The reduction in the number of psychiatric in-patient care (de-hospitalization) beds began in the second half of the 1900s in most industrialized countries. In many Scandinavian cases, mental hospitals have, to a great extent, been replaced by psychiatric interventions and social support in open care, principally regarding housing and recreation. A call has also been issued for new knowledge about the construction of mental problems and practices conducive to recovery (de-institutionalization) in the Scandinavian countries (Arvidsson & Ericson, 2005; Borg & Askheim, 2010; Topor, Andersson, Denhov, Holmquist, Mattsson, Stefansson, & Bülow, 2015). The central feature of this process in Scandinavia was the normalization of the living conditions of persons with severe problems and not of the person him/herself (Arvidsson & Ericson, 2005; Eriksson & Hummelvoll, 2008). Patients were now to be regarded as service users and citizens with the same rights as all other citizens.
The concept of normalization and citizenship incorporates the notion of equal rights for every individual to basic civil, political, social and economic opportunities. This equality also includes the right of every individual to be protected from exclusionary laws and social practices that may lead to segregation or discrimination of any kind. It is acknowledged, however, that the existence of laws protecting these rights does not necessarily lead to their implementation. This tendency is evidenced by the fact that many people with mental disorders or substance abuse problems are often prevented from accessing goods and services because of the stigma attached to their situation (Prior, 2007).
Inside psychiatric institutions, written and unwritten rules and regulations were emphasized as an important part of a therapeutic environment (Castel, 1988; Larsen, 2009; Larsen & Terkelsen, 2013; Metzner, 1998; Øye, Bjelland, Skorpen & Andersen 2009). The written house rules most often pertained to a regular everyday schedule involving, for example, mealtimes, bedtime, and leisure activities. Moreover, the house rules regulated where and when a patient was allowed to receive visitors. They also prohibited the use of alcohol and drugs. Those rules were seldom open for discussion (Bowl, 1996; Øye et.al, 2009). Following de-hospitalization and the focus on civil rights and empowerment, the tension between authoritarianism represented by the rules and individual user participation has become a challenge (Storm & Edwards, 2013). Infraction of some rules in various housing types in the USA was sanctioned by various forms of punishment (Segal & Moyles, 1997). In addition, certain «unwritten rules» regulated, for example, the number of cigarettes one could smoke per day, when one had to stop drinking coffee in the evenings, what to talk about and not talk about in the common areas and how to behave with fellow patients (Larsen, 2009; Larsen & Terkelsen, 2013).
The studies by Pfhol (1972) and Solan (2012) focus on rules inside psychiatric hospitals versus standards in legislation. They conclude that because the rules are meant for the protection of individual patients, they cannot be instructed according to a «one-size-fits-all» principle. One meta-analysis of housing models for persons diagnosed as mentally ill found three different models of housing: (1) In the Residential care and treatment housing model, house rules were often written and implemented solely by housing staff. As such, they tended to prioritize residents who needed continued treatment but were able to follow the rules. (2) The Residential continuum housing model had written recovery goals. (3) The Permanent supported housing model had few rules of conduct but stressed abstinence from alcohol and other drugs (Leff et. al, 2009).
Some research studies focusing on the life of people with mental health problems living in the community mention house rules. Eriksson and Hummelvoll (2011) write about expectations and demands in a day center, such as «not hurting others» and «not being drunk or having a hangover» (p. 419). House rules in sober living houses include regulating smoking and abstaining from alcohol and drugs (Polcin et. al., 2010).
Analyzing house rules in sheltered housing and day centers may be one approach in identifying some qualitative aspects of the new organized living conditions for people with mental health and substance abuse problems. In such services, created to facilitate de-hospitalization, a new organization of specific parts of everyday life was to be established and new sets of rules formulated. It might be expected that those rules would reflect the inclusionary life as a community citizen (Barham & Hayward, 1991). In this article, we aim to analyze how written house rules in sheltered housing and day centers in CMHS are presented and what they are about. Additionally, we place and discuss our data and analysis in the context of de- and re-institutionalization.
