Everyday work, working culture and patient care. A qualitative study on professionals’ perceptions of the establishment of a specialized brief therapy unit in a district psychiatric center. CURRENT

Background: Increasing mental health problems and a scarcity of treatment resources put pressure on service innovation in mental health services. Innovative efforts include providing brief or short-term treatment to patients who have moderate mental health problems. So far, there is limited knowledge on how implementing brief therapy approaches in mental health organizations influence the professionals and their work. The aim of this study was to explore the professionals’ perceptions on how the establishment of a specialized brief therapy unit in a district psychiatric center had affected the work in the outpatient clinics, specifically the everyday work, working culture and patient care. Methods: Eleven professionals, five men and six women, took part in semi-structured individual interviews. All participants were between 40 and 60 years old and had leading or coordinating positions in the organization. Their professional backgrounds were within psychology, nursing and medicine, most of them specialists in their field. Results: The professionals’ experiences represented four main themes: (1) The brief therapy unit was perceived as successful and celebrated. (2) The general outpatient clinics, on the other hand, were by some, perceived as “forgotten”. (3) The establishment process had elucidated different treatment cultures in the outpatient clinics and had set off (3) a discussion regarding the criteria for prioritizing in mental health services. Conclusion: Implementation of new services calls attention to the distribution of scarce resources and differences in professional cultures. A strong focus on efficiency might challenge professionals’ perceptions of autonomy. Focusing on patients with moderate mental health problems can raise questions concerning resource use and the appropriate level of treatment provision. Before implementing new services, it is important to ensure information and, if possible, understanding for the process in the organization.

3 challenges for communities in terms of production loss and health and social care expenses [2]. This also implies indirect costs like sickness absence, disability and early retirement [1,4]. Improved psychological treatments are needed to reduce the burden of mental illness [2,3], calling on the health sector to increase cost efficiency [5]. Scarce resources have led to a growing interest in evidence-based approaches in psychiatric and psychotherapeutic treatments that are cost-effective [6], contributing to a focus on innovation and flexibility.
In Norway, the health authorities have identified several important challenges for the mental health services in the future; changes in the population, a need for clearer requirements for documentation of quality, scarcity of employees in the health services, and slowing economic growth in secondary care [7,8], generating a need for change in the mental health services. Here, innovation is described as developing new products, services or organizational forms that contribute to increased quality, improved work processes and safety for patients and employees. Service innovation is closely linked to development projects in hospitals and is expected by the authorities to be important for strengthening the organization and operation of the future health services. The development of innovative therapy approaches is expected to help reducing waiting lists, filling gaps in current services, standardizing information exchange and improving clinical pathways. [7,8].
In order to meet the increased pressure on the mental health services, a District Psychiatric Center (DPC) in Central Norway set an example of service innovation. From 2009 to 2014 the center had an increase of 42 % in referrals of patients in need for outpatient treatment, and the number of patients who needed such treatment increased with over 43 % [9] To answer this challenge, the DPC in 2016 added a specialized outpatient unit to their general outpatient services. The objective was to provide brief therapy for patients diagnosed with moderate affective and/or anxiety disorders, expecting to achieve good treatment results for this specific patient group [9]. This DPC was the setting for this study.
Brief therapy is defined as an efficient mental health therapy approach, focusing on the present ("here and now") and the patient's strengths, and having a decisive approach [10]. In addition, brief therapy is time limited, and, although debated, the words short-term, time limited and brief therapy 4 are often used interchangeably [10]. Limitation of therapy processes developed originally as a contrast to long and comprehensive psychoanalytic treatment [10]. Studies have shown that shortterm psychotherapeutic psychotherapy is beneficial for adults with common mental disorders [11], and short-term cognitive behavioral treatment (CBT) has a good effect on depression and anxiety [12]. Others have shown that a limitation of treatment in fact can accelerate symptom reduction and thereby improved the outcome [5,13]. Many studies have investigated the appropriate length and comprehensiveness of treatment to achieve adequate treatment effect for different patient groups [10]. Studies exploring the therapists' perspectives show, on the other hand, skepticism regarding limitation of treatment, fearing that therapy becomes superficial and less client-centered [14,15].
Although brief therapy is shown to be an efficient treatment approach for several patient groups [5,[11][12][13] evidence does not guarantee that knowledge will be successfully implemented in practice [16]. Implementing a new service or unit in an organization usually faces many potential barriers and facilitators embedded in the characteristics of the intervention; the setting, the individuals involved, and the implementation process [17]. Context, complexity and process have been described as aspects that influence the outcomes from implementation efforts [16]. The establishment of a new treatment unit providing a specialized service, such as brief therapy, to a specific patient group, might thus influence the organization in several ways. The aim of this study was therefore to explore the professionals' perceptions on how the establishment of a specialized brief therapy unit had affected the work in the outpatient clinics, specifically the everyday work, working culture and patient care.

