A sort of friend: narratives from young people and parents about collaboration with a mental health outreach team

ABSTRACT

Mental health issues among young people have received increasing attention in Norway as more are diagnosed with and report mental health problems. In this study, we focus on the personal and social recovery processes of young people with mental health difficulties. The aim of the study was to explore how young people and parents experience collaboration with a community-based mental health outreach team around recovery processes, using a narrative analysis. Three topics from the findings are discussed: relationships and collaborations built on the service user’s goals, closeness and distance in professional helping relationships, and comprehension of professionalism.

KEYWORDS:

• Narratives
• recovery processes
• youth
• collaboration
• phenomenological psychology
• mental health

Introduction

Mental health issues among young people have received increasing attention in Norway as more are diagnosed with and report mental health problems (Bakken, 2018; Norwegian Institute of Public Health, 2014). About 15 to 20 percent of children and youth between three and 18 years old have impaired function because of mental health issues such as anxiety, depression and behavioral disorders (Norwegian Institute of Public Health, 2014). Population studies among children and youth have shown that 7 percent have serious symptoms and satisfy the criteria for mental health disorders (Heiervang et al., 2007; Wichstrøm et al., 2012). In 2016, 5 percent of the population under the age of 18 received treatment in mental health services (Krogh, Indergård, Solbakken, & Urfjell, 2017). The prevalence of mental health disorders in general is on the same level in the Norwegian population compared to other western countries.

Over the last decade, focus has been growing on developing different models and practices for collaboration and on strengthening service user involvement for people with mental health difficulties. Recovery as a concept and area of knowledge has expanded in Norway, and considerable reforms have occurred in the mental health field since the 1980s (Ekeland, 2011). Emphasis has been placed on recovery-oriented practices in policies for mental health services, for which the aim is to strengthen service users’ participation, reduce institutionalization, and offer community-based services where people live, both in their homes and in their communities (Borg, Karlsson, & Kim, 2009; Norwegian Directorate of Health, 2014). Recovery can be seen as an experience-based field of knowledge, a philosophy, a paradigm, a movement, a vision, and a mode (Karlsson & Borg, 2017). When research on recovery in American user environments became more prevalent in the 1980s and 1990s, recovery was primarily seen as a personal process (Borg, Karlsson, & Stenhammer, 2013). However, if we understand recovery as both a social and personal process, focus is put on the dynamic relationship between people and their everyday lives, for which living conditions, humane services, and community are essential (Biong & Borg, 2016; Borg et al., 2009; Tew et al., 2012). This conception of recovery differs from the clinical view of recovery as the impartial aim and effect of treatment (Slade, 2009). If we see recovery as merely a personal process, we risk overlooking the part of the recovery process that corresponds to the individuals’ living conditions that interact with personal network and service providers (Topor, Borg, Di Girolamo, & Davidson, 2011). We then risk individualizing societal issues, which limits people and causes them difficulties, and also makes them responsible for their own recovery processes without providing them access to the services they need (Karlsson & Borg, 2017).

In this study, we focus on the personal and social recovery processes of young people with mental health difficulties rather than symptom reduction resulting from medical treatment, which is the more common biomedical understanding of recovery. The subjective experiences of young service users with mental health issues and their parents are in focus. Particularly, we emphasize the collaboration between service users and providers as an essential part of the recovery process for individuals and their networks. We understand “collaboration” as something that occurs through relationships and dialogue: “As relational beings who mutually influence each other, our ‘selves’ cannot be separated from the relationship systems we are a part of” (Anderson, 2012, p. 14). Through dialogue, we include the other person’s intentions and meanings into our own, and in that manner, our responses are influenced by the relationship with the other person and the context (Bakhtin, 1981; Anderson, 2012). A collaboration requires room for each person to be equally present, which can lead to a sense of belonging, co-ownership, and sharing responsibility (Anderson, 2012).

