Inledning Alltsedan psykiatrins avinstitutionalisering tog fart under 1980- och 1990-talen har en utveckling av samhällsbaserade psykosociala insatser förespråkats för att erbjuda vård och stöd till personer med psykisk funktionsnedsättning. Insatserna förväntas bidra till att brukarna får tillgång till effektiv vård och stöd, samtidigt som de inkluderas i samhället. Vidare förutsätts insatserna baseras på kunskap och evidens, samt bygga på brukarens delaktighet och stödja dennes återhämtning. En annan målsättning är att vissa insatser ges i form av integrerade modeller, så att personer ur målgruppen får tillgång till sammanhållet stöd från inblandade myndigheter. Även om Sverige räknas som ett resursstarkt land som har kommit långt på området, så förekommer kritik mot utvecklingen. Kritiken har berört både planering och styrning på politisk nivå, men även utförandet av de insatser som erbjuds till brukarna. Kritiken har bland annat handlat om bristande samverkan mellan landsting och kommuner, och om stora lokala variationer i den erbjudna servicens kvalitet. I den här avhandlingen studeras dels utformningen av policy på området, dels implementering av specifika insatser. Syftet med avhandlingen är att undersöka hur svenska policymakare på nationell nivå har hanterat utvecklingen av psykosociala insatser för personer med psykisk funktionsnedsättning, samt att analysera möjligheter och svårigheter för organisationer och personal när det gäller att implementera de insatser som förespråkas av beslutsfattare. De frågeställningar som avhandlingen söker besvara är följande: Hur formuleras policy som syftar till att införa samhällsbaserade psykosociala insatser, och vad kan policyns egenskaper innebära för genomförandet av den? Vilka styrstrategier uttrycks i statliga policydokument? Vad hämmar respektive underlättar implementeringen av föreslagna integrerade psykosociala insatser? Hur kan vi förstå vad som påverkar möjligheten att erbjuda integrerade psykosociala insatser, i termer av lokala förutsättningar och strategier för implementering? Metod Policy på området studerades genom en studie av tre av de övergripande dokument som beslutats på regeringsnivå de senaste 20 åren. Riktade kvalitativa innehållsanalyser baserade på relevant litteratur genomfördes. Implementering av insatser studerades genom att 15 program följdes under 3 års tid. 14 av dessa arbetade med att implementera arbetsrehabiliteringsprogram utifrån modellen Individual Placement and Support (IPS). Under samma tidsperiod följdes ett team som implementerade den intensiva samordnings-, vård- och stödmodellen Assertive Community Treatment (ACT). För att bedöma verksamheternas följsamhet till modellerna genomfördes programtrohetsskattningar av samtliga program. Data avseende programmens målgrupp samlades också in. Tre IPS-program deltog i en fördjupningsstudie där kvalitativa intervjuer genomfördes med ledare, personal och samverkanspartners. Implementeringen av dessa program analyserades utifrån implementeringsramverket the Consolidated Framework for Implementation Research. Implementeringen av samtliga 14 IPS-program studerades med hjälp av skattningsskalan the Sustainable Implementation Scale (SIS). När det gäller ACT-teamet genomfördes dels kvalitativa innehållsanalyser av djupintervjuer, och dels skattningar av implementeringskomponenter med hjälp av SIS. Resultat Policy på området har innehållit stora mått av otydlighet och konflikt, både gällande de mål och medel som har formulerats. Regeringen har främst förespråkat så kallade mjuka styrstrategier, vanligen i form av statliga stimulansbidrag. Vissa förtydliganden och konkretioner har skett under tid, vilka ibland går i linje med de internationella rörelserna New Public Management och evidensbaserad praktik. Exempel på försök att strama upp styrningen är målformuleringar som förespråkar riktade och prestationsbaserade stimulansbidrag, samt nationella riktlinjer för att styra utvecklingen mot utvalda specificerade insatser. Trots detta är det fortfarande de berörda myndigheterna som är ansvariga för att välja ut, utforma och implementera psykosociala insatser. På verksamhetsnivå leder detta till att många otydligheter består, vilka ibland är relaterade till svårigheter att avgränsa ansvarsområden och att förändra hindrande regelverk och traditioner. Dessutom förekommer konflikter, exempelvis i form av konkurrerande målsättningar och ojämn resurstilldelning. Studierna av de integrerade modellerna IPS och ACT visar att implementering av dessa är möjlig, även i en sektoriserad välfärdskontext som den svenska. Det finns dock en rad faktorer på såväl organisationsnivå som teamnivå, som försvårar implementeringen. Exempel på dessa är de involverade organisationernas varierande målsättningar och traditioner, regelverkens utformning, samt svårigheter att erhålla långsiktig