Is there any coherence?
The coherence of the efforts to help persons suffering from homelessness, substance abuse and/or mental illness
Summary
The focus of the study
This study seeks to establish how local organisations monitor efforts to help marginalised citizens suffering from one or more problems such as mental illness, substance abuse or homelessness.
The study sheds light on the interaction between meaning universes and architecture. A meaning universe is the set of attitudes, ideas and notions about what problem needs to be solved and how to solve it. The architecture consists of the programmes which are expected to solve the problem and the administration behind these programmes which acts as the superior authority. In the architecture, there are different methods and paths which give the players a chance to express themselves about what is right and wrong. In this way, they form a meaning universe which is supplemented by the users to the extent they can make themselves heard. The meaning universe simultaneously justifies the architecture. The meaning universe can be either preserving or developing, depending on the knowledge which is formulated by the political and administrative system, the users and any external parties.
The architecture and meaning universe are, on the one hand, provided by the players who are members of organisations which have the autonomy to make independent decisions: i.e. the county, the municipality and the individual private organisations. Within the organisation, there are a number of sub-organisations in the form of departments, institutions and the like which have less sovereignty, in spite of a certain amount of autonomy, and which are often part of a hierarchical system of sub-organisations.
On the other hand, the outside world also influences the architecture and meaning universe. The organisation cannot be sequestered as an isolated universe, but is influenced from the outside. The meaning universe is influenced by the press, research studies, controversial cases and the goals stated in Danish legislation. The architecture is influenced by legislation and local organisations which demand special types of programmes for the users.
The study consists of 42 interviews with 58 key persons in five regions in Denmark conducted in spring 2002. The interviewees were municipal and county politicians, high-ranking civil servants in various public administrations, managers of different types of programmes and representatives from private, often volunteer, programmes. Users and employees were not interviewed for this part of the study. Thus, only part of the meaning universe is presented in the following – that represented by those who help monitor and work within the framework of the architecture.
Notions about users and sources of knowledge
The dominating notion is that persons suffering from homelessness, substance abuse and mental illness (HSMs) are lonely and isolated. They display deviant behaviour and have a very limited network. There is no room in society for their obvious displays of deviancy and so they are marginalised with regard to social treatment, housing, work, etc. They are often viewed as being difficult because they do not fit the profiles of the programmes available.
This notion gives rise to two strategies. The first is a care strategy where users are cared for by way of drop-in centres, overnight shelters, food, conversation, contact, etc. and in places which accept their deviant behaviour. This is a strategy which is motivated by the opinion that treatment does not help and so is not worth the effort. Instead, the focus is on ensuring a tolerable existence for such persons. This attitude is formulated, for the most part, by politicians in the sector. The other strategy is care combined with treatment where care is viewed as a way to make contact with the user in order to offer treatment when it is relevant and acceptable. For some – mainly programme managers – this is motivated by a desire to open up for the possibility of normalisation and for participation in society through housing, work, etc. This strategy is often motivated by a philanthropic perception of the users where the experiences of many failed treatment attempts are often linked to great patience in the hope that one day treatment will work.
One of the reasons programme managers harbour great sympathy for the combination strategy is most likely because they are engaged in treatment by virtue of their professionalism and on-the-job experience. It can be difficult to carry out your work if you do not believe it is important for the users, for example that they can be cured of their substance abuse and mental illness.
These strategies for action are represented in every region. But in four regions, they have resulted in special programmes for persons suffering from mental illness with substance abuse problems which combine housing with care and treatment but without influencing the architecture of the region.
These perceptions of the users only come to a limited extent from the users themselves. They are seldom supplemented by independent user surveys. These perceptions primarily come from the programme managers who take as their point of departure the programme’s users and their daily lives. This results in only a few statements regarding what kind of life the users lead and may result in new needs and new contexts, which should influence the architecture in the sector, coming to light very late or not at all. Thus the programme managers and workers have a biased view of the users which most likely results in the programmes appearing to be more positive than the users find them to be. If the users are adjusted to fit the programmes rather than the programmes to fit the users, there is a distinct possibility that these aspects will not come to light.
Organisation and monitoring
This study sheds light on four types of monitoring which are used in the sector:
- Monitoring via structure
- Monitoring via interdisciplinary forums
- Monitoring via programme managers
- Monitoring via competency development
Monitoring via structure consists of distributing tasks in different »blocks« among the various sub-organisations. This takes place when the duties of a political committee are extended or limited, such as by gathering hospital, district and social psychiatry under the same committee, as has been done in all the counties studied, or by combining substance abuse and homelessness under the same committee. This type of monitoring also takes place when the public administration’s focus areas are changed or when the county yields competences to a municipality in areas such as drug abuse.
Monitoring via interdisciplinary forums consists of meetings between organisations or sub-organisations in which certain issues and actions are discussed. The respective parties choose to yield competences to each other and the meetings can be seen as a kind of negotiation where efforts are combined to produce special solutions from case to case. This is a vulnerable form of monitoring, which must be characterised by consensus and tolerance in order to succeed.
Monitoring via programme managers consists of meetings between public administration managers and programme managers. The administration officials are very aware of the fact that the managers of the institutions are key figures when it comes to target realisation. It is important to obtain their support since they subsequently have to convince and influence front office staff.
Monitoring via competency development consists of improving staff competencies by initiating a joint discussion across sub-organisational and professional boundaries. This may involve special user histories or perceptions of care and treatment in the form of common interdisciplinary courses, which have been carried out in two regions.
A common element in all the monitoring forms is getting to know one another better and transcending the usual organisational and professional boundaries. Public administration managers want everyone to move in the same direction and want the decision-making process in most areas to reflect a consensus. The programmes are not monitored using written directives, and public administration managers prefer to use dialogue rather than top-down orders, even when making conflict-ridden or unpleasant decisions.
