Discourses of service user involvement in meeting places in Norwegian community mental health care: a discourse analysis of staff accounts

Abstract

In previous research, meeting places have been favourably addressed by service users, but they have also been contested as exclusionary. In this participatory explorative study, we sought to perform a contextual analysis of meeting places in Norway based on a discourse analysis of three focus group discussions with 15 staff members. We asked the following question: how do meeting-place employees discuss their concrete and abstract encounters with service users and their experiences? We focused on service user involvement, which was largely analysed as neoliberal consultation and responsibilisation. Service users were positioned as resisting responsibility trickling down and defending staffed meeting places. Social democratic discourse was identified in the gaps of neoliberal discourse, which is noteworthy given that Norway is a social democracy. This relates to global concerns about displacements of democracy. We suggest that meeting places appear to hold the potential for staff and service users to collaborate more democratically.

Keywords:

• Participatory research
• service user involvement
• mental health day centres
• discourse analysis
• neoliberalism
• social democracy

Points of interest

•	We are a participatory research team that explored meeting places in Norwegian community mental health care in relation to their larger contexts.
•	In this article, we report on an analysis of employees’ group discussions that primarily focus on service user involvement.
•	In Norway, service user involvement is a legally protected right.
•	The dominant form of involvement looked less like a right and more a duty and responsibility for service users, and appeared to relate to management requesting suggestions and then making decisions on behalf of service users. Throughout the analysis, service users were portrayed as resisting such processes.
•	The analysis also found democratic collaboration to be another form of service user involvement, but this alternative was in the minority. Our findings relate to global signs and concerns about threats to democracy.
•	We suggest that meeting places could offer opportunities for staff and service users to collaborate more democratically.

Introduction

In the field of community mental health care, meeting places – also known as day or activity centres – appear to have a recent history that is especially contested. In England, a national assessment was conducted, after which meeting places were questioned about whether they contributed to maintaining (rather than combating) social exclusion; meeting places were deemed under-efficient and were slated for modernisation (National Inclusion Programme, National Institute of Mental Health England, and Care Services Improvement Partnership 2006; National Social Inclusion Programme 2008; Social Exclusion Unit 2004).

In contrast, meeting places appear to be consistently favourably addressed by service users and in most of the identified relevant literature, dilemmas and untoward implications notwithstanding (for example, Bryant, Tibbs, and Clark 2011; Conradson 2003; Elstad and Kristiansen 2009; Hultqvist, Eklund, and Leufstadius 2015; Swan 2010; Tucker 2010). Similar findings were also reported in the Social Exclusion Unit’s (2004) assessment.

In Norway, meeting places were prioritised in the National Action Plan for Mental Health (1999–2008) with regard to combating social isolation (Ministry of Health and Care Services 1998, para. 4.2.4.). These apparent contradictions question whose and what evidence counts, why and when.

In the neoliberal era, whether services are claimed to lack evidence of efficiency or whether they are tested and fall short of target indicators of efficiency, modernisation seems to be the solution. The preferred method of obtaining evidence seems to be through research designs with a narrow gaze (i.e. randomised controlled trials), stripped of any contextual analysis of the complex social landscapes involved (Fine 2012). This could entail discarding most peer-reviewed research as poor evidence. For instance, in a Cochrane review of meeting places (Catty et al. 2008), randomised controlled trials could not be identified, resulting in the claim that provision of day centres is ‘not based on good evidence as to their effectiveness for people suffering from severe mental illness’ (2008, 2). This argument was made in spite of inquiries stretching back to the 1940s attesting to benefits of meeting places in all their ‘untidy’ complexity (Bryant 2011, 554). Similarly, the increasing global social inequality (OECD 2014) does not count as evidence in designs with a narrow gaze, although the devastating implications of inequalities are intimately bound to individuals who use services. Instead of documenting that something is wrong with society, testing might therefore find that something is not right with the individuals or the investigated service, thus perpetuating historical circuits of dispossession (Fine 2012).

However, critical scholars, such as Michelle Fine (2012), counter the narrow gaze with calls for wide-angle lenses tracing broad and complex landscapes of human lives situated in history, politics, economics and social dynamics, rooted in the Lewinian social psychological heritage and in line with participatory predecessors such as Martín-Baró. Despite the rich, everyday complexities involved in meeting places (Bryant, Tibbs, and Clark 2011; Tucker 2010), the reviewed literature offers few studies that view this particular service from wide-angle lenses, with some exceptions (for example, Bryant 2011; Ekeland and Bergem 2006; Pinford 2000).