This study is part of a research project that aims to explore, describe and analyze the normalized living conditions for people with severe mental health and/or substance abuse problems. The data was collected in all the housing facilities and day centers in a Southern Norway municipality with 43,000 inhabitants and about 500 service users in the mental health and substance abuse services.
Institutional rules in CMHS regulate important parts of the user’s daily life. In order to extract how people with mental health and substance abuse problems are presented, it is important to collect data from various services regulated by house rules.
Data collection and material
The data was collected from four sheltered housing facilities and three day centers. Three of the sheltered housing facilities were run by the municipality, and people with mental health and drug problems were living there. One was run by a voluntary organization. All the day centers having house rules were run by the municipality.
One sheltered housing facility used only the Norwegian Tenancy Act (Husleieloven, 2007) as the basis for the contract between landlords and tenants. The law regulates agreements for the right to use property in return for compensation and is of relevance for the rights and obligations of the landlord and tenants in the included sheltered housing. Consequently, the law is used as a point of reference in the study.
We chose qualitative content analyses. On the one hand, this analysis focuses on the visible, obvious components in the text, referred to as the manifest content. On the other hand, this analysis deals with the relationship aspect and involves an interpretation of the underlying meaning of the text, referred to as the latent content (Kondracki, Wellman, & Amundson, 2002).
We began the analytic process by reading and rereading the collected house rules (Jacobsen, 2005). First, we read them individually to sort out what each of us experienced as the obvious message. Then we came together and discussed the language used by and the content contained in each set of house rules as well as what the latent content might be. Then we discussed the house rules in the context of de- and re-institutionalization and how people with mental health and substance abuse problems were presented. As a result of this process, we discerned some patterns in the house rules in general and some patterns related to the services’ target group.
We also read the website presentations of the different facilities to ascertain who the places were meant to serve and who was working there. Studying the websites was one way of contextualizing the house rules. Another way of contextualizing the services was to read the Norwegian Tenancy Act regulating the rights and obligations for landlords and tenants in general, in addition to policy documents at both the local and national level. The goal of this reading was to get a better grip on the local understanding of the concept of normalization and citizenship.
When analyzing, we noticed that the presentation of the house rules varied, as did the one meant for sheltered housing and the one meant for day centers. We became aware of the form of the language, leading to five themes: 1) commanding; 2) threatening; 3) appealing; 4) expressing community solidarity; and 5) formulating precisely. We also analyzed the content and found the following five themes: 1) order; 2) cleanliness; 3) use of drugs; 4) social life; and 5) atmosphere.
Ethical and methodological considerations
When analyzing the content, our own experiences became part of the interpretation, and sometimes we became critical of what we interpreted as strong regulation of people’s daily lives. This might seem unfair to the rule makers, and we are aware that all the rules have been written for the benefit of both the service users and the staff. Therefore, we presented and discussed a preliminary analysis of the house rules with a panel of service users and leaders from the municipal services. The panel informed our analysis and we quote some of the comments from the service users and the leaders in the article. Additionally, the service users recognized the rules from other parts of the mental health and substance abuse services with which they were familiar.
The study aims to explore and describe how written house rules in sheltered housing and day centers in CMHS are presented and what they are about. The main findings are presented under the heading «The construction of the house rules.» However, initially it seems important to provide a brief presentation of the house rules in order to contextualize the findings.
Presentation of house rules for housing facilities
The house rules from the municipality-run sheltered housing are all written on one page. Moreover, the rules from two facilities are quite similar. They consist of 13 numbered rules and have only a few rules written differently. The heading of the documents is «House Rules.» The first sentences refer to the Norwegian Tenancy Act, expressing that the tenants have fewer rights than tenants in ordinary residences. The documents end with the sentence: «Violation of the house rules may result in the termination or cancellation of the contract.» It is to be noted that although two different facilities had quite similar house rules, the places were meant for people with various needs of support. The tenants at one of them had staff on hand both day and night, while the other had staff available only during the daytime.