Research on personal and social recovery processes and the stories people tell about their recovery experiences shows that connection to people and communities, hope and faith in the future, and rebuilding of a positive identity and purpose are important (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011; Sælør, Ness, Holgersen, & Davidson, 2014). Recovery is described as a process that is provided through supportive and caring relationships and environments. In this understanding of recovery, focus is put on the subjective experiences of recovering and not on becoming free of symptoms or all problems (Leamy et al., 2011). Central in these processes are also relationships and how collaboration is accomplished between service users and providers. These relationships should, in this perspective, emphasize the subjective goals of the recovery process, the person’s empowerment, and their regaining of control over their own life conditions.

However, many recovery studies have been conducted on an older population, so there is a need for studies that focus on youth experiences in recovery processes (Kelly & Coughlan, 2019; Oswald, 2006). A person’s network is an important element in the recovery process, but for young people, family might be even more crucial as parents or guardians might significantly impact decision-making in recovery processes. Existing studies on recovery among young people suggest that this process might be unique because it is nonlinear and calls for individualized approaches (Kelly & Coughlan, 2019). Further, a better understanding of service users’ collaboration experiences during recovery processes can contribute to knowledge about how service providers can create more helpful relationships with such users.

To develop such practices in mental health services, more knowledge is needed about how young people and parents experience getting help during the recovery process (Kelly & Coughlan, 2019; Leamy et al., 2011). Thus, the aim of the current study was to explore how young people and parents experience collaboration with a community-based mental health outreach team that was supporting the young people’s recovery processes, using a narrative analysis. Focus was on what they considered helpful and of importance in the helping relationships with professional service providers. To explore these issues, we asked the following research question: “What kind of narratives did young people and parents create about their collaboration experiences with a mental health outreach team that was helping with their recovery processes?”

Methodology

The study was conducted in a collaborative research tradition and centered on services for young people with mental health issues and collaborative knowledge development between researchers, service providers, and service users (Veseth, Binder, Borg, & Davidson, 2017). The design and methods used were based on the belief that knowledge is co-constructed through collaboration between people who have experienced difficulties related to mental health and researchers.

This study had an exploratory and descriptive design. The philosophy used was inspired by phenomenology: we aimed to describe phenomena through participants’ descriptions. We based our approach on qualitative research principles of phenomenological psychology and created narratives from interviews with young people and parents about their collaboration with a community-based mental health outreach team (Desai, Pavlo, Davidson, Harpaz-Rotem, & Roenheck, 2016; Malterud, 2012; Sells, Topor, & Davidson, 2004). A narrative, or story, is a connection between the past, present, and future. The story and the lived experience are not the same, but the story may help us understand different experiences. Our methodological tool is consistent with what Sells et al. (2004) have described as “empathic bridges,” using first-person storytelling to better understand the collaboration processes and experiences with the outreach team around recovery processes. The narrative structure of storytelling can provide an opportunity to build an empathic bridge between the researchers performing the analysis, the reader, and the experiences of the informant (Davidson, 2003; Sells et al., 2004).

Research context

The study was conducted in a municipality in Norway with a mental health outreach team that had clinical contact with young people between 13 and 23 years old and their families. In Norway, treatment based on diagnosis for mental health disorders are specialist health services and part of the hospitals and health services. The outreach team was not considered as treatment in this sense, but as mental health services based in community work. The service users could have a diagnosed mental health disorder, but this was not a criterion for receiving help from the team. The team provided low-threshold services in a flexible manner regarding frequency of contact and duration of the services. Service users could be referred by other parts of the welfare system, or through self- or family-based referral. What kind of services the team provided was decided in a collaboration between service user and service provider (Soggiu, Klevan, Davidson, & Karlsson, 2019). The team was a local, community-based social and health service that supported young people to enable school- or work-related activities, provide training in social skills, and coordinate different welfare-system services.

Participants

Participants (i.e., service users of the outreach team) were recruited through the help of service providers on the outreach team. They were informed about the study, and if they decided to participate, gave informed consent. Participants under the age of 16 were required to have permission from a guardian or parent who also signed the form together with them. Data from nine participants was used in this study. These were five young service users and four parents. Among the young participants, there were four girls and one boy. All of the parents were biological parents, three mothers and one father. One parent and one young person were from the same family, while the rest had no connection.