This article seeks to engage in an exploration of Norwegian meeting places in relation to their larger contexts through wide-angle lenses calibrated via a participatory research team with first-hand (co-researchers) and academic knowledge of mental health services and the approaches of service user-involved participatory research (Borg and Kristiansen 2009; Brydon-Miller et al. 2011; Russo and Beresford 2015) and community psychology (Hanlin et al. 2008). The study is based on a discourse analysis (Parker 1992) of focus group discussions with staff members from different meeting places.

Meeting places in community mental health care

In Norway, municipalities are the main providers and funders of meeting places. The service is not required by law, although the National Action Plan for Mental Health (Ministry of Health and Care Services 1998) did prioritise it. In a 2012 report (Osborg Ose and Slettebak 2012), approximately 80% of municipalities provided at least one meeting place. They often constitute easy-access drop-in centres or groups, although some require formal referrals. In a 2008 report (Kalseth, Pettersen, and Kalseth 2008), these centres were found to be the second most-populated service in municipal community mental health care, after individual outreach services. Given that meeting places offer community, affordable meals and a variety of daytime activities (Norwegian Directorate of Health 2005), they play a noteworthy role in the everyday lives of many people. The significance of meeting places is further emphasised by the systematic barriers to accessing sustainable employment confronted by many people who are administratively categorised as service users (Sayce and Curran 2007).

As previous research has suggested (for example, Bryant, Tibbs, and Clark 2011), meeting places thus stand out as a highly complex and contextually tailored service. This diversity seems to be echoed in the Norwegian guidelines for Community Mental Health Care for Adults in the Municipalities, which call for different types of meeting places that promote ideals such as service user involvement, social equality, recognition, safety, community, support, possibilities for meaningful things to do and general development (Norwegian Directorate of Health 2005).

The concept and practice of ‘service user involvement’ gained momentum in Norway from the 1990s, and was institutionalised as a right in health and care services in The Patients’ and Service Users’ Rights Act of 1999 (Ministry of Health and Care Services 1999, § 3-1). Leading up to the aforementioned Action Plan for Mental Health (Ministry of Health and Care Services 1998), ‘psychiatric patients’ were considered ‘the neglected group of the welfare state’ (Norwegian Council for Mental Health 1995, 1), and the Action Plan officially represented a new direction.

Thus, adherence to patients’ and service users’ rights is officially a responsibility of the Norwegian welfare state, which has issued guidelines, reports and teaching materials (for example, Norwegian Directorate of Health 2006). In practice, however, many service providers purportedly struggle with service user involvement (Osborg Ose and Slettebak 2012).

The political landscape

During the project period, the discourse of neoliberalism appears to have been strengthened in the Norwegian welfare state, flagged by the first coalition government between the conservative party and the classic liberalist party. Neoliberalism, which emerged globally during the late 1970s and early 1980s, entail freeing markets from state regulations, deregulating previous state responsibilities, such as health, care and welfare services, and implementing market mechanisms as the governing principle (Harvey 2005).

Across the North Sea from Norway is the United Kingdom. In the United Kingdom, health, social and welfare services have seen massive reforms since the first waves of neoliberalism (Conradson 2003; Harvey 2005) and, more recently, following the global financial crisis and the Conservative Government’s politics. According to a two-year prospective case study, ‘Destination Unknown’, the reforms have amounted to ‘an ever-diminishing civic and community life, the end of the safety net, deteriorating mental health, and the burden of care’ for disabled people (Wood 2012, 79).

Similarly, the Norwegian government has announced welfare modernisations of its municipalities by 2017 (Government.no 2014). Because municipalities are the main providers of meeting places, the destination for meeting places are also arguably unknown given an expert committee’s advice to merge Norway’s 428 municipalities into approximately 100 (Vermes 2014).

Viewing and working through wide-angle lenses

We understand meeting places to be intended as social safety nets. Critical scholars are discussing that states are increasingly assessing their safety nets for efficiency through research designs with a narrow gaze, as already introduced (for example, Fine 2012). A basic belief of all of our theoretical–methodological lenses is that there are great diversities in how to see, be in and know social worlds (Brydon-Miller et al. 2011; Hanlin et al. 2008; Parker 1992; Russo and Beresford 2015). Standardised designs with a narrow gaze are not equipped to include diverse versions of social realities and their differential historical privileging in society (Fine 2012). Thus, narrow assessments omit vast amounts of information on the social terrains that are central to understanding the need for safety nets and their complex interrelations with gaps in social equality (Fine 2012). Thus, service modernisations and deregulations are strongly critiqued for being based on overly limited information that results in incorrect interpretations of what is actually found when measures indicate inefficiency (Fine 2012; Mattheys 2015). The critical dimensions to this problem unfold in light of analyses and documentation indicating that narrow assessments and modernisations have cost many former service users their safety nets, resulting in even greater inequality (Dean 2014; Fine 2012; Harvey 2005; Mattheys 2015; Wood 2012).

