The right place? Users and professionals’ constructions of the place’s influence on personal recovery in community mental health services

The right place? Users and professionals’ constructions of the place’s influence on personal... Background: Current mental health policy emphasizes the importance of community-based service delivery for people with mental health problems to encompass personal recovery. The aim of this study is to explore how users and professionals construct the place’s influence on personal recovery in community mental health services. Methods: This is a qualitative, interpretive study based on ten individual, semi-structured interviews with users and professionals, respectively. A discourse analysis inspired by the work of Foucault was used to analyze the interviews. Results: The findings show how place can be constructed as a potential for and as a barrier against recovery. Con- structions of the aim of the services matter when choosing a place for the services. Further, constructions of user–pro- fessional relationships and flexibility are important in the constructions of an appropriate place for the services. Conclusions: The aim of the service, the user–professional relationship, and flexibility in choosing place were essen- tial in the participants’ constructions. To find “the right place” for mental health services was constructed as context- sensitive and complex processes of assessment and co-determination. Trial registration The study is approved by the Regional Committee for Medical Research Ethics, Norway (REK-Midt 2011/2057) Keywords: Community mental health services, Personal recovery, Place, Productive power, Social constructionism Background space by focusing on constructions of how place in com- Current mental health policy emphasizes the importance munity mental health services impacts personal recovery of community-based service delivery for people with by focusing on place as a social construction. mental health problems to encompass personal recovery [1]. The place community mental health services are pro - Place and recovery in the context of community mental vided in can be understood as materiality, as a physical health services place. In this paper, however, place is in addition consid- Recovery has become a forefront of the policy agenda in ered as social constructions. Previously, place and space many countries [1, 2], and is central to hopes for progress have been described as emerging after hospitalization to in mental health policy. The World Health Organization offer shelter and care for people with mental problems (WHO) claim that “community-based service delivery [3, 4]. This study contributes to the research on place and for mental health needs to encompass a recovery-based approach that puts the emphasis on supporting individu- als with mental disorders and psychosocial disabilities *Correspondence: ingrid.femdal@hiof.no to achieve their own aspirations and goals” [1], p. 14. Department of Health and Social Work Studies, Østfold University Community mental health service is supposed to pro- College, 1671 Kråkerøy, Norway mote independence, belonging, and to strengthen the Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Femdal Int J Ment Health Syst (2018) 12:26 Page 2 of 9 ability to cope with life [5], p. 7, reflecting expectations of relationships, like place as a healing place. As such, for progress. Personal recovery is described as subjec- it is constructed as a social place in terms of interper- tive and unique, taking place within the context of the sonal relationships involving user and provider [14]. The person’s everyday life [6]. It is defined as “a deeply per - nurse’s presence is considered as a therapeutic enterprise sonal, unique process of changing one’s attitudes, values, and as contributing a unique and comforting element to feelings, goals, skills, and/or roles. (…) a way of living a the person’s illness experience [14, 15]. Constructed as satisfying, hopeful, and contributing life even with limi- a social place, place refers to interpersonal relationships tations caused by illness” [7]. Davidson and Roe [8] developing between user and provider, and between rela- identified two different meanings of recovery: “recovery tives and provider. Such relationships are central in the from” mental illness and “recovery in” mental illness. The current discourse on mental health services [16, 17]. In notion “recovery from” is based upon people who had this discourse, the ideal relationship is presented as sup- been given diagnoses of severe mental illness becoming porting personal recovery [18]. symptom free and not returning to the patient role. By Community based mental health services are sup- contrast, the notion “recovery in” derives from the Men- posed to encompass a recovery-based approach, based tal Health Consumer or Survivor Movement and refers to on the individual’s own aspirations and goals [1]. One of the person’s own effort and work in getting on with life the places to do so is in the user’s home. The home envi - and creating a life in a community despite their mental ronment represents a multitude of meanings, like per- health problems [8]. “Recovery from” can be understood sonal security, privacy [13, 18–22], comfort, control [19], in terms of medical discourses, focusing on symptoms identity, [22] and autonomy [20, 21]. The notion home is and disease, while “recovery in” emphasizes discourses not just spaces in a mundane sense. Rather, it is imbued that are social and existential. From a “recovery-in” per- with emotions, relations and histories [23]. Home as lived spective, professionals are expected to use their skills and experience, space and social place means that the con- expertise in collaborative partnerships with the person’s structions depends on the power relationships between own change process [9]. These collaborative relation - the involved persons. Professionals’ constructions of a ships take place and are constructed in multiple ways. user’s home may be based on what the user’s home look Cresswell [10] claims that “place is a word that seems like, if it is neat and clean or messy and unclean, how it to speak for itself ” and there has been a rather shallow is decorated with items, furnishings and other effects. understanding of what the word place means. He argues A home visit is thus a professional tool to enter private that place is space invested with meaning in the context home-spaces, observe and collect data required for pro- of power [10]. Place-making is seen as a process of trans- fessional assessments [4]. Physical structures may accord- forming “space” (that is no-place) into “place” [11]. ingly be seen as representing underlying social structures Gieryn [12] describes place as having three defining and other invisible divisions [13]. Dyck et al. [19], p. 175 features. Place as a geographic location refers to a distinct claim that “the home’s materiality is also a signifier of a physical spot (ibid.). People attach meaning to geographic person’s location within power relations that influence locations through their own experiences and understand- access to material resources, as well as culturally valued ings, and through social, cultural and economic circum- consumer goods”. Healthcare delivery in a person’s home stances [13]. Secondly, place has a material form, like a is frequently cast as an invasion of privacy or an intrusion living room or an office. Social processes, such as power, on a person’s space [24]. Some claim that the privacy of happen in the material forms we design, build and use the home is challenged and, as a consequence, the user’s [12]. The third feature of place is investment with mean - ability to restrict public surveillance is compromised [13]. ing and value. Gieryn [12] claims that without naming, However, professionals’ sense of power, authority, control identification or representation by people, a place is not a and sense of a controlled workspace may also be altered place. Place is described as an investment with meaning, [13]. and value appears in constructions of place as lived expe- Mental health service can be provided in mental health rience, sense of belonging, social place and healing place. workers’ offices and other places in addition to the users’ Place as lived experience, implies that people experience homes [25–27]. it in distinct ways, like when one person experiences a Some perceive the professional’s office as a formal place place different at different times, as the experiences and [25] and emphasize the potential of using the users’ sur- constructions of place are changing [10, 13]. Place as roundings in an effort to achieve good contact or practic - ‘the meaning and significance people accord to a specific ing on everyday situations the users perceive as difficult place’ refers to a sense of belonging [14], p. 204. Con- [27]. Some use public places such as shops and cafés to structions of place sometimes demonstrate the meaning practice the management of situations the users find Femdal Int J Ment Health Syst (2018) 12:26 Page 3 of 9 extremely discomforting, like going out among other Methods people [26]. This qualitative, interpretive work using individual, semi-structured interviews was designed to explore Care relationships and productive power how the place influence personal recovery in commu - “Care and care relationships are located in, shaped by, nity mental health services from the perspectives of and shape particular spaces and places… (..)”, accord- both users and professionals. ing to Milligan and Wiles [28], p. 736. To develop an understanding of how relationships and power shape Recruitment of participants and sample the constructions of places’ meaning for individual sup- Participants