In responding to young people’s mental healthcare needs and national policies, YCs engage in the three simultaneous, but at times contradictory, responses of protecting, managing and bending boundaries. Remaining true to their core mission as a low-threshold health-promotion service compels them to protect their boundaries and limit the type of mental health issues that, according to the FLMHCY, they should address. However, the perceived malfunctioning of specialized services and YCs’ commitment towards youth leads them to, sometimes bend these boundaries to allow in more young people with more severe mental health problems. Caught in between what they perceive as their core mission (promote health, avoid making psychiatric diagnoses) and the fact that young people with different mental health problems do present at YCs, managing boundaries to decide who should be allowed in and who should go somewhere else emerges as a middle-way response, which is not free from conflicts.
Using the concept of biomedicalization to theorize our results [
26‐
28], this study raises two crucial questions that future mental health programmes and policies for youth should bear in mind. The first relates to whether it is possible to support young people and their mental health without reinforcing discourses that represent young people as particularly vulnerable and collectively at risk [
12], and if so how this could be achieved. The second relates to the provision of mental healthcare for young people, and the need to identify conditions for integrating diagnosis and treatment within community-based youth mental health services, without hindering their holistic and youth-centred approach. Alternatively (or in conjunction), there is a need to identify conditions to ensure that services to diagnose and treat young people with mental ill health can offer the same holistic and youth-centred approach as community-based services, such as YCs. There are models, like Open Dialogue, that aim to strengthen continuity by strengthening collaboration and relying on teams of professionals from various levels to provide care that is centred on the specific needs of each individual user [
38,
39]. However, Open Dialogue has focused on addressing the needs of users who had psychiatric diagnosis. To what extent and how such model could include young people who may not require (or fulfil the criteria to get) psychiatric diagnosis has, to the extent of our knowledge, not been studied.
Youth and their mental health as the object of the healthcare system
YCs’ reluctance to engage with mental ill health diagnoses and treatment is congruent with their focus on making ‘normal’ youth their target. This focus could be interpreted as a form of resistance to biopsychiatry and its embracing of a medicalized model of psychiatric disorders [
12]. This approach of avoiding pathologizing mental health symptoms and diagnosis and instead promote personal autonomy and social network involvement is also in line with contemporary approaches of organizing and conceptualizing mental health services, seen in for example the Open-dialogue approach [
38,
39]. In our study this is demonstrated, for example, in YCs’ hesitancy to use medical-psychiatric terms despite the fact that young people themselves may utilize such language. An approach that considers sadness, grief, anxiety or stress as normal can result in the destigmatizing of certain experiences of mental ill health and a broadening of the spectrum of what it may be considered ‘normal’ to experience without being considered sickness. On the other hand, it can also risk trivializing young people’s self-perceived health problems, worries and concerns, since they are deemed ‘normal’.
Our results align with how the Swedish Association of YCs describes the core mission of these services: to focus on youth mental health instead of on sickness, prioritizing prevention and promotion, and reaching every young person by making healthcare services available nearby [
1]. Such an approach also forms the basis for the community-based mental health models that are currently being implemented in several countries worldwide [
15,
20]. Such approaches aim to improve access and reduce system fragmentation, while providing a single point of entry to comprehensive, evidence-based services [
20]. Efforts to develop policies to strengthen such approaches speak of the responsibility of the healthcare system towards youth, which can be interpreted as increased attention being directed towards young people and their needs.
From a biomedicalization approach, however, we can also interpret the focus on ‘normal’ youth and targeting healthy young people as an expansion of the mission of the health system to address life itself [
28,
40] for one specific group: young people, who thus become the target of the health system. The expansion of the medical gaze into health and life itself means that young people no longer need to have particular symptoms to be considered at risk; instead, they are all constructed as being in the potential process of becoming ill [
41] and, hence, legitimate subjects of health-related discourses [
26]. Such a focus contributes to representing young people as a group for whom risks are seen to be higher [
35,
40]. Thus, they require the knowledge and support of expert professionals in order to be properly monitored, reassured and corrected in relation to their own diagnosis, and supported in making an appropriate transition towards adulthood.
From a biomedicalization perspective, the role of medicine then becomes not only to monitor, reduce and manage risks but also to reshape the way in which we understand our bodies and lives as always open for enhancement. The aim of empowering and strengthening young people in this way can be connected with technologies of the self, forms of self-governance that people internalize [
26,
34,
41]. In this case, enhancement to make the best of oneself becomes the individual responsibility of every young person [
28,
40,
42]. The regulation of young people is no longer only achieved through the direct intervention of medical professionals, but also through behavioural and lifestyle modifications internalized by young people as they seek a transformation of their health and, ultimately, themselves [
26,
43].