Methods
This was a qualitative study with individual in-depth interviews with professionals in a DPC. The study was conducted from October 2018 to February 2019.

Study setting
In Norway, health care is organized at two levels, in the primary or secondary health services. The responsibility and supervision for most secondary services and the hospitals lies with Ministry of Health and Care Services, while the municipalities provide primary care services such as preventive 5 services and general practitioners (GPs) [18]. Psychiatric care is organized as treatment wards in hospitals and as DPCs, the latter can be organized within a larger hospital. The Ministry of Health governs the DPC's activities through the Regional Health Authorities in annual "letters of instruction" [19].
The DPC in the present study was part of a university hospital in Central Norway, producing 260 manyears and being one of three similar DPCs in the hospital trust. The catchment area included approximately 110.000 persons in urban and semirural areas and parts of a large city. The DPC provided in-patient treatment, ambulatory services, and different types of outpatient treatment.
Patients were mainly referred to the DPC from their GP, or by psychologists or psychiatrists in private practice. The DPC determined whether treatment was needed and offered a right to treatment within a specific time period (a waiting period guarantee). Before 2016, the DPC's outpatient services was organized in three outpatient clinics, all with a generalist focus. In 2016, one of the general outpatient clinics was selected to provide brief (short-term) therapy in a delimited unit [9]. The unit encompassed 10.5 therapists specializing in short-term therapy, in contrast to the more generalist approach in the other general outpatient clinics in DPC. The unit's target group was patients with anxiety and/or depressive disorders who previously had good functioning and self-esteem, but with a sudden fall in function, reactive states or sudden life events [9]. Treatment in the brief therapy unit was limited up to ten treatment sessions, individually or in groups, and included CBT [20], metacognitive therapy [21], mindfulness [22,23] and Acceptance and commitment therapy [22].

Participants and recruitment
Eligible participants in this study were leaders and key personnel on different levels in the outpatient clinics at the DPC, as well as the head clinic leader and leaders of the mental health services at the hospital. They received written and oral information about the study and were asked by the first author (HVM) to participate in individual interviews.
The sampling aimed at recruiting participants that had experience with the implementation of the brief therapy unit, and of the operation of the different parts of the DPC's outpatient services. Initial study participants were suggested by the DPC's management. The first author (HVM) subsequently 6 recruited additional relevant participants to strengthen the diversity and representativity of the sample. Twelve participants were asked and consented to participate in the study. Due to illness, one of the informants was unable to participate, and the final study sample included 11 professionals.

Data collection
Interviews were conducted using a semi-structured interview guide [24]. The guide included themes and questions intended to allow the professionals to reflect and discuss how the establishment of the brief therapy unit had influenced their work and the overall work in the DPC. Important themes were how the work at the DPC had developed during and after the establishment of the brief therapy unit, potential benefits and challenges herein, the overall quality of services, and the work culture and environment. The first author (HVM) conducted all interviews, either in the professional's office or in a meeting room, according to the professional's wish. The interviews lasted between 50 minutes to one hour and 21 minutes. The interviewer (HVM) made notes during and after each interview. All interviews were audio recorded and transcribed verbatim by the first author (HVM).
As the aim was to explore the professionals' experiences, we were cautious not to put up too strict boundaries for themes that came up in the interviews. While some topics identified in the first interviews were incorporated into the interview guide, the main issues remained constant. A new topic that was incorporated was the brief therapy unit's potential to release resources for patients with more extensive needs, and how the establishment had influenced the overall workload in the outpatient services.