In contrast, following our theoretical–methodological approaches, we sought to accompany those who are positioned in complex social realities – here, service users and staff – and their comprehensive insights into and knowledges of these terrains (Brydon-Miller et al. 2011; Hanlin et al. 2008; Russo and Beresford 2015). In this article, we focus on staff accounts, and in another line of inquiry in progress we focus on service users’ accounts, in order to analyse and discuss how meeting places appear from the two positionings in their own rights. As service providers in a setting that is considered to serve as a social safety net, staff members are seen as uniquely positioned to discuss concrete and abstract encounters between staff and service users, and between the meeting places’ spaces and service users. To explore meeting places in relation to their larger contexts in light of this focus, we considered the following research question to be a good point of departure: how do meeting-place employees discuss their concrete and abstract encounters with service users and their experiences?

Methodology

This participatory inquiry of meeting places in community mental health care was initiated in 2012 in western Norway and is part of a PhD project. A participatory research team co-developed and co-conducted most of the project. We found focus group interviews to be suitable for engaging in discussions about how service users and their experiences are encountered in meeting places given the method’s facilitation of inquiries into the variability of social worlds. To engage in a wide-angle, contextually oriented analysis, we saw discourse analysis as most relevant because it views all meaning as parts of larger systems of meaning (i.e. discourses). We follow Parker’s (1992, 3–22) Foucauldian working definition of discourse as a system of statements that construct objects and position subjects. In this line of inquiry, we report on a discourse analysis of staff accounts that were generated through three focus group discussions with employees from different meeting places in Norway

The participatory research team

The first author (a PhD student) initiated the collaboration and suggested anchoring it in community psychology (Hanlin et al. 2008) and emancipatory participatory research traditions (Borg and Kristiansen 2009), supported by mentors (the third, fourth and fifth authors). Subsequently, more than 10 people with lived experiences of psychosocial distress from organisations, services and programmes oriented towards mental health service users, participated in co-creating the research project from scratch.

At the time of this writing, we had collaborated for three years on most of the aspects of the inquiry, including continuous project developments, focus groups, discourse analysis, academic authorship and other disseminations. We have continuously engaged in informal and formal capacity-building and critical reflexivity to strengthen our team’s collaboration, along with our theoretical, ethical, critical and practical competencies, and understandings, in line with participatory ideals (Grant, Nelson, and Mitchell 2008).

From the outset, we have continuously reflected on and discussed how to facilitate participatory principles of maximising benefits and minimising costs for co-researchers. Ultimately, our guiding principle is self-determination on whether benefits outweigh disadvantages, as discussed by Grant, Nelson, and Mitchell (2008). In terms of material resources, we have been awarded a modest sum from a trust to collectively benefit co-researchers. In addition, the second author (co-researcher) is currently formally employed through the project, and another co-researcher held a temporary transcriber position. The routes to these positions were not through project funding, which primarily covers basic operating costs.

Focus groups

Recruitment process

Our main inclusion criterion was being employed as staff in meeting places of different shapes and sizes across a delimited region of western Norway. This criterion aimed to facilitate focus group discussions that would enable inquires into meeting places' variability, complexities, and contradictions. We made formal agreements with relevant municipalities and non-governmental organisations: they would assist in recruitment, and we would discuss the project’s progression with them.

Participants

The 15 participants who volunteered reported backgrounds in fields such as art, craftsmanship, health, and social and societal studies. Some had learned to be service providers from practice. Many had worked in one or two meeting places for between five and 20 years. Men were the minority. Roughly one-third of the participants reported lived experiences as carers or with psychosocial distress.

The focus group discussions

We arranged three separate focus groups, each of which included staff from at least three different meeting places. Each of the focus groups lasted for approximately 90 minutes and was held during working hours, supported by the participants and the municipalities/non-governmental organisations. Everyone agreed to the focus groups being held in a university lunchroom.

Between focus groups, our research team engaged in collaborative reflexive and revisionary work. The focus group topic guide covered service user involvement, job descriptions, conflicts, rules and regulations, and relationships between meeting places and their surrounding communities. The first author was responsible for moderating the dialogues. The second author co-moderated all of the focus groups. Another co-researcher co-moderated one focus group. The co-moderators took notes on non-verbal interactions and asked follow-up questions based on their first-hand knowledges of meeting places and hardships. Often, the topics were discussed with minimal moderating. Many staff members commented that they had found the participation to be beneficial. The Norwegian Social Science Data Services approved the project (reference number 34030).

