Ad ances in Dual Diagnosis
Engagemen in help-seeking o dual diagnosed mo he s a a low- h eshold se ice: g asping li e h ough
co-c ea ed oppo uni ies
Minna A. So sa, I ma Kiikkala, Päi i Ås ed -Ku ki,
A icle in o ma ion:
To ci e his documen :
Minna A. So sa, I ma Kiikkala, Päi i Ås ed -Ku ki, (2018) "Engagemen in help-seeking o dual diagnosed mo he s a a low-
h eshold se ice: g asping li e h ough co-c ea ed oppo uni ies", Ad ances in Dual Diagnosis, Vol. 11 Issue: 2, pp.88-100,
h ps://doi.o g/10.1108/ADD-11-2017-0025
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Engagemen in help-seeking o dual
diagnosed mo he s a a low- h eshold
se ice: g asping li e h ough
co-c ea ed oppo uni ies
Minna A. So sa, I ma Kiikkala and Päi i Ås ed -Ku ki
Abs ac
Pu pose –Mo he s wi h a dual diagnosis (men al ill heal h and subs ance use) ha e delays in accessing
se ices, o hei ca e may be in e up ed p io o he apeu ic ela ionships being o med. The pu pose o his
pape is o explo e and desc ibe how engagemen me ges in he con ex o mo he s wi h a dual diagnosis.
Design/me hodology/app oach –This is a quali a i e, ocused e hnog aphic s udy a a low- h eshold
se ice o subs ance abusing amilies. The da a con ain in e iews, obse a ions, ield no es, and e lec ions.
The analysis ollowed se e al sys ema ic s eps.
Findings –Engagemen is he co-c ea ion o possibili ies be ween wo kplace s a and he clien in di e en
in e aces. I is no a single ac , emo ion, o e bal communica ion, bu a complex in e wined sys em o
e en s ha can awaken o enable he clien o ge a g asp on li e. The sensi i i y o he wo ke is one ool o
engaging he clien in mani old ways in di e en in e aces: e en he smalles e en s wi h connec ion a e
iewed as aluable. Engagemen in ol es he in en ional clien in he p ocess o in e ac ion: he clien needs
o pa icipa e and become an ac ing and sensing pa o he change, which occu s on an expe ien ial le el.
The p ocess is desc ibed wi h he me apho o a seed.
O iginali y/ alue –Engagemen as inne in ol emen challenges he cu en wo king me hods, and equi es
sensi i i y, because he mo he s wi h a dual diagnosis may no ha e e balisable goals when a i ing o
he se ices.
Keywo ds Engagemen , E hnog aphy, Help-seeking, Dual diagnosis, Mo he s/mo he ing
Pape ype Resea ch pape
Mo he s wi h a dual diagnosis (men al ill heal h and subs ance use) and ulne able backg ounds
o abuse and expe ienced iolence may ha e delays in accessing se ices (Blegen e al., 2010;
Tsan e ski e al., 2015). As hei li e p oblems may be oo ed ac oss gene a ions (Wilson e al.,
2013), he mo he s may eel di e en , ejec ed, lonely, and expe ience exclusion om e e yday
ac i i ies such as ela ionships and employmen (Cho l on and Smi h, 2016). The ea o
impe ec mo he hood and s igma may lead mo he s o expe ience ailu e, shame, and guil
(Blegen e al., 2010) and powe lessness (So sa and Ås ed -Ku ki, 2013). The dually diagnosed
may be di icul o engage in he se ices because hey may lack hope and appea eluc an
(Coombes and W a en, 2007).
In gene al, men al ill heal h and subs ance use can c ea e delayed help-seeking and may esul
in nega i e ou comes wi h mo e symp oms, poo e unc ioning, and less sa is ac o y quali y o
li e (Clemen e al., 2012; McKee, 2017; Nu e al., 2017). Pe sons wi h a dual diagnosis may
no know whe e o look o help, since he se ices may seem bu eauc a ic o he sys em
complex, and hey may ha e di icul ies in engaging wi h he se ices (Coombes and W a en,
2007; Mo a-Ochoa e al.,2017;Nesse al., 2014; S aige e al., 2011; Tsan e ski e al., 2015).
