Bakgrund: Flera tusen personer vårdas varje år enligt lagen om psykiatrisk tvångsvård (LPT). Tvångsvård får endast utföras om patienten lider av allvarligpsykisk störning, motsätter sig vård och har ett oundvikligt behov av vårdsom endast kan tillgodoses på en sluten psykiatrisk avdelning. Patientersom lider av allvarliga psykotiska tillstånd, depressioner med suicidtankareller har andra allvarliga psykiska funktionsnedsättningar kan vara i behov av tvångsvård. Syfte: Att beskriva vuxna patienters upplevelser av psykiatrisk tvångsvård. Metod: Litteraturöversikt av 12 kvalitativa studier publicerade mellan år 2001–2015 är hämtade från databaserna CINAHL Complete, PubMed och psycINFO. Artiklarna analyserades sedan i enlighet med Fribergsmetodbeskrivning (2012) för att identifiera likheter och skillnader och kategoriserades slutligen i fem teman vilka var; Att bli informerad, Att varadelaktig, Att bli sedd och respekterad som människa, Att behålla integritetoch autonomi, Den egna synen på tvångsvård som behandling. Resultat: Patienter upplevde brist på information och delaktighet i sin vård.Upplevelser av vårdpersonal som utnyttjade sin maktposition, var ignorantoch visade en brist på kompetens. Patienterna uppgav en viss ambivalensgällande om tvångsvården hade varit nödvändig eller inte. Diskussion: Metoddiskussionen koncentreras runt styrkor och svagheter i urvalet avartiklar samt till tematiseringsprocessen. I resultatdiskussion så diskuteraspatienternas upplevelser av sjuksköterskans omvårdnad och bemötande.Vidare diskuteras vad som kan påverka dessa variabler och på vilket sätt dessa påverkar patienten. Detta anknyts till Erikssons (1994) teori omlidande. / Background: Several thousands of people are treated each year in accordance to the Swedish law regarding compulsory psychiatric care, lag om psykiatrisktvångsvård (LPT). Compulsory psychiatric care can only be applied if thepatient is suffering from a severe psychiatric condition, is opposing careand has an unavoidable need of care that only can be given in a lockedpsychiatric ward. Patients’ suffering from severe psychotic conditions,depressions with suicidal thoughts or other severe psychiatric disabilitiesmay be in need of coercive care. Aim: To describe adult patients’ experiences of compulsory psychiatric care. Method: Literature review of 12 qualitative studies published between the years of2001–2015 and was gathered from databases CINAHL Complete, PubMed and psycINFO. The studies were analyzed in accordance with Friberg’s description of method (2012) to identify similarities anddifferences and the data was then categorized into five different themeswhich were; To be informed, To be participating, To be seen andrespected as a human being, To keep ones integrity and autonomy, Theown view on compulsory psychiatric care as treatment. Results: Patients experienced a lack of information and a lack of involvement intheir own care. Experiences of staff abusing their position of powertowards the patients, acting ignorant and showing a lack of competence.Patients were ambivalent towards the necessity of coercive care. Discussion: The strengths and weaknesses of the method is discussed and thediscussion is mainly centred around the sampling of articles and the thematization process. The patients' experiences of nursing activities andtreatment are discussed. Furthermore, what could have an impact ontheese variables and what impact theese variables might have on thepatients is discussed. This is discussed in relation to Eriksson’s (1994) theory on suffering from care.