Transcriptions

The audio-recorded discussions were in Norwegian and were transcribed verbatim primarily by the first author, assisted by the second author and another co-researcher. The excerpts discussed in this article are freely translated from oral Norwegian dialects to a written English format in which non-essential information is kept to a minimum to increase readability. To protect participants’ anonymity and dignity, characteristics that could possibly identify them were altered.

Discourse analysis as a theoretical–methodological approach

Our analysis was guided by psychologist Ian Parker’s (1992, 3–22) version of discourse analysis, which consists of seven basic and three auxiliary criteria for identifying discourses. In practical order, we thus understand discourses as (1) coherent systems of meaning that are (2) realised in texts and that construct particular (3) objects and (4) subjects in society. They are situated in (5) time and space, standing in traceable relationships with (6) themselves as self-reflecting systems, (7) other discourses and (i) societal institutions. Moreover, they (ii) reproduce or oppose dominant power relations and have (iii) ideological effects. Similar basic views appear to be shared within community psychology (for example, Hanlin et al. 2008) and participatory research traditions (for example, Brydon-Miller et al. 2011).

During a tailored two-day discourse analysis research seminar and spread-out collaborative analysis sessions thereafter, we focused on two approaches: using free association to trace and develop preliminary suggested contours of a discourse; and a collaborative speed analysis of delimited sections of text. To analyse the material comprehensively, individual work was also performed. The first author began with a time-consuming word-to-word approach to the 230 pages but turned to a more intuitive approach to Parker’s criteria as discussed by Kvale et al. (2009, 232–236). The second author and another co-researcher offered to participate more with discursive readings and reflections on full transcripts. The first author synthesised and analysed contributions and presented the preliminary analysis, at which time everyone was again welcome to contribute with their readings and critical reflections.

Analysis and discussion

The topic of service user involvement caught our attention during the focus groups and analysis. Relevant sections from the interviews proved difficult to analyse, and it was not until we read them aided by other relevant texts that we began to distinguish names and contours of discourses (see Parker [1992] for more information on analysis of discourses’ self-reflections). In the following, we will account for and discuss the particular analysis that emerged, generally guided by the question: how do meeting-place employees discuss their concrete and abstract encounters with service users and their experiences? We emphasise that our discourse analysis relates staff accounts and discussions to the larger webs of meaning in which they are understood to be parts of. Our analysis is not directly concerned with the phenomenology of participating employees’ subjective experiences or what they might have intended to say.

Co-determination as neoliberal consultation

In our three focus group discussions, questions regarding service user involvement were consistently met with descriptions of standardised co-determination or involvement procedures/processes. These procedures consisted of technically named meetings at pre-determined time intervals during the year, as described by ‘Tracy’:

Interviewer L:

… I was wondering, could everyone say something about what service users are involved in deciding at your places?

Tracy:

We have a service user council that has been led by a person who is a co-worker with service user experiences. What’s more, they have several regular prearranged meetings during a year …

L:

Do you have an example of wh-what they are involved in then?

Tracy:

We have a suggestion box we usually check for suggestions before a meeting. And we set the agenda together from meeting to meeting, with like, ‘what should we address next time’, for example. Then, there is a dialogue between service users and staff about what should be on the meeting agenda or what we want their opinions on, or, yeah. One of the topics has been alcohol on trips, rules for comfort. We have been working on the suggestion of a name change, not calling it ‘house rules’ but rather ‘rules for comfort’. And that was a very long process. So basically, yes. That is basically it. What things are happening, if they are satisfied with the existing service, if we should do it differently, if they miss something, and also for Christmas they had wishes about a Christmas fair, so we set up a Christmas fair, sales fair …

We identified the contours of the neoliberal discourse through prolonged analytical work on these diverging yet interrelated notions of involvement, such as ‘what we want their opinions on’. Here co-determination appeared to involve consultation at the discretion of management, and seemed to operate as a device for governing rather than a mode of collaboration, as the next excerpt illustrates:

Tracy:

… The person who used to lead it [the service user council] is quitting, so I thought ‘Who do we have who could be utilised for that?’. Then, it turned out that someone wanted to take over. But at the same time, I thought that it would be important that there is a staff member present [another staff member: Yes!] through the meeting, so that we – I’ve thought a bit about if we should have some kind of alternation.

