Vol. 5, No. 2, 2018, pp. 125–139 ISSN 1903-7031 Treatment of Dual Diagnosis in Denmark: Models for Cooperation and Positions of Power Katrine Schepelern Johansen Competence Centre for Dual Diagnosis, Mental Health Services in the Capital Region, Boserupvej 2, 4000 Roskilde: Denmark (katrine.schepelern.johansen@regionh.dk) • Treatment for dual diagnosis in Denmark is divided between a medically based psychiatric treatment system and a sociallyoriented substance use treatment system; consequently, in order to deliver the most effective treatment to people with dual diagnosis, the two need to cooperate. A number of projects have been initiated to try out different models for cooperation, yet, on a larger, societal scale, we have not solved the puzzle of how it can be made to work in practice. My focus in this article is to suggest some reasons why it is so difficult to introduce cooperation between psychiatry and addiction treatment despite the many projects directed explicitly towards this. I suggest that at least part of the answer lies in the unequal power relations between psychiatry and substance use treatment. Keywords: dual diagnosis, cooperation, organizational interfaces, power. • Introduction ‘Dual diagnosis’ is the term used to describe the co-presence of a mental disorder and a sub- stance use disorder in a single individual. It is a rather common occurrence, although ac- tual numbers are uncertain and disputed. In the Danish context, it is often estimated that approximately 50% of people in substance use treatment also have a mental disorder and ap- proximately 30% of people with a mental dis- order will, at some point, have a substance use disorder (Flensborg-Madsen et al., 2009; Fred- eriksen, 2009; Toftdahl, Nordentoft, & Hjorthoj, 2016). In other European countries the num- bers seem to be a bit lower, in the US somewhat higher (Carrà, Bartoli, Brambilla, Crocamo, & Clerici, 2015). Treatment for dual diagnosis in Denmark is divided between a medically based psychi- atric treatment system and a socially oriented substance use treatment system, meaning that, in order to deliver the most effective treatment to people with dual diagnosis, the two sys- tems need to cooperate.1 This has been em- phasized in political statements (Sundheds- og Sundheds- og Ældreministeren, 2016) and bu- reaucratic guidelines, and a number of projects have been initiated to try out different mod- els for cooperation, yet, on a larger, societal scale we have not solved the puzzle of how it can be made to work in practice. My focus in this article is to suggest some reasons why it is so difficult to introduce cooperation between psychiatry and addiction treatment despite the many projects explicitly directed towards do- ing so. In this analysis I draw upon the ana- lytical framework of ‘organizational interfaces’ from organizational theory (Brown, 1983) to de- scribe the cooperation between psychiatry and substance use treatment. However, I further de- velop Brown’s concept by explicating the hi- erarchical relations between the two organiza- tions, thereby introducing power as an impor- tant dimension in understanding what is going on in the course of cooperation. Power, I should point out, is an issue that none of the projects have addressed explicitly. After this introduction, I briefly present why the constellation of mental and substance use disorders make up a special problem area, and then review the organization of the dual diagnosis field in Denmark more thoroughly. An introduction to the different cooperation projects on which I build my analysis in this ar- 125 mailto:katrine.schepelern.johansen@regionh.dk 126 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 ticle follows, including a discussion of my posi- tion as researcher and practitioner in the dual diagnosis field. In the ensuing analysis I de- scribe current cooperation between psychiatry and substance use treatment before presenting some learning points that could guide future work in the dual diagnosis field. I conclude with a review of the analysis and my methodological approach. The Problems of Dual Diagnosis Dual diagnosis patients are one of the groups that create difficulties for the treatment system and the way it is organized. This is the case not only in Denmark but throughout the Western world, where most existing research takes place (Carrà et al., 2015; Drake et al., 2016; Mueser, Noordsy, Drake, & Fox, 2003). As an illustra- tion, I begin by introducing Michelle, a woman with a dual diagnosis whom I met at a treat- ment facility (Johansen, 2009), before summa- rizing the different types of difficulties. Michelle had a very serious personality dis- order and used a range of drugs, including heroin, cocaine and cannabis. She often had psychotic episodes after drug use or when she was stressed – frequent occurrences due to her drug habit. She lived in a small two- room flat with her boyfriend who, like Michelle, also had a personality disorder and used drugs; they financed their drug habit by dealing and Michelle’s having sex with men for money. Michelle had many – often negative – contacts with different treatment facilities. She was reg- istered at a drug treatment facility where she received methadone for her heroin addiction, but because of her chaotic lifestyle she often missed her appointments and was reduced in dosage because of no-shows. This made her contact with drug treatment a largely negative experience, as most of it was about methadone doses. Furthermore, she had a preference for injecting her methadone when possible and it created conflicts when she could not take it home with her but had to take it at the treat- ment facility. Staff members strongly doubted whether all the conflict was due to her person- ality disorder. They had tried to refer her to the psychiatric treatment system but she was rejected as she could not be diagnosed prop- erly due to her frequent drug intoxication, and because there was no treatment for patients with personality disorders if they were using drugs at the same time. She was told to return when she had been clear for some months. She was, however, often in contact with the psychi- atric emergency room when she became psy- chotic. No long-term contact with psychiatry was established on the basis of these visits as Michelle was always eager to leave the facility as quickly as possible to return to her boyfriend and the drugs. Due to her lifestyle and the drug use Michelle’s physical health was also in poor condition. She had no contact with her gen- eral practitioner after she had been