Young people with complex needs meet complex organizations: an interview study with Swedish professionals about sustainable work practices

ABSTRACT

This paper concerns preconditions for the well-being of young people with mental ill-health combined with social vulnerabilities, also referred to as youth with complex needs. Research questions are: What barriers to sustainable work practices for young people labelled as having complex needs do professionals encounter? What do professionals identify as possible ways to overcome these barriers? Sustainable work practices are reflected in three themes: empowerment, relationships and collaboration. The findings are based on semi-structured interviews with 24 professionals, 3 men and 21 women, working in psychiatric care and the social services in two Swedish municipalities in 2016 and 2017. Major barriers are lack of continuity and co-ordination in staff and support, and fragmentation of work practices. As a consequence of the increased specialization of human service organizations, young people have to interact with many different professionals which could cause disparate interventions. Possible ways mentioned to overcome these barriers are supported through good interactional skills, using keyworkers as well therapeutic alliances, wrap-around services and case management. Complexity is linked to organizations and work practices rather than to young people. An often dysfunctional service delivery system in organizations with rigid boundaries may also affect professionals’ aim for sustainable support.

RÉSUMÉ

Cet article concerne les conditions préalables au bien-être des jeunes souffrant de maladies mentales associées à des vulnérabilités sociales, également appelées jeunes ayant des besoins complexes. Les questions de recherche sont les suivantes: Quels sont les obstacles aux pratiques de travail durable pour les jeunes considérés comme ayant des besoins complexes? Qu'est-ce que les professionnels identifient comme moyens possibles de surmonter ces obstacles? Les pratiques de travail durable se reflètent dans trois thèmes: l'autonomisation, les relations et la collaboration. Les résultats sont basés sur des entretiens semi-structuré avec vingt-quatre professionnels, trois hommes et vingt et une femmes, travaillant en psychiatrie et dans les services sociaux dans deux municipalités suédoises en 2016 et 2017. Les principaux obstacles sont le manque de continuité et de coordination, dans le personnel et le soutien, et la fragmentation des pratiques de travail. En conséquence de la spécialisation accrue des organisations de services humains, les jeunes doivent interagir avec de nombreux professionnels différents, ce qui peut entraîner des interventions a disparetres. Les moyens possibles de surmonter ces obstacles sont le soutien par de bonnes compétences interactionnelles, l’utilisation de travailleurs clés ainsi que des alliances thérapeutiques, des services complets et la gestion de cas. La complexité est liée aux organisations et aux pratiques de travail plutôt qu'aux jeunes. Un système de prestation de services souvent disfonctionnels dans des organisations aux frontières rigides peut également affecter l’objectif des professionnels en matière de soutien durable.

KEYWORDS:

• Complex needs
• sustainability
• Sweden
• well-being
• work practices
• young people

MOTS-CLÉS:

• Besoins complexes
• durabilité
• Suède
• bien-être
• pratiques de travail
• jeunes

Mental ill-health, especially among youth, is an increasing problem in Sweden (National Board of Health and Social Affairs, 2017), as indeed, globally (WHO, 2017). Young people with mental ill-health are a disadvantaged group in contemporary culture. To find successful ways to support this group is, therefore, all the more needed in today’s societies. This paper analyses work practices among Swedish professionals who work with young people with mental ill-health in combination with social vulnerabilities, also referred to as young people with complex needs. Mental ill-health is often connected to social vulnerabilities, such as difficulties with completing one’s education (de Ridder et al., 2013) and participating in the labour market (Lager & Bremberg, 2009) which may lead to further negative outcomes such as increased mental ill-health and heightened risk of drug abuse (Sellström, Bremberg, & O’campo, 2011).

A critical challenge for modern welfare states is to meet the needs that changing economic and societal conditions bring about for their citizens. Due to societal changes in the labour market at large, higher educational levels are demanded in workplaces and new kinds of competences and capabilities are requested (Allvin, Aronsson, Hagström, Johansson, & Lundberg, 2006). Citizens who are assumed to lack these types of abilities are at risk of semi-permanent exclusion from the labour market, with long-term negative consequences in the form of poverty over the life span. Young people with mental ill-health are thus at risk of further marginalization, which highlights the importance of finding ways to improve work practices regarding this group in order to prevent an accumulation of social problems and mental ill-health leading to further exclusion later in adulthood.