were recruited through the public commu- port, the work of Foucault [29, 30] is applied. Foucault nity mental health services at municipality level, based was interested in power as an omnipresent and rela- on the acceptance of the service leaders. To meet the tional phenomenon and studied power at the level of inclusion criteria, professional participants had a bach- society as a whole as well at what he referred to as “the elor’s degree in a health or social profession and work capillary level of power” [29]. He claimed that power is half- to full-time position for at least 6  months. The always present in human relationships and preferred service leaders recruited mental health workers who the phrase “relations of power” over “power” [30]. met the criteria. Inclusion criteria for service users Power relations are described as mobile, reversible, were adults (> 18  years), assisted by community men- and unstable [31]. Thus, power is unavoidably present tal health services at least once every other week for in all social relations, such as those between users and at least 2  months, diagnosed with schizophrenia, psy- professionals, and users’ and professionals’ actions and chosis or moderate/severe depression, who would give beliefs shape and are shaped by such power relations. informed consent. The users’ contact persons at the “We cannot jump outside the situation, and there is no community mental health care service recruited users point where you are free from all power relations. But to the study. The researcher received contact informa - you can always change it” [30]. tion only to users and professionals when they accepted In mental health services power often has negative to participate in the study. The material presented here connotations, and is associated with restricting other is based on 10 users and 10 professionals, seven women people’s freedom, domination, control and coercion, in and three men in each group. a hierarchic system where health professionals possess power [32]. According to Foucault however, power is The interviews not a substance or a property one can claim to possess. The participants chose the place for their interview: Within such a perspective, power is not understood as in the participant’s home, at the community mental repressive, but rather as a productive force that pro- health care center or at the interviewer’s workplace. mote actions [33]. However, in this paper I draw on The author, who is a mental health nurse and a Ph.D. Foucault’s notion of power as “to be able to”. In English, candidate, did the interviews. The themes in the inter - the term power refers to both the capacity to do some- view guide focused on experiences of user–professional thing and to the act itself [34]. The French language, by interaction and cooperation to promote reflections on contrast, has two terms to decipher power, puissance roles, expectations, opportunities and experiences. and pouvoir (…), where broadly the former denotes Questions were asked from the themes in the interview capacity and the latter denotes the act of power [34], guide. The interviews lasted for 45–60  min, and were p. 105–106). Elden [35] claims that Foucault attempts audiotaped and transcribed verbatim by the author. to capture the creative, productive sense of power by using the French word pouvoir meaning, “to be able to”. Data analysis A discourse analysis inspired by the work of Foucault was used to analyze the interviews. By using the six Aim stages developed by Willig [36] the author performed The aim of this paper is to explore how users and pro - the analysis manually. Initially, the text was read with- fessionals construct the place’s influence on personal out any purpose of analyzing. To understand the con- recovery in community mental health services. It follows structions of places’ influence on personal recovery in from this that the intention is not to present the true community mental health service was the discursive right place for these services, but to present how “the object and a basic point for the analysis. The aim in right place” is co-constructed by people involved in stage 1 was to identify all the ways the phenomena of community-based community mental health services. study were described and constructed. I explored how Femdal Int J Ment Health Syst (2018) 12:26 Page 4 of 9 the discursive objects were constructed through lan- service: the place as a potential for recovery and as barri- guage, and what types of objects that were constructed. ers against recovery. In stage 2, various discourses behind users’ and health professionals’ constructions were identified by focusing Constructions of place as a potential for recovery on the differences between their constructions and by User–professional relationships were often involved in asking what discourses the constructions were based the participants’ constructions of place as a potential on and what their relationship to each other were. In for recovery. The meaning of the relationship comes to the third stage, I analyzed the achievements of the con- the forefront, when Hanna (user) explains how she feels structions and what is gained by deploying them in when Caroline (professional) visits her at home: this position. In stage 4, I asked why the participants “I don’t have to be stressed doing housework before positioned themselves as they did in the situations to Caroline comes. You want to make a good impres- understand how place and actions opened up or closed sion when you are having guests. It is not like that down opportunities for action. Stage 5 maps the oppor- when she comes. You don’t have to make up an tunities provided by this positioning. In the sixth stage, excuse and delay the visit—just because you could I wanted to identify the subjectivity of the object when not handle the housework. She is not a friend. It is placed in the specific positions. The focus here was to something else” (Hanna, user). detect what potentially can be felt, thought and expe- rienced from the available subject positions [36]. The By her statement, Hanna demonstrated that she did not author used the input of colleagues to temper personal feel pressure from too great expectations when the pro- biases. The steps are shown in Table 1 . fessional visit her at home. Rather, she felt more relaxed than when she is having guests. She created a position Ethical considerations for the professional that released herself from duties The guidelines of the Helsinki Declaration have been expected to be fulfilled when having guests. followed and the study is approved by the Regional The user’s autonomy and right to decide is essential in Committee for Medical Research Ethics (REK-Midt the participants’ constructions of the place’s influence 2011/2057). Ethical approval of the project was given on personal recovery when professionals visits users with the requirement that users should be recruited by at home. Professionals cannot take it for granted to be professionals who were not themselves involved as par- invited in, Hanna (user) claims; “It is up to me to unlock ticipants in this study. All participants gave their written the door.” (laughs). “Or else they cannot come in. When consent prior to the interviews and they were informed you are feeling down, it is easy to lock the door and close about the opportunity to withdraw from the study at any the curtains”. By this statement, Hanna showed that she is time without consequences. Participants’ names in the in charge to decide whether she wanted to give the pro- findings are fictional. fessional access to her home or not. Furthermore, the participants describe a transformation of users’ and pro- Findings fessionals’ roles and positions when a user receives ser- The overall impression working with the data is that the vices in his or her home. constructions were related to the place’s meaning and potential for personal recovery and not on the physi- “A user can say; “It’s enough”, and I have to comply cal place as such. By studying the dynamics of place and to his or her wishes. In my opinion, they have more recovery, processes of user–professional relationships power at home than here (…). “This is my home. I came to the fore. The findings reveal two main areas smoke whenever I want to”. In fact, that is difficult. when the participants constructed the place’s influ - To be in someone’s home when he or she smokes a ence on personal recovery in community mental health lot. To have to change clothes after you have left. Table 1 The analysis process, based on Willig’s six-stage analysis model Stage 1 Discursive constructions How were the place’s influence on personal recovery constructed in the data? Stage 2 Discourses What discourses are the statements drawn upon and how are they related? Stage 3 Action orientation What do the constructions achieve and what is gained from deploying them? Stage 4 Positioning What subject positions are made available by these constructions? Stage 5 Practice What possibilities for action are mapped out by these constructions? Stage 6 Subjectivity What might the users and professionals feel, think and experience from the available positions? Femdal Int J Ment Health Syst (2018) 12:26 Page 5 of 9 Their autonomy… where you can sit, where to go… Professionals expected themselves to motivate users to it is their homes. They decide. When you are there, keep up with their housework, and looked for solutions they control you a little as well. I have my space, that could motivate and empower the users: but it is far less than the user’s. This is my space. “Sometimes I suggest that we do the dishes as we talk I have to ask for permission. “May I use the bath- about what the week was like, when it is messy in a room?” I cannot just take another