Abstract Deprivation of liberty is always an infringement of a person's constitutional rights. During the past decades, Western countries have focused on their Mental Health legislation, in particular, by making changes concerning involuntary treatment. After all, little is known about the frequency and quality of involuntary treatment, yet this information is needed to modificate the phenomenon. The present thesis is a part of the Nordic study ''Paternalism and Autonomy''. Two Finnish data have been used in this thesis: the register and the interview studies. The material of the register study comprises all admissions to the study hospitals (Tampere, Turku and Oulu) during a six-month period. The material of the interview study comprises the interviews of 50 patients admitted involuntarily and the interviews of the 50 voluntarily admitted patients following each involuntary admission. Both studies used a questionnaire based on previous studies. In Finland the rate of involuntary treatment is high. The motivation for deprivation of liberty is, however, the interest of patients. Deprivation of liberty was predicted by a diagnosis of a psychotic disorder as well as previous involuntary treatment. Harmfulness to others-criterion as the motivation of involuntary treatment was rarely used. In this material, it was never used as the sole motivation of detainment. Agitation/desorientation was the common reason for seclusion/restraint. Actual violence was more frequently the reason for seclusion of female patients whereas threat of violence was the reason for seclusion/restraint of men. There were differencies among the study hospitals concerning the rate of seclusion/restraint: in Oulu mechanical restraint was used more frequently than in other study hospitals. International comparison of deprivation of liberty is difficult because of the differences among countries in legislation and the paucity of the previous studies. Ward culture as well as the methods of registration vary in different countries, and, thus reliable comparison is restricted. The results of the current study confirm the notion that deprivation of liberty is more frequent in Finland that in many other countries. / Tiivistelmä Vapauden rajoittaminen on aina kajoamista ihmisen perustuslailliseen oikeuteen ja siten tahdosta riippumaton hoito psykiatriassa on ongelmallinen alue. Länsimaissa on herätty keskustelemaan tästä aiheesta viime vuosikymmeninä ja tahdosta riippumatonta hoitoa on pyritty vähentämään lainsäädännöllisin keinoin. Jotta tahdosta riippumattoman hoidon ja toimenpiteiden käyttöön voidaan vaikuttaa, tarvitaan vertailukelpoista tietoa sen määrästä ja laadusta. Tämä tutkimus on osa yhteispohjoismaista tutkimushanketta "Paternalism and Autonomy – A Nordic Study on the Use of Coercion in the Mental Health Care System". Tähän väitöskirjaan on käytetty em. tutkimushankkeen kahta suomalaista aineistoa: rekisteritutkimusta ja haastattelututkimusta. Rekisteritutkimukseen kerättiin kaikki 6 kuukauden aikana tutkimussairaaloihin (Tampere, Turku ja Oulu) tulleiden potilaiden tiedot. Haastattelututkimukseen pyydettiin 6 kuukauden aikana 50 tahdosta riippumattomalla lähetteellä tullutta ja heille 50 vapaaehtoisesti tullutta verrokkia. Molemmissa tutkimuksissa käytettiin aiempiin tutkimuksiin pohjautuvia kyselylomakkeita. Rekisteritutkimukseen kerättiin sosiodemografiset taustatiedot, aiempi sairaalahoitohistoria ja ajankohtaisen hoitojakson vapauden rajoittamista koskevat tiedot sekä diagnoosit. Haastattelututkimukseen kerättiin tietoja potilaan kokemuksesta sairaalaantoimittamisesta ja mahdollisuudesta vaikuttaa toteutuvaan hoitoon. Potilaiden psyykkinen tila arvioitiin haastattelututkimusosiossa käyttäen standardoituja psykiatrisia arviointiasteikkoja. Vapauden rajoittaminen psykiatriassa on Suomessa yleistä, tahdosta riippumattoman hoidon osuus on suuri. Vapautta rajoitetaan kuitenkin potilaan etua ajatellen (hoidon tarve ja potilaan vaarallisuus itselle). Psykoosi oli vapauden rajoitusta ennustava tekijä, kuten kuuluukin olla, koska psykoosi on tahdosta riippumattoman hoidon edellytys. Selittäväksi tekijäksi nousi myös aiempi tahdosta riippumaton hoito. Vaarallinen muille-kriteeriä käytettiin harvoin tahdosta riippumattoman hoidon perusteena, tässä