The therapists in this study described treatment strategies when coping with managing resources and situations where needs were difficult to meet. Patients who chose medication-free treatment were reported to need extended support and other treatment measures with close follow-up to succeed. The therapists communicated how their role was based on an overarching wish to help patients, which was difficult to balance with conformance to guidelines, laws, and available resources in treatment practice. Shared decision-making and spending time considering patient preferences was perceived to be important in the treatment process. The alliance was sometimes fragile, and periods of patients worsening were worrisome.
Discretion and prioritizing
Health care services are paradoxical in the sense that care is delivered by people to people, requiring human interaction and caring, but also delivered through a bureaucracy, which invokes a model of detachment and equal treatment under conditions of resource limitations and constraints. The delivery of street-level policy through bureaucracy depends on health care workers’ abilities to embrace this paradox [42]. One example of resource deficiency from our study was the lack of adapted housing within the municipality. This kept patients admitted longer than needed. Specialist mental health supported housing is considered key to a graduated level of care from institutionalized to independent living in the community [46]. The participants in this study wanted to secure the best solution to the problem of housing for their patients. The problem of discharging was solved by keeping patients in care longer than the guidelines suggested was necessary. This occurred because mental health therapists feared their patients would perish without necessary support once they were outside the institution. This stretching of their allowed discretion was possible because SLB, such as these mental healthcare therapists, are able to use and interpret rules and constraints that are externally imposed upon them to achieve their preferred ends [42]. Other examples of resource deficiency were waiting lists to attend music therapy, or simply patients having needs that the mental care system could not meet. Often, this meant that the relatives were more burdened with taking care of their own than the therapists would consider sustainable in the long term. Research has shown that family members caring for relatives with schizophrenia experience a high level of objective and subjective burdens [47]. Additionally, scholarship suggests a higher degree of relapse and mortality when patients discontinue anti-psychotic medication [48]. Hence, the therapists worried this burden would increase when patients chose to discontinue medication.
Patients who chose medication-free treatment in this study were considered to need extended support and treatment measures, and it was believed that success required close follow-up. The implementation of medication-free services in Bergen has enlarged the available treatment options in district psychiatric clinics. The therapists indicated that they discussed problems with prioritizing medication-free patients over other patients. Careful consideration of individual needs was perceived to be the best way to decide whether or not the patient needed medication and was the main tool for prioritizing treatment measures. This process was supposed to be mainly controlled by patient wishes and perceived needs, rather than the therapists’ discretion.
Psychosocial support measures are recommended, and are already validated as efficient in the recovery process for patients suffering from severe mental illness, including schizophrenia. Evidence based measures are available and constitutes a so-called “menu” from which the therapists can make informed choices and present to the patient [49]. The process of shared decision-making corresponds with recommended approaches to enhance the relationship with and the recovery process of the patient [40]. At the same time, it is shown how discontinuing anti-psychotic medication might have a negative impact regarding relapses, defined as increased hospitalization, and mortality. Psychosocial measures are resource demanding, and will inevitably meet requirements of cost-effectiveness in a health care system with limited funding. These requirements will be managed by therapists, as SLB, trying to balance both the implementation of a more resource-demanding treatment, held together with the increased risk of patients worsening and hence needing more resources in their follow-up. Prioritization is a part of the difficult task balancing human care with the demand for equal treatment within limited resources. Medication-free treatment seems to require more human resources, as well as additional human and other resources for close follow-up if a patient is worsening. This stands in conflict with cost–benefit demands of the Norwegian mental healthcare system and its guidelines on the use of resources. Efficiency in resource use is an organization-centered goal, and requires that SLB prioritize in their role as gatekeepers. This may affect elements of care for their patients.
