Where psychiatric institutions and services previously focused largely on direct and passive help, rendering the mental health patients dependent on the health and welfare services (Botslangen 2015; Skårderud 2012; Aaslestad 2007), the focus in contemporary services is on communication, inclusion, autonomy and everyday coping strategies. Various reforms in Norway in the last two decades have enhanced a holistic and user-centered perspective, which is meant to minimize the shortcomings of the welfare bureaucracy’s institutional character and its fragmented organization (Helse og omsorgsdepartementet 2011, 2009; Sosial- og helsedepartementet 1998, 1997). One of the democratic ideals is to implement user participation and to level the relationship between service users and service providers, which is seen, for example, in the implementation of ‘individual care plans’ that aim to assure user involvement in service provision (Helse- og omsorgsdepartementet 2011), and in the restrictions of coercion in psychiatric services (Ekeland 2011).
Policy documents and research literature describe ‘user participation’ in relation to different levels of participation (Thompson 2007; Rise 2012; Klausen and Hamran 2016; Norheim 2014), ranging from stakeholder organizations participating on a structural level in policy devolvement and the overall organization of services, to everyday relationships between service users and service providers. The latter form of participation, the individual service relationship, is where user participation most often takes place (Haukelien, Vike & Møller 2011).
In policy documents that deal with diagnostics, treatment and follow-up practices for individuals with psychiatric disorders, a good relationship between patients/users and frontline professionals is highlighted as pivotal. The ideal service relationship is characterized as being built on equality, empathy, respect, commitment and the dissemination of hope, security and realistic optimism (Helsedirektoratet 2014, 2013; Sosial- og helsedirektoratet 2006).
Studies have shown that a symmetrical service relationship in which the institutional character is minimized is important for both the therapeutic outcome and the general recovery for persons with mental health problems (Almvik et al. 2011; Skatvedt 2009). When service providers adapt to service users with complex everyday problems – seeing, hearing and understanding the service users from their point of view the service provision is more successful (Anvik, Gustavsen & Wrede-Jäntti 2016; Follesø, Halås & Anvik 2016; Backe-Hansen 2014; Borg and Topor 2014; Halvorsen, Hansen & Tägström 2012; Follesø 2011). Further, services that have a low threshold, have flexible opening hours, provide user-driven activities, offer alternative forms of treatment and have offices located in the neighborhoods where the service users live are valued by young service users with complex problems (Andreassen 2016; Järvinen 2016; Elstad 2014).
Thus, establishing symmetrical human service relationships between individual service users and service providers becomes a key objective in mental health services both for ideological and professional reasons (Branfield 2006; Andreassen 2008; Shakespeare and Collins 2016).
Despite the fact that empowerment and user-centeredness have been central issues in legislation, policy documents and inside the field of social and health care service in recent decades, very little has changed: implementation of collaboration between service users and service providers remains scarce (Andreassen 2016; Uggerhøj 2014; Rambøll 2012; Järvinen et al. 2002). Critical studies have scrutinized the way user participation is practiced by service providers, showing that a symmetrical service relationship seldom occurs in everyday service provision (Øye 2010; Oeye et al. 2009).
Research suggests that a main barrier to establishing a symmetrical service relationship is the service providers’ lack of capability to build up relationships of engagement, human decency and sincerity (Uggerhøj 2014; Øye 2010; Andreassen 2007).
In this article, I will explore in detail how young adults with mental health problems experience everyday encounters with service providers, and reveal how the service relationship is perceived from their specific standpoint. The cases analyzed do not focus on a single institution, but different services and relations (an institutional complex), as the young people participating in this study have been (and still are) in contact with many different psychiatric and mental health services in their everyday lives. Thus, the object of inquiry is the service relationship and how this is connected to institutional practices and ideals that shape the interaction between service users and service providers. I will answer the following question:
How do young service users with mental health problems experience the everyday relationship with service providers, and what kind of institutional logics and practices complicate the possibility of achieving a symmetrical human service relationship?
Utilizing theoretical aspects from Institutional Ethnography (IE) (Smith 2005, 1999), I take my methodological point of departure in the standpoint of service users situated in concrete local institutional practices in order to understand how these practices are shaped by social and ruling relations. In doing so I illustrate how different institutional texts coordinate, in a variety of ways, everyday embodied interactions between service users and service providers such that informal relationships are difficult.
