Tvång är en realitet i psykiatrisk slutenvård och påverkan på individens autonomi utgör en viktig kunskapskälla för omvårdnadspersonal. Under 1990-talet genomfördes betydande förändringar inom psykiatrins område med uppkomst av Psykiatrireformen, Lag om psykiatrisk tvångsvård och Lag om rättspsykiatrisk vård, i syfte att förbättra vård och behandling av individer med psykiatriska åkommor. Tvångsåtgärder som förekommer inom den psykiatriska vården utgörs av bältning, isolering, kvarhållande på en sluten psykiatrisk vårdenhet och dylika frihetsberövande åtgärder. Syftet var att beskriva upplevelser och erfarenheter hos individer som genomgått psykiatrisk tvångsvård inom slutenvården. Metoden var en litteraturstudie av kvalitativ design med induktiv ansats. Resultatets fyra bärande teman är: Individen och autonomi, Individen, tvångets skepnad och omgivningen, Individen och relationer samt Individen under tvång. Litteraturstudiens slutsatser består till en del utav informationens betydelse. Därutöver är en omvårdande relation utav yttersta vikt samt att innehållet i vad som upplevs som tvång differentierar. Tvång är alltid närvarande i omvårdnadssituationer där hot om detta föreligger. Implikationen för grundutbildningen till sjuksköterska är att öka sjuksköterskestudenternas förståelse för individens upplevelser och erfarenheter av tvångsvård samt tillhandahålla verktyg för bemötande. Framtida forskning bör koncentrera sig på individens upplevelser och erfarenheter av tvång inom psykiatrisk slutenvård, i syfte att höja kvalitéten på den omvårdnad som tillhandahålls. / Coercion is a reality in psychiatric inpatient care and how it affects the individual’s autonomy is an important source of knowledge for nursing staff. During the 1990´s, important changes were conducted within the area of psychiatry with creation of “Psykiatrireformen”, “Lag om psykiatrisk tvångsvård” and “Lag om rättspsykiatrisk vård”, aiming to improve care and treatment of individual´s with psychiatric diseases. Coercive measures that occurs within psychiatric care consists of mechanical restraint, seclusion, detention in a psychiatric unit and similar confinement measures. The aim was to describe the experiences of individuals who have undergone coercion within psychiatric inpatient care. The method was a literature study of qualitative design with an inductive approach.  The result’s four carrying themes are: The individual and autonomy, The Individual, the semblance of coercion and surroundings, The individual and relationships and The individual during coercion. Conclusions of this literature study consist to a part of the importance of information. In addition, a caring relationship is of the most importance and the content in the experience of coercion is differentiating.  Coercion is alwayspresent in nursing situations where the threat of this exists. Implication for thenurse basic education consists in providing greater understanding for the individual’sexperiences of psychiatric inpatient coercion and providing tools inencountering. Future research should concentrate at the individual’sexperiences of coercion in psychiatric inpatient care, aiming to increase thequality of the care that is provided.