According to WHO’s (2017) global estimates of mental health, the number of people living with mental ill-health has increased and WHO has launched a comprehensive mental health action plan with the major aim of changing attitudes that perpetuate stigma and discrimination against persons with mental health issues. One major objective is to offer comprehensive mental health and social care services in community-based settings (WHO and Calouste Gulbenkian Foundation, 2017). Well-being and sustainability have more or less become buzzwords in Western rhetoric. Health and well-being are prerequisites for active participation in family life as well as community life, let alone in the labour market. In this paper, these notions are linked to the group of young people labelled as having complex needs.

The present study is the second part of a larger Swedish project, conducted from 2016 to 2018, with the overall aim to improve work practices for supporting persons labelled young people with complex needs, aged 15–25 years. The background is that mental ill-health among Swedish 10–24 year olds has increased by 100% over the past decade. This means that in 2017 about 10% of girls, boys and young men, and 15% of young women in Sweden suffered from mental ill-health (National Board of Health and Social Affairs, 2017). Some of them have adequate supportive networks and do not need support from the social services. However, a significant proportion of these young people have more complicated life situations, and they are often referred to as having complex needs. The types of problems and needs that young people categorized as having complex needs have can vary. In short, complex needs is a term that is used to categorize people or families with multiple and intersecting needs, a group of young people that often is presented as ‘a challenge to services’ (Valentine, 2016: 241). The term complex needs indicate multiple social vulnerabilities or difficulties such as poverty, unemployment, abuse, crime and mental or physical disability which occur simultaneously and intersect in different ways (Spratt, 2011).

In the Swedish context, important actors for promoting well-being and sustainable support for young people with complex needs are the social services and the psychiatric care. As mentioned earlier, complex needs designate multiple social problems in combination with mental health problems, and these young people may, therefore, receive assistance from both the social services and psychiatric care. Their needs are often handled by many different professionals from different organizations in the welfare state. In Sweden, young people’s social needs are the responsibility of the social services on the municipal level, and needs concerning mental ill-health are the responsibility of the psychiatric care on the county council level. Both these organizations have the authority to issue voluntary as well as compulsory measures. Young people in need of support from several actors within the social services and psychiatric care have the right to coherent assistance, according to a recent act issued by the Swedish Association of Local Authorities and Regions (SALAR, 2017). This means that professionals at the municipal and county council levels have a statutory obligation to collaborate with each other and, if necessary, also with others involved in the care to provide more coherent assistance, based on the young person’s needs and current life situation (SALAR, 2017).

Young people labelled as having complex needs often lack stable parental contact, making it all the more important that professionals be successful in supporting these young people through their work practices. The importance of stable relations to parents and peers for well-being and life-satisfaction among adolescents is shown in previous research (Armsden & Greenberg, 1987). Notably, a lack of parenting ability caused by parents’ mental ill-health does not necessarily result in future adversity for their children (McCormack, White, & Cuenca, 2017). Research by Grealish et al. (2017) shows the importance of empowerment in mediating the relationship between psychological processes, mental health and well-being in young people.

The aim of this paper is to analyse preconditions for the well-being of young people with complex needs and sustainable work practices to assist them, reflected in three themes; empowerment, relationships and collaboration. We focus on two research questions. First, what barriers to sustainable work practices for young people labelled as having complex needs do professionals encounter? Second, what do professionals identify as possible ways to overcome these barriers? With organizations, we refer to authorities within the welfare state with legal obligations towards the citizens.

Previous research

Before turning to our methods and findings, we present previous research on work practices related to young people with complex needs. In the first section, we discuss findings from studies of what young people with complex needs consider to be important, namely empowerment-related work practices. After that follows a presentation of relationship-oriented work practices. We end this part by highlighting research on collaboration-oriented work practices.

Empowerment-oriented work practices

Empowerment-oriented work practices concern how professionals balance the power inequality between welfare state organizations, professionals, young people and their families and can be seen as working at the individual as well as the organizational level. The best predictions for successful treatment outcomes are associated with practices that involve the young person’s personal agency and include the young person’s family or other members of the community (Ungar, Liebenberg, Dudding, Armstrong, & van de Vijver, 2013). Malvaso, Delfabbro, Hackett, and Mills (2016) highlight the importance of the professional’s interaction style and skills. Empowerment can, according to Malvaso et al., be achieved by professionals who use an interaction style that is informal, is focused on outreach activities rather than office meetings, is centred on the client’s knowledge and strengths, and offers individual and life-related activities. Empowerment-oriented work practices are giving young people information about different options, allow them to formulate their own opinions, and give young people the time and possibility to make a choice (Malvaso et al., 2016).