Knowledge concerning the social services’ use of the Care of Young Persons (Special Provisions) Act 1990:52 (CYPA) is relatively scarce, especially when it comes to the protection of adolescents victimized by abuse. The overall aim of this thesis is to investigate and discuss different conceptualisations of abuse, adolescents’ agency regarding abuse, victimization and social intervention, and how abuse and adolescent victimization are responded to, primarily by the social services. This is done from a stance influenced by critical realism as well as victim- and child-centred responses. The dissertation consists of four papers and examines these themes in two samples of judgments and related documents concerning applications for care of adolescents aged 13-17 under the CYPA. The findings from the total study of all judgments in the selected year clearly confirm § 2 CYPA as a rare intervention to protect adolescents. In only 85 of Sweden's 290 municipalities was a CYPA application made, but a main finding is that such care to a large extent was used to protect adolescents from various forms of abuse. In the total study, the applications of § 2 CYPA concerned 196 adolescents, for 70 per cent of whom abuse was described, and where more girls (96) than boys (41) were being considered for care based on abuse. Of all the girls, 79 per cent were described as subjected to abuse and of the boys 55 per cent. Also in the smaller sample consisting of judgments for 37 girls in care under § 2 CYPA and §§ 2 and 3 CYPA, abuse was described for many. For several adolescents in both samples abuse was described as having been exerted to maintain standards of honour, shame and virginity, and/ or to enable a forced marriage. The initiative and agency of the adolescents themselves in both the disclosure of abuse as well as the decision on alternative care is one of the most striking findings in the thesis. The majority of the adolescents, 71 per cent, were categorized as having intentionally disclosed the abuse. The aftermath of the disclosure was for many of the adolescents described as intensely challenging. For the majority the abuse was denied during the investigation, not only by the alleged abusers but also by non-abusing parents and other relatives. The findings relating to the social services responses suggest that the initial response to a high degree could be understood as parent-oriented. For 33 per cent, the judgment also revealed that the abuse had been disclosed to authorities one or several times prior to the investigation leading to the application for care under the CYPA. That the abuse in these cases had been known to the social services for on average 5 years can from a child-centred position be seen as a major failure regarding the system’s ability to reach children and stop abuse. A central conclusion is that the various forms of abuse described seem more connected to domination, fear, power and control than to conflict; to some extent mirroring the kind of systematic oppression described for victimized adults seeking the protection of NGOs and public authorities. The findings imply that interventions under the CYPA may enable more child-centred, safe and stable protection of children subjected to this kind of abuse. Given the findings in the present thesis it is argued that it may be important to differentiate the concept of abuse as well as to acknowledge the agency of children in both research and in practice. / <p>At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Manuscript.</p>

Apart from the significant amount of research based in the perspective of social service workers, parents’ viewpoints of their experiences with children in long-term foster care is notably underrepresented within social science literature. To address this lack in coverage this paper discusses parents’ experiences of compulsory care (LVU) using content analysis drawing on selected comment sections from two internet-based discussion forums, Flashback and Familjeliv. Our main objective was to analyse parents’ descriptions of their relations with the social services and changes in the perceptions of the role of parenting after the emergency removal. Applying the theoretical framework of social trust we sought to achieve a deeper understanding for the parents’ situation. The social trust theory aims at analysing individuals’ trust for the state and state institutions, especially in relation to different social groups. The study shows that the high levels of trust between citizen and authorities, one of the Swedish society’s central trademarks, was not reflected in the material collected concerning parents’ experiences of the so-called social safety net. In line with previous research, parents’ narratives demonstrated a significant distrust for the social services and their descriptions indicated a sense of neglect. Parents’ comments also suggested a lack of understanding for the judgements made by social service workers and the resulting compulsory care.

The purpose of this qualitative study is to examine barriers and facilitators to collaboration within compulsory care for substance abusers according to LVM. Furthermore, the aim is to examine how these factors affect the care provided to clients with comorbidity of substance abuse and mental health disorders. The empirical data are based on experiences of professionals who work at the social services, at LVM-institutions and at operations that accept clients according to 27 § LVM. The result is divided into three periods, which are before the institution, during the institution and after the institution. The barriers and facilitators are divided into three theoretical themes in each period. These themes are regulations, organisation and point of view. Different forms of vertical and horizontal integration are used to supplement the analysis and examine what significance each form of integration has on the care provided to clients with comorbidity. The result shows that the barriers and facilitators are relatively similar in each period of the LVM-care. Overall, it seems that it is set up for the collaboration to fail at some point because of the unpredictable barriers, which is why it is important that a high degree of both vertical and horizontal integration exist, since one of them is not enough to bring overall satisfactory care for the clients with comorbidity. A closeness to each other and an organisation that is more coordinated can lead to a high degree of integration on both levels.