People, who do no seek help in ques ions ela ed o dual diagnosis, do so because o
economic cons ain s, incon enien opening hou s, and una ailabili y o help (McKee, 2017;
Recei ed 23 No embe 2017
Re ised 14 Janua y 2018
22 Feb ua y 2018
Accep ed 5 Ma ch 2018
© Minna A. So sa, I ma Kiikkala,
and Päi i Ås ed -Ku ki. Published by
Eme ald Publishing Limi ed. This
a icle is published unde he
C ea i e Commons A ibu ion
(CC BY 4.0) licence. Anyone may
ep oduce, dis ibu e, ansla e and
c ea e de i a i e wo ks o his a icle
( o bo h comme cial & non-
comme cial pu poses), subjec o
ull a ibu ion o he o iginal
publica ion and au ho s. The ull
e ms o his licence may be seen a
h p://c ea i ecommons.o g/
licences/by/4.0/legalcode
Finnish Doc o al Educa ion
Ne wo k in Nu sing Science
(Academy o Finland), Tyyne
Ylönen und a Finnish Nu ses
Associa ion.
Minna A. So sa is an
In e na ional co-o dina o a he
Depa men o Child Psychia y,
Pi kanmaa Hospi al Dis ic ,
Tampe e, Finland; and is a he
Facul y o Social Sciences,
Uni e si y o Tampe e,
Tampe e, Finland.
I ma Kiikkala is based a he
Uni e si y o Eas e n Finland,
Kuopio, Finland.
Päi i Ås ed -Ku ki is based a
he Facul y o Social Sciences,
Nu sing Science, Uni e si y o
Tampe e, Tampe e, Finland.
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Mo a-Ochoa e al., 2017; Nidecke , e al., 2009). Clien s may wan o a oid being labelled
men ally ill and addic (Mo a-Ochoa e al., 2017), and hus mo he s may no seek help (Blegen
e al., 2010; So sa and Ås ed -Ku ki, 2013). Women may a oid se ices o p ac ical easons
due o lacking childca e o on emo ional basis, as a ea o hei child en being aken in o
cus ody (Blegen e al., 2010; Tsan e ski e al., 2015). Howe e , a endance in se ices has been
ecognised as one o he mos impo an p edic o s o posi i e ou comes in addic ion ea men
(Schul e e al., 2010).
Indi idual s a membe s may no eel com o able o connec wi h clien s who a e demanding,
non-collabo a i e, o unwilling o pa icipa e (Spie s and Wood, 2010). Pe haps due o he
complexi y and con adic ions aised by hese clien s, i seems ha s a conside he dually
diagnosed among he mos challenging clien g oups, as s a expe ience us a ion,
helplessness, and nega i i y (Schul e e al., 2010). As he wo ke ’s ole is emo ionally
demanding, suppo ing a posi i e clinical en i onmen equi es aining, and expe iences o
collabo a ion wi h his g oup o clien s in o de o enhance unde s anding owa ds he
clien s (Nu e al., 2017). Wi h such complexi y and ulne abili y o clien s, he s a need o pu
mo e e o in o engaging clien s, and use such ools as espec o hei clien s and belie in he
clien possibili ies (Holm and Se e insson, 2011; Ness e al., 2014; Nu e al.,2017;
Peplau, 1991). S a need he capaci y and willingness o sha e uncom o able expe iences, so
ha hey can wo k owa ds engagemen and ongoing he apeu ic wo k (Thibeaul , 2016).
Whils he apeu ic op imism is impo an , a posi i e app oach only is no su icien o
p e en d opou . P ac i ione ’s sel - a ed compe ency has been linked wi h a be e
abili y o add ess and suppo clien s’di e se needs, and hus enhancing engagemen
(Schul e e al., 2010).
Mee ing he clien as an indi idual may gi e he dually diagnosed a eeling o being alued,
which may enhance ac i e engagemen (S anhope, 2012; Ness e al., 2014). Mo he s wi h a
dual diagnosis may no seek help, since hey may expe ience shame and ailu e due o hei
illness, which may p e en hem om disclosing hei p oblems o p o essionals (Blegen e al.,
2010; Cho l on and Smi h, 2016). I is, he e o e, essen ial o look o ways o enhancing hei
commi men and engagemen in ca e. Help-seeking and engagemen a e connec ed as
e ms, since a phase when a pe son is no ye willing and mo i a ed in o ea men equi e s a
o ocus on c ea ing a he apeu ic ela ionship (Muese and Fox, 2002; P ochaska and
DiClemen e, 1992). The he apeu ic app oaches should be modi ied acco ding o he
clien willingness o be in ol ed (McKee, 2017; Muese and Fox, 2002; P ochaska and
DiClemen e, 1992).
