Involving service users in inpatient care and recovery planning has gained interest worldwide. Our purpose was to evaluate the process of implementation of a coproduced Recovery Guide (RG) intervention in 22 inpatient wards in Sweden, in terms of context, implementation process and mechanisms of impact over 12 months.A mixed method design and a process evaluation framework were used to guide data collection and to deductively analyze perspectives and descriptive statistics of delivery from three stakeholder groups.Results showed that although initial contextual barriers were present , it was possible to implement the RG in 14 wards, where 53% of admitted service users received the intervention. Legitimacy of the intervention, engaged managers and staff, capacity of staff and ward organization, coproduction and continuous support from user organization were critical mediators. Mechanisms of impact concerned (1) a new perspective on mental health, well‐being and recovery, (2) capacity building of a recovery approach in inpatient settings and (3) a meaningful outlet for users' thoughts and feelings on recovery, sharing narratives and influencing care and goals.The RG intervention has the potential to promote a recovery approach in inpatient mental health services (MHSs). Coproduction among stakeholders created trust and a sustainable implementation that made it possible for wards to resume implementation when contextual barriers had been resolved.The current study involved stakeholders including a service user organization, the public, first‐line managers and staff (including peer support workers) in inpatient and community MHS and researchers, who greatly contributed to the implementation programme, including codesign of the RG intervention as well as coproduction of the implementation in inpatient MHS. All authors have their own lived experiences of mental health problems as a service user or as a relative. Yet it might be precisely during such times that recovery‐oriented services are the most crucial when users need the most support in trying to make sense, process, cope and remain hopeful.The growing awareness of the importance of meaningfully involving service users and user organizations in the augmentation of MHS has evolved in response to critiques of traditional care.The purpose of the present study was to investigate the implementation of the RG intervention in inpatient MHS settings that was part of their regular quality improvement. More specifically, guided by the Medical Research Council (MRC) process evaluation framework,22.1n = 22) agreed to participate. Staff participating in focus group interviews (n = 32) were recruited by means of convenience sampling as they worked in shifts. For the brief survey about the RG intervention (after Education Step 1), 139 staff participated. Furthermore, 33 users anonymously filled in a survey. In all, 226 participants partook in the data collection.According to the MRC framework,Informed consent was obtained by all participants. The NSPH informed staff and managers about the purpose, and terms and use of data collection, for example, that it complied to general data protection regulation, was voluntary, would be analyzed to facilitate on‐going implementation and reported to stakeholders in relation to the quality improvement in MHS. Staff informed inpatient users about the same, who were invited as experts acting in an advisory capacity. They were asked to complete a paper–pencil survey about their perception of the RG intervention and put it in a closed envelope. Staff gathered all material and handed it to NSPH. All participants were informed that they consented to participation as they entered data collection, that data was anonymized and securely stored and that they could decline participation anytime. Researchers had no contact with participants and were subjected to secondary data that were available to the public and revealed no sensitive or personal information. Pulling together data sets during analysis neither posed  risk of deanonymizing participants. Furthermore, the intervention was the subject for data collection and not the human, that is, the questions posed concerned the use of the intervention and posed limited risk, harm or inconvenience for participants. Since nonpersonal and nonsensitive data was aggregated in these regular quality development activities of MHS, minimal harm was done.2.2The Recovery Guide—For You in Inpatient care.The RG intervention regards the introduction and follow‐ups of The springboard for the development was the Danish self‐help project named ‘Discharged’ in which a digital material ‘When you are discharged’ is designed to minimize frictions between inpatient and outpatient MHSs and prepare for discharge.The development was coproduced among stakeholders representing reference groups, unit‐ and first‐line managers and staff Table  from all2.3Implementation planning in different steps forms a critical part of quality implementation.The programme entailed implementation in 22 wards. Firstly in eight wards, and secondly in the remaining 14 wards. Including stakeholders at both meso‐ and microlevels of the organization helped to mitigate uncertainties that can arise in both vertical and horizontal relationships.2.4context component refers to factors that affect intervention, implementation and potential outcomes. The implementation process focuses on the dose delivered or received, the target group reached and possible adaptations. Mechanisms of impact focus on how participants respond to interactions with interventions.A convergent parallel mixed methods design was used to study the process evaluation components, using both qualitative and quantitative data.n = 32) and individual interviews with first‐line managers (n = 8) were performed. Furthermore, the user survey (n = 33) was administered by staff. Beyond this point, checklists and progress reports were collected for each ward (n = 22) during monthly site visits by NSPH (May–December). Fieldnotes further contributed information on context, implementation process and mechanisms of impact. Themes used for interview protocols, survey, monthly reports and fieldnotes were: (1) overall reflection on the implementation in relation to context, (2) routines and collaboration around the organization of the delivery, barriers and facilitators with regard to (3) introduction and follow‐ups (delivery), (4) RG content and usage and (5) need for implementation planning and support. Themes helped to ensure that similar information was collected across data sets. In addition, education was evaluated by means of two global survey questions for attendees: ‘Was education content and RG intervention relevant for your practice?’ and ‘Do you feel ready to use the RG in your practice?’ Focus group interviews with staff lasted 45–60 min,Data from managers and staff were collected by C. A., J. A. and L. N. from NSPH (with support from CEPI), who all have previous experience of this in MHS settings. Initial data collection covered the implementation of eight wards and occurred in connection to Education Step 1 . The next passage concerned a deductive and summative analysis of secondary data according to the process evaluation components by the first author (U. B.). One spreadsheet for each inpatient ward was created for within‐group analysis, involving triangulation of data. Two rows corresponded to qualitative or quantitative data, respectively, while 10 columns represented data of education, follow‐up at 3 months and eight monthly visits. All spreadsheets were then merged into one comprehensive spreadsheet to allow for in‐between ward comparisons on similarities and differences. Next data, collapsed spreadsheet and interview material, was deemed as belonging to either of the process evaluation components of context, implementation process, or mechanisms of impact. As a final step, analysis and triangulation of data sets were transformed into a coherent text. When no particular stakeholder group is mentioned in the results, all participants are represented. Data treatment steps and analysis were critically reviewed by all authors to mitigate interpreter bias and increase validity.33.1No matter what, it is always difficult to introduce something new because of the high workload. But the Recovery Guide is a simple tool, so it feels natural. We like that it is a coherent, it becomes more structured and may facilitate our work. (Manager)During the preparatory phases of the implementation programme Table , all stamake patients interested in working with the RG’, ‘how will we make the patients believe that this is valuable’, ‘how can we make patients realise that it is an opportunity’ occurred. This outlook on users' capability affected both managers' and staff's priority, willingness and energy to introduce the RG. In six wards, the initial contextual barriers lasted. One manager explained, ‘staff may be keen on changes and are not reactionaries, yet some interventions are not followed through’ (Manager).However, during the initial delivery, after the Education Steps, all wards faced implementation barriers. Lack of resources at an organizational (meso) level greatly affected managers' and staff's outlook and possibilities of implementing the RG (microlevel). Wards that were subjected to reorganization had an extreme and unstable workplace with little capacity left for implementing new interventions. Staff felt unwell, lacked energy, and were too busy getting settled . The manager's perspectives of the RG intervention facilitated quality implementation. One manager said, ‘I am in a position where I can get all the pieces in the puzzle together’. Another facilitator was when managers recognized staff's need for attitude and behaviour change and focused on solutions that could be incorporated into regular routines, meetings and administration. They facilitated discussions about recovery and supported staff through everyday nudging. RG responsible staff functioned as ‘champions’, and some wards shared ‘superchampions’ to facilitate collaborative change. Coproduction at meso‐ and microorganization levels was thus critical for sharing resources and solutions, and for creating overall culture, incentives that facilitated wards' capacity to implement the RG intervention. Peer supporters  further facilitated attitudinal change towards recovery perspectives. Notably, once staff started to deliver the RG and thus gained experience of working ‘with’ the users, their beliefs about mental illness and recovery, and whether implementation was achievable, clearly changed. One staff said in a focus group interview, ‘I believe that everything that benefits the service user is positive’. Staff became essentially positive and perceived the RG as fun to work with, and considered it to be a long‐awaited material and tool to connect with users. This new way of working was perceived as ‘right’ for both staff and users and enhanced their relationship and dialogue since it helped staff to recognize and realize users' point of view and experiences.The continuous dialogue among NSPH, staff and managers further facilitated implementation. Monthly site visits were decisive for the initiation, resumption and sustainability of the delivery, ‘to keep it alive’. Since coproduction did not cease during the study period, the implementation of the RG could be resumed when contextual barriers could be resolved. For example, five wards set new dates for education , and another six wards