A well-functioning interaction pattern between service providers, caregivers and adolescents is also based on family empowerment, this means allowing the family to be involved in the care and ensuring that the priorities of the family are met (Ungar, Liebenberg, Landry, & Ikeda, 2012). Empowerment-oriented work practices (on individual and organizational levels) often problematize the top-down bureaucratic principles of organizations. They are characterized instead by more flexible and accessible ways of reaching out to young people, such as when professionals engage locally with the youth in their community and on their own terms. In their study of professionals working with sexually exploited female adolescents, Edinburgh and Saewyc (2009) highlight professionals’ work practices such as engaging locally with the girls in their homes and schools, and empowering them through therapeutic group counselling, as ways to reduce trauma and increase self-esteem.

Relationship-oriented work practices

The way young people experience the quality of relationships with professionals is in previous studies related to treatment outcomes (Ungar et al., 2012; Ungar, Liebenberg, & Ikeda, 2014). The hallmark of good quality in relationships is when young people experience authenticity in their relations with professionals, sensing that the professionals truly care about them, and are not judgmental (Cahill, Holt, & Kirwan, 2016; Ungar et al., 2012; Ungar et al., 2014). A study by Harder, Knorth, and Kalverboer (2013) of the relationship between staff and young people in a youth treatment centre show that good relationships with professionals are when professionals show commitment, can take the young person’s perspective, can be trusted, show respect for the young person and provide positive feedback.

In a study by Ådnanes and Steihaug (2016) based on interviews with young adult service users with mental ill-health in Norway, continuity of care and stable relationships between youth and professionals are highlighted as important. Cahill et al. (2016) identified key aspects of high-quality relationships between youth and professionals to be based on genuineness, congruence and continuity across the young person’s life, as well as acting in a compatible and transparent way in relation to the young person. Relationship-oriented work practices are also by Cahill et al. based on an organization of care that take the opinions of young people into consideration. ‘Management by keyworking’ (Cahill et al., 2016, pp. 220–221) is when one member of staff is assigned to be a ‘keyworker’ for an individual young person. It is based on who the young person becomes attached to and how well the personalities and characteristics of the young person and the professional mesh. The young person also has a say in who becomes the keyworker. Relationship-oriented work practices can also be studied as the formation of different types of therapeutic alliances. Lamers and Vermeiren’s (2015) study of multidisciplinary teams of parent counsellors identified that, depending on the situation, there were different alliances which were formed between young people, professionals as well as parents.

Collaboration-oriented work practices

To understand complex needs, one must also take into consideration how complex needs evolve as part of an increasingly specialized and complex welfare state (Green & McDermott, 2010; Grell, 2016, p. 18; Stevens & Cox, 2008). Requiring support and interventions from multiple actors contributes to making problems and needs more complex (Ungar et al., 2014).

Previous research about young people who receive support from multiple actors indicates that they are at risk of receiving fragmented care (Bunger, 2010; Ungar et al., 2014). Absence of a common theoretical framework can create problems in the collaboration between social workers and other professionals. Finding consistent, congruent or complementary treatment philosophies can be a way to reduce potential conflicts and improve coordination, as different actors can approach treatment and interventions from a similar starting point (Bunger, 2010). Management control systems for inter-agency collaboration (Alam & Griffiths, 2016) handle problems like fragmentation and may contain both a horizontal and a vertical dimension. If the support is seen only as a differentiation of separate tasks within the organization, mainly the horizontal dimension comes forward. The vertical dimension and a hierarchical difference become particularly clear in so-called ‘buy- and sell-organizations’ (Bunger, Doogan, & Cao, 2014; Grell, 2016) emphasizing the importance of collaboration between organizations. Trustworthiness may be reinforced by agencies using referral partnerships. This also makes it possible to establish a foundation for collaborative activities – for example, sharing of staff expertise. Therefore, referral partnerships can mediate the process by which potential partners come to trust one another and develop a collaboration for multiple service delivery.

In their study of mental health care for children, Pavkov, Soloski, and Deliberty (2012, p. 673) defined what they called ‘funding silos’. This means that each service system has its own definition of how service provision should be approached and its own perspective on what service users need. As a result, professionals from different systems may lack an understanding of the various systems’ different roles (Pavkov et al., 2012; see also Miller, Blau, Christopher, & Jordan, 2012). Bunger (2010) views case management as a method by which professionals can handle complex needs in a way that enhance the coordination of care when care is provided by multiple disciplines or in multiple settings. Case management can be used to connect a client to multiple forms of services, functioning as a bridge to move clients from one type of service to another. Case management involves pooling resources, whereas ‘wrap-around’ is a process which integrates assessment and planning, and knits together services from all involved providers to address the needs of the child and family. A wrap-around process, therefore, represents a more highly elaborated coordination and integration of care (Bunger, 2010).

