1In this article, the development of community-based accommodation services for people with psychiatric disabilities, meaning people with serious and long-term consequences of mental health problems, will be discussed, based on service providers’ experiences from a Swedish sample of ten local municipalities. The term used in this article, psychiatric disabilities, can in accordance with Rudnick (2014) be viewed in different ways – as deviations from statistical norms, or inability to achieve personal goals. Established definitions, however, normally put emphasis not on the “psychiatric” part of the term, but on the long-term everyday consequences of mental ill-health. For example, the Americans with Disabilities Act (ADA, 1990) defines it as “a mental impairment that substantially limits one or more of the major life activities of an individual”. In Sweden, the term´s focus is on (dis-)abilities to participate in society and in important life areas and is explicitly connected to the biopsychosocial model presented in WHO´s classification of functioning, disability, and health (WHO, 2001).
2The deinstitutionalisation of mental health services in the western world has been accompanied, during the last few decades, by powerful policy intentions to strengthen human rights and normalise living conditions for people with psychiatric disabilities (Samele, Frew & Urquia, 2013). One essential area of concern for reform in the field is housing and the living environment for people targeted in the policies. If housing situations, to a great extent, were associated with institutionalised environments and disciplinary practices during the mental hospital era – the “post-institutional landscape” is supposed to offer housing facilities in the community characterised by freedom of choice and access to open society (Friesinger et al., 2019; Fossey, Harvey & McDermott, 2020; Högström, 2018).
3The realisation of these policy goals exposes a scattered pattern in terms of speed, direction, and content between different jurisdictions – parts of southern and eastern Europe still have a large number of institutional arrangements, while, for example, large portions of northern Europe, the UK, and the USA practice a spectrum of community-based solutions (EEGTICC, 2012; WHO, 2013). Some models of accommodation services have a clinical orientation, closely connected to specialised psychiatric services or clinical outreach teams, while other models have been developed from local social services with support mainly delivered by non-professionally qualified staff (Friesinger et al., 2019). Some arrangements consist of group accommodation with staff on-site, others of independent apartments with mobile teams delivering support. In addition, there’s considerable variation regarding, for example, physical structure, staffing levels, professional orientation, and autonomy for the residents (Tabol, Drebing & Rosenheck, 2010). This heterogeneity could illustrate an explorative and innovative approach with great sensitivity to national and local traditions, and to individual needs, but it can also be interpreted as a lack of a coherent international knowledge base (McPherson, Krotofil & Killaspy, 2018a). One consequence of the variety is the sometimes inconsistent terminology used to describe and analyse the field of supported accommodation services, which affects the way research results are reported in the literature, and the ability to compare service models (Fossey, Harvey & McDermott, 2020; McPherson, Krotofil & Killaspy, 2018b). However, some attempts have been made to develop classification systems on the field, tackling the challenge of being comprehensive and user-friendly at the same time (Siskind et al., 2013). One of the most recent initiatives come from a British research group that developed a simple taxonomy for the classification of supported accommodation, STAX-sa. This taxonomy comprises five types of services, based on four domains: staffing location, level of support, emphasis on move-on, and physical setting (McPherson, Krotofil & Killaspy, 2018b). According to experiences so far, it covers the two main types of services that have often been referred to in the literature: group homes with staff on-site offering high levels of support, and more moderate support delivered by mobile staff to people living in individual accommodations, often called housing support (McPherson, Krotofil & Killaspy, 2018b; Parker et al., 2019).