forbidden to visit the consultation for threatening the doc- tor in an attempt to have him prescribe benzo- diazepines for her. Staff at the drug treatment facility tried on a number of occasions to estab- lish cooperation with the psychiatric treatment system but this was always declined on the ba- sis that, firstly, Michelle was not a patient of theirs and, secondly, that she was not properly diagnosed as her diagnosis had been made by the doctor at the drug treatment facility who specialized in general medicine, not by a psy- chiatrist. The difficulties with dual diagnosis lie at three different levels in the Danish context: that of the individual patient/client, of organization and of cooperation: Patient/client level: Dual diagnosis patients have more serious symptoms and a poorer prognosis than those with only a mental or sub- stance use disorder, as the two disorders appar- ently mutually reinforce each other, interact- ing in complex ways that impact both medical and social treatment (Helsedirektoratet, 2012; Johansen, 2009; Mueser et al., 2003). Organizational level: The division of the treatment system between psychiatric and sub- stance use treatment creates uncertainty about which system has treatment responsibility for a particular patient. The psychiatric treatment system has a history of rejecting or discharging people with co-occurring substance use prob- lems and the substance use treatment system has traditionally not had the competencies to diagnose and treat mental health problems (Jo- hansen, 2009; Merinder, 2007). Cooperation level: The two systems have difficulties cooperating for several reasons: dif- K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 127 ferences in treatment approach, professional culture / language and in legal terms; a lack of incentives supporting cooperation and thus of- ten an absence of management support; and no common IT systems frequently combined with physical distance between the units (Johansen & Børsting-Andersen, 2015; Regeringens Ud- valg vedrørende Psykiatri, 2013; Rambøl & Im- plement, 2017). The difficulties linked to the interactions of mental disorder and substance use disorder and its patients are not unique to the Danish con- text, and are thoroughly described in the liter- ature (Drake et al., 2006; Mueser et al., 2003). The difficulties linked to different professional cultures are also well described (ibid.). There is considerable literature discussing cooperation problems between specialized, hospital-based psychiatry and more community-based inter- ventions (Bengtsson, 2011; Folker et al., 2017; Johansen, Larsen, & Nielsen, 2012; Ware, Tu- genberg, Dickey, & McHorney, 1999).2 How- ever, Denmark has created a treatment system where we experience the full force of the dif- ficulties. In the following section I look more closely at the organization of dual diagnosis treatment in Denmark. The Dual Diagnosis Field in Denmark From the time when psychiatry was established as a professional discipline at the beginning of the 18th century up until the 1960s, sub- stance use disorders – primarily alcoholism and morphinism – were conventionally con- sidered mental disorders that should be treated in psychiatry along with other disorders such as schizophrenia, bipolar disorder and depres- sion (Kragh, 2015). But in the 1960s and 1970s Denmark removed substance use disorders –– especially drug use disorders— from the field of psychiatry, making them the object of a growing field of social substance use treatment (Houborg, 2014; Winsløw, 1984). Alcohol use disorders were not removed in quite the same way; the psychiatric treatment system retained the task of treating acute alcohol intoxication, while more long-term therapy became the task of general practitioners and, later, treatment fa- cilities located in the municipality or private agents. The division between medically based psy- chiatry and socially oriented substance use treatment that was established in those years is still maintained in Denmark. Psychiatry is part of the health care system and, as such, it is the responsibility of the Danish regions (of which there are five); the treatment system consists of emergency rooms, closed and open wards, and district mental health centers offering out- patient treatment. Outside of the hospitals we find privately practicing psychiatrists and psy- chologists. All these are defined as special- ized treatment, while non-specialized psychi- atric treatment is offered by general practition- ers. Apart from psychologists, treatment is free, with access to the psychiatric treatment system being gained either by referral from a general practitioner or from the emergency units. Sub- stance use treatment, on the other hand, is the responsibility of the municipalities (of which there are 98 in Denmark). Many municipalities have their own substance use treatment facil- ity, while some buy services from other munic- ipalities or private agents. Most treatment slots are for outpatients; in-patient treatment de- mands referral by the municipality. Substance use treatment in Denmark consists of both so- cial interventions and – if appropriate for the substance use in question – medical interven- tion (for example, substitution treatment). There only exist a few specialized treatment facilities for dual diagnosis in Denmark – most of them located in the Capital Region – and the majority of people with dual diagnosis will re- ceive psychiatric and substance use treatment separately (if they receive treatment at all). Yet the division of the treatment system contra- dicts a range of different recommendations for dual diagnosis, all of which advocate integrated treatment in which both the psychiatric and the substance use disorder are treated at the same time (see, for example, Helsedirektoratet, 2012; NICE, 2011, 2016). Another characteristic of the division is that it exists at all levels: from front- line staff, through organizational units, to the authorities, the law, ministries and so on. There is no place in the bureaucratic hierarchy where the two elements come together, no one who has joint responsibility for the dual diagnosis field, and therefore no one who can make a final 128 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 decision on, for example, whose responsibility it is to provide proper treatment for a patient like Michelle. At the same time, there is considerable po- litical and bureaucratic interest in the field, re- cently exemplified by a new guideline issued by the Danish Health Authorities in Decem- ber 2016 that references