piece of cake or person’s home. It is part of working on the relation- coffee if the user has not asked me to” (Lars, profes - ship, doing something practical and helping the per- sional). son doing some housework” (Linda, professional). By asking for permission and expecting the user’s This statement presents doing housework together as rules to be dominant, Lars positioned himself as a serving several purposes: It can be a way to reflect on the visitor in the user’s home. In a home, there is no pub- passing week, work on the relationship, and to clean up lic smoking law. The resident decides—it is his or her the house. The disorganized home can be interpreted as domain. These constructions differs from a traditional a sign of mental illness, and doing homework together paternalistic one, where professionals’ make the rules. as attempt to make the user active and participating The aim of the service needed was important in the again. However, the professional do not do the house- constructions of the place as a potential for recovery. work on behalf of the user but expect him to participate, The participants constructed places as motivating and which can be interpreted as part of a user participation empowering for the users. Some described the impor- discourse. tance of having an appointment at the community men- The participants did not only construct the user’s home tal health center as a way to become motivated. or an office as places with potential for recovery in men - “When I have an appointment, it helps me to get tal health services. Participants explained that meeting out. Get up in the morning, get out of the house, in other places, like sitting on a bench outside the user’s and make sure I get there on time. When I am ill home, in the woods, go for a walk or at a café, could be and feeling down, I usually stay at home. It is of a way to create a safe environment in which they could great importance, especially in situations like that, be exposed to the things the user fear or avoid. The pro - to get out”. (Greta, user) fessionals positioned themselves as the ones making the suggestions, even though they rather wanted the users to The way to or back from the mental health care do so themselves; “Usually, the idea comes from me. Nev- center was sometimes described as an opportunity to ertheless, sometimes they make proposals after a while. practice skills they struggle with, like doing some shop- Some have suggestions as to where they would like to go. ping on the way home, taking the bus by themselves or I encourage them to do so. Usually, they are my sugges- talking to someone they meet on the way. Finding solu- tions” (Erik, professional). By being the one who makes tions together and to be flexible in order to meet the the suggestions, Erik takes the position as the one who users’ challenges in their everyday lives were described govern the process. He tries to encourage the user to as motivating for the users. “When a person feels that make the same suggestions as he did as well. it is too hard to come, I visit them at home” (Emma, Professionals argued that it was necessary to visit a professional). Lars (professional) claimed: “If they don’t user at home in order to get important information about manage to come here themselves, I sometimes ask if a person’s everyday life with mental health problems in they want me go along with them… if they don’t have some situations. someone to accompany them”. By this quotation, the journey from the user’s home to the community mental “When a person is at home, it is easier to under- health care center is constructed as a way to overcome stand what he or she struggles with. They can sit in an obstacle. my office saying everything is all right at home, or Even measures that are usually negatively connoted, just the opposite. When you come home to a person, as being controlled in their own homes, could be moti- you make an assessment yourself” (Lars, profes- vational for some of the users: sional). “They came to check if I have done the things we The statement may be interpreted as a sign of distrust agreed on. (…) When it happened, it was all right. in the user, as the professional did not trust the user to I had an excuse to clean and clear up. It would be come forward with the important information them- difficult to do it if they did not come to check. It is selves. At the same time, it can be understood as a way to a kind of motivation”. (Anna, user) learn to know the user and the place’s influence on how the user cope with their mental health problems. Many of Femdal Int J Ment Health Syst (2018) 12:26 Page 6 of 9 the users lived in families. The presence of family mem - needs. In accordance, some professionals claimed they bers at home was used as an argument to make the user were concerned about how to end a user–professional come to the professional’s office: “Often the users want it relationship to avoid that the number of users accumu- themselves. ‘My wife is at home, too. I would rather not lates. This way, the users’ individual needs become subor - talk about my problems when she is present.’ So we talk dinate to the system and the need to save money. At the about his or her situation and find a solution” (Marie, same time, a dominant understanding among users and professional). In this case, the user is an active part of the professionals was that it takes time to get to know each decision-making. “At home, the telephone is calling, there other well and to establish a good alliance. A good user– are things they need to do. The concentration on the con - professional relationship based on trust was described as versation is much better here. Here we have provided a a prerequisite to feeling safe and comfortable, regardless place and time for the conversation” (Hilda, professional). of the physical place. By this argumentation, Hilda underline the importance of It was a dominant understanding by users and profes- being flexible and cooperative without interruptions. sionals that users felt vulnerable and uncomfortable in some situations and at some places. However, the profes- Constructions of place as a barrier against recovery sionals were also constructed as vulnerable and scared: As in constructions of place as a potential for recovery, “Health workers can feel threatened and be afraid of user–professional relationships were often involved accusations when they visit a person at home. Some- in the participants’ constructions of place as a barrier times we go two mental health workers when we feel against recovery. The Place was described as somewhere insecure… Sometimes sexual matters affects the sit - the participants felt vulnerable or uncomfortable. “First, uation. You can be accused of things you have not you have to open up your home, and then you have to done. I have never been in a situation like that, but open up yourself. I think I would have felt more vulner- sometimes I am afraid to be accused of having other able if she came to my house” (Siv, user). By talking about intentions than I have. When it comes to avoiding her feeling of vulnerability if the professionals came to physical attacks, it is smart to be two, too”. (Martin, her house, an asymmetry in the relationship appears. The professional) professionals did not open their homes for the users. She said she feels extra vulnerable and nervous when the pro- In this quote, Martin talks about ways to protect him- fessional came to her house. self from false accusations and physical attacks. At the same time, he position users as dangerous and unpredict- “There was a time I did not make myself dinner. able. What he does not talk about is the user’s reaction It was not because I did not know how to. It was to this behavior, like when two professionals visit them in because I would rather not eat. I remember a health their own homes. This behavior may reinforce the differ - worker who came to my house to help me make din- ences, as the user does not necessarily have support from ner. They said I needed to practice cooking. I did a partner. Accordingly, the professional’s fear and insecu- not want it to happen, but I did not dear to say no. rity can work as a barrier against the user’s recovery. The Wanted to be a good client. Was afraid of the conse- procedure at the professionals’ offices at mental health quences if I resisted… I was afraid of several things. centers could also reinforce the differences between user I was afraid they would be mad at me, that it would and professional: lead to many negative things. That Tobias (fictive name on the professional) would be mad and talk “Usually they come to talk in my office. (…) I go to about it a lot. Even worse… Maybe he did not want the waiting room to bring him or her to my office to talk to me again” (Siv, user). when it is time, because the doors are locked. I show him or her to my office and the conversation takes Siv talked as if the professionals took for granted that place here. I use to sit here and the user there (points they knew what was best for her—even without asking at the chairs”) (Anna, professional). about her opinion. The fear for the consequences seemed to surpass the fact that she did not want the profession- Differences in the roles and the surroundings can be als to come to her house to practice cooking. By putting seen as reflecting differences in power: One is coming pressure on Siv and not ask for her opinion, they demon- to get help; the other is supposed to help. “The person strated a rather paternalistic attitude. who needs help is at the provider’s office”, The men - Some professionals offered the users services at their tal health worker is in possession of an office. He or she office to save time. By doing this, they had time for more waited for