Abstract
Introduction: Debates about coercive practices have challenged a traditional biomedical hegemony in mental health care. The perspectives of service user organizations have gained considerable ground, such as in the development of the Convention on the Rights of Persons with Disabilities. Such changes are often contested, and might in practice be a result of (implicit) negotiation between stakeholders with different discursive positions. To improve understanding of such processes, and how discursive positions may manifest and interact, we analyzed texts published over a 10 year period related to the introduction of medication-free inpatient services in Norway.Methods: We conducted qualitative analyses of 36 policy documents related to the introduction of medication-free services and 75 opinion pieces from a subsequent debate. We examined discursive practices in these texts as expressions of what is perceived as legitimate knowledge upon which to base mental health care from the standpoints of government, user organizations and representatives of the psychiatric profession. We paid particular attention to how standpoints were framed in different discourse surrounding mental health care, and how these interacted and changed during the study period (2008–2018).Results: The analysis shows how elements from the discourse promoted by service user organizations—most notably the legitimacy of personal experiences as a legitimate source of knowledge—entered the mainstream by being incorporated into public policy. Strong reactions to this shift, firmly based in biomedical discourse, endorsed evidence-based medicine as the authoritative source of knowledge to ensure quality care, although accepting patient involvement. Involuntary medication, and how best to help those with non-response to antipsychotic medication represented a point at which discursive positions seemed irreconcilable.Conclusion: The relative authorities of different sources of knowledge remain an area of contention, and especially in determining how best to help patients who do not benefit from antipsychotics. Future non-inferiority trials of medication-free services may go some way to break this discursive deadlock.
Highlights
Debates about coercive practices have challenged a traditional biomedical hegemony in mental health care
Placing medicationfree inpatient services (MFS) on the Policy Agenda (2008–2010) The first mention we could find of MFS was in a presentation given by the user organization We Shall Overcome to a consultative parliamentary hearing in 2008, where it was presented as a measure to reduce coercion in acute care
The document criticized the discriminatory nature of mental health legislation on the basis that “a separate legislation for mental health care reinforces the attitude that those with severe mental disorders are a group of people so different that the Patient Rights Act does not apply to them.”
Summary
Debates about coercive practices have challenged a traditional biomedical hegemony in mental health care. The perspectives of service user organizations have gained considerable ground, such as in the development of the Convention on the Rights of Persons with Disabilities Such changes are often contested, and might in practice be a result of (implicit) negotiation between stakeholders with different discursive positions. The last 60 years have seen continuous efforts from user organizations and their academic, clinical, legal or political allies to challenge the traditional hegemony in psychiatric services through political or legal processes [6]. Patient autonomy was a decisive factor when involuntary medication was (temporarily) considered unlawful by the German Federal Supreme Court in 2011; this too happened against the opinion expressed by professional associations [13]
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