the division between substance use treatments and psychiatry, and the concomitant need for cooperation (Sund- hedsstyrelsen, 2017). Another example is a project that the Ministry of Innovation ran in 2017 identifying different ways that digitaliza- tion could support cooperation between sub- stance use treatment and psychiatry (Rambøl & Implement, 2017). In December 2017 the Min- istry of Health announced that it was looking at models for another way of organizing the dual diagnosis field (Sundheds- og Ældreministeriet, 2017). In March 2018, the Danish Regions and some partners published their idea of what this could look like, suggesting that the psychiatric treatment system take over the responsibility of dual diagnosis treatment (Lægeforeningen, Dansk Psykiatrisk Selskab, Bedre Psykiatri, & Danske Regioner, 2018). In Denmark, the situation is often described as one in which the dual diagnosis patient falls between two stools – that of substance use treatment and psychiatry; talking about the interstices between welfare service organiza- tions is a case in point, as clearly illustrated by Michelle’s case. Political and bureaucratic levels have tried to deal with this in the Dan- ish context by calling for cooperation – better cooperation and more of it (Regeringens Ud- valg vedrørende Psykiatri, 2013) – meaning that many projects focusing on initiating and sup- porting cooperation have been carried out in recent years. If we look at the joint dual diagnosis field in terms of treatment initiatives and projects, it is possible to develop the typology presented below of different categories of treatment and cooperation within it. 1. Actual treatment units providing inte- grated treatment. 2. The extension of one kind of current treatment to include aspects of the other mode: when substance use treatment also provides, for example, treatment for anxiety; or the community psychiatric center offers groups focusing on sub- stance use. This often has an ad hoc char- acter depending on locally experienced needs and/or the competencies of local staff. 3. The employment of staff from one sec- tor in the other sector: for example, when substance use treatment facilities hire psychiatrists or when nurses with expertise in substance use are hired in psychiatry. 4. The establishment of formal and obligat- ing cooperation. This mode can be fur- ther subdivided into the following lev- els (Socialstyrelsen & Sundhedsstyrelsen, 2015): • Exchange of information; • Stable patterns of cooperation; • Coordinator; • Cross-sectional teams; • Organizational integration. The first two categories, as already mentioned, run counter to the official organization of the field in Denmark, and no publicly funded projects have been carried out focusing on these types of interventions. We do, however, find a few treatment units, both regional and local, providing integrated treatment (Category 1) or more informal adjustment of treatment methods (Category 2). The institutions found under Category 1 are exceptions in Denmark. Their establishment and continued existence is often linked either to visionary leaders promot- ing this kind of treatment, or a local institu- tional history wherein the profound need for a facility that could contain dual diagnosis pa- tients, often with behavioral problems, was ex- perienced. The different projects that have been carried out in the last couple of years (presented below) all fall into the third and fourth cate- gories. Empirical Material My analysis draws on two different sources of empirical material. In my current position, I K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 129 work as head of the Competence Centre for Dual Diagnosis (CCDD) in the Mental Health Services in the Capital Region in Denmark. The CCDD is a small department working with re- search and development within the dual diag- nosis field. That means that I am both a re- searcher with a background in social anthro- pology and a practitioner in the dual diagno- sis field, working with the organization of the field and competence development among staff, as well as research. That puts me in a unique position to gather knowledge and empirical ex- amples, resulting in a deep understanding of the field and the challenges it contains (Watson, 2011; Ybema, Yanow, Wels, & Kamsteeg, 2009). This means that I have a very privileged posi- tion in terms of conducting participant obser- vation – the traditional data-generating method in anthropology. One of the challenges of participant observation is to find the proper balance between participating and observation (O’Reilly, 2005). This is no less of a challenge when one is a salaried and integral element of the observational field. Alvesson, who encour- ages the conduct of fieldwork in one’s own or- ganization due to the intimate knowledge and easy access thus provided, writes of the concept of participant observation: The person [the fieldworker] is thus not an ethnographer in the sense of being a ‘professional stranger’ (Agar, 1986) or a researcher primarily oriented to study- ing the specific setting. Participant ob- servation is thus not a good label in this case; ‘observing participant’ is better at capturing the meaning I have in mind…. Participation comes first and is only occasionally complemented with obser- vation in a researched-focused sense. (2009, p. 4) This description resonates with my own expe- rience. Another challenge – also described in detail in textbooks on ethnographic methods (Emerson, Fretz, & Shaw, 2011) – lies in keeping meticulous fieldnotes, a challenge which does not decrease when one is part of the discussion, workshop or meeting, with no time afterwards to write it up. Consequently, I have a profound sense of the field and ‘the game’ of dual diagno- sis in the Danish context, but not piles of notes to sort and code when working with an article like this. I do not have a clinical background. There- fore, I am part of the field without actually treating patients or clients; I can talk to them without checking for symptoms or signs of treatment success or failure, interact with them without having to act (except in extreme situa- tions like the threat of suicide). Furthermore, I am in a situation in which both patients / clients and staff are my informants, with both perspec- tives equally important and equally valid. This means that, while I am not best qualified to de- scribe and comprehend, for example, the clin- ical effect of a specific medical or therapeuti- cal intervention, the anthropological perspec- tive provides insight into social