Data analysis
Data analysis was based on phenomenology according to systematic text condensation [24]. The analysis was conducted in a group of three researchers with different backgrounds (medicine, psychology and social sciences). HVM is a doctoral candidate in medicine with a professional background as a society planner at MA-level, and several years of experience from mental health hospital planning including service innovation tasks from this area of Norway. LA is a researcher and physician (specialist in physical medicine and rehabilitation). MBR is a professor in mental health work with a background from psychology and public health. 7 Firstly, all interviews were read by the first author (HVM) to achieve an overview of the material.
Mindjet MindManager (2017) was used to capture and visualize the most prominent content of each interview. Each researcher read the same three interviews and suggested «codes» for a coding list.
The authors discussed codes and made a final coding list. After discussion of preliminary themes, all the interviews were coded by HVM. Based on categories, themes were constructed and validated through discussions in the author group. Empirical dimensions were formed for each interview and similarities across interviews were reflected in the themes. The first author (HVM) also presented preliminary findings in meetings with two different research groups. The researchers in these groups had complementary experiences and gave fruitful feedback and input during the analytic processes.
The reiterative analysis process continued until data reached a point of convergence, where four themes encompassed the most prominent of the material. All three authors were continuously looking for alternative interpretations in several meetings and critical discussions, before agreeing on preliminary themes. The first author (HVM) summarized and decontextualized the text from the interviews that could illuminate the chosen codes and themes, focusing on the informant's experiences. Finally, the authors discussed if the reduced text reflected the main topics in the data material. Quotes from the data material were chosen to elaborate and illustrate the results. They were translated by the third author (MBR) and checked and approved by the first (HVM) and second author (LA).

Results
Eleven professionals took part in interviews, five men and six women, all between 40 and 60 years old. All had leading or coordinating positions in the DPC when the interviews took place. Their professional backgrounds were within psychology, nursing and medicine, most of them specialists in their field.
According to the professionals, the establishment of the brief therapy unit was the answer to a growing crisis in the DPC, a crisis due to an increase in referrals but not in resources. They described that the DPC would not have tolerated the pressure much longer, and something had to be done to relieve the pressure. However, according to the professionals, the number of referrals had continued 8 to increase. At the time of the interviews, the capacity problem was described as almost the same as before the establishment of the brief therapy unit.
The results are presented as four themes: 1) Brief therapy provided by a celebrated unit, 2) The "forgotten" clinics, 3) Elucidating different treatment cultures and 4) Influencing the criteria for prioritizing.

Brief therapy provided by a celebrated unit
The brief therapy unit was described as a most welcome innovative effort, and many portrayed the brief therapy unit as successful and celebrated. Some said that the unit had evolved to become a "separate and cool unit". Soon after the establishment, the brief therapy unit had also become an arena for trying out further innovative means, such as online-therapy. The professionals described that leaders and professionals from hospitals across the country came to visit and to learn from their work.

Others are interested in this… because our situation with an increasing number of referrals is not
unique, it is the same all over the country, so others are searching… I think this is the fourth DPC that have visited us so far… no, the fifth, actually. (HP1)

I have noticed that the brief therapy clinic is held up as a good example. Something excellent and good that we should be proud of and that visitors come to see and that is celebrated. (HP2)
According to the professionals, there was no doubt that the DPC treated far more patients after the implementation of the brief therapy unit, and that young patients with less severe diagnoses seemed to profit from this treatment approach. Furthermore, the professionals said that the brief therapy approach had the same treatment effect and level of patient satisfaction, compared to another outpatient services. The results were so good that the management wanted to expand and develop the service further.
It appears to be a potent service with high quality that provides our patients… contribute to giving [them] a sense of achievement… that is important in itself… and makes us want to keep the service and develop it to become even better. (HP3) Professionals described a unique "team-feeling" among the staff in the brief therapy unit, and a 9 specialization of treatment approaches, compared to the general outpatient clinics. The professionals who worked in the brief therapy unit described it as positive and beneficial.

