Asiakkaiden ja työntekijöiden vastuullistaminen mielenterveystyön käytännöissä (2011-2016)

 

Premises of the research project

The starting assumption of the project was that under advanced liberal governance, professionals and clients are expected to take greater individual responsibility in mental health services and rehabilitation processes. Our hypothesis was that this shift in responsibilities has had a strong influence on everyday mental health practices. The objectives of the study were:
•To investigate how responsibilization is recognised, interpreted and managed in everyday mental health practices
•To investigate the existence of negotiation, manipulation and counter-discourses to the discourse of responsibilization
•To assess how responsibilization affects professionals’ work and clients’ everyday encounters
•To compare the practices of responsibilization in Finland and England

The qualitative data were collected in a variety of ways within everyday organisational processes. This included multiple text, talk and interaction data. The study was based on ethnomethodological approaches which focus the attention to everyday actions in mental health. Six research settings included:
•Four supported housing and floating support services for people with mental health (and substance abuse) problems (2 in Finland and
•2 in England)
•A low-threshold outpatient clinic for people with severe drug abuse problems (Finland)
•A project offering housing and social skills training for young adults with diagnosed schizophrenia (Finland).

The data gathered in the settings include:
•Interviews with clients (82), clients’ care coordinators (5), grass-roots level and managerial level workers in the service-providing
•NGOs, and the commissioners as representatives of the service purchasers (14)
•Focus groups with the grass-roots workers in the services (17)
•Client–worker conversations during home visits (39)
•Multi-party case-planning meetings (23) and care conferences (18)
•Team meetings among the grass-roots level workers (109)
•Different kinds of documents, such as care plans and final statements used in services
•Fieldnotes

During the course of the research project we scrutinised these data in detail to examine and demonstrate how responsibilities are talked into being as everyday issues that need to be addressed.Although the issues related to responsibilization are present in many ways in mental health, they are not often available for reflection in any straightforward manner by clients and workers. In ethnomethodological terms they are “seen, but unnoticed” (Garfinkel 1967). To make them more noticed we examined connections between policy level discussions on responsibilization (examined in the governmentality literature) and grass-roots level service practices. Furthermore, we asked how currently influential welfare discourses related to responsibilities are present and oriented to in everyday practices. This connection between policies and practices was developed by following ideas of the turn to researching practices in social and human sciences and by utilising mediating analytic concepts that made it possible to examine such talk, text and interaction that may indicate the presence of responsibilization in grassroots level welfare services. The applied analytic concepts were: responsibilities, accountability, catergorisation, boundary work, sequentiality, advice-giving, narrative and resistance.

Reflecting clients’ responsibilities

We noticed that clients’ responsibilization is embedded in citizenship, self-management, recovery, resilience and empowerment discourses. All these discourses expect clients to become self-governing and goal-oriented: for instance, in monitoring symptoms and seeking help, managing care contacts, making plans, re-entering the community and taking care of personal, everyday matters. Individuals are expected to actively manage their own health and make responsible lifestyle choices. The research demonstrates that clients on the one hand present themselves as people who try to reach the ideal “responsible self”, and on the other hand they resist such cultural expectations as impossible or unreasonable due to their ill-health, limited resources and abilities. When the clients draw on advanced liberal responsibilization expectations, they express that they need to, and can make the required life changes by themselves in order to be a full citizen and to re-enter the community. In contrast, when they resist the idea of the responsible self they use “fatalistic talk” and “drifting talk” to indicate that there are no possibilities available to try to change things for the better. Resisting “the responsible self” or not achieving it, locates the clients as prime candidates for more coercive re-responsibilization, rehabilitation and education projects. Clients also identify risks of failures in recovery and are aware of gaps between societal expectations and their actions: for them the gap is alternatively something that is possible to overcome, or something that they just have to accept and adjust to. Our analysis of clients’ responsibilities raises some critical questions. Is trying to overcome the gap – to struggle to become more selfgoverned and active in the community – too demanding and risky for some clients? When does the principle of self-responsibility support empowerment and change for the better, and when does it provide opportunities for blaming, abandonment, exclusion,exhaustion and disempowering defeats in their everyday lives? However, relevant questions for the clients remain: what are legitimate accounts, excuses or justifications for not taking responsibility? What are sufficient activities for active citizens? This research shows that the clients are active in making their way to better well-being and participation. However, to be active requires future prospects, support and recourses and is often accomplished partially, begrudgingly and carried out in gradual steps.