relations, cul- tural meanings and structures of power, all of which have equal importance if we want to un- derstand what goes on in the dual diagnosis field (Watson, 2011; Ybema et al., 2009). In this article, this knowledge allows me to produce a thorough description of the context of the dif- ferent examples and projects mentioned. The other type of data used in this article is drawn from a range of cooperation projects that have been carried out within the dual di- agnosis field in Denmark from 2008-2017.3 The six projects presented here all took place in the Capital Region of Denmark, although projects have also been carried out in the four other re- gions; many of them along the same lines as the projects described here. Most have produced evaluation reports that describe the interven- tions and provide an impression of their suc- cess; these constitute the main part of my em- pirical material (I should mention that I have contributed to several of them). Two of the projects have not yet been officially evaluated and my knowledge of those stems from my in- volvement qua my position as head of CCDD. I want to emphasize that this is not a study of what actually goes on in interactions as staff from the fields of psychiatry and substance use treatment try to cooperate. I am working with another kind of data here: the reports of, and dialogue with, the practitioners who have been working with the specific projects, with the purpose of discovering what we can learn about the dual diagnosis field by looking at how the cooperation is described. As such, I am inspired 130 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 by the approach described by Shore and Wright in their book, Anthropology of Policy (1997), and the research questions they perceive within this frame: How do policies ‘work’ as instruments of governance, and why do they some- times fail to function as intended? What are the mobilizing metaphors and lin- guistic devices that cloak policy with the symbols and trappings of political legitimacy? … How are normative claims used to present a particular way of defining a problem and its solution, as if these were the only ones possi- ble, while enforcing closure or silence on other ways of thinking and talking? (1997: 3) In the same way, I am interested in the focus on cooperation in the different publicly funded projects and the lack of focus on the uneven power structures between the cooperating part- ners. The projects are very briefly summarized below. The Social Nursing Project (Projekt Social- sygepleje – det gode patientforløb). This was part of a larger project in which nurses special- izing in substance use treatment were placed in hospitals – both somatic and psychiatric. Their task was to facilitate better treatment for pa- tients who also had a substance use disorder. The project was well evaluated at the somatic hospitals and continued in those locations af- ter the project period finished. In the psychi- atric departments, however, the social nursing project was not successful. The social work- ers in the psychiatric departments perceived the nurses from the project as competitors, and their competence in substance use treatment was not recognized by the psychiatrists. Fur- thermore, the psychiatric nursing staff expe- rienced competition with the social nurses in making alliances with the patients (Ludvigsen & Brünés, 2013). The Integrated Approach Project (Projekt In- tegreret Indsats). This was a cooperation project involving one psychiatric hospital and two local municipalities. The project worked with seriously mentally ill people who were also in contact with social psychiatry and sub- stance use treatment. The working method of the project comprised cross-sectional treatment meetings every other week, during which com- mon clients/patients were discussed and a joint approach decided upon. The project found that these meetings created an integrated approach to the clients/patients that facilitated both co- operation and a better treatment outcome for the patients (Deloitte.Social, 2016). However, the project managers also reported that it was important that the cooperation received ongo- ing attention and that the different institutional cultures were addressed directly and continu- ously if cooperation were to be successful (Jo- hansen & Børsting-Andersen, 2015). The Clinic for Substance Use and Non- Psychotic Mental Disorder (Klinik for misbrug og ikke-psykotiske sindslidelser). This was an- other cooperation project involving a different psychiatric hospital and seven municipalities, which was directed at dual diagnosis patients with non-psychotic disorders. The clinic was established at the psychiatric hospital and treat- ment staff from the local substance use treat- ment facilities were to join the work at the clinic. The project was rather un-successful. The psychiatry-based clinic did not manage to incorporate the staff or treatment approaches from substance use regimens. On the contrary, several of the approaches applied in substance use treatment were rejected with the explana- tion that they were not evidence-based and not sufficiently well described to be included in a psychiatric treatment facility. The project man- agers from the psychiatric hospital themselves conducted a literature survey and decided on screening instruments and treatment principles identified through this work. The psychiatric staff did not see the need to include the staff from the substance use treatment facilities, and the latter could not see why they should partic- ipate. Instead of cooperation, the project cre- ated a situation of competition among the par- ticipants (Buch, Thygesen, & Johansen, 2015). The Cross-Sectional Team at a Social Psychi- atric Housing Facility (Fællesteam på botilbud). This was yet another cooperation project be- tween a psychiatric hospital and a municipal- ity. Two psychiatric nurses, a psychiatric con- sultant and two staff members from the local substance use treatment facility formed a team to provide integrated treatment of dual diagno- K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 131 sis to people living at a social psychiatric hous- ing facility. The team reported having been able to include most residents in the treatment de- spite earlier problems with retention. Coop- eration with the local psychiatric hospital was successful and facilitated more planned admis- sions, although the team experienced major ob- stacles to accessing the IT systems of the psy- chiatric hospital and the municipality, making cross-sectional work difficult. Despite