Research ethics

The Norwegian Center for Research Data approved the study (#52349). Written informed consent was required before participation, and data were made anonymous through the transcription process by moderating or removing details that could have been used to identify the participants.

Competence group

As we used collaborative research methods in the study, we established a competence group of co-researchers consisting of two young service users, two parents, two service providers, and the first author. In collaborative research in mental health including people with lived experience is considered an important part of the research method when developing knowledge for the mental health field (Veseth et al., 2017). The members of the competence group were considered as co-researchers in the study and contributed in different parts of the research process. The whole group contributed in different ways to the current study: they provided input on themes for the interview guide, one group member participated in the analysis process, and the whole group took part in discussions about the findings, using their own experience-based knowledge, to help the researchers understand the narratives created. In this manner, the competence group also contributed to the Discussion section in this paper.

Interviews

The interviews were conducted by the first author. As the study was grounded in phenomenological psychology, the interviewer asked open-ended questions that invited free storytelling around certain topics from the participants. To explore experiences of collaboration around recovery processes the interviews included topics like collaboration with the outreach team, user involvement, management of disagreements, the planning process for collaborations, their feelings about their influence and trust during the collaboration, and if they felt the collaboration facilitated or hindered their recovery process and in what way. These topics was chosen because they revolve around important content of collaboration with respect to personal recovery processes. Recovery as a concept was not defined by the interviewer, as we wanted the participants` subjective meaning on how to collaborate around help to their own processes of recovering. Together we explored experiences with help and collaboration with the team, and what the participants found helpful. The opening question in the first interview with the participants was: “How did you come into contact with the outreach team? Tell me about what happened.” The participants responded freely, and the interviewer checked the list of previously decided-upon topics and asked questions about them if the participants had not already addressed them during their storytelling. At the end of the interview, the participants were asked how they felt about the dialogue with the interviewer and if there was anything else they wished to add.

Some of the participants were interviewed more than once. As part of the participatory research approach, the participants took part in knowledge development throughout the whole project, and the researchers had dialogue with the outreach team about their practices. As part of a circular process, the different study participants (the competence group, outreach team, and interviewees) were given feedback about preliminary findings from interviews to comment on, converse about, and reflect on in terms of other participants’ remarks. We did not use a new interview guide in the second or third interviews. The interviewer shared preliminary findings from the previous interviews. The participants were invited to talk about what they identified with or what was not recognizable. We did not introduce new topics as the preliminary findings evolved around the themes that were talked about in the first interviews. Interviews were conducted three times over one year in 2018; in the second and third interviews, the participants were asked to reflect on preliminary findings the interviewer presented to them. The first round of interviews took about one hour each. The second and third interviews were shorter, from 20 to 30 minutes. Three parents were interviewed once and one parent twice. Three young people were interviewed three times and two young people twice. Data from all interviews are included in the study. The interviews were conducted in Norwegian and audio recordings from all interviews were transcribed word-for-word.

Analysis

The first author and one co-researcher from the competence group participated in all stages of the analysis process. The co-researcher was a parent of a child who had received help from the outreach team. Using the qualitative research principles of phenomenological psychology and Malterud’s (2012) systematic text condensation, we analyzed the data and transformed findings into narratives (Desai et al., 2016; Malterud, 2012; Sells et al., 2004). Psychological phenomenological analysis is the foundation for systematic text condensation. The analytic procedure consisted of creating a one-page narrative from each of the participant interview(s) that reflected the essential meaning they had expressed about their experiences. If the participant had been interviewed more than once, all interviews were consolidated and analyzed as one and only one narrative was created for each participant. We read the transcripts line-by-line looking for meaning units. According to Malterud (2012), “a meaning unit is a text fragment containing some information about the research question” (p. 797). We then constructed the narratives (one for each participant) using their own language by taking quotes from the interviews. In this way, we framed the narratives in autobiographical terms by summarizing the participants’ stories in the first person (Sells et al., 2004). The next step was to create one narrative for each group of participants: young people and parents.