planned continuous education sessions to boost implementation , all in the forthcoming year of 2020 , and felt ready to use the RG intervention . However, with regard to the implementation phases henceforth, the extent to which the 22 wards had the capacity to implement the RG varied. As addressed in Table The preceding four phases of the Implementation programme Table  were pos3.2.1What to deliver varied among staff. Some favoured chapters on users' rights, while others portioned out brief 15 min sessions, while at the same time nurturing an open dialogue about recovery according to user needs. Notably, in wards where implementation was not completed, managers and staff perceived it as difficult to assess when, what part and how much of the content would benefit a service user. At times, the RG material was simply delivered on the bed table (adaptation). Users needed to take initiatives and approach staff themselves.The dose delivered by staff, that is, how much, when, what of the RG content that was delivered during information and follow‐ups, was neither consistent among wards. As shown in Table manager), ‘it is simple to deliver and does not require much extra work’ (staff). All data reflected that the format was appropriate, for example, texture, layout with calm colours and clear division of chapters. The content was considered elaborate and profound and addressed recovery issues in relation to inpatient care and discharge. The voice was kind and nonoffensive, and empty spaces allowed users to interact, comment and reflect on plans and goals. Staff, however, thought that the perspective of being a parent was missing. One staff member mentioned,It is important to address children's situation in the guide. That there is support to get, so this does not get perceived as scary. (Staff)The quality of the RG material enhanced legitimacy and facilitated delivery. It was considered easy to introduce; ‘it sells itself and is sensible’  rated the overall impression to be very good , or good , while three did not . However, the relevance in relation to discharge was not entirely clear . The format and pedagogic structure were perceived as thorough, complete and well‐performed, and the majority thought it was completely comprehensive , or to a certain extent , while four said that it was not , and one did not know . Otherwise, the clarity of the RG content was very good  or good , while two rated less good , and two, bad even . At first, the material could be perceived as too extensive, and that a lot of efforts was required by the users. However, there was an agreement that ‘once you got into it’ it became useful. The majority (n = 32) thought the length was good , while some meant it was too long , or short . According to staff, a certain level of endurance was required and some users lost attention and concentration.The dose received among users varied and depended on the degree of flexibility and personalization of support. Most users stated that the content was easy to learn and satisfying to use, and worked through all chapters. Some had difficulty absorbing it during the first period of their stay or when they felt unwell. Yet others preferred the RG at the beginning, especially those who were inpatients for the first time. Services users who replied  and assimilation. Family, friends and community support were thought as critical for usage.3.2.2n = 33) perceived that the RG fitted inpatients completely  or to a certain extent , while one ticked off ‘I did not know’ (3%) and three users ‘no’ (9%). One user wrote that it may be difficult to reach those with lower cognitive functions and/or reading difficulties. Staff affected reach through their beliefs, that first‐time inpatients benefitted the most. Those who had been previously exposed, been there long, had self‐admitted themselves, or had a psychosis, withdrawal symptoms, or had long‐term treatment plans, for example, residential treatment, supported housing accommodations, were at risk of not being reached. Of note, staff from wards with no regular implementation shared these assumptions. Other staff suggested adaptations to increase reach, a thinner and simpler version, visible tabs to more freely browse, locate and explore and other languages.Reach, that is, whether the intended target group is reached and comes in contact with the intervention, is reflected in Table 3.3A new perspective on mental health, well‐being and recovery; Capacity building of a recovery approach in inpatient settings; and A meaningful outlet for users' thoughts and feelings on recovery, sharing narratives and posing goals.Participants' responses and reflections on the impact of the intervention were categorized as: A new perspective on mental health, well‐being and recovery. It changed staffs' outlook and increased positive attitudes around recovery in inpatient care. It provided tangible support and functioned as an ‘ice‐breaker’, a tool for approaching and sharing perspectives, knowledge and decisions with users helped to build staff–user relationships. The enhanced focus on solutions, strengths and well‐being was also mentioned.Delivering the RG intervention provided staff with Capacity building of a recovery approach in inpatient settings concerned developing a neutral language, focusing on mental health, enabling both organized and spontaneous discussions about recovery. Recovery goals were reported in regular treatment planning records. According to managers, building capacity required no extra efforts or costs once initial contextual barriers were resolved, that is, applying new perspectives, finding time and resources, and integrating new regular routines had passed. Instead, it offered quality improvement, for example, new ways of working together and approaching and sharing perspectives and decisions with users.A meaningful outlet for users' thoughts and feelings on recovery, sharing narratives and posing goals. The quality of the RG facilitated acceptability and was considered a nonoffensive material with space for own narratives, thoughts and feelings, which made it possible to identify needs and make sense of experiences in the past and present. It facilitated a reflection process to safely express expectations and fears, as well as hope for better times. The discharge chapter formed a link to the home, outpatient and community context. The following citations represent five different users.How great this is! Can you read where you want and write how much you want? (User)It was great to be able to write it off your system […] I thought about it even before, how important it can be to have an outlet for your thoughts and feelings by writing. Previously, I wrote a diary every day […] some may not dare to talk about their innermost thoughts, so now you can write instead. Then staff can read, if you are up to it. (User)It helped me to have something meaningful to work with, while waiting for my mental health to get better. (User)It was very nice that you could have dreams. I think you easily forget that otherwise. I love to travel, and was reminded a lot about that. (User)This RG should have existed many years ago. The first time I ended up in a ward, in the ‘90s’, I wish it existed then. (User)The RG intervention was reflected by users and staff as Some users became more self‐directed and shared their goals, which at times were integrated into the care plan (adherence to guidelines). According to staff, narratives of others' lived experiences were much appreciated by users, to connect with others.3.3.1From the beginning it was very difficult to support them to get started with their work. Status reports were rarely submitted, and we were told things like ‘our patients do not need to work on recovery’. After the follow‐up in October, staff had completely turned around, and had started groups and become very engaged. Now they are working on just fine. (Fieldnote)During preparatory phases, critical mediators for change were the (1) perception of acceptability and value of RG intervention, and (2) the buy‐in and coproduction among all stakeholders. During active implementation (start of delivery), several mediators helped to overcome the implementation barriers, that is, (3) engaged managers and staff who believe that benefits outweigh the initial extra workload, (4) ward capacity to integrate delivery into routines and develop a reflective culture of recovery, (5) managers who prompt and nudge staff for desired delivery, and perhaps the most critical mediator, (6) staff who develops experiential knowledge through ‘doing’ the RG intervention with users. Once views and attitudes about recovery changed, (7) staff's interest and willingness to implement the RG became equally important mediators. A fieldnote from a site visit revealed,Moreover, the (8) NPSH user organization functioned as a mediator for change during the entire implementation process Table . They en4The process evaluation showed that it was feasible to implement the RG intervention in inpatient ward settings, regardless of specialty. When initial contextual barriers were overcome the RG intervention had the potential to provide staff with new perspectives on mental health and recovery, organizational capacity to integrate a recovery approach and users with a meaningful outlet of lived experience to influence treatment goals. The actual delivery provided staff with experiences and tools to ‘do things with users’, to start a conversation, listen, learn, share and plan for care and recovery goals and, to reach common grounds, which previous research has emphasized.The components of implementation components were feasible to implement Table  without Adaptations are increasingly recognized as an inevitable part of the implementation process and uptake of an intervention.Sustainability is regarded when adherence to the original intervention seems fair, and the capacity to continue delivery has been developed.The MRC framework provided helpful guidance for planning, analyzing and reporting our study, which strengthens transferability and comparability across process evaluations.5The process evaluation provided an understanding and shed light on the complexity of the translation, the interplay of the intervention and its delivery across 22 inpatient ward contexts. The guide and what has been learned from its ambitious widespread dissemination can contribute to the formation of new perspectives on mental health, capacity in inpatient wards to develop a recovery approach and opportunities for users to share narratives and reflect on recovery and meaningful goals. Mediators helped to improve the effective uptake and fit of the RG interventions to inpatient wards. Coproduction created horizontal and vertical certainty, which implicated sustainability. This knowledge may inform future implementation not only of the RG in similar contexts but also the design and performance of a randomized trial, that is, draw valid hypotheses and include outcomes that reflect mechanisms of impact.The authors declare no conflicts of interest.All authors have significantly contributed to the present study. Ulrika Bejerholm and David Roe conceptualized and designed the research study. Conny Allaskog, Jessica Andersson and Linda Nordstöm completed the implementation programme and contributed to data collection and initial analysis. Ulrika Bejerholm produced the first draft. All authors supported each other in their respective processes and contributed to the final version of the manuscript.