good re- sults, the team was shut down after the project period. The experience gained through this project was used to create two new cooperation projects. The Coordination Plan (Den Koordinerende Indsatsplan). In 2014, the government issued new guidelines on what is called the Coordina- tion Plan. This suggests that people who are in contact with both the psychiatric treatment system and the substance use treatment sys- tem should have such a plan, to be developed at a meeting between representatives for both treatment systems and the patient/client. Here it should be agreed upon ‘who would do what and when’, so that the different treatment ini- tiatives could be coordinated. The Coordination Plan has been implemented in several projects but without marked success. Staff members find it demanding of resources to initiate and are often in doubt whether it is actually neces- sary to have such planning meetings, while it has proven difficult to get consent from some patients / clients (Buch & Petersen, 2017). It has also been clear that psychiatry and sub- stance use treatment systems have very differ- ent incentives for involving themselves in the work of implementing such plans. Substance use treatment operatives hoped that the Coor- dination Plan could work as a shortcut into psy- chiatry, thus avoiding standard visitation pro- cedures and also assuring clients treatment in psychiatry, whereas the psychiatric treatment system primarily had an interest in assuring that this did not happen, thus safeguarding their limited resources. The Joint Screening Project (Screeningspro- jekt på Frederiksberg). The last project to be mentioned is one focusing on screening for mental disorders at a local substance use treat- ment center. This type of project has been carried out several times in several places, re- sulting in an article describing a project insti- gated in Århus (Frederiksen, 2009); the Fred- eriksberg project that I discuss here is a du- plicate. Staff at the local substance use treat- ment center use standardized screening tools for mental disorder. If they identify someone with problems, they can refer the client for further assessment by a psychiatrist at the lo- cal psychiatric hospital. This psychiatrist also makes an evaluation of relevant treatment pos- sibilities and will refer the client to the correct treatment facility (most often psychiatry or a general practitioner). The project is positively evaluated by the participants. Among other things, they mention that the formalized coop- eration makes informal exchange possible and facilitates counselling when necessary. Though these six projects are very differ- ent in size and scope they indicate the politi- cal interest in the field, meanwhile document- ing how cooperation is seen as the main solu- tion to the challenges of the dual diagnosis field. The projects are summarized in Table 1 below: 132 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 Table 1: Overview over Projects and Problems Identified. Cooperation Between Psychiatry and Sub- stance Use Treatment — Organizational In- terfaces Organizational theorist David Brown has intro- duced the concept ‘organizational interfaces’ (Brown, 1983) that is central when analyzing cooperating organizations.4 Brown states that ‘[t]he definition of an interface depends on the shared goals and interdependencies that press parties to continue to act’ (1983: 22). He con- tinues: Many organizational interfaces, for in- stance, are defined by shared tasks, for whose accomplishment the parties need each other. … Other interfaces are based on common social identifications. … Some interfaces are defined by accep- tance of common authorities… still other interfaces are defined by physical space. (ibid.: 22–23) In his approach there are four central elements that require analysis in order to comprehend organizational interfaces: 1) the interface itself; 2) the parties to the interface; 3) the party repre- sentatives; and 4) the larger context. If we apply Brown’s concepts to the Danish dual diagnosis field, we can produce the following model: K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 133 Figure 1: The Danish Dual Diagnosis Field, version 1. If we look at the different projects through the lens of Brown’s organizational interfaces we can see that, to a large extent, they may be char- acterized by this concept. We can identify the interface between psychiatry and substance use treatment and we can identify the cooperating parties – psychiatry and substance use treat- ment. The party representatives in the differ- ent projects can be identified – whether they be social nurses, ordinary staff assigned to the project or project managers working with the projects – and likewise the context in which the cooperation takes place: the larger Danish so- ciety. In some of the projects, cooperation seemed rather successful and in line with Brown’s model. Staff from the two sectors seemed to agree that both parties are needed if proper treatment solutions are to be made. The Integrated Approach Project and The Cross- Sectional Team at a Social Psychiatric Housing Facility are examples of this. Yet some of the projects show quite an- other picture, one that makes Brown’s model seem too equable. Some of the projects clearly showed that the rationales for substance use treatment and psychiatry when entering into agreements of cooperation and joint project work are not necessarily the same. The ratio- nale of those operating in substance use treat- ment seems to be a wish to gain access to psy- chiatric professionalism, diagnosis and treat- ment, as demonstrated by the project exploring the Coordination Plan. If one applies the def- inition of cooperation borrowed from Brown, then, from their perspective, there is a need for cooperation that is defined by a shared task – that of treating people with a dual diagno- sis. The psychiatric field, on the other hand, does not seem interested in the professional perspective of substance use treatment, at least not to the same extent. In one project – The Clinic for Substance Use and Non-Psychotic Mental Disorder – psychiatry operatives dis- missed the perspective of substance use treat- ment altogether when they characterized it as ‘not evidence-based’. In another project – The Social Nursing Project – the psychiatric staff did not seem to think that social nurses had anything to contribute. Rather, they seemed to be confident that they could manage dual diagnosis treatment quite well on their own. 134 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 