Reflecting workers’ responsibilities

In turn workers are also objects and subjects of responsibilization with conflicting discourses of managerialism, professional ethics, risk assessment and recovery. These discourses make workers personally accountable for the clients’ engagement and commitment to services and progress, as well as for the economical sustainability of services. In other words the grass-roots level workers are responsibilized by themselves, managers and commissioners to make the clients responsible for their conduct and recovery outcomes. We have demonstrated how the workers need to balance managerial expectations and clients’ specific needs. Clients are not left to manage by themselves; instead workers are busy planning, assessing, directing, controlling and coaching. Clients are expected to utilise professional advice and support. In turn, workers are expected to provide support for those who are entitled to services and included on their case load. The workers are responsible for several issues such as supporting clients to take small risks and avoiding taking high risks, as well as making appropriate use of services. In addition, the workers are responsible for managing the client flow and collaboration with other professionals in the field. This requires constant assessment of the clients’ needs and what service they are entitled to; which client is to be transferred to what institution and what is the scope of expertise and mandate of each professional in the network. This produces activity that aims both to limit and extend the workers’ responsibilities in particular cases. We have displayed several technologies and techniques by which workers carry out their various responsibilities at the institutional,collaborative and individual client level. Institutional level technologies are, for example, commissioning contracts, case planning meetings, institutional forms and performance measures. At the collaborative level, special discursive techniques were identified to distribute responsibilities between “we” and other workers involved with the client that were summarised as exclusionary and inclusionary boundary work. The workers also utilise various discursive techniques to promote the clients’ responsibilization and to manage the distribution of responsibilities between themselves and the clients, such as planning, coaching, going along with, directing, giving advice and questioning the clients’ willingness to change and their commitment to the service and recovery process.

Summary

All in all the research has brought more perspectives and nuances to the prevailing policy level analyses of responsibilization by demonstrating and problematising the management of responsibilities in everyday welfare services. The research has made it clear that this kind of ethnomethodologically oriented research has strengths but also limitations. Unquestionably, there is a distance between macro-level policies and discourses and micro-level everyday practices. Narrowing this distance requires interpretative imagination and becoming familiar with policies and theories as well as ethnomethodological data analysis.

Publications:

Anttonen, Anneli & Häikiö, Liisa & Raitakari, Suvi (eds.) (2013) Hyvinvointivaltiosta ja takaisin  [From welfare states to marketization of welfare and back?]. Special issue. Janus 21(4).

Günther, Kirsi (2012) Kirjatut ammatilliset kehykset: mielenterveyskuntoutus asiakassuunnitelmien kuvaamana [Documented Professional Frames in Mental Health Rehabilitation Care Plans]. Janus 20(1), 15-31.

Günther, Kirsi (2014) Multi-voiced Assessment in a Mental Health Statement. Text & Talk 34(6), 665-684.

Günther, Kirsi (2015) Asiakasdokumentaatio arviointina mielenterveystyön arjessa: Tutkimus ammatillisesta kirjaamisesta [Client Documentation as Assessment in the Everyday Practices of Mental Health Social Work: A Study on Professional Reporting]. Tampere: Acta Universitatis Tamperensis 2108.

Günther, Kirsi & Raitakari, Suvi (2012) Mielenterveyskuntoutusta avoimen ja yksityiskohtaisen suunnitelmalomakkeen ohjaamana [Open and Detailed Planning Forms as Tools in Directing Mental Health Rehabilitation]. In Heikkinen Vesa et al (eds.) Genreanalyysi – tekstilajitutkimuksen käytäntöä: Kotimaisten kielten keskus, 101-128. (Kotimaisten kielten keskuksen verkkojulkaisuja 29).

Günther, Kirsi & Raitakari, Suvi & Juhila, Kirsi (2015) From Plan Meetings to Care Plans: Genre Chains and the Intertextual Relations of Text and Talk. Discourse & Communication 9(1), 65-79.      