Two staff members:

Yeah.mmm

Tracy:

So that we gain even more, how to say, interactional influence. Basically, so that those who work at the house know what happens in the service user council …

Tracy and her staff appeared to be positioned as mandated to manage, regulate and monitor service user involvement. Following Tracy’s account, here service user involvement paradoxically did not involve consulting service users, even on the topic of the service user council. As such, our reconstruction of co-determination as neoliberal consultation would appear to be discursively coherent with discussions in the broader service user involvement literature of the managerialist/consumerist ideology of service user involvement (Beresford and Carr 2012). Both in the literature and in our focus groups, this construction of involvement explicitly raises questions of whether service user involvement is only ‘pretend’ co-determination directed at practicalities rather than involving users in fundamental decisions. This is sometimes discussed as tokenistic involvement in the literature. As such, tokenistic involvement appears to involve concerns for people being led to believe that their influence is greater than it is (for example, Arnstein 1969; Beresford and Carr 2012; Borg, Karlsson, and Kim 2009; Meehan and Glover 2007).

The benefits of tokenistic group consultations for neoliberal discourse could be understood in light of the classic action research findings of Lewin (1947). Lewin and colleagues documented that groups appeared to take more responsibility for making changes when they had been involved in the decision-making that led to the changes than if those changes were initiated from above.

Responsibilisation – a neoliberal strategy

Often initiated by staff, the topic of responsibility arose at various points implicitly or explicitly related to service user involvement, as in the following excerpt:

Ramona:

So we get a lot of ‘Staff doesn’t do that, well they don’t. They don’t they don’t take responsibility!’, from service users.

Maryanne:

No, right.

Ramona:

But we experience that we are running our legs off. We just aren’t able to manage to do everything right.

?:

No.

Ramona:

But when you say; ‘Yes, but what could you do?’ Like, ‘No, it isn’t our job!’ [Ramona chuckles.]

Alyssa:

Have the different roles ever been defined? Just thinking about it, users and staff, like, have it like?

Ramona:

No, we try all the time, right. And it is discussed from time to time.

Alyssa:

Yes.

Ramona:

But it is, like, no one actually speaks of the service users’ responsibility. That is, is there a responsibility attached to being able to be in control?

Alyssa:

The general assembly should take up the question of ‘what is a service user responsibility?’ [Interrupts and talks simultaneously.]

The importance of this topic and section was particularly emphasised by the team members with first-hand knowledge and was decisive for engaging in the prolonged work necessary to analyse what now appears obvious: the excerpt triggers an image of the welfare state’s responsibility for service user involvement trickling down, first to the meeting-place employees, who must ‘make do’ within economic limits that were questioned and problematised during some discussions. Moreover, with staff overwhelmed by service users highlighting their poorly met needs given increasing inequality, responsibility inevitably trickles further down to the service users. We suggest that this could be understood in terms of the neoliberal strategy of responsibilisation:

… a term developed in the governmentality literature to refer to the process whereby subjects are rendered individually responsible for a task which previously would have been the duty of another – usually a state agency – or would not have been recognized as a responsibility at all. The process is strongly associated with neo-liberal political discourses, where it takes on the implication that the subject being responsibilized has avoided this duty or the responsibility has been taken away from them in the welfare state era and managed by an expert or government agency. (O’Malley 2009, 277)

These quotations also attest to splitting between services and service users in which each blames the other for difficulties with service user involvement. In the neoliberal discourse, service users who do not partake in managing the meeting place appear to be positioned as not taking responsibility and to be implicitly portrayed as lazy, irresponsible and ungrateful, leaving all of the heavy lifting to the responsible (and exhausted) staff members. Simultaneously, staff seem to be positioned as doing service users a disservice by taking away their responsibility.

In our focus groups, staff explicitly discussed cost-cutting and deregulating measures. Some constantly had to negotiate the threat of having to close the meeting place. The employees discussed this threat in relation to meeting places not being legally protected and in relation to reductions in and restrictions on available fixed assets. A recently enforced registration system for service users’ data was also addressed as raising concerns for staff and users alike after obviously tokenistic consultations from higher levels. A quick gaze at the United Kingdom’s shattered services demonstrates that it is wise to take these modernisations seriously (Mattheys 2015; Wood 2012).

Resisting responsibilisation

We have also identified the contours of service users being positioned as resisting the responsibility placed on them, as seen in Ramona’s earlier excerpt. We particularly identified resistance of responsibilisation in relation to what might otherwise be viewed as employees’ jobs, such as managing the meeting place, as discussed by ‘Barbara’:

Barbara:

We have tried to have the place open without staff. That went a little bit well the first night, not so well the second, and eventually, no one came.

Jake:

Mmm.

Barbara:

At all.

Several other staff members:

Mmm.

Barbara:

So that didn’t work. To have staff present in an environment like that, that safety factor, it means incredibly much.

Several other staff members:

Mmm, mmm.