In the ICD‐11 diagnostic guidelines, preoccupation has been introduced as the new core symptom of adjustment disorder. Despite this essential innovation, preoccupation has so far largely been defined as rumination and worry and does not feature a distinct character as an independent symptom. In order to investigate the nature of preoccupation, various cognitive approaches are evaluated and linked to preoccupation. Furthermore, the aim of this review is to define preoccupation more precisely and to distinguish it from other symptoms in psychopathology. The evaluation of key features of cognitive dissonance theory, attention bias theory, memory theories, and other cognitive paradigms indicates that preoccupation is constituted by a complex interaction of cognitive–emotional mechanisms. In addition, this review implies that preoccupation in AjD can be defined as stressor‐related factual thinking, which is time‐consuming and often associated with negative emotions. It is assumed that rumination and dysfunctional worry serve as reactive processes to cope with preoccupation. For further distinction, this review presents similarities and differences of preoccupation and other symptoms, including negative automatic thoughts, flashbacks, and yearning. Finally, implications and suggestions for future research on preoccupation are offered. Overall, it is plausible that preoccupation is not only associated with adjustment disorder but also possesses a transdiagnostic character. Preoccupation has been introduced as the new core symptom of adjustment disorder in ICD‐11Preoccupation can be defined as stressor‐related factual thinking, which is time‐consuming and associated with negative emotionsPreoccupation may not be limited to adjustment disorder but possesses a transdiagnostic character1the core symptom for adjustment disorder (AjD)  WHO, . AjD hasjD) WHO, , it has jD) WHO, . The preBesides preoccupation as core symptom, the current definition of AjD includes a stressor criterion (the existence of at least one stressful event in the recent past), as well as failure to adapt to the stressor. Furthermore, AjD typically resolves within 6 months, unless the stressor persists for a longer duration WHO, . Origina1.1Disorders caused by a psychosocial stressor such as AjD, PTSD, and prolonged grief disorder (PGD) can, according to Horowitz's  stress–r1.2To date, there is no generally accepted psychopathological definition of preoccupation. The Oxford English Dictionary . offers The ICD‐11 definition of AjD describes preoccupation as “preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications” WHO, . Thus, tFurthermore, it is important to distinguish other constructs in psychology from preoccupation, such as flashbacks, yearning, and negative automatic thoughts. Repetitive and intrusive processes are recurrent phenomena in various disorders  theory  are defined as the process of thinking attentively, repetitively, or frequently about oneself and one's world  and the dynamics of the two symptoms (rumination as avoidance of preoccupation). Therefore, it could be concluded that preoccupation and rumination are two different symptoms. Further implications to this conclusion follow below.5.3A very subtle cognitive phenomenon are negative automatic thoughts (NATs), which are defined as immediate and negative evaluations people make about their situation, themselves, or their future  and worry (anxiety‐based thinking with exclusive orientation into the future) are distinct symptoms. It is plausible that dysfunctional worry represents an avoidance strategy as a reaction to preoccupation.5.5As factual thinking, preoccupation also raises the question of how to distinguish it from neutral, everyday thinking. Such thinking is often researched in nonclinical populations  thoughtsThoughts in preoccupation are stressor‐relatedPreoccupation is time‐consumingPreoccupation is often associated with negative emotionsSeveral other features are additionally decisive. Theoretical considerations that are outlined in the differentiation to other symptoms indicate that the temporal orientation of preoccupation can be in the past, present, or future. Moreover, it is likely that preoccupation is triggered not only by one of the described cognitive processes but also by the interaction of several of these mechanisms and represents a complex, cognitive–emotional construct , to clarify the transdiagnostic potential of preoccupation. Finally, it is possible that preoccupation represents a generic risk factor for the development of psychopathology. Investigating the nature of this symptom could therefore help understand psychopathological mechanisms more generally.This review also entails practical implications. It has been repeatedly shown that preoccupation represents a natural process after experiencing an aversive life event. Accordingly, patients who suffer from a distressing experience should be reconfirmed that repetitive and distressing thoughts are a normal way of reprocessing such events. Although the function of preoccupation remains debatable, it is likely that this symptom serves to integrate an aversive experience into one's own biography. Cognitive theories further imply that a deeper understanding of aversive experiences is important to overcome persistent preoccupation. In conclusion, clients should be supported to reprocess and understand their experiences in order to integrate them into the own biography and to derive meaning from them (see also Neimeyer et al., 7.5In sum, this review shows that preoccupation is embedded in a dynamic system of different, psychological phenomena. The illustration of cognitive theories as well as differentiation from other symptoms has produced unique characteristics of preoccupation that enhance understanding of this symptom. Many of the presented ideas, however, remain only assumptions, which need to be tested empirically. Nevertheless, a new conception of preoccupation seems necessary. If preoccupation is simply regarded as rumination or worry, a stress‐related condition may be classified as depression or GAD, rather than a stress‐related disorder, which might entail a different, and perhaps problematic, therapeutic procedure. Ultimately, the outlined considerations could help to provide important discriminatory guidance for preoccupation, which can cause significant improvements for individuals who experienced a stressful life event.No conflict of interest was reported by the authors.


Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions.n = 2, with field notes taken) and the corresponding audio files (n = 3), interviews with appraisal committee members (n = 10 in seven interviews) and with Institute employees (n = 5 in three interviews), and relevant documents (n = 4).This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings  findings and  arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision.We conceptualise decisions as Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy. Health care coverage decisions specify whether or not a specific health care technology is to be provided or reimbursed at a national level. In many cases, a document with reasons for these decisions is available to the public. Various elements may be present in such a document. The  evidence collated and generated through Health Technology Assessment (HTA) is but a part of this: many formalised criteria also contain qualitative considerations –4. In adSince the turn of the century, scholars have closely examined deliberative processes on health care coverage –15, showsteps in clustering the variety of elements into a decision.Many authors working inductively on these deliberations have shown how they involve combining rationales. These authors generally draw conclusions at a relatively broad level, not infrequently classifying deliberations and their outcomes as ‘pragmatic’ , 28–31. In this paper, we construct a model for clustering elements during deliberations on health care coverage, drawing from literature on decision making that yields outcomes that are ‘robust’, that is, able to withstand pressure in society. Such pressure may take the form of media attention or even public controversy, which has previously resulted in the reversal of decisions, generally through a direct appeal to the Minister of Health or other public authority responsible , 34. Relcombinations of elements. The element types we distinguish are findings, arguments, and values. We describe three steps to achieving robust decisions: 1) identifying elements, 2) designing combinations of elements, and 3) testing these different combinations. We will illustrate this model with qualitative comparative case research data on two Dutch health care coverage decisions, namely on maternity care and paracetamol and vitamins. In the Netherlands, like in many other countries, the HTA body  is responsible for combining such elements into a decision containing publicly available reasons. Notably, in the Dutch system, this is an advised decision, as the Minister of Health takes the final decision. S/he generally follows the advised decision but sometimes deviates from it  are available in the cultural repertoire, but with increasing robustness, the linkages between elements of the view and with their context increase in number and in articulation .” link elements into clusters of factors [design and testing of (…) [multiple] solutions that integrate a plurality of points of view, demands, and expectations”  of this week, following the draft advice that was released, you'll see that maternity care is associated straightaway with prepping beschuitjes.” [Laughter] “And if at that point someone would say, “Wait a minute, er, should I pay for that?”, I would have some sympathy with that.” “There are signals that solidarity no longer goes without saying. To put it bluntly: “I do not think I shall need maternity care for the rest of my life, so I’m not going to pay for it”. . “Things could be a bit more nuanced. If you look at that article in This comment has a direct impact on the final decision document, where the following line was added:beschuit met muisjes.” (Discussion document 1.2)“[In terms of] necessary maternity care for which we show solidarity, we envision care with a medical purpose and not the image of the maternity care worker who serves different combinations play a role in the deliberations  available outside the pharmacy. Given the situation, this is our answer: if it has to be bought at the pharmacy, it has to be reimbursed. But we advise you to think carefully about