The article thereby contributes to a small but growing body of work that investigates the everyday service relationship between service users with mental health problems and service providers, explored from the standpoint of young adults in troublesome life situations (Anvik, Gustavsen & Wrede-Jäntti 2016; Elstad 2014).
Agreeing with Dorothy E. Smith’s understanding of the modern institution, I see the institutional not as a specific entity or organization, such as a hospital, a school or a family. I rather perceive ‘institutions’ as interconnected relations that link the local institutional context with trans-local ruling relations, coordinating various functions of the modern liberal welfare state, that are not necessarily limited to one specific organization (Smith 2005, 1999). The starting point for an inquiry that utilizes an IE perspective is to explore institutional conditions from the standpoint of the persons experiencing the consequences of institutional organization in their everyday lives. In particular, objectified and often textually meditated forms of consciousness, discourses, ideas, organization and practices govern people’s everyday dealings and doings. Smith conceptualizes ‘texts’ broadly as discourses that can be duplicated and distributed in identical form to many different locations simultaneously, which ensures a degree of institutional stability. The fact that the texts are identical does not mean that they are interpreted or activated in the same way in different local institutional contexts; on the contrary, the local activation is exactly this – local. What people do locally and how they use institutional texts demonstrates their knowledge of institutional practices and organization. Thus, I look at my informants as ‘knowers’ who, through their work, activate text-based forms of knowledge that connect them with translocal ruling relations. ‘Work’ should, in IE terminology, be understood in the broadest sense of the word, as processing anything or doing something and is not confined to formal work or paid labor. Accordingly, a young unemployed person with mental health problems carries out a large amount of work in his everyday life; the service user should, for example, comply with the demands and activities in relation to NAV (Norwegian Labour and Welfare Administration) (Olesen, forthcoming), the treatment at VOP (Adult Psychiatric Outpatient Clinic), attend the local drop-in center, and so on. It is not possible to explore all these services as a whole, organizational unit. The ambition in this article is rather to uncover a particular component within an institutional complex by showing how people as ‘knowers’ have embodied knowledge they act out when performing their everyday work. In this article, I explore how everyday service relationships are performed and experienced by service users in specific institutional settings – focusing on how apparently insignificant texts and interactions are governed by institutional logics and specific understandings of the service relationship. In other words, how small actions are implanted in larger institutional complexes.
Method, Data Production and Extracts
The analysis in this article is based on empirical data from a multi-method/multi-sited fieldwork (Marcus 1995). Interviews, observations, conversations, self-filming and text analysis are all applied. Twelve service users and 13 front-line professionals from different municipalities in northern Norway participated in the study.
Two different recruitment methods were applied: Based on a self-recruitment method, I visited and distributed information flyers in local drop-in centers and in sheltered houses for persons with mental health problems. Any service user who wanted to participate in the project could contact me via SMS, phone or e-mail. In line with basic principles in Institutional Ethnography (Campbell and Gregor 2002), I mapped out the services the young service users attended in their everyday lives and recruited the professional participants from some of these services and institutions.
At the beginning of the project, the service users were between age 16 and 33, and they had some sort of mental health problems that they regarded as an obstacle in their everyday life. Mental health problems are, in relation to recruitment criteria, understood as non-physical health problems that the young person perceives as problematic in relation to finishing an education or retaining work.
All the informants, both service providers and service users, initially participated in a semi-structured interview (Järvinen & Mik-Meyer 2005; Smith 2005; Holstein & Gubrium 1995) with a duration from 45 minutes to 2 hours and 45 minutes. Based on the interview, four service users participated in a film project, three were observed meeting their caseworker from NAV, and five participated in additional conversations. Three service users gave me access to their NAV records and gave their consent that their records could be used in the research project. Thus, some informants participated only in one part of the study, while others participated in several parts simultaneously.
The interviews were based on a schedule consisting of four overall themes covering everyday institutional work, user involvement and experiences of being a service user, work and education, and the service relationship. The schedule was used as a guide in the interview situation, yet each interview evolved in its own direction. The informants participating in the video project were given a simple camcorder and filmed sequences from their everyday institutional lives. Subsequently, the filmed material was used as a basis for a conversation where the participants elaborated on the filmed sequences. These conversations were openly structured and written down as field notes.
The entire body of data material forms the basis for this article, while extracts from the data material will be given emphasis as cases; three service users’ experiences of encountering different service providers will be extracted and highlighted in particular. Thus, the perspective of frontline professionals is backgrounded in this article.