It is an advantage to work in a similar manner… have a shared professional profile… it gives us the opportunity to develop a specialist environment and be good at that specific service. (HP4)
While the professionals working in the brief therapy unit highly valued the unique team-feeling, several of the professionals working in other parts of the organization were more critical. They highlighted that the brief therapy unit was in a different building, thus geographically separated from the rest of the DPC, and that the unit had evolved into a separate and specialized unit. External research funding had also made possible more professional development in the new unit, compared to the general outpatient clinics.
They are perceived as somewhat outside of the organization […] and they are outside geographically.
And they have their own systems and their own projects… so they are somewhat in a bubble, by themselves. And they could, preferably, be more integrated with the rest of the organization. (HP5)

The "forgotten" clinics
While the brief therapy unit was described as the innovative and celebrated part of the DPC, the general outpatient clinics were described by several as "forgotten". Professionals working here said that they had expected the implementation of the brief therapy unit to give them more room for working with the more complex patient cases. According to them, this had not happened. The work pressure had instead increased, and the establishment of the new unit had not led to the expected ease in workload. Several expressed that the brief therapy unit now treated the "easiest" cases, while the more complicated and complex cases were allocated to the general outpatient clinics. The latter group demanded extra resources and time, and only a slow positive improvement could be expected.
Many described that this led to fewer positive stories and experiences of success, leading to frustration among the professionals.
We don't see the success stories anymore. The stories that held us up… that we sometimes discharged a patient as recovered… we hardly see that anymore. Now  Some of the professionals working in the general outpatient clinics said that the consequences for the general outpatient clinics, in form of an increased workload, neither was anticipated nor acknowledged by the DPC's management. In their view, "the rest of the organization" had not been properly involved in the development of better services. They missed that the management focused on the work and increased effort in the general outpatient clinics.

They watch these new units that […] are celebrated and advertised as the clever ones […] that is
where the success is… they can do it. While those who take responsibility for the ill and co-morbid and severe cases… Nobody is celebrating them… nobody is boasting about them… nobody is pointing The professionals pointed to the wide range of tasks in the general outpatient clinics and said that it was nearly impossible to keep updated, professionally and methodically, to handle the different and complex diagnoses. Several said that they missed consideration and recognition of the various disciplinary approaches, and that they had too little time to meet the needs of different patient groups. Several professionals in the general outpatient units said they were worried about the increasing patient volume, and that they felt an increasing pressure to be more efficient. Some voiced concerns about whether the treatment process for some of the more complex cases had become "diluted". This implied scheduling more infrequent treatment sessions and terminate treatment earlier.

I think the reason is that we cannot influence how many patients we receive […] and to manage [the case load] we "dilute" [the treatment]. This is against professional advice… and I think that
professionals from different traditions experience this as a problem. Individual professional has too many patients on the list… more than they can manage. (HP7)

Elucidating different treatment cultures
The establishment of the brief therapy unit seemed to have highlighted the existence of different treatment cultures within the DPC, namely different views on what constitutes good treatment. While some professionals highlighted short-term treatment as a success and a promising approach for the future, others voiced concerns about how focusing on short therapy could result in poorer treatment for patients with more complex needs.
The professionals who were most positive to the short-term approach emphasized that the brief therapy unit was a positive addition to the outpatient treatment, providing targeted treatment to a large and increasing patient group. They attributed this to the DPC's young patient population and said that targeting the youngest adults could have significant long-term benefits for the DPC.
According to them, the implementation had provided a possibility for young adults to come early in contact with the mental health services, receiving targeted treatment quickly and, potentially, returning rapidly to society.
[…] there are many good professional arguments that the first contact in a case… should focus on coping and here and now. We should give them hope that this will pass… be clear about the need for the patient's own effort… and see how far this helps the patient. If that doesn't work… we can think differently. But we cannot meet a young person with a "Now we are going to investigate every little part and understand how you have become like this by going back in time"… I think there are very good professional arguments for […] using an approach that is founded in the here and now, and the future…not the past. (HP1) The more critical professionals said that young adults with mental health problems potentially received too limited treatment in their first meeting with psychiatry. They were concerned that all new patients struggling with anxiety and depression now received the same treatment approach, and that short-term treatment had become "the quick and only option" for a large group of young adults.