finansiering. I en del fall beskrivs de arbetssätt som modellerna förespråkar som försvårande, då de upplevs som annorlunda och utmanande för existerande rutiner och uppfattningar om stöd till målgruppen. Ett stort hinder för effektiv implementering är svårigheter att samverka, främst mellan, men även inom inblandade organisationer. De flesta program som lyckades genomföra en hållbar implementering hade personal som var duktiga på att navigera förbi de hinder som orsakades av ogynnsamma regler, och de lyckades även hitta vägar för att etablera samverkan, både horisontellt (med samarbetspartners på samma hierarkiska nivå) och vertikalt (mellan ledning och personal). En verksamhetsledare som har möjlighet att påverka samverkansrelationer i både horisontell och vertikal riktning är gynnande för implementeringen. Andra betydelsefulla komponenter som underlättar implementering är en noggrann planering innan ett program startas, medveten rekrytering av personal, formering av ändamålsenliga styrgrupper, samt att tidigt i processen arbeta strategiskt för att lösa finansieringsfrågan. Även programtrohetsskattningar var betydelsefulla, då de både fungerade som instrument för att identifiera förbättringsområden för programmen, men också hade en legitimerande funktion vid återkoppling till ledningen. Slutsatser Det råder en samstämmighet i övergripande målsättningar som syftar till att utveckla området integrerade psykosociala insatser. På en mer konkret nivå är läget betydligt oklarare, både gällande målsättningar i policy och av vem och hur insatserna ska implementeras. Även om vissa förändringar skett, står regeringen fortsatt för en mjuk styrning vilken lämnar ett stort ansvar till de myndigheter som ska implementera valda insatser. Detta innebär en rad svårigheter för frontlinjepersonalen, vilket leder till att de ofta behöver lägga mycket tid och energi på att hitta vägar för att överkomma dessa svårigheter. I många fall har ledare och personal goda möjligheter att uppnå en hög programtrohet på teamnivå, men för en hållbar implementering krävs det att ett program är väl förankrat både vertikalt och horisontellt. Därför finns ett behov av att forskare och beslutsfattare tar ett tydligare helhetsgrepp, både på området policy och implementering av specifika insatser. Skattningar av programtrohet och implementering kan vara ett stöd i att identifiera vad som fungerar samt vad som behöver förändras i och mellan organisationer. Men för att programmen ska lyckas med en effektiv implementering på organisationsnivå behöver deras legitimitet stärkas vertikalt, och planering för långsiktig lokal finansiering behöver göras i ett tidigt skede. / Introduction Since the deinstitutionalization of psychiatry started in the 1980’s, the field of psychiatry has moved in the direction of community-based psychosocial interventions for people with mental illnesses. The interventions selected should be based on knowledge and evidence, and support the users’ empowerment and recovery. In addition, some of the services should be provided in forms of integrated models, meaning that all agencies involved should provide cohesive care and support. Two examples of such interventions are the occupational rehabilitation program Individual Placement and Support (IPS) and the intensive case management model Assertive Community Treatment (ACT). Although Sweden is considered a high-resource country, the availability of psychosocial services has been criticized. This criticism has been related to policymaking as well as the quality of the services provided. Examples of areas considered problematic include collaboration deficiencies among disparate human service organizations and substantial local variations in available types of services. This thesis aims to examine how national-level policymakers in Sweden have handled the development of psychosocial support and to analyze facilitators and barriers experienced by these organizations in their implementation of community-based and integrated models. The research questions are as follows: -       How have policies concerning community-based psychosocial interventions been formulated and how do the characteristics of these policies affect the implementation of its goals? -       How do different types of steering strategies influence national-level policy implementation proposals? -       Which facilitators and barriers to effective implementation of proposed integrated interventions can be identified? -       How can the ability to provide integrated psychosocial interventions be explained in terms of local conditions and strategies used for implementation? Methods A study of community mental health policy covering three of the major documents published at the national level from the last 20 years was performed. Directed content analysis based on literature relevant for the research area was used. In order to study the implementation of the selected interventions, 15 programs were followed for a three-year period. 