Data and methods

Sweden has a population of approximately 10 million inhabitants and consists of 290 municipalities and 21 counties. The municipalities are responsible for the social services and the county councils for healthcare (SALAR, 2018b). For this study, two municipalities (100,000 and 150,000 inhabitants respectively) in two counties (250,000 and 290,000 inhabitants respectively) located in central Sweden were selected. The selection of counties was based on similarity yet variation. The number of municipalities in the two counties is similar (9 and 10, respectively). The counties are bordering each other, and there may be similarities between them in terms of organization, staff and work practices due to their geographic proximity. Compared to the national figure for mental ill-health among young people, both counties are close to the national average. Furthermore, there are differences between the counties. Visits for care related to substance abuse have more than doubled between 2016 and 2017 in one of the counties, from 2.5 visits per 10,000 inhabitants, 0–17 years. The same figure slightly decreased during the same period of time in the other county (SALAR, 2018a).

For the selection of participants, a reference group consisting of six professionals in managerial positions in child and youth psychiatry and the social services at the county council and municipal level was consulted. The participants were informed about the project and invited to participate through members of the above-mentioned project reference group. We were very careful to emphasize for the reference group that taking part in the study was completely voluntary and that no pressure should be put on the professionals to participate in the study.

Inclusion criteria for the participants were that they should be working either in psychiatric care or social services and that they had experience of working with young people with complex needs, aged 15–25 years. We wanted variation in terms of treatment professionals and participants in managerial positions. Of the 24 professionals interviewed, 13 worked in social services and 11 in psychiatric care. There was a variation between participants in terms of professionals directly involved with young people (n = 19) and professionals on a strategic level (n = 5) who were less directly involved with the young people. Of the professionals, 21 were women and 3 were men. This gender bias may be explained by that fact that a majority of the employees in these sectors (social work and psychiatric care) are women. In Sweden, 86% of the social workers are women (Statistics Sweden, 2016). The age range of the participants was 27– 62 years, the average age is 44 years. Among the participants, 21 had university degrees, and 3 had an upper-secondary school education. The participants had occupations such as counsellor, therapist, psychiatric nurse, and residential care worker. Of those working in psychiatric care, five worked with young adults and five with children. Of those working in social services, four worked with out-of-home care-related issues, three worked with issues concerning education and employment, and two worked with youth substance abuse. Their occupational experience of working with youth with complex needs ranged between 6 months and 30 years (with an average of 16 years).

Semi-structured interviews were chosen as research method. It is an appropriate method for gaining a deeper understanding of a phenomenon (Denscombe, 2000). The aim was to discover possible patterns based on the empirically generated results. Semi-structured interviews would allow for this, but would still be open for follow-up questions. The authors conducted the interviews in their own offices or at the participant’s workplace. The interviews lasted between 45 and 75 min. Before the start of the interview, the participants filled in a questionnaire with basic demographic information and were informed of the ethical principles that apply when doing research in Sweden (Swedish Research Council, 2017). These rules concern the right for participants to be informed that participation is voluntary. Participation in research must be based on participants’ informed consent. Other ethical considerations regard confidentiality, which means that the researcher must take measures to protect research subjects’ privacy and integrity, which in this case means that names of participants and their workplaces are not revealed.

The interviews were conducted in two phases: The first phase, consisting of 7 interviews, was performed in autumn 2016, and the second phase, 17 interviews, was performed in the spring and summer 2017. In the first interview phase, the interview guide was more exploratory. It contained questions about different aspects of work practices concerning young people with complex needs, distribution of girls/boys or young women/men, ethnicity and socio-economic background. The participants were asked how they defined complex needs, what kinds of needs they considered a young person with complex needs might have, how they worked with young people categorized as having complex needs and if they used any special methods for working with this group. The results of these initial interviews, together with a literature review (Almqvist & Lassinantti, 2018), were used to further develop the interview guide for the second phase of interviews. We retained some of the questions from the first phase of interviews but also included more targeted questions regarding work practices. In the second phase, we specifically asked about the three major themes we had identified in the previously published literature review; accordingly the professionals were asked whether and to what extent they considered young people and their families to be involved in decision making and interventions, whether and how they created relationships with the young person and the family, and whether and how they collaborated with other professionals.

