Thesis (doctoral)-Universität, Bielfeld, 2000. / Includes bibliographical references (p. 478-506) and index.

Within the framework of ethnography, an inquiry was made into the many dimensions of psychological treatment and training in a psychiatric hospital, with particular reference to State Patients. Ethnography is the study of an intact cultural or social group based mainly on observations over a prolonged period of time in which the researcher is a participant. The multicultural aspects of the therapeutic community were also inquired into. Ethnographic data was collected and processed over a period of 16 years in three psychiatric hospitals, the main source of data gathered from Weskoppies Hospital in Pretoria. The ecosystemic psychotherapeutic perspective was used as a meta-model to describe eight therapeutic approaches in which intern-psychologists were trained. The hospital is described as a therapeutic community in which rehabilitation is a multi-professional responsibility. Each profession, or sub-culture, has its own framework and culture in which it works within the broader system of the psychiatric hospital. Ethical considerations and recommendations are levelled at the academic and practical aspects of clinical psychology, hospital management, and different levels of government. / Psychology / D.Litt. et Phil.

The purpose of this study was to determine the factors associated with choosing mental health nursing as a career, and to explore the possible ways of improving recruitment and retention of mental health nurses in Kenya. Quantitative, explorative descriptive research was conducted. Data collection was done by using questionnaires and focus group discussions. Three groups participated in the study: practicing mental health nurses (n=10), post-basic mental health nursing students (n=10) and final year basic nursing students (n=184). The findings revealed that basic nursing students do not intend to pursue a career in mental health nursing, and that there is an aging population of mental health nurses. The barriers to the mental health field include stigma, a poor working environment and inadequate career guidance. Marketing, policy and regulatory reforms, as well as positive work environments have been identified as strategies for improving the recruitment and retention of mental health nurses in Kenya. / Health Studies / Thesis (M.A. (Health Studies))

O objeto desta tese é o movimento da Reforma Psiquiátrica no Município de Cuiabá/MT, analisado por meio dos processos de trabalho das equipes de saúde mental nos serviços extra-hospitalares de atenção à saúde mental, numa abordagem dialética-marxista. Compreende-se que o processo de trabalho, sendo o fundamento do modo de produção e, portanto, da sociabilidade humana, permite analisar toda a problemática envolvida nas práticas de saúde, que se efetivam em uma determinada realidade concreta, complexa e representam a síntese de múltiplas determinações histórico-sociais. O movimento de Reforma Psiquiátrica nos anos 1970/1980 teve, em Cuiabá/MT, uma correspondência com a expansão da rede hospitalar psiquiátrica privada, determinada pelo peculiar processo de desenvolvimento econômico-social local. Atualmente, constata-se uma hegemonia do setor hospitalar privado no contexto de assistência à saúde mental em Cuiabá e, simultaneamente, uma discreta reorganização administrativa da assistência orientada para práticas extra-hospitalares que, entretanto, não confronta, quantitativa e qualitativamente, com o modelo de atenção médico-psiquiátrico que embasa as práticas da psiquiatria hospitalar. Tal reorganização visa atender, prioritariamente, às regras atuais de financiamento do setor. Observou-se uma centralização do poder administrativo e vínculos, muitas vezes, precários de trabalho dos profissionais, além da ausência ou restrição de número e de categorias de profissionais que seriam necessários para imprimir uma modificação no modelo de atenção ao trabalho das equipes. A cidadania – instrumento e finalidade do processo terapêutico na Reforma Psiquiátrica - é dissociada da vivência e organização do trabalho de profissionais e usuários. A referência de cidadania predominante nos processos de trabalho foi a cidadania tutelada. Não se observou uma problematização da condição de cidadania de doentes mentais e, não sendo exploradas as contradições das práticas que os profissionais operam - simultaneamente restrição de liberdade e atenção psicossocial - observou-se uma alienação dos mesmos