14 of these programs were implementing IPS and the other one implemented ACT. In order to monitor the programs’ adherence to the selected models, program fidelity assessments were performed. Data on the programs’ target groups were collected. Three of the IPS-programs participated in an in-depth study where qualitative interviews with leaders, staff, and collaboration partners were performed. The implementation of the three programs were analyzed utilizing the Consolidated Framework for Implementation Research. All of the 14 IPS programs were included in an implementation study where the Sustainable Implementation Scale (SIS) was used to identify facilitators and barriers to implementation. In the study of the ACT team, qualitative directed content analysis of in-depth interviews and SIS-assessments were performed. After three years, the sustainability of all programs was assessed. Results Mental health policies have involved high levels of ambiguity and conflict in relation to both the goals and the means. The government has prioritized soft steering strategies, usually in the form of financial stimulus grants. Over time, these policies have (at least to some degree) been clearer when psychosocial interventions are being described. In addition, the development of policy has led to harder steering strategies, illustrated by targeted and performance-based grants and the advocacy of national guidelines to steer agencies towards preferred interventions. Despite these changes, independent agencies are still responsible for selection, framing, and implementation of the interventions. Implementation of the integrated models IPS and ACT is possible, even in the context of a sectored welfare system such as Sweden.  However, there are a number of implementation barriers at the organizational and team levels. Obstructive factions include involved agencies disparate traditions and regulations, as well as the programs’ difficulties in securing long-term funding. Some of the staff interviewed considered the characteristics of the interventions as problematic since they challenged existing routines and views about support of the target group. Another critical component was the ability to establish collaboration, both horizontally (with partners at the same hierarchical level), and vertically (between management and staff). A team leader with the mandate to influence interactions horizontally and vertically is therefore a facilitating factor. In most of the programs that managed to perform a sustainable implementation of the models, a critical success factor was found to be staffs’ ability to navigate around a variety of barriers. Additional facilitators to successful implementation was careful planning before the start-up of a program, effective staff recruitment, the formation of a dedicated steering group, and a plan for local funding early in the implementation process. Regularly-performed program fidelity assessments were also noted as an important means to identify improvement opportunities for the programs. Collectively, these components served as tools to increase the programs’ legitimacy since the team leaders used them to provide feedback to the local decision makers. Conclusions At an abstract level, there is general agreement of the overarching needs in the area of integrated psychosocial interventions, but there are discrepancies when it comes to how to best convert this shared definition of need into concrete psychosocial interventions. The majority of steering strategies used are still considered ‘soft’, which leaves much of the responsibility to the implementing agencies.  At a grass-root level this leads to several difficulties, including unclear responsibility definitions and collaboration challenges between agencies. Instead of prioritizing the work with their clients, the staff are forced to put a lot of time and energy into solving these problems. In most cases, team leaders and staff are able to reach high program fidelity at a team level. However, a sustainable implementation demands that a program has been anchored both vertically and horizontally. There is a need for a holistic approach by researchers and decision makers, both in the area of policymaking and implementation of selected psychosocial interventions. Assessments of program fidelity and implementation have the potential to help agencies identify strengths and opportunities for growth both within each entity and between involved organizations. In order to implement the selected models successfully at an organizational level, the programs´ vertical legitimacy has to increase, and plans for long-term local funding strategies have to be initiated early in the implementation process.