This points to asymmetrical power relations in the organizational interface wherein the psy- chiatric profession has the upper hand. There are probably several different expla- nations for this. One could be that psychiatry – as a specialized service with restricted access – represents a scarce and therefore more at- tractive resource than substance use treatment, which is a low threshold treatment mode open to everybody. Another obvious explanation is that psychiatry as a medical profession draws on the prestige of modern medicine, whereas substance use treatment in the Danish context is linked to the less prestigious field of social work: an issue throughout the otherwise suc- cessful Integrated Approach Project. The rejec- tion of the approaches of substance use treat- ment with the argument that they were not evidence-based that we saw in the project with the Clinic for Substance Use and Non-Psychotic Mental Disorder is also an example of medicine being more prestigious than social work. Another characteristic of the Danish dual diagnosis field is, as mentioned in the intro- duction, that the division between psychiatry and substance use treatment exists on all levels – from frontline staff, through organizational units, to the authorities, the law and ministries – and none of these levels offers joint respon- sibility in the dual diagnosis field. That means that the context of the organizational interface does not really provide a frame for interaction, as the model presented above indicates. I would therefore suggest that the model for organizational interface, when it comes to the dual diagnosis field in Denmark, is more prop- erly portrayed like this in some situations: Figure 2: The Danish Dual Diagnosis Field, version 2. Most of the cooperation projects introduced above do not address this potentially conflict- ual cooperation situation, with the Integrated Approach Project being a partial exception as, half-way through the project, the project man- agers established a meeting forum for project participants where different institutional cul- tures, ethical questions and power relations K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 135 were directly addressed (Johansen & Børsting- Andersen, 2015). In the majority of the projects, the project designers and project managers seemed to think that the situation resembled that indicated in Model 1. For some of the projects this might have been true initially, but then, during the course of the project, the orga- nizational interface developed into a situation more like that presented in Model 2. For other projects, the situation was probably more like Model 2 from the outset but without project de- signers and project managers addressing this is- sue in the project design and project work. This indicates that the organizational interface be- tween substance use treatment and psychiatry is not static; rather, it can change over time. The actual manifestation of the interface will prob- ably also depend on, for example, local organi- zational principles and histories of cooperation, among other elements. Model 1 and Model 2 can also be seen as the poles of a continuum, with most coopera- tion projects being placed somewhere between the two extremes, although tending to be placed closer to Model 2 if questions of differences in culture, language and power are not explicitly addressed (see also Johansen et al., 2012). An Under-Organized Interface In Model 2 of the organizational interface, I introduce another of Brown’s analytical con- cepts – that of organizational interfaces as ei- ther underorganized or overorganized – neither of which is a positive outcome (1982: 28-30). An underorganized interface has the following characteristics: There is little agreement about who has authority, and interface goals are unde- fined or conflicting. Formal regulatory mechanisms are not well-developed: Representative roles are fragmented, conflicted, of undefined, and procedures for handling issues are unclear or inef- fectual. Informal mechanisms provide few clear constraints: Theories and val- ues about the interface are not shared; representatives believe that chaos is im- minent, some fighting or fleeing are ap- propriate; cultural differences based in the invading environment are more im- portant than task differences. (1982: 28) The dual diagnosis interface can best be de- scribed as underorganized (see also Chris- tensen, 2011), and the underorganized interface creates a range of problems. In Brown’s words: Several problems are characterized within underorganized interfaces. Re- sources are typically in short supply; the interface lacks personnel, informa- tion, energy and time. Available energy is diffused by the lack of clear focus and the everpresent potential for leaving the system. Finally, differences easily lead to two forms of negative conflict per- mitted by loose organization: (1) with- drawal from differences and (2) escala- tion of conflict. (1982: 28) Again, we find these characteristics in the dif- ferent projects described above. Some of the agents – in my material primarily psychiatric staff – do seem reluctant to invest in the in- terface, seeming to prioritize using their re- sources within their own system. In two of the projects – The Clinic for Substance Use and Non-Psychotic Disorders and The Social Nurs- ing Project – we saw a situation with a high level of conflict between the two parties. It is also tempting to understand the con- cept of underorganized in a slightly different way than Brown, however. Suggesting that a field is underorganized could also describe a sit- uation in which there is room for a range of lo- cal initiatives and projects. The above lists of treatment initiatives and projects and models of cooperation could thus be seen as the result of the underorganization of the field: as formal regulations for the interface are lacking and as there is no formal structure to regulate the dual diagnosis field, local initiatives are created in an attempt to fill its interstices. On the one hand this could be seen as positive – there is room for local initiatives and models for cooperation. But I suggest that the underorganized character of the field, resulting in the large number and variety of local initiatives, add a further level of difficulty to the dual diagnosis field. Not only do we have those connected to patient/client organization and cooperation mentioned in the introduction to this article, the many different 136 K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 initiatives also create a field