em relação ao seu trabalho, que ficou então reduzido à realização de atividades. A medicalização é o mecanismo estruturante de todas as práticas analisadas e os instrumentos mais evidentes na abordagem terapêutica são os medicamentos psicotrópicos. A conformação de um novo paradigma de assistência – Reforma Psiquiátrica – requer a confrontação com o antigo modelo médico psiquiátrico, o que não se observou na realidade estudada. / The study object of this thesis is the movement for a Psychiatric Reform carried out in the district of Cuiabá (MT), analyzed through the work processes of the teams in charge of mental health outpatient attention and based on a dialectic-Marxist approach. It is understood that the working process, being the foundation of the production manner and human interaction, allows us to analyze all the problems involved in health practices which become effective in a certain concrete and complex reality. These practices represent a synthesis of the multiple socio-historical orders. The movement of Psychiatric Reform in the 70’s and 80’s in Cuiabá coincided with the growth of the number of hospitals in the private area, determined by the peculiar local socio-economic development process. We can, nowadays, notice the preeminence of private hospitals in the context of mental health assistance in Cuiabá and, at the same time, observe a slight administrative re-organization of the assistance to outpatients although it cannot be compared, in quantity nor quality, to the medical-psychiatric attention model provided by hospital psychiatry. This re-organization seeks to attend to, on a first instance, the present financing rules of the sector. A centralization of the administrative power has been observed together with somehow failing work-bonds for professionals and the absence or restriction of number and professional categories that should be considered essential to achieve a modified pattern of attention to the teams’ work. Citizenship – instrument and purpose of the therapeutic process within the Psychiatric Reform – is disassociated from the experience and working organization of professionals and users. The predominant reference to citizenship in the working processes is that of a tutored citizenship. We were not able to observe the problematics of the citizenship condition of the mentally disabled and as the contradictions in the professionals’ practice – simultaneous occurrence of independence restrictions and psycho-social attention – were not explored, a certain alienation was detected as far as their work was concerned, which was reduced to task compliance. Medication is the structuring mechanism of all the analyzed practices and the most apparent instruments for the therapeutic approach are psychotropic drugs. The conformation of a new assistance paradigm – Psychiatric Reform – requires the confrontation with the old psychiatric medicine model, which was not observed in the reality context we studied.

A expressão transtornos de aprendizagem pode ser encontrada tanto no Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-IV, 2000) quanto na Classificação Internacional de Doenças e Problemas Relacionados à Saúde (CID-10, 1993) obras de referência, no Brasil, na taxonomia dos ditos transtornos ou distúrbios psicológicos. Esses textos apresentam em seu conteúdo a descrição de uma sintomatologia e diagnóstico diferencial de perturbações que se manifestariam pela primeira vez na infância ou adolescência. Dentre esses problemas estão os que envolvem os processos de aprendizagem e/ou escolarização. Parte da nomenclatura nosográfica utilizada nessas obras aparece incorporada ao discurso de alguns educadores para designar entraves vivenciados pelos alunos na escola, silenciando em categorias o que é considerado inadequado no comportamento desses sujeitos. Neste trabalho de doutorado, procuramos analisar, sob uma ótica foucaultiana, diferentes formas de articulação entre saber e poder como fundamentação para o surgimento de conceitos e orientação de uma práxis. Buscaremos traçar, especialmente, uma genealogia do emprego do discurso psiquiátrico no campo da educação, partindo do pressuposto de que existe uma correspondência imaginária entre loucura e fracasso escolar, o que será demonstrado por meio do estudo dos desdobramentos desta relação em algumas práticas pedagógicas, sobretudo a escrita de relatórios sobre alunos que vão mal na escola. Na primeira parte da tese, estudaremos como as afecções hoje entendidas como transtornos de