In Peplaus’s (1991) heo y, help-seeking is he phase o o ien a ion, as mos clien s a e
ambi alen and may no necessa ily be able o exp ess hei expec a ions. The engagemen
s a egies in he ca e o he dually diagnosed we e lis ed by Muese and Ginge ich (2013) as
asse i e ou each ools, suppo on p ac ical ques ions such as clo hing and ood, suppo in he
clien social ne wo k and c isis esolu ion. Asse i e ou each e e s o ac i ely eaching o he
clien s o in ol e hem in ea men (McKee, 2017). Engagemen has been linked wi h bo h a
phase when a clien is no connec ed o ca e p o ide s, and an al eady exis ing he apeu ic
ela ionship and in ol emen o amily membe s (Liza di and S anley, 2010). Engagemen can
mean commi men o using se ices a a p ac ical le el, bu i can also mean emo ional
in ol emen on an indi idual le el (S anhope, 2012). The la e is less well known, as he e a e no
exis ing and comp ehensi e de ini ions on he ype o help equi ed o inne emo ional
in ol emen o appea . A ocused e hnog aphic s udy a a low- h eshold se ice o subs ance
abusing amilies was conduc ed. The aim was o explo e and desc ibe how engagemen is
me ging in he con ex o mo he s wi h dual diagnosis.
Me hod
Focused e hnog aphy has e ol ed as a me hod o imp o e ca e and ca e p ocesses, and is
sui able o s udying speci ied ques ions, wi hin subcul u es in pa icula se ings (Higginbo om
e al., 2013; Rashid e al., 2015). The goal o e hnoscience is o sys ema ically collec quali a i e
da a by obse a ions and in e iews, and h ough pa icipa ion in e en s o a ce ain cul u e
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(Gee z, 1973; McFa land e al., 2012). P e iously e hnog aphe s explo ed cul u e in a b oade
con ex , whe eas i can cu en ly deal wi h speci ic ques ions such as expe iences o single
g oups (Higginbo om e al., 2013; Rashid e al., 2015). In his s udy, we link subjec i e iewpoin s
wi h socially es ablished s uc u es o meaning in he quali a i e esea ch p ocess in such a way
ha he s uc u e c ea ed e lec s he emic iew o he pa icipan s (Gee z, 1973). Ou app oach
is desc ip i e and in e p e a i e, as we sea ch o meaning. The cul u e shapes e e yday li e
expe iences, and hus he e hnog aphic iewpoin is connec ed o a phenomenological li ewo ld
pe spec i e –also in plu alised, complex, o ambi alen si ua ions (Desja lais and Th oop, 2011).
The con ex o he s udy
In ocused e hnog aphy, i is o impo ance o loca e pa icipan s wi h in-dep h knowledge o he
a ea o in e es (Higginbo om e al., 2013). The da a we e collec ed a a low- h eshold se ice o
d ug-abusing women and amilies in sou he n Finland. In he na ional se ice deli e y con ex , all
p egnan women ecei e ma e ni y ca e: he coun y’s 311 municipali ies a e esponsible o
p o iding ee heal h ca e o expec an mo he s and hei child en (Finnish Municipali ies and
Regions, 2017). A low- h eshold se ice is an umb ella e m o many di e en ypes o se ices
o d ug abuse s (Islam e al., 2013). These se ices aim a educing ba ie s o ca e by engaging
clien s in se ices, whe e hey a e willing o mee wi hin an in i ing a mosphe e. In yea 2014,
bup eno ine (Subu ex) was he bigges p oblem o hose en e ing subs ance se ices in Finland.
O all adul s (n¼1,777) using subs ance se ices in 2014, 42 pe cen had a child, and
80 pe cen we e clien s o child p o ec ion se ices (Päihdehuollon huumeasiakkaa , 2014). Dual
diagnosis is common among mo he s wi h subs ance- ela ed p oblems, since 57 pe cen o he
women wi hin a psychia ic clinic on addic ion had a psychia ic diso de (S engell e al., 2015).
A he esea ch si e, which is wi hin child p o ec ion se ices, mos o he clien s a e pa en s, who
a i e by a e e al o an o de by a social wo ke , and he pa en s ace he isk ha hei child en
will be aken in o cus ody unless hey commi o abs inence and ehabili a ion. Mos o he clien s
a e be ween 20 and 30 yea s old, and mos ha e used d ugs o many yea s. The se ice is
communi y based and unded by se e al municipali ies in he a ea. I is a join unde aking wi h a
subs i u ion clinic and a small amily wa d. The e is also ou each in o he communi y and
ne wo king wi h di e en agencies in he a ea.
The ield esea ch was planned in ad ance by a anging se e al mee ings wi h he managemen
and s a o he low- h eshold se ice. Ques ions abou con iden iali y and e hical ques ions
ela ed o wo king wi h such a ulne able popula ion equi ed ha a con iden iali y ag eemen was
signed by he i s au ho . Since he e hnog aphic esea che ’s ole as a pa icipan o obse e in
he e hnog aphic da a collec ion was a co e issue (McFa land e al., 2012), he esea ch was
planned so ha au ho could in e change be ween he oles o pa icipan and obse e du ing
he s udy.