In my opinion, the brief therapy unit has a narrow professional approach. They work mainly with socalled cognitive and metacognitive principles […] I think that some patients could have benefited from other approaches, such as psychodynamic therapy and existential psychotherapy […] Their professional position is too narrow. (HP4)
Several stated that the establishment of brief therapy in the DPC was an expression of a trend towards attempting to resolve mental problems or disorders as quickly as possible. According to some, the brief therapy unit had cultivated a standardized working method in "a one-sided manner", describing this as an expression of a "quick fix". Others said that while the management tried to handle the increased volume of referral, they forgot the patients with complex needs. In their view, the short-term approach was not sufficient to provide good treatment to the general patient population, since many patients would not benefit from standardized or time limited treatment.

Influencing the criteria for prioritizing?
Many of the professionals discussed whether the development towards more short-term approaches influenced the criteria for prioritizing in the mental health services. The focus on young adults with anxiety and depression, was described as a potential driver for lowering the threshold for treatment in 13 the DPC. Some said that the threshold had already been lowered after the implementation of brief therapy, resulting in more referrals of patients with less severe diagnoses. Others claimed that the patient population in the DPC had changed over two decades, and that an increasing group of younger patients with moderate problems demanded a larger share of the resources.
We perceive that a different age group is asking for help, and they take a lot of our resources… […] there is a change in the society, that young people are asking for help sooner. It is less taboo… Is there an increased morbidity? Maybe… in any case there is a larger group of young people asking for help. (HP7) Some said that society was responsible for handling and normalizing some of the mild mental challenges some experienced, and that referring and providing treatment to all types of mental problems was neither sustainable nor appropriate.

What is the need [for this patient]? We tend to "therapeuticize" needs in people. I think this is part of the explanation for the large group we shall manage. That we over-use therapy. Yes […] I do not think
that is the full answer. Absolutely not. In my opinion, we must normalize problems again. We have been good at viewing things as problems, now we must normalize. (HP5) The professionals also attributed a potential lowering of the threshold for treatment in the specialized services to the current priority guidelines in the mental health services. Some said that they had to balance what they perceived as conflicting guidelines: to prioritize between patients and at the same time reject fewer, describing this as an impossible task. Many emphasized that the government's guidelines, stating that youth should be prioritized, probably resulted in more young people with moderate diagnoses being offered treatment in the DPC.
One the one hand we are supposed to prioritize. On the other hand, we have a minister of health that gets a tummy ache thinking of someone who will be rejected. So, we should meet everybody and be available, but we also must prioritize. It does not add up. (HP1) Professionals discussed the future of the DPC and how the system could handle the increasing number of patients in need of treatment. According to some, treating more patients with less severe diagnoses implied doing the work for primary care, thus affecting the treatment of patients with more 14 complex problems who should be the most important group for the DPC. Several were concerned that the resources were used incorrectly, and that moderate mental problems should have been treated elsewhere. In their view, the general increase in mental health problems, particularly among young people, should have resulted in more responsibility for these patients within other parts of the health care system, such as the student health services and the municipal health service.
We are, in part, taking over the responsibility from primary care. As  Other professionals, on the other hand, said that it was a misconception that the brief therapy unit treated only moderate problems. In their opinion, the patients were too sick to receive treatment at the primary care level and that the brief therapy approach mainly had contributed to more differentiation of the services and thus more targeted treatment in DPC.

The shift towards short-term treatment
The present study showed that the establishment of a brief therapy unit represented a trend that also influenced the other outpatient clinics. Many said that brief treatment approaches complied with treatment guidelines provided by the health authorities, aiming to treat more patients without increasing the resources. It has been argued that third parties, such as health authorities and insurers have an increasing influence on mental health services, for example in limiting the amount of treatment [6,15]. In the present study health authorities, through emphasizing general efficiency and treatment limitations might be viewed as a "third party", influencing the treatment processes in several ways, [19].
The results also showed that the establishment of a brief therapy unit had elucidated different treatment cultures within the DPC. Some of the professionals said that the trend of brief therapy represented a positive influence on the organization by drawing attention to the provision of effective and adequate treatment. Others argued that brief therapy represented a superficial approach to complex patient needs. Both previous and current mental health care encompass different schools of thought with different perspectives on how to explain and treat mental illness [6]. Differences in therapeutic approach and treatment cultures were also found in the present study. Since cognitive behavioral therapists are more used to having a directive role in therapy [10], they might be more positive to a development towards restrictions of treatment length. In the present study, the professionals' different views on what is adequate therapy can thus be attributed to their preferred therapy approach and their professional and educational backgrounds. This also confirms that time limitation of treatment is not a neutral intervention [10]. Whether the establishment of brief therapy was perceived positively or negatively in the present study, seemed strongly related to where in the organization the person worked.