These rejections of attending unstaffed meeting places were discussed multiple times during the focus groups. Service users were obviously also positioned to assume responsibilities and to manage the meeting places – often in situations involving higher user-to-staff ratios and unavailable staff. In such cases, we understand service users positioned as responsible for managing meeting places as attesting to the power of neoliberalism because a discourse only functions and grows if people occupy its positions (Parker 1992). Through its thorough intertwinement with most aspects of life in the late modernity, neoliberalism could be said to position most of us, for instance, telling us that the right thing to do is to maintain ourselves as able-bodied and healthy, or at least able-disabled, to decrease the need for public safety nets (Goodley, Lawthom, and Runswick-Cole 2014).

In our focus groups, certain service users were discussed as always having to step up to manage in employees’ stead because those users were the only volunteers. For years, feminist research has critiqued the practice of exhausting those who chronically take responsibility when those who should be answering the calls are absent (Fine 2012).

Sometimes, staff discussed it as confusing that service users were not more eager to initiate activities. This concern might be viewed in light of a neoliberal campaign of undermining professional power because it implies that untrained persons can do employees’ jobs. Service users, in contrast, appeared to be positioned as safeguarding staffed meeting places. The importance of staff appears to be consistently emphasised by service users across studies (for example, Elstad and Kristiansen 2009; Pinford 2000).

Responsibilisation threatens safety nets

In their discussion on threats to service user involvement, Russo and Beresford (2015) particularly discuss colonisation and exclusion. We argue for adding responsibilisation, which is interrelated with being colonised into believing you are responsible for being caught in inequality gaps and excluded as lazy, and because you know better but you do not do anything about it, you deserve distress. However, at the risk of inciting a controversy, our analysis suggests caution against viewing the highest level of Arnstein’s (1969) ladder, citizen control, as the answer. Our analysis raises concerns that control could be co-opted to be serving the neoliberal agenda of deregulating and freeing state-owned resources, a process that takes place through positioning individuals and non-governmental organisations to increasingly take responsibility for what has thus far been the state’s responsibility. If responsibility is accepted and we waive our collective rights to state resources, it would logically follow that we are led to believe that we decided this for ourselves and thus must live with the austere consequences. This process occurs while state resources are claimed to be reducing the liberty of ordinary citizens, whereas the 1%, to the contrary, appear very liberated by the deregulated versions of those same resources.

Thus, service users’ movements’ important struggle for equality vis-à-vis professionals and State (for example, Chamberlin 2005) could be at risk of being exploited towards such neoliberal agendas (Ekeland, Stefansen, and Steinstø 2011; Harvey 2005). If this was to occur, we might find a different liberty than what was sought, such as the deregulation of our public safety nets.

Finding ourselves critically aware of at least the possibilities of such clearly unintended scenarios of taking control, we suggest that there are pressing needs for further work on this threat, including examinations of alternatives.

Co-determination as social democratic collaboration

From the gaps in neoliberal discourse, we untangled another thread of co-determination, which we termed social democratic collaboration. As we can see in the following excerpt, even foundational issues at meeting places, such as the content of house rules, were decided together by both service users and staff:

Interviewer L:

… So we just wonder a little bit about what the users are involved in deciding, regarding these limits and rules. Could you say something about that?

Layla:

We have made house rules together with the service users. And the service users are basically involved in deciding in every service user council and general assembly. And most of the time, there is something to disagree about. And then the majority decides on it at general assembly. We have a handful of user councils every year [two staff-members: mmm, mmm], and thereafter – by the way, service users are in the majority and staff in the minority …

At a later point in this discussion, the limits to democracy were discussed in terms of what would happen if staff found a majority decision made by service users to be professionally inadvisable (brief interruptions are marked by brackets):

Jessica:

But who, I mean, this is what I’m so concerned with; who ‘wins’ then?

Staff member:

Yes.

Layla:

Well, but I mean … Well, but, I mean [], ehh, yes, but we have ehr []…If and when there is voting [], right, then there is the majority. But we do let them [service users] know it if we judge it to be professionally inadvisable.

Several times it was emphasised that majority rule trumped professional opinion. This signifies democracy, perhaps especially so in the mental-health field in which professional opinion still mostly dominates, service user movements’ struggle notwithstanding (Russo and Beresford 2015). Brandal, Bratberg, and Thorsen (2013, 1–15) contend that a central characteristic of Nordic social democracy is to acknowledge that there exist different interests and social inequalities among social groups that this ideology seeks to reduce, as exemplified in the earlier excerpts. This clearly contrasts with the previously discussed neoliberal consultation model that does not acknowledge the differing interests of management and those being managed on the assumption that everyone is working towards the same targets, which are unilaterally decided by upper management (Beresford 2002; Bjerke and Eilertsen 2011).