The analyses in this article reveal patterns in the young service users’ experiences of different institutional practices and show how these experiences are related to larger institutional logics of governance.
The study has been subjected to ethical review by NSD, the Norwegian Centre for Research. All data material is anonymous: the names of persons, places and to some degree institutions that appear in the paper have been altered to avoid recognition.
‘Inside the System’
The young adults with mental health problems in the study recount that they have never been in education or in a regular job, or have been only for short periods; they more or less entered adulthood under the supervision of different psychiatric and welfare services and ever-changing succession of service providers. Eva, 28 years old, who has been in and out of psychiatric services since her early teenage years, explains how she and a friend she met in a psychiatric ward when they were children, sometimes go out in public and try to act like regular people:
[…] we’ve always talked about what regular people do. We once went to a café and we agreed not to talk about mental illness for 30 minutes. That was a big challenge, but we actually succeeded. A lot of quiet moments between us though.
The young woman says that usually she talks to her friends or service providers about subjects concerning diagnoses, medicine, treatments, services and so on. To her those are normal subjects, relating to her everyday life, being a long-term service user with mental health problems. This illustrates how service users who entered the psychiatric service system as children or teenagers and enter adulthood within the psychiatric apparatus identify, to a large degree, with institutional identities as ‘user’ or ‘patient’. They have internalized the institutional norms and perceive themselves as alienated from ‘regular’ people. Other service users speak of an ‘inside’ and an ‘outside’ of the institutional system, where the ‘outside’ is the space not associated with service providers. The ‘inside’ is not bound, as in E. Goffman’s (1968) classic analysis of the total institution, to a physical building or a specific institution, but to all parts and all relations related to the widespread health and welfare services they encounter in their everyday lives. Through their work (Smith 2005) – having mental health problems and dealing with service providers – most aspects of the young service users’ everyday life are somehow related to services: from economic benefits and admission to specialized psychiatric (and/or substance abuse) services, to everyday leisure activities at the local drop-in center and friendships.
The young adults describe the number of service providers they encounter in their everyday lives as massive. Mette, 25 years old, concludes that she ‘has met maybe as many as one thousand different service providers’, in the eight years she has been in contact with the psychiatric apparatus. Other service users have attended coordination meetings1 with up to ten different professional representatives from different services. Furthermore, the relations to these professionals are not stable – as a service user, you meet new service providers all the time. You get a new caseworker at NAV, you are admitted to the psychiatric ward where you meet new patients, nurses, and doctors, or you get a new contact person at the follow-up service (Norwegian: oppfølgingstjenesten), your therapist stops working at the Psychiatric Outpatient Clinic (Norwegian: psykiatrisk poliklinik) and you get a new one. Mette says that out of the hundreds of different service providers she has met, ‘I had a relationship to around twenty, while a handful of them really meant something to me’. This illustrates how long-term service users are constantly building relationships with professionals and breaking them off again.
When most of their daily activities are connected to services, they have very few relations on the ‘outside’ – they do not interact in any considerable way with ‘regular’ people, only ‘system’ people. Often the only regular contact with people from the ‘outside’ is with their closest relatives; their mother, father, siblings or grandparents. Beside service providers, ‘system’ people also include their close friends. A young woman describes her friendships like this:
Some or all the people I am friends with I have met and are from inside the system. That is three people. There are some people in town that are my family and that I knew growing up, but I don’t have any contact with them.
Since most of the young adults in the study have spent considerable periods frequenting different psychiatric institutions and services in their teens and early twenties, this is where they have shaped their identity and built friendships. Eva explains that, after a long stay at a hospital ward, she was discharged, which made her anxious, ‘it was like being thrown out of home’, since she had ‘no friends outside the hospital’. The institutional relationships the young persons have built up, both with service providers and other users, are to a large degree their primary relationships in their everyday life. This demonstrates the precarious life situation the service users have: they cannot choose not to be dependent on various services, they have to interact with the professionals they encounter and the relationships to service providers largely determine their life circumstances. Peter, 29 years old, explains how he makes an effort to show the service providers he encounters that he has a personality, because he thinks that it makes service providers more engaged with him, and thereby be more obligated to provide the care he needs:
If I am just one of the many that goes in and comes out of there [services], why should they [service providers] have the commitment to make an effort? … Sometimes I feel I have to make an effort to show that I have a personality in addition to being a patient.