aprendizagem descendem de categorias que ao longo do século XIX (o qual assistiu o surgimento da psiquiatria moderna e da psicologia experimental) eram consideradas um tipo de loucura na forma de idiotia e imbecilidade. Visamos destacar como o uso de procedimentos pedagógicos tomados como terapia ou profilaxia dos transtornos mentais permitiu a importação do discurso psiquiátrico para as instituições escolares. Na segunda parte, à luz do conceito de poder psiquiátrico formulado por Foucault, analisaremos o solo epistemológico e as forças que permitem a circulação de um discurso médico e psicológico acerca dos fenômenos escolares. A última parte da tese versará sobre formas como se tecem as tramas entre loucura, doença mental, transtorno psicológico, inadequação de comportamento, discurso psiquiátrico e insucesso escolar. Para exemplificar esse movimento partiremos da análise documental e de relatórios de educadores e profissionais de saúde sobre alunos com supostos problemas de aprendizagem produzidos estes no âmbito de um serviço de Saúde Escolar, localizado num município da Região Metropolitana de São Paulo e coletados em Pesquisa de Campo realizada entre 2007 e 2010. Esse material será analisado dentro de uma abordagem qualitativa, na perspectiva de Albuquerque (1986) e Maingueneau (1997, 2008a, 2008b) de análise do discurso institucional. Ao término deste trabalho demonstraremos como a circulação do discurso psiquiátrico no campo da educação gera o esvaziamento do ato educativo, e é por ele alimentado. / The expression learning disorders may be found both in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 2000) and in the International Classification of Diseases and Health Related Problems (DSM-IV, 2000) reference works, in Brazil, in the taxonomy of then so-called psychological disorders or disabilities. In their content, these texts present the description of symptoms and differential diagnosis of \"disorder\" that would appear for the first time in childhood or adolescence. Among these \"problems\" are those that involve the processes of learning and / or schooling. Part of the nosographic nomenclature used in these works are incorporated in the discourse of some educators to refer to barriers experienced by students in school, hiding in categories what is considered \"inappropriate\" behavior in these subjects. In this doctoral work, we analyze, from a Foucauldian perspective, different forms of articulation between knowledge and power as the basis for the emergence of concepts and guidance of praxis. We will try to draw, especially, one genealogy of the use of psychiatric discourse in education, on the assumption that there is an imaginary correspondence between madness and school failure, which will be demonstrated through the study of the consequences of this relationship in some teaching practices, especially writing reports on students who \"do poorly in school.\" In the first part of the thesis we will study how the diseases - nowadays understood as \"learning disorders\" come from categories that throughout the nineteenth century (which saw the emergence of modern psychiatry and experimental psychology) were considered a kind of madness in the form of idiocy and imbecility. We aim to highlight how the use of pedagogical practices taken as therapy or prophylaxis of mental disorders has allowed the introduction of psychiatric discourse to the schools. In the second part, in the light of the concept of psychiatric power formulated by Foucault, we will analyze the epistemological ground and the forces that allow the circulation of a medical and psychological discourse about school phenomena. The last part of the thesis will focus on the ways madness, mental illness, psychological disorder, \"inappropriate\" behavior, school failure and psychiatric discourse are produced. To exemplify this movement, we will use the analysis of documents and the reports about students with alleged learning problems that were produced as part of a school health service, located in a town of the metropolitan region of São Paulo, and collected from field research conducted between 2007 and 2010. This material will be analyzed in a qualitative approach, under the perspective of Albuquerque (1986) and Maingueneau (1997, 2008a, 2008b) of institutional analysis of discourse.At the end of this work, we will demonstrate how the circulation of the psychiatric speech in the field of education produces the emptying of the educative act and nurtures itself.