Många motståndare till paternalism har försökt hitta icke-paternalistiska motiveringar för policys som de anser vara försvarbara. Detta har kulminerat till ett ”project of reconcilliation” som menar att förespråka och försvara vissa till synes paternalistiska policys utan att acceptera paternalism. Denna uppsats har till syfte att undersöka, framför allt, tre av dessa möjliga icke-paternalistiska motiveringar, specifikt i förhållande till tvångsvård – ”the psychic harm argument”; autonomi som intrinsikalt värdefullt, och fall av ofrivillighet eller mjuk paternalism. Denna uppsats menar att visa att tvångsvård inte alltid går att motivera icke-paternalistiskt, och att dessa anti-paternalistiska motiveringar lider av vissa stora brister som gör de svåra att acceptera som tillfredsställande, och därmed att ”the project of reconcilliation” misslyckas. / Many opponents of paternalism have tried to find non-paternalistic justifications for policies that they consider justifiable. This has culminated in a "project of reconciliation" that means to advocate and defend some paternalistic policies without accepting paternalism. The purpose of this essay is to examine, in particular, three of these possible non-paternalistic motivations, specifically in relation to compulsory care - "the psychic harm argument", autonomy as intrinsically valuable, and cases of involuntariness or soft paternalism. This thesis aims to show that compulsory care cannot always be motivated by non-paternalism, and that these anti-paternalistic motivations suffer from certain major shortcomings that make them difficult to accept as satisfactory, and thus that “the project of reconcilliation” fails.

Abstract Background: The use of coercion is an essential part of psychiatry despite occurrence of harm to patients and psychiatric staff. Contrasting to a global trend to reduce coercion, the number of coercive admissions and coercive treatment in Swedish psychiatry remains stable. Previous research identified frontline-workers to be especially likely to experience ethical dilemmas in their work with coerced patients. The literature identified for this study explored links between ethical judgement and the use of coercion. Research indicates that ethical dilemmas can lead to moral distress, inconsistency in practice and overuse of coercion. The literature identified for this study indicates that eEthical reasoning deliberations in contrast can mitigate moral distress can improve both the well-being and job satisfaction of psychiatric staff as well asand can  to decrease the usage of coercion without detrimental effects to frequency of violence or  treatment outcome. Research question: Which underlying conditions, context, values, power differences and ethical frameworks are involved in the experience of an ethical dilemma in psychiatric care for coerced patients? Data collection and analysis: Therefore, the current study seeks to identify ethical dilemmas as experienced by frontline workers to investigate situations and conditions that cause ethical dilemmas and analyze ethical reasoning. Seven interviews with frontline-workers (nurses, caretakers) from two different institutions were conducted. andData analyzedanalysis utilizedsing discourse analysis, following suggestions from Siegfried Jägers dispositive analysis that is based on Foucault’s discourse theory.  Results: Participants describe ethical dilemmas as a reoccurring phenomenon that is part of their daily work. The structural context from which they arise was described with naming impersonal and unchangeable factors such as legislation and hierarchy or a risk-avoidance paradigm. Diametrically dilemmas themselves were experienced within social interaction and characterised by personal values, emotions and empathy. The patient’s best, patient autonomy, patient autonomy, the responsibility to provide care to people in need were identified as main values. Descriptions of ethical dilemmas were shaped by ambiguity, but the justification of coercion was presented with a high degree of certainty. Discourses that were drawn upon were medical and philosophical discourse as well as inter-discourse. The critical interpretation of these findings on the background of previous research led to the identification of problematic aspects within psychiatry and consequently suggestions for improvement.suggestions Tof ethical deliberation as tool to detect, reflect upon and resolve ethical dilemmas with the aim to strengthen staff rights as well as patients’ rights, ethical reasoning methods should be taught and staff should get the possibility to discuss ethical dilemmas. Ethical deliberation should be aimed to improve psychiatric practice and patient rights. The responsibility of psychiatry for patients with capacity that are suicidal or aggressive must be debated. The psychiatrist role in assessment of dangerousness of patients must be debated on the background of an increasing trend towards risk avoidance. Patients’ possibility to appeal erroneous decisions about coercion must be strengthen, since the current system rarely leads to consequences despite a frequent erroneous decision. decrease coercion by abolishing arbitrariness of ethical reasoning. However, changes to dissolve sources of power differences would need changes of legislation and organization of psychiatry.