The aim of the analysis process was to identify meaning units in all the interviews that represented a story about collaboration with the outreach team around recovery processes. The two analysts (first author and the co-researcher) had no experience of using the method prior to the process. The first author had used Malterud’s (2012) text condensation in earlier research and had also received guidance from a coauthor (L.D.), who had previously developed the method for creating narratives based on the research principles of phenomenological psychology. The two analysts sat together as they analyzed all the material. Between the different phases of the analysis process, they compared and discussed findings. First, they separately identified meaning units; they then compared their findings before creating one-page narratives separately. The first author then proposed how the two one-page narratives (one from each analyst) of one participant’s story could be combined and presented it to the other analyst. They then agreed on a one-page narrative for each participant. The process of creating one narrative was conducted in the same matter for each group (youth and parents).

All data were kept in Norwegian throughout the analysis. The narratives were translated into English after they had been completed.

Findings

Narratives of experiences of collaboration around recovery processes

In this section, we present two narratives created during the analysis phase to represent our findings. These narratives were constructed as first-person stories with a fundament based on the meaning units in the one-page narratives. The two narratives are amalgamations of all the meaning units from the participants’ individual narratives. In the narratives, we included ideas as expressed by the participants during the interviews: for example, the phrases “trust,” “friend,” and “good chemistry.” The purpose of creating the narratives in this way was to remain faithful to the manner in which the stories were told by the participants. The narratives were written in a positive matter of what the participants needed to happen in the services. A meaning unit could have contradictory stories about what happened when they had collaborated around help, but end up as the same meaning unit. As an example “trust” as a phenomenon could have been talked about as both something they had experienced or as something they lacked. The narrative structure of storytelling can help us build empathic bridges between the experiences of the participants and between our own experiences as researchers and practitioners (Sells et al., 2004).

Narrative 1

The stories young people told about collaboration with the outreach team

To be able to receive help, I need to trust those who are helping me. To trust someone, I need time because I have met people before who have disappointed me. I need someone who doesn’t give up even though I dismiss them sometimes because I am scared, or I can’t make it to an appointment because I don’t feel well that day. I need someone who can convince me they are there to help and that they like me. I need them to take initiative when I am not capable of it. I need someone who will be a sort of friend, or not a friend maybe, but someone who is not just professional and strict but who can share something personal about herself as well.

To tell my story, I need to know something about the person I am telling it to. Sometimes I don’t want to tell my friends or family something because they will get worried, but I need someone to tell it to. I need someone who likes me, cares about me, and doesn’t just want to talk about all the bad stuff. Maybe take me for a ride, pick me up at home, because sometimes I don’t want to go outside. Help me get in touch with other helpers when I am scared or worried or just sick and tired of them. Like my teacher at school and people from social services. Or just help me write a CV, go for a walk instead of just sitting inside the office. When I need help changes. Sometimes I need to meet more than once a week, other times I don’t need to meet at all. To trust someone, we just need to click, you know? Have good chemistry.

Narrative 2

The stories parents told about collaboration with the outreach team

I need to trust my child’s helpers. I need to know that my child is in safe hands. When I feel the service providers want the best for her, I feel safe that she will get the help she needs and that the help is beneficial. I can trust she is receiving good help when I get the impression that the relationship between my child and the service providers is good, either because my child tells me that she likes them or if she has contact with them voluntarily without me having to pressure her. So, when I know that they have a good relationship, I don’t feel the need to know everything about what they talk about or do together. I want to be involved, get information and updates, but I don’t feel the need to know everything. As long as I trust them, I think it is good that my child has someone other than us in the family to talk to about stuff she doesn’t feel comfortable talking to us about.

In addition, the service providers are competent with things I don`t know how to handle. I think good help should be flexible and able to adapt to my child’s shifting needs. When my child doesn’t want to leave the house and I’m not able to do anything about it, I really need someone to come to my home and help me. We have been receiving help from so many different places, and it’s hard to collaborate and get in touch with everybody. I need someone to handle that collaboration. When I am certain the service providers really like my child, I believe in the support she gets, and I trust that it will help her.

