Time,Trust,and Telling: Narrative Pathways to Shared Decision-Making

Abstract

This article explores how mental health professionals narrate successful experiences of implementing shared decision-making (SDM) within coordinated individual care planning (CIP) for adults with severe mental illness in Sweden. Drawing on narrative theory and the concepts of master and counter-narratives, the study analyzes two in-depth interviews with professionals who adopted a new SDM-oriented CIP model. While previous research has highlighted barriers to implementation, this study focuses on stories of localized success. The findings show that professionals engage in narrative identity work to navigate and, at times, resist dominant institutional discourses centered on time scarcity, user passivity, and bureaucratic rigidity. Through reflective practice, relational engagement, and adaptive use of tools such as pre-meetings and informational media, the professionals reframe SDM as both feasible and desirable. These counter-narratives reveal the importance of time, trust, and storytelling as enabling conditions for change. The study highlights the role of narrative as a tool of professional agency, offering insight into how small-scale innovations can challenge organizational inertia and foster more participatory models of care.

Background

Shared decision-making (SDM) is increasingly recognized as a core component of ethical, person-centered care across health and social service systems. It refers to a collaborative process in which professionals and service users jointly deliberate on treatment or support options, integrating clinical expertise with users’ preferences, values, and lived experiences (O’Connor et al., 2009; Slade, 2017). Rather than being a single intervention, SDM represents a general model of interaction that shifts power dynamics and enhances user agency across care contexts (Duncan et al., 2010; Eliacin et al., 2015). As such, it has been widely promoted in mental health policy as a means to increase user involvement, reduce coercion, and improve satisfaction with services (Abuzied et al., 2021; Dahlqvist-Jönsson et al., 2015; Jorgensen & Rendtorff, 2018; Smith & Williams, 2016).

In the Swedish context, Coordinated Individual Care Planning (CIP) provides a legally mandated framework for interprofessional collaboration for individuals with complex, long-term care needs. A CIP is initiated when a user’s situation spans several providers, such as health care and municipal social services. It aims to secure structured communication, shared goals, and continuity of care through steps such as needs assessment, coordination, and follow-up (Grim et al., 2019; Jones, 2025; Matscheck & Piuva, 2022a; Nordström et al., 2023). While CIP offers a structural process for collaboration, it does not guarantee user involvement. SDM can be seen as the normative ideal that should guide how a CIP is carried out, complementing its procedural framework (Jones et al., 2020; Levin et al., 2017).

However, research shows that this alignment is rarely achieved in practice. Studies indicate that CIP meetings often turn into bureaucratic routines dominated by professionals rather than forums for user participation (Bromark et al., 2022; Jones et al., 2022; Matscheck & Piuva, 2022b; Nordström et al., 2023). Common barriers include power asymmetries, unclear roles, time constraints, and organizational culture (Chisholm & Petrakis, 2023; Glantz et al., 2025). Although legislation mandates coordination and user involvement, successful implementation depends on how professionals interpret and operationalize these requirements in practice (Nykänen et al., 2023).

Conversely, evidence shows that SDM can be effectively integrated into CIP when certain conditions are met: mutual trust, adequate preparation, flexible communication tools, and supportive leadership (Glantz et al., 2025; Jones et al., 2020). In such cases, professionals reframe their roles, invite users’ experiential knowledge, and engage in relational work.

Despite growing recognition of SDM, its translation from policy to practice has been contested (Jorgensen & Rendtorff, 2018; Levin et al., 2017). Barriers such as efficiency demands, clinical risk aversion, and hierarchical authority reflect deeper institutional logics that marginalize users’ experiential knowledge (Andersson et al., 2023; Chisholm & Petrakis, 2023; Matscheck & Piuva, 2022a). Implementation is also hindered by structural fragmentation, staff turnover, and limited organizational support (Glasby et al., 2011; Jones, 2025; O’Connor et al., 2009). CIP, in particular, has been criticized for becoming routinized and procedural rather than dialogical, with users’ voices often sidelined (Matscheck & Piuva, 2022b).

While much literature focuses on obstacles, fewer studies examine enabling conditions. Exceptions include work emphasizing co-production, joint learning, and the reframing of professional–user relations (Glantz et al., 2025; Jones et al., 2020). These studies shift attention from individual competencies to organizational culture, power relations, and narrative framing.

Narrative research provides further insight into how professionals construct and justify their roles in relation to user involvement. Narratives not only convey experience but also construct identity and guide action (Riessman, 2008). Professional storytelling often reproduces dominant “master narratives,” positioning users as passive and professionals as pressured decision-makers (McLean & Syed, 2015).

At the same time, counter-narratives allow professionals to reframe their work and articulate alternative modes of engagement. These can highlight successful collaboration and flexible problem-solving, even when deviating from standard procedures (Bamberg & Andrews, 2004). The narrative turn in mental health and social work research thus shifts attention to implementation as a cultural and discursive process. Storytelling helps professionals navigate complexity and assert legitimacy in reform contexts (Wellington et al., 2024).

Against this backdrop, our study examines how professionals narrate “success” in implementing SDM within CIP, focusing on how narrative labor creates space for relational and ethical practice even in constrained institutional settings.