Behavioral and cognitive skills training for increasing assertive behavior in college students were compared to an equally credible expectancy-control. One significant multivariate function successfully discriminated between the behavioral and control groups, and between the cognitive and control groups. This function was interpreted as showing enhanced behavioral/cognitive construction competencies in the behavioral and cognitive groups. A second function, though not significant, suggested that the cognitive training resulted in more aggressive behavior.

This study aimed to investigate the use of accommodation of assertive utterances (AUs) in the conversations of 49 girls aged 5;0-13;1. Based on the findings of earlier research that the use of such language is more closely related to age than to gender, it was predicted speakers would accommodate their use of and response to assertive utterances as a result of their partner's age. Naturalistic language from these speakers was collected over a year, and evidence of accommodation was observed in all speakers. Fewer AUs were used with younger speakers compared to older ones, and those used with younger girls were more likely to be produced with the sole purpose of controlling the hearer's behaviour. In addition, AUs were more likely to be complied with, or accepted, when they were produced by older girls. Given what is known about the types of language used by powerful/powerless individuals, it appears that these speakers consider age to be an indicator of status. A particularly interesting finding was that it was the age of a speaker in relation to other members of the conversation that influenced their use of and response to AUs, rather than the age of the speaker alone.

Forty-nine Cache Valley residents, between the ages of 18 and 45, who volunteered to participate in an assertion training class were assigned to one of seven groups. Subjects were administered pre- and posttests and a two month follow-up evaluation. Measures included Rotter's Internal-External Locus of Control Scale, the Rathus Assertive Scale, and the Berger Self-Acceptance Scale. The results obtained indicate that self-acceptance and assertiveness changed as a result of assertion training and that these changes were maintained at follow-up. No difference between internals and externals was observed as a result of semi-structured assertion training.

Made available in DSpace on 2016-06-02T20:30:49Z (GMT). No. of bitstreams: 1 2888.pdf: 2165994 bytes, checksum: 2302be6a886be6ae9fdf9d9e8e158377 (MD5) Previous issue date: 2010-02-10 / Universidade Federal de Minas Gerais / Given current social concerns with respect to senior´s rights, this study describes and evaluates a Social-Skills Assertiveness Training-Program (ASSTP) for elderly people. The sample (two men and 13 women) participated in one of two intervention groups: Experimental (EG, which received the ASSTP) or Placebo (PG, which received educational interactive presentations), based on a placebo design. For pre, post-test and follow-up measures, participants were evaluated using the IHSI-Del-Prette (a Social Skills inventory for the elderly) and the IREI (a questionnaire for the evaluation of the extent to which elderly people understand and exercise their rights). Also, during the post-test, participants completed a program evaluation questionnaire User´s Satisfaction with the Training Program . Results indicated acquisition and maintenance of the assertiveness social-skills repertoire in the EG, but not in the PG. Assessments carried out in the pre, post and followup using the IREI multiple choice items indicated no differences between these results in either EG or the PG. For the requiring written responses, however qualitative questions of IREI statiscally significant differences were found for Spontaneous reports of senior rights (for the EG, but not the for PG) and for Discrimination of situations when elderly had their rights disrespected by others , between the posttest and follow-up results for both the EG and the PG. With respect to their satisfaction, both groups presented high means for: (1) satisfaction with the program received, (2) importance of the program´s procedures, (3) readiness to perform assertive social skills, and (4) self evaluation of their performance in the program, but the PG indicated higher levels of satisfaction than the EG. We discuss the impact and effectiveness of