The interviews were conducted in Swedish and were transcribed verbatim. For the analysis, we used content analysis (Morgan, 1993) and an approach that Hsieh and Shannon (2005) term directed content analysis. This approach in content analysis is more structured. Open-ended questions were used, followed by targeted questions related to the predetermined categories. During the second phase of interviews, the three themes that had emerged in the first phase as well as in a literature review (Almqvist & Lassinantti, 2018), namely, empowerment, relationships and collaboration, became target questions as well as the focus for the analysis. The authors engaged in open coding initially and then focused coding related to discussions about work practices in relation to young people and their families.

Findings

The notions of well-being and sustainable support are reflected in the three above-mentioned themes that are significant for work practices, namely empowerment, relationships and collaboration. We start with the first theme, empowerment, where the young person is more actively taking part or is encouraged to do so by professionals. The next theme focuses on the relationship between the young person, parents and the professional. The final theme focuses on different forms of collaboration, between the professionals themselves and between their organizations. This collaboration may also include parents and non-governmental organizations.

Empowerment-oriented work practices

Empowerment-oriented practices address the problem of the inequality in power between social service organizations, professionals and young people and their parents. All participants in the study considered the participation and involvement of youth and parents to be of great importance and stated in various ways that they tried to make it part of their daily work routines. Participation could take the form of asking young people if they agree with the doctor’s description of their difficulties, or if they consent to the treatments and suggestions made by the professionals:

We present how we can work, what kind of treatment we can offer  … and ask the patient, ‘Does it feel as if this could be something, or does it feel  … completely weird?’ Many say right at the outset, ‘Yes, it was interesting to listen to, but no thank you’  …  we can’t force a patient to do anything  … If we notice a doubt in a patient, then we say, ‘Yes, but think it over for a week, we can call you next Thursday and check’  … I’m allergic to talking over someone’s head. (Psychiatric nurse)

Creating empowerment means to involve young people’s personal agency (Ungar et al., 2013) by using work practices that try to get them more involved in decision making and care (cf. Malvaso et al., 2016; Ungar et al., 2012; Ungar et al., 2014). These measures may contribute to decreasing the organization’s complexity, in terms of how it may be perceived by the young person. Empowerment-oriented strategies do not always involve big decisions; they can also be about ‘small things’ in daily life or in meetings, as illustrated by this participant: ‘If someone [another professional] turns to me at a meeting and asks, “What do you think his situation is like?” Then I turn to the young person and ask him, “Can you tell us how you think things are?”’ (Social worker, residential care)

By reminding the other professionals that they should ask the young person directly instead of talking to each other as if she or he is not there, this professional sides with the young person against the other professionals, to avoid asymmetries in power. The quote highlights that empowerment as a work practice is connected to a professional’s personal interaction style and skills (cf. Malvaso et al., 2016). Furthermore, a key element in empowerment-oriented work practices is to counteract power relations where the work practices of professionals in social service organizations risk silencing the voices of young people. The voices of young people with complex needs may also be suppressed, according to the following participant, especially among girls and young women:

When someone comes to us, it’s because it hasn’t worked elsewhere. Why it hasn’t worked is difficult to say. You could say that others are making the decisions, but these girls are often people with very low self-esteem; they’re not used to speaking up for themselves the way you’re supposed to do these days … They often need to be encourage to express themselves and to explain their needs. (Physician)

The participant considered it a work task to encourage girls she encounters to be assertive and express their needs and wishes. According to Malvaso et al. (2016), empowerment-oriented work practices aim to make it possible for young people to formulate their own opinions. In this quotation, the ability ‘to speak up for themselves’ is connected to gender and self-esteem, but is also postulated as an ability you are supposed to have nowadays.

Relationship-oriented work practices

All participants in the study considered good relationships to be of great importance for treatment outcomes, however, several impediments to relationship-building with young people and their families were also highlighted. The participants argued that lack of continuity due to high staff turnover is problematic, which is also shown in previous research (Cahill et al., 2016; Ådnanes & Steihaug, 2016). This is a strain not only for the young people but also for the professionals. The opportunities for prolonged contact improve the chances of building relations over time.