Context and Intervention

This study forms part of a larger research project aimed at supporting and evaluating the implementation of shared decision-making (SDM) within Coordinated Individual Plans (CIP) for adults with severe mental illness (Andersson et al., 2023). Conducted across three Swedish regions, four sites were designated as implementation test beds. The intervention included stakeholder analysis, a half-day training, and facilitation support. Participating services comprised psychiatric inpatient and outpatient units and municipal social services.

The intervention centered on a co-produced CIP process, involving both users and professionals in applying SDM principles (Knutsson et al., 2025). The procedure reflected five key SDM components: (1) agreement on the problem, (2) mutual information exchange, (3) exploration of options, (4) shared decision-making, and (5) consensus on follow-up actions. A revised CIP form—co-developed and annotated to align with SDM—served as a practical tool for implementation.

Follow-up focus groups six months post-training revealed limited SDM uptake (Authors, forthcoming). While professionals expressed enthusiasm for the revised CIP process and affirmed its value, they cited barriers including time constraints, inter-organizational challenges, and doubts about user capacity for SDM. In two cases, however, professionals reported having applied the new approach and utilized the revised CIP form. These individuals were subsequently invited to participate in in-depth interviews, which constitute the empirical basis of this study.

Theoretical Concepts

This study draws on the conceptual lens of master and counter-narratives, to explore how professionals construct meaning around successful SDM implementation. Master narratives are broad cultural and organizational scripts that often center on resource scarcity, procedural standardization, and professional authority. Counter-narratives, resist these dominant logics by emphasizing relationship-centered practices, user agency, and adaptive professionalism (Bamberg & Wipff, 2020; McLean & Syed, 2015).

Narrative theory provides a useful lens to understand how professionals construct meaning from their experiences, particularly in complex and uncertain settings such as mental health care (cf. Currie & Brown, 2003). At its core, narrative theory posits that individuals make sense of the world by organizing their experiences into stories that are structured around characters, settings, actions, and moral evaluations (Clandinin & Connelly, 2000; Riessman, 2008). These stories are not simply reflections of events but are shaped by broader cultural and institutional discourses, and in turn, shape how people act, relate, and position themselves in professional contexts (Georgakopoulou, 2006a).

In this study, we are more specifically concerned with how professionals narrate “success” in implementing SDM within the context of CIP. Our analytic approach focuses on the narrative structure and content of these stories, including how characters (e.g., professionals, service users and services) are portrayed, how agency is distributed, and how professional identity is claimed and justified. We pay attention to turning points in the narrative where something shifts and to the underlying narrative logic that links problems to solutions.

Central to our analysis are the concepts of master narratives and counter-narratives. Master narratives refer to dominant cultural storylines that convey widely accepted values, expectations, and norms about how things should be (Bamberg & Andrews, 2004; McLean & Syed, 2015). These narratives often reflect institutional logics, such as the prioritization of efficiency, risk aversion, and professional control in mental health services. Master narratives are typically internalized and reproduced, shaping what professionals consider realistic, appropriate, or legitimate in their work. They become visible especially when they are contested or disrupted.

Counter-narratives, in contrast, challenge, resist, or reconfigure these dominant scripts. They offer alternative ways of understanding practice, often foregrounding marginalized perspectives, relational ethics, and user agency (Bamberg & Wipff, 2020; Meretoja, 2020). In the context of this study, counter-narratives emerge when professionals frame their work in terms that depart from dominant discourses. Counter-narratives are understood as intentional narrative practices that give form to alternative professional identities and working alliances. However, master and counter-narratives are not understood as fixed or mutually exclusive categories. Rather, they are seen as dialogically related and often intertwined within the same story. A single narrative may begin within a dominant frame but shift as the teller reflects on their actions, justifies deviations, or articulates new values. Following Georgakopoulou (2006b), we view these as “small stories” embedded within “everyday talk” that index broader structural dynamics and social positions.

In this sense, the analytic measure in this study is not only what professionals say, but also how they say it. How their stories are structured, how normative assumptions are invoked or subverted, and how identity, responsibility, and legitimacy are narratively constructed. By focusing on narrative form, function, and context, we aim to illuminate the discursive strategies professionals use to make sense of SDM implementation in CIP and the narrative means by which they challenge or sustain institutional constraints. This approach allows us to explore professional storytelling as a site of both adaptation and resistance, revealing how everyday practices of meaning-making can support broader transformations in mental health care culture.

Method and Analysis

Study Design

A qualitative narrative methodology was used to explore how professionals in mental health services construct and communicate stories of successfully implementing SDM within CIP processes. The research forms part of a broader implementation project conducted across multiple Swedish regions, aimed at introducing and evaluating an SDM-informed CIP model (Andersson et al., 2023; Grim et al., 2025; Knutsson et al., 2025). Our specific focus in this study is on two selected narratives from professionals who reported relatively successful implementation experiences.

Study Setting

Data were generated through semi-structured interviews conducted via Zoom. The interview setting was conceptualized as a co-constructed space, in which both researcher and participant shaped the narrative. The interviewer facilitated storytelling through open-ended prompts, active listening, and contextual sensitivity, rather than extracting information (Abuzied et al., 2024; Clandinin & Connelly, 2000). The interviews were conducted in Swedish. Conducting interviews in healthcare settings is often challenging due to power dynamics, confidentiality concerns, and participants’ workload constraints. Professionals may be cautious in sharing critical reflections, and ethical considerations, including informed consent and protection of sensitive information, require careful attention. These factors can influence both the depth and richness of the data collected. However, no particular difficulties were identified during these interviews that clearly affected the research interview.