aineistossa sitä ei käytetty yksinään sitovassa hoitopäätöksessä koskaan. Agitaatio/desorientaatio oli yleisin syy eristämiselle (eristys huoneeseen/leposide-eristys). Miehiä eristettiin hieman yleisemmin kuin naisia ja naisten eristys edellytti ajankohtaisen väkivaltaisuuden, kun miehiä eristettiin uhkaavan väkivallan vuoksi. Väestöön suhteutetut eristysluvut erosivat eri tutkimussairaaloiden välillä: Oulussa leposide-eristettiin muita sairaaloita yleisemmin. Eristystä ennusti parhaiten tutkimussairaala, mutta vapauden rajoituksen runsasta käyttöä ennusti aiempi tahdosta riippumaton hoito sekä ajankohtainen tahdosta riippumaton status. Tahdosta riippumattoman hoidon samoin kuin eristysten yleisyyden kansainvälinen vertailu on hankalaa aiempien tutkimusten vähäisyyden ja eri maiden välisten lainsäädännöllisten erojen vuoksi. Luotettavaa vertailua vaikeuttavat myös erilaiset hoitokäytännöt sekä rekisteröintimenetelmät. Saadut tulokset tukevat käsitystä, että psykiatristen potilaiden vapauden rajoittaminen on Suomessa yleisempää kuin monissa muissa maissa.

Emotionally triggered involuntary violent behaviour not attributed to a mental disorder: conceptual criteria and their reliability. This study conceptualised emotionally triggered involuntary violent behaviour (ETIVB), developed criteria for the identification of ETIVB, and examined their validity and reliability. South Africa criminal courts allow for a defence called “non-pathological criminal incapacity”. It refers inter alia to extreme emotional arousal triggering involuntary violent behaviour. This is usually called an “emotional storm” or a so-called “psychological blow automatism”. Psychiatrists are often called to give expert testimony in this regard, but there is no conceptual clarity or criteria upon which to base it. This difficulty is compounded by the requirement set by the criminal courts that the behaviour may not be attributed to a mental disorder (in this thesis the terms mental disorder and mental illness are used interchangeably). The first advance in obtaining clarity was afforded by focusing on the behaviour as distinct from 1) legal and jurisprudential considerations as well as 2) whether the behaviour is (not) attributed to mental disorder. The subsequent research questions driving the study were, “what counts as ETIVB?” In particular, what counts respectively as „emotional triggered‟, „involuntary‟, „violent‟, and „behaviour‟. Through conceptual methods suggested in the work of J.L. Austin, draft ETIVB-criteria were developed and then repetitively applied to a set of 28 cases. Twenty seven of these cases involved a charge of murder. The other one had behaved violently, but was not charged. The criteria were refined and their content validity derived by a repetitive to-and-fro process between comparative exploration of the concepts and their empirical application to the set of cases. The criteria were formulated into an instrument by which a psychiatrist can identify ETIVB. In addition provision was made to record whether ETIVB is, or is not, attributed to specific causes including mental disorder, but only as an attribution that follows after ETIVB has been identified. The ETIVB-instrument was subjected to reliability testing among 14 psychiatrists and 10 psychiatrists in training. They applied the ETIVB-criteria to a set of 5 externally validated case summaries. The participants had first been trained in the use of the instrument by considering other example cases. Statistical analyses of inter-rater reliability were performed. The modified kappa agreement ranged from 0.388 (fair) to 0.636 (substantial) across study cases for all criteria A.1 – H.1. The criteria for violence had exceptionally high inter-rater agreement, all being 0.947 and higher. The complexity of the ETIVB-construct transpired when inter-rater reliability analyses were compared between cases in that different cases posed different challenges for inter-rater agreement. The reliability testing across cases however, showed which less agreed-upon items would benefit from refinement. / Thesis (PhD)--University of Pretoria, 2015. / gm2015 / Psychiatry / PhD / Unrestricted