4Regardless of service types, there´s still no solid knowledge base regarding the long-term effects of mental health supported accommodation, though the field of research is expanding. One explanation is the unique features of the services, which often means a lack of clear outcome measures, and hampers the use of studies with experimental-designs – it can be seen as ethically dubious to randomise people to different forms of accommodation. However, reviews show positive outcomes for homeless people with severe mental illness who receive support according to the housing first-model. There are also indicators pointing to reduced needs of in-patient care for long-term mentally ill people receiving supported accommodation (McPherson, Krotofil & Killaspy, 2018a). To gain insights regarding the mechanism, and the challenges associated with supported accommodation, qualitative studies on individuals’ own experiences seems often to be a more fruitful source. A common opinion among this rich set of research is that community-based housing support is better than living in an hospital ward, and that it has a positive impact on the recovery process (Apostolopoulou et al., 2020; Krotofil, McPherson & Killaspy, 2018). Important components emphasised are people’s choice, control, privacy, and security. Service users seem to prefer individually tailored, and less restrictive services that are based on a supportive relationship with the staff. In addition, a common theme is the preference for transitional models of support with move-on-orientation, where emphasis is put on learning new skills and moving the individual towards greater independency (Fossey, Harvey & McDermott, 2020; Friesinger et al., 2019; Krotofil, McPherson & Killaspy, 2018; Parker et al., 2019). Negative aspects of living in community-based settings highlighted in research often correspond to the absence of the mentioned components. It can be about accommodation overregulated by staff, unsafe living environments, but foremost, about loneliness and isolation (Fossey, Harvey & McDermott, 2020; Tjörnstrand et al., 2020). As Krotofil and colleagues (2018) summarise the results from their review, research shows a complex interplay of individual, service level, and community factors in shaping the experiences of service users (Krotofil, McPherson & Killaspy, 2018).
5Aside the concrete change of physical arrangements and settings related to housing, paradigms and ideas have also been under reconsideration. The concept of personal recovery has brought great attention among policy makers and service providers in the most recent decade. Recovery is defined as a path through which people with mental health problems can regain and develop significant relationships with family, friends, and the community, and at the same time cope with the detrimental effects of stigma through empowerment (Apostolopoulou et al., 2020). This optimistic philosophy is framed by several guiding principles, like connectivity, hope, identity, meaning, and empowerment (Slade, 2009), and has sometimes, as with Markström and Lindqvist (2015), been viewed as in tension with a more paternalistic, caring approach. Referring to recent policy statements, it would be possible to describe many western countries as being in a post-deinstitutional era, meaning that they are moving beyond the first generation of community-based solutions (characterised by a paternalistic caring approach), and now putting more emphasis on recovery principles and ideals of individuals’ autonomy and independence (Markström & Lindqvist, 2015; Lindqvist & Sépulchre, 2016). Despite the increasing interest in recovery, the remaining question is of course to what extent these policies and ideas are put into practice in different mental health systems.
6Our study focuses on the features of mental health services delivery in Sweden. More specifically, we examine the characteristics of supported accommodation services for people with psychiatric disabilities, according to the experiences of the service providers, and in relation to international development. A focus is put on the service’s organisational setting, main orientation, and conceptual content. The article is based on a collective case study of ten Swedish municipalities.
7To understand the way an organisation, or a whole organisational field or sector works, we need to grasp the fundamental notions that define it, and that provide guidance on decisions and action strategies. One concept often used in organisational analysis, and which we will apply in relation to the field of mental health accommodation services, is that of institutional logics, introduced by Friedland and Alford (1991). Society is, according to this perspective, looked upon as a system, where all organisations are linked together, while at the same time they also have their own set of value systems – logics – depending on each institution’s characteristics. Tension may arise between normative and regulative elements linked to the organisation’s tasks (Cooney, 2007; Maynard-Moodey & Musheno, 2012). Dilemmas that arise from regulative requirements of human services organisations can result in tension between what can be done given formal administrative demands, and what should be done according to professional norms. According to Scott (1995), there are three types of “pillars” in all institutions that relate to organisational practice legitimacy, those being regulative, normative, and cognitive elements. Regulative elements are the legal systems, policy-schemes, and rules that constitute a binding organisational framework for professionals to comply with. Normative elements comprise workplace norms and common congruent professional behaviours and approaches within a given organisational local context. Cognitive elements, in turn, include cultural systems and values that are individually internalised beliefs, where the perception of legitimate practices is independent from both regulative and normative elements (Palthe, 2014). We will use this framework to characterise the current organisational field.
