Services’ Ruptures and Negotiations at the Front Doors of the Mental Health System

Services’ Ruptures and Negotiations at the Front Doors of the Mental Health System

In the mental health systems’ front line, numerous state agents (also called “street-level bureaucrats” – Lipksy, 1980) with different status (e.g. doctors, nurses, social workers) implement public policies and interact with persons in distress. At these system’s front doors, some persons in distress who may arrive with members of their informal support network (e.g. family members, friends) can benefit from a comprehensive medical management while others are quickly sent back in the community. In certain cases, persons are sent back without services that meet their needs.

In a context of deinstitutionalization and austerity, many persons in distress live in the community but how can we understand such “services’ ruptures” (i.e. situations where persons in distress are left to themselves or to an informal support network without neither privileged system’s access nor adequate resources)?

I argue that we can study services’ ruptures by focusing on the interactions and negotiations (Strauss, 1978, Allain, 2004) between the persons in distress and the system at system’s front doors. By doing this, organizational and institutional contexts of the street-level bureaucrats’ work have to be analyzed as much as the contexts of living and the informal support networks of the persons in distress.

I propose to combine relational ethnography (Desmond, 2014) and trajectory-networks perspective (White, 2016) to study the conditions of (in)accessibility of the mental health system and situations of services’ ruptures.

Relational ethnography’s starting points will be two front doors of Montreal’s mental health system : a Psychiatric Emergency Service and a “Crisis Center”. Semi-structured interviews (N=50) will be conducted with: persons in distress; members of informal support networks; and members of care teams. With these interviews, trajectory-networks of help-seeking steps in time and space will be reconstructed for a dozen of cases.