Participant and Demographic

Participants were experienced professionals working in regional or municipal mental health services in Sweden. One interview involved a pair of regional professionals (a counselor and an assistant nurse), while the other featured a municipal social worker. All participants had over ten years of professional experience in mental health care. Regarding their demographic characteristics participants were one counselor, one assistant nurse and one municipal social worker, all women. They were active in southern and central Sweden, all had over 10 years of practical experience. As mention in the context and intervention section, the participants in this interview study are also participants in the overall research project, but they participated in these interviews because they expressed a positive implementation in previous focus groups. Thus, inclusion criteria were professionals with extensive experience in mental health services and direct involvement in CIP processes, and those who reported relatively successful SDM implementation in previous focus groups.

Sampling Technique

A purposive sampling strategy was employed, focusing on “positive deviant” cases (Patton, 2002) to capture rich, complex, and analytically valuable accounts of successful SDM implementation. These cases were selected not to represent the norm, but to reveal conditions that make successful implementation narratable, consistent with theoretical sampling principles (Gerring, 2004; Ragin, 1999).

Data Collection: Tools, Procedure, Analysis and Reflexivity

Data were collected through semi-structured interviews using a teller-focused approach (Hydén, 2014). Open-ended prompts such as “Tell me about a time you felt the new approach worked well” encouraged extended, coherent narratives and moral evaluations embedded in professional storytelling. The main interview questions that guided the interviews were as follows ¹ :

- Could you tell me about your experience using the new form? Can you describe a specific case and how it went?

- How has the new form been helpful for you as a professional and for the service user?

- What challenges or difficulties have you encountered when using the new form?

- How has your work changed with the introduction of the new pre-meeting process?

- Do you feel there is a need for additional support in this work, such as guidance or collaboration with others?

- How would you describe the cooperation between the regional and municipal services?

- What do you think is needed for the implementation of the new process to be successful?

Interviews lasted between 25 and 40 minutes, were audio-recorded with participants’ oral informed consent, and transcribed verbatim, yielding 27 pages of narrative material. Participants were reminded of their right to withdraw at any stage. Ethical approval was obtained from the relevant review board. To protect privacy and confidentiality, identifiers were removed during transcription, pseudonyms were used, and raw data were securely stored on encrypted drives accessible only to the research team.

Analysis involved iterative close readings of the narratives, focusing on narrative structure, temporal sequencing, voice positioning, and implicit or explicit evaluations. An abductive approach guided the process, allowing movement between empirical material and theoretical concepts such as identity work, narrative positioning, and institutional discourse (Timmermans & Tavory, 2012). Central analytic units included “relational turning points”—moments where narrative trajectories shifted due to new insights, conflicts, or emotional responses, highlighting professional agency and decision-making. While thematic patterns were noted, the study prioritized narrative coherence and integrity over fragmenting data into decontextualized codes (Riessman, 2005, 2007, 2008).

The research team remained reflexive regarding their role and the institutional context. Narratives were treated as social acts that perform identity work and contribute to the negotiation of professional practice. This approach acknowledges the situated, performative, and interpretive nature of narrative data, and clarifies that the study does not aim to provide a comprehensive picture of SDM implementation but rather to illuminate how change is storied, contested, and made possible in professional practice.

Ethical Considerations

The study is embedded within a larger implementation project conducted across several Swedish regions. Ethical considerations were central throughout the project. Approval was granted by the Swedish Ethical Review Authority [Ref 2020-00584] and ethics were approached as a continuous and reflective process. Ethical principles informed every phase of the research, from the development of research questions to the communication of findings.

Result

The analysis revealed two narrative cases that illustrate how professionals enacted and articulated successful experiences of implementing SDM within CIP processes. Each story demonstrates how master narratives such as time scarcity, professional control, and service user passivity are engaged, negotiated, and at times subverted through counter-narrative strategies. The findings underscore the role of narrative identity work in enabling professionals to reframe challenges and claim legitimacy for alternative, relationship-centered practices.

The Silent Service User: Professional Initiative and Structured Dialogue

In the first case, Maria ² , a counselor, and Therese, an assistant nurse participates; they collaborate at the same regionally operated mental health facility. They described their work with Johan, a young man with autism who had difficulty communicating verbally. They coordinated multiple pre-meetings, primarily involving the service user’s mother as a representative. These meetings allowed for detailed planning and agenda-setting, leading to a focused and predictable CIP meeting.

While Johan remained largely silent, Maria and Therese emphasized the value of preparation and clear communication. Their narrative constructed a version of success centered on relational trust, parental advocacy, and professional structure. Johan was positioned as passive but central, reinforcing the professionals’ role as responsible facilitators. This narrative aligns with both the master narrative of clinical order and the counter-narrative of user-centered planning.