The political committees are consensus-oriented in their methods and the majority of decisions are made in agreement. The relationship between politicians and employees is characterised by interaction which jointly seeks to promote mutual consensus. The public administration primarily takes the initiative to raise new questions, set agendas, present target goals and propose specific initiatives. This takes place in close collaboration with the committee chairperson who plays a central role and participates in the debates on new initiatives. Politicians do not have as much contact with the institutions as the public administration officials do, and their contact is usually limited to annual meetings with the managers of the institutions.
Prioritisation and evaluation of the HSM sector
The traditional affiliation of the programmes to the different groups in the HSM sector means that the integration of the different services for persons suffering from several types of substance abuse or from both mental illness and substance abuse is problematic. The lack of integrated programmes or coordination between the various services is the predominant organisational problem. There are many individual programmes which seem relevant, but it is difficult to establish a collaboration that works when the user needs the help of several different programmes. The historical division into three (four) areas, and the division into county and municipal systems as well as a number of private programmes, makes it difficult to achieve solutions for persons with several problems requiring treatment.
The conclusion is that the existing organisation in the HSM sector is inadequate and, in spite of a decade of increased focus, there are still problems in the area.
Collaboration between county and municipality
The architecture in the sector is dominated by the two major organisations – county and municipality. Collaboration between the two is organised based on the three types of user groups, where drug and alcohol abuse are viewed as one group.
The overall collaboration takes place, in part, through meetings between county and municipal politicians. It may also take place through visits or meetings with groups of municipalities. These meetings may be held regularly or arranged for a specific purpose, with the respective managers meeting at either meetings for directors of social affairs or with selected groups of municipalities. The form and location of such meetings varies greatly. In one region, there are no meetings on the general issues in the sector between the municipality and the county at either the political or managerial level.
In all regions, there are collaborative structures in the three respective areas. The psychiatric sector is the most developed.
One point of criticism is that it takes time to initiate a collaboration, since the smaller municipalities, in particular, often lack relevant specialist staff. Another point of criticism is that there is a good collaborative structure in the psychiatric sector in several regions, but the county’s treatment of mentally ill persons suffering from substance abuse is not good enough. A third point is when a county makes plans centrally to locate all psychiatric services within the vicinity of its hospitals.
With regard to the quality of the collaboration, the establishment and maintenance of the network of players is an important role. The direct personal relationship is emphasised as the most important element.
The collaboration between private organisations and counties/municipalities
Private organisations enter into collaborative relationships in different ways. Some enter into actual agreements regarding the operation of institutions and programmes, while others enter into agreements on initiatives based on volunteer workers.
The perception of the collaboration between private organisations and the public sector falls within three typically idealistic points of view:
- complementary where their work is different and essential
- substitutive where they perform the same function only in another context
- problematic and therefore non-existent
The county/municipality generally seeks to collaborate with volunteer and private organisations. This collaboration is problematic and almost nonexistent in only one region. In three of the regions, the collaboration is perceived as complementary with regard to public action. The private organisations can do something which the public authorities cannot. They spend more time with the users, get them more involved and achieve a closer contact – for instance, they can provide better and more mutual care. In one of the regions, the collaboration is viewed as substitutive, where the private programmes perform a number of duties which could be performed by the public authorities. This is a region where the public administration is satisfied with the collaborative relationship with the private organisations, but feels their efforts focus too much on substitutive work rather than on what they should be good at – complementary work.
There are three themes which influence the perception of the quality of the private organisations’ initiatives. First, there is the degree of autonomy in relation to independence, where private organisations emphasise the importance of autonomy. Second, there is the degree of amateurism in relation to professionalism. In this regard, the focus in the public system is often on the fact that treatment requires professionals and cannot be carried out by volunteers. In some places, the main focus is on not exposing the users to amateurs. Third, it depends on whose interests the private organisations are looking after. For instance, it is clear that the largest organisation – the Danish Federation for Mental Health – looks after the interests of both users and their families.
Collaboration with the users
The most formalised collaboration is in the psychiatric sector. The most active organisation is the Danish Federation of Mental Health, but in several places LAP (the National Association of Psychiatric Users) and Better Psychiatry – the National Association of Relatives of Mentally Ill People are also active. None of the regions name any relevant user organisations for people suffering from homelessness and substance abuse.
Thus, only organisations for the mentally ill are represented and included in the general planning process.
One relevant and often used body of influence is the user council at institutions and housing provisions.
Perhaps the most crucial type of user influence involves the direct contact between personnel and users in the individual programme. However, this depends on the responsiveness of the staff. An analysis of the individual sectors shows that the users in the substance abuse and homeless sectors have slightly more influence on what is to happen compared to programmes for the mentally ill. Conversely, it seems as though the most difficult task is to establish action plans for the homeless.
The importance of the central government
The central authorities exert influence through legislation and government grants. The legislation prescribes certain goals and guidelines for the initiatives. This legislation has been renewed in 1998 with the Service Act and in 2002 with the Basic Rate Reform.
It should be noted that the Service Act has played an important role in the establishment of a local body for dealing with the problems of this user group. In addition, many feel that this is because the Danish Parliament, led by the Minister of Social Affairs, has been a driven, well-formulated and committed advocate on the subject.
A more significant factor for the development of the sector has been the special state allocations, which many are satisfied with. Some dissatisfaction is expressed by politicians and managers who would prefer that the municipalities could receive the funds directly rather than having to apply for them. However, most admit that many programmes would never have been started without the special allocations. They also feel that there is always a follow-up interest in making the projects which receive support permanent and it is preferable to ensure this permanent status in advance.
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