the prescription rule because that creates a completely unequal ratio between those cheap medicines that are and those that are not available on prescription.” care entails, thereby actively broadening the decision's scope and the committee’s remit.Giving the Minister advice on the prescription rule has little to do with determining the basic benefits basket: it falls outside the appraisal committee's remit. However, this type of recommendation provides an strengthening element of a combination. The scope of the decision is broadened by going beyond the coverage decision. Specifically, the direction the combination is broadened in through such recommendations remains at the committee’s discretion. Sometimes they formulate advice to the Minister, sometimes to other stakeholders. In this way, the committee not only specifies what a good basic benefits basket is but also what good Black-boxing links is the final and the most robust aspect of designing combinations. The example provided by Rip concerns the link between smoking and cancer  costs that might occur later on, for example when these people do not take these medicines and get fractures, [which is] miserable for those people [but] also means additional costs.” The third and final step is to test these different decision combinations. The fact that different combinations may exist, and that one needs to be chosen, has previously been described for a decision for a costly treatment, which gained a positive coverage status because one set of clustered argumentations together weighed more heavily than another set , 19. Calmore links to the former combination and then dismissing this combination by noting it as another’s responsibility:“Through the argument of not being able to afford [the tablets] it seems as if (…) there is some sort of poverty boundary where people through the calcium tablets will suddenly end up on the wrong side. But in those cases, (…) there is probably already more going on, with those people, already the government, all kinds of related measures, rent subsidies, benefits, are happening. And it won’t [mean] those benefits agencies will give extra benefits because of this tablet, but there is a whole host of expenses, gas, light, and oh yes, the costs of this medicine, so there’s much more to it. I think it is almost, how should I say it, almost a self-centred idea that we or the [collective health] insurance were going to make the difference between poverty and no poverty. So, I would argue to leave the poverty and the not being able to afford [things] to agencies that deal with these things, [because] it will not be influenced by that one-and-a-half calcium tablet (…). You can talk about those 100 euros, but it is always, low cost – just put it aside.” .This potent alternative combination of taking care of vulnerable groups, arguing in favour of coverage, required an equally strong combination arguing against coverage. Committee member 4 achieves this by making Trouw, committee member 8 continues:“[But] I think it's important to indicate something like: “Yes, but wait a minute, maternity care is about other matters, er, breastfeeding, detecting risky situations, etc., etc., for which it is completely just to be calling for solidarity”.” First, this is a notable remark as it narrows the committee’s responsibility, counter to broadening it (see above). Second, this combination was quickly considered to be decisive, with little discussion; the committee responded primarily by noting that this problem should not indeed be solved through health insurance  and the fact that “the whole system is inefficient” . Different combinations were also available in the repertoire in the maternity care case, as the alternative element combination placed it on the agenda, as described above. Having summarised this alternative line of argumentation based on newspaper Trouw by decisively linking several essential elements together , also had little subsequent discussion. It shows how different decision combinations are tested against each other in health care coverage decisions’ deliberative phase before one is chosen.This comment, which dismissed the element combination present in Much inductive scholarship on health care coverage notes that decision-making processes feature many different considerations and may be classified as ‘pragmatic’. Most, however, do not necessarily seek structure in these processes. We have derived a model for making such decisions from Science and Technology Studies literature on robustness. By conceptualising decisions as combinations of heterogeneous elements , we distinguish different ‘actions’ that decision-makers may take while deliberating: identifying elements, linking them together into combinations, and testing these combinations.This model leads to three concrete recommendations: two for decision makers and one for research. First, we recommend that decision makers try to identify potential elements from a wider variety of sources. This work may include considering real-world data sources like social media  but as aSecond, decision makers should work towards approximating a hybrid forum-like setting for their decisions, enabling many more stakeholders to contribute. Achieving such a setting means opening the decision process (further) to specific personal interests, making some uncomfortable, who fear these interests may hijack deliberations . We follchecklists of potentially relevant criteria. Such checklists leave little room for emotions and affect [We thus broadly align with recent scholarship on evidence-informed deliberative processes , 6. We wd affect  and may d affect .Third, further research should investigate the relationship between combination strength and how decisions’ robustness is perceived. Many STS scholars place the testing of the decision’s robustness outside the decision-making setting: in society, which indeed happens in health care coverage –35. We c


Sensemaking inOrganizations, 1995), by applying innovative visualmethods to the approach. Through his version of visual Sensemaking,the author identifies a set of principles to inform innovation incollaborative, interdisciplinary visual communication.This article addresses the challenges and opportunities associated withthe development of new visual communication practices and outputs,using an example of such work conducted in a UK interdisciplinaryapplied health project. Reflecting on his role as co-researcher andpractice as a visual ethnographer in the study, the author argues thatnew visual communication practices may emerge from ‘mess’ and evenugliness. In the case discussed, the author comes to terms with messand elements of failure as potential phenomena of learning through aprocess of Sensemaking (see Weick’s  Visual communication and visual methods in research have grown in popularity inrecent decades see . For somI write this reflective article as an educator and researcher with experienceof using visual methods to connect, communicate and support collaborativeaction, utilized here in an interdisciplinary and collaborative healthstudy. I am concerned with visual communication in research because I am avisual ethnographer, that is, someone interested in material enquiry intothe way things happen in specific situations. I also write it as someone whohad to learn again how to go about visual communication with others and,specifically, how to develop a methodology that could inform future visualinterdisciplinary research practice. This article links to the others inthis Special Issue through the idea of mess. By mess, I mean the uniquestatus of ‘the visual’ as a form of acting and knowing that is dynamic,ambiguous and polyphonous. In other words, I suggest that visual processesand products do different things for different people. This messy quality, Iargue, is both an opportunity for creativity and production of the new, butalso can be troublesome if unexamined.Why ‘dilemmas’? . . .Again, this sounds verging on the anti-vax . .. I have no idea what it means other than suggesting if Ihappened to be sat next to the author in the pub I’d move tables. . . I’m completely lost. I don’t know what any of this meansbut, more to the point, I don’t see why it is relevant . . .Thislayout is just really confusing . . . No idea what this is . . .I am so lost here that I am only able to scan and not even surewhere to start reading anymore – I could be reading Latin.My experience of mess is as a starting point for reflection and action. Thatthe study I discuss here was interdisciplinary was especially significant asit was a new context for my visual practice. The project was a study intothe development of multiple long-term health conditions (‘multimorbidity’),which brought together a diverse set of collaborative stakeholders: datascientists, clinical academics, partners in public services and members ofthe public. I was lead for engagement and impact, and my preference forvisual methods in enquiry and visualizing the practice I was part of as avisual ethnographer shaped my contribution. After (collectively) completingthe first phase of the study, I began drafting a paper I imagined could beabout our ‘successful shared visual language’. Writing prompted me to beexplicit about what I was doing with visual communication in the study, butI pressed on without clarity. Having shared an early draft with colleagues,I selectively focused on what I then saw to be their negative feedback: I saw issues as dilemmas that others may not have seen as such, and saw thatthe original draft of an article was abstract and did not connect to what mycollaborators found productive and useful in working with visual material.This was a troublesome mess because it was unexamined, I reasoned. Anyhow,these responses were my starting point for reflexive insight given myBefore that story is told, some other starting points are needed. I set theseout below in relation to (a) visual communication in health domains, and (b)the status of ‘the visual’ as a form of knowledge.Today, visual communication is a familiar part of primary healthprovision, research and education. Members of the public, patients,health researchers, educators and clinicians deal with visualcommunication that relates to illness and health in their daily lives.This is evident in public health discourse  and in tWhat is the something that goes up and down, or gets a newnumerical designation: Moods? Feelings? Energy? Will?Whatever it is, it comes from a private, individual, andinterior space. The chart converts specific experiencesinto obstructions