Shifting from paternalistic mental healthcare to one of increased user participation brings challenges for practitioners and service users.

Aligned with recovery orientated mental healthcare, and influenced broadly by mental health policy, service users are increasingly expected to participate in their own mental healthcare. Central to this participation are power relations between practitioners and service users.

In an interesting new qualitative study, Femdal and Knutsen (2017) examine this power through analysing discourse from practitioners and service users.

Methods

The aim of this study was to increase understanding of relational power in terms of service user participation and how this is played out in practitioner-service user relationships.

The authors used purposive sampling whereby mental health service leaders identified participants from 5 Norwegian municipalities, eventually leading to the recruitment of 10 practitioners and 10 community service users (all aged over 18 years). Interactions from participant interviews were analyzed with reference to a Foucauldian notion of discourse and power. Very briefly, for Foucault, power is constructed through discourse and is conjoined with knowledge (Foucault, 1975). Power is conceived as being productive and, through Foucault’s concept of ‘governmentality’ (Foucault, 1991), is shaped by individuals’ active part in their own self-government and their dynamic interactions between people.

Results

The authors identified a dynamic nature of relational power between practitioners and service users and the subsequent influence of this on the negotiations for service user participation.

Femdal and Knutsen report that ideals of participation are played out within the interactions in these relationships. From interview texts, the authors identified that both service users and practitioners took various positions during interactions when negotiating users’ participation in treatment.

Ideals of service user participation are played out in practitioner-service user relationships. Such dynamic interactions are within a backdrop of societal structures of discourse. Included within these structural factors are the constraints of mental health services. Within this context, the authors argue that practitioners attempt to activate service users into participating in mental health services and become increasingly independent from services to the point of discharge.

Negotiations for participation took place from 5 themed positions:

1. Position as activator and promoter of change. Practitioners hold an idealistic view that service users should be active (i.e. getting up in the morning or making and attending appointments), even when struggling with their mental health. Where service users might be unable to do this, for example due to lack of motivation, practitioners see it as their responsibility to find ways to get service users to take responsibility and become active. As such, practitioners position themselves as leaders of change. The authors comment that a service expectation for service users to be discharged and for only a limited number to be in receipt of treatment might influence practitioners’ drive for activation.
2. Position as dependent. Complementary to the above position, service users try to comply with what they believe the practitioners want and thus become dependent on practitioners. This can help avoid conflict but also puts the service user in a subordinate position.
3. Position as resistant. Not all service users took a dependent position. Some actively resisted practitioners and declined the services offered.
4. Position as persuader. Practitioners persuade service users to continue with treatment, for example medication, through a range of attempts to convince the service user to remain compliant. This amounted to varying degrees of coercion, ranging from subtle forms of persuasion to more explicit threatening forms such as warning the service user that a practitioner would visit to observe medication compliance. Elsewhere in the literature such coercion has been described as a form of varying treatment pressures commonly observed in mental health practice (Lidz et al, 1998; Szmukler and Appelbaum, 2008).
5. Position as knowledgeable. This final position captures the tendency for professional ‘expert’ discourse (e.g. “it’s for the patient’s own good”) to dominate and, thus, enable practitioners to take power and control. Interestingly, practitioners become insecure in their knowledge when service users demonstrate their own knowledge about their health and treatment.

Conclusions

This study illuminates complex and dynamic relational power between practitioners and service users. In so doing they argue that these interactions are influenced by societal structural factors such as mental health service agendas that actively encourage service user independence and subsequent discharge from services. A conundrum is then presented wherein practitioners perceive their need to activate service users through governing whilst at the same time trying to help service users to become independent and self-activated through self-governing. As such, brokerage of responsibility is central to the negotiations of power within these interactions.

Strengths and limitations

This is an interesting study in terms of the ‘micro-focus’ on power played out between practitioners and service users. But it also leaves us with several questions. Whilst emphasis is given to the position taken in the negotiations between practitioners and service users, it is important to understand individual influences on this. For example, it would be helpful to understand how the health status of service users during the study influenced the position taken. Presumably, being acutely distressed would impact differently on this than compared to being relatively stable. If so, then this would presumably influence interactions with practitioners and subsequent negotiations relating to responsibility, independence, etc.

Implications for practice

The findings from this study help provide some insight into the shifting positions of practitioners and service users during negotiations for user participation. As such, it challenges practitioners to become reflexive and critical in their approach in providing care. This includes awareness of the impact of service-related pressures on treatment approaches and subsequent practitioner-service user interactions.

Links

Primary paper

Femdal I, Knutsen IR. (2017) Dependence and resistance in community mental health care – Negotiations of user participation between staff and users. J Psychiatr Ment Health Nurs. 2017;24:600–609. https://doi.org/10.1111/jpm.12407

Other references

Foucault, M (1975) Discipline and Punish: the Birth of the Prison, New York, Random House.

Foucault, M. (1991) Governmentality, in G. Burchell, C. Gordon and P. Miller (eds) The Foucault Effect: Studies in Governmentality (pp 87-104) (PDF). Hemel Hempstead: Harvester Wheatsheaf.

Lidz, C.W., Mulvey, E.P., Hoge, S.K., Kirsch, B.L., Monahan, J., Eisenberg, M., et al. (1998). Factual sources of psychiatric patients’ perceptions of coercion in the hospital admission process. American Journal of Psychiatry, 155, 1254–1260.

Szmukler, G and Appelbaum, P (2008). Treatment pressures, leverage, coercion, and compulsion in mental health care. Journal of Mental Health. 17. 233-244. 10.1080/09638230802052203.