Attention here is given to the narrative concerning a relatively successful implementation of the new approach aimed at enhancing user involvement and SDM in CIP. This is how they present their case, which centers around Johan, who is in his twenties and lives with his mother:

Johan is 21 years old and has autism. He has a mother who advocates for him, as he finds it challenging to communicate in larger groups, or simply finds it difficult to express himself verbally. Therefore, his mother holds a power of attorney to represent him.

The excerpt marks the start of the interview, where Maria and Therese frame the implementation by emphasizing Johan’s need for an advocate. This raises questions about whose participation is being foregrounded. While they seek an engaged counterpart capable of expressing personal preferences, the initial interaction—between Johan/his mother and the professionals—reveals both a master narrative and a counter-narrative. The master narrative, anchored in Johan’s diagnosis, legitimizes support but risks reinforcing categorization and stigma (cf. Chisholm & Petrakis, 2023), potentially limiting deeper dialogue.

Maria and Therese go on to describe a pre-meeting that was scheduled prior to the actual CIP meeting in order to reach consensus on the nature of the problem and exchange information and knowledge between user and professionals. These are the two first steps in the SDM in CIP process. This was narrated in the following manner:

We have a coordination meeting where we convene, you and I attend, and there is a designated contact person as well. We consistently operate with two contact persons for each patient, so she attends too. And then we try to ascertain the nature of the problem, or what Johan perceives as problematic, or, in this case, what the mother deems relevant, as Johan did not seem to consider his situation particularly troublesome.

Maria and Therese retain control of the narrative by seeking to “ascertain” the problem themselves, rather than enabling Johan—or his mother—to define his support needs. Implicitly, they assume Johan does not perceive himself as having significant difficulties. At this stage, both the master and counter-narratives are shaped by the professionals, raising questions about narrative ownership. Johan’s mother, acting as his advocate, adds complexity: while her involvement may be supportive, it also mediates and potentially reshapes Johan’s voice. Thus, the narrative is co-constructed by the professionals and the mother, reflecting a joint meaning-making process (Glantz et al., 2025) that may constitute a working alliance (Eliacin et al., 2015).

It should also be noted that the preliminary meeting discussed by Maria and Therese is outside the scope of the new intervention. They went on to describe another preliminary meeting related to the new intervention. In other words, they had two preliminary meetings with Johan and his mother, a deviation from the prescribed model with just one pre-meeting. They describe the “second” pre-meeting as follows:

T: And then we proceeded to the next meeting, which was the preparatory meeting or pre-meeting. This took place a few weeks later, as we had received approval from them that they also found the CIP promising and hopeful.

M: We discussed who to include in the meeting.

T: Yes, but during that pre-meeting, it was similar. Johan consented to allowing his mother to speak on his behalf, even though he was physically present and listened to us. We then agreed on who they wished to invite, and based on what they had expressed, we shared our thoughts from the previous meeting and reflected on it.

I: I see.

M: Building on the information they provided, yes, and attempted to summarize to ensure we understood it correctly.

T: Yes, exactly. Then, we can present what we concluded from those points. We asked them, what assistance do you need? What topics would you like to discuss in a SIP?

I: Yes.

M: Yes, and then it was determined that there was a lack of communication between the somatic care and...

T: Between the various –

M: Between the various entities. For example, the diabetes clinic and the health center.

Maria and Therese note similarities between the two pre-meetings, complicating efforts to isolate the effects of the new intervention. As they shift initiative to Johan’s mother, his indirect participation increases, opening space for a potential counter-narrative. However, what unfolds is less a challenge to the master narrative than a reinforcement of Johan’s perceived deficiencies. While a counter-narrative may be emerging, the dynamics of resistance and power typically associated with such narratives remain ambiguous. Further, among the outcomes of the second pre-meeting, it was described as follows:

Based on the challenges or issues they identified, we held this preparatory meeting before the SIP, determining whom to invite.

Here Maria emphasizes what “they” identified, suggesting that Johan’s opinions were considered important. This account does not necessarily need to be interpreted as a counter-narrative, as Maria and Therese are not presenting an alternative story. Instead, what emerges is a co-produced narrative (Wellington et al., 2024). It could also be understood as Maria and Therese, along with Johan and his mother, are creating a counter-narrative in relation to the overarching narrative of the context, where, for example, time constraints are often highlighted as a barrier to holding pre-meetings before the CIP.

Maria and Therese went on to describe their work between the pre-meeting and the upcoming CIP meeting as follows:

After the preparatory meeting, where we agreed on the invited participants, we initiated telephone contact with the municipality. We informed them about the plans, outlining the three specific points the patient wished to address. During this interaction, we inquired if the municipality had any preferences or considerations for their participation. If they had any additional points, we would have needed to reconvene with Johan and his mother to communicate that the municipality had specific requests to include in the discussion.

Between the pre-meeting and the CIP meeting, Maria and Therese reclaimed responsibility by informing the municipality about what they had concluded in the meeting and asking whether the municipality had anything to add. This creates an additional space for various narratives to take shape regarding Johan and his situation: two parties now become three parties. In previous studies (Andersson et al., 2023), the exchange between municipalities and regions is often described as a potential area of conflict where the differing needs and opportunities of each party may collide, resulting in the service user being caught in the middle. However, this was not the case here, as Therese indicates:

Because it was crucial that the discussion just be about what was planned to be addressed in the CIP and nothing else, any new unforeseen points were to be deferred to the subsequent follow-up meeting. This ensured a focused discussion on the planned topics. Since they had no further requests and consented to the three specified points, there was no need for an additional meeting with Johan and his mother.