8Historically, Sweden had an extensive system of mental hospitals, which by the mid 1960s included more than 35 000 inpatient beds (Markström, Sandlund & Lindqvist, 2004). Since the 1980s, this number decreased as a consequence of new policies – today specialised mental health services only consist of about 3 000 inpatient beds (Swedish Commission for Mental Health, 2017). In 1995, a mental health care reform was launched, which transferred to local municipalities the responsibility for supporting people with psychiatric disabilities in the domains of housing and daily occupation. The initial development of housing facilities and supported accommodation services was fast – four years into the reform more than 800 group homes were established offering support for about 8 000 service users. The transfer of mental hospitals long duration stay patients to community services was carefully carried out and prevented in most cases people from ending up homeless or in prison (Markström, 2003; Markström, Sansdlund & Lindqvist, 2004). In the last two decades, the number of group homes remained stable. Instead, a growing number of more flexible and mobile units supporting people living in individual accommodations has been instituted and support today an estimated 27 000 people (National Board of Health and Welfare, 2020). Despite regular inventories, there´s still scarce information about how municipalities define major housing services rules and processes for persons with psychiatric disabilities. Also, in Sweden, the demarcation of both different service user groups and service types, lack clarity. Consequently, the field has been difficult to analyse. Some studies have, however, contributed to a higher understanding for instance of service users’ preferences, satisfaction with services, and their views on the living environment (Andersson, 2016; Brolin et al., 2015, 2016; Eklund & Brunt, 2019). One study examined the strategies among Swedish municipalities regarding the whole sector of community mental health services, and found indicators of a reorientation from a service supply designed for older ex-patients from mental hospitals, to services more adapted to younger service users, preferring independence and flexible forms of support (Markström & Lindqvist, 2015).
9Social services in Sweden are mainly regulated by the Social Service Act (SSA) (SFS, 2001: 453), whose core paragraph states that services to vulnerable and exposed groups shall guarantee a reasonable standard of living. There are specific provisions targeting people with disabilities, including housing conditions and occupation. In addition, the Disability Act (DA) (SFS, 1993: 387) regulates the right to support for people with extensive and persistent disabilities – striving to guarantee them good living conditions. In comparison with the SSA, the DA is highly regulated, demands a higher quality of services, and will in practice translate into higher costs for service providers, most often explained by higher staffing. One extensively regulated service is “accommodation with specific service,” interpreted as residential care in a group home with high or more moderate support. Both people with psychiatric disabilities and autism spectrum disorders can formally receive support from the DA, but the final decision is always based on an individual need assessment. Experiences show difficulties for people with psychiatric disabilities to receive support in accordance with the DA in general, and an inconsistent interpretation of the legislation among responsible authorities. In application of the DA, the Swedish government applies a compensation system, where national financial resources are redistributed according to the size of the disability population served by the different municipalities.
10This study is part of a larger project examining housing and living environments for people with psychiatric disabilities, including studies with different designs and researchers from different disciplines (social work and urban planning). The article is based on data from mapping conducted as a multiple case study (Yin, 2014). Existing data on the housing situation for this group in Sweden is until today mainly based on the limited information reported from municipalities to the National Board of Health and Welfare (NBHW), covering the number of people having taken decision on some kind of accommodation services. As mentioned earlier, this rather shallow information needs to be complemented with more nuanced knowledge about the service providers’ views, and the ideas and strategies characterising this field of services. Therefore, our ambition has been to make a strategic but at the same time limited sample of municipalities, to be able to collect and analyse rich data from each site, and at the same time have the possibility to compare experiences from municipalities with different sizes and geographic locations.
11The present study investigates services for people with psychiatric disabilities, characterized by mental health problems that result in negative and long-term consequences on people’s life. Service providers themselves described the community of service users in their context. They draw on this definition of the group to identify the organisation’s priorities, and who in this group of people received the support in a given local context.
12The selection was conducted based on a national classification of municipalities by types, compiled by the Swedish Association of Local Authorities and Regions (SALAR). In total, 10 municipalities were selected – covering municipalities from all parts of Sweden, of different population sizes and with a range of demographic features. The researchers established contact with each municipalities’ social service and city planning offices, respectively. A selection of key informants was made, including managers at different levels, coordinators, and other officials with a function relevant for the study. Semi-structured interviews were then conducted, based on thematic interview guidelines designed for each type of informant. In addition, several strategic documents were selected, for example housing provision programmes, service descriptions, or maps showing the geographic location of service facilities. One part of the study was also an in-depth mapping of all accommodation service units provided to the target group in each municipality, partly based on the STAX-sa taxonomy mentioned in the introduction of this article (Lilliehorn et al., 2023). The data used in the present study comes from interviews with social services. We provide in table one a description of the municipalities included in the study, the number of interviews, and the characteristics of the accommodation units.