Like Peter, many young service users express that when the majority of their everyday interactions and relations are with professionals, the institutional character of the service relation becomes an additional strain, and is at times experienced as overwhelming.
As I will show in the following, the everyday human service relationships are embedded in institutional complexities that impede informal and permanent relations between service users and service providers.
Activating the Duty of Confidentiality
Mette, quoted above, filmed herself talking about an encounter she had a couple of hours earlier with a former service provider:
Tonight, I went to the supermarket to get some food.
In the store, I met a care worker. The reason I didn’t recognize her at first, was because she lives 400 km away.
We were just buying groceries in the same store and passed each other countless times, and our eyes met at least twice. I couldn’t get myself to say ‘hello’.
The encounter with her set many feelings in motion. A loss and a sorrow, because of the help I got, which I lost. A longing after the people who helped me. Who for the first time took me seriously […]
I regret that I didn’t say hello and I miss her. I was confident with her […].
At the same time, I’m afraid that she wouldn’t remember me, because she meant a lot to me. I only managed to look at her, I didn’t manage to say hello, and after a while I just looked through her when she was around. I miss our relationship, and it’s difficult when it’s cut off. It’s difficult to imagine that I’m never going back to the place where I got the best help I ever got.
[Transcribed video sequence]
Mette explains, in a conversation based on the self-filmed material, that the person she encountered in the supermarket was a mental health care worker from a specialized mental health care service to which Mette was admitted for six weeks. Mette explains that at the specialized service, she was met with an intimacy that she never encountered before. It was natural for the staff to hold hands, give hugs and in general have an informal interaction with the service users, which Mette found helpful and reassuring. She describes that the service providers at the service for the first time saw her real problems and understood her as both a patient and a person. The encounter in the supermarket made her remember the special relationship she had with this particular service provider and how now it is gone.
In the video, when Mette talks about the seemingly trivial (lack of) interaction between the two people at the store; she at the same time expounds her work-knowledge of the institutional complexity the interaction is embedded in: the two people are performing an institutional practice coordinated by trans-local relations.
Mette explains that the former care worker ‘could not say hello, […] because then she would violate her duty of confidentiality’. The young woman explains that it is common practice that out in public the service user should say hello first, and then the service provider can say hello subsequently, but not the other way around. I was told about the same practice in most interviews with both service providers and service users; it is an unspoken norm practiced particularly in health services, where the professional duty of confidentiality covers everything that may reveal that a service user has a relationship to healthcare providers. This institutional instruction is not specifically written down or clarified in official guidelines or law texts, but is an interpretation or ‘text-reading convention’ (Smith 2005), of the general law regulating the professional duty of confidentiality.2 Accordingly, the duty of confidentiality is activated as a fundamental bureaucratic principle coordinating the professional conduct of the service provider in order to protect the privacy of the service user. Mette explains that even if the former care worker would like to talk to her, she was restricted because of the institutional code of ethical conduct.
The two people in the store conduct themselves in a very specific and rule-bound way; G. H. Mead (Mead et al. 2015: 261) would say that their attitudes follow the appropriate response within a specific institutional setting that appears adequate to them. In another social setting, and acted out by persons in a position not familiar with the specific institutional attitude (not having knowledge about ‘the duty of confidentiality’), similar conduct would appear strange or disrespectful. Thus, the practice of not saying hello shows how institutional forms of ruling are internalized and naturalized by both Mette and the former service provider; they are both actively involved in an institutional complexity, categorizing them and coordinating their local practice, even long after their formal relationship has ended.
What Mette describes is a clear oppositional relationship where the demarcation between the positions of ‘service provider’ and ‘service user’ is evident, but at the same time the relationship is not distinctly hierarchical: Mette is in a position where it is her choice to engage with the former service provider, but she cannot make herself do this. This clarifies how the ‘duty of confidentiality’ is built on ideals of equality and empowerment, since the service user ‘on paper’ has the possibility (and power) to choose how and when she will interact with service providers; the service provider is ideally balancing the relationship of power by handing over power to the service user.
Mette explains that she always found this sort of regulated interaction with service providers strange and, as the extract above shows, at times hurtful. Another service user has the same experience: he says that his GP walks past him in public, ‘as if I do not exist in this world’.