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Bakgrund: Den fysiska miljö vi befinner oss i påverkar oss alltid. Vårdmiljön kan påverka sjuksköterskorna och patienterna antingen positivt eller negativt beroende hur den är utformad. Den fysiska miljön kan även ha betydelse för de interaktioner som äger rum mellan sjuksköterskorna och patienterna. Syfte: Att belysa sjuksköterskans uppfattning av den fysiska vårdmiljön inom psykiatrin. Metod: Kvalitativ ansats. Sex intervjuer med sjuksköterskor på tre olika avdelningar alla verksamma inom psykiatrin genomfördes för att belysa deras erfarenheter och uppfattningar om den fysiska vårdmiljön inom psykiatrin. Resultat: Materialet resulterade i sju teman. Dessa var uppfattning, förutsättningar, känslor, negativa faktorer, positiva faktorer, fysisk påverkan samt visioner. Resultatet visade att personalen är medveten om att det finns brister i den fysiska vårdmiljön, men att det saknas ekonomiska resurser för att kunna göra de förändringar som skulle behövas. Slutsats: Samtliga sjuksköterskor hade visioner om hur den fysiska vårdmiljön skulle kunna förbättras och förändras men på flera avdelningar kom sjuksköterskornas och patienternas säkerhet på avdelningen i första hand framför den fysiska vårdmiljön. En bättre fysisk vårdmiljö skulle sannolikt gynna både sjuksköterskornas och patienternas återhämtning. / Background: The physical environment that we are in always affects us. It can also affect the nurses and the patients in a positive or negative way depending on how it’s designed. The physical environment might also affect the interactions between the nurses and the patients. Purpose: To illuminate the nurses perceptions about the physical environment in psychiatric care. Design: Qualitative method. Six interviews with nurses working on different psychiatric wards were performed to illuminate their experiences and perceptions about the physical environment in psychiatric care. Results: Seven themes could be seen. These were perception, conditions, feelings, negative factors, positive factors, physical impact and visions. The result showed that the nurses are aware of the shortcomings of the physical care environment, but the economical resources are missing to make the changes that are needed. Conclusion: All the nurses had visions about how the physical environment could be changed and improved but the security of the nurses and the patients was a priority in several of the wards. An improved physical care environment would probably benefit both nurses and patients and promote a better health.

I vårdverksamhet för patienter med komplexa vårdbehov är teamarbete en vanlig arbetsform. I forskning om mångprofessionellt teamarbete i vården beskrivs fördelar med organisationsformen, samtidigt som svårigheter påtalas somden mångprofessionella sammansättningen kan medföra. Inom forskningen har man dock i liten utsträckning undersökthuruvida de patientinsatser som görs av mångprofessionella vårdteam verkligen präglas av teamens breda kompetens. Manredovisar heller någon övergripande teoretisk modell som beskriver faktorer betydelsefulla för utfallet av vårdteams arbete ibemärkelsen mångdimensionalitet. Syftet med detta arbete har varit att undersöka i vilken utsträckning patientarbetet i mångprofessionella psykiatriska teampräglas av teamets samlade kompetens, samt på vilket sätt de olika professionerna bidrar till grad av mångdimensionalitet ipatientarbetet. Ett syfte har också varit att undersökta vad som kan vara viktiga påverkansfaktorer för utnyttjandet av densamlade kompetensen i psykiatriska team. Två empiriska studier har genomförts. Den första studien syftade till att ge en bild av grad av mångdimensionalitet ipatientarbetet, samt av på vilket sätt de olika professionerna bidrar med sin kompetens. I denna studie observeradesvuxenpsykiatriska teams arbete under behandlingskonferens. Resultatet av observationsstudien visade att de studeradeteamen hade svårigheter att under hela diskussionen belysa patienterna på ett mångsidigt sätt – diskussionen dominerades avdet sociala perspektivet. Till denna dominans av det sociala perspektivet bidrog alla professionerna. Resultatet pekade ävenpå ett underutnyttjande främst av omvårdnadspersonalen men även av kuratorerna under behandlingskonferens. Vidarevisade resultatet att en mycket stor del av diskussionsutrymmet ägnades åt att beskriva patienten och en mycket liten del åtanalys- och beslutsprocessen. Till dominansen av det beskrivande momentet bidrog alla professionerna. Den andra studien syftade till att belysa vad som kan vara viktiga påverkansfaktorer för huruvida patientarbetet ipsykiatriska team får en mångdimensionell prägel. I denna studie intervjuades personal från psykiatrin, och utgångspunkt förintervjuerna var resultatet från observationsstudien. De förklaringar intervjugrupperna lämnade till det sociala perspektivetsdominans och till dominansen av det beskrivande momentet handlade om behov hos medlemmar i psykiatriska team av attkänna sig delaktiga och jämlika, samt av att relationerna i teamet skall vara konfliktfria. Ett underutnyttjande avomvårdnadspersonal samt kuratorer förklarade man med ett hierarkiskt förhållande mellan medlemmar i psykiatriska team. Sammanfattningsvis kan sägas att resultatet av de två studierna pekar mot att relationella aspekter av teamarbetet samt etthierarkiskt förhållande mellan professionerna kan begränsa psykiatriska teams möjlighet till att under behandlingskonferensbelysa patientärenden på ett mångsidigt sätt, samt till fullo utnyttja teamets samlade kompetens. / In the healthcare sector, multi professional teamwork is a common way to organize health care services in areas where thepatients care need is multidimensional. Described in literature are several advantages of the multi professional approach inproducing high quality care. Also shown is that problems might arise from the professional diversity of a team. Research onteamwork in health care settings shows that little is known of whether health care teams make full use of their multiprofessional competence when designing patient care. There is also no overall theoretical framework describing importantfactors influencing the possibilities of a health care teams to make full use of their competence. The aim of this thesis was to investigate how psychiatric teams make use of their multi professional competence indesigning patient care. To meet the aims of this thesis two empirical studies where conducted. The aim of the first study was to investigate to what extent patient care was designed in a multi professional way, an inwhat way the different profession contributed to a multi professional designed care. Multi professional psychiatric teamswhere observed during treatment conference. The results indicate that when discussing patient care, the observed teams to alarge extent did not view the patients in a multidimensional way. The main focus was on the social aspect of patients and thiswas something that all the professions contributed to. The result also showed that when the discussions were viewed as awhole, and during the phase of describing the patient, clinical nurses took part in the discussions to a lesser extent than didthe other professions. Results also showed that the observed teams to very a large extent used the discussions for describingthe patients in relation to analyzing causes of symptoms and deciding interventions. In the second study four group interviews where conducted to investigate what might influence the psychiatric teams'ability to use its multi professional competence when designing patient care. Participating in the interviews where physicians,social workers, clinical nurses and psychologists. To a large extent the explanations suggested for the domination of thesocial perspective concerned relational aspects of team work. The interview groups described team members´ need to feelthat they participate in the discussions and understand what is said, that all team members are considered equal and thatconflicts are avoided. The same kinds of explanations were given for the fact that the observed teams to a large extent usedthe discussions for describing the patients in relation to analyzing causes and deciding interventions. Hierarchy in psychiatricteams was the most frequently used explanation to the fact that clinical nurses took part in the discussions to a lesser extentthan did the other professions. To summarize — the results indicate that relational aspects of team work and a hierarchic situation in psychiatric teamsmight impede on the psychiatric teams’ ability to draw on its multi professional competence.