Table 1. Description of participating municipalities and informants
13This article is primarily based on 29 interviews done with officials in charge of accommodation services for people with psychiatric disabilities. Analysis includes a description of the services provided, and their own experiences in accommodation services. In each municipality, one high level official (often the head of the social service organisation), and one official more knowledgeable of the delivery process of actual services were interviewed (often a unit or mid-level manager). In three cases, additional interviews were conducted. In municipality A, a housing provision planner and a service coordinator were interviewed in addition to the higher official and the mid-level manager. In municipality B, higher level officials in disability-, elderly-, and individual- and family-services were all interviewed, as well as two officials familiar with service delivery and three case workers being engaged in support to the target group. In total, eight people were interviewed. In municipality F, finally, one high level official and two officials familiar with service delivery were interviewed. Interview guidelines included the following themes: description of the services provided (type of services, number of units, staff, service users, etc.); reflections on the target group; routines followed for need assessment and decisions; local changes over time; methods and approaches used; strategies for recruitment and training; collaboration with mental health care, city planning and service user organisations; and reflections on the concept of social sustainable housing. Depending on the formal position of the informant, emphasis was placed on different themes in the guidelines. The interviews lasted for about 90 minutes on average and were recorded and transcribed verbatim. The data was analysed using descriptive content analysis (Hsieh & Shannon, 2005). Statements from all interviews were first sorted by identified theme, and then classified in categories and sub-categories on which authors reached consensus. In the following phase, we compiled identified categories, and a selection of illustrative quotations. The following categories were identified and used to structure the present study: a new generation of service users, a diversified organizational field, pragmatic interventions, and service development and staff qualifications. Examples of sub-categories connected to the target group-category were expectations on autonomy, diversity of diagnoses, and difficult to place.
14The results were shared with a national reference group put together for the project, including representatives from The Swedish Association of Local Authorities and Regions (SALAR), National Board of Housing, Building and Planning (NBHW), and the National Alliance for Mental Health (NSPH). The study has been approved by the National Authority of Research Ethics (Dnr: 2019-02812).
15All municipalities (except the smallest one) mentioned that existing services were designed for a “historical” group of people characterised with serious and persistent disabilities, most often caused by psychosis. This group still formed a crucial part of existing need for services, but was, according to many officials, increasingly replaced by a group of younger service users, often with neuropsychiatric conditions. A manager of accommodation services in municipality F described the ongoing changes:
Our unit for housing support still deliver services to users with experiences of being treated at a mental hospital. However, they are quite few, and very old. Some of them are transferred to elderly care. Instead, we have new groups of service users entering the system – the inflow of people with neuropsychiatric disabilities is remarkable.
16A recurrent theme in the interviews was about the difficulty to match a traditional organization based on a typology of services with users who require concomitantly multiple services. This new generation of service users are people with complex needs and a high degree of comorbidity making it difficult to link them with a unique service provider in the traditional organisation. These individuals are characterised by a diversity of conditions: psychiatric diagnoses, drug addiction, behavioural disorders, intellectual disabilities, but it also could be about different forms of general social vulnerability.
I feel that our service users have many different kinds of challenges, yes. Comorbidity, that you have ADHD or ADD, but foremost ADHD, Asperger, autism, connected to drug use or anxiety, depression, yes. Or all three. Or maybe an intellectual disability. (Middle manager, municipality A)
It can be serious depression, and often, I think, it has become more common with service users with a large number of diagnoses. It can be both ADHD and Asperger and maybe behavioural difficulties. This was not the case twenty years ago, things have changed a lot. (Manager of social services, municipality G)
17Despite the complex needs described by our informants, one of the sub-categories was about expectations about autonomy of service users. Younger service users especially were portraited as eager to live independently, expectations that were perceived as challenging by services with a tradition of caring for the “historical” group.