The narrative reflects a strong sense of professionalism through its emphasis on the structured CIP meeting, serving as a counter-narrative to the common framing of CIP implementation as a “wicked problem” requiring multi-stakeholder collaboration. Wicked problems, as Buchanan (1992) describes, resist simple solutions and involve ambiguous definitions, conflicting stakeholder goals, and systemic complexity. Maria and Therese highlight the intervention’s core aim: ensuring that all issues are resolved prior to the CIP meeting, fostering a shared narrative to which all parties adhere. Their description leads me to ask: Why do you believe the new intervention worked so effectively in this particular case?

T: I believe that we had ample time.

M: Mm.

T: Because that’s ... you need time to plan and take one thing at a time, involving the patient in the process. It’s important to provide clear information and have the time to sit down with the patient and talk. Ensuring that the patient’s preferences can be heard, so we don’t overlook the patient's perspective, assuming we know what he needs or thinking he has certain needs. I remember feeling good about these meetings. In this case, the patient himself didn’t say anything, but the meetings were very thorough, and we felt that we had trust in the mother.

I: Mm.

T: She had a lot of knowledge about her son and had been following him. So, it didn't feel like she was exaggerating or holding back. At least, we didn't get that impression.

M: And then, I think, [it worked] a bit because this is really almost how we work anyway. I must say that we do work with this kind of preparation; maybe we’re not excellent at communicating it to all stakeholders, informing everyone about what the meeting is about. But here, we’ve been extra careful about it.

I: So, it’s partially a new element then?

M: Yes, well, in a way.

Time emerges as a critical factor enabling SDM in CIP, consistent with its status as a master narrative in prior research (Andersson et al., 2023). Uncontested among actors, time is recognized as essential for effective intervention. Moreover, time functions as a locus of power: limited time risks marginalizing the service user, while sufficient time facilitates dialogue and mutual understanding. Consequently, time shapes the nature of co-constructed narratives, as evidenced by the apparent consensus among the region, municipality, and Johan in this case.

Another aspect worth mentioning is what emerges at the end of the excerpt above: Therese and Maria note that they already partially work with pre-meetings (adding another dimension to the uncertainties of evaluating the advantages of the new intervention). Therese and Maria describe the advantages of pre-meetings:

T: So, we can focus, and it felt, I thought it felt so good to inform the patient, especially, so that he knew what to expect at this meeting. You had informed him; you had a lot of contact with him before.

M: It becomes predictable, in a way.

T: Yes, and everyone around the table knew that this is what we’re going to talk about because differences can easily arise and the patient might feel left out, thinking everyone has talked, when will I get my turn. Then, of course, he didn’t speak, and usually, we would ask him, but no, we asked the mother if there was anything she wanted to start with.

I: Mm.

T: And he had written on paper that she should speak, exactly this idea of letting the patient go first if he or she wants.

I: Yes.

T: If we start, and after half an hour, the patient doesn't remember to say anything, no, I thought that was a good thing about this.

M: Yes, and a sense of security. Both for the patient and for us. If we don't feel in control, we might get a bit stressed or uncertain. But when we feel that, yes, this is check, check, check, we've done everything we can, we have it under control, then we are calm. Hopefully, we also convey a sense of calmness to the patient, not making it a bigger deal than it is.

I: Mm.

T: This shows how much significance preparatory work holds.

M: Yes, it’s almost crucial.

T: For the patient and for all of us involved.

Preliminary meetings are valued not only for their benefits to professionals but also for enhancing predictability and outcomes by engaging the service user earlier in the process. This practice reduces unexpected developments in subsequent CIP meetings, as all parties have preemptively contributed to the agenda, thereby promoting transparency in information exchange.

Maria and Therese’s account foregrounds the service users—Johan and his mother—who receive supportive engagement from professionals, fostering mutual trust and collaborative oversight of interests. This co-produced narrative positions Johan centrally, forming a localized master narrative that may either challenge or coexist with broader organizational narratives, such as those emphasizing time constraints (Andersson et al., 2023; Glantz et al., 2025; Wellington et al., 2024).

The Video-Watching Service User: Flexible Communication and Empowerment

The second case involved a social worker from municipal services working with a young woman with autism who had previously struggled to engage with support systems. The social worker introduced the CIP concept through an informational video, followed by a pre-meeting where the user was actively involved in selecting participants and identifying issues.

The professional’s narrative stressed adaptability, empathy, and user empowerment. The use of a video resource was particularly significant in facilitating understanding and agency. Despite organizational barriers and time constraints, the meeting was seen as a success due to mutual preparation and shared expectations. Here, the counter-narrative was more pronounced, challenging dominant stories of user passivity and systemic inertia.

In the second interview, Sara participates, a municipal social worker who possesses extensive experience with the target group and in the field of social work. In this interview too, the narrative unfolds organically and in some cases in long passages. Sara begins as follows:

Well, [the case] concerns a relatively young individual with, among other things, an autism diagnosis, who has been offered interventions from the municipality several times in recent years and has had significant difficulty benefiting from these interventions. When I first met her almost a year ago, she applied for housing support, and it was very apparent that she had a need for assistance in her living arrangements.