At a third facility, the rules were simpler. There was no opening sentence nor any ending or signature line. The document consisted of nine numbered rules. According to the leaders in the municipality, this place had very few tenants and the document labeled «House Rules» was understood to be more a part of the individual treatment meant for one of the tenants. Hence, the leaders were surprised that the document was presented as house rules. This comment made it easier to see that the origin and purpose of the house rules were unclear. None of the set of rules had a visible author. Except for one, it was not clear when the house rules had been written or how long they were intended to remain in force.
The current edition of the house rules from the place run by the voluntary organization was edited in September 2013. It is written on two pages and consists of 18 rules. The first sentences underline the tenants’ responsibility to obey the house rules and make sure that visitors comply accordingly. The paper ends by stating that violation of one or several of the house rules might lead to termination of the contract.
Another housing facility run by the municipality did not have internal house rules but followed the Norwegian Tenancy Act. Some of the other housing facilities did not refer to this law at all. The commonality was that they were all intended to regulate people’s everyday lives in their own homes in different ways.
Presentation of house rules for day centers
The house rules in the day centers differ in both form and content from those representing the sheltered housing. One set of house rules consists of nine rules and is decorated with a leaf fringe border. Under the heading «Welcome to [day center] user-led center – creative workshop,» there is an introduction and a list of six points concerning what this center expects from the service users. Three smiling faces complete the presentation. The last set of rules from the day centers was called «House Rules [day center]» and consists of eight rules. A picture of a cream cake ended the rules. None of them had the author visible or a space for signing the document.
According to the panel of service users and leaders from the municipality services, all house rules were solely written by professionals except the one that was service-user-managed.
The construction of house rules
Five themes were analyzed regarding the language form of the house rules: 1) commanding; 2) threatening; 3) appealing; 4) expressing community solidarity; and 5) formulating precisely. The analysis of the content of the house rules resulted also in five themes: 1) order; 2) cleanliness; 3) use of drugs; 4) social life; and 5) atmosphere.
The language form of the house rules
First of all, the house rules in the day centers and sheltered housing differ in language form. While the rules from some are presented in an official language, those from another are written in a personal style. The rules were sometimes written in poor language; the sentences were not complete and the expressions used were open to different interpretations. Nevertheless, the house rules were written in an instructive way and seemed to reflect an ambition to convey a clear and unambiguous message.
Commanding. The language used in the house rules for most sheltered housing had what could be called a commanding tone, such as «you are obliged to …,» «you are not allowed to …,» «it is forbidden …,» «you have to …,» «you are responsible for …,» and «… are not accepted.» One, «Alcohol is not allowed in the car,» seems adapted to a local situation and can be interpreted in various ways. A day center also had commanding expressions like «not allowed to …» and «not accepted …» (e.g., about drugs). This commanding tone is not to be found in the Norwegian Tenancy Act used by one of the sheltered housing facilities or in the day centers.
Threatening. Sometimes the tone in the house rules for some of the sheltered housing was more threatening, such as «commercial dealing in drugs, or suspicion of it, will be reported to the police,» «illegal drugs will be reported to the police,» and «breaking the house rules may result in termination or annulment of the tenant’s agreement.» A housing facility run by the voluntary organization had 1 of 18 rules that could be interpreted as having a threatening tone: «Violence/threats against either staff/volunteers or tenants are unacceptable. This will be reported.» This threatening tone was also found in rules for the day centers but in a milder form. One day center had this stipulation: «Any kind of drug is unacceptable in the day center and might result in expulsion and/or loss of the service.» Another had: «Users who are obviously intoxicated will be expelled but are welcome to return later.»