Here we have the opportunity to offer long-term contacts, and I think that’s what’s needed for this group … it’s hard [for the young people] to trust other people, it’s hard to … build up this relationship, it takes time and maybe doesn’t always succeed. But here we have [this] opportunity. (Therapist, psychiatric care)

Another barrier to sustainable support for young people, according to the following participant, is that many professionals and organizations are often involved. Young people with extensive problems and complicated life situations are therefore expected to handle interactions with many persons.

I think we take actions that I wouldn’t be able to manage, although I’m fully functioning. I wouldn’t be able to attend all the meetings that we require our clients to come to. You hardly know who’s who and who does what. (Social worker, managerial position)

The downside of so many different professionals being involved is that it may impair relationship-oriented work practices. This indicates that it may not only be that needs are complex, but the organizations that the young people encounter, as well.

One of the participants stated that relationship-oriented work practices necessitate close relations between professionals and the young person: ‘There must be someone who gets close to the youth first, someone who can start building a relationship … ’ (Social worker). The approach that this participant is requesting can be compared to ‘management by keyworking’, as previously mentioned (Cahill et al., 2016, pp. 220–221). The participants described too many and disparate interventions as a problem that also may be a consequence of professionals’ goals and ambitions, as one participant reported:

I think we have much higher ambitions than the client. We pull them through our systems, and they come out the other side and haven’t learned anything, instead have a feeling of not knowing what happened. I think it’s about our own needs. We want so much to help, we want to succeed to such an extent that we believe more interventions are the solution. (Social worker, managerial position)

This professional highlights the problems that may occur if the professional’s own desire to help does not correspond with the needs and wishes of the young person. This can be avoided if professionals are more open-minded and have less fixed preconceptions about the problem, as another professional reported:

It could be something completely different that is close to the young person’s heart. It might not be the thing that the parents are worried about when they phone  …  you [should] try to listen to them  …  be open to what’s coming up  …  But also respect them  …  They should be able to maintain their integrity  …  So it’s necessary to balance between information gathering and respect. (Psychiatric nurse)

The quotation above emphazises the importance of professionals’ skills in the art of listening when collecting information. This requires an ability to adopt the young person’s perspective and show respect for the young person’s integrity. These are qualities that young service users also consider to be important skills for professionals, as is shown in previous research (Harder et al., 2013).

When different professions are involved, professionals may also need work practices for how handling conflicts that may arise. Conflicts may occur between different professions, as well as between professionals or between professionals and the young person or the parents. These conflicts may concern different opinions regarding the cause of problems, or which intervention or treatment would be best for the young person. For example, some professionals spend more time with the families, and conflicts may arise if they side with the young people and their parents against other professionals. These potential turf wars can however be resolved if one of the professionals in the meeting takes on the role of a neutral mediator:

I can take on a more neutral role and say, ‘Hi, I don’t know anyone here, but I’m holding this meeting, and the purpose of this meeting is for us to find a solution that is good’ … And then the staff from the ward can side with the parents in the meeting so the parents can get their opinions validated, or encourage the teenager to state his or her opinion … I can hold the meeting and shift between them. Maybe the social services also have to be supported sometimes, and asked to clarify: ‘Yes, what do you mean then?’, ‘What’s the purpose of that?’. (Therapist, psychiatric care)

The example above can be interpreted as professionals forming different types of therapeutic alliances (cf. Lamers & Vermeiren, 2015). When some of the professionals side with the parents, they support parents in a way that validates the parents’ opinions. The professional who acts as chairperson or mediator can be seen as adopting a more neutral position to bridge conflicting opinions which in the long run can lead to more constructive meetings and that important decisions that have to be made are not delayed due to conflicts.

Collaboration-oriented work practices

Collaboration among organizations and between professionals was found to be an aspect of great importance in promoting sustainable support for youth with complex needs. On the question about complex needs and complex organizations, a participant working with strategic issues stated that complex needs arise when interventions are not adapted to the young person’s needs and when there is poor coordination between the involved services. Furthermore, there needs to be a strong focus on how the support is provided within the organization or in collaboration with the health care sector and employment services, as well as substance abuse treatment centres. The participant expressed several barriers to collaboration. Inter-agency coordination is not enough; intra-agency coordination is needed too, as also argued by Grell (2016). This is moreover noted by Bunger et al. (2014), who emphasize the importance of collaboration between organizations, as mentioned earlier. When needs occur simultaneously and intersect, there can be difficulties in determining when and in what ways it should be a responsibility of psychiatric care or the social services. One participant stated:

There may be someone who needs a psychiatric assessment, which we in the social services can’t do anything about. There’s something about their mental health, but we can’t really pinpoint what it is. They’re bouncing in and out of treatment centres … The drug abuse increases, and then the health and medical services send them back to us saying, ‘This is drug abuse, and that’s your responsibility’. But wait now, ‘Stop, it’s a combination!’ How can we handle cases that require skills in treating both addiction and psychiatric problems? … usually you need some kind of special solution earlier. (Strategic level, social services)

Differentiation of responsibilities may be driven by professionals’ assessments of whether the needs of young people are best met by social services or psychiatric care. It may however also be a question of who is going to pay, as was highlighted by this participant:

We can’t sit in front of the young person or the family and argue about who does what.  … The sad thing is that sometimes it comes down to money. And we have talked about the fact that we’d like mutual funding for these cases, then we wouldn’t have to have these arguments L But it’s getting better. Now we have collaborative forums at different levels. (Strategic level, social services)

Instead of favouring the mutual goal of the young person’s interest, organizations may protect their own interests, a consequence of what Pavkov et al. (2012, p. 673) refer to as ‘funding silos’. Another negative effect of there being many organizations involved is lack of coordination of interventions, as reported by another participant:

It’s important that you get in touch with each other as soon as possible in order to conduct your investigations simultaneously, so that the service user doesn’t have to wait for the next investigation. Otherwise you could first be investigated by social services, and they say ‘We need psychiatric care as well’. And then they send an application … and they investigate it there … We should be able to do these investigations simultaneously: ‘Okay, what kinds of services can we collaborate around, together?’ (Strategic level, social services)

The participants requested closer collaboration between the social services and psychiatric care and gave examples of more beneficial ways of giving support such as wrap-around services and case management (cf. Bunger, 2010). The level of involvement may vary from coordinating only briefly to being more fully engaged in the provision of services. A neutral mediator with no interest in controlling the agenda is requested by another participant: ‘I think it would be good whenever there is someone with complex needs … anyone who has power both in the municipality and in the county council, now there isn’t any’ (Social worker). The importance of having a team collaborating jointly around a person with complex needs is previously emphasized by Alam and Griffiths (2016), who pointed to the difficulties with overly extensive fragmentation.

Discussion and conclusion

The objective of this study was, from the perspective of professionals in psychiatric care and social services in Sweden, to analyse barriers to sustainable work practices when it comes to supporting young people with mental ill-health and social vulnerability (also referred to as young people with complex needs), as well as possible ways to overcome such barriers. Work practices have been gathered under three themes: empowerment, relationships and collaboration. We start with the first question: What barriers to sustainable work practices for young people labelled as having complex needs do professionals encounter? One major barrier for sustainable support that is addressed by the professionals is lack of continuity, which is partly regarded as a consequence of high staff turnover. Another barrier is fragmented support. Fragmentation can be connected to an increasing specialization of the human services sector in Sweden and internationally. Previous research shows that this creates difficulties for clients with complex needs (Grell, 2016). The participants highlight how the far-reaching specialization has negative outcomes. Young people and their families have to interact with many different professionals. This indicates that the complexity may be a feature not only of the young people’s needs, but also of the organizations they encounter. When organizations in the service sector form their own provision in line with their own interests – also referred to as ‘funding silos’ (cf. Pavkov et al., 2012, p. 673) – young people are at risk of receiving overly disparate interventions.

Further, the participants describe the involvement of too many professionals as a potential barrier to work practices that are relationship-oriented and built on continuity and trust. This may also have a negative impact on professionals in terms of work satisfaction. Participants describe feeling forced by organizational logics, to work in ways they consider counter-productive to sustainable support. Professionals testify to having to follow the logic of a highly specialized and fragmented welfare state organization. Here, the young person’s needs are handled by different organizations and professions and no one has an overall view or control. This is instead of providing support structured around a holistic and relationship-oriented perspective, taking account of who the young person becomes attached to and trusts. Further, professionals’ good intentions may create barriers if the interventions they offer do not primarily originate from the young people’s needs, but rather from the professionals’ own desire to be good helpers.

Continuing to the second question: What do professionals identify as possible ways to overcome these barriers? Professionals express that more collaboration is needed between the social services (municipal level) and psychiatry (county level), and describe a need for joint funding as well as more coordination of the services provided by the different organizations. Wrap-around services and case management are mentioned as ways to increase collaboration. At the same time, collaborative efforts do not always reduce the number of people involved, which, as mentioned earlier, can be a barrier for work practices that are more relationship-oriented. The importance of professionals’ interactional and relationship-building skills is mentioned, as work practices that empower youth. Another way to overcome obstacles to sustainable support is through increased awareness of the significance of the different therapeutic alliances. They can be formed between professionals, young people and their parents and mitigate potential turf wars and enable more well-functioning interaction patterns between professionals, young people and their families.