Sara constructs a clear profile of the service user, Mona, whose needs are articulated and validated, initiating a process of categorization within a diagnostic framework. This framework functions as a master narrative, mutually acknowledged and guiding their interaction. While the diagnosis need not imply stigma (cf. Chisholm & Petrakis, 2023), it delineates roles of support provision. For Sara, it informs possible interventions; for Mona, it facilitates expression of daily challenges. Nonetheless, Mona’s prior engagement with interventions has been unsuccessful, with underlying causes remaining unclear. Sara goes on to describes the preliminary meeting with Mona as follows:

I thought that maybe we should try suggesting a CIP, but I understood that proposing it directly might be challenging. So, I used the informational video we received during training. I wrote a brief e-mail, suggesting that coordinated individual planning could be beneficial for her. I asked her to watch the video and get back to me for a meeting to discuss it further. I received a response fairly quickly, stating that the video was excellent. The video had been a helpful tool for her comprehension. We then scheduled a pre-meeting where I was prepared with information about her support network, and we wrote down very concretely with pen and paper who should be invited. We had some clear issues that we intended to address.

Mona’s prior difficulties with interventions likely prompted Sara to adopt the new approach, initiating with a pre-meeting followed by a CIP meeting. Sara’s extensive experience may have enabled her to cautiously deviate from standard practice by sharing an informational video from her training. This suggests a nuanced understanding of Mona’s challenges and an adaptive approach. Consequently, progress appears driven more by the therapeutic alliance Sara establishes than by the method itself.

Mona’s response to the video leads to a pre-meeting focused on participant selection for the CIP meeting. Unlike Maria and Therese, Sara does not routinely employ pre-meetings, highlighting this as a deliberate, specialized practice. Sara’s portrayal of herself and Mona as active agents underscores her role in fostering mutual identity and strengthening the working alliance (Eliacin et al., 2015).

Sara is slightly more cohesive and direct in her narrative compared to Maria and Therese. She summarizes the CIP meeting in the following manner:

Some attempted to back out, which is not uncommon when calling for a CIP. I also spoke with family members who were completely surprised that anyone could be so engaged and initiate this kind of meeting, as they had never experienced this in the twenty years they had been in contact with mental health services—true or not, I don’t know. Anyhow, the scheduled date arrived and the support worker and I were prepared for a meeting. However, no one showed up, and then the support worker gets a text, “I’ll be a little late.” And I’m thinking, oh, typical behavior, some anxiety about the meeting got triggered. Fortunately, we had the opportunity to use the venue, and we connected with those who were joining digitally, allowing us to introduce ourselves more formally to each other. This turned out to be beneficial, given that the client had met each of us individually before. Subsequently, she and a family member arrived, and we had a good meeting, following the protocol. We addressed the existing issues, and it became clear what psychiatric interventions could be implemented at present. She was placed on a waiting list for additional interventions, and we discussed what the municipality would do in the meantime while waiting for the interventions to get going. I found it to be a good, clear meeting, and I also received feedback from the client herself afterward, indicating that it had been a positive experience. Since then, there may not have been much progress, but progress tends to be slow in these matters, I suppose.

Sara highlights both unexpected and familiar elements in the new working method. By conducting a pre-meeting, contact is established with Mona’s network, something that apparently has never occurred before, and Mona is able to bring a relative to the upcoming CIP meeting. Much as in the case of Maria and Therese, the pre-meeting approach provides a structure that ensures clarity in the CIP meeting: everyone knows what will be addressed, even if the process seems slow. The narrative that gradually emerges from Sara’s account is a co-produced one, with Mona placed at the center: Mona’s voice and her needs become paramount.

Sara goes on to explain why she considers this working method to be an effective one, while also acknowledging the challenges involved:

Yes, I believe it would be great from a client perspective. However, it becomes a matter of prioritizing our time and resources, as scheduling an additional meeting takes much more time. As caseworkers, we are the ones who need to organize it, and we are already juggling many other tasks. I also think that the pre-meeting might not have such a significant impact, but the fact that I, as the caseworker, am leading the meeting while also having a substantial stake in the issues can be a bit challenging. I have experienced in many previous CIP meetings that the back-and-forth discussions can overshadow the role of the meeting facilitator and the support person for the individual. Unfortunately, it sometimes turns into a lot of debate about who can do what, when and why it takes so long, and why certain tasks have not been completed.

Like Maria and Therese, Sara recognizes the benefits of pre-meetings for all parties but stresses their dependence on time and competing priorities. While earlier endorsing pre-meetings, she later minimizes their importance, reflecting on their feasibility within her broader workload. Thus, what initially appears as a valuable isolated practice becomes a challenge when integrated into routine professional demands. Nonetheless, pre-meetings clearly enhance meeting structure, reduce conflict, and clarify the service user’s role in CIP meetings.

This reveals two competing master narratives: the dominant narrative of time constraints and the counter-narrative emphasizing pre-meetings’ structural value. Prior research similarly identifies this tension between resource limitations and process improvements (Andersson et al., 2023; Glantz et al., 2025). While time scarcity remains a persistent barrier, pre-meetings emerge as a promising strategy to facilitate effective decision-making within CIP.