through numeric measurement . . .but italso makes these experiences social along the way. (p.195)However, much of this material is underpinned by particular assumptionsand worldviews, and is designed to be ‘read’ in particular ways. Indiscussing visual material in the doctor–patient relationship, So, despite being in popular use , the worElsewhere, in the field of medical humanities and specific fields such asgraphic medicine, activity speaks to how research and clinicalpractice may utilize visual communication differently. It has been a constant belief of scientists, poets andartists alike that an illustration alongside a text ismore than just another representation of the same idea.Not only does a picture say more than a thousand words;compared to text, images show different thingsdifferently. As previous examples illustrate, most images relate firmly to words,usually illustrating or framing them. Visual communication differsfrom the formal symbolic meanings of written communication and sodeserves consideration as another category of communication. Visualcommunication operates as a distinctive category in many ways,especially through how it communicates the phenomena of ambiguity andaffect . It is lConsideration of what sort of knowledge visual images belong to is anage-old debate. Beyond questions of status, literature can speak to the work that imagescan do. Here too, philosophers provide different explanations. One way of considering the work of images is to consider them asinteractive experiences. Seen as active, not passive elements, images can be considered to act, orhave effect, in different ways. Some of this ‘work’ that visual imagescan do is generally appreciated. For example, the fact that visualimages can operate through metaphor is tacitly recognized. Throughmetaphor, images can be utilized to transfer meaning from one subjectto another  through juxtaposition, replacement or fusion ofimages. Hence, one type of ‘work’ that images do is rhetorical –techniques of persuasion that construct a particular meaning. Visualmetaphors are arguably a ‘fundamental way of thinking’  which reIn summary, these examples show that visual communication may do morethan reproduce the world or communicate factual content. Some of itspotential for both productivity and ‘troublesome mess’ is implied whenit is discussed as an interactive event which creates a space ofencounter, as metaphor, as opportunity to foreground, or to ‘move’ theviewer in a direct, embodied way. Visual communication has qualitiesthat are open to interpretation and may be experienced in differentways, it can be less precise or fixed than written communication,displaying ambiguity or polyphony . One strContrasting philosophical claims about the status and potential of images withexamples of how they are used in health domains seems to suggest a huge gap.On one hand, images in a medical paradigm mostly exist to illustrate ordecorate written, logical argument. On the other, images offer an ambitiousbut abstract ability to refigure and encounter different perspectives onreality. In the interdisciplinary health study, I wanted to make sense of amess that seemed troublesome, one in which I was not sure ‘what was goingon’ with my visual communication. My goal was practical because I needed toensure that visual communication was supporting our shared enquiry, so aparticular focus for my reflexive work was what was productive, or hadpotential to be productive in that study’s shared visual activity.One perspective that offers to connect both the specific/practical seen inhealth and the speculative and creative potential of images discussed inphilosophy is the tradition of Sensemaking. Sensemaking is a term coined byI was particularly interested in what I saw as the under-developed potential ofthe third principle listed by As noted, the context for my Sensemaking was as a member of a newlyestablished applied health research collaborative and, specifically,an exploratory study into the developmental origins and mechanisms ofmultiple long-term health conditions (multimorbidity) as they begin inearly life. One aspect of my role as lead for ‘engagement and impact’was to work with diverse non-clinical and scientific stakeholders aswe co-created an understanding of what multimorbidity was, couldunderstand it, explain its key mechanisms and possible points ofintervention for health and other practitioners. As a visualresearcher, I had earlier found that visualizing illness was apotentially contentious matter. For example, in the work I led withparent and carer representatives, supported by a UK children’scharity, we found that visually communicating the development ofillness across the life course raised difficult questions . The practical activities involved inthe multimorbidity study included the production of visualconsultation materials for parent and patient stakeholder groups,creation of visuals for events and presentations, and development ofan interactive ‘causal map’ of multimorbidity. In addition, much of mypersonal correspondence with fellow researchers utilized visualnote-making. In the light of feedback, I had to work out why I nowfound this to be a ‘mess’, and find what, if anything, was productivein it.As part of this diverse group, I was required to collaborate at a fastpace during an initial exploratory phase of the study. Members of thestudy team related well socially, but had different communicationstyles and disciplinary perspectives. Working with those who weredifferent from me was rewarding, but I took time to remember that ourrespective appreciations and uses of visual communication were basedon different paradigms see , differeI think we need more wonder in qualitative research, andespecially in our engagements with data, as a counterpartto the exercise of reason through interpretation,classification, and representation . . . Wonder is notnecessarily a safe, comforting, or uncomplicatedlypositive affect. It shades into curiosity, horror,fascination, disgust, and monstrosity.Challenging feedback mentioned earlier led me to review all the data created in and for thestudy, to notice cues, those things that stood out as strange,interesting or irritating, that could act as starting points forenquiry , includiI imported images from my study archive into a digital illustrationsoftware program, based on the criteria of what seemed to generatethis sense of wonder. Working with these selected marks, images andclippings of text, and adding to them, constituted the visualsensemaking I was looking for and had previously practiced . As elemIn this section, I consider key insights produced from my visual Sensemakingactivity, but I first return to the context of the study to consider theissue of ‘audience’. My position, as one who undertook the visualSensemaking, was as a member of a research collaborative that intentionallyconnected to a range of stakeholders – the wider early child health researchcommunity, the research collaborative members I had undertaken researchwith, and our consultation partners who were asked to make their own senseof the topic of multimorbidity. Insights that follow therefore arepotentially applicable to all of these stakeholder groups, as our ‘research’was applied in nature, as we developed, refined and tested concepts andfindings in practice and service user contexts. At the level of principle,what ‘worked’ in the collaborative speaks to what could work in visualconsultation, and indeed in wider efforts to generate and interact with datain the child health research community. Each can take these principles andengage in their own Sensemaking as they apply them to their visualcommunication.Amplify and extend ideas’: I saw thatvisual communication helped me to materialize emergingthoughts, ideas and feelings from correspondence orinteractions with colleagues. I would often seize on acommon idea, image or analogy and take the opportunity toextend this: (a) by making it more concrete and explicit,and (b) by imagining how it might be used in presentingfurther ideas.‘Force a third language’: In the originalactivity, and this new Sensemaking activity, I used visualcommunication to create a parallel ‘what if’ conversation.This had the effect of disturbing existing lines ofargument and provoking us to contribute to a new event ofmaking sense, instead of repeating existing positions.‘Image as lens’: Once used in interactions,elements in visual notes supported play andexperimentation. A suggested function could be applied toan example, or a question could be posed, such as ‘in whatway do those things work together?’.‘In Create a surface for action’: elements ofvisual communication became a surface for connectingseparate observations, insights and questions .We could work on what we could see, each ‘reading’ theimage to see how or if it worked. Activity did not producea workable prototype, but the image supported criticalreview and suggestions.‘Fold contributions’: when the groupinteracted with sketches and versions of prototype pages,productive work seemed to be driven by moments ofenthusiasm or displeasure. The folding of contributionsalways produced a new variation of the layouts which wasenergized by the reception of, and work with, each versionof the prototype.‘Mobilize and act with’: the image was notenough. I remembered how we printed a final draft fortesting with the groups’ family, friends and neighbours.Materializing the designs created artefacts andtransformed parent-volunteers into presenters. Changingthe format and interaction with the prototype transformedthe work it could do.‘One of the most challenging processes was the development of a ‘causalmap’, which showed how multimorbidity developed in early life andonwards, informed by a detailed literature search for evidence onearly life determinants of later life multimorbidity. My attempts tovisualize the results confirmed the views of the team who hadcompleted the literature search that creating a ‘causal map’ would beproblematic. This was largely because the studies found were verydifferent from one another with few elements to link them . . . whatwas described did not speak to linkages between elements, orcumulative effects. Visual Sensemaking helped me remember cycles offrustration, which involved asking ‘what do you want me to visualizeagain?’ When I showed the parent-volunteer group simple sketchesabstracting the data, they just found them confusing, not in terms ofscientific assessment, but because they did not know how to read oruse them. Their analysis of very early versions of the map immediatelythrew up pained faces over video calls, with questions like ‘what isthis for?’, ‘it’s a depressing story’, ‘so it’s all my fault?’, ‘whatdifference does it make?’ and so on. Visualizing foregroundedquestions – were we creating a fatalistic tale of individual moralfailures, as if illness was just about ‘laziness’, or ‘gluttony’? Insuch a map, where was the agency to challenge and change structuralinequalities linked to the development of illness?Whilst wondering if more data would come, I dealt with our frustration bysketching flows  ‘what else can this be?’, taking the topicand pushing back against the representation ofmultimorbidity as single left to right line which seems toindividualize illness. Things  float beneath the line, challenging therepresentation of developing multimorbidity as the soleresult of ‘poor’ individual choices.‘Translate’: as ideas and dialogue arematerialized as visual communication, tacit assumptionsand potentials appear. Authors can ask ‘is that how yousee it?’ When drawn as a sketch, ideas can be annotatedand added to. When the thinking is seen, it becomespossible to interrogate the images, with questions like‘but what is being collected as the heart icon moves downthe line?’‘Moving and composing in the image  distilleMess is necessary in interdisciplinary, collaborative and developmental work,such as the example in this article. To resist mess is to resist enquiry,learning and innovation, but we are encouraged instead to foreground theperfect, the impressive and convincing. Mess can be suppressed but, in doingso, we remove a huge resource for learning. Many artists and educatorsembrace mess in visual communication, describing visual thinking as anemerging process . In my eMy creation of collage-like Sensemaking images is an example of a Sensemakingbetter equipped to correspond with the visual, a method which supporteddialogues between images, the senses and emotions and rational dialogue.This visual Sensemaking method is one that visual practitioners could adaptand develop new approaches suited to their task. The method ‘worked’ in thiscase because it extended Sensemaking is consideration of things together – but I have shown that, inthis collaborative research, visual Sensemaking must literally bring thingstogether in the frame. Materializing diverse elements in a series of imagesenables visual Sensemaking work to be done, sifting what is troublesome andproductive about mess. In visual Sensemaking, our aesthetic and sensoryfaculties are utilized to greater effect. As we compose images, we read forpatterns, test relations between elements, and more. Visualizing the processof Sensemaking materializes the process, and enables social aspects of thepractice. This has implications for visual practitioners seeking to work inreflexive, interdisciplinary and collaborative ways. Firstly, followingGadamer (2913[1975]) to see visual Sensemaking as event(s) in the process ofrelational dialogue, with different parties being aware of, and choosing tobe part of that event. In other words, visual Sensemaking is not ‘automatic’and the inclusion of ‘the visual’ offers no guarantees of additional insightor benefit. Secondly, that those who would be part of the dialogue of visualSensemaking can learn to attend to the sensory, embodied and affectiveaspects visual communication can present, as I did. In doing this, thebenefits of using visual processes and artefacts are realized – we learn tohave different conversations, and appreciate different aspects of phenomena.Thirdly, practitioners must be committed to the reflexive demands


This paper investigates the relationship between apparent lexicalization and deletion of the comparative morpheme on the preceding adjective. While state-of-the-art traditional corpora contain so few tokens they can be counted on one hand, twitter yields almost 300,000 tokens over a 10 year sample period. This paper uses web scraping of Twitter to gather all plausible orthographic representations of the intensifier, and uses logistic regression to analyze the extent to which markers of lexicalization and reanalysis are associated with a corresponding shift from comparative to bare morphology on the adjective the intensifier modifies, finding that, indeed, degree of apparent lexicalization is strongly associated with bare morphology, suggesting ongoing lexicalization and subsequent reanalysis at the phrase level. This digital approach reveals ongoing grammatical change, with the new intensifier associated with bare, note comparative, adjectives, and that there is seemingly stable variation correlated with the degree to which the intensifier has lexicalized. Orthographic representations of African American English on social media are shown to be a locus of identity construction and grammatical change.There are some linguistic forms that may be known to both speakers and linguists, but that occur naturally with such low frequency that traditional sociolinguistic methods do not allow for study. This study investigates one such phenomenon: the grammatical reanalysis of an intensifier in some forms of African American English—from a full phrase  Examples include the associative plural 'nem  constraints and language external  constraints on the occurrence of a variant. The investigator may use reading passages, carefully constructed interviews with prompts designed to excite the speaker and lower their self-inhibition  (rendered here as -er than a motherfucker(1) a. It's colddennamugb. It's cold-∅ There is a small number of counterintuitive exceptions to this generalization, discussed in further detail in Section 4 below (2).er dennamug...(2) Them 8's and Barkley's availabldennamug is rare compared to other lexical items, unstudied, and provides a window into linguistic variation and change in AAE outside of the well-described domain of tense, aspect, and mood. Given the recency of study of AAE, and the focus in sociolinguistics on a handful of topics within the study of AAE , not much is known about linguistic variation and change in contemporary AAE as relates to lexicalization, reanalysis, and change at the intersection of phonetics, phonology, and syntax.Intensifier dennamug is evidently the result of a number of different, interrelated linguistic processes: it is an intensifier phrase combined with taboo avoidance, understudied AAE phonology, and competing solutions to the problem posed by phonetic ambiguity. Writing on social media requires authors to derive solutions to the orthography problem posed by standard English orthography's inability to capture some aspects of AAE phonology, and this provides a potential window into the etymological transparency (or opacity) of the intensifier.Intensifier than a muh(fucka) is the origin of a single lexical item, with multiple phonological representations in the speech community, that has very different syntactic properties than its origin—the starting point is a full comparative phrase, and the most advanced syntactic change is a lexical item that modifies a bare  adjective.The confluence of factors prior to writing is the result of phonetic ambiguity that feeds phonetic reanalysis, which in turn feeds syntactic ambiguity that feeds syntactic reanalysis. In other words, the phrase degree of lexicalization and reanalysis of dennamug using all instances of the term on twitter in a roughly 10 year period that are consistent with reasonable orthographic representations of AAE phonology. Here, lexicalization is the degree to which than a mother has been from a phrase to a lexical item , and reanalysis describes the extent to which it is now treated as a lexical intensifier (which therefore no longer requires comparative morphology on the adjective it modifies). The first sections of the paper describe the phenomenon under investigation, and the subsequent sections investigate the degree of lexicalization and reanalysis using quantitative methods drawing on a corpus of tweets specifically gathered to investigate this topic. Twitter is a mechanism, albeit an imperfect one, for the study of dennamug because, despite its low frequency in conversation and the difficulty eliciting it in a traditional sociolinguistic interview setting, there are hundreds of thousands of tokens, and the written format forces speakers to choose whether they write the intensifier as a single word or as a phrase, what the phonological components of the intensifier are, and whether it is accompanied by comparative morphology. Moreover, traditional sociolinguistic corpora are not viable for the present study, as there are no tokens of dennamug present in the Corpus of Regional African American Language , derivational affixes derived from roots in compounds, some fixed phrases, multiword verbs, composite predicates or complex verbs , and phrase discourse markers  ” and English goodbye from God be with you. Some argue that while rare, these are exemplars of lexicalization because they are not just fusion—the obligatory collocation of previously separable material—but also of conversion, in which an item shifts from one category to another. In the case of dennamug, the most extreme forms are fully univerbated, and have gone from a comparative phrase to a lexical adverb .Demorphologization describes a process “whereby a morpheme loses (most of) its grammatical-semantic contribution to the word and becomes an indistinguishable part of the construction of the word, while retaining part of its original phonological substance.”  