Eleven professionals took part in interviews, five men and six women, all between 40 and 60 years old and with more than 3 years of college/university education. All worked on different levels in the outpatient clinics at the DPC, five of them as leaders, while six had responsibility as coordinators. Their professional backgrounds were within psychology (8), nursing (2) and medicine (1), most of them specialists in their field.
According to the professionals, the establishment of the brief therapy unit was the answer to a growing crisis in the DPC, a crisis due to an increase in referrals but not in resources. They described that the DPC would not have tolerated this much longer, and something had to be done to relieve the pressure.
The results are presented as four themes: 1) Brief therapy provided by a celebrated unit, 2) The “forgotten” clinics, 3) Elucidating different views on treatment and 4) Influencing the criteria for prioritizing.
Brief therapy provided by a celebrated unit
The brief therapy unit was described as a most welcome innovative effort, and many portrayed the brief therapy unit as successful and celebrated. Soon after the establishment, the brief therapy unit had also become an arena for trying out further innovative means, such as online-therapy. The professionals described that leaders and professionals from hospitals across the country came to visit and to learn from their creation of the unit. They elaborated that visitors were told about the beneficial changes in the DPC, such as the structured number of treatment hours, research-based and structured treatment methods, and shorter waiting times. The professionals described no doubt that the DPC treated far more patients after the implementation of the brief therapy unit, and that young patients with less severe diagnoses seemed to profit from this treatment approach. They also told about an internal evaluation report measuring clinical outcomes at the patient level, showing that patients could achieve good results with brief therapy. The results were so good that the management wanted to expand and develop the service further.
I have noticed that the brief therapy unit is held up as a good example of success. Something excellent and good that we should be proud of. (HP2)
Professionals within the brief therapy unit described a unique “team-feeling” among the staff, and a specialization of treatment approaches, compared to the general outpatient clinics. They elaborated that the unit had gathered a team of professionals who were interested in the same treatment approach and that the environment was inspiring, motivating, and energizing. The professionals who worked in the brief therapy unit described this as positive and beneficial, appreciating the possibility to specialize together with other professionals with the same interest. They also expressed feeling safe as fellow professionals in the team and said they helped and supported each other.
It is an advantage to work in a similar manner and to have a shared professional profile. It gives us the opportunity to develop a specialist environment and be good at that specific service. (HP4)
Several of the professionals working in other parts of the organization were more critical to the establishment of the brief therapy unit. They highlighted that the new unit was in a different building, geographically separated from the rest of the DPC, and that the unit had evolved into a separate unit without contact or collaboration with the other outpatient clinics. External research funding had also made possible more professional development in the new unit, compared to the general outpatient clinics. Several voiced a lack of integration between the new unit and the rest of the outpatient services.
The “forgotten” clinics
While the brief therapy unit was described as an innovative and celebrated part of the DPC, the general outpatient clinics were described by several as “forgotten”. Professionals working here said that they had expected the implementation of the brief therapy unit to give them more room for working with the more complex patient cases. According to them, this had not happened. The work pressure had instead increased, and the establishment of the new unit had not led to the expected ease in workload. Several expressed that increasing referral volume had led to the brief therapy unit now treated the “easiest” cases, while the far more complicated and complex cases were allocated to the general outpatient clinics. The latter group demanded extra resources and time, and only a slow positive improvement could be expected. Many described that this led to fewer positive stories and experiences of success, leading to frustration among the professionals.
We don’t see the success stories anymore. The stories that held us up… that we sometimes discharged a patient as recovered… we hardly see that anymore. Now we are overloaded […] we don’t have the success stories and we report it as a personal work environment problem. [The professionals] feel that they are not competent anymore. (HP6)
Some of the professionals working in the general outpatient clinics said that the increased workload neither was anticipated nor acknowledged by the DPC’s management. In their view, the delimited treatment focus in the new unit had resulted in a more distinct focus on prioritization between demanding patients in the general outpatient services. In their view, “the rest of the organization” had not been properly involved in the innovative approaches and development of better services. They missed that the management focused on the work and increased effort in the general outpatient clinics. The professionals pointed to the wide range of tasks in the general outpatient clinics and said that it was nearly impossible to keep updated, professionally and methodically, to handle the different and complex diagnoses. Several said that they missed consideration and recognition of the various disciplinary approaches, and that they had too little time to meet the needs of different patient groups. Some described a fear of having to schedule more infrequent treatment sessions for patients and to terminate treatment too early.