Da a
The da a collec ion in his ocused e hnog aphy ook place o e i e weeks on 23 sepa a e days
(a o al o 149 hou s). The da a comp ise 117 ield no e en ies. All 12 membe s o he s a a he
low- h eshold se ice we e in e iewed using open-ended in e iews ques ions. These in e iews
las ed 30-90 minu es, he a e age being 62 minu es. The 12 s a membe s in e iewed we e
women, hey we e aged 34-57 (median age 44), en we e counsello s wi h di e en aining
backg ounds in he heal h and social se ices, and se e al had aining in o he ields p io o hei
cu en wo k. Two people had no educa ion in he ca ing p o essions. Addi ionally wo clien s
we e in e iewed on ou occasions each.
Da a analysis
An induc i e app oach in he da a collec ion and quali a i e analysis was used. Da a analysis
commenced du ing he ieldwo k, and con inued o he du a ion o he s udy (McFa land e al.,
2012). QSR NVi o 11 P o so wa e was used o assis da a handling. T ansc ibed no es and
in e iews we e hema ically analysed and he p elimina y hemes om ieldwo k a ose:
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connec ing, a ailable space and ma e ial, and doing. The iden i ied names o he hemes
and classi ied subse s we e ela ed o each heme. An indi idual-le el analysis and he no es
con aining obse a ions we e compa ed wi h he in e iew da a. The hemes we e de eloped
s epwise by asking di e en ques ions om he da a so ha he eme ging unde s anding could
be e i ied. The las phase included he in e p e a ion and syn hesis o indings. The
in e connec ion o di e en hemes appea ed as a me apho o desc ibe he complex
phenomena and s uc u e o engagemen a an expe ien ial le el. A me apho can concep ualise
subjec i e unde s anding and e eal he s uc u e o expe ience (Lako and Johnson, 1999).
E hical ques ions in he s udy
The p o ocol o he esea ch p ojec was app o ed by he E hics Commi ee a Tampe e
Uni e si y Hospi al. The esea ch p ojec con o ms o he p o isions o he Decla a ion o Helsinki
(WMA 1995/2004). The s udy pa icipan s ga e hei in o med consen . To ensu e anonymi y, he
indi idual esponden s a e no p esen ed in he ci a ions o his pape .
Resul s
The ollowing i e hemes we e iden i ied o explo e engagemen . The hemes we desc ibe a e:
ecognising he con ex wi h ulne abili y, ca ing o mo he s in human- o-human encoun e s,
connec ing h ough di e en in e aces: sensi i i y as he ool, ocusing on he de elopmen o he
clien ’s wishes and hope in mani old ways: e en he smalles e en s a e aluable, and
engagemen is he co-c ea ion o possibili ies a an expe ien ial le el – he seed.
Recognising he con ex wi h ulne abili y
The p o essional wo k necessi a ed knowledge and a deep app ecia ion o he backg ound o
he clien s. The con ex appea ed o be complex, e oking disco d, and disc epancies in he
wo kplace: a he same ime as he s a we e au ho i ies wi hin child p o ec ion, hey we e
equi ed o nego ia e he di icul ies a ising om hei clien s’pas . Many clien s ha e expe ienced
childhood neglec , iolence, loneliness o ejec ion, and ha e missed ou on amily suppo :
This led o anxie y and men al heal h p oblems, mainly anxie y, which was medica ed because he e
a e no ools, no means a home o wo k wi h.
Many clien s held ea s o being assaul ed, a backg ound iewpoin leading o mis us , which
may ha e added o he clien s’ ulne able expe iences o loneliness. Pe haps hei adolescence
and de elopmen a he ime o s a ing d ug use we e in e up ed and eplaced wi h in ol emen
in he d ug communi y. Being pa o a hidden communi y, cha ac e ised by c ime and iolence,
wi h o dina y, e e yday li e becoming ocused on looking o d ugs, inding he means o a o d
d ugs, o ob aining d ugs by he o o he c iminal beha iou mean he clien s d i ed in o such a
li es yle whe e he so-called no mal hings in li e we e ou side he pe sonal sphe e:
A 21-yea old mo he , who had spen 9 yea s in he d ug communi y had ne e used elec onic bank
paymen s and had no debi ca d, so e en shopping is no simple.
All he clien s had expe ienced emo ionally bu densome and insecu e yea s. Many had
expe iences o elapses and ailu es in ela ion o addic i e subs ances and a ending se ices.