Appealing. Unlike the sheltered housing facilities, an appealing tone was found in the house rules for two of the day centers, for example, «the day center is based on mutual trust,» «respect the opening and closing times,» and «work to avoid people making cliques, and at the same time, take care of the service users.» In addition, the user-led center had one appealing rule: «Here we respect each other and our creativity.»
Expressing community solidarity. Sometimes the day centers used «we» like a statement of community: «We show each other common politeness and code of behavior» and «We also tidy and clean twice a year.» The user-led center used formulations like «please,» «here we,» and «we want you to» as well as decorations that reflect a different atmosphere than that found in a municipality-run institution. The last rule in one of the day centers stated: «Do unto others as you would have them do unto you.» Statements of community and politeness were not found in the rules for the sheltered housing facilities.
Formulating precisely. Some of the rules had an exact and detailed form, for example, «one is not allowed to refuse admittance of the staff to visit the apartment,» «the main entrance is locked all day and night,» «you pay 100 kroner for a key card,» and «the apartment must be cleaned once a week.» These rules made it clear that tenants have to open the door for the staff, pay money if they needed a key card, and clean regularly.
Other rules were unclear and difficult to understand just by reading them. Some examples are «the tenants are obligated to receive the services offered by the municipality,» «common decency toward the staff is obvious,» «if you behave rudely, you have to go to your apartment,» «do not drink together with other residents,» and «keep your own apartment tidy.»
In formulating rules one opens the door for uncertainties. It should be kept in mind that all the rules, except those of the user-led center, represent the professionals’ voices, even though they are ambiguous. It remains unclear what the rule makers mean by «the service offered.» In addition, terms like «common decency» and «rude behavior» are difficult to interpret because their meaning depends on who someone is, who he or she is together with, and where he or she is. Additionally one might wonder why the tenants are not allowed to drink with others. Maybe they mean «do not drink alcohol,» but this is not how the rule is worded. Moreover, was drinking alcohol while alone acceptable while drinking in company was not? The Norwegian Tenancy Act is also unclear when writing about «common» behavior, because what is common behavior?
Obvious differences are to be found between the house rules representing sheltered housing in the municipality and those representing the voluntary organization. The latter seem more detailed and thoroughly prepared, as is most of the Norwegian Tenancy Act. The user-led center reflected a spirit of community and politeness throughout its rules and is meant for unemployed people in general and not only for people with mental health or substance abuse problems.
The content of the house rules
The content is intended to regulate people’s daily lives. It is concerned what the staff members are allowed to do in the tenants’ apartments but not about what the tenants can expect from staff.
Order. All sheltered housings had rules about order. Peace and quiet at night was highlighted, and there was the added stipulation of «no noise between 23:00 and 07:00.» However, the Norwegian Tenancy Act is not specific but rather appeals to «common peace and quiet.» Additionally, two sheltered homes stressed that «volume from music, TV, etc. must not disturb other tenants or staff.» One home had a rule stipulating: «In the case of vandalism there will be a claim for compensation.» Another had: «If willful destruction of property is suspected, the staff is also able to unlock the door to the apartment.»
The day centers also had rules about order. Two told the service users to put dishes in the dishwasher and encouraged them to keep things in order.
Cleanliness. Two housing facilities had rules about cleanliness. One rule said that «all tenants have to keep things tidy in their own apartments,» and house rules in another said that the apartments had to be cleaned once a week. Some rules were about keeping outdoor areas tidy, and others were about disposing of litter and where to throw it. Two day centers had no rules about cleanliness; the third had one about voluntary work twice a year to clean the center.
Drug use. Drug use was stressed everywhere in the rules for the sheltered housing facilities. Two had rules about alcohol and drug consumption, which was forbidden in the common areas. All the housing facilities said that dealing drugs was forbidden. In one of them, 8 of 9 rules were about restrictions on alcohol consumption, smoking, and dealing drugs. The Norwegian Tenancy Act has no rules about drugs.