Diante do expressivo número de Hospitais Psiquiátricos no Estado de São Paulo, que continuam presentes no atendimento das pessoas com transtornos mentais mesmo frente à política de desinstitucionalização e a priorização do atendimento nos serviços substitutivos, surge a questão se os profissionais que trabalham neles conhecem e discutem o conceito de reabilitação psicossocial e como trabalham no contexto da Reforma Psiquiátrica. Este estudo objetivou analisar as possibilidades e impossibilidades de se implantar estratégias de reabilitação psicossocial em hospitais psiquiátricos, foi escolhido como objeto as representações que os trabalhadores têm sobre a reabilitação psicossocial e como categorias analíticas, as representações sociais e o processo de trabalho em saúde. Os dados foram coletados no período entre novembro e dezembro de 2011, por meio de entrevistas semiestruturadas com questões norteadoras, junto a dezoito trabalhadores dos lares abrigados em um hospital psiquiátrico no Município de São Paulo. Após a transcrição das falas, os dados foram analisados conforme a metodologia de análise temática. A análise dos discursos dos entrevistados revelou temas que por aproximação configuraram a categoria Processo de Trabalho: Os temas que formaram esta categoria foram: o agente, instrumentos, objeto, finalidade e as dificuldades e facilidades do processo de trabalho. Também foram encontrados temas que por aproximação configuraram a categoria Processo de Reabilitação Psicossocial: objeto, instrumentos e finalidade do processo de reabilitação psicossocial. A categoria representações sociais possibilitou compreender a concepção dos trabalhadores sobre a reabilitação psicossocial; sendo sua finalidade independência, aumento do poder contratual, resgate da cidadania e dos direitos: de morar, trabalhar e reestabelecer laços sociais. A categoria analítica processo de trabalho desvelou o próprio processo de trabalho da equipe e o processo de reabilitar; os discursos apresentaram contradições em que coexistem as concepções embasadas no modelo da psiquiatria tradicional e concepções coerentes com as da reabilitação psicossocial. O que limita as possibilidades de reabilitação é: a precariedade da rede de saúde mental em São Paulo, escassez de recursos humanos e materiais, resistência por parte das famílias. As possibilidades ocorrem pela superação das práticas centradas na doença para práticas centradas nas necessidades materiais e psicossociais da pessoa. Os trabalhadores compreendem o hospital psiquiátrico como local de zero troca, reiterando vasta literatura sobre o tema, por isso, a finalidade do processo de trabalho é a alta do morador. Pode-se dizer que o trabalho nos lares abrigados proporciona a desospitalização do paciente e uma permanência com possibilidade de vida mais digna do que em enfermarias, pois tem a possibilidade de habitar e não simplesmente estar. Entretanto, é importante salientar que os moradores continuam sob o poder do hospital psiquiátrico e da equipe, limitados às normas institucionais, menos rígidas em relação às das enfermarias, mas ainda presentes, o que a análise revelou ser entendido pelos trabalhadores, evidenciando uma superação em relação à concepção do hospital como protetor ou local para tratar a crise. / Facing the expressive number of psychiatric hospitals in the state of São Paulo, which are still present in the assistance of people with mental disorders even facing the politics of desinstitutionalization and the prioritization in the assistance of substitutive services, arises the question whether the professional who works in them know and discuss the concept of psychosocial rehabilitation and how they work in the context of Psychiatric Reform. This study aimed in analyzing the impossibilities of implanting strategies of psychosocial rehabilitation in psychiatric hospitals, it was chosen as object the social representations in which workers have about the psychosocial rehabilitation and as analytical categories the social representations and in health work process. The data were collected between the periods from November to December of 2011, by means of semi-structured interviews with leading questions, with eighteen workers from shelters in a psychiatric hospital in the city of São Paulo. After the voices transcriptions, the data were analyzed following the methodology of thematics analysis. The analysis of the interviewed people have revealed themes that per approaching set the category Process of Work: the themes which have formed this category were : the agent, the instruments, objects, purpose and the difficulties and facilities in the process of work. There were also found themes that per approaching set the category Process in Psychosocial Rehabilitation: object, instruments and purpose in the process of psychosocial rehabilitation. The category social representations have allowed to make it understood the conception of workers about the psychosocial rehabilitation, being its purpose the independency, increase of contractual power, rescue of citizenship and the rights: of living, working and reestablish social bonds. The analytical category process of work unveiled the own team process of work and the process of rehabilitate; the discourses have shown contradictions where there is the coexistence the conceptions based on the model of traditional psychiatry and conceptions consistent with the psychosocial rehabilitation one. What limits the possibilities of rehabilitation are: the precariousness in the mental health of public services in São Paulo, lack of human resources and materials, resistance from part of the families. The possibilities are given in the overcoming of practices centered in the disease for centered practices in the persons material and psychosocial necessities. The workers comprehend the psychiatric hospital as a place of zero Exchange, reiterating wide literature about the theme, thats why the purpose in the work process is the cure of the inhabitant. We could say that the work in the shelters allows the patient not to be in the hospital any longer with the chance of a healthier life than in the nursing, because there is the chance of living and not simply being. However, it is important to mention that the inhabitants keep under the control of the psychiatric hospital and its staff, being limited to the institutional, less strict when comparing to the nursing ones, but yet present, the analysis have shown it was understood by the workers making it evident an overcoming in relation to the concept of the hospital as a protector or a place to treat the crisis.