Günther, Kirsi & Raitakari, Suvi & Juhila, Kirsi & Saario, Sirpa & Kulmala, Anna & Kaartamo, Riina  (2013) Asiakaslähtöisyys vakavaa mielen sairautta sairastavien nuorten aikuisten kuntoutuskurssilla: etnometodologinen tapaustutkimus [Client centeredness in the rehabiliation course targeted to young adults suffering from serious mental health problems: ethnomethodological case study]. Tampere: Muotialan asuin- ja toimintakeskus. http://www.muotiala.fi/yhdistys/julkaisut/

Günther, Kirsi & Räsänen, Jenni-Mari (2022) The reported responsibilities of mental health workers and clients. Communication and Medicine. Advance access published 24.3.2022. https://doi.org/10.1558/cam.21587

Haahtela, Riikka & Juhila, Kirsi (2016) Arjen valinnat ja neuvot kotikuntoutuksen kohtaamisissa [Everyday Choices and Advice-giving in the Encounters of Home Rehabilitation]. In Kirsi Juhila & Teppo Kröger (eds.) Siirtymät ja valinnat asumispoluilla [Transitions and Choices in Housing Pathways]. Jyväskylä: SoPhi, 192-214.

Hall, Christopher & Juhila, Kirsi & Matarese, Maureen & van Nijnatten, Carolus (eds.) (2014) Analysing Social Work Communication: Discourse in Practice. London: Routledge.

Hall, Christopher & Morriss, Lisa & Juhila, Kirsi (2017) Negotiating Risks, Choices and Progress in Case-planning Meetings. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 128-150.

Hansen Löfstrand, Cecilia & Juhila, Kirsi (2012) The Discourse of Consumer Choice in the Pathways Housing First Model. European Journal of Homelessness 6(2), 47-68.

Jokinen Arja, Juhila, Kirsi & Suoninen, Eero (2012) Kategoriat, kulttuuri ja moraali – johdatus kategoria-analyysiin [Categories, Culture and Moral Order – Introduction to Categorization Analysis]. Tampere: Vastapaino.

Juhila, Kirsi & Günther, Kirsi (2013) Kunnan, järjestöjen ja asiakkaiden oikeudet ja velvollisuudet tilaaja-tuottajamallissa: tutkimus asumispalvelujen tarjouspyyntöasiakirjoista [Rights and Responsibilities of the Municipality, Non-governmental Organizations and Service Users in the Purchaser-Provider Model], Janus 21(4), 298-313.

Juhila, Kirsi & Günther, Kirsi & Raitakari, Suvi (2015) Negotiating Mental Health Rehabilitation Plans: Joint Future Talk and Clashing Time Talk in Professional Client Interaction. Time & Society 24(1), 5-26.

Juhila, Kirsi & Caswell, Dorte & Raitakari, Suvi (2013) Resistance. In Christopher Hall & Kirsi Juhila & Maureen Matarese & Carolus van Nijnatten (eds.) Analysing Social Work Communication: Discourse in Practice. London: Routledge, 117-135.

Juhila, Kirsi & Hall, Christopher (2017) Analysing the Management of Responsibilities at the Margins of Welfare Practices. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 11-34.In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 57-79.

Juhila, Kirsi & Hall, Christopher & Günther, Kirsi & Raitakari ,Suvi & Saario, Sirpa (2015) Accepting and Negotiating Service Users’ Choices in Mental Health Transition Meetings. Social Policy & Administration 49(5), 612-630.

Juhila, Kirsi & Hall, Christopher & Raitakari, Suvi (2016) Interaction During Mental Health Floating Support Home Visits: Managing Host-Guest and Professional-Client Identities in Home-spaces. Social and Cultural Geography 17(1), 101–119.

Juhila, Kirsi & Jokinen, Arja & Saario, Sirpa (2013) Reported Speech. In Christopher Hall & Kirsi Juhila & Maureen Matarese & Carolus van Nijnatten (eds.) Analysing Social Work Communication: Discourse in Practice. London: Routledge, 154-172.