Regarding what Sara believes is necessary for the new working method to have a greater impact, beyond the recurring mention of resources, she says:

Yes, but it’s also about practicing a pre-meeting or allowing oneself the time for it. Otherwise, one might just say yes, inform the individual about what CIP is, and then put together an invitation, plain and simple.

Sara emphasizes an important aspect here: the opportunity to continue practicing these pre-meetings, which brings the issue of time constraints back into focus. This suggests that time constraints may be considered a master narrative in this context, particularly in relation to the implementation of new tasks. However, the contradiction lies in the fact that time constraints are addressed by professionals from a short-term perspective. In the long term, this working method is more likely to free up time than to add to the workload, as the professionals have implicitly suggested through the clear structure that CIP meetings have provided.

Discussion

The aim of this study has been to explore how mental health professionals create narratives about actions to promote user involvement and shared decision-making in coordinated individual care planning processes. By analyzing two stories through a lens of master and counter-narratives, the diversity and complexity of implementing SDM in CIP processes emerge. The narratives of the participants in this study, in a sense, represent counter-narratives in relation to their colleagues and the organization at large, as the study participants have attempted to implement the new SDM in CIP methods despite the obstacles they also articulate.

Both narratives illustrate the importance of Time and Preparation: Adequate time enabled relational work and clarity. Professional Reflexivity: Professionals described adapting their approaches based on user needs and Co-Production: Successful implementation hinged on collaborative meaning-making. While time scarcity is typically framed as a barrier (a master narrative), participants strategically subvert this logic by emphasizing how time invested early (in pre-meetings) ultimately streamlines care planning and improves outcomes. This reframing constitutes a counter-narrative rooted in experiential learning and situated practice. Thus, these stories are not merely oppositional; they are hybrid constructions that simultaneously reproduce and resist institutional norms. A narrative can begin in alignment with the master narrative but evolve toward a counter-narrative through reflection and relational engagement.

These findings reveal that professionals navigated systemic barriers by constructing new practices grounded in responsiveness and relational trust. Furthermore, success itself is narratively constructed. It is not an objective outcome but a negotiated status achieved through performative storytelling. These stories do more than recount—they justify, persuade, and legitimize. Professionals adopt particular narrative strategies to position themselves as competent, collaborative, and adaptive, thereby reframing their professional identity in light of new expectations surrounding SDM.

Moreover, as seen, individual narratives can encompass both master narratives and counter-narratives that regulate the relationships between participants in the story. In other words, these analytical concepts can be applied at both the macro and the micro level. However, the main finding is that service users and professionals co-create a narrative (“someone needs help”) that can later be contrasted against a broader overarching narrative in which time and place function as organizational constraints which highlights aspects such as reflexivity and relationships building (Wellington et al., 2024). The initial goal of this study was to shed light on good examples of how professionals talked about the implementation process of SDM. The following section will further develop the discussion through three newly introduced analytical themes.

Negotiating Professional Practice: Counter-narratives and the Constraints of Organizational Master Narratives

By employing the theoretical frameworks of master narrative (Bamberg & Wipff, 2020; McLean & Syed, 2015) and counter-narrative (Bamberg & Wipff, 2020; Meretoja, 2020), worker narratives can be analyzed as dynamic and situated negotiations shaped by both individual agency and institutional discourse (Bamberg & Andrews, 2004). These narratives reveal both explicit and implicit negotiations with colleagues, which simultaneously reflect a broader engagement with the organization’s dominant narrative.

This dynamic becomes particularly evident when participants reflect on anticipated barriers to sustaining the newly implemented practice. Interestingly, there appears to be limited negotiation with service users themselves; instead, participants describe a form of relational work that is mutually valued. The implementation process thus emerges as a shared learning experience, wherein both professionals and service users encounter new insights—aligning with Glantz and colleagues (2025) conceptualization of joint learning processes.

However, a notable tension arises from the lack of curiosity or engagement among colleagues toward the new approach. This resistance may not indicate direct opposition but rather a manifestation of the prevailing master narrative, which maintains the status quo and inhibits organizational flexibility. As Jess and Nehlin (2024) observe, such inertia may also reflect insufficient managerial support, further complicating the implementation process and the establishment of counter-narratives in everyday professional practice.

Narratives of Resistance: Reframing Implementation through Professional Agency and Empowerment

Previous research (e.g., Andersson et al., 2023; Chisholm & Petrakis, 2023; Glantz et al., 2025) has consistently highlighted the difficulties associated with implementing new working methods within mental health care settings. Within this context, the two narratives analyzed here can be understood as deviant stories—that is, counter-narratives that challenge the dominant discourse (or master narrative) which posits that professionals are either unwilling or unable to adopt new approaches due to individual reluctance, collegial resistance, or structural constraints.

These narratives, however, can be interpreted as narratives of resistance (McKenzie-Mohr & Lafrance, 2017), in which professionals actively resist reductionist assumptions about their capacity for change. Rather than conforming to static or deficit-oriented representations of the implementation process, these accounts highlight professionals’ efforts to redefine and reclaim agency within their practice. This reframing is not merely rhetorical; it engages with questions of power, autonomy, and professional identity. As Chisholm and Petrakis (2023) emphasize, empowerment is central to meaningful practice change and can foster a deeper recognition of service users as complex, diverse individuals.