the ASST Program, the viability and the importance of using placebo designs in order to assess internal validity of social-skills assertiveness training-programs and its critical features, as well as the relevance of this kind of intervention for the elderly, at this time. / Dado o atual cenário de preocupação social com os direitos das pessoas de terceira idade, esse estudo descreve e avalia um programa de Treinamento de Habilidades Sociais Assertivas (THSA) com foco na compreensão e no exercício de direitos por idosos. A amostra (dois homens e 13 mulheres) participou de um de dois grupos de intervenção com delineamento placebo: Experimental (GE, com o programa THSA) e o controle Placebo (GP, com Exposição Educativa Dialogadas, EED). Para as avaliações de pré, pós-teste e seguimento, foram utilizados: Inventário de Habilidades Sociais (IHS-Del-Prette) e Inventário sobre Reconhecimento de Direitos garantidos pelo Estatuto do Idoso (IREI). No pós-teste também foi utilizado o Questionário de Avaliação de Satisfação do Usuário. As Avaliações realizadas nas etapas pré, pós e seguimento, com o IHSI-Del-Prette, indicaram aquisição e manutenção habilidades sociais, especialmente as assertivas para o GE, mas não para o GP. Para as questões de múltipla escolha do IREI não foram encontradas diferenças nos resultados para o GE nem para o GP. Para as questões qualitativas do IREI, houve diferença estatisticamente significativa apenas para o GE, para reconhecimento espontâneo de direitos dos idosos, entre pré e pós-teste, e para os dois grupos em discriminação de situações de violação de direitos dos idosos, entre pós-teste e seguimento. Na avaliação de satisfação do usuário, o GE e o GP tiveram médias altas para: (1) satisfação com o programa recebido, (2) importância atribuída aos procedimentos do programa, (3) avaliação de preparo para emitir habilidades sociais assertivas ensinadas no THSA, e (4) avaliação do desempenho no programa, sendo que a satisfação do GP foi sistematicamente maior que o GE. Discute-se o impacto e a efetividade do programa de THSA, bem como a viabilidade e importância do uso de delineamento placebo para aferir a validade interna de programas de THSA e de seus componentes críticos, e a pertinência de intervenções desse tipo para a população de terceira idade na realidade contemporânea.

Made available in DSpace on 2016-03-15T19:34:41Z (GMT). No. of bitstreams: 1 Jairo Haber.pdf: 462280 bytes, checksum: 32f8690833548015b92488d8236ffd9d (MD5) Previous issue date: 2008-11-24 / This work looks for solutions for the Judiciary Court working performance. The analyze of its contentious and adversative system will verify the difficulties in the service rendered to society that must be more efficient, explores the possibility of a paradigmatic change in conflictive human interactions, trying to aggregate interdisciplinary instrumental, suggesting management and solutions to structured conflicts that will become access to justice, not only using the conventional Judiciary Court structure but also using preventive adequate strategies and techniques to solve interpersonal conflicts, stimulating solutions and interpersonal agreements as an instrument of democracy and civil rights. We propose the use and practice of abilities and interdisciplinary comprehension as a tool for the ethic sense of professionalism and the understanding of the juridical phenomenon. / O presente trabalho procura, a partir da análise do atual quadro institucional e diagnóstico do Poder Judiciário e o seu sistema de atuação, contenciosa e adversarial, que resulta na verificação das dificuldades enfrentadas para a prestação de serviço eficiente à sociedade, explorar a possibilidade de mudança paradigmática na apreciação das interações humanas conflituosas de forma a agregar instrumental interdisciplinar, sugerindo, mecanismos de gestão e solução de conflitos estruturados que propiciem a realização do acesso à Justiça, não apenas pela estrutura convencional do Poder Judiciário, mas também por meio de estratégias e técnicas adequadas de prevenção, gestão e solução de conflitos interpessoais, que estimulem soluções autocompositivas não adversariais, como instrumento de democratização e efetivação de um Estado de Direito. O trabalho propõe, ainda, o uso e prática de habilidades e compreensão interdisciplinar, como ferramenta de desenvolvimento do senso ético profissional e de apreensão do fenômeno jurídico.