negation (?didn't shoot the breeze), internal modification , or topicalization (*the breeze he shot).Lack of substitutability: synonymous lexical items cannot be substituted , nor can items be reversed or deleted.than a mother ~ than a bitch), through moderate univerbation and demorphologization while still exhibiting some level of compositionality and substitutability (danna muv ~ danna bish), to fully univerbated, demorphologized, and idiomaticized (dennamug). The best evidence for reanalysis is not just univerbation, demorphologization, and idiomaticization, but subsequent changes elsewhere in the clause or sentence. As will be shown below, the greater degree to which dennamug exhibits these characteristics of lexicalization, the greater the likelihood that the adjective dennamug modifies appears as a bare adjective, without comparative morphology, because dennamug is functioning differently grammatically than the comparative phrase than a mother. Before demonstrating this, it is necessary to discuss the morphosyntax of intensifiers (Section 1.2) comparative phrases (Section 1.3) and the interactions between relevant AAE phonology (Section 1.4) and taboo avoidance (Section 1.5).Relevant intensifiers in informal AAE span a full spectrum between clearly non-idiomaitic, compositional and substitutable :ass day(3) a. a cold really cold dayb. Predicative intensifiers modify predicate adjectives:so fine(4) a. she's really sweet  > deadass + predicate .deadass is the result of grammatical reanalysis of an earlier form, itself the result of reanalysis.Some intensifiers, like  Spears, , and thapitch “extremely.” Originally a comparison referring to the black resin used to caulk sailing vessels called pitch, as in as black as pitch or pitch black, pitch now modifies other verbs of perception, as in pitch quiet and pitch silent (5).Some intensifiers have historically come from comparisons that lose semantic force, for instance, (5) Our old neighborhood was perfect. It was pitch quiet.as hell, which no longer draws a comparison to a specific conception of the afterlife, as in pleasant as hell “very pleasant.”A similar case is dennamug is the result of lexicalization and grammatical reanalysis.The object of study in the present paper is a predicative intensifier , derived from a comparative phrase. In the next section I discuss comparatives, as reduction of comparative morphology is one form of evidence that easy + -er), and adjectives with more than two syllables almost always occur with a periphrastic comparative  whereas phrasal comparatives do not require a comparative clause and may instead use case marking, for instance, the adessive case in Hungarian  or inequality .Comparatives are similarly complex, and vary across multiple parameters including whether they are bound or periphrastic, clausal or phrasal, and whether they express equality or inequality of degree. English has both bound and periphrastic comparatives , hypothesized to be sensitive to the number of syllables the adjective comprises, so bound comparatives are preferred for monosyllables  > dennamug is made easier by the fact that AAE phonology is not well served by standard English spelling conventions, and that many expressions and words in AAE are not described in any style guide or dictionary, leaving it to the speakers themselves to determine how to map sounds to spelling. The next section discusses relevant AAE phonology and the following discusses taboo avoidance and deformation relevant to the phonological shape of than a mo(ther) as it lexicalizes.The exact syntactic structure of comparatives has been a matter of lively debate since at least the 1970s, with various structures proposed by Bresnan , Izvorskstopping and TH-fronting. Less known and under-researched phonological variables include stop devoicing, debuccalization, and deletion . The word motherfucker itself was subject to grammaticalization: it has undergone semantic broadening from an epithet suggesting taboo sexual relations to an individual lexeme that serves as an purpose exclamation, and it is in this context that the first word has undergone reduction. It is often rendered muhfugga in writing on social media, reflecting actual pronunciation, attested as early as 1995There are multiple possible pathways from Smokey: “You know what they say, the older the berry, the sweeter the juice.”blacker the berry.”Craig: “n—, it's the |mʌfəkə], too.”Smokey: “Yeah, well, she blacker than a motherfucker , won't it?I don't blame 'em. Be in a cave two thousand year that'll make you , without further research.Possible pathways of phonological change leading to [mʌ:] include:stopping > elision of schwa > postvocalic stop deletion/r/ vocalization and deletion > TH-stopping > elision of schwa > postvocalic /v/ deletion/r/ vocalization and deletion > TH-stopping > elision of schwa > voicing assimilation on postvocalic /v/ preceding onset /f//r/ vocalization and deletion > TH-motherfucker is pronounced, and frequently written, as muhfucka or muhfugga, and it is this pronunciation that is the starting point for dennamug.Regardless the specific phonological pathway, the result is that incomplete neutralization . In this case, a closing consonant is implied, and people writing on social media are compelled to choose one of either < d>, < g>, < v>, < b>, or the generic < h> to avoid readers imagining the unwanted pronunciation /mu/. Some of these forms are more suggestive of truncation (< muh>) or regional AAE phonological processes (< muv>) and others are more phonologically opaque . If speakers do not hear or produce a word final consonant, but know that the surface string has a phonologically illicit long lax vowel, then they can infer that there is a closing voiced consonant, but may be unsure what the precise nature of the consonant is. Perhaps unsurprisingly, there are metalinguistic discussions about which spelling of dennamug is “correct”:The crucial factor here is that the surface phonology of some varieties of AAE allow lax vowels in open syllables, so seemingly un-checked wedge occurs in words like [mʌ:] “mother,” [brʌ:] “brother,” and [lʌ:] “love,” but that these are instances of what Farrington  calls in(6) a. Dennamug or Dennamud ?b. Das no typo tho. “than a mub” is a southern saying.c. yes it is . It a typo cuz its *mug (in response to 6b).than a mother is technically correct. While it is also theoretically possible that the /f/ in /mʌfʌɡə/ underwent lenition, and the final schwa underwent apocope, resulting in the change /mʌfʌɡə/→mʌ:ɡə→mʌ:ɡ→mʌ: as a third possible pathway, there is no literature on AAE phonology that would support such a change , and no comparable examples, to my knowledge.Surprisingly, the responses all indicate ... < mug> is “correct” and none claim ukuhlonipa “politeness” in the Nguni languages requires deformation of phonemes or syllables related to the names of family by marriage, resulting in a rich set of synonyms. In most varieties of English, the words subject to taboo avoidance are scatological, sexual, and religious in nature , rhyme (bloody > ruddy), metrical substitutions , deletion, and acronyms (as fuck > A. F. > ayeff ).Taboo avoidance is cross lingusitically common and takes many forms. Different languages may treat different classes of words as taboo, so for instance Motherfucker is a taboo word, even thought it may be somewhat meliorated in some informal varieties of AAE  and taboo avoidance creates the perfect conditions for reanalysis, where the syntactically complex [dɪn [ə [mʌ:]]] is reanalyzed as a single word :Furthermore, widespread postvocalic /r/ deletion in AAE means that the comparative morpheme (7) a. b. dennamug among AAE speakers is adduced as further evidence for a cline of lexicalizing forms. In Section 2, I turn to the materials and methods for the present study, investigating the extent to which there is quantitative evidence for rebracketing and reanalysis.In the next section, evidence for metalinguistic discussion of dennamug to be a lexical item and not a comparative clause. Urban dictionary has an entry from 2006 for than-a-mug with the definition “To the extreme of something's current state,” and an entry from 2003 for dennamug with the definition “hella, a lot, very much.”dennamug cannot be merely an orthographic meme on social media. Evidence of speaker perceptions are not limited to written attestations, either: for instance, in 2013, YouTube personality Kevin Fredericks (known as Kev On Stage) made a video of “Black Folks Slang” in which explains dennamug (which he spells on screen as < dennamug>) is “the measure of unit of something that is something else” and elaborates that “whatever dennamug is, that unit measure, you've gotta be doing more than that.”than a mother. Of the six examples of his own he provides, five had comparative morphology, and one did not, of the five examples he provides from others, none had comparative morphology.Further evidence for possible lexicalization comes from how speakers themselves discuss the language. Beyond exchanges on twitter like that in example 6, above, there is evidence that some AAE speakers believe dennamug is (1) a phenomenon in spoken AAE that (2) speakers expect others to understand, and as such, it is widespread ; and I searched for word final < d>, < g>, < v>, and < h>. I did not initially search for word final < b>; however, I later gathered all 143 tokens manually. While it is possible there are unaccounted for spellings, they are so rare as to be irrelevant to the analysis here . I used a shell script to generate all possible spellings meeting the above criteria and to make individual calls to the now deprecated get-tweet script in Python.For the present study, I gathered all tokens of all spellings of she's uglier than a mud fence, or nothing better than a mug of hot chocolate), eliminating tweets that included some spelling of fucker immediately following the token, and eliminating false positives in other languages,The resulting data set comprised 294,364 tweets, plus another 143 observations with a word final < b>, for a total of 294,507 tweets. After eliminating false positives , preceding adjective, and whether comparative morphology was present or absent. User profile pictures were also collected. While, in principle, these could be used to code gender , approximate age, and (not self-identified) “race,” those were not coded for in the present analysis and remain an area for future inquiry, however, there is no a priori reason to think gender and age are relevant to use of dennamug and race is only relevant insofar as it is a highly correlated but imperfect proxy for use of AAE. pin-pen merger, coda cluster simplification, TH-stopping, TH-stopping, etc.), AAE morphosyntax , and AAE lexical items that have not yet been borrowed by the white mainstream . I normalized the most common variant spellings, changing word final < a> and < ah> to < er> and normalizing arbitrarily many repeated letters, as in < sleeeeepy> to < sleepy>, but did not normalize other respellings that were not merely lengthening, as in < fye> “fire” or < asapidlier> ASAPedly-er “quicker.”Data gathered included tweet ID, username, tweet text, date, time, retweets, likes, geolocation (where applicable), mentions, hashtags, and permalink. I created variables for which token was contained in the tweet . The predictor variables were the presence or absence of orthographic representation of TH-stopping ; the orthographic representation of initial vowel (with < a> as a reference category); the orthographic representation of the final “closing” consonant (with < g> as a reference category);hungry, hungrier, and