characterized by randomness and changeability. Learning Points Based on the included projects and the analysis of the interface it is possible to identify some elements in the projects that could assist in the direction of policy-making. In The Integrated Approach Project, as al- ready mentioned, the project managers became aware that they needed to address the cultural differences between the participating parties (in this case, psychiatry, substance use treat- ment and social psychiatry). In their expe- rience, staff members from the different sec- tors wanted to cooperate but, when facing diffi- cult cases or situations, they often withdrew to more traditional and therefore safer positions – focusing on the core tasks of their own insti- tution and not on cross-sectional cooperation. In their experience, the cultural differences need continuous attention if this withdrawal from cooperation is to be avoided (Johansen & Børsting-Andersen, 2015). Examples of activi- ties addressing this problem are cross-sectional competence development, cross-sectional su- pervision and the involvement of relevant lead- ers in supporting the cross-sectional work (see also Johansen & Wiuff, 2014). Another positive example from the projects listed above is The Cross-Sectional Team at a Social Psychiatric Housing Facility. They suc- cessfully established a team that worked well together, where the different perspectives of the involved staff members were fully integrated, thereby providing evidence that such a setup is possible, at least under certain conditions. It is worth noting that the staff members working in this project were very experienced in their respective professions. Moreover, the Cross- Sectional Team worked as a relatively small, au- tonomous unit away from the institution of ori- gin and well-established power relations. One could claim that, in consequence, it did not challenge institutional structures or power hi- erarchies. In other words, it was not dangerous and its members could be left to work together rather undisturbed. As also pointed out, the project was not continued after the project pe- riod ran out and the experiences were not used to change the treatment systems. In the course of The Joint Screening Project successful cooperation was also established. It is a characteristic of that project that it does not challenge structural borders or the competen- cies of psychiatry. On the contrary, it is built on a recognition of psychiatrists’ possessing an ex- clusive knowledge of mental disorders that sub- stance use treatment can only access through a psychiatrist. The services provided by the psy- chiatrists hired in the project are very specific and delimited. To summarize: if we do not want to change the organization of the dual diagnosis field but are only aiming for more successful coopera- tion, the above analyzed projects seem to point to three different models of cooperation: • Autonomous units consisting of expe- rienced professionals working out their own approach; • Recognition of psychiatry as the domi- nant element and a concomitant adapta- tion of cooperation patterns to accommo- date this; • Continuing insistence that cooperation is possible – meanwhile providing time, re- sources and space for the participants to develop a fully cooperative culture. These are pragmatic suggestions and their abil- ity to change the basic structures of the dual diagnosis field are limited. The analysis presented above indicates that one of the reasons why it seems difficult for psychiatry and substance use treatment to co- operate is that the two institutions do not en- ter into cooperation on equal terms and do not seem to agree on its necessity. While I was writing the first draft of this article in January 2018, the Ministry of Health issued a policy paper suggesting that the re- gions should take over responsibility from the municipalities for substance use treatment for people with dual diagnosis. The purpose of this would be to secure a better quality of treatment for these patients. At first reading this could be seen as recognition that cooperation is not the way ahead in securing the most effective treatment for people with dual diagnosis. In- deed, this is a structural change rather than fur- K. Johansen: Models for Cooperation and Positions of Power Qualitative Studies 5(2), pp. 125–139 ©2018 137 ther instigation of projects exploring coopera- tion. Looking somewhat more closely at the suggestion, however, the picture – as always – becomes much more blurred. Effective sub- stance use treatment consists of both social and medical interventions. Yet, as the regions only have competences within medicine, we risk a situation where social substance use treat- ment is marginalized in the medically dom- inated regions. Meanwhile, cooperation be- tween the medically dominated regions and the socially dominated municipalities still needs to take place, with the unequal power relations between the two parties now being reinforced with arguments of quality. Concluding Remarks This article has presented an analysis of the or- ganizational interface between psychiatry and substance use treatment. The analysis has shown that the interface is characterized by very different perceptions of the need for co- operation and an unequal relation of power be- tween the two parties. This means that the co- operation between the two central agents in the field of dual diagnosis is latently – and some- times in practice – full of conflict, meaning that the treatment for dual diagnosis in the Danish welfare state is not coherent. The data used in the article stem from evalu- ation reports from the different projects. Other data were collected through my employment in the Competence Center for Dual Diagnosis. I have hereby placed myself with that tradition of organizational ethnography in which the re- searcher investigates her own organization. As other researchers have highlighted (Alvesson, 2009; Watson, 2011), in my experience this has given me a much more thorough knowledge of the dual diagnosis field, as well as access to fora (e.g. management and strategical development) to which I would not have had access as an ex- ternal fieldworker. Yet this approach raises two central questions that for which I have no final answers. The first is the dilemma concerning how critical one can be as researcher in relation to the organization for which one works: both in regard to how critical one can be without be- ing met with sanctions, but also to the more emotional question of how critical one is capa- ble of being