The wo ke s buil a desc ip ion o hei clien s as u e ly ulne able, ha ing su e ed a duous
expe iences and lacking he abili y o cope wi h di e en challenges in li e:
The bounda ies a e es ed, since nobody p e iously se any: he amily had no bounda ies, and in he
d ug communi y no limi s exis , since hea en is he only limi .
S a desc ibed imes o using and non-using, whe e he abili y o he clien changes acco ding o
whe he hey use d ugs o a e abs inen . Upon a i al a he low- h eshold se ice, he mo he s
and a he s a e i ed o e en exhaus ed. Upon en e ing his se ice, many o he women a e
p egnan o he i s ime o in he ea ly s ages o hei p egnancy, while o he s a e mo he s o
a he s o small child en. This is a main mo i a ional pe spec i e when he pa en s seek help
hemsel es. G owing in o mo he hood and a he hood we e jus some o he challenges hey had
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o ace. Pa en hood may ha e eminded hem o hei own expe ienced insecu i y. One pa o he
s a ’s unde s anding and commi men o hei clien s g ew ou o a deep- oo ed unde s anding
and empa hy o hei con ex o dis up ion and ulne abili y:
These mo he s do no ha e i : hey did no ge he chance. They may ha e s a ed cycling h ough
ins i u ions, and hey may ha e been placed so ha hey could ne e exp ess hei nega i e eelings,
which ed hei addic ion e en mo e, so i supp essed he pain and his is why we alk abou dually
diagnosed clien s. I is du ing hei pain ul imes ha hey should ha e ecei ed p ope ea men , bu
hen he d ugs came, which helped.
The s a had o deal wi h dis up ion and ulne abili y. The ambi alen help-seeking needs
changed om eage ness o be helped in o a oidance o ecei ing help. Clien s desc ibed hei
si ua ion o no iden i ying a need o help, and hey explained ha hey did no know whe e o
how o look o help. On he con a y, clien s quickly changed hei mood and help was
no accessed:
She canno ask o help, because i is a sign ha she is no coping wi h he child, so i is a p oblem.
F om he pe spec i e o he s a , hei a i ude was app o ing he clien s no ma e wha , hey
needed he knowledge base and p o essionalism. These we e in e wined so ha nego ia ion and
belie could be used o c ea e consis ency, us , di ec ion, and a sense o s eng h. The s a
needed o be deeply in ol ed in hei clien s’o e all ou look on li e.
Ca ing o mo he s in human- o-human encoun e s
The unde lying hinking o he s a was a belie ha clien s can only be helped wi h an
app ecia i e and ca ing app oach. This cul u al iewpoin was exp essed in he wo ke s’
app oach o ca e:
I I ake eally good ca e o hem and ea hem well wi h espec , like o dina y people, I hink ha hey
will likewise do he same wi h hei child en, so ha i can somehow ans e : hey ecei e ca e and
good expe iences in a human ela ionship, and hen hey manage o ansmi his o hei child en and
o he ela ionships.
The s a saw hei wo k and a i ude being deeply meaning ul also o he child en in he amilies
a ending. The s a needed a ious ways o ela ing wi h clien s, which was isible in e e yday
e en s such as how he s a me wi h clien s as hey welcomed hem. The connec ions occu ed
in he many in e aces. The human- o-human app oach wi h empa hy and a suppo i e a i ude is
no su icien alone. Pe se e ance is equi ed o hold on o he clien , so ha he clien would ge a
be e chance o connec ing:
We hold on o he clien and he mos impo an hing is ha we will no le he clien anish. We jus
hold on, we keep in con ac , and we pick up and we ollow he clien whe e e needed.
Especially a he beginning, i may ake se e al occasions be o e he s a ac ually mee s wi h he
clien s, as he clien s do no necessa ily a i e as ag eed o mee ings. This knowledge helps he
wo ke s in hei a i ude owa ds hei clien s and hei app ecia ion o he clien s’decisions.
This equi es cons an e alua ion o how o connec :
We lea e a message, we call and say ha we a e he e, you a e on ou minds, we will call you again
omo ow, we a e wo ied, and how a e you?
The s a aimed owa ds p olonged a unemen , holding on o he clien , pa ience and also
pe se e ing in si ua ions o e hical di icul y. A p o essional and app ecia i e app oach is
especially complica ed o he s a i he clien is beha ing inapp op ia ely owa ds a child:
She is en aged, i ascible, and yells a he child as I go inside wi h my colleague. As we ha e a good
ela ionship, we know how o gi e eedback in such a way ha he mo he ge s a g ip o he sel , “hi,
wha ’s wi h you? Conside his om you child’s iewpoin , wha is you son hinking now and why is
he beha ing like his?”