Located squarely within the experiences of legal aid lawyers, with particular emphasis on the challenges they face in delivering effective representation, this dissertation, designed as an institutional ethnography, problematizes the provisions and practices related to involuntary admission in psychiatric facilities in Poland, as well as the organization of legal aid representation in involuntary admission cases. Through detailed accounts of paramedics, psychiatrists, judges, and legal aid lawyers’ work, connected and coordinated by legal and administrative texts, I demonstrate how the disjuncture between institutional regimes and lawyers’ experiences is institutionally produced by the set of legal, professional, financial, and social relations that organize both the involuntary admission procedure and the system of legal aid in Poland. While I start my exploration with legal aid lawyers’ embodied experiences of performing their work, accounting for how that work is organized and coordinated in local sites, this dissertation moves beyond a solo ethnographic description in seeking to discover relations, especially the social and legal relations mediated by the texts that govern these local experiences and practices. I trace the material and discursive practices that operate in key sites to organize the legal aid system, involuntary commitment procedures, and judicial decision-making. In Poland, the overwhelming majority of involuntary commitment cases are taken on by legal aid lawyers, whose work conduct is bound by both the law and a code of professional ethics. In this dissertation, I advance my thesis by closely reviewing the legal context of involuntary commitment; the material practices associated with legal aid lawyers, such as appointment, client access, and remuneration; the processes through which psychiatric documents are created and attached to admittees; and the role psychiatrist-generated texts play in court. I argue that within the context of involuntary admission, lawyering is organized in such a way that legal aid attorneys are unable to perform at their utmost, in a way that would most benefit their clients. Moreover, through my research I show that―despite perhaps their best intentions―legal aid lawyers not only actively participate in the practices that circumscribe the space for their legal advocacy for admittees, but also reproduce the very discourses and practices that objectify people during involuntary admission procedures to psychiatric facilities in Poland. / Graduate

Junior enlisted personnel are the workforce of the U.S. Army and a recruiting pool for Warrant and Officer Candidate School training programs. Before fulfilling their initial obligation of 8 years, 25 to 30 percent of enlistees receive separation orders from the Army. Consequently, attrition in this group has created a substantial problem in maintaining a trained and ready Army. The purpose of this correlational study was to understand what factors contribute to unfilled service of enlisted personnel. Specifically, this study focused on the number of years of service before departure, the cause of the early separations, and the subcategories as factors contributing to early separations. This was in comparison to the recruiting results of first-term, junior enlisted personnel. The data for this study came from the U.S. Department of Defense Demographics reports for years 2008 through 2013. These data were analyzed using a factor analysis procedure. The findings indicated 5 subcategories of early separations: Failure to meet military requirements, behavior unbecoming a soldier, inability to achieve the minimum Army standards, individual voluntarily requests for discharge, and serving their minimum active duty contractual obligations. The factor analyses revealed the percentage of variance of the early separations were most significant for individual voluntary requests for discharge and serving the minimum active duty contractual obligations. The positive social change implications stemming from this study include recommendations to the Defense Department to support eliminating the females’ exemptions from registering. This will allow all eligible individuals to register with the Selective Service, thereby advancing the integration of women into combat arms positions throughout the military services.