18The observed heterogeneity in the target group has influenced some municipalities to abandon a highly specialised organisation model for a “catch all” organisation, providing a broader set of disability service. In practice, narrow criteria for approval of benefits (“have a psychosis diagnosis”) were replaced by more general need-based criteria (“have a need for night supervision”). In the smallest municipality, where housing support was delivered by one staff member only, the approach followed was much more pragmatic, making services available to all kinds of mental health diagnoses or difficulties.
19Six municipalities stated that they only provide individual support through the legal framework SSA (“reasonable standard”), which included accommodation services for both individuals and groups. Some informants mentioned that the other framework, the DA, (“good standard”) had never been considered as an option for the target group. However, most municipalities adopted a variety of strategies ranging from examples of single, exceptional decisions according to the DA, to the largest municipality (A) where all decisions regarding group accommodation services were made according to DA. One representative of the social services in (A) reflects on their approach:
Why the DA? It´s mainly because of the national cost equalisation. There are more subsidies to get if you use the DA. Many municipalities are surprised when they hear about this. It´s also about traditions – for better or worse our organisation has for a long time been careful to always assess people’s needs according to the most favourable regulation, seen from the perspective of the client. And in this case, the DA is more favourable than the SSA.
20Despite the above quote, people with psychiatric disabilities were generally viewed as not qualifying for support on basis of the DA, illustrating the ambiguous status of the group as part of the disability service sector. Several respondents also described people with psychiatric disabilities as generally marginalised in the local welfare system.
Regarding accommodation services, most of the focus is without question put on elderly care. It´s where social services have their interests, and their driving force. There is a strong group of stakeholders arguing for generous services to the elderly. Another group is people with intellectual disabilities, whose parents also are strong stakeholders, fighting for their loved ones and their rights to, for example, group homes. When it comes to people with drug addiction or mental illness, no one is fighting for them. I would say that they are placed last in line. (Manager for disability services, municipality C)
21We classified these experiences under a sub-category called low-status group. They reflect the views that psychiatric disabilities is questionably a “real” disability, as shown by the low number of DA-decisions, and quotes about how the large amount of low qualified staff could threaten the benefits of service users with psychiatric disabilities.
22The overall services organisation varied between municipalities. Officially, the target group is often described as having psychiatric or mental disabilities. In seven out of ten municipalities, the accommodation units were integrated in the disability services. In five of them, the accommodation services were part of a sub-unit, specialised for people with psychiatric or mental disabilities, and named “social psychiatry.” In two cases, these units were composed of a very small number of staff and service users, but could survive, according to the interviews, because of a strong local tradition of mental health services, consisting of highly engaged stakeholders. In one of these municipalities, the closure of a nearby mental hospital a couple of decades ago, led to the recruitment of both managers and staff with extensive experiences in the mental health services, affecting the priorities made in the local services today.
23In the two municipalities where mental health services were not part of disability services, they were incorporated in individual and family care, which often also includes income support, addiction treatment, or interventions to support the different needs of families. In the remaining small municipality, finally, a special unit directly placed under the director of the office for social services was formed to support the group.
24There was considerable variation in terms of available support in our mapping, both within, and between municipalities. We divided services into three rough categories: a) housing support, delivered by a mobile team (during the day and sometimes even at night ) to service users living in individual accommodations, b) group homes, which provide collective residential services, with staff available 24/7, and c) other types of services, which include services that didn´t fit in the previous two categories, for example services for people living in their own flat but physically arranged in a “semi-collective” way, for example with a small common area such as a courtyard or in the same staircases, and services with special arrangements with a small group of staff supporting one single service user with extensive and complex needs. The use of the STAX-sa taxonomy in relation to our data is presented elsewhere (Lilliehorn et al., 2023). We did also examine if the municipalities used external placements or particularly social contracts as a strategy to meet the needs of the target group. The results from this part of the mapping are summarized in table 2.
Table 2. Distribution of service types among included municipalities
25As shown in the table, mobile housing support is a corner stone in municipalities services. The largest teams in our material (E and F), consisted of 18 and 20 staff members respectively who delivered support to about 250 service users each. The smallest unit (B) had only one staff member, responsible for about 10 users. In the other municipalities, the case load was low, often with a mean staff/client ratio of 1/7. The support offered was described as “help for self-help” and directed to increase the service user’s autonomy. In the case of municipality A, this was manifested in an explicit move-on ambition of increased independence for all, including for service users already living in individual accommodations. Emphasis was made on service users’ own choice, and the strive for independence and empowerment were expressed in nearly all municipalities.
