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Engagement and Barriers in Help-seeking of Dually-diagnosed Mothers: Grasping life or letting go?


MSc Minna Sorsa defended her doctoral thesis at University of Tampere, Finland May 9th 2018

The opponent was professor Lena Wiklund Gustin from Arctic University, Norway. 


In the acknowledgements section of her thesis, Minna writes: ”The ENTER Mental Health Network inspired me to pursue the subject of care in complex life situations, and I am deeply grateful to the ISADORA project, which opened my eyes to the problems of addiction and dual diagnosis.”


The aim of Minna’s study is to describe and explore help-seeking and connecting with different services by mothers suffering from both mental health and substance-abuse problems at the same time, the dual diagnosis syndrome. She seeks answers to the following questions: 1) What kinds of barriers exist with regard to help-seeking in the service delivery system for a dually-diagnosed mother seeking help? 2) What creates engagement in the service delivery system when a dually-diagnosed mother seeks help? 3) How can researchers influence data in open-ended qualitative interviews? 4) What is the theoretical structure of engagement and the barriers in help-seeking for dually-diagnosed mothers?


The background of the study is the complex life situations of persons with dual diagnosis. Mothers with a dual diagnosis may decide not to seek professional help, which is controversial from the service delivery standpoint, as a fundamental goal of the service delivery system is to ensure the well-being of children. A history of adversity reveals many reasons why barriers may emerge and why services designed to assist clients may actually result in additional barriers to care. The context and the theoretical lens utilised: the mental health model and the cultural determinants of help-seeking. Help-seeking and engagement have not been sufficiently conceptualised in psychiatric and mental health nursing. The tools within mental health care could be further developed to eliminate barriers and promote inclusion as the goal of equitable service provision.


The study materials: a case study (n=1), staff interviews (n=104) in a specific geographical area and an ethnographic field study at a low threshold service, including observations, field notes and interviews with staff (n=12) and clients (n=2). The methods utilised are Giorgis’s phenomenology, conventional content analysis and Leininger’s ethnographic analysis. The studies were synthesised using Noblit and Hare’s meta-ethnography. Additionally, a literature review was conducted on bracketing in open-ended qualitative interviews.


The result is a situation-specific model of engagement and the barriers to help-seeking faced by dually-diagnosed mothers. The results show that the vulnerable background of clients creates barriers from the standpoint of the client, staff and the service delivery system.


Help-seeking may be a long-term process. It requires action on behalf of the client, when not all clients have verbalisable wishes and needs. Engagement is formed at the experiential level for mothers, and it requires specific sensitivity to the interfaces and micro-moments and different interfaces where clients connect with services. The mother’s experiential and emotional level of engagement differs from her practical level of engagement. The inner experiential level of engagement is described via the metaphor of a seed recognising the client experience being valued and the importance of the environment. Barriers and engagement are co-created between the mothers and staff and the staff’s potential to approve of their client’s past. Barriers may operate in such a way that connections cannot be formed.


Engagement is the phase when a therapeutic alliance does not yet exist, and it can occur repeatedly. Interfaces consist of all types of boundaries or settings where the client encounters service delivery. It consists also of interfaces other than just verbal communication, such as the availability of staff. The tool suggested for mental health care is an individualised, family-oriented, knowledge-based and humane approach within a wide variety of interfaces and micro-moments in time. Sufficient time resources and perseverance are needed. Special attention was given to bracketing, since researchers themselves also affect the research process. Bracketing, disclosing the past or using pre-understanding intentionally are implemented not to influence the participant’s understanding of the phenomenon.


Finding solutions at policy and service delivery levels to help these mothers is a priority, and the study demonstrates a core process within the services: the clients cannot be helped without their own engagement and motivation. One reason for the presence of barriers may be that the staff can only partly make use of their knowledge and expertise obtained from training, since organisational functioning and the time pressures placed on practitioners may build walls rather than eliminate them. Staff should revisit their ethical requirements as a prerequisite to helping each client. On a policy level, while the tools for enhancing the inclusion and participation of dually-diagnosed mothers as well as their positive mental health do exist, a key issue is to decide who bears the ultimate responsibility.



The thesis can be found at:

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