the helper to unlock the door; the helper has users. This can be interpreted, as the need to save time a key to unlock the door. One decides where to sit; the and be effective was superior to the users’ individual other person was offered a place to sit. The asymmetry Femdal Int J Ment Health Syst (2018) 12:26 Page 7 of 9 is even more obvious when she later tells that the staff ability of people to be governed. She claims that despite and the people seeking their help use separate toilets: the ideas of redistribution of power are emphasised “Yes, of course. The public toilet is down the hall. Ours in contemporary health care, power relations are not is right over there”. In these discourses, Anna talks about changed, and practices of empowerment end in depend- the asymmetry as self-evident. The statement underlines ency (ibid.). A user–professional collaborative treatment the differences between helpers and people coming for process towards the user’s expectations for treatment help, it becomes a “they” and “us”. The distance became and personal aims for treatment and life, is claimed to be evident through the asymmetry described by where they important to recover from mental health problems [26, meet and what the room is like: 40]. In the study constructions of user–professional rela- “It depends on the setting… This is kind of my tionship was essential when a place was chosen, showing domain. This is my office. We also have a meeting that the power relation can open up or close the possi- room. I don’t like it so much because it is cold and bilities to develop, regardless of the physical location. By impersonal. In our office, there are chairs and a lit - choosing place related to the goals for the interaction, the tle table in the middle. It is so much more comfort- users were be able to work on challenging situations. This able… I don’t like to talk with clients the way we sit is an example of how power is productive and not just right now (in the meeting room, chairs on each side repressive, in line with Foucault’s notion of power as stra- of the table). It is almost like an examination. And tegic acts that encompass all directions [29]. Community I don’t mean to examine them” (Lars, professional). nursing means thinking about how place matters in the By this statement, Lars suggests that any room at the users’ lives and ask them about the meaning that particu- center is appropriate, regardless of the design and func- lar place hold for them [13]. tions of the room. He shows how the room can work as The study illuminates how the constructions of the an obstacle to recovery if the way they sit and talk feels user’s home as the place for user–professional interac- like an examination. tions lead to diametrically different directions: as safe and comfortable or as surveillance and a stressful situation. Usually, a home is considered as a private place, a place Discussion from which they can exclude unwanted outsiders [13]. In this study, places were created as frames the person There may be a risk that routines and security require - recovers in. The constructions of place were not neces - ments that originate from hospital norms and values will sarily located to a specific geographic location, rather to be transferred to the home without critical reflection [41, the function the place had in a person’s recovery process. 42]. What was meant to be a part of deinstitutionaliza- Constructions of place can be considered as fluid and tion might be considered as an institutionalization of a relational, with experience and actions understood as person’s home, and the home space become more “pub- produced distinct from rather than within space [23]. lic” [19]. There has been warned against modelling home The study demonstrates that users and professionals care for people with mental health problems on institu- constructed place as a social place in terms of interper- tional care [43, 44]. Heritage [45] claim that professionals sonal relationship between user and professional. The perform their institutional identities in the users’ homes, importance of creating and preserving a good, trusting when they use topics during visits which have an insti- user–professional relationship is underlined in the lit- tutional agenda (like goal orientation, targeted and based erature [4], as it is in this study as well. The findings illu - on care plans), or when they follow certain procedures minate how the choice of place sometimes is taken for discussing and checking the condition of the clients and granted when the professionals assume they know what is their apartments. As a consequence, users can find it best for the users to recover in. They are told, rather than degrading when they have to adapt their activities in their provided an opportunity to engage in a relationship that own homes to the routines of the professionals [20]. On is reciprocal, to influence on their recovery process. Per - the contrary, social call talks without any professional kins and Slade [37] claim that a good relationship is very aims may contribute to a “recovery in” inclusion process difficult when power is not acknowledged or addressed [4]. through the process. To be treated as a person and not In this study, professionals struggle to find ways to as an object gives the patient a feeling of being respected cooperate with the users and exercise their role as profes- [20]. However, the professionals act in different ways to sionals, leading to frustration regarding how to exercise govern users; to make and keep users active, participat- their work as a professional, as well as paternalism. Some ing, enterprising and self-governing, and users respond claim that professionals take their power for granted in and take part within the same discursive framework [38]. user–professional relationships [13]. Juhila et  al. [4], p. Powers [39] argues that empowerment improves the Femdal Int J Ment Health Syst (2018) 12:26 Page 8 of 9 106 argues that homes “can be institutionalized, if work- construction and different knowledge regimes state what ers take a leading, authoritative, controlling and interven- is true or false. tionist role in home encounters.” The constructions of the boundaries between public and private become blurred. Conclusion On the contrary, the blurred boundaries between per- The constructions show that there is no such place as sonal and professional in community mental health ser- “the right one” in community mental health services. On vices can create spaces that engender a more egalitarian the contrary, to find places that is suitable to recovery in partnership between users and professionals [46]. The mental health problems is a complex process of assess- study also shows that professionals are challenged when ments, flexibility and co-determinations. By clearing the there service users and professionals have competing discourses at play within the place’s influence on per - needs. For instance, when a professional visits a user who sonal recovery in community mental health services, the smokes a lot in his or her home, and the professional existing practices in the field can be opened up to further changes his clothes before meeting the next user. On one reflections and awareness when choosing places in com - hand, users have the right to smoke in their own homes. munity mental health services. Decisional autonomy is believed to be one of the basic Authors’ contributions principles of an ethical health care system [47]. On the The author read and approved the final manuscript. other hand, the home is also mental health workers’ work environment. The health workers are exposed to the ciga - Author details Department of Health and Social Work Studies, Østfold University College, rette smoke whether they want it or not. Furthermore, 1671 Kråkerøy, Norway. Department of Public Health and Nursing, Norwe- the smell of smoke from the health workers’ hair and gian University of Science and Technology, 7491 Trondheim, Norway. clothes may feel uncomfortable to other users. Acknowledgements The study shows that institutional thinking has been I would like to thank the users and professionals who participated as inform- transferred to community mental health care when pro- ants in this study. fessionals come to pick up the user at the waiting room, The article is part of Ingrid Femdal’s doctorate. unlock the doors, lead the conversation against goals, and care plans. One can ask if the users really are able to Competing interests cooperate and make autonomous decisions if the profes- The author declare that there is no competing interests. sionals set the rules, and if professionals only ‘pretend’ Ethics approval and consent to participate co-determination directed at practicalities rather than The study is approved by the Regional Committee for Medical Research Ethics, involving users in fundamental decisions [48]. This is Norway (REK-Midt 2011/2057). considered as tokenistic involvement when people are led Funding to believe that their influence is greater than it actually is. The author received no specific funding for this work. Publisher’s Note Strengths and limitations of the study Springer Nature remains neutral with regard to jurisdictional claims in pub- The strengths in this study lies in its focus on both users’ lished maps and institutional affiliations. and professionals’ constructions of the place’s influence Received: 21 February 2018 Accepted: 25 May 2018 on personal recovery in community mental health ser- vices. The purpose of a discourse interview would not be to look for a true and external reality that science to a greater or lesser degree can correspond to [49]. Never- References theless, awareness of the meaning of place is important to 1. WHO ( World Health Organization). Mental health action plan 2013–2020; increase reflexive and improved understandings of how place influences recovery processes. 2. Slade M, Amering M, Oades L Recovery: an international perspective. Epidemiol Psychiatr Sci. 2008;17(2):128–137 The fact that I understand my inquiry to be inextricably 3. Curtis S. 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The right place? Users and professionals’ constructions of the place’s influence on personal recovery in community mental health services