I think the reason is that we cannot influence how many patients we receive […] and to manage [the case load] we “dilute” [the treatment]. This is against professional advice… and I think that professionals from different traditions experience this as a problem. Individual professional has too many patients on the list… more than they can manage. (HP7)
Elucidating different views on treatment
The establishment of the brief therapy unit also seemed to have highlighted the existence of different views on treatment within the DPC, namely on what constitutes good treatment. While some professionals highlighted short-term treatment as a success and a promising approach for the future, others voiced concerns about how focusing on short-term therapy could result in poorer treatment for patients with more complex needs. The professionals who were most positive to the short-term approach emphasized that the brief therapy unit was a positive addition to the outpatient treatment, providing targeted treatment to a large and increasing patient group. They attributed this to the DPC’s young patient population and said that targeting the youngest adults could have significant long-term benefits for the DPC. According to them, the implementation had provided a possibility for young adults to come early in contact with the mental health services, receiving targeted treatment quickly and, potentially, returning rapidly to society.
The more critical professionals said that young adults with mental health problems potentially received too limited treatment in their first meeting with psychiatry. They were concerned that all new patients struggling with anxiety and depression now received the same treatment approach, and that short-term treatment had become "the quick and only option" for a large group of young adults. Several stated that the establishment of brief therapy in the DPC was an expression of a trend towards attempting to resolve mental problems or disorders as quickly as possible.
[Brief therapy] can be at the expense of thoroughness… making you lose eye with the underlying… and if you are focused on quick improvement, it governs the way we view a person, view the patient, understand the patient… In my opinion, it could be a risk. (HP7)
According to some, the brief therapy unit had cultivated a standardized working method in “a one-sided manner”, describing this as an expression of a "quick fix". Others said that while the management tried to handle the increased volume of referral, they forgot the patients with complex needs. In their view, the short-term approach was not sufficient to provide good treatment to the general patient population, since many patients would not benefit from standardized or time limited treatment.
[ The development of time limited treatment] has an unintended effect. The development I am talking about here is that we are expected to provide good services to more people with fewer resources. It is not possible to give good therapy to all in so short time. When this is presented as the solution to a much bigger problem, I become doubtful. We use internal resources to focus more on time limited treatment, resources that could have been used for patients with more complex needs. (HP6)
Influencing the criteria for prioritizing?
Many of the professionals discussed whether the development towards more short-term approaches influenced the criteria for prioritizing in the mental health services. The focus on young adults with anxiety and depression, was described as a potential driver for lowering the threshold for treatment in the DPC. Some said that the threshold had already been lowered after the implementation of brief therapy, resulting in more referrals of patients with less severe diagnoses. Others claimed that the patient population in the DPC had changed over two decades, and that an increasing group of younger patients with moderate problems demanded a larger share of the resources. Some said that society was responsible for handling and normalizing some of the mild mental challenges the patients experienced, and that referring and providing treatment to all types of mental problems was neither sustainable nor appropriate.
We tend to “therapeuticize” needs in people. I think this is part of the explanation for the large group we shall manage. That we over-use therapy. (HP5)
The professionals also attributed a potential lowering of the threshold for treatment in the specialized services to the current priority guidelines in the mental health services. Some said that they had to balance what they perceived as conflicting guidelines: To prioritize between patients and at the same time reject fewer, describing this as an impossible task. Many emphasized that the government's guidelines, stating that youth should be prioritized, probably resulted in more young people with moderate diagnoses being offered treatment in the DPC.
One the one hand we are supposed to prioritize. On the other hand, we have a minister of health that gets a tummy ache thinking of someone who will be rejected. So, we should meet everybody and be available, but we also must prioritize. It does not add up. (HP1)
Professionals discussed the future of the DPC and how the system could handle the increasing number of patients in need of treatment. According to some, treating more patients with less severe diagnoses implied doing the work for primary care, thus affecting the treatment of patients with more complex problems who should be the most important group for the DPC. Several were concerned that the resources were used incorrectly, and that moderate mental problems should have been treated elsewhere. In their view, the general increase in mental health problems, particularly among young people, should have resulted in more responsibility for these patients within other parts of the health care system, such as the student health services and the municipal health services. Some said that a general patient admission across service levels could improve this situation. They advocated the establishment of an interdisciplinary team for improving the prioritization of patients between different levels of mental health services.
The more we establish frontline services like this, the more we undermine the expectations that the municipality ... primary care, should be managing these patient groups. (HP6)
Some stated that it was a misconception that the brief therapy unit treated only moderate problems. In their opinion, the patients were too sick to receive treatment at the primary care level and that the brief therapy approach mainly had contributed to more differentiation of the services and thus more targeted treatment in DPC.
The cases are not mild, that is a myth. When we look at the diagnoses they have […] not only anxiety and depressions. They have other types of problems as well. They have recurrent depressions; they have personality problems. I don’t know whether they are very different from the patient population in the general outpatient clinics, except for the comprehensive and complex cases where it is obvious that ten sessions are not sufficient. […] Besides that, I do not think the patient population is very different. (HP9)