Creating categories, assessing and sorting youth and their needs
Our results also highlight that healthcare services focusing on enhancing the normal and the healthy cannot exist without establishing boundaries. The problem with drawing boundaries around first-line youth mental healthcare services is not unique to Sweden. Similar models of integrated community-based youth service hubs face the problem of how to respond to young people who present with complex mental healthcare needs to services that were initially designed with promotion and prevention in focus [
14,
19,
20]. To note, as users of mental health services young people can be understood as ‘active agents’ or ‘consumers’ [
44,
45], also with the right to be engaged and involved in decision-making [
46]. The involvement of youth in their healing is a key feature in the recovery literature that implies a shift of perspective from the health provider to the individual and personal perspective on the experience of mental health and the recovery from mental health problems [
47,
48]. Digital health technologies and social media are relatively new arenas where they can seek and produce knowledge, and share experiences, to make sense of their bodies and health [
44]. By this, also youth themselves are engaged in creating categories, assessing and sorting their needs.
A mental health subsystem that is structured into different levels of care requires that young people are sorted, in a process of ‘triage’, into categories and cared for in different places. Triaging to distinguish between who can be cared for within YCs, and who cannot, not only organizes the work and divides responsibilities but also contributes to representing two distinct youth subpopulations: those who are mentally healthy, and those who are mentally sick, and creates a division between mental health and mental sickness. Such a division can be interpreted as building upon biopsychiatric conceptualizations of mental illness and health as a single bipolar dimension, with mental health at one of the extremes and mental illness at the other [
49]. Within such a binary conceptualization, YCs should only deal with mental health, and specialized psychiatric services should deal with sickness/diagnosis. On the other hand, YCs’ focus on ‘the normal’ and ‘the healthy’ can also be interpreted as a conceptualization similar to Keyes’ continuum of mental health, which considers that, instead of being opposite extremes, mental health and illness are ‘distinct but correlated axes’ (p. 546)[
49]. Under such a conceptualization, mental health should be addressed in its own right, being itself a continuum between flourishing and languishing – where languishing does not equate with mental illness. Our results highlight that both conceptualizations (binary, continuum) seem to coexist within the Swedish mental healthcare subsystem. In this scenario, it becomes difficult for YCs to reconcile a focus on mental health in its own right (aiming to promote the flourishing of mental health) while at the same time approaching it as one extreme of a binary (aiming to prevent progression to mental ill health). We agree with Sweet [
30] that, while continuum discourses may suggest that ‘we have moved away from binaristic notions of normality and wellness, binaries still operate importantly in psychiatric discourses, even those that circulate as progressive and humanistic’ (p. 105). To summarize, while YCs focus on ‘the normal’ and enhancement can be interpreted as a shift towards a conceptualization of normality as a continuum, such a continuum does not encompass every experience of mental ill health.
The process of setting boundaries for what constitutes mental illness is often based on expert knowledge [
26]. From our results, the complaints articulated by young people who present at YCs, for example anxiety, were deemed by the participants to differ from mental ill health. This shows that anxiety in its diagnostic form is understood as something for healthcare professionals to judge and decide upon, not the young people themselves. This can be connected to the idea of expert positions and knowledge having the power and means to distinguish between the mentally healthy and the mentally ill [
27,
28]. The creation of boundaries and classifications requires an apparatus for its own functioning and preservation: expert professionals who are able to judge, instruments to make such classifications, and referral pathways to link one service with another, to name just a few. On the one hand, such a system creates possibilities, in terms of access to wider or specialized resources, the use of standards that are less arbitrary, and facilitate monitoring and evaluation, which can enhance quality. On the other hand, the complexity of the system and the fact that it reproduces the mainstream way of organizing healthcare makes it difficult to challenge and think of other, alternative organizational forms. The possibility of having services that could deal with the whole spectrum of mental health and ill health was, in fact, never mentioned. This could be tracked back to how mental healthcare, in Sweden and elsewhere, is organized around diagnosis and/or stages. In this way, the mind/body divide is also reproduced, and mental and physical/somatic health are kept separated – all according to a biomedical model of organizing health services.
Establishing diagnostic categories and separating the healthy from the sick, the body from the mind, lies at the core of medicalization processes [
29], of which biopsychiatry is an exponent [
12]. Such a structure allows for increasing specialization, which, arguably, can provide a better response to needs that require specific competences. However, specialization has also been criticized for contributing to fragmentation, and as not being the best way to approach bio-psycho-social complexity [
50], which is often the situation in youth mental health. While the benefit of this specialized way of organizing is that it claims to offer more adequate care due to different needs being catered for in different spaces that are appropriately specialized, our results indicate that such boundary creation makes it harder for young users to navigate the system and to find the care they need. If holistic and youth-centred care is equated with prevention, promotion and health and the work of first-line services, then those young people who are considered too mentally unwell might be left out of prevention and promotion initiatives. Here, while the low threshold of YCs and similar services is imagined to improve access for young people, we can also reimagine it as limiting this access to certain groups of young people, those who, in fact, may be most in need of care and support.