This paper is interested in Swedish psychiatry during the period between 1930-1950,localized to Mariebergs hospital in Sweden. The purpose of this paper has been to testSjöstroms evidence of the pattern that he used to create three analytical concepts, roughlytranslated to; morally educative discipline-treatment, the production process and the idealinstitution citizen. Sjöström motivates that his concepts gives insight into one aspect of thepsychiatric expansion between 1860-1960 as well as creates an understanding of psychiatryas an institution. The source material for this paper has been patients' medical notes writtenby the chief physician of the institution. Via a method which mainly different from Sjöstromin its selection, categorization and more thorough presentation, this paper has seen the samepatterns which Sjöström has created his three concepts from. The ideal institution citizen,defined by its well behaved and calm behaviour emerges also in this papers quantitativecompilation of qualitative data as the clear majority. The morally educative disciplinetreatment,treatments and punishments that focuses on creating an acceptable behaviourrather than the treatment of insanity itself, can be seen in the adjective behaviouraldescriptions of the type well-behaved / badly-behaved which are dominant. The focus in thejournals is behaviour rather than mental decease symptoms such as hallucinations andtreatment is based on unaccepted behaviour rather than symptoms. Also, the sequential orderthat exists between badly-behaved behaviour and treatments, and well-behaved behaviourand rewards shows the focus on behaviour which the concept is based on. The previous tworesults together is the two parts of Sjöströms production process, that trough the morallyeducative discipline-treatment the institution creates an acceptable, quiet and well behavedideal institution citizen were the mental decease becomes secondary.