The assertive training literature has documented the effectiveness of both behavioral and cognitive methods to increase individual's assertiveness. However, the ability for such methods to enhance the generalization of treatment effects to untrained assertive response classes and the natural environment has been poor. In addition, little notice has been paid to the durability of these changes. Although the past several years have witnessed more intensive efforts by investigators to program generalization as part of their interventions, results have continued to be disappointing. A specific generalization-enhancing treatment strategy, self-directed practice, has been utilized with much success in phobic populations. This strategy, and the theoretical orientation it reflects, has been proposed for use in assertive training. The present study sought to examine the effectiveness of this method as compared to the traditional assertive training procedures and investigate the role of self-efficacy expectations in mediating initial behavior change and its subsequent generalization.

Research shows that people with severe mental illness (SMI) have extensive trauma histories and higher rates of post-traumatic stress disorder (PTSD) than the general population. However, research also shows that both the trauma history and PTSD in people with SMIs are vastly unrecognized and untreated. Additionally, the relationships between SMI, trauma, PTSD, substance use, and other psychosocial factors is still not well understood, as there has been limited experimental research examining these relationships despite an awareness of their connections. The SMI-PTSD descriptive model was originally proposed by Mueser et al. (2002) to better understand these variables, and is often referenced in the literature, yet there is very little empirical evidence and understanding of how this model may differ by gender in people with SMI. Assertive Community Treatment (ACT) is an evidence-based treatment for those with SMI, yet the extent to which trauma is addressed within the ACT model is not consistently known, nor how the team’s practitioners work with their clients on trauma-related issues and PTSD. By definition, all ACT clients have an SMI and represent a population with complex and intensive needs; therefore, a better understanding the population ACT serves, as well as how the teams work with the trauma present in their clients, will aid in providing better and more consistent treatment and care. This dissertation examines gender differences in the relationship between SMI, substance use, trauma, PTSD, psychosocial factors, the SMI-PTSD descriptive model, and attempts to ascertain the perspectives of ACT providers in working with trauma and PTSD in clients. In Study 1, I conducted retrospective chart reviews to extract information on trauma histories, PTSD, substance use, and psychosocial factors in 282 clients from four ACT teams (178 men, 104 women) to assess the gender differences in types of trauma, instances of PTSD, substances of choice, problematic substance use, and the SMI-PTSD model. Findings indicate that rates of sexual trauma, emotional abuse, serious suicide attempts, rates of trauma in adulthood, and PTSD are higher among women, whereas rates of alcohol, marijuana, and stimulant use as well as lifetime problematic substance use are higher among men. For the SMI-PTSD model, results suggest that the model better corresponds to the experiences and possible trajectory of men with SMI. In Study 2, I employed thematic analysis through interviewing ACT providers to better understand their perspectives on working with trauma and PTSD in clients. Five overarching themes with 21 sub-themes emerged. The five themes were the role and scope of ACT teams and model regarding trauma; discussions of trauma with clients; current treatment of trauma; barriers to working with trauma; and recommendations for enabling trauma discussions and treatment. These two studies have important implications for further research. Research should take gender identity into consideration when proposing and testing models, as Study 1 has demonstrated that two genders experience a well-accepted proposed model differently; this finding may be applicable to people of all genders, as well as other models. Further research could be done to gather perspectives from workers on the strengths and challenges of the ACT model. Future work should also include the views of ACT clients to get a fuller picture of their experience with receiving care for their trauma experiences. Clinically, health care providers should better recognize and treat PTSD and traumatic-stress symptoms of people with SMI. Doing so will ensure that health-care is moving towards trauma-informed practice on a systemic level.

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