Two of the day centers had rules regarding drugs, stating that drugs were «not accepted» or «users who are obviously intoxicated will be expelled but are welcome to return later.» It is to be noted that the day center run by the service users themselves had no rules about drugs, and another center meant for people with severe drug problems had no written rules at all.
Social life. The house rules regulated the tenants’ social life in different ways. Two housing facilities allowed the staff admission to the tenants’ apartments without permission. Members of the staff «are allowed to send off unwanted visitors» and they also had a key and were able to unlock the door to come to the assistance of a tenant if they thought his/her life was at risk.
Three house rules from the sheltered housing as well as the Norwegian Tenancy Act mentioned pets. In those housing facilities, «one is not allowed to keep pets in the apartments.» The Norwegian Tenancy Act used in another housing facility was less strict, saying, «Even if the owner says it is forbidden to keep pets, the tenant can keep pets if there are good reasons to do so.» The day centers’ house rules did not mention animals.
Other restrictions that might involve people’s social lives in their own homes pertained to such matters as when the tenants were allowed to lock their doors, undesirable visitors, guests staying overnight, and the use of alcohol. Those aspects are not mentioned in the Norwegian Tenancy Act.
Two housing facilities had rules about what was unacceptable to discuss. The first did not want the service users to talk about medication, illness, and private matters that might be «annoying to others.» It stated, «You have to talk to the therapists/nurses about difficult problems and how to solve them.» The latter mentioned the day center as «a neutral place regarding religion, culture, and politics.» This rule did not clearly formulate that service users were not allowed to talk about these issues, so the specific consequences of this rule remained obscure.
Atmosphere. All the centers had rules about what kind of atmosphere they wanted to create. Examples include «the day center is based on mutual trust,» «be aware of each other,» «nice and caring atmosphere where we appreciate each other,» «respect each other and our creativity,» and «no bullying and slandering.» the sheltered housing facilities had no such rules.
House rules are part of sociocultural and ideological discourses about persons who live in sheltered housing facilities or visit day centers. Hence, they might reflect the ideology behind the creation of post-hospital services in the community. It is possible to argue that the rules are formulated based on the will to care for the service users, and as such they tell us something about the professionals’ way of caring. In the discussion, we aim to reflect upon the possible social consequences of these pictures for the affected citizens. Additionally, we discuss whether this picture reflects a practice inherited from the in-patient care.
Pictures of the service users
It seems possible to claim that the specific rules in the new institutions over and above common law reflect an image of special persons in need of special attention: an organized normality, the contrary of normalization (Hansson, 1993). Moreover, the written rules seem to represent an understanding of people with mental health and substance abuse problems as people who are unable to control themselves and therefore are in need of being controlled.
The basic picture derived from the house rules, even though these rules vary and are sometimes unclear, is that service users seem not to be perceived as individuals but rather as a group with characteristics common to people with psychiatric or drug disorders who can be disciplined through general rules—often having a threatening or commanding form. Thus, the service users might be understood as not being able to know what is good for them, and they may be in need of being told what to do in a language that implies suspicion, especially in relation to their own homes. According to the rules, the service users are addressed as though they are unable to understand the need for order and cleanliness, and even if they do so, they are not capable of making their own decisions and putting them into practice. Additionally, they are seen as needing to be informed, for example, about how often they should clean their homes. The characteristic focus on keeping things neat and clean suggests the rule makers’ preconceived notions and experiences of the service users as untidy.
Another part of the picture of people with mental health and substance abuse problems seems to be that they are unpredictable and may become dangerous to themselves and others. This notion might be reflected in the rules about vandalism and the claim for compensation. In general, some rules seem obvious, and it should not be necessary to have written rules about compensation for vandalism or drug dealing. Both are forbidden everywhere.