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Medicine & Public Health; Psychiatry; Clinical Psychology; Health Administration
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Abstract

Background: Current mental health policy emphasizes the importance of community-based service delivery for people with mental health problems to encompass personal recovery. The aim of this study is to explore how users and professionals construct the place’s influence on personal recovery in community mental health services. Methods: This is a qualitative, interpretive study based on ten individual, semi-structured interviews with users and professionals, respectively. A discourse analysis inspired by the work of Foucault was used to analyze the interviews. Results: The findings show how place can be constructed as a potential for and as a barrier against recovery. Con- structions of the aim of the services matter when choosing a place for the services. Further, constructions of user–pro- fessional relationships and flexibility are important in the constructions of an appropriate place for the services. Conclusions: The aim of the service, the user–professional relationship, and flexibility in choosing place were essen- tial in the participants’ constructions. To find “the right place” for mental health services was constructed as context- sensitive and complex processes of assessment and co-determination. Trial registration The study is approved by the Regional Committee for Medical Research Ethics, Norway (REK-Midt 2011/2057) Keywords: Community mental health services, Personal recovery, Place, Productive power, Social constructionism Background space by focusing on constructions of how place in com- Current mental health policy emphasizes the importance munity mental health services impacts personal recovery of community-based service delivery for people with by focusing on place as a social construction. mental health problems to encompass personal recovery [1]. The place community mental health services are pro - Place and recovery in the context of community mental vided in can be understood as materiality, as a physical health services place. In this paper, however, place is in addition consid- Recovery has become a forefront of the policy agenda in ered as social constructions. Previously, place and space many countries [1, 2], and is central to hopes for progress have been described as emerging after hospitalization to in mental health policy. The World Health Organization offer shelter and care for people with mental problems (WHO) claim that “community-based service delivery [3, 4]. This study contributes to the research on place and for mental health needs to encompass a recovery-based approach that puts the emphasis on supporting individu- als with mental disorders and psychosocial disabilities *Correspondence: ingrid.femdal@hiof.no to achieve their own aspirations and goals” [1], p. 14. Department of Health and Social Work Studies, Østfold University Community mental health service is supposed to pro- College, 1671 Kråkerøy, Norway mote independence, belonging, and to strengthen the Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Femdal Int J Ment Health Syst (2018) 12:26 Page 2 of 9 ability to cope with life [5], p. 7, reflecting expectations of relationships, like place as a healing place. As such, for progress. Personal recovery is described as subjec- it is constructed as a social place in terms of interper- tive and unique, taking place within the context of the sonal relationships involving user and provider [14]. The person’s everyday life [6]. It is defined as “a deeply per - nurse’s presence is considered as a therapeutic enterprise sonal, unique process of changing one’s attitudes, values, and as contributing a unique and comforting element to feelings, goals, skills, and/or roles. (…) a way of living a the person’s illness experience [14, 15]. Constructed as satisfying, hopeful, and contributing life even with limi- a social place, place refers to interpersonal relationships tations caused by illness” [7]. Davidson and Roe [8] developing between user and provider, and between rela- identified two different meanings of recovery: “recovery tives and provider. Such relationships are central in the from” mental illness and “recovery in” mental illness. The current discourse on mental health services [16, 17]. In notion “recovery from” is based upon people who had this discourse, the ideal relationship is presented as sup- been given diagnoses of severe mental illness becoming porting personal recovery [18]. symptom free and not returning to the patient role. By Community based mental health services are sup- contrast, the notion “recovery in” derives from the Men- posed to encompass a recovery-based approach, based tal Health Consumer or Survivor Movement and refers to on the individual’s own aspirations and goals [1]. One of the person’s own effort and work in getting on with life the places to do so is in the user’s home. The home envi - and creating a life in a community despite their mental ronment represents a multitude of meanings, like per- health problems [8]. “Recovery from” can be understood sonal security, privacy [13, 18–22], comfort, control [19], in terms of medical discourses, focusing on symptoms identity, [22] and autonomy [20, 21]. The notion home is and disease, while “recovery in” emphasizes discourses not just spaces in a mundane sense. Rather, it is imbued that are social and existential. From a “recovery-in” per- with emotions, relations and histories [23]. Home as lived spective, professionals are expected to use their skills and experience, space and social place means that the con- expertise in collaborative partnerships with the person’s structions depends on the power relationships between own change process [9]. These collaborative relation - the involved persons. Professionals’ constructions of a ships take place and are constructed in multiple ways. user’s home may be based on what the user’s home look Cresswell [10] claims that “place is a word that seems like, if it is neat and clean or messy and unclean, how it to speak for itself ” and there has been a rather shallow is decorated with items, furnishings and other effects. understanding of what the word place means. He argues A home visit is thus a professional tool to enter private that place is space invested with meaning in the context home-spaces, observe and collect data required for pro- of power [10]. Place-making is seen as a process of trans- fessional assessments [4]. Physical structures may accord- forming “space” (that is no-place) into “place” [11]. ingly be seen as representing underlying social structures Gieryn [12] describes place as having three defining and other invisible divisions [13]. Dyck et al. [19], p. 175 features. Place as a geographic location refers to a distinct claim that “the home’s materiality is also a signifier of a physical spot (ibid.). People attach meaning to geographic person’s location within power relations that influence locations through their own experiences and understand- access to material resources, as well as culturally valued ings, and through social, cultural and economic circum- consumer goods”. Healthcare delivery in a person’s home stances [13]. Secondly, place has a material form, like a is frequently cast as an invasion of privacy or an intrusion living room or an office. Social processes, such as power, on a person’s space [24]. Some claim that the privacy of happen in the material forms we design, build and use the home is challenged and, as a consequence, the user’s [12]. The third feature of place is investment with mean - ability to restrict public surveillance is compromised [13]. ing and value. Gieryn [12] claims that without naming, However, professionals’ sense of power, authority, control identification or representation by people, a place is not a and sense of a controlled workspace may also be altered place. Place is described as an investment with meaning, [13]. and value appears in constructions of place as lived expe- Mental health service can be provided in mental health rience, sense of belonging, social place and healing place. workers’ offices and other places in addition to the users’ Place as lived experience, implies that people experience homes [25–27]. it in distinct ways, like when one person experiences a Some perceive the professional’s office as a formal place place different at different times, as the experiences and [25] and emphasize the potential of using the users’ sur- constructions of place are changing [10, 13]. Place as roundings in an effort to achieve good contact or practic - ‘the meaning and significance people accord to a specific ing on everyday situations the users perceive as difficult place’ refers to a sense of belonging [14], p. 204. Con- [27]. Some use public places such as shops and cafés to structions of place sometimes demonstrate the meaning practice the management of situations the users find Femdal Int J Ment Health Syst (2018) 12:26 Page 3 of 9 extremely discomforting, like going out among other Methods people [26]. This qualitative, interpretive work using individual, semi-structured interviews was designed to explore Care relationships and