Juhila, Kirsi & Kröger, Teppo (eds.) (2016) Siirtymät ja valinnat asumispoluilla [Transitions and Choices in Housing Pathways]. Jyväskylä: SoPhi. http://urn.fi/URN:ISBN:978-951-39-6664-5

Juhila, Kirsi & Mäkitalo, Åsa & Noordegraaf, Martine (2013) Analysing Social Work Interaction: Premises and Approaches. In Christopher Hall & Kirsi Juhila & Maureen Matarese & Carolus van Nijnatten (eds.) Analysing Social Work Communication: Discourse in Practice. London: Routledge, 9-24.

Juhila, Kirsi & Raitakari, Suvi (2016) Pieni aika sosiaali- ja mielenterveystyössä [Small Time in Social and Mental Health Work]. In Sirpa Kannasoja, Marjo Kuronen & Tytti Poikolainen (eds.) Sosiaalityön aika. Talentia-lehti ja Sosiaalityön tutkimuksen seura, 37-41.

Juhila, Kirsi & Raitakari, Suvi & Hall, Christopher (eds.) (2017) Responsibilisation at the Margins of Welfare. London: Routledge.

Juhila, Kirsi & Raitakari, Suvi & Hall, Christopher (2017) Introduction. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 1-8.

Juhila, Kirsi & Raitakari, Suvi & Hansen Löfstrand, Cecilia (2017) Responsibilisation in Governmentality Literature. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 11-34.

Juhila, Kirsi & Raitakari, Suvi & Hansen Löfstrand, Cecilia (2017) Responsibilities and Current Welfare Discourses. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 35-56.

Juhila, Kirsi & Saario, Sirpa & Günther, Kirsi & Raitakari Suvi (2014) Reported Client–practitioner Conversations as Assessment in Mental Health Practitioners’ Talk. Text & Talk 34(1), 69–88.

Raitakari, Suvi (2016) Neuvottelut mielenterveys- ja päihdeasiakkaiden asumisen siirtymistä: toiveita, haasteita ja toimijuutta [Negotiating the Housing Transitions of Clients in Mental Health and Substance Abuse Services: Hopes, Challenges and Agency]. In Kirsi Juhila & Teppo Kröger (eds.) Siirtymät ja valinnat asumispoluilla [Transitions and Choices in Housing Pathways]. Jyväskylä: SoPhi. 108-133.

Raitakari, Suvi & Günther, Kirsi (2015) Mielenterveysasiakkaan asema portaikkomallin ja Asunto Ensin -mallin asumispoluilla [Mental health clients’ position in the staircase and Housing First pathways. Janus 23(1), 66-82.

Raitakari, Suvi & Günther, Kirsi (2017) Clients Accounting for the Responsible Self in Interviews. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 83-105.

Raitakari, Suvi & Günther, Kirsi & Juhila, Kirsi & Saario, Sirpa (2013) Causal Accounts as a Consequential Device in Categorizing Mental Health and Substance Abuse Problems. Communication & Medicine 10(3), 237-248.

Raitakari, Suvi & Haahtela, Riikka & Juhila, Kirsi (2015) Tackling Community Integration in Mental Health Home Visit Integration in Finland. Health and Social Care in the Community. doi: 10.1111/hsc.12246

Raitakari, Suvi & Juhila, Kirsi (2013) Kuluttajuusdiskurssit ja palveluvalinnat mielenterveyskuntoutuksen asiakaspalavereissa [Consumer discourses and service choices in mental health rehabilitation meetings]. In Merja Laitinen & Asta Niskala (eds.) Asiakkaat toimijoina sosiaalityössä. Tampere: Vastapaino, 167-195.

Raitakari, Suvi & Juhila, Kirsi & Günther, Kirsi & Kulmala, Anna & Saario, Sirpa (2012) Asiakaslähtöisyydet asiakas-ammattilainen vuorovaikutuksessa: kuluttajuus, kumppanuus ja huolenpito mielenterveyskuntoutuksessa [The Forms of Client Centredness in Client-professional Interaction: Consumerism, Partnership and Care]. In Anneli Anttonen et al. (eds) Julkisen ja yksityisen rajalla – julkisen palvelun muutos. Tampere: Tampere University Press, 47-80.

Raitakari, Suvi & Juhila, Kirsi & Hall, Christopher (2017) Conclusions. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 218-223.