Amalie Skram (1846-1905) was born in Norway but lived in Denmark. She published several books about gender relations and built up a reputation as a naturalistic writer. In 1894, a nervous breakdown made her seek help from the famous psychiatrist Knud Pontoppidan. He sent her to an asylum, but she returned home after spending two months in psychiatric care. In 1895, Skram published two novels about the painter Else Kant, based on her own experiences but not written as autobiographies. The books, Professor Hieronimus and På Sct. Jørgen, came to be part of an ongoing debate about the rights of psychiatric patients. My purpose is to analyze the exercise of power in Skram's portrayal of psychiatry, especially the way it is gendered. The power relations are examined with concepts established by Foucault in his power analysis and with relevant medical history as a context. I treat the books as fictive narratives, that should not be seen as describing Skram's own experiences. My result actualizes several of Foucault's main concepts. Psychiatry works through the power to define – the right to give a name. Psychiatry define what madness is, and thus what normality is. The patient is, when defined as mad, also defined as unable to tell the truth about herself and the world. The treatment is a project of normalization and moral upbringing, where the patient is required to learn the norms she is thought to lack, and also to control her feelings instead of expressing them. Hysteria is the diagnosis for expressing strong feelings and can be read as an opposition to the male society, as well as the medical system. Gazes play a big part in these two books. Else is looked at by the medical, defining, gaze. She is herself observing the psychiatry and uses her gaze to look at the other patients in a way that raises questions about both abnormality and normality. In my reading, the gaze exercises power and the so called "male gaze" can also be used by women. The text is ambivalent concerning Else's possible madness. She is described as troubled and almost psychotic in the beginning, but later as sane. My conclusion is that Else gains her own form of sanity, not because of the treatment, but as a way of opposing it. Else is never made an object by the objectifying medical gaze. Instead, she creates herself as an agent and a subject. She is defined as mad, but is determined to in turn define and describe the psychiatry as a form of counter-power.

Mental illness is common, and usually starts early in life. However, the majority of those affected never seek mental health care. The overall aim of this thesis was to increase knowledge about help-seeking young adults with mental illness in order to improve diagnostic procedures in clinical psychiatry. A group of young adult psychiatric out-patients (n=217) were consecutively invited to participate in the study between October 2002 and September 2003. Altogether 200 (92%) agreed to participate. Among them, there were 161 (80%) women and 39 (20%) men. Participants’ mean age was 22.4±1.9 years. All participants were carefully and comprehensively assessed with respect to axes I, II, IV and V in the DSM-IV. Psychiatric disorders and personality disorders were assessed using the Structured Clinical Interview for DSM-IV for axis I disorders and the Structured Clinical Interview for DSM-IV for axis II disorders. Psychosocial and environmental problems (axis IV) were evaluated through structured interviewing by a social worker and by self-assessment with a questionnaire. Professional and patient ratings on the Global Assessment of Functioning scale were compared before and after treatment. Patients also reported on the Swedish universities Scales of Personality, the Child and Adolescent Psychiatric Screening Inventory-Retrospect and the Coddington’s life event scale. Taken together, the young adult, psychiatric outpatients were characterized by an early onset of their mental disorders, by co-morbidity, by being female and by having mood or anxiety disorders. There were no significant differences between self-referred and those referred by medical professionals according to either number of current or lifetime diagnoses. Childhood onset of depression was associated with more severe symptoms, more psychosocial risk factors, and more childhood developmental delays. Axis IV psychosocial stress categories were related to the presence of axis I disorders, personality disorders, co-morbidity, and impaired functioning. Agreement between patients’ and professionals’ ratings on the GAF scale was good before treatment and excellent after treatment. In summary, the findings suggest that direct self-referral to specialized psychiatric care does not seem to be associated with overutilization of such care. Childhood onset of depression is associated with a more complex illness. The revised axis IV according to DSM-IV seems to have concurrent validity, but is still hampered by limited reliability. And finally, the results support the usefulness of the self-report GAF instrument for measuring outcome in psychiatric care.

Diss. Uppsala : Uppsala universitet, 2007.

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 5 uppsatser.