Ambiguity and complexity
SLB typically have jobs with conflicting and ambiguous goals [42]. Within mental health care, this might be even more evident when patients (i) claim they are not sick, and hence do not need treatment, (ii) are not satisfied with the treatment they are offered and therefore do not want their help, and/or (iii) are subjected to coercive treatment. All these aspects were raised by the therapists in our study, although coercive treatment only as something to avoid. In health care systems, the defined goal is to provide the best possible treatment and care for all patients, a client-centered goal. A person experiencing a physical illness, like cancer or heart disease, is most likely to seek professional help. However, for mental health care, it is paradoxical that higher symptom load would predict a lower likelihood for that person to seek help [50]. Hence, the client-centered goal might be challenging to achieve when patients do not want the help they are offered.
The ambiguity of the task also surfaces in the relationship the therapists have with their patients. Clients of most bureaucratic systems, including health care systems, are non-voluntary; street-level bureaucracies provide essential services that citizens cannot obtain elsewhere. Hence, patients in mental health care may be non-voluntary in more than one sense; both as a client of a bureaucratic system providing an essential service unobtainable elsewhere, but also as a person suffering from an illness where their help seeking behavior is largely affected by the symptom load as described in the paradox above.
The therapists in this study, although expressing an overarching aim to help patients, felt ambiguity when balancing improved patient influence and their ability to provide essential services. When patients understand the concept of help differently than the therapist, their role was to resolve these conflicting perceptions, and to provide treatment perceived as acceptable and useful to the patient within the available resources. Providing patients with thorough information about treatment choices, including medication, was important. SLB in our study interpreted intensified information sharing as a way to fulfill the need and demand for shared decision-making [51].
Critics of medical authority in mental health services have described the Norwegian system as one that uses patriarchal ways of communication rather than patient-centered decision-making [52, 53]. This study indicates the participants intended to promote a democratic mode of decision-making, which is consistent with a study that explored psychiatrists’ attitudes toward shared decision-making [54]. The therapists in this study emphasized the importance of spending time carefully considering pros and cons together with the patient to avoid hasty decision-making, and to accept patient choices even when they worried about the outcome.
In this context of emphasizing choice and shared decision-making, the social construction of the client–SLB relationship aims toward a more horizontal structure. However, shared decision-making is at the core of the conflict between the two possibly diverging perceptions of the kind of help needed and can be difficult to negotiate. Society and management expect professional discretion and responsibility in decisions affecting health care delivery. As such, the options offered must be within the scope of available resources, laws, and guidelines. Because there are resource and time constraints, health personnel should be provided with a range of relevant treatment options, from which they can build an appropriate treatment menu for each patient, process the information and produce an appropriate response to patient needs [42]. In this study, this is described as the treatment ‘menu’ presented to the patient. This is a way to reduce the complexity of treating mental illness to a manageable level of choices for the health personnel, but runs the risk of reducing the influence of the patient if the patient is presenting needs outside of the available “menu”. The structure of the simplification or routines in presenting a “menu” of choices creates a low-level decision-making environment, where the frame is politically determined, and the presentation of choices is at the discretion of the therapist. In this sense, the SLB in this study shape medication-free policy, allocating available goods and services, ideally, but not necessarily, based on mutual consent of patient needs.
Concerns within the therapeutic alliance
In mental health care provision, the patient’s level of symptoms and illness largely dictate which law and guidelines are at play. Many of the therapists in our study expressed how they worried about their patients worsening, because of the possible implications for the patient, and for the change in relationship and responsibility for the therapist. One participant described how a patient became so sick he could no longer take care of himself. This implies the therapist must take on a different role, where shared decision-making is no longer perceived as useful and forced treatment has to be considered. In this phase of psychosis, when a patient’s paranoid tendencies and withdrawal from interactions with others may lead them to avoid therapy, the therapists in our study became concerned about their patients’ safety and sought ways to keep them in treatment using their agency as SLB. Additionally, patients may have delusions about what might work to reduce their symptoms and ask for measures outside treatment guidelines and resources. However, denying a patient’s request can be highly uncomfortable [55], and requires specific skills from the therapist. This becomes especially complicated when patient safety is conditioned by the fragile alliance between health personnel and the patient [56]. Although the therapeutic alliance is suggested to be a key component in successful mental health care delivery [57, 58], some studies have found no evidence that alliance predicts the outcome of complex psychiatric treatment for patients with psychosis [59]. Nevertheless, this provides a backdrop for how health care workers understand and interpret their role, particularly when therapists in this study worried about patients worsening and quitting all therapy. When the relationship with one therapist was endangered by turning down patient requests, use of other health care team members was described as a way to remain in a position to treat the patient. Communicating limitations in patient choices while maintaining a good relationship with the patient is a challenging dilemma in mental health care delivery.