It´s a support, it´s not a compensating but a supporting service. A help for self-help were you, beside accomplishing things together with the person, it also deals with underlying challenges in their everyday life. How do you use your time? Why do you experience a lack of energy? How can we build up your strengths? The job is extremely complex and looks completely different depending on who is the client. (Staff at mobile team)
26Housing support should be flexible and aim towards a high functioning in everyday situation, as illustrated by personnel from municipality G:
For example, to buy food, that you don’t manage to go out and buy food. One service user used to visit the store as soon it opened, very early in the morning, because it was the only time when she could avoid a stressful environment. Then she could start doing the shopping together with the staff, during daytime. In that way it´s possible to, like a bit inspired by cognitive behavioural therapy, take step by step towards a situation where she can manage to buy food during daytime without support.
27Overall, outreach housing support was viewed as the arrangement that best corresponded to the municipalities’ underlying ideas about services for the target group. As expressed by the director of social services in municipality I, the approach shifted from a “taking-care-of” philosophy, to a focus on the service users’ strengths and capacities, under a new manager that had brought “new thoughts with him” and influenced the organisation to adopt this new approach.
28The views on collective accommodation services, as group homes, differed between the directors of social services who were interviewed. Municipality A described their extensive services as part of a long tradition of generous local mental health support, where recovery ideas have been recently established as one pillar. Their great volume of group home services has led to the development of a “model house” with space for six service users, produced by the real estate administration following guidelines from the social services.
29The sub-category disinvestment highlighted the process of shifting from one to another type of service. Half of the interviews described group homes, originally designed for older people with permanent psychiatric disabilities, as being running as long as the group exists. Some of these group homes include a large number of service users. Those were formally criticised by the authorities because of poor staffing (characterised by low qualification and too few of them), low quality service delivery, and with high density of service users in one group home. But most group homes included about five to eight residents. In municipalities F and J, some services included over 10 residents. In J, 36 service users composed one large group home.
People with psychiatric disabilities who apply for accommodation services today are often between 20 and 30 years of age, and they are mainly not applying for a place in a group home. They will have housing support, or maybe support in a semi-collective arrangement. So, we will not build any new group homes, there’s no need for it right now. (Manager for social services, municipality H)
30An additional reason behind the low number of group homes was the strategy of some municipalities to purchase spots in privately run services. This was particularly the case in metropolitan areas (E and F) and was motivated by both a lack of available dwellings and the prices of land.
31Beside housing support and group homes, municipalities looked for alternative solutions such as pragmatic arrangements for individuals with specific needs. Municipality A established a small staff unit available close to individuals with very complex needs living away from urban areas. Municipality B arranged for staff from a group home to deliver support to clients living in apartments in the same neighbourhood. Clients were invited to take part in the group homes’ social spaces and share meals. An additional strategy common to most municipalities to promote stable and long-term living arrangements was to conclude a social contract. After an initial period where a client is hosted in an apartment alone, if things turn out satisfactorily, the initial social contract is transformed into a first-hand contract. Some municipalities used training apartments where individuals can stay for a shorter period of time before moving to an accommodation with a customised level of support.
32Community mental health services have been viewed as a field with a low level of professionalisation compared to specialised psychiatric services. We found a variety of qualifications and educational backgrounds. However, assistant nurses are the most common first-line personnel, sometimes without a specialisation, but mostly with mental health expertise. All municipalities had assistant nurses employed in their accommodation services. They all had staff with high academic credentials, even the smallest municipality B, where the one staff responsible for housing support was a licensed social worker. Representatives of the larger municipalities argued that recruitment of employees with good qualification was part of a strategy to strengthen client-centred and community-oriented approaches in accommodation services.