Not being able to take care of oneself is also found in the rules that give staff the right to send away unwanted visitors. However, this notion may also derive from the preconception of a general impairment of the tenants’ capacity to conduct a social life based on reciprocal relationships. This could be confirmed by the rule mentioning that the residents are not allowed to have friends stay overnight or even to have their own cat or dog. The residents have to make an appointment with the staff the previous day just for one person to sleep over, and not for more than two nights. The incapacity to make good choices in their social lives is clearly expressed in one rule: «The staff decides who unwanted guests are.» This preconception is in line with what Juhila, Hall, and Raitakari (2010) write, «Principles like self-determination and choice are constantly compromised when faced with practice exigencies» (p. 60).
The written text about the service users lacks their contribution (except for one). Nevertheless, it must be mentioned that the content in the rules from the user-led center does not differ very much from those from the other day centers. The ideology of de-hospitalization was to transform the patient into a full-fledged person and a participating citizen. The house rule discourses perpetuate the picture of the helpless patient. The users of two day centers even have restrictions on what to talk about. In normal, non-institutionalized settings people talk about personal matters with each other, but in the new normalized institutions designed for coming together and meeting people, one is not allowed to talk about problems with friends or staff. Instead, one has to talk to a healthcare professional.
This can be considered the opposite of both the national and the local mental health policy in Norway. In the healthcare plan for the municipality where the house rules were collected, the following policy is emphasized: «The future healthcare services need to emphasize user involvement and possibilities of choices for each individual» (X Municipality, 2010, p. 16). The local policymakers strongly emphasize the importance of user involvement and user-tailored care. The house rules make way for a different practice. Russo & Beresford (2014) write, «Mad voices have been—and continue to be—not heard, overwritten, silenced, or even erased in the course of psychiatric treatment» (p. 1).
An inherited practice?
As a part of the de-institutionalized community-centered care, the policymakers wanted to deconstruct the picture of people having mental health or substance abuse problems as unreasonable people in need of being controlled. Thus, they desired to construct a new picture of the service user: a person who is able to cooperate and negotiate with professionals under equal conditions. It is doubtful that specific house rules could be part of this kind of narrative, and the ambition of normalization of the living conditions is still unfulfilled. In some ways, the house rules still stress that the service users are in «lack of reality testing» and that their capacity for social relationships is impaired (American Psychiatric Association, 1994).
The way of understanding seemed influenced by the ideological practices inherited from constructions made before de-hospitalization in the mental health services took place (Scull, 1989; 2005). Thus, house rules construct the person not as a common citizen but rather as a marginalized person unable to conduct a «normal» life. The discourses are in line with those developed inside the psychiatric hospitals when the overcrowded institutions were reduced to controlling and regulating all aspects of the patient’s life, in what Goffman called the «total institutions» (Goffman, 1961). It was difficult to find differences between house rules formulated in the one housing facility for persons with drug abuse issues and the other facilities meant for people with both drug and mental health problems. The perpetuation of an ideology inherited from the «total institutions» is also found in the rules of the day centers. Nevertheless, such rules can be analyzed as a tool of reason to control the unreasonable.
House rules tend to reproduce the old image of an outsider and perpetuate old institutional identities.
As it looks today, the institutions should not be credited in the process of restoring persons with severe mental illness and drug addiction to participanting citizens. De-hospitalization in the Scandinavian countries was intended to be synonymous with de-institutionalization and to include a normalization of those patients’ living conditions. Specially designed regulations and local rules can be considered as counterproductive in this quest. Instead, the use of house rules tends to reproduce the old image of an outsider and perpetuates old institutional practices and identities in both people’s own homes and the places designated for recreation and social gathering.
According to the official discussions of normalization, house rules should not perpetuate the old conceptualization of persons with mental illnesses or substance abuse problems as «others.» It should instead promote the view that they are equal citizens. In creating new settings, special attention should be given to the material conditions and the regulation of everyday life of the persons who are intended to benefit from the services. Do these measures normalize living conditions, or do they focus on normalizing the person? More importantly, are house rules a mechanism by which to institutionalize rather than de-institutionalize?
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