hongryyyyyy all count as tokens of hungry); whether the lemma was good (to account for the now enregistered gooder dennamug); and random intercepts in the mixed effects model for username to account for unmeasured author characteristics. The form of the intensifier used was not included, as the first four variables completely and uniquely describe it , and any model that included it would suffer from severe multicollinearity. Similarly, adjective lemma was not included, as lemma frequency was highly correlated with it.Of primary interest was the relationship between orthographic indicators of reanalysis as a single, opaque lexical item, and presence or absence of comparative morphology. To investigate this I performed both traditional logistic regression, and mixed effects logistic regression to account for unmeasured author characteristics. The response variable was presence of comparative morphology on the adjective , as was the distribution of orthographic complexity . Because the final consonants are easily divided into two natural classes , the model was run with a binary variable for The form of the basic model was therefore:and for mixed effects logistic regression:year, which was not significant in the models that included it, and in some cases caused failure to converge. Vowels other than < a>, final consonants other than < v> and < h>, and reduced orthographic complexity (suggestive of univerbation), were anticipated to be associated with greater comparative deletion. TH-stopping was not expected to be associated with change in comparative morphology, as it is a productive process in AAE phonology. Use of the lemma good was expected to be associated with an increase in comparative morphology, because of the enregistered idiom gooder than.... Lemma frequency was likewise expected to be associated with greater use of comparative morphology.Model comparison and post-estimation tests confirmed that these models outperformed similar models that dropped variables included in these models. It also dramatically outperformed models that included h-stopping was associated with a small, but significant increased probability of encountering comparative morphology on the preceding adjective (see below for discussion). Initial vowels other than < a> were associated with a significant decrease in probability of comparative morphology (33 percentage points for < e> and 28 percentage points for < i>). Fortition of the final consonant, and reduced orthographic complexity were both associated with significant decreases in probability of encountering comparative morphology. Lemma frequency was associated with a small but positive effect—more common words were more likely to exhibit comparative morphology, all things being equal. The word good was associated with a significant, positive effect: if the lemma was good, it was much more likely for the form of the word to be gooder, regardless of the form of the following intensifier (as anticipated). All things being equal, comparative morphology on the adjective was associated with a probability of 0.15 of appearing before a univerbated intensifier with initial /d/, raised first vowel, and a word-final stop . That is, univerbation and phonological opacity obscuring the relationship to than and mother were associated with a dramatic loss of comparative morphology on the adjective.The results of the logistic regression performed on the full data set are presented in th-stopping is no longer a significant predictor. The effect directions are the same, and the magnitudes are approximately the same as in the model on the full data set, except for the effect for orthographic complexity, which is larger by a factor of three.Performing logistic regression on the subset of tweets for which the author only tweeted once, the results are similar, and are presented in Finally, the results of mixed-effects logistic regression accounting for unmeasured author characteristics on those who tweeted at least 10 times is presented in th-stopping is once again significant, and positively associated with the presence of comparative morphology. Raising of the initial vowel was associated with loss of comparative morphology, as was fortition of the closing consonant. Orthographic complexity and lemma frequency were not significant.For this subset of the data, than a mother, < than a muv> and < than a muh>, have a probability of 0.61 of appearing with an adjective that exhibits comparative morphology—by far the highest probability of any forms that actually appears in the data. The least transparently related possible forms to the original comparative phrase, , were predicted to have a 0.19 probability of appearing with comparative morphology. The form in the data associated with the greatest likelihood of comparative deletion is < thenna mud> which appears 60 times in these data and never with comparative morphology on the adjective. The variable associated with the largest increase in likelihood of comparative morphology on the preceding word was whether the preceeding word was a form of good, although ironically, this was not due to preference for the word better, but rather for gooder.Across all of the data, most common form was < than a mug>, with 82,944 tokens. Extrapolating from the coefficients in the first model, the probability of seeing comparative morphology on the adjective for this form was 0.41 or approximately two in five. The forms that are most transparently related to dennamug and not than a mother, we are not merely looking at creative orthography to represent spoken accent  < b>, < g>, or < d>, changing the initial vowel so the first syllable is no longer transparently than—are all associated with greater probability of encountering a bare adjective.dennamug is already only two in three, which alone is strong evidence for lexicalization and grammatical reanalysis: comparative morphology before a comparative phrase is syntactically obligatory elsewhere in AAE, and with very few exceptions, intensifiers precede the adjective they modify.Taken together, these results suggest that when looking at pin-pen merger. Not only is this consistent with some of the written forms  and with the common pronunciations, but this is only possible if the initial syllable is no longer clearly “than” to all speakers. Similarly, the above findings are consistent with the hypothesis that mother is more recoverable from < muv>, (cf muv [mʌvə] “mother” in some varieties of AAE), and less recoverable from the non-word < mub> or from the words < mud> and < mug> which may be associated with lexical interference. Indeed, as noted above, the form most likely to exhibit comparative deletion was < thenna mud>, which is not only no longer transparently than a mu:, but is also spelled in such a way that each component invites lexical interference.In many varieties of AAE, a prenasal /æ/ can be realized as [ɛ] Jones, .30 In thdennamug is a non-prestige form . Dennamug has already become enregistered  among many others. Moreover, authors employ comparative morphology on words that do not ever receive comparative morphology in standard English: antisocialer, catholicer, beautifuler, startlinger, overrateder, sunburnter, negligenter, tirededer, fadeder , and confuseder, among others. Most prominent of these is gooder, which occurs 3,778 times in these data, and is sufficiently enregistered that there are multiple songs with the name “gooder dennamug.”It should be noted that, at least on twitter, authors seem to have a high level of awareness that ed Agha,  for somedennamug in them, 16,884 used a single spelling  a. She is driving leisurely than a mugb. I am employed....gainfully then a mug tooIt can now modify noun phrases:(dennamug)(9) a. binary thinking (dennamug)b. false advertising (dennamug)c. foreshadowing (dennamug)d. Power trip It can now modify prepositional phrases:(10) My accent gonna be outchea dennamug because I'm going to be exhaustedIt can now modify verb phrases:(11) a. Procrastinating dennamugb. Back when Trick was hot I was illegally dl'ing den a mugc. That chick is line stepping dennamugd. I'm laughing dennamug cause I'm sure they gone get rid of your favorite. Trust mee. Projecting dennamug!!f. Tweet watching dennamugg. I be scanning dennamug on a day like this here.h. Cramping dennamugAnd it can even modify entire clauses and sentences:(12) a. No weapon formed against me shall prosper. Dennamug.b. “You one of them or one of us?” That was a loaded question dinamug. #ShotsFiredpersonae  a. I'm hongrier than a mug in this class. Lord, please give me skrenf [strength]b. Hot than a mug out here in these skreets... [streets]d. it's skrowng than a muh [strong]man that game skressful thanamug [stressful]There is much future research that could, and should, be done on this subject. One domain for future inquiry is the possibility of age grading Hockett, . One fri(14) Just realized I'm too grown to be saying dennamugmug and mud, that a future psycholinguistic study could disentangle. One important question future research should address is the question of whether bare adjectival morphology is the result of lexicalization of than a mother or if it preceded and fed that lexicalization. I am unaware of academic literature on bare adjectives in comparative constructions in AAE, however the phenomenon is known by AAE speaking linguists . The temporal ordering of these changes, whether it's bare adjectives → reduction of than a motherfucker to dennamug or vice versa, will provide important insight into pathways of grammatical change in AAE.Future work could make use of targeted elicitation, and of surveys, to better tease apart social factors related to adoption and use of this form. It is possible that autocorrect plays a role in the strong preference for < mug> and < mud> in the written data. It should be noted that those who chose to write < than a mub> must intentionally override autocorrect. There may also be lexical interference from words like dennamug is an intensifier that is the result of ongoing lexicalization. Moreover, this ongoing lexicalization would have been impossible to study just a few years ago, despite being in widespread use among AAE speakers, not just because it is unlikely to appear in more formal written registers,Nevertheless, while there is still much more to tease apart, it is clear from the above that AAE https://github.com/TaylorWJones/dennamug.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: The author confirms being the sole contributor of this work and has approved it for publication.