Mette’s description shows that the subtle but institutionalized conduct of both Mette and the former service provider is not experienced as empowering; on the contrary, the interaction makes obvious that their relationship is essentially institutional and defined by formal bureaucratic regulations. Despite Mette’s good memories of her relationship to this specific care worker, she is reminded that it is not an equal or candid relationship. The position as (former) service user and (former) service provider, and the following activation of ‘the duty of confidentiality’ is an institutional action that transforms (and formats) the public space of the supermarket to an institutional space. This should be seen in relation to the young service users’ general consumption of services mentioned above, and the character of their service relationships; the young service users are not going to their GP a couple of times a year, but are constantly building relationships with different service providers, and these relationships are important in their lives. Thus, the interaction in the supermarket clarified for Mette that when the formal institutional connection to the former service provider ended, their relationship ended as well, which Mette finds agonizing: ‘the sorrow is like an open wound that can’t close again’.
Mette’s account shows that it is possible for service providers and service users to build a meaningful and close relationship, but it will most often be limited in time and space due to formal bureaucratic rules and regulations. The position as service user and service provider and the activation of the ‘duty of confidentiality’ excludes an informal interaction between the service user and service provider in public, thereby illustrating that their service relationship is necessarily institutional.
The exclusion of informal interactions is manifested differently in different institutional contexts; different professions and different institutions practice the separation more or less strictly. The exclusion of the informal interactions is particularly pronounced in the hospitals’ psychiatric wards. Here the exclusion is not just something happening in public, or when the service relations have ended, but a regular aspect of the service relationship, regulating everyday interactions, as the following will exemplify.
The ID Card
Eva explained to me in an interview how she has been in and out of psychiatric wards, and has been receiving treatment, care and medication for several years. The nurses, doctors and other professional staff at the hospital have, from her perspective, always been very professional. They have in general provided a high standard of professional care – her room was cleaned, food was served, she received therapy, she was relatively well medicated and she received benefits.3 As a result, all her objective basic needs were met. After being a psychiatric patient for years, she reflects on her experience and the care she received at the hospital:
I believed it was compassion [Norwegian: omsorg] that made the staff keep me alive. I believed that if they were fighting to keep me alive, it was because I meant something to them. Instead, it was only due to routine that they kept you alive, for practical reasons […] They were just following their guidelines.
Eva expresses how she, from her point of view, was primarily perceived as a patient with complex psychiatric diagnoses, which meant that the hospital staff provided a certain type of standard care. Eva tells that the staff would tell her to trust them since they are experts: ‘you have to listen to us, we know best. You are like this and that. You have to trust us because we have knowledge about this’. Eva’s account demonstrates how she sees the care she received at the hospital as largely bound to professional guidelines and expert knowledge, and she elaborates on her experience of the highly professional and standardized care she received there:
What I missed was someone who could give me a bit of themselves too, not just walk around with a nametag where the last name was covered up because you did not need to know their last names.
Not all staff at the hospital covered their last name on their ID card with tape, but Eva explains that usually some of the staff do. The reason for only showing the first name, the young woman explains, is to hide and cover their civilian identity, thereby highlighting their professional identity. In the psychiatric wards, it is common for neither the patients nor the staff to wear institutional clothing – the ID card is the only visible symbol that separates the staff from the patients. The ID card, as a ‘text’ in Smith’s terminology, connects the local work at the hospital to trans-local social relations, by coordinating and objectifying the different institutional positions. When covering the last name with tape, the staff are responding to the institutional positions objectified and embedded in the ID card even further, stressing that at the hospital, their private identity does not matter. That this practice is acceptable exposes the staff’s work-knowledge by stressing that an informal care relation to the patient is of little importance, thereby emphasizing that the service relationship at the hospital is built on ideals of hierarchy, expert knowledge and standardization.
Eva’s account of the staff covering the ID card shows how seemingly trivial everyday actions constitute an institutionalization of the human service relationship when viewed from her standpoint; it constitutes a signature of power (Dean 2012). The same exclusion of informal interaction is practiced in conversations. It is expected, Eva explains, that you as a patient are open, and that you give a detailed personal account when asked, while the opposite is the case with regard to the service providers. Most often, the staff would not engage in a personal conversation and Eva thinks this reveals an odd relationship, ‘because you’re giving a lot of yourself, but you get nothing back’.