Våren 2020 förändrades stora delar av vårt samhälle och arbetsmarknaden i stort. Ett nytt virus hade upptäckts i Kina vilken kunde överföras mellan människor. Viruset har fått namnet SARS-coronavirus-2 och den officiella benämningen är Covid-19. Utifrån Folkhälsomyndighetens rekommendationer uppmanade arbetsgivare sina anställda att arbetet skulle bedrivas hemifrån i sådan stor omfattning som möjligt. Att bedriva det dagliga arbetet har på det sättet skapat nya utmaningar både för arbetsgivaren och medarbetare. Då begränsningar setts av att arbeta på distans utifrån ett chefsperspektiv blir därför syftet med denna studie att undersöka hur chefer upplever det att ofrivilligt behöva arbeta på distans under rådande pandemi, med fokus på de positiva samt de negativa effekterna av distansarbetet. Studien baseras på åtta kvalitativa intervjuer med chefer på Region Dalarna vilka gått över till att arbeta på distans i samband med pandemin. Det insamlade materialet från intervjuerna har jämförts med den tidigare forskningen utifrån fastställda teman vilken sedan mynnat ut i en resultatanalys. Resultatet visar på att distansarbetet är komplext och att många olika faktorer påverkar chefernas upplevelser samt att det finns både positiva och negativa sidor av denna arbetsform. Effektiviteten upplevs öka vid distansarbete samtidigt för den med sig flertalet negativa effekter som ett uppskruvat arbetstempo, minskad social interaktion och avsaknad av informella mötesarenor. Studien kan bidra till att medvetandegöra de positiva och negativa effekterna av distansarbete vilka kan problematiseras och skapa diskussion. / In the spring of 2020, large parts of our society and the labor market in general changed. A new virus had been discovered in China which could be transmitted between humans. The virus was named SARS-coronavirus-2 and the official name is Covid-19. Based on the Swedish Public Health Agency's recommendations, employers urged their employees to work from home to the greatest extent possible. Conducting the daily work has in this way created new challenges for both the employer and employees. As limitations have been seen of working remotely from a managerial perspective, the purpose of this study will therefore be to investigate how managers experience working involuntary remotely, during the current pandemic, with a focus on the positive and negative effects of teleworking. The study is based on eight qualitative interviews with managers at Region Dalarna who have switched to working remotely in connection with the pandemic. The material collected from the interviews has been compared with the previous research based on established themes, which then resulted in a results analysis. The results show that working from distance is complex and that many different factors affect managers' experiences and that there are both positive and negative sides to this form of work. Efficiency is perceived to increase in teleworking at the same time as it brings with it the majority of negative effects such as an increased work pace, reduced social interaction and a lack of informal meeting arenas. The study can help to raise awareness of the positive and negative effects of telework which can be problematised and create discussion.

The purpose of this essay was to examine the experience of loneliness as well as the strategies used to manage loneliness as described in Swedish podcasts. Swedish podcasts concerning the experience and managing of loneliness were picked using a strategic selection based on several criteria relating to the questions posed by the study. To analyse the empirical data a qualitative content analysis was used, combined with a theoretical framework based on the dramaturgical perspective and stigma theories of sociologist Erving Goffman. The experience of loneliness was found to be paradoxical in nature due to its social and relational elements. The interviewees throughout the study appeared to compare and relate their experience to that of other people. Furthermore, the study found loneliness to be heavily reliant on social interactions and thus did not exist in a vacuum of social isolation. Several coping methods were identified and in turn grouped as either constructive and active or counterproductive and passive.