In the cases presented, professionals are afforded a narrative space in which to articulate alternative visions of successful implementation—visions grounded in lived experience and reflective practice. These stories not only contest dominant institutional narratives but also offer inspiration and legitimacy to colleagues who may initially be skeptical of change. Over time, such counter-narratives can contribute to a broader cultural shift within organizations by demonstrating that the adoption of new methods is not only feasible but also professionally and ethically rewarding. As Chisholm and Petrakis (2023) underscore, communication remains central to such transformative processes.

Constructing Professional and User Subjectivities: Tensions and Positionings in Implementation Narratives

Implementation research underscores the necessity for professionals to feel knowledgeable and skilled in applying new methodologies, as such confidence is often a prerequisite for effectively introducing these methods to service users. The two narratives analyzed here represent relatively successful implementation cases from both municipal and regional contexts. However, they also illustrate the inherent contradictions within the process, where opportunities and barriers coexist. These contradictions are not merely obstacles to overcome but are integral to the implementation process itself, and their open acknowledgment reflects a nuanced balancing act central to professional identity formation.

From this perspective, professional identity involves negotiating between confidence and uncertainty, compliance and critique. What emerges in both narratives is a portrayal of the professionals as simultaneously competent and compliant, and this positioning extends to the service users, who are also described as compliant. This portrayal is analytically significant given that service user accounts often highlight a lack of adequate support from professionals and recurrent experiences of being positioned as non-compliant.

A closer examination reveals how multiple and shifting subject positions are constructed through the professionals’ storytelling—ranging from “helper” and “competent practitioner” to “friend” and “bridge-builder.” These subject positions are not static but emerge relationally and contextually, reflecting the complexities of identity work in practice. Importantly, the narratives also illustrate how professional self-positioning can obscure tensions and contradictions in the professional–service user relationship, raising critical questions about voice, recognition, and power in the implementation discourse.

To sum up, the findings demonstrate that successful SDM implementation within CIP requires more than structural tools—it depends on relational, temporal, and narrative conditions. The cases exemplify counter-narratives that resist dominant organizational discourses of scarcity, inefficiency, and user disengagement. By framing their stories through competence, collaboration, and adaptability, professionals positioned themselves as proactive agents of change. This aligns with the notion of “narratives of resistance” (McKenzie-Mohr & Lafrance, 2017), where storytelling becomes a method of challenging static institutional norms. At the same time, the service users’ roles were often mediated by others, such as relatives, raising questions about the authenticity and inclusivity of co-produced narratives. The results support previous research emphasizing the role of leadership (Jess & Nehlin, 2024), permissive organizational culture (Glantz et al., 2025), and structural support (Nordström et al., 2023) in enabling SDM. They also underline the importance of narrative inquiry as a method for uncovering professional reasoning, emotional labor, and tacit strategies in implementation work. The insights gained from these narratives suggest that successful SDM implementation within CIP hinges on relational work, temporal investment, and professional reflexivity. While the cases are context-specific, the principles they illustrate—such as the strategic use of pre-meetings, collaborative meaning-making, and the construction of counter-narratives to challenge dominant organizational norms—may be transferable to other settings where systemic constraints and hierarchical cultures limit user involvement. These findings indicate that fostering narrative agency, relational trust, and reflective practice could support broader adoption of SDM approaches across diverse mental health and social care contexts.

Limitations

In the context of this study, it is important to note that the narratives provided by the professionals represent only a portion of their working situation. While this limitation may potentially restrict the generalizability of their stories, such reservations are seldom expressed within qualitative methodological frameworks (Riessman, 2005, 2007, 2008). As emphasized by Clandinin and Connelly (2000), there exists a tension regarding certainty due to the undeniable reality of diverse interpretations coexisting. Nonetheless, it is essential to recognize the inherent limitations of narrative analysis. One notable limitation is that various forms of representation, including both textual and verbal forms, may incompletely, selectively, or imperfectly convey the full story. The professionals’ narratives also reveal that they did not adhere strictly to the steps of the new SDM approach in CIP, which could be a limitation; however, their narratives also illustrates that the new approach saves time and increases service involvement, and demonstrates that it is indeed possible to modify established working methods on a small scale. This points to a new way of thinking and relating to oneself, colleagues, and the organization.

Conclusion

This study examines how professionals narrate experiences of success in implementing SDM within CIP, emphasizing the dynamic interplay between organizational structures, professional agency, and relational work. The narratives illustrate that meaningful user involvement, even in the face of systemic challenges, depends on both institutional support and the reconfiguration of professional storytelling.

A key finding is the difficulty of achieving collective learning, as demonstrated by the fact that only a few professionals adopted the new intervention. This highlights the role of local champions rather than organization-wide narrative leadership. Nevertheless, the accounts analyzed provide a tentative model of how adoption can occur (cf. Glantz et al., 2025). As Eliacin et al. (2015) note, establishing genuine, strong relationships is a fundamental prerequisite for effective SDM, and such relational foundations contributed to the cautiously positive outcomes observed here. Furthermore, a focus on the working alliance between service users and professionals is essential to fostering mutual participation and enhancing the quality of decision-making (Eliacin et al., 2015).