Discussion

This study explored the narratives young people and parents created in dialogs about their collaboration experiences with a mental health outreach team that was supporting the young people’s recovery processes. In this section, we will discuss what the participants considered to be helpful and important in the helping relationships with the professional service providers. The discussion takes a reflective approach in which we explore and assess the professional helping relationship. The narratives show what the participants needed and how the services should be adjusted to facilitate for recovery processes. How a collaboration was practiced was significant to get help in their recovering. Three topics are discussed: relationships and collaboration built on the service user’s goals, closeness and distance in professional helping relationships, and the comprehension of professionalism.

Relationships and collaboration built on the service user’s goals

There are many similarities between the narratives of the parents and the young people despite the differences in their collaborator roles. Flexibility regarding service, the team ensuring collaboration with other units of the welfare system, and the relationship between collaborators were mentioned as important to the recovery process by both parents and young people. Research on recovery has determined that the dynamic between everyday life and personalized help based on a person’s needs, life goals, dreams, and hopes is important (Biong & Borg, 2016; Biong & Soggiu, 2015; Borg et al., 2009; Tew et al., 2012). Getting help to improve service users’ quality of life is connected to the relationships and collaboration with service providers regarding areas and goals that service users find important (Biong & Soggiu, 2015). Biong and Soggiu (2015) studied service users’ experiences of psycho-social follow-up from a mental health and substance abuse team and observed a phenomenon they named “grasping it by the hands and doing something about it,” which refers to a way of offering help based on service users’ day-to-day needs. The narratives from the current study show a similar need for flexible service, in which the help that is offered is broad in scale, from the practical to the psychological and more traditional, conversational-style therapy. This was also the mandate for the outreach team in practice. As we understand recovery as both a social and personal process, service users should be in control of the kind of help they need and receive, and, in that sense, a broad definition of therapy or help is necessary. The narratives create a more in-depth understanding of help in the recovery process and indicate that an extensive portfolio of helping tools is required from practitioners in recovery-oriented mental health services, with an essential focus on building relationships in any collaborations that occur.

Closeness and distance in professional helping relationships

Trust was given meaning in the narratives as a belief related to the quality of the relationship in the collaboration. While young people sought trust in terms of a personal relationship that included knowledge about the person they were interacting with, similar to a relationship with a friend, parents connected trust to a relationship that allowed them to feel that their child was taken care of by a competent service provider. In both narratives, the concept of “being liked” and a relationship built on mutual recognition was emphasized. When the competence group reflected on the narratives, one member drew a comparison to his own work in sales: that in sales, trust is the most important component for success, and close personal relationship is crucial to get your job done. This is considered to be the professional role of a sales person. He reflected about why the same thing was considered unprofessional when trying to help someone in the mental health field. Keeping a distance might be seen as a professional skill, and closeness as the opposite. He wondered if it had to do with someone being an expert that possesses knowledge, that the one in need of help is considered not to hold, when practicing as a professional in the mental health field. The significance of the relationship is considered to have a larger impact than the therapeutic methods in recovery processes (Denhov & Topor, 2012). As given meaning in the narratives, other studies have shown that service users want relationships that are not merely professional in a narrow sense, but also have a personal dimension (Ljungberg, Denhov, & Topor, 2017). In a traditional biomedical model of professional help, the service provider holds knowledge about what helps, and the service user is considered to need that knowledge to get better. The professional role is mostly characterized by knowledge, distance and neutrality (Parsons, 1951/2012). According to theories about therapeutic alliances, the relationship should be built on mutually depending factors in terms of agreement about goals and tasks. A bond built on mutual trust, accept and confidence is crucial to the alliance (Bordin, 1979). If recovery is understood as merely clinical, a personal relationship in the collaboration can be seen as of less importance or in some cases as interfering with the professional help that is provided. The narratives as well as other studies on service users ‘experiences and opinions of quality in help in recovery processes, requests services built on equality in collaboration. A social and personal recovery-oriented practice emphasizes an equal relationship when it comes to the understanding of knowledge, where lived experience is considered as an important competence in the mental health services. The relationship between the service user and provider in itself is emphasized in these recovery processes (Denhov & Topor, 2012). Practicing as service providers in the mental health field require practitioners to navigate in an area of tensions created by contradictory policies that require recovery-oriented practice within a discourse of pathologizing mental health issues (Ekeland, 2011; Soggiu et al., 2019). If we are to listen to what services users have told us in this study as well as in other studies, we have to develop a practice where relationships are based on equality, and also have a personal component to contribute in recovery processes.