When patients chose to withdraw from treatment, even if the therapist perceived their symptoms as worsening, the therapists in their roles as SLB in our study felt they had to respect and accept the patients’ choice. Acceptance of a patient’s choice that may lead to deterioration in their somatic, mental, social, or physical quality of life may be interpreted as alienation from therapists’ key function, which is to safeguard all their patients. This is similar to the findings from a recent study of sources and features of moral distress experienced by acute psychiatric nurses. The feeling of being squeezed between ideals of good care and a harsher clinical reality caused bad conscience, feelings of inadequacy, and emotional numbness. The study concluded with how moral distress may lead to reduced quality of care with nurses distancing and disconnecting themselves from their patients and their inner selves [60]. The implementation of medication-free treatment was by many psychiatrists in particular not regarded as based in a scientific view on professional and good care of patients with severe mental illness [41]. This debate is well known in the society [61]. Hence, when there is an experienced dissonance between objectives (cure/help the patient) and capabilities (personal and resource/system-related limitations), workers develop mechanisms such as alienation to shield them from the implications of the gap between expectations and accomplishment [42]. In our study, the implementation of the medication-free treatment might have added to the range of treatments and the emphasis on shared decision making for the patients, but it may also be resource demanding and a source of worry and distress for the therapists.
Reflexivity, strengths, and limitations
This article focuses on how therapists experience the challenges regarding the implementation of medication-free treatment, rather than the opportunities provided by the same policy change. This limitation of the study scope gives more space to explore these challenges. The down side is the lack of focus on the positive aspects given in the data, including the possibilities provided by such a change of policy. Additionally, we need to include the experiences of other stakeholders, such as relatives and patients in addition to already existing studies on this topic [62, 63].
The researcher’s background and position will inevitably influence the outcome of a study by affecting choice of topic, choice of methods, and framing of findings and conclusions. Contemporary theory of knowledge disputes the belief of the neutral observer [64]. Reflexivity has been a guiding principle that has given our interdisciplinary team of coauthors room to discuss and reflect on all aspects of the study, from design to dissemination. Importantly, experts-by-experience were co-researchers throughout the entire research process, which we believe has strengthened the trustworthiness of the study, providing feedback from the most important voices, the users of the health care system.
The scope of the data collection was limited to one context in Norway, and we cannot assume that our findings are similar in other implementation settings. However, the use of theoretical framework structured our interpretation and presentation to focus common themes in policy implementation in health care workers’ roles, such as democratization of the therapist–patient relationship, level of discretion, and management of resources.
Choosing Lipsky’s theoretical framework has helped clarify how health workers are affected by policy implementation and how they navigate the ways in which they decided to put it into practice in their everyday work. Nevertheless, this framework was developed in the 1960s and 1970s in the United States. The differences in cultures, health systems and contexts could have affected the interpretation. Additionally, this framework may not have been sufficient in addressing some important aspects, such as different professional roles and the relationship between workers and management [65]. Professional roles influence the level of discretion, the level of freedom granted and cooperation between workers and management, and it would have been interesting to explore how different health workers perceived the influence of their professional background and hierarchical situation on their experience of medication-free treatment implementation. This was, however, not the topic of the study.
At the time of the focus groups discussions, the implementation of medication-free services was just starting. This might have affected the extent to which health care workers had experience with and felt familiar with patients choosing to discontinue their medication. On the other hand, this may have led to policy implementation and changes in practice being fresh in the mind of the participants.
For future research, we suggest looking into one key factor in decisions regarding treatment, which is how therapists consider patients’ capacity for giving an informed consent.