When service providers exclude informal interactions, they demonstrate that they perceive the care they provide for the patients as objective and neutral. It is therefore without importance what the name of the service provider is, or whether she has children, or has personal experience with mental health problems, and so on. In this light, the relationship between service providers and service users can be seen as oppositional, displaying what R. K. Merton regards as a typical client-professional relationship, where the authority has the power to prescribe the client to fulfill specific actions, modify her behavior or make her abandon preferred practices and ideals (Merton 1976: 26). As Christine Øye has highlighted in her research from psychiatric hospital wards (Øye 2010), the human service relationship inside this institutional context has a distinct service logic in which the power relationship between staff and users is permanently asymmetrical. Based on Marcel Mauss’s theory of reciprocity, Øye shows how mental health patients have little or nothing to give the service providers and the service provider has the power to reject any ‘gifts’ (goods or services) derived from the user. At the same time, there is no possibility for the patients to reject the service given to them by the service providers, since the institutional relationship is imposed on the service users by being admitted to the hospital. When it comes to Eva’s account, she focuses on the exchange of informal things like feelings and personal experiences, and in that respect she experiences the asymmetrical reciprocal exchange the opposite way. Following her experience, the service users disclose their innermost feelings and perceptions of their everyday lives, while service providers deliver professional service without involving themselves, which emphasizes the imbalance. This type of asymmetrical service relationship is based on a power relationship between a passive service user and expert service provider, which makes clear that it is the service user that needs the professional’s skills and knowledge, not the other way around.
The accounts analyzed above show how a selection of small, seemingly insignificant institutional ‘texts’ and practices affect how the relationship is performed between service users and service providers, which clarifies that the service relationship is essentially institutional and defined by formal bureaucratic regulations. In both institutional contexts – in public and in the hospital – the young service users quoted perceived the exclusion of informal relationships as hurtful and as a need not met by service providers. The censorship of the surname, for example, is experienced by Eva as something that obstructs or underlines the lack of a balanced relationship, a relationship that the service users express a desire to have. The accounts above show that service users experience that service providers rarely cross the formal boundaries of professional expertise and conduct, since the service relationships are coordinated by institutional logics: the service users are distributed specific institutional roles that function as barriers to achieving a symmetrical and informal service relationship.
The institutional relations coordinating the service relationships are, on the other hand, not frozen solid. They coordinate the local actions, but not in a deterministic way. Sometimes service providers do cross the formal boundaries of professional expertise and conduct by not rigidly following bureaucratic rules and regulations, blurring the demarcation between the individual service user’s everyday life and the service provider’s formal work.
Crossing the Border
Peter, 29 years old, who due to mental health problems has been unemployed and a service user all his adult life, explains in an interview that after his first therapist got a new job, she gave him her new work telephone number and email address and suggested that Peter, her now former patient, could contact her if he needed to talk to her. From Peter’s perspective, the psychologist’s action is a proof of her genuine care for him, because it is not just something the therapist does as an official part of her professional work, but as something additional:
She understood that it would make it much worse if I lost her entirely, because she understands that to lose people, that is kind of a very big deal […] she is really the one who knows me best of all the therapists I have had. She has never judged me. I feel that she understands a lot.
The unusual thoughtfulness this therapist showed her former patient is unique: to have the possibility to keep seeing a therapist when your formal relationship has been terminated is not customary, Peter tells. He elaborates on service providers in general, and therapists specifically:
They are so professional—it becomes so square. I understand that they cannot mix their private life up in it, they wouldn’t manage it… they cannot take their job home with them, that would be too much […] I don’t know… Some are like… You wonder if they even care about you as a person, or if it is just a professional job they have.
From Peter’s perspective, that his first therapist informally gave him the possibility of preserving the relationship means that he experiences a continuity in his institutional relations—that he has another person, a professional therapist, who has personal knowledge about his difficulties over a long period. Peter, in other words, describes how his former therapist crosses the border of her bureaucratic obligations by giving Peter her telephone number, and as a result maintains her relationship with Peter. Peter describes this as a unique act meant to fulfill his needs for a more permanent service relationship.
Other studies have shown the intrinsic value for the service user when encountering service providers who do ‘a little extra’ (Norvoll 2007; Almvik et al. 2011). The informal element can facilitate an individual centeredness that meets the service user’s needs, thereby having a positive value for the service user’s view of the service relationship.
When Peter perceives the relatively small, informal deed from the former therapist as a unique act, it shows that his experiences with service providers are largely shaped by a formal and rigid delivery of care and that his individual need for a permanent (informal) service relationship is rarely constituted in the services he receives. Likewise, most service users (including Peter, Mette and Eva) describe a lack of stable relations as a permanent condition, and their everyday interactions with service providers are experienced as constrained, formal and fragmented. Hence, Peter (and several other participants) describes how he fits his everyday life to the frames, rules and structures of the services, not the other way around – only encountering informal service relationships sporadically.