The s a mus connec wi h he clien s on an emo ional le el, since knowledge alone does no
b ing abou a ca ing app oach. The cul u al o de o he wo kplace equi es app ecia ion and
acknowledgemen ha clien s a e i s o all pa en s, mo he s, a he s, women and men, and only
second indi iduals wi h subs ance and/o men al heal h p oblems.
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Connec ing h ough di e en in e aces: sensi i i y as he ool
As he clien s can a i e a any ime when he se ice is open, any s a membe may encoun e hem
a hei a i al. The i s momen is conside ed o impo ance in o ming some ype o connec ion:
I a new clien a i es, she comes wi h a pal o alone, and you as he wo ke a e he e om he i s
momen and welcoming he , so he clien connec s wi h you. I hink he clien connec s wi h he pe son
who mee s he . The i s con ac c ea ed can in luence he le el o us e en u he .
The s a see hemsel es connec ing wi h clien s ia hei p esence, which helps in inding he
co ec way o esponding, beha ing, and gi ing eedback o he clien . A non- e bal le el o
communica ion may be eached ia as u e lis ening and conscious choices. P esence is
desc ibed as being a en i e and i equi es sensi i i y:
My mos impo an ask is o be p esen , o si he e and be p esen , being a ailable when somebody
needs help.
The clien s engage in human connec ions, hey do no engage wi h ea men models, wi h a si e
and i s se ices, o ia s uc u es, bu ia no mal human habi s and s eps in connec ing wi h o he s:
I is qui e easy o engage wi h a human who looks you in he eye and lis ens o you, and speaking,
doing, and ges u es discloses ha you a e conside ed impo an and ca ed o .
The expe ien ial le el is whe e mee ing he pe son (koh aaminen) occu s. I in ol es ac s,
oge he ness, and an app oach wi h a suppo i e a i ude. The e is a ich se ing o small
i ems ha may become signi ican om he clien ’s pe spec i e. I he connec ion wi h he clien is
success ul, he clien may wan o e u n. Some o he clien s a i e a he se ice while
in oxica ed. A his low- h eshold se ice, he e is an unde s anding ha ine i able elapses
occu . Fo he s a his means ha hey need o acknowledge he s a us o clien s and he
possibili y o whe he d ugs we e used ha day. A his s age, he clien s a e no ye ully engaged
in collabo a ing, bu he s a and clien s a e c ea ing models o ehabili a ion a he same ime.
All wo ke s in he eam help he clien s o de elop hei g asp o li e ( a umapin a):
I is like a s o y o eco e ing om addic ion, and i can s a whils being in oxica ed. Wha a ises is
in e es , and hey may s ill con inue using […] engagemen occu s be o e hey a e d ug- ee. Yes, I
hink ehabili a ion can s a ea lie .
The clien s ha e aken majo s eps p io o accessing se ices, and his cen e is in ended o
hem. The s a do no wan o blame hei clien s; ins ead, hey encou age all clien s o a i e on
bo h good and bad days. The wo ke s’a i udes ha e an impac and hey see he complexi y also
in help-seeking, whe he i is exp essed openly o no :
We he e will no say oh oh, we hink he pe son has he sel done a lo o ha . The s uc u e was buil by
s a ing o hink o a place whe e hese people would da e come, e en hough hey ha e such a se e e
subs ance p oblem, so e ible ha somebody migh possibly ake away hei kids.
They ecognise ha he mo he s need o do he men al wo k in o de o make decisions. A i ing
a he si e can be iewed as an ac o cou age and concession, since he clien s ha e aced hei
connec ion wi h d ugs:
I is a qui e ha d s ep o ake o en e as a mo he and o admi you ha e an addic ion p oblem, ha is
ough, and o admi onesel , ha yeah I ha e a p oblem wi h spi i s, pills, o d ugs.
A i ing may mean ha he clien is labelled as a d ug-abusing pa en , and e en non-using amily
membe s ha e o ace his ba ie , since i is gene ally known ha his si e is in ended o amilies
wi h subs ance abuse p oblems. As i is possible o a i e anonymously, some may a end
wi hou connec ing o a longe ime p io o con ac ing s a :
A mo he came he e o qui e long, and did no alk o s a o anybody, she jus came wi h a mo he
who had a ela ionship wi h us and suddenly BANG, his mo he , who had no connec ed wi h
anybody, said now I wan o alk, I ha e a p oblem. She had been he e o wo mon hs jus
con empla ing he si ua ion […]. And hen she da ed o ask o help. Then he e a e also hose mo he s
who al eady ha e he p oblem, hey s ep in and say i aloud.