The purpose of this study is to examine people with substance abuse and their experiences of compulsory care. The reason for this is that there can be an increased vulnerability for the individual with addiction. Health and social aspects affect the individual due to addiction. Compulsory care can seem like a deprivation of liberty to the individual. It is an action to be taken as a last resort. However, research has shown that individuals are at higher risk of being re-institutionalized due to various factors, hence the purpose of the study. A literature study was performed in which 10 qualitative articles were analyzed. The result of the analysis was that the individual may feel that compulsory care is offensive in various ways. This is partly due to lack of integrity, but the individual also experiences stigma because of compulsory care. On the other hand, there are views that compulsory care is necessary because the individual's addiction problem is so serious. Overall, there is a great deal of guilt and shame for the individual. The individual can therefore experience social exclusion and lack of community. This leads to individuals relapsing. A large part of the reason is because the individual ends up in the same pattern and context as the time before compulsory care. This may be the reason why the individual has a higher risk of being put under compulsory care again. Thus, preventive measures may be necessary for the individual. There may be a need for a comprehensive effort for individuals with substance abuse.

Introduction: Compulsory care as an intervention to treat alcohol-use disorder has been acontroversial practice, and the law on care of misusers in certain cases (LVM) often comesunder criticism from different areas of Swedish society.  Aim: The purpose of this paper was to conduct a historical and ethical analysis pertaining tothe use of compulsory care for alcohol-use in Sweden. Method: Text was analysed using a hermeneutical approach. Historical information wasgathered through 3 different types of sources: academical dissertation, laws, andgovernmental investigations. Empirical data regarding LVM was gathered through asystematic search in psycinfo, Cochrane, and pubmed Results: Compulsory care against alcohol-use disorder started in 1913, The initial iteration ofthis was utilitarian. There has always been a heavy class-element to Swedish alcohol politics,especially before the 1950s. The legislation surrounding compulsory care has not drasticallychanged, nor has the characteristics of the individuals sanctioned under the laws. The mainethical conflicts are between individual autonomy and integrity, and the states responsibilitytowards its populace. Conclusions: The process of LVM is still reminiscent of earlier iterations of the law, and thediscussions surrounding compulsory care on a legislative level has not changed drasticallyduring the last 50 years. The efficacy of the intervention is not apparent, the process ofdefining who needs the intervention is not transparent, and it is not apparent that the socialwelfare board is equipped to make these decisions. This adds to the already dubious ethicaldilemmas regarding autonomy and integrity inherent to compulsory care.