It seems that the institutional formalization of the interaction between the front-line professionals and the young users is perceived in itself as problematic by the informants quoted in this article. They express a longing, not necessarily for a private relationship, but for ‘ordinary’ or everyday interactions not regulated by rigid rules and guidelines. A type of relationship that is not terminated when the formal ties between service provider and service user end.
This clarifies the difficulty of providing a symmetrical service relationship in relation to young adults with mental health problems in need of multifaceted services.
Indeed, the welfare bureaucracy is what Smith calls a ‘regime of ruling’ (Smith 2005, 2006) which, in the form of trans-local ruling relations, coordinate people’s doings within this regime. Put differently, the bureaucratic organization includes, or demands, one set of actions (impartiality, division of expertise, standardization, professional conduct, etc.), while excluding others (informal conduct, lasting service relationships, disorganization, etc.).
In the concluding discussion, I will discuss the dilemmas of delivering a symmetrical service relationship from inside this welfare bureaucracy.
The Challenging Service Relationship
The analyses in this article illustrate how ‘small’ institutional texts and practices are activated in different institutional settings, and how these practices, from the standpoint of the service users, signify an asymmetrical power relationship that excludes, in different ways, a more symmetrical service relationship. ‘The duty of confidentiality’ and the covering of ID cards are, as signatures of power, connecting the local practice to trans-local institutional and bureaucratic logics and ideals, illustrating how seemingly insignificant institutional actions and conduct are part of a large institutional complex. The accounts expose how the young service users perceive the exclusion of informal relationships as problematic and as a need not met by service providers.
When service users perceive a continuous and symmetric relationship to service providers as being crucial for the quality of the care they receive and for their recovery, the service relationship they desire is primarily subjective and biased, and subsequently difficult to define and govern due to its arbitrary character. How should service providers go about standardizing such informal relations as affection, reciprocity or mutual commitment, normally associated with informal relations inside friendships, families and local communities? Besides placing a greater responsibility on the service user, it likewise places the individual service provider in an ambiguous position: the individual service provider is made accountable for providing a service relationship that is grounded on the individual service user’s needs. This means that the service provider, in order to live up to the ideal, has to conduct herself in a way that makes her available to the service user – just as Peter’s former therapist did. It requires that the street-level bureaucrat, to some degree, steps outside the bureaucratically and formally defined work assignment, and instead builds informal, subjective and individual relationships to the service users as an official part of the everyday work. The implementation of this kind of service relationship places a vast responsibility on the shoulders of the individual front-line professional, since the service relationship would necessarily rely on the will and ability of the individual service provider to do so. When the ambition to provide universal and high-quality services additionally includes the provision of informal service relationships, the expectations on the front-line professionals appear overwhelming.
This exposes the ambivalent character of the symmetrical service relationship. The service provider must assume the role of the professional expert and at the same time take on the role of an informal other; as the quotation from Peter above described the demarcation between the formal and informal relationship; ‘…they cannot mix in their private life up in it, they wouldn’t manage it’. In Peter’s account, the service provider manages to accommodate Peter’s need for an informal organization of their relationship, but the fact is that service providers have a service relationship, not to one or two, but many different service users at the same time. In the light of this condition, and especially due to the fact that the informal service relation is not grounded on universal criteria or standards, but primarily subjective needs and preferences, a symmetrical service relationship inside the formal welfare system seems very ambitious, even utopian.
The analyses in this article thereby show that the liberal reform ideal of user-centeredness, individual participation and holistic care is problematic in several ways: Young service users rarely experience their relations with service providers as symmetrical. On a larger level, if the ideal of user-centeredness were truly to be practiced to accommodate the needs of the service users, it would undermine the psychiatric welfare services by dismantling the professional practice of providing standardized and formalized care, being incompatible with other governance ideals, both professional and bureaucratic. The institutionalized relationship between service provider and service user is, per se, an asymmetrical relationship, where one part depends on the other.
If the welfare state is to implement the ideal of the symmetrical service relationship differently, the boundary between client and professional would need to be reimagined. Alternatively, the informal and stable human relationships could be looked for outside the sphere of professional care provision. Arenas such as voluntary associations and leisure activities might have the potential to facilitate this; however, further research is needed in this field.