productive power how the place influence personal recovery in commu - “Care and care relationships are located in, shaped by, nity mental health services from the perspectives of and shape particular spaces and places… (..)”, accord- both users and professionals. ing to Milligan and Wiles [28], p. 736. To develop an understanding of how relationships and power shape Recruitment of participants and sample the constructions of places’ meaning for individual sup- Participants were recruited through the public commu- port, the work of Foucault [29, 30] is applied. Foucault nity mental health services at municipality level, based was interested in power as an omnipresent and rela- on the acceptance of the service leaders. To meet the tional phenomenon and studied power at the level of inclusion criteria, professional participants had a bach- society as a whole as well at what he referred to as “the elor’s degree in a health or social profession and work capillary level of power” [29]. He claimed that power is half- to full-time position for at least 6  months. The always present in human relationships and preferred service leaders recruited mental health workers who the phrase “relations of power” over “power” [30]. met the criteria. Inclusion criteria for service users Power relations are described as mobile, reversible, were adults (> 18  years), assisted by community men- and unstable [31]. Thus, power is unavoidably present tal health services at least once every other week for in all social relations, such as those between users and at least 2  months, diagnosed with schizophrenia, psy- professionals, and users’ and professionals’ actions and chosis or moderate/severe depression, who would give beliefs shape and are shaped by such power relations. informed consent. The users’ contact persons at the “We cannot jump outside the situation, and there is no community mental health care service recruited users point where you are free from all power relations. But to the study. The researcher received contact informa - you can always change it” [30]. tion only to users and professionals when they accepted In mental health services power often has negative to participate in the study. The material presented here connotations, and is associated with restricting other is based on 10 users and 10 professionals, seven women people’s freedom, domination, control and coercion, in and three men in each group. a hierarchic system where health professionals possess power [32]. According to Foucault however, power is The interviews not a substance or a property one can claim to possess. The participants chose the place for their interview: Within such a perspective, power is not understood as in the participant’s home, at the community mental repressive, but rather as a productive force that pro- health care center or at the interviewer’s workplace. mote actions [33]. However, in this paper I draw on The author, who is a mental health nurse and a Ph.D. Foucault’s notion of power as “to be able to”. In English, candidate, did the interviews. The themes in the inter - the term power refers to both the capacity to do some- view guide focused on experiences of user–professional thing and to the act itself [34]. The French language, by interaction and cooperation to promote reflections on contrast, has two terms to decipher power, puissance roles, expectations, opportunities and experiences. and pouvoir (…), where broadly the former denotes Questions were asked from the themes in the interview capacity and the latter denotes the act of power [34], guide. The interviews lasted for 45–60  min, and were p. 105–106). Elden [35] claims that Foucault attempts audiotaped and transcribed verbatim by the author. to capture the creative, productive sense of power by using the French word pouvoir meaning, “to be able to”. Data analysis A discourse analysis inspired by the work of Foucault was used to analyze the interviews. By using the six Aim stages developed by Willig [36] the author performed The aim of this paper is to explore how users and pro - the analysis manually. Initially, the text was read with- fessionals construct the place’s influence on personal out any purpose of analyzing. To understand the con- recovery in community mental health services. It follows structions of places’ influence on personal recovery in from this that the intention is not to present the true community mental health service was the discursive right place for these services, but to present how “the object and a basic point for the analysis. The aim in right place” is co-constructed by people involved in stage 1 was to identify all the ways the phenomena of community-based community mental health services. study were described and constructed. I explored how Femdal Int J Ment Health Syst (2018) 12:26 Page 4 of 9 the discursive objects were constructed through lan- service: the place as a potential for recovery and as barri- guage, and what types of objects that were constructed. ers against recovery. In stage 2, various discourses behind users’ and health professionals’ constructions were identified by focusing Constructions of place as a potential for recovery on the differences between their constructions and by User–professional relationships were often involved in asking what discourses the constructions were based the participants’ constructions of place as a potential on and what their relationship to each other were. In for recovery. The meaning of the relationship comes to the third stage, I analyzed the achievements of the con- the forefront, when Hanna (user) explains how she feels structions and what is gained by deploying them in when Caroline (professional) visits her at home: this position. In stage 4, I asked why the participants “I don’t have to be stressed doing housework before positioned themselves as they did in the situations to Caroline comes. You want to make a good impres- understand how place and actions opened up or closed sion when you are having guests. It is not like that down opportunities for action. Stage 5 maps the oppor- when she comes. You don’t have to make up an tunities provided by this positioning. In the sixth stage, excuse and delay the visit—just because you could I wanted to identify the subjectivity of the object when not handle the housework. She is not a friend. It is placed in the specific positions. The focus here was to something else” (Hanna, user). detect what potentially can be felt, thought and expe- rienced from the available subject positions [36]. The By her statement, Hanna demonstrated that she did not author used the input of colleagues to temper personal feel pressure from too great expectations when the pro- biases. The steps are shown in Table 1 . fessional visit her at home. Rather, she felt more relaxed than when she is having guests. She created a position Ethical considerations for the professional that released herself from duties The guidelines of the Helsinki Declaration have been expected to be fulfilled when having guests. followed and the study is approved by the Regional The user’s autonomy and right to decide is essential in Committee for Medical Research Ethics (REK-Midt the participants’ constructions of the place’s influence 2011/2057). Ethical approval of the project was given on personal recovery when professionals visits users with the requirement that users should be recruited by at home. Professionals cannot take it for granted to be professionals who were not themselves involved as par- invited in, Hanna (user) claims; “It is up to me to unlock ticipants in this study. All participants gave their written the door.” (laughs). “Or else they cannot come in. When consent prior to the interviews and they were informed you are feeling down, it is easy to lock the door and close about the opportunity to withdraw from the study at any the curtains”. By this statement, Hanna showed that she is time without consequences. Participants’ names in the in charge to decide whether she wanted to give the pro- findings are fictional. fessional access to her home or not. Furthermore, the participants describe a transformation of users’ and pro- Findings fessionals’ roles and positions when a user receives ser- The overall impression working with the data is that the vices in his or her home. constructions were related to the place’s meaning and potential for personal recovery and not on the physi- “A user can say; “It’s enough”, and I have to comply cal place as such. By studying the dynamics of place and to his or her wishes. In my opinion, they have more recovery, processes of user–professional relationships power at home than here (…). “This is my home. I came to the fore. The findings reveal two main areas smoke whenever I want to”. In fact, that is difficult. when the participants constructed the place’s influ - To be in someone’s home when he or she smokes a ence on personal recovery in community mental health lot. To have to change clothes after you have left. Table 1 The analysis process, based on Willig’s six-stage analysis model Stage 1 Discursive constructions How were the place’s influence on personal recovery constructed in the data? Stage 2 Discourses What discourses are the statements drawn upon and how are they related? Stage 3 Action orientation What do the constructions achieve and what is gained from deploying them? Stage 4 Positioning What subject positions are made available by these constructions? Stage 5 Practice What possibilities for action are mapped out by these constructions? Stage 6 Subjectivity What might the users and professionals feel, think and experience from the available positions? Femdal Int J Ment Health Syst (2018) 12:26 Page 5 of 9 Their autonomy… where you can sit, where to go… Professionals expected