Implementing a new effort influences other parts of the organization
The present study investigated an intentional change in one part of the organization that had two aims; to provide efficient treatment for a targeted patient group, and thereby to ease the workload in the other outpatient clinics. The results showed that while the establishment of a brief therapy unit was perceived as successful, it did not fulfil the goal of easing the workload and improve the work in the other parts of the outpatient services. On the contrary, the most negative experiences were voiced by the professionals working outside the brief therapy unit; feeling forgotten and not acknowledged by the DPCs management, and of having more complex patients and an increased workload. The present study cannot confirm whether the patient population in the general outpatient clinics changed because of the establishment of the brief therapy unit. Neither can it confirm or set aside the professionals' perception of lack of acknowledgement from the management. Further studies should investigate this. Improvement efforts in complex health care organizations involve different potential challenges, such as organizational differences, heterogeneous patient groups, and different professional cultures [25].
Several have described prerequisites for successful implementation of new efforts [17,26]. One aspect described is the importance of collective action; that all participants agree on the implementation of the new effort and are willing to contribute in the work [27]. The results from the present study show that the establishment of the brief therapy unit mainly was perceived as the DPC management's response to the authorities' demands for efficiency and better utilization of resources.
Many of the professionals in the outpatient clinics felt that they had not been concurrently and properly involved in finding united solutions. Including all stakeholders in planning and preparing is recommended before implementing changes [27]. Not properly securing support in all parts of the organization over time might also have influenced the professionals' perceptions.

Providing mental health care on the appropriate level
The present study showed that several of the professionals meant that young adults with moderate mental health problems, such as anxiety and/or depression, should not be treated in the DPC, but rather be the responsibility of primary care. This is in line with one of the main aims of the Norwegian Coordination Reform [28], requiring a transferal of tasks and responsibility to the primary health services. Similarly, The World Health Organization has stated that mental health treatment should take place in primary care [29]. On what care level common mental health problems should be treated is an ongoing discussion regarding accurate identification of problem, appropriate treatment, costs, and waiting time [30]. Providing mental health treatment in primary care should secure treatment that is effective, efficient, accessible, and equitable.
Whether mental health care is provided mainly at the primary or secondary care level varies a lot in Europe [31]. Researchers have claimed that collaboration between the primary and secondary mental health services is needed to provide care across systems [32], and that a shift in resource balance between the care levels is needed [33]. Collaboration between primary and secondary health services is also emphasized and advised in treatment guidelines for common mental health treatment [30,34], and several models have been suggested for closer integration and collaboration [35]. Such models include training of primary care professionals, consultation-liaison collaboration (where a secondary care specialist provides support during care whenever needed), collaborative care (where appointed care managers secure a collaboration between primary and secondary care professionals), and referral (where the patient is referred to secondary care for treatment) [35]. Collaborative models for treatment of depression and anxiety disorders in primary health care have shown to be effective, and providing mental health care at this level is cost-effective [32,36,37].
Similarly, treatment in primary care with a permanent care manager can be positive and represent continuity for patients who need long-term treatment and follow-up [38]. In addition, brief psychological treatment approaches (CBT, counselling and problem-solving therapy) can be provided effectively in primary health care [39]. Although the results showed disagreement between the professionals about the severity of the patients' illness, patients with moderate anxiety or depression could be successfully treated in or in some type of collaboration with primary care.