Bakgrund: Enligt Hälso- och sjukvårdslagen ställs kravet att vården ska bygga på respekt   för patientens integritet och självbestämmande. Trots detta visar studier att kravet inte uppnås, då patienter inte känner sig delaktiga i vården i den utsträckning de önskar. Studier visar på att det inom psykiatrin kan ta tid att införliva patientdelaktighet, då ett gammalt paternalistiskt synsätt på patienter lever kvar på sina håll. Inom ätstörningsvården beskrivs patientdelaktighet som en ledstjärna i behandlingen, men många människor med ätstörningar är svåra att engagera i behandling då de kan vara ambivalenta eller förnekar och inte ser allvaret i sjukdomen. I vårdsituationer uppstår ibland en konflikt mellan patientens rätt till delaktighet i sin egen vård och vad vårdpersonal tänker är det rätta och bästa för personen. Sjuksköterskan är den som står patienten närmast i omvårdnaden och har ett professionellt ansvar att göra patienten delaktig i sin behandling.  Syfte: Syftet med föreliggande studie är att undersöka hur sjuksköterskor beskriver  patientdelaktighet vid ätstörningsbehandling i psykiatrisk heldygnsvård. Metod: Studien är en kvalitativ studie med induktiv ansats där semistrukturerade intervjuer genomfördes med sex sjuksköterskor verksamma inom ätstörningsvården, från två olika heldygnsavdelningar i Stockholm. Intervjuerna spelades in och transkriberades för att sedan analyseras enligt kvalitativ innehållsanalys. Resultat: Studien resulterade; i sex huvudkategorier; Påverkan, Bemötande, Relation,  Organisation och vårdmiljö, Sjuksköterskans situation och Patientens situation med vardera tre underkategorier. Diskussion: Resultatet diskuterade utifrån Kari Martinsens omvårdnadsteori samt annan relevant forskning. / Background: The Swedish Health Care Act states that all care in Sweden should be based in the respect for patient integrity and self-determination. Despite     this, studies show that this requirement is not achieved, as patients do not feel involved in the care to the extent that they would wish. Studies have shown that in psychiatric care, it may take time to incorporate patient- participation, as healthcare professionals' view of patients in many places still tends to be characterized by paternalism. Patient participation is described to be a guiding principle in the treatment within eating disorder care, but as patients can often be either ambivalent to their illness, deny it or not take it seriously, their involvement in the treatment can be difficult to achieve. In situations of care giving, a conflict sometimes occurs between the patient’s right to participate in his or her own care, and the healthcare professional´s ideas of what is right and best for the person. The nurse is the one working the closest to the patient in nursing care and hence has a professional responsibility to make the patient involved in the treatment. Aim: The aim of the study is to investigate nurses’ descriptions of patient participation in eating disorders treatment in psychiatric inpatient care. Method: The study is a qualitative inductive study. Semi-structured interviews were conducted with six nurses from two different inpatient care wards specialized in treatment of eating disorders. The interviews were recorded and transcribed and then analyzed through qualitative content analysis. Results: The study resulted in six main