Social inequality is also clearly among the central foci of service user movements and their democratic approaches and emancipatory ideologies aimed at social equality for service users (Beresford 2002). Important ideological overlaps aside, we nevertheless see distinctions between a Nordic social democratic discourse and our readings of the ideals of Anglo-American service user movements. For instance, service user movements appear to favour a more participatory route to democracy – taking understandable precautions concerning state arrangements given psychiatric oppression (Beresford 2002; Chamberlin 2005). The social democratic discourse, on the other hand, seeks to counter inequalities through institutionalised solidarity and arrangements within the welfare state (Brandal, Bratberg, and Thorsen 2013).

The social democratic discourse is as such extensively embedded in Nordic culture –gaining momentum from the turn of the twentieth century (Brandal, Bratberg, and Thorsen 2013). Thus, it is noteworthy that we only identified this discourse in a few sections of the focus groups. The interruptions during Layla’s discussion might be read as another sign of marginalisation. Reviewing the service user involvement literature, this resonates with discussions of the neoliberal managerialist construction of involvement, gaining increasing predominance since approximately the 1980s (Beresford and Carr 2012).

Another central aspect of Nordic social democracy, and an example of mentioned institutionalised solidarity processes, is the tripartite collaborative co-determination between trade unions, employers and the state (Brandal, Bratberg, and Thorsen 2013). Norwegian trade unions are voicing concern about the future of social democratic collaboration. The knowledge centre for trade unionists, De Facto, reports on a case study of the Norwegian Tax Administration which documented that the consultation model seemed to have displaced tripartite social democratic collaboration to a considerable degree following major restructuring and modernisations (Bjerke and Eilertsen 2011).

Reflecting on the field of community mental health care, it is situated in the highly women-dominated frontline care landscapes, which are globally characterised by weaker labour rights and lower pay, and the job is positioned as a labour of love (Razavi and Staab 2010). As a labour of love, the claiming of rights might be rendered unethical for care workers, especially if those rights are suspected of being detrimental to the rights and needs of service users.

Viewing signs of displacement of democracy through even wider lenses, there are deep global concerns about neoliberalism’s threat to democracy itself (Harvey 2005). That threat is related to corrosions from below (as addressed here) and co-options from above though a high concentration of the world’s resources among a relatively small elite (Kornbluth 2013).

Spaces of restriction, protection and possibilities

Although there is potential for fruitful collaborations embodied in the social democratic discourse, we found what seemed to be many similarities between the described concrete interactions in social democratic and neoliberal service user involvement. In both, involvement was addressed as encounters between rational parties in dispassionate decision-making about decontextualised cases. We understand this to be related to a classical version of deliberative democracy that is criticised not only for excluding people who are marked by difference and disabilities but also for excluding affect and inequality (Raisio, Valkama, and Peltola 2014). A similar pattern was also found in a conglomerate of other relevant discourses, which triggered an image of a check-in desk where service user experiences have to be checked-in upon entry to the meeting place, to leave them in the wardrobe so to speak, as illustrated in the following excerpt:

Interviewer L:

Could you say something about why it [mental disease] is off-topic?

Rebecca:

Our meeting place is supposed to be a free space.

Several staff members:

Yes, mmm, yes.

Rebecca:

This is supposed to be a free space. The focus doesn’t revolve around the fact that you have a mental disease. That is completely uninteresting when you are at our place.

Many of those with whom we spoke in this study supported regulated freedom of speech concerning certain topics such as psychosocial distress. This regulation was discussed as necessary to avoid burdening others at the meeting place. Similar rules also seem to have been reported in previous studies of meeting places (Tucker 2010) and psychiatric hospitals (Skorpen et al. 2008). The regulation of civil rights is discussed as an issue of concern in the broader Anglo-American service user movement (Chamberlin 2005). This notwithstanding, the detailing of this topic in our focus groups seem to point to a highly complex terrain of social regulation and discipline that future studies are suggested to explore, and we hope to do so at a later point.

Beyond ‘check-ins’, however, employees were positioned to enable and protect service users bringing with them their full ranges of experiences and difference in what appeared to be designated areas. For instance, taboo topics such as psychosocial hardships were described as ‘allowed’ and protected on the edges of the meeting places, as described in the following excerpt by ‘Maryanne’. Parts of what is going on in this excerpt calls for future discursive inquiries of the social realities of service users:

Maryanne:

And, and they [service users] really benefit from each other socially. After all, there is a social network in which they in a way meet peers and of course talk about disease aaand about all these things, right. [Many supportive comments from others.]

Alyssa:

Medicaaations and …

Maryanne:

About medications, about … they know all about these things, and of course, we don’t interfere with that.

Ramona:

No.

Interviewer L:

Mmm.

Maryanne:

Not in the slightest; they have to be allowed [to talk] among themselves.