Therapist autonomy in mental health treatment
The present study showed that the establishment of the brief therapy unit, and particularly the accompanying trend of brief treatment, challenged the autonomy of some of the professionals. This is in line with previous research, showing that standardization of services, such as time limitations, often lead to medical professionals' skepticism and resistance [25]. In addition to making them feel that their professional judgement and autonomy are challenged [25], they also perceive having less room for independence [6]. Research has suggested that the regulation that lies within bureaucratization and national governance weakens medical professionals' autonomy [40]. The medical profession has been described as founded on self-regulation and internally motivation, and not by external rewards [41]. Guidelines that entail rationalizing treatment make professionals argue that patient needs should influence clinical decisions more than economy [6].
Some of those working in the general outpatient units said that they felt a pressure to work more efficiently and terminate treatment earlier due to an increased work load. Time limitations of treatment might influence the therapy process, both positively and negatively [10]. Limiting the number of treatment is associated with professionals experiencing loss of control over treatment decisions, changing the way to define and approach problems, and an emphasis on symptom removal instead of maintaining positive outcome [15]. Mental health professionals might feel frustrated and ethically challenged when having to limit therapy to superficial problems or terminate treatment prematurely, and that this challenges the therapist-patient relationship [14]. Professionals also say that they would go deeper into the patients' issues and be less symptom focused if there were no time limitations [10,15].
While some professionals were critical to the so-called brief therapy trend, the present study also included professionals who praised it as a positive influence, pressing some professionals to work more efficient. This finding suggests that the strengthened focus on shorter and more efficient treatment also is viewed as a way to limit some professionals' autonomy to choose treatment length and approach. All public health service provision is subject to guidelines, recommending type of treatment and length, according to the patient's diagnoses. However, the present study showed a tension between the individual professionals' autonomy and an overarching focus on efficient use of scarce resources. The task of improving both treatment and cost efficiency, while maintaining professionals' sense of autonomy and motivation, is an important task when implementing changes in health service organizations in the future.

Strengths and limitations
The study sample consisted of leaders and key personnel. They had first-hand knowledge and experience with the work in the outpatient clinics before, during and after the brief therapy unit was established. This provided data material that reflected the width of professionals' experiences and strengthens this study. Although the first participants were identified and suggested by the DPC's management, the first author (HVM) recruited more professionals to include various perspectives. The final sample had good gender representation and diversity of experiences from different parts of the outpatient clinics in the DPC. A qualitative semi-structured interview approach made it possible to explore the professionals' individual experiences without setting boundaries for the themes brought up during interviews. This strengthened the exploratory approach.
However, the exploratory focus on the professionals' experiences and perceptions also constitute a major limitation. Most of the results convey the professionals' personal experiences and points of view and are not confirmed by any other types of data. Many of the findings must therefore be interpreted with caution. One important example is some of the professionals' perception that some of the patients received shorter treatment and less follow-up, due to the increased focus on short-term treatment. Another is the statement that the general outpatient clinics were forgotten and not acknowledged by the DPC's management. We have no other data material confirming these statements.
The analysis was conducted by three authors with backgrounds in social science/public health, medicine and psychology. The 3 rd author (MBR) has extensive experience with qualitative analyses, and the 2 nd author (LAa) has some experience. The diversity in backgrounds and experience is a strength in this study. The author group had several meetings, continuously looking for alterative interpretations before agreeing on every step in the analysis process. To allow for alternative 20 understandings and perspectives on the data material, preliminary results were discussed several times in two separate research groups, one group with an exclusively qualitative methods approach, and one with a more comprehensive methodological focus. This helped provide alternative points of view in the analysis process and is considered a strength.
The Norwegian socio-cultural context, such as the organization of mental health care and the comprehensiveness of the welfare system, somewhat limits the transferability to other countries. The present study did not measure treatment outcome or patients' experiences. Neither can we be certain whether the professionals' perception of increasing time constraints was a result of the establishment of brief therapy or part of a general development in the mental health services. Other types of studies are needed to investigate this.

Conclusion
This study explored the professionals' experiences with the establishment of a specialized brief therapy unit in a DPC. Implementation of a new service influences a health service organization in several ways, calling attention to the distribution of scarce resources and highlighting differences in professional cultures. A strong focus on limitation of treatment to increase efficiency might also trickle down to other parts of the organization, challenging professionals' judgement and autonomy.
When a new treatment approach is provided to patients with moderate mental health problems, this can raise questions concerning resource use and the appropriate level of treatment provision.
Securing agreement and collective action in all parts of the organization is important before and during the implementation of innovative services, as is facilitating for exchange of experiences between professionals.

Consent for publication
Not applicable.

Availability of data and materials
The datasets generated and analysed during the current study are not publicly available due to ethical approval but are available from the corresponding author on reasonable request.