In the narrative of the young people the phrases “friend” and “good chemistry” are used, as they were used by participants during the dialogs when trying to describe a good helping relationship. Similar phrases (personal chemistry) also appear in other recovery studies as ways of describing the content of a helping relationship with service providers (Borg & Kristiansen, 2004; Denhov & Topor, 2012; Ness, 2016; Topor, Bøe, & Larsen, 2018). Skatvedt (2013) explored small talk as a therapeutic method. She found that what happened between the therapist and the services users outside the therapeutic room in everyday settings, had a significant impact on service users` experiences of helpful help. As an example she phrases it “the smoking break as an expression of love” between service user and provider (Skatvedt, 2013). Even though research shows that service users find personal relationships with their helpers to be of crucial importance for their recovery processes, we know that there is a common tension between closeness and distance in the line of what is considered professional helping relationships (Denhov & Topor, 2012; Levin, 2004; Ljungberg et al., 2017).

Comprehensions of professionalism

In a different study of the outreach team by the first author, a finding was that the outreach team struggled with the notion of professionalism when dialoguing about closeness and distance in relationships between themselves and the service users (Soggiu et al., 2019). What is considered professional does not involve using one’s own life experiences and creating a more personal relationship with the service users. The concept of acting as a professional expert is taken from discourse from a biomedical model of both the definition of mental health issues and how help should be provided. The narratives of both the young people and the parents identify personal relationships in collaborations as important in recovery processes. This leads to a paradox: research on service provider perspectives of helping relationships that discuss building more personal relationships with service users are considered to advocate a technique that leads practitioners to act unprofessionally; then, because research on this topic is discouraged, practitioners lack language to articulate this side of their practice. We then run the risk of developing practices that are not discussed as part of the service, as they are something forbidden, as well as not developing skills for creating more personal relationships. We wonder if a broader perception of professional relationships in mental health services could help in the developing of better services. Constructing more recovery-oriented services in which the social as well as the personal levels of the service users are taken in to consideration might challenge how we perceive professionalism and how we arrange services. It also challenges our training, as becoming experts through formal education in the mental health field rejects the subjectivity of the people collaborating in helping relationships (Strauss, Lawless, & Sells, 2009). From the present study’s narratives, it is evident that equality between service users and providers impacts the recovery processes. It is concerning that the professional approach in some matters involves relationships characterized by creating a distance between collaborators, as the service users in this study and other studies have shown that the opposite would be more helpful (Borg & Kristiansen, 2004; Denhov & Topor, 2012).

Conclusion

This paper raises issues about the relationships between service users and service providers collaborating to support users’ recovery processes related to mental health issues. In this study, we have explored young service users’ and parents’ experiences with collaboration centering on recovery processes. As the title of the paper notes, when talking about their collaboration experiences, young people want close, personal relationships; in other words, friends. Thus, it is a challenge that, in the mental health services field, what is considered professional excludes these aspects of the relationship; in fact, to some extent, a personal relationship is considered quite the opposite, as unprofessional. Research about the therapeutic alliances support the importance of the relationship and collaboration on recovery processes (Bordin, 1979). This study contributes to a research tradition on recovery processes, that has shown the importance of personal relationships and in that sense we believe that the narratives’ description of helpful collaboration calls for an even broader understanding of helpful relationships and professionalism in the mental health field. If more can be learned about service users by using a more friendly approach in professional recovery-oriented services, better help may be able to be provided.

Limitations

This study were based on a small number of interviews with service users, which were recruited by their service providers. It was conducted in Norway, which has wide-ranging welfare services, and in a very flexible community based mental health service for youth. The implications of the study should be seen in light of this.

Acknowledgments

Anthony Pavlo, PhD, Associate Research Scientist at Yale University gave input on how to use Psychological phenomenological analysis. Thank you for your contribution

Disclosure statement

No potential conflict of interest was reported by the authors.