33In terms of continuing training and education, we identified three most influential models. Six municipalities offered regular training to staff members following the “social and independent living skills programme” model. This model, a psycho-pedagogical intervention, was perceived as relevant and as conveying useful tools for personnel at different levels. Some informants and available documents described this training as part of a broader development effort towards strengthening clients’ recovery and empowerment. Many municipalities organised training in so-called “low arousal approach,” designed for services for people with neuropsychiatric disabilities or people with behaviours of concern that lack the ability to display a regulating affect. This model focuses on creating pedagogical environments characterised by safety and positive expectations. Respondents found this model useful for both staff and a broad range of service users. The third model, “motivational interviewing,” offered on a regular basis to staff in five of the municipalities was also positively perceived. This client centred counselling method was originally developed for people with drinking problems but used here as the mainstream approach in all accommodation services. These three models were part of the generic knowledge sub-category. They are part of a common approach to look for all-encompassing educational programs providing general skills that can be useful for the whole organisation, and to a variety of target groups. Besides the models above, a range of themes was covered through local training efforts. A few municipalities also sent personnel to take part in university courses about case management-methodology.
34The smallest municipalities stated that the resources for training were scarce, and that they needed to find pragmatic arrangements. Strategies used were to invite guest-lecturers or to let personnel use educational material available on the internet. This approach can be illustrated by the manager for accommodation services in municipality C:
Instead of sending people to training and stuff, when the money disappears quickly, we bought a screen and a projector, and put it all together. So now we can save money, and at the same time watch a lot of very good lectures accessible on different websites, from SALAR and other authorities. We tailor it ourselves. All in all, this means that we have more of continuing training today, compared to when we bought expensive courses.
35This study aimed at examining some of the features of accommodation services for people with psychiatric disabilities in Sweden, using available documentation and interviews with service providers’ representatives. We adopted a descriptive approach to present organisational characteristics, range of services, and current lines of development work. One shortcoming is the limited number of municipalities that we have data from, which limits generalisability. Furthermore, we collected information from managers and staff occupying strategic positions, meaning that both service users and first-line staff perspectives are missing. We have no information about the experiences and challenges regarding service users’ interactions with the community. This absence of other stakeholders’ perspective makes a more nuanced view of the field more difficult. People that see themselves as representatives of an organisation or unit may tend to emphasize strengths over shortcomings in their discourse. Such tendencies have been observed in some of the interviews. In others, however, we were struck by the openness and self-criticism that characterised some of the answers. For instance, informants mentioned issues of high staff turnover, poor collaboration with healthcare services, lack of knowledge and limited self-confidence to engage in a more strategic approach to housing provision. To address this limitation, we also reviewed the international and Swedish literature to link our observations to the relevant theoretical context. In addition, we carefully selected a wide spectrum of municipalities with the ambition to get access to rich and nuanced data. Another limitation is the cross-sectional design of the study that captures a given moment but hardly changes over time besides informants’ retrospective statements. Overall, we believe our findings provide a good picture of conditions and trends in Swedish accommodation services.
36We found that a process of post-deinstitutionalisation seems unravelling. Services have developed in multiple directions, and service providers have been questioning services’ arrangements established during the first wave of deinstitutionalisation, which took place about three decades ago. In some cases, managers explicitly expressed an ambition to abandon certain arrangements, especially large-scale group homes, in favour of outreach housing support. In accordance with Parker (et al., 2019), signs of a transitional model of support are visible, where new perspectives and concepts are introduced. However, the picture is not uniform – the design of services can locally be based on a pragmatic and problem-solving approach that is insensitive to trends. The variation between municipalities seems, as shown in other Swedish studies, substantial (Markström & Lindqvist, 2015).
37When applying the concept of institutional logics (Scott, 1995) to the field of mental health accommodation services, it is of interest to note that changes described here have been implemented during a period without any substantial changes in relevant legislation. This shows that regulation has not changed and that freedom of action is still the rule for municipalities. Municipalities can choose how to design the overall organisation of accommodation services, or how to put into practice available legislation like the DA, launched in 1994, and the SSA, launched in 1982 but revisited in 2001(cf. Eliasson & Markström, 2020). Considerations about which legal space to use seems to be based on a mix between ideological arguments and local practices taking the available budget into account.