themselves to motivate users to it is their homes. They decide. When you are there, keep up with their housework, and looked for solutions they control you a little as well. I have my space, that could motivate and empower the users: but it is far less than the user’s. This is my space. “Sometimes I suggest that we do the dishes as we talk I have to ask for permission. “May I use the bath- about what the week was like, when it is messy in a room?” I cannot just take another piece of cake or person’s home. It is part of working on the relation- coffee if the user has not asked me to” (Lars, profes - ship, doing something practical and helping the per- sional). son doing some housework” (Linda, professional). By asking for permission and expecting the user’s This statement presents doing housework together as rules to be dominant, Lars positioned himself as a serving several purposes: It can be a way to reflect on the visitor in the user’s home. In a home, there is no pub- passing week, work on the relationship, and to clean up lic smoking law. The resident decides—it is his or her the house. The disorganized home can be interpreted as domain. These constructions differs from a traditional a sign of mental illness, and doing homework together paternalistic one, where professionals’ make the rules. as attempt to make the user active and participating The aim of the service needed was important in the again. However, the professional do not do the house- constructions of the place as a potential for recovery. work on behalf of the user but expect him to participate, The participants constructed places as motivating and which can be interpreted as part of a user participation empowering for the users. Some described the impor- discourse. tance of having an appointment at the community men- The participants did not only construct the user’s home tal health center as a way to become motivated. or an office as places with potential for recovery in men - “When I have an appointment, it helps me to get tal health services. Participants explained that meeting out. Get up in the morning, get out of the house, in other places, like sitting on a bench outside the user’s and make sure I get there on time. When I am ill home, in the woods, go for a walk or at a café, could be and feeling down, I usually stay at home. It is of a way to create a safe environment in which they could great importance, especially in situations like that, be exposed to the things the user fear or avoid. The pro - to get out”. (Greta, user) fessionals positioned themselves as the ones making the suggestions, even though they rather wanted the users to The way to or back from the mental health care do so themselves; “Usually, the idea comes from me. Nev- center was sometimes described as an opportunity to ertheless, sometimes they make proposals after a while. practice skills they struggle with, like doing some shop- Some have suggestions as to where they would like to go. ping on the way home, taking the bus by themselves or I encourage them to do so. Usually, they are my sugges- talking to someone they meet on the way. Finding solu- tions” (Erik, professional). By being the one who makes tions together and to be flexible in order to meet the the suggestions, Erik takes the position as the one who users’ challenges in their everyday lives were described govern the process. He tries to encourage the user to as motivating for the users. “When a person feels that make the same suggestions as he did as well. it is too hard to come, I visit them at home” (Emma, Professionals argued that it was necessary to visit a professional). Lars (professional) claimed: “If they don’t user at home in order to get important information about manage to come here themselves, I sometimes ask if a person’s everyday life with mental health problems in they want me go along with them… if they don’t have some situations. someone to accompany them”. By this quotation, the journey from the user’s home to the community mental “When a person is at home, it is easier to under- health care center is constructed as a way to overcome stand what he or she struggles with. They can sit in an obstacle. my office saying everything is all right at home, or Even measures that are usually negatively connoted, just the opposite. When you come home to a person, as being controlled in their own homes, could be moti- you make an assessment yourself” (Lars, profes- vational for some of the users: sional). “They came to check if I have done the things we The statement may be interpreted as a sign of distrust agreed on. (…) When it happened, it was all right. in the user, as the professional did not trust the user to I had an excuse to clean and clear up. It would be come forward with the important information them- difficult to do it if they did not come to check. It is selves. At the same time, it can be understood as a way to a kind of motivation”. (Anna, user) learn to know the user and the place’s influence on how the user cope with their mental health problems. Many of Femdal Int J Ment Health Syst (2018) 12:26 Page 6 of 9 the users lived in families. The presence of family mem - needs. In accordance, some professionals claimed they bers at home was used as an argument to make the user were concerned about how to end a user–professional come to the professional’s office: “Often the users want it relationship to avoid that the number of users accumu- themselves. ‘My wife is at home, too. I would rather not lates. This way, the users’ individual needs become subor - talk about my problems when she is present.’ So we talk dinate to the system and the need to save money. At the about his or her situation and find a solution” (Marie, same time, a dominant understanding among users and professional). In this case, the user is an active part of the professionals was that it takes time to get to know each decision-making. “At home, the telephone is calling, there other well and to establish a good alliance. A good user– are things they need to do. The concentration on the con - professional relationship based on trust was described as versation is much better here. Here we have provided a a prerequisite to feeling safe and comfortable, regardless place and time for the conversation” (Hilda, professional). of the physical place. By this argumentation, Hilda underline the importance of It was a dominant understanding by users and profes- being flexible and cooperative without interruptions. sionals that users felt vulnerable and uncomfortable in some situations and at some places. However, the profes- Constructions of place as a barrier against recovery sionals were also constructed as vulnerable and scared: As in constructions of place as a potential for recovery, “Health workers can feel threatened and be afraid of user–professional relationships were often involved accusations when they visit a person at home. Some- in the participants’ constructions of place as a barrier times we go two mental health workers when we feel against recovery. The Place was described as somewhere insecure… Sometimes sexual matters affects the sit - the participants felt vulnerable or uncomfortable. “First, uation. You can be accused of things you have not you have to open up your home, and then you have to done. I have never been in a situation like that, but open up yourself. I think I would have felt more vulner- sometimes I am afraid to be accused of having other able if she came to my house” (Siv, user). By talking about intentions than I have. When it comes to avoiding her feeling of vulnerability if the professionals came to physical attacks, it is smart to be two, too”. (Martin, her house, an asymmetry in the relationship appears. The professional) professionals did not open their homes for the users. She said she feels extra vulnerable and nervous when the pro- In this quote, Martin talks about ways to protect him- fessional came to her house. self from false accusations and physical attacks. At the same time, he position users as dangerous and unpredict- “There was a time I did not make myself dinner. able. What he does not talk about is the user’s reaction It was not because I did not know how to. It was to this behavior, like when two professionals visit them in because I would rather not eat. I remember a health their own homes. This behavior may reinforce the differ - worker who came to my house to help me make din- ences, as the user does not necessarily have support from ner. They said I needed to practice cooking. I did a partner. Accordingly, the professional’s fear and insecu- not want it to happen, but I did not dear to say no. rity can work as a barrier against the user’s recovery. The Wanted to be a good client. Was afraid of the conse- procedure at the professionals’ offices at mental health quences if I resisted… I was afraid of several things. centers could also reinforce the differences between user I was afraid they would be mad at me, that it would and professional: lead to many negative things. That Tobias (fictive name on the professional) would be mad and talk “Usually they come to talk in my office. (…) I go to about it a lot. Even worse… Maybe he did not want the waiting room to bring him or her to my office to talk to me again” (Siv, user). when it is time, because the doors are locked. I show him or her to my office and the conversation takes Siv talked as if the professionals took for granted that place here. I use to sit here and the user there (points they knew what was best for her—even without asking at the chairs”) (Anna, professional). about her opinion. The fear for the consequences seemed to surpass the fact that she did not want the profession- Differences in the roles and the surroundings can be als to come to her house to