Many mo he s a i e needing help, bu hey canno e balise hei need. Fo he s a , i is no
always possible o know how a pe son can be helped, no can i be p edic ed. Fo he s a o
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c ea e engagemen , hey need o lis en ca e ully, ask complemen a y ques ions, and gi e
suppo i e eedback. This can occu ia he di e en in e aces, such as ac ion p o ided a he
low- h eshold se ice (Table I).
S a may use new o ms o communica ion, such as using e-mails and ex messages. Thei
app oach needs o be e y sensi i e, espec ul, lexible, changeable, and oppo uni y
dependen . When mee ing and connec ing wi h he clien , he wo ke s’sensi i i y equi es an
inne endu ance: hey mus be p esen and lis en in a ca ing manne . They wai o he clien o
make a wish, e en a iny one. This is he ou e o c ea ing any mo emen , ac ion, a glimpse o
hope o us , and e en ually engagemen . An ou side canno s ep in and ell he clien how he
p oblems could be sol ed in he easies way, since such an app oach may be oo ex e nal o oo
ac i e, igno e he clien ’s pe spec i e, and may no include he co-c ea ion o wishes. The clien
decides wha help she can accep . I he clien senses help being imposed ex e nally and no
mee ing occu s, she can eel excluded.
Focusing on he de elopmen o he clien ’s wishes and hope in mani old ways: e en he
smalles e en s a e aluable –space and a ailabili y
A e a pe son has en e ed he acili ies, connec ing can appea ia deeds, in di e en small
momen s, no i ying someone, and asking o s a a discussion. The e a e many a eas o
in e aces whe e ac ion can be aken. The e a e hin s o e e yday li e, ye his is no e e yday li e:
he ocus is on he goal o de elopmen o he clien ’s wishes and hope in mani old ways in o de
o co-c ea e possibili ies ia space and a ailabili y. These in e aces c ea e a cul u e whe e
connec ions can occu ia human ela ions o h ough ac ions and how hings a e done.
The ooms a e designed o in i e clien s o use he acili ies. The space c ea es a possibili y as
such o engagemen in he ooms and he ac i i ies aking place in hem.
The bigges oom in he se ice acili ies is a la ge lounge, which con ains so as, oys, and a
ele ision; i is a space o passing h ough o any o he oom in he building. I con ains a
big able, which seemed o be he hea o uno icial discussions. A no ice boa d con ained he
daily schedule and in o abou a ailable ec ea ional ac i i ies. The big so as in he oom in i e he
clien s o elax o ake a nap. E en hough he s a ’s wo k may ha e appea ed o in ol e hanging
a ound some imes, in ac hey need o be awa e o each momen and wha ollowed om any
discussions, o example. The counsello s a e all indi iduals and ha e hei pe sonal way o
wo king and app oaching he clien , many desc ibed small mic o-momen s o communica ion:
I always conside ca e ully, should I say ‘no’, and i I say ‘no’, why do I say so?
E e ybody spends ime in he lounge: he clien s, amily membe s, and he s a spen ime a he
able. Lunch was a ailable e e y day. I seemed as hough ime s opped a he able:
They come o ea and spend ime –qui e long ime he e –a he low h eshold se ice, o ha e
discussions ha a e a li le ligh e .
Table I In e aces h ough which engagemen can be c ea ed (iden i ied in ield wo k)
Space and ma e ials Human ela ions Ac ions and p ac ices
Child en’s play oom, oys, ood able, co ee,
ood, so as, possibili y o make phone calls
( aking ca e o hings, he wo ke s can be
eached by cellphone 24/7, oppo uni y o send
SMS messages), using he in e ne , doing
laund y, ecycling child en’s clo hes, sauna,
ec ea ion: icke s o ice hockey games, mo ies,
access o a gym, aes he ics in deco a ion
Obs acles: he loca ion ou side he ci y
equi es coming o he se ice speci ically,
no space a ailable
Opening he doo , mee ing a human as pe son,
clien -wo ke chemis y: a b idge, smiling,
looking/being seen, lis ening/being hea d, o he
clien s: bo h known and unknown, di e en
g oups, access o childca e, ea ing oge he ,
pee s: o he s in he same li e si ua ion, special
expe ise: discussions, counselling, gynecology
se ices
Obs acles: being bypassed, conside ed no
impo an , being in a hu y, absence o
special expe ise
Loca ion o he si e, knowledge o he si e ia
ne wo k, lye s, in e ne , One’s own place wi h
eedom o come and go, wish o e u n,
anonymi y, sui able opening hou s , mee ing
each indi idual, he co e a en ion and in e es is
on he whole amily, a espec ul and
app ecia i e a i ude, pe missi eness, he
e e ing wo ke may equi e pa icipa ion and
sc eenings: he consequences?