Another practice for overcoming barriers is ‘management by keyworking (Cahill et al., 2016, pp. 220–221), where the young person is supported by a professional who is assigned to be his or her ‘keyworker’. A possibility that is highlighted as a way to overcome the tendency to offer too many and too complex interventions is to take smaller steps and work from the inside out, through relationship-building centred around the young person’s needs in the here and now. The observation that sustainable support, from the perspective of young people, is based on professionals’ empowerment- and relationship-building skills is in accordance with previous research, where the quality of relations between young people and professionals is described as crucial for successful treatment (Ungar et al., 2014).

On a professional level, sustainable support and work practices primarily concern the individual level and aim at more long-lasting implications for the individual. Sustainability, on the other hand, has a different connotation on an organizational level and a more strategic perspective. It is merely about how to achieve more long-lasting effects within the organization. The concept of sustainability could also relate to the strategic and professional levels at the same time. Research indicates that action plans for education for sustainability on a strategic level, and as a national priority, may be linked to social competencies such as skills, knowledge, and values that enable people to problem-solve, adapt, and change in a complex world as is also noted by Whiteside et al. (2017)

This study has some limitations. The results are based on interviews with 24 professionals in psychiatry and social services in two municipalities and two county councils in Sweden. Needless to say, if the study had been performed in a country with a different type of welfare state regime than Sweden’s, the barriers and possible ways to overcome them would probably have been different than those identified and addressed in this paper. Further, it is a qualitative study; the results can therefore not be seen as representative for all Swedish municipalities and county councils. The aim of qualitative studies, however, is not generalizability but rather the offering of in-depth insight into a phenomenon. Hence, this paper contributes to the literature in the growing field of research concerning complex needs and complex welfare state organizations. It does so by identifying barriers, but also by suggesting possible avenues for future provision of support to young people with mental ill-health and social vulnerabilities.

Concludingly, the challenge, as described in a report by WHO (WHO and Calouste Gulbenkian Foundation, 2017) is to develop more sustainable mental health and social care services in community-based settings, and change the attitudes that create stigmatization and discrimination against people with mental ill-health. Based on their experiences of supporting young people with mental-ill health and social vulnerabilities, the professionals who participated in this study have mentioned a number of barriers, but also identified possible ways to overcome these barriers. We have discussed work practices reflected in the themes empowerment, relationships and collaboration which we identified as key elements for improving the support provided to young people with complex needs. Consequently, more research is needed to shed light on the young people’s own opinons and experiences about the support they receive and the organizations they face.

In order to maintain a sustainable society and provide increased well-being for youth, it is important to remember that complexity is linked to organizations and work practices rather than to young people. The study also found that not only the young people suffer from the complex organizations but also the professionals themselves. They aim for empowerment and well-functioning relationships with service users, framed within a service delivery system which is often dysfunctional, having fairly rigid boundaries.

Acknowledgement

We would like to thank the participants for the generous sharing of their experiences.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Anna-Lena Almqvist is an Associate Professor in Social work from Mälardalen University, Eskilstuna, Sweden. Her research focuses on work, youth and their families, and policy issues, often in a comparative perspective. Recent projects concern youth with complex needs, families with two mothers and teenage parenthood in Thailand. She has recently published in the American Journal of Men’s Health, Child and Adolescent Social Work Journal, and Men and Masculinities.

Kitty Lassinantti is a Senior Lecturer in Social Work from Mälardalen University, Eskilstuna, Sweden. Her research focuses on critical medical sociology, with a particular focus on psychiatric diagnoses and identity construction, disability and gender. Her thesis ‘The Dilemmas of Diagnosis’ is a qualitative study of how women negotiate identity in relation to a neuropsychiatric diagnosis. She has recently published in Child and Adolescent Social Work Journal.

ORCID

Anna-Lena Almqvist http://orcid.org/0000-0002-6223-1109

Kitty Lassinantti http://orcid.org/0000-0001-5387-325X

Additional information

Funding

Mälardalen Skills Centre for Health and Welfare (MKHV) has funded the project ‘Young people with complex needs', grant No. 2016/2198.