38Experiences among the informants seem, however, to be strongly influenced by the way the target group is locally described and categorised. The historical group often carried experiences of long episodes at mental hospitals and is characterised by extensive needs. The design of accommodation services responded to these needs through a caring approach characterised by 24/7 staffing and sheltered settings (Markström & Lindqvist, 2015; Rosenberg, 2009). Some of these solutions for older people with severe mental illness remain in place. But attention turns currently towards “new long stay clients,” with different kinds of preferences and needs. Again, this results into a conflict between a traditional organisation of service delivery specialisation and service users with complex and multiple needs (cf. Rosenberg, 2009). Needs and preferences were locally identified based on each municipality’s understanding. But part of the adopted approach can, however, be traced back to the national mental health policy, which in recent years has emphasised a broadened perspective on mental ill-health, highlighting prevention and early intervention, as well as supporting young people without manifest mental illness (Fjellfeldt, 2021). In that respect, one can argue that existing policies do have some influence on municipalities’ interventions (Scott, 1995).
39The mixture of diagnoses and needs described here can open new perspectives for services where normative, and sometimes cognitive elements, from different traditions and sectors in social services and community mental health, meet. These perspectives can be influenced by delivery of services for people with psychosis, intellectual disabilities, neuropsychiatric conditions, addiction problems, or the so-called NEET-group (Not in Employment, Education or Training). This new generation of service users confront existing organisations that face several challenges, such as expertise and training of professionals, the overall design of accommodation services, and the form that collaboration with other actors in the local welfare system takes (cf. Rosenberg, 2009). In the best-case scenario, the different normative and cognitive elements can be integrated and constitute the foundation for a new institutional approach. In the worse-case scenario, the sector can be stuck in a transitional phase, where different logics compete (cf. Maynard-Moodey & Musheno, 2012). We showed that the situation substantially varies from one municipality to the next. The most common types are small urban areas and rural municipalities with a small population, which is reflected in our selection of cases. In these municipalities, both public resources and the number of inhabitants in needs of mental health support and accommodation services are limited, which makes delivery of targeted services difficult. Instead, they offer general support to a broad group of service users with different needs. Consequently, institutional logics related to community support and mental health accommodation services differ from large and high-level resourced municipalities.
40We observed a great variety of available support. The historical group influences all the supply of group homes. But the core accommodation services’ approach seems to be housing support delivered by mobile staff and led by managers highly influenced by principles of personal recovery. Most interesting is a third category of services (“other”), consisting of a mix of arrangements, sometimes best described as hybrids or sub-types of the former types of services. This third category can be seen as the result of short-term or pragmatic local solutions, but sometimes reflects a more deliberated service development approach that emphasizes flexible and individually tailored solutions (cf. Maynard-Moodey & Musheno, 2012). One might have a sense of messiness, but we would argue that the variety of approaches illustrates a response to increasingly multifaceted needs, combined with a philosophical reorientation where new normative elements have been introduced – partly influenced by a policy pressure towards client centredness and community-oriented support. We showed elsewhere that social service officials looking for locations for new supported accommodation units, must balance between a pragmatic approach aimed at solving urgent problems, and a clearly articulated rationale of social inclusion that drives their vision (Fjellfeldt et al., 2021). One common attribute among assistant nurses and other staff is a mix of specific skills and a good educational background. Another characteristic of the field is the low level of caseloads which allow staff to apply a transitional model of support and recovery. How ideas about recovery will be balanced against requirements of efficiency among service providers will be important to address in future research. Can the “recovery movement” leads to unrealistic expectations about service users’ ability to live independently? And is there a risk that the strive for increased autonomy will be used as an argument for service cuts? These questions are also of importance for policy makers and service providers to address, so that new normative elements or trends don’t lead to simplified solutions and to a range of services that mismatch the needs of the target group.
41To summarize, our findings suggest that the Swedish field of accommodation services for people with psychiatric disabilities is changing. This means that target groups, organisational structure, service supply, and even the professionals’ work schemes, are under pressure to shift direction. We hardly identified a shared institutional logic among municipalities part of the present study, but we argued here that a new normative framework associated to the concept of personal recovery with an emphasis put on increased service users’ autonomy and empowerment are gaining momentum among service providers. Still, tensions remain between this new framework and elements of a pragmatic approach applied formerly in the municipalities studied. These tensions characterise a field in organisational transition.
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