Disputas: Eva Brekke

Stipendiat Eva Brekke har til forsvar for graden philosophia doctor (ph.d.) i ph.d.-programmet Person Centred Healthcare innlevert avhandling med tittelen: Recovery in co-occurring mental health and substance use disorders: A qualitative study of first-person and staff experiences.

Brekke har i sitt doktorgradsarbeid undersøkt hvordan mennesker med samtidige rusproblemer og psykiske vansker (rop-lidelse) opplever bedring (recovery), og hva det vil si for tjenestene å arbeide recovery-orientert med denne gruppa.

Gjennom kvalitative intervjuer med personer med rop-lidelse har hun beskrevet og utforsket hvordan det oppleves å få det bedre, og hva som kan bidra til å få det bedre.

Gjennom fokusgruppeintervjuer med ansatte i et rus- og psykisk helseteam i en mellomstor norsk kommune har hun beskrevet og utforsket dilemmaer ved recovery-orientert praksis for å hjelpe mennesker med rop-lidelse.

En rådgivningsgruppe bestående av medlemmer med egen erfaring med rop-lidelse, erfaring som pårørende og som fagpersoner har bidratt gjennom hele prosjektet.

Deltagerne i denne studien opplevde bedring som mer enn symptomlette. Å bli godtatt og bidra i lokalsamfunnet, å bli glad i seg selv, å mestre livet og å tre fram som den man er ble beskrevet som dimensjoner av bedring. Utrygg boligsituasjon og mangel på løsninger på økonomiske vansker ble beskrevet som å være til hinder for å få det bedre.

Tillit ble beskrevet som grunnleggende for at profesjonelle hjelpere skal kunne bidra til bedring. Tillit kan etableres ved at profesjonelle hjelpere formidler håp og virkelig bryr seg, er der over tid, er ærlige og direkte, og viser mot og handlekraft.

Ansatte i et kommunalt rus- og psykisk helseteam beskrev tre dilemmaer ved recovery-orientert praksis: å balansere mestring og hjelpeløshet, å balansere styrende intervensjoner og en ikke-dømmende holdning, og å balansere et mål om totalavhold og aksept av rusmiddelbruk.   

Resultatene peker mot at tjenester til personer med rop-lidelse bør være fleksible og langvarige. Man bør kunne adressere levekår og ensomhet, og øke mulighetene for å delta i lokalsamfunnet. Tjenestene bør kunne behandle rusmiddelproblemer på kompetente og individuelt tilpassede måter.  

Det trengs mer forskning på hvordan kunnskap fra recovery-forskning kan overføres til praksis. Vi trenger mer kunnskap om bedringsprosesser utenfor kliniske settinger, for eksempel om relasjoner til familie og venner og deltagelse i lokalsamfunnet.

Abstract in English:

People with co-occurring mental health and substance use disorders (COD) face challenges related to living conditions, community participation, and a lack of tailored and integrated health and social services. Recovery and person-centred approaches allow for an understanding of COD that is grounded in each individual person and his or her context, where lived experience is seen as a valued source of knowledge. There is a need for knowledge of how recovery and professional help are experienced by people with COD in different contexts. While recovery-oriented practice is recommended through national guidelines, there is little knowledge of how such practice works at the service delivery level. Knowledge is also needed on how practitioners experience recovery-oriented practice to support people with COD.

This thesis has sought to contribute to the scientific knowledge on recovery and recovery-oriented practice in COD, with a particular focus on community services, by describing and exploring the lived experiences of people with COD and practitioners who work to support recovery in this group. An overarching purpose of the project was to make these lived experiences visible to decision makers in the field. The first aim was to explore and describe experiences of recovery among people with COD. The second aim was to explore and describe behaviour and attributes of professional helpers that support recovery, as experienced by people with COD. The third aim was to explore and describe practitioners’ experiences with dilemmas in recovery-oriented practice to support people with COD.

This project is influenced by phenomenological and collaborative methodology and consists of two qualitative studies. Study 1 consisted of eight individual, in-depth, interviews with people with COD, which were analysed with systematic text condensation. Study 2 consisted of three focus group interviews with practitioners in a municipal mental health and addictions team that was committed to developing recovery-oriented practice. The interviews in Study 2 were analysed using thematic analysis. Both studies were conducted in the same local authority area in Norway. An advisory group with people from the community with lived experience of COD, experience as family members, and professional experience has been involved in the project throughout.

Results from this project support findings from other qualitative studies which indicate that control over symptoms may be a pathway to, but not the essence of, recovery. Systematic investigation of first-person experiences in this project has painted a broader picture of recovery in COD, which includes community participation, living conditions, and existential phenomena. Community participation, particularly feeling useful, may be a central facilitator in recovery. Adverse living conditions and loneliness may be important barriers to recovery in COD. There were individual differences in how participants related to substance use, but control over substance use seemed necessary in the process of coming to love oneself and emerging as a person.

Professional helpers may play a central role in the recovery process once a trusting relationship has been established. Professional helpers’ ability to understand and act on people’s everyday struggles, and to address substance use in a competent and straightforward way, appear as specific valued attributes in professional helpers by people with COD.

Practitioners described dilemmas in recovery-oriented practice to support people with co-occurring disorders; these involved how to relate to substance use in a recovery-oriented way, how to give enough help and still facilitate empowerment, and how to relate to people’s own life goals with neither moralism nor indifference. People with COD were described as expecting too little from services and tolerating unacceptable living conditions, which elicited directiveness from practitioners.

This thesis concludes that a better life is possible for people with COD. While perceptions of a good life are similar to, and equally diverse as, perceptions in the general population, the degree of adverse living conditions and the amount of barriers in solving them seem particular to this group of citizens. In order for professional helpers to support recovery for people with COD, a trusting relationship is fundamental. Practitioners may experience dilemmas in recovery-oriented practice to support people with COD. Different traditions of understanding substance use may lead to different understandings of what it means to address substance use in a recovery-oriented way. Results from this thesis suggest that services to people with COD need to be flexible, integrated and allow for continuity. Professional helpers and services should be able to address living conditions and loneliness, and increase opportunities for genuine community participation for people with COD. Services should be able to address substance use in competent and individualised ways.