Bakgrund: Ofrivillig barnlöshet drabbar omkring 15% av kvinnorna som försöker skaffa barn, i Sverige. Ungefär en tredjedel av de 15% är helt infertila. Utredningar visar att problemet i cirka var tredje fall ligger hos kvinnan, i var tredje fall hos mannen. I den återstående tredjedel av fallen går det inte att fastställa vad infertiliteten beror på. Att leva med ofrivillig barnlöshet kan ge psykiska och fysiska hälsokonsekvenser. Syfte: Syftet var att beskriva kvinnans upplevelser av att leva med ofrivillig barnlöshet. Metod: Metoden som användes var en litteraturöversikt där tio vetenskapliga artiklar av kvalitativ metod analyserades enligt Fribergs metod. Sökningar genomfördes i databaserna CINAHL Complete och Pubmed. Resultat: I resultatet presenteras tre huvudkategorier: Sociala och samhällsmässigaupplevelser av ofrivillig barnlöshet, känsla av lidande och kulturell skillnad i upplevelser av ofrivillig barnlöshet med sex underkategorier: Stigmatisering, samhällets förväntningar och social press, social status och isolering, otillräcklighet och förnedring, psykisk påverkan, religiös och kulturell påverkan på upplevelsen. Det framkommer i resultatet att ofrivillig barnlöshet kan bidra till psykiskt lidande. Slutsats: Kvinnans upplevelser av infertilitet speglas främst genom en brist i livslust med följder som social, emotionell och psykisk påverkan. I arbetet har författarna fångat upp den bristande vården kring att behandla och hjälpa dessa kvinnor med stöd. / Background: Involuntary childlessness affects about 15 % of women that are trying toget pregnant in Sweden. About a third of the 15% are completely infertile. Investigations show that in about every third case the problem lies with the woman, in every third case with the man. In the remaining third of the cases, it is not possible to determine what the infertility is due to. Living with involuntary childlessness can have psychological and physical health consequences. Aim: The aim of this study was to describe the women’s experiences of living with involuntary childlessness. Method: The method is a literature review where ten scientific articles of qualitative method were analyzed by Friberg’s method. The searchings were made in CINAHL Complete and Pubmed. Results: The result is presented in three main categories: Social and societal experiences of involuntary childlessness, feeling of suffering and culturaldifference in experiences of involuntary childlessness with six subcategories: Stigmatization, society's expectations and social pressure, social status and isolation, inadequacy and humiliation, psychological influence, religious and cultural influence on the experience. It appears in the results that involuntary childlessness can contribute to mental suffering. Conclusion: The women's experiences of infertility are mainly reflected in a lack of zest for life with consequences such as social, emotional and psychological impact. In their work, the authors have captured the lack of care around treating and helping these women with support.

Change in body weight is an important determinant of risk of osteoporotic hip fracture in aging adults. Weight loss has been associated with an increased risk of hip fracture and weight gain has been associated with a decreased risk of hip fracture . . Weight gain cannot be recommended as appropriate prevention against hip fracture, however, because it is associated with such adverse health outcomes as cardiovascular disease and diabetes, and weight loss is commonly recommended in the treatment of these types of diseases. Clarification of how weight loss is related to risk of hip fracture is needed to resolve this issue. An extensive review of published literature was completed to assess the relationships between hip fracture and body weight, weight change, and involuntary and voluntary weight loss. Change in body weight and weight lll loss that was either intentional or unintentional were then assessed for their effects on risk of hip fracture in a population-based case-control study of risk factors for osteoporotic hip fracture in aging Utah residents. Analyses of risk of hip fracture by quintile of weight change since age 18 and according to weight loss intention were performed through logistic regression modeling. Weight loss after age 18 was associated with an increased risk of hip fracture in men and women, and above average weight gain after age 18 was protective against hip fracture in women. Involuntary weight loss of more than 20 pounds was associated with an increased risk of hip fracture in men and women aged 50 to 69 years, but was not related to risk of hip fracture in participants aged 70 to 89. Voluntary weight loss of more than 20 pounds did not significantly increase risk of hip fracture in either age group. It was concluded that involuntary weight loss may be an important predictor of risk of hip fracture in aging adults and that voluntary weight loss may be safely recommended to aging adults without increasing their risk of hip fracture