Obs acles: being bypassed, insu icien wo ke
esou ces, con lic ing schedules, clien ’s li e
hy hm does no i opening hou s
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Many clien s come o lunch, and he la ge lounge is like an a ena o in o mal and o mal pee
discussions. Ea ing is impo an , bu i is no only abou he ood:
I has somehow anspi ed ha we o e ood he e. I he e was only a smo gasbo d, bu he e we e no
wo ke s –humans –i would no be nice o come he e.
A he speci ic lunch hou s, sizable g oups can a end; he adul s alk while he child en play on
he loo . Food and he ac o ea ing oge he play a majo ole a he low- h eshold se ice.
Food is an en ance o ea ing adi ions, memo ies, smells, and as es; i is a basic need and an
example o e e yday ou ines. I also se es as an example o ea ing habi s and ood p epa a ion.
The e is a speci ic posi i e a mosphe e a ound he able:
The ki chen is a he hea , like he mo he ’s ole.
Many s a membe s si beside he clien s wi h babies in hei lap. The s a ind ha connec ing
wi h he babies is a way o connec ing wi h hei clien s. The smalle ooms a e used o in ima e
and pe sonal discussions be ween clien s and s a , o o o icial mee ings be ween di e en
se ice p o ide s, such as gynecological ca e. I was possible o wash and d y clo hes a he
se ice acili ies. Addi ionally, he e is a showe and sauna o he clien s’use. The space p o ided
o e s many in e aces o connec ion o occu , i he clien wishes so. The s a a e awa e and
ecognise ha o some clien s, accep ing help is a necessi y o change o occu : hese a ious
s eps in he p ocess o change a e necessa y. Fo some clien s, issues may exis only on he
non- e bal le el. Taking ac ion can be a s ep wi hou e balisa ion, and connec ing can occu in a
numbe o ways and in di e en speci ic, e en de ailed si ua ions:
Such hings ha e happened ha usually we alk abou hea y s u , and, o example, he colou s and
ab ics igge speci ic memo ies. By ques ioning emo ions and hough s, we can go h ough
many hings.
The s a can see hei clien s’g asp o li e g owing:
Always when an ac ion s a s mo ing om somewhe e, i s a s o look o i s own channels and
de elops ce ain hings.
In his low- h eshold cul u e, he iewpoin is ha no ma e how small i may be, a small change
may lead o a bigge change in he u u e, and hope may eme ge. Since he mo he s ha e hidden,
un ecognised, and complex p oblems ha ha e an impac on hei own li es and hose o
hei child en, many ways o helping and connec ing a e needed. The oppo uni ies and
he pe spec i e o hope may inc ease engagemen , since he main mo i a ion o he clien s
is mo he hood:
P egnancy, yes i is e y impo an o a woman, and in all he mo he s I ha e seen p egnan , hey
ponde many hings, and do so di e en ly. They eally hink o he baby’s well-being […] bu i hey ge
no connec ion o ha hey hemsel es, i can easily occu ha a e he child is bo n, ‘wha does ma e
anymo e?’, and subs ance use can con inue. Bu i hey a he same ime eel ha hey hemsel es a e
o impo ance, and hey see he signi icance o s aying sobe , hen he e is a longe -las ing impac .
Clien engagemen may be possible o he ime un il he baby is bo n, and i is p eceded by
mee ing he pe son, he c ea ion o any ype o mo emen .
Engagemen is he co-c ea ion o possibili ies a an expe ien ial le el – he seed
The hemes desc ibed abo e a e in e connec ed; engagemen is he co-c ea ion o possibili ies
a an expe ien ial le el. The wo k en ails complexi y in he nego ia ions o e ulne abili y. The
clien wishes and hope may awaken as a esul o connec ing in be ween he clien and s a a he
di e en in e aces (Table I). A a phenomenological le el, engagemen in ol es he in en ional
clien in he p ocess o in e ac ion: he clien needs o pa icipa e and become an ac ing and
sensing pa o he change, which occu s on an indi idual and expe ien ial le el.
The cul u al model and s a wo k c ea e inne change wi hin he clien , and as he s a desc ibed
ha howe e small, he change is o alue o engagemen o occu . The expe ien ial le el and he
me ging engagemen is like a seed g owing (Figu e 1). This is a me apho ha connec s he
p e ious hemes so ha i in o ms o he goal, and ells abou he needed changes, as well as
pays a ocus on he indi idual mo he as he key ac o . The backg ound con ex o dis up ion and
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