The background to this empirical study is the recent media attention that children and young people in compulsory and inpatient care have received in Sweden. The media has described the care as ineffective and that many young people experience increased mental illness within the care period. Therefore we want to investigate children's and young people's experiences which they have shared in an online forum setting, with emphasis on their personal recount of coercion and inpatient care, as well as how they describe the long-term consequences the care has had on them. Such online forums give access to the narratives of young people that has been in compulsory and inpatient care. The results of the care has shown to be counterproductive and in some cases their medical conditions have worsened after the period of compulsory care. Hence, the continuation of this study is encouraged as further research is needed for the subject matter. The study is based on a qualitative method. The material has been collected through an online forum where young people can share their experiences of compulsory and inpatient care. The selection of forum posts was directed by the inclusion criteria: the author describing themselves as being under 18 years of age and having experience of compulsory and inpatient care. Included posts were analyzed with a thematic analysis method with an abductive approach. The result of the research analysis shows that a majority of the personal recounts indicate that children and young people who have been in compulsory and inpatient care have been negatively affected. A result pattern of increased mental illness for the focus group was observed as a result of the care the individual had been exposed to. The results also showed that compulsory and inpatient care caused long-term consequences for the focus group. The worsened mental health of the young patients both short and long term, could be strongly correlated to the professional care given to them by the staff. / Bakgrunden till denna empiriska studie är den senaste tidens medieuppmärksamhet som barn och unga i tvångs- och slutenvård har fått i Sverige. Media har beskrivit vården som ineffektiv och att många unga upplever ökad psykisk ohälsa inom vårdtiden. Därför vill vi undersöka barn och ungas erfarenheter som de har delat i ett onlineforum, med tonvikt på deras personliga berättelser om tvångs- och slutenvård, samt hur de beskriver de långsiktiga konsekvenser som vården har haft på dem. Sådana onlineforum ger tillgång till berättelser om ungdomar som varit i tvångs- och slutenvård. Vårdens resultat har visat sig vara kontraproduktivt och i vissa fall har deras sjukdomstillstånd förvärrats efter att de tvångsvårdats. Därför är det angeläget att denna studie görs för att bidra med ytterligare forskning inom ämnet. Studien bygger på en kvalitativ metod. Materialet har samlats in genom ett onlineforum där unga kan dela med sig av sina erfarenheter av tvångs- och slutenvård. Valet av foruminlägg styrdes av inklusionskriterierna: författaren beskrev sig vara under 18 år och med erfarenhet av tvångs- och/eller slutenvård. Berättelserna analyserades med en tematisk analysmetod och med en abduktiv ansats. Resultatet av forskningsanalysen visar att en majoritet av de barn och unga som varit i tvångsoch slutenvård har påverkats negativt. Vidare framkommer en ökad psykisk ohälsa av de unga som tvångs- eller slutenvårdats samt även långsiktiga konsekvenser till följd av den vård individen utsatts för. Vi såg även ett samband mellan den psykiska ohälsan hos de unga på kort- och långsikt och hur de bemöttes av den professionella vården.

Studien utgår ifrån behandlingspersonal på ett SiS LVM-hem och deras beskrivningar av sitt förhållningssätt gentemot kvinnor med samsjuklighet i form av missbruk och ätstörning, samt vilka utmaningar och möjligheter som de upplever i sitt arbete i förhållande till gruppen. Studien har en kvalitativ ansats med semi-strukturerade intervjuer som utförts med fem personer som arbetar som behandlingspersonal på ett SiS LVM-hem i Sverige. Den insamlade datan har framställts i en tematisk analys med fem identifierade huvudteman och 13 subteman som tolkats utifrån tolkningsramen, vilken inkluderar nationella regelverk och de teoretiska begreppen yrkeskompetens; relationskompetens och handlingskompetens samt teori om idealtypiska handlingar. Resultatet visar att det förekommer missbruk och ätstörning på LVM-hemmet och att behandlingspersonalen arbetar med det genom att förhålla sig lika till klienten oberoende dess problematik med viljan att hjälpa och anpassa strategier till problematiken, även om syftet med LVM inte är att behandla ätstörningar och det saknas förutsättningar på organisatoriskt plan. Resultatet visar även att behandlingspersonalen har fokus vid att arbeta relationsskapande för att nå klienterna och motivera dem. Studiens slutsatser är att det saknas kompetens om ätstörningar inom LVM-hemmet men att behandlingspersonalen bemöter missbruk och ätstörning genom att använda rutiner och begränsningar samt sin yrkes- och relationskompetens / The study is based on treatment workers at a SiS LVM-home and their descriptions of their approach to women with co-morbidity in the form of substance abuse and eating disorders, as well as the challenges and opportunities they experience in their work in relation to the group. The study has a qualitative approach with semi-structured interviews conducted with five treatment workers from one SiS LVM-home. The collected data have been represented in a thematic analysis with five identified main themes and 13 sub-themes interpreted based on our interpretive framework which includes the following theoretical concepts of professional competence; relational competence and action competence as well as the theory of four ideal actions. The result shows that there is substance abuse and eating disorders at the LVM-home and that the treatment staff works with it by treating the client equally regardless of their problem with the desire to help and adapt strategies to the problem, even if the purpose of LVM is not to treat eating disorders and that there are no prerequisites on an organizational level. The results also show that the treatment workers have a focus on relationship-building in order to reach the clients and motivate them. The study's conclusions are that there is a lack of expertise on eating disorders within the LVM-home, but that the treatment staff deal with addiction and eating disorders by using routines and restrictions as well as using their professional and relational skills