Handling dilemmas of self-determination in 'user-centred' rehabilitation

To describe discursive strategies used by different professionals and parents to handle dilemmas of self-determination versus paternalism during six 'user-centred' team meetings in the Swedish rehabilitation sector. The dilemmas arise when the users' responses do not fully meet the demands of the liberal ideal of self-determination.

Three cases are used to illustrate three discursive strategies that have been found by means of discourse analysis of transcriptions of the audio-recorded meetings. Four teams consisting of one user each participate in the study. The users have been ascribed physical and/or cognitive disabilities and their ages vary between 14 and 30.

The dilemmas were never made explicit. Parents and professionals performed a kind of paternalistic steering termed 'challenging the user's response', 'substituting for the user', or 'dropping the user's response'.

The least paternalistic steering includes making the dilemma explicit and offering the user the opportunity of sharing the responsibility for the handling of the situation. However, due to the complexity of the interactions no strategy can be found to either completely prevent the occurrence of dilemmatic situations, or definitely maintain the user's self-determination during dilemmatic situations. Paternalism may occasionally be a just way of enhancing future autonomy.