towards an organization by which one has chosen to be employed. Most people – and I include myself – will probably not choose to work for an organization that they think de- serving of severe criticism. The other dilemma, already touched upon in the methods section, is about transferring the privileged position of data collection into solid data. Even though one gets a much bet- ter ‘feel for the game’ (Bourdieu, 1977) by actu- ally playing it, the challenge of producing the fieldnotes that will provide the departure point for later analysis is ever present. How this may be done in practice is a continuous, but under- addressed, challenge of doing fieldwork in one’s own organization. Acknowledgements I would like to thank associate professor Bagga Bjerge for inviting me to the workshop where the first draft of this paper was presented, and to the participants at the work- shop for valuable comments. Also, I would like to thank the anonymous reviewers of an earlier draft of the paper for constructive suggestions to improve the argument. Endnotes 1. In this article I write about ‘psychiatry’ and ‘substance use treatment’ as if they were coherent institutional units with common practices and values. That is of course an analytical simplification (some might even say an ana- lytical violation). Psychiatry comprises many different things, substance use treatment even more. My reason for doing this, however, is that I want to focus my atten- tion on the interface between psychiatry and substance use treatment. I want to develop an understanding of the complexity of that interface, not of the complexity of the two institutions trying to cooperate. Exploration of the complexity of psychiatry and substance use treatment re- spectively is the province of other articles. 2. In much of this literature the focus has been on ‘conti- nuity of care’ (Ware et al., 1999). However, when dealing with the dual diagnosis field the discussion seems to fo- cus on how we can integrate psychiatry and substance use treatment, and integrated treatment seems to be the keyword (Mueser et al., 2003). 3. Besides these projects focusing on dual diagnosis there exists a number of other projects focusing on cre- ating connection between different welfare services for people with mental health problems (Folker et al., 2017). 4. I have been introduced to David Brown’s work by Professor Janne Seemann from Ålborg University who has used his concepts in her own work with institutions, including psychiatric institutions, in the Danish welfare state (for example, Christensen, 2011; Seemann, 2008). 138 K. 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London: Sage Publications Ltd. • About the Author Katrine Schepelern Johansen is trained as a social an- thropologist and has her PhD on transcultural psychia- try from the Department of Anthropology, University of Copenhagen. Since 2014, Katrine has been head and se- nior researcher at the Competence Centre for Dual Diag- nosis in the Mental Health Services of the Capital Region of Denmark. As an anthropologist Katrine has a spe- cial focus on the individual human being in the treat- ment system and the special challenges that vulnerable and marginalized patients pose in the organisation of the social system and of the health care system. Paper 1: A Qualitative Gaze on how Mundane Public Administration Works Introduction Accomplishing Public Sector Service: Theorising Interstices and Imbrications from a Qualitative Stance Contributions in This Special Issue A Case Study of Casework Tinkering Health Care Professionalism Without Doctors: Spatial Surroundings and Counter-Identification in Local Health Houses Using Ignorance as (Un)Conscious Bureaucratic Strategy: Street-Level Practices and Structural Influences in the Field of Migration Enforcement Assembling Advice Treatment of Dual Diagnosis in Denmark — Models for Cooperation and Positions of Power Cross-Pollinating Discussions and Contributions of the Special Issue Acknowledgements About the Authors Paper 2: A Case Study of Casework Tinkering Introduction Empirical Data Casework Tinkering — An Analytical Lens 1. Probing Possibilities 2. Tinkering with Services to Fit The Case 3. Tinkering with Individuals to Fit Resources Negotiating Discrepancies — Crafting a Case Response Concluding Remarks Acknowledgements About the Authors Paper 3: Spatial Surroundings and Counter-Identification in Local Health Houses Introduction Theoretical Framework: Professionalization in Site-Specific Contexts Identification and Counter-Identification Mixed Methodological Research Design: Case Selection and Vignette Construction Analytical Section: Observations and Interviews in Two Distinct Types of Health Houses The Medical–Clinical Health House: “Press If You Have An Appointment” Health Professionals in a Medical–Clinical Health House: “We Are Health Consultants” Former Cancer Patient, Now in Rehabilitation: “I Meet People Facing the Same Struggles as Myself” The Community–Based Health House: “A Flat Screen Promotes Various Events” Health Professional in a Community-Based Health House: “I Miss My Work When I Am on Vacation” Citizens on the Edge of the City: “It's the Best the Municipality Has Ever Done for Its Citizens” Conclusion: Counter-Identification With Hospitals and Doctors Acknowledgements About the Author Appendices Paper 4: Street-Level Practices and Structural Influences in the Field of Migration Enforcement Introduction Theoretical Framework Defining Structural Violence in Bureaucratic Encounters The Relation Between Indifference and Ignorance Understanding Uncertainty Understanding Ignorance Methodological Framework Ignorance in Street-Level Encounters Migrants' Use of Ignorance Ignorance as Inherit Feature of the State Conclusion — What Is The Cost of Ignorance? Acknowledgements About the Author Paper 5: Ethnographic Explorations of the Changing Relationship Between Voluntary Advi… Introduction Research Methods Citizens Advice: Some Background Theoretical Tools: On Assemblage Thinking An Advice Service as an Assemblage: The Data The Use of Volunteers On Funding, Funders and Regulatory Effects Legal Aid Funding The Funding Mosaic: Entrepreneurialism and Independence Fragile Futures Acknowledgements About the Authors Paper 6: Models for Cooperation and Positions of Power Introduction The Problems of Dual Diagnosis The Dual Diagnosis Field in Denmark Empirical Material Cooperation Between Psychiatry and Substance Use Treatment — Organizational Interfaces An Under-Organized Interface Learning Points Concluding Remarks Acknowledgements About the Author