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Structural Disavowal and Individual Inundation – Dilemmas of Mental Health Work"


Catharina Bjørkquist

Østfold University College, NO
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Professional work in the welfare state is met with expectations of loyalty to management, budgetary discipline as well as performance in accordance with professional quality standards and ethics. Disparity between resources and service users’ needs is a continuous challenge.  Organisation models and financial steering systems tend to decentralize responsibilities for balancing these expectations to local service units and individual service providers at floor level, implicating individualisation and fragmentation in ways to cope with these contradictory expectations. 

This project explores how to provide integrated services for patients with dual diagnosis in their local settings. The organization of the service system for these patients is in most western countries – characterised by disintegration at several dimensions. In Norway, services are provided in a complex web of vertical (between state run specialized services and local services) and horizontally (between the historical divide between services for mental health disorders and addiction problems. The project aims at identifying the mechanisms behind responses by professionals and work organisations to these challenges when dealing with individual patients.  

Methods and theoretical approaches:

The study reports from research in three local authorities in Norway and in specialised mental health services, by interviews, documents and attending meetings. The analyses are based upon theories on working life in the welfare state and profession theories.


The findings display two – seemingly contradictory – responses to the way claims of action when encountering these dilemmas when services are provided. We name these (structural) disavowals of responsibility and (individual) inundation of responsibility. (Structural) disavowals of responsibility refer, according to local services, to specialist services when these refuse to receive, or when they discharge, patients still seriously ill.  Individual inundation of responsibility happens when individual service providers tend to take on a personal responsibility for services to patients and do more than is stated in their job description, e.g. breaking time schedules, providing services at their free time, spending private money, etc.


Disavowal of responsibility refers to rejection of serving the patient. This implicates rejecting services by e.g. arguments that there is a disparity between the patients’ problems and the competence the professionals hold. This happens by the mechanism referred to in the literature as “negative coordination”. Being inundated with responsibility refers to individual professional providers who define the patients’ needs to be higher and more complex than standardised orders. Here, the mechanism referred to in the literature is as representation of the professional/individual “conscience of the welfare state”, which contributes to an intensified and borderless professional working life.


These responses are not necessarily contradictory in practical work settings.  We find a complex web of the two types, embedded in a number of strategies in daily work decisions.

There are certain limitations to the generalizability of this study given it is designed as a case study.

There is a need for further research on to which extent, and how, these mechanisms work on a broader scale, both nationally and internationally.

How to Cite: Bjørkquist C. Structural Disavowal and Individual Inundation – Dilemmas of Mental Health Work\". International Journal of Integrated Care. 2021;21(S1):269. DOI:
Published on 01 Sep 2021.


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