Raitakari, Suvi & Kulmala, Anna & Günther, Kirsi. & Juhila, Kirsi & Saario, Sirpa  (2011) Vakava mielen sairaus ja eriarvoisuudet arjessa [Serious mental illness and inequalities in everyday life] Janus 19 (4), 221-237.

Raitakari, Suvi & Saario ,Sirpa & Juhila, Kirsi & Günther, Kirsi (2015) Client Participation in Mental Health: Shifting Positions in Decision-Making. Nordic Social Work Research 5(1), 35-49.

Raitakari, Suvi & Permin Berger, Nichlas (2017) Making Active Citizens in the Commounity in Client-Worker Interaction. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 106-127.

Ranta, Johanna & Raitakari, Suvi & Juhila, Kirsi (2017) Vastuuneuvottelut huumeidenkäyttäjien asunnottomuuden toiminnallisissa loukuissa. Yhteiskuntapolitiikka 82(2), 165-175.

Ranta, Johanna & Ovaska, Anne (2018) Voiko huumeita käyttävien ihmisten asunnottomuutta ratkaista? Tiimi 1/2018.

Ranta, Johanna (2020) Huumeista riippuvaisen toimijuus vahvistuu matalan kynnyksen palveluissa [The agency of a drug-addicted person is strengthened in low-threshold services]. Yhteiskuntapolitiikka 85(5–6), 592–595.

Ranta, Johanna (2020) Suhteellinen toimijuus huumeita käyttävien matalan kynnyksen palveluissa: Tutkimus institutionaalisesta vuorovaikutuksesta [Relational agency in low-threshold services for people using drugs: A study of institutional interaction]. Tampereen yliopiston väitöskirjat 279. Tampere: Tampereen yliopisto.

Räsänen, Jenni-Mari & Saario, Sirpa (2015) Telecare as Institutional Interaction: Checking up on the Client and Creating Continuity. Journal of Technology in Human Sciences 33(3), 205-224.

Räsänen, Jenni-Mari & Saario, Sirpa (2017) Welfare Workers Reflecting their Everyday Responsibilities in Focus Groups. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 153-173.

Räsänen, Jenni-Mari & Saario, Sirpa (2022) Aikuissosiaalityön vastuut asumisen turvaajana perustoimeentulotuen Kela-siirron jälkeen [The responsibilities of adult social work on the safeguarding of clients’ housing after the transition of basic income support to Kela]. In Arja Jokinen, Suvi Raitakari & Johanna Ranta (eds.) Sosiaalityö yhteiskunnan marginaaleissa: Konstruktionistisia jäsennyksiä [Social work at the margins of society: Constructionist perspectives]. Tampere: Vastapaino, 199–231. 

Saario, Sirpa (2011) Arviointitekniikat ja mielenterveystyö: tutkimus ammattilaisten luovinnasta työn arvioinnissa ja seurannassa. In Ilpo Hélen (ed.) Reformin pirstaleet: mielenterveyspolitiikka hyvinvointivaltion jälkeen. Tampere: Vastapaino, 182-230.

Saario Sirpa (2014) Arviointikulttuurin leviäminen ammattikäytäntöihin [Spreading of Audit Culture into Professional Practices]. Kuntoutus 37(2), 48-51.

Saario, Sirpa (2014) Audit Techniques in Mental Health. Practitioners Responses to Electronic Health Records and  Service Purchasing Agreements. Tampere: Acta Universitatis Tamperensis : 1907 and Acta Electronica Universitatis Tamperensis : 1391.

Saario, Sirpa & Caswell, Dorte & Hall, Christopher (2017) Constructing Service Providers’ Responsibilities in Interviews on Commissioning. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 196-217.

Saario, Sirpa & Juhila, Kirsi & Raitakari, Suvi (2015) Boundary Work in Inter-agency and Interprofessional Client Transitions. Journal of Interprofessional Care 29(6), 610–615.

Saario, Sirpa & Räsänen, Jenni-Mari & Hall, Christopher (2017) Negotiating Boundaries of Professional Responsibilities in Team Meetings. In Kirsi Juhila, Suvi Raitakari & Christopher Hall (eds.) Responsibilisation at the Margins of Welfare. London: Routledge, 174-195.