practice cooking. By putting seen as reflecting differences in power: One is coming pressure on Siv and not ask for her opinion, they demon- to get help; the other is supposed to help. “The person strated a rather paternalistic attitude. who needs help is at the provider’s office”, The men - Some professionals offered the users services at their tal health worker is in possession of an office. He or she office to save time. By doing this, they had time for more waited for the helper to unlock the door; the helper has users. This can be interpreted, as the need to save time a key to unlock the door. One decides where to sit; the and be effective was superior to the users’ individual other person was offered a place to sit. The asymmetry Femdal Int J Ment Health Syst (2018) 12:26 Page 7 of 9 is even more obvious when she later tells that the staff ability of people to be governed. She claims that despite and the people seeking their help use separate toilets: the ideas of redistribution of power are emphasised “Yes, of course. The public toilet is down the hall. Ours in contemporary health care, power relations are not is right over there”. In these discourses, Anna talks about changed, and practices of empowerment end in depend- the asymmetry as self-evident. The statement underlines ency (ibid.). A user–professional collaborative treatment the differences between helpers and people coming for process towards the user’s expectations for treatment help, it becomes a “they” and “us”. The distance became and personal aims for treatment and life, is claimed to be evident through the asymmetry described by where they important to recover from mental health problems [26, meet and what the room is like: 40]. In the study constructions of user–professional rela- “It depends on the setting… This is kind of my tionship was essential when a place was chosen, showing domain. This is my office. We also have a meeting that the power relation can open up or close the possi- room. I don’t like it so much because it is cold and bilities to develop, regardless of the physical location. By impersonal. In our office, there are chairs and a lit - choosing place related to the goals for the interaction, the tle table in the middle. It is so much more comfort- users were be able to work on challenging situations. This able… I don’t like to talk with clients the way we sit is an example of how power is productive and not just right now (in the meeting room, chairs on each side repressive, in line with Foucault’s notion of power as stra- of the table). It is almost like an examination. And tegic acts that encompass all directions [29]. Community I don’t mean to examine them” (Lars, professional). nursing means thinking about how place matters in the By this statement, Lars suggests that any room at the users’ lives and ask them about the meaning that particu- center is appropriate, regardless of the design and func- lar place hold for them [13]. tions of the room. He shows how the room can work as The study illuminates how the constructions of the an obstacle to recovery if the way they sit and talk feels user’s home as the place for user–professional interac- like an examination. tions lead to diametrically different directions: as safe and comfortable or as surveillance and a stressful situation. Usually, a home is considered as a private place, a place Discussion from which they can exclude unwanted outsiders [13]. In this study, places were created as frames the person There may be a risk that routines and security require - recovers in. The constructions of place were not neces - ments that originate from hospital norms and values will sarily located to a specific geographic location, rather to be transferred to the home without critical reflection [41, the function the place had in a person’s recovery process. 42]. What was meant to be a part of deinstitutionaliza- Constructions of place can be considered as fluid and tion might be considered as an institutionalization of a relational, with experience and actions understood as person’s home, and the home space become more “pub- produced distinct from rather than within space [23]. lic” [19]. There has been warned against modelling home The study demonstrates that users and professionals care for people with mental health problems on institu- constructed place as a social place in terms of interper- tional care [43, 44]. Heritage [45] claim that professionals sonal relationship between user and professional. The perform their institutional identities in the users’ homes, importance of creating and preserving a good, trusting when they use topics during visits which have an insti- user–professional relationship is underlined in the lit- tutional agenda (like goal orientation, targeted and based erature [4], as it is in this study as well. The findings illu - on care plans), or when they follow certain procedures minate how the choice of place sometimes is taken for discussing and checking the condition of the clients and granted when the professionals assume they know what is their apartments. As a consequence, users can find it best for the users to recover in. They are told, rather than degrading when they have to adapt their activities in their provided an opportunity to engage in a relationship that own homes to the routines of the professionals [20]. On is reciprocal, to influence on their recovery process. Per - the contrary, social call talks without any professional kins and Slade [37] claim that a good relationship is very aims may contribute to a “recovery in” inclusion process difficult when power is not acknowledged or addressed [4]. through the process. To be treated as a person and not In this study, professionals struggle to find ways to as an object gives the patient a feeling of being respected cooperate with the users and exercise their role as profes- [20]. However, the professionals act in different ways to sionals, leading to frustration regarding how to exercise govern users; to make and keep users active, participat- their work as a professional, as well as paternalism. Some ing, enterprising and self-governing, and users respond claim that professionals take their power for granted in and take part within the same discursive framework [38]. user–professional relationships [13]. Juhila et  al. [4], p. Powers [39] argues that empowerment improves the Femdal Int J Ment Health Syst (2018) 12:26 Page 8 of 9 106 argues that homes “can be institutionalized, if work- construction and different knowledge regimes state what ers take a leading, authoritative, controlling and interven- is true or false. tionist role in home encounters.” The constructions of the boundaries between public and private become blurred. Conclusion On the contrary, the blurred boundaries between per- The constructions show that there is no such place as sonal and professional in community mental health ser- “the right one” in community mental health services. On vices can create spaces that engender a more egalitarian the contrary, to find places that is suitable to recovery in partnership between users and professionals [46]. The mental health problems is a complex process of assess- study also shows that professionals are challenged when ments, flexibility and co-determinations. By clearing the there service users and professionals have competing discourses at play within the place’s influence on per - needs. For instance, when a professional visits a user who sonal recovery in community mental health services, the smokes a lot in his or her home, and the professional existing practices in the field can be opened up to further changes his clothes before meeting the next user. On one reflections and awareness when choosing places in com - hand, users have the right to smoke in their own homes. munity mental health services. Decisional autonomy is believed to be one of the basic Authors’ contributions principles of an ethical health care system [47]. On the The author read and approved the final manuscript. other hand, the home is also mental health workers’ work environment. The health workers are exposed to the ciga - Author details Department of Health and Social Work Studies, Østfold University College, rette smoke whether they want it or not. Furthermore, 1671 Kråkerøy, Norway. Department of Public Health and Nursing, Norwe- the smell of smoke from the health workers’ hair and gian University of Science and Technology, 7491 Trondheim, Norway. clothes may feel uncomfortable to other users. Acknowledgements The study shows that institutional thinking has been I would like to thank the users and professionals who participated as inform- transferred to community mental health care when pro- ants in this study. fessionals come to pick up the user at the waiting room, The article is part of Ingrid Femdal’s doctorate. unlock the doors, lead the conversation against goals, and care plans. One can ask if the users really are able to Competing interests cooperate and make autonomous decisions if the profes- The author declare that there is no competing interests. sionals set the rules, and if professionals only ‘pretend’ Ethics approval and consent to participate co-determination directed at practicalities rather than The study is approved by the Regional Committee for Medical Research Ethics, involving users in fundamental decisions [48]. This is Norway (REK-Midt 2011/2057). considered as tokenistic involvement when people are led Funding to believe that their influence is greater than it actually is. The author received no specific funding for this work. 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International Journal of Mental Health SystemsSpringer Journals

Published: May 31, 2018

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