Ramona:

Yes.

Maryanne:

Unless it happens like (1.5-second pause).

L:

Unless it happens in plenum? But …

Maryanne:

Yes, in plen … [simultaneous talk by L and Maryanne]

Reflections on limitations

Our collaborative inquiry has been based on the understanding that knowledge is constructed through the actions engaged in to obtain it and that such actions should benefit those who are exposed to them, particularly co-researchers, service users and staff of meeting places. As a team, we have continually worked in and on the unjust power relations and privileges of academia, while remaining critically aware of the numerous discursive, material and institutional barriers that require collective efforts for social transformations (Parker 2014).

Reviewing specific strengths and limitations, a strength with Parker’s (1992) approach to discourse analysis is that it encourages participation, and facilitates collaborative analysis. Nevertheless, it unavoidably tilted power relations of the team towards academic knowledges. However, to our understanding, our capacity-building and capability-building workshops empowered our team to discuss and disagree on both analytical readings of transcripts and how to craft our discourse analysis.

This said, we acknowledge that our approach to discourse analysis has its limitations. For instance, we have focused less on a historical analysis than emphasised in ‘Foucault proper’, and more on discourses’ variability and consequences for service users. In contrast to following an academic recipe, our understanding of Parker’s theorising is that every inquiry by default involves new readings, and should therefore be reflexively crafted to its purposes within malleable guidelines, preferably together with experts by experience in the area of question, as we have done here.

Widening our lens, we furthermore understand our inquiry to be inextricably bound to our positions in social worlds and to the particular Norwegian meeting places and the people who we met there. For instance, the Norwegian context enabled us to study meeting places in community mental health care, a service that appears to be retrenched in advanced neoliberal western countries, somewhat questioning the relevance for our analysis. This notwithstanding, our analysis indicates that overall patterns similar to those based on our focus groups seem to resonate far beyond Norwegian meeting places.

Closing reflections

In this article, the participatory research team discourse analysed three focus group discussions with staff from various meeting places in Norwegian community mental health care, seeking to engage in a wide-angle contextual analysis. We identified neoliberal consultation and responsibilisation strategies in most of the spaces discussed as ‘service user involvement’. In contrast, a discourse of social democratic collaboration was identified in the gaps in the neoliberal discourse. This resonates with Norwegian trade unions’ concern about signs of neoliberal consultation displacing social democratic collaboration in work life. In Norway, co-determination is considered a pillar of democracy (Brandal, Bratberg, and Thorsen 2013) and therefore signs of displacements of democracy in everyday life are disconcerting in contexts far beyond meeting places. This aligns with warnings at the global level for neoliberalism’s threat to democracy itself.

In our focus groups, however, resistance to neoliberalism was also identified, with service users being positioned as not accepting neoliberal responsibilisation and defending the safety net of staffed meeting places. We argue that meeting places and similar day services seem to provide an advantageous position for local staff and service users to strengthen the possibilities for democracy. This is because service user involvement is already required in most such spaces and to a certain degree, democracy might be available. The predominant discourse of neoliberalism and its allies cannot be changed at will: they are deeply intertwined with how society is structured in webs of discourses, practices, material conditions and power relations. However, as we have shown through this analysis, critical questioning, reflexivity and discussion can identify gaps in dominant discourses and spaces for resistance that make it possible to work on changes (within limits). We thus encourage staff and service users to ask critical questions and reflect on their ways of doing things in edge spaces such as smoking areas, service user councils, staff meetings, general assemblies and informally in the common areas. For example, the following questions could be posed: are there other, possibly better, ways of involving service users? How can we make more space to meet service users’ self-defined interests and needs? How can we use gaps in tokenistic involvements to make them as democratic as possible?

We do understand that every reading is new, and we welcome understandings from other angles. In the current political and economic climate, however, we had some concerns about discussing this analysis because of the looming threat to deregulate meeting places, at least in some districts. Thus, we emphasise that the analysis and discussions in this article highlight neoliberalism and its consequences as embedded in the fabric of society and trickling down to meeting places. However, through this analysis, staffed meeting places seem also to embody safety nets by offering spaces from which it is possible to resist responsibilisation, to defend the need for staff and to engage in everyday democracy.

Disclosure statement

The authors have no conflicts of interest to declare.

Funding

This work was funded by the University of Bergen, and supported by the charitable Norwegian trust Josef og Haldis Andresens Legat.

Acknowledgements

The authors thank Vegard Haugland for important contributions to the project, and everyone who generously participated in the collaborative research team, the focus groups and who otherwise contributed to the research process. Thanks to Mental Health Norway, Bergen and The Norwegian Association of Youth Mental Health, Bergen, for their support.