Bakgrund: Psykisk lidande kan leda till situationer där patienter vårdas mot sin vilja.  Autonomin blir begränsad vilket kan medföra hotfulla situationer som i sin tur präglar vårdrelationen. När detta inträffar är det av stor betydelse att ha en bra kommunikation och respektfullt bemötande i kontakten med patienten. Vid tvångsvård kan patienter känna sig övergivna och osäker då vissa av deras rättigheterna blir borttagen. Med hänsyn till detta borde det läggas vikt på hur patienter blir bemött under denna speciella tiden, där tvångsvård pågår.  Syfte: Att beskriva patienters upplevelse av vårdpersonalens bemötande under tvångsvård  Metod: Litteraturöversikt utifrån sju kvalitativa artiklar och en med en mixad metod. En integrerad analys genomfördes för att kunna besvara arbetens syfte.  Resultat: Analysen av patienters upplevelse av vårdpersonalens bemötande under tvångsvård resulterade i två teman: Olämplig bemötande och holistisk bemötande. Tema Olämpligt bemötande består av kategorierna Maktutövande attityder och Bristande kommunikation. Tema Holistiskt bemötande består av kategorierna Empatiskt professionellt förhållningssätt och Människan bakom patientrollen. Slutsats: Bemötande av patienter under tvångsvård påverkas av vårdpersonalens attityd. Maktutövande attityder och bristfällig kommunikation leder till att patienter känner sig förolämpade och inte delaktiga i sin vårdprocess. Patienter uppskattar omtänksamhet. Underlåtelsen av små handlingar som tillgodoser basala grundbehov påverkar dock patienters välmående negativ. Ett empatiskt professionellt förhållningssätt vägleder vårdpersonalen till att se människan bakom patientrollen. Kunskap i området anses i dagsläget som otillfredsställande och borde behöva uppmärksammas i det dagliga arbetet för att öka vårdkvaliteten inom psykiatrisk omvårdnad. / Background: Mental illness can lead to situations where  patients are cared for against their will. Autonomy becomes limited, and this can lead to threatening situations which in turn characterize the care relationship. When this occurs, it is of great importance to maintain  good communication and provide respectful contact to the patient. In case of involuntary treatment, the patients may feel abandoned and insecure when some of their rights are removed. With this in mind, emphasis should be placed on how patients are treated under this abnormal condition, when  involuntary treatment is ongoing.  Aim: To describe patient`s experiences of healthcare staff's attitudes during involuntary treatment.  Method Literature review based on seven qualitative articles and a mixed method. An integrated analysis was conducted to answer the question related to the issue.  Results: An analysis of  patients` experience of  healthcare staff`s attitudes during involuntary treatment resulted in two themes: Inappropriate treatment and Holistic treatment. The theme of Inappropriate treatment consists of the categories Powerful Attitudes and Lack of Communication. The theme of Holistic treatment consists of the categories Empathic professional approach and the human being behind the patient role. Conclusion The treatment of patient`s during involuntary treatment is influenced by the attitude of the healthcare staff. Attitudes of exercise of power and inadequate communication have led patient`s to feel insulted and not involved in their care process. Patient`s appreciated  consideration. However, the neglect of small actions which addressed their basic needs, affected the patients´ wellbeing negatively. An empathetic professional approach led healthcare staff to see the human being behind the patient role. The knowledge in this domain is currently unsatisfactory and in order to improve the quality of psychiatric nursing, attention needs to be paid to this in the daily work.

A thoughtful survey of the history of psychiatry sheds light on a rich and intricate story of our evolving understanding, experience, and treatment of mental illness through time. These chronicles are at once a show of human curiosity for the mind-body connection, and an experiment in cruel and unusual treatment of illnesses that have proven difficult to quantify through both ancient and modern scientific means. It is the latter that makes an ethical study of the past so vital in a concerted effort to write a more just future for all patients. This paper provides a survey of the history of mental health and psychiatry from ancient Egypt to modern-day America, highlighting the injustices suffered by patients with mental illness throughout all times with a particular focus on the burden shouldered by vulnerable and underprivileged persons, minorities, and urban populations. Through an analysis of landmark American cases, it examines the establishment of civil rights for psychiatric patients in the areas of: the right to treatment, right to refuse treatment, and civil commitment. Drawing upon these precedents and historical contexts, this paper explores how the principles of bioethics can be applied to the future of psychiatry with respect to emerging trends like the use of social media, telehealth, gene editing, and AI/VR in medicine. By thoughtfully reflecting on the past and applying the lessons we have gleaned to the future, this thesis aims to promote a more ethical and equitable approach to mental healthcare, one that protects and actively fosters the empowerment of all patients, regardless of background, mental status, or socioeconomic status. / Urban Bioethics