality). The final box (the “ethics” of the title) describes the ethical principles of respect for patient autonomy, non-maleficence, beneficence and justice that underpin psychiatric diagnosis. The dialogic interaction between the main text and these boxes represents the complexity of evidence-based practice in a profession that seems sophisticated, intellectually mature, reflexive and nuanced.
Text A offers segments of dot points, in a comparable way. These relate to defining effective teaching, factors other than quantitative evidence that need to be considered, and elements of an evidence-based programme titled “Success for all”; these are strategies used by effective teachers and distinctive teaching strategies that may be required by learners with additional needs. Alert to contradictions, we note that these segmented sections often function at odds with the main text, seeming to argue cases that contradict with other statements, and seem to us to align more with what we consider better practice (as opposed to a linear evidence-based teacher-centred process that homogenises diverse students as apparently advocated by early sections of the text).
While the various textual elements of Text A are consistent, cohesive and coherent, Text B undermines its own strict evidence-based approach with the difficult-to-measure concepts of changing student values, supporting student independence in the future and developing a sense of wellbeing in learners. The second segmented section recognises factors other than evidence that teachers take into account, including experiences, values, ideology, political beliefs, tradition and pragmatics. These, however, are presented as less reliable than “sound” evidence. Despite the treatment of students as groups, for example, those with the highly problematic label “mental retardation”, the authors also claim that “one size will not fit all”. One sentence in the text seems to come from a different source and to describe something other than the evidence-based approach predominant in other paragraphs:
Our strong advice is that you develop a repertoire of such [evidence-based] strategies nested within your own philosophy, personality, craft knowledge, reflective practice, professional wisdom, and, above all, your knowledge of the characteristics and needs of your students and your knowledge of local circumstances.
The more times we read Text B, the more bemused we were by its internal contradictions, its coercive posturing in relation to evidence-based practice conflicting with its snapshots of more holistic practice. It both determines to fix categories of students and yet is occasionally attentive to the diversity of learner needs. How to account for this? Is this a function of two authors with different perspectives and an inadequate editor? Is this because this version of medical evidence-based practice is an add-on to teaching, not yet adequately internalised and assimilated? Are the fragments of more holistic inclusive practice mere lip service to other ways of teaching, incorporated to secure hegemonic compliance from teachers? Are the authors’ allegiances genuinely split? Or are they peddling what is neoliberally compliant but unsustainable at the level of craft?
This brings us to wonder if the possibility that the project of genuine inclusion is too disruptive for education to bear. Does this text actually seek to do the work of exclusion, a noted effect of inclusive education (Slee, 2013), by positioning teachers and students as subservient to science and an imagined, archaic version of medicine? This is a version of medicine very different from that presented by Text A, which leads us to question the motivation behind this particular discursive construct of medicine in education.
Conclusions of texts
We turn to the final two paragraphs of the texts. Andy feels Text A intertextually references RD Laing’s famous chapter “The ghost of the weed garden” (1990), in which Laing describes Julie, who has chronic schizophrenia. This chapter and the book as a whole were a radical intervention in the psychiatric status quo, as Laing proposed that “normal” people might be more mad than those considered “insane”. A corollary of this, in relation to neurodiversity in education, would be for Lucinda’s student “Becky’s” behaviour to be considered more appropriate than that of other students. Becky, with a diagnosis as being on the autism spectrum, could only come to class if she could sit cross-legged in a corner facing the wall with her laptop on the floor in front of her, against a black wall. While this proposition might be readily dismissed, thinking with Laing, the requirement for humans to spend two hours in a room with no natural light or ventilation, 40 screens on small desks in cramped conditions, uncomfortable chairs, a glaring projector light and enormous screen at the front of the room, no soft surfaces, multiple cords and devices dangling from the ceiling, busy overhead beams and harsh, amplified sound is something to be interrogated. Those classed as neurotypical might be able to endure these conditions, but at what cost? The biophilic movement is beginning to suggest that Becky’s behaviour, which seemed bizarre to other students, was eminently sensible.
We include this example simply to demonstrate the kind of disruptive thinking that Text A countenances, even if only intertexually, through alluding to Laing and citing Launer, as two examples. Launer’s work challenges “traditional” medical approaches, even questioning “diagnosis” itself (2021). There is no evidence of this kind of reflexive, creative and radical thinking in Text B, suggesting a much more static “body” of professional knowledge and more conservative orientation. The intertextual imaginaries of these texts, both explicit and implied, are very different. Along with the works mentioned above, Text A invokes stories, case notes, classificatory schedules, a patient-authored blog, prescriptions, referral letters and formulations. Its citations include both evidence-based academic literature and works critical of existing paradigms. Text B invokes reports, blueprints, graphs, standardised tests, percentiles and the massed works making up a “body of evidence”. Its notes refer to quantitative research, and also studies showing how unscientific interventions such as facilitated communication and the determination of learning styles can harm students. There is some unintentional irony here, as certainly learning styles were introduced to education as empirically proven and scientific concepts. The authors here do not countenance that science itself changes, its truths change and provide no absolute, enduring warrants. Text A does not hesitate to accept this.
The final paragraph of Text A defines the general practitioner’s job as being more like a gardener than a botanist, “applying their skills to nurture and support the health of their patients within their rich contexts” (p. 801). This metaphor is one of nurturing, attention, care and temporality. Text B desires to “tune” teachers in to “how sound research will enhance [their] teaching” (p. 6). Teachers who do not use the strategies in this book are out of tune, not in harmony, discordant, or, like engines, running rough. Teachers are figuratively realised here as instruments, or machines, to be operated on or by others (including the authors, the “body of research”, academics and experts). According to Text B, teachers “should” become reflective practitioners, be self-critical and responsive, and produce research. Yet, contradictory to the end, this apparently means they should “find opportunities to collaborate with professional researchers to advance the evidence base for good teaching practice” … by participating in randomised controlled trials. The authors close, in a paternal tone, with a desire that extends the machinic metaphor. They use second person (“you”), as they do throughout, ostensibly to “connect” with the reader, but also making a direct demand on our attention and, ultimately, compliance. The imagined success of their project is also coercively performed by the present tense of the final verb “are”:
At the very least we hope that you will bring a scientific approach to your teaching… in other words, you are a data-driven professional.
To complicate this even further, however, Text B’s true final word, in the very last endnote, suggests teachers begin to add to the evidence base by conducting action research. This is surprising, as teacher-led action research is a form of qualitative research that is devalued in the scientist-led evidence-based paradigm currently in fashion in education. Text A ends the formal section of the text with a reminder of the importance of “systematically exploring the science, art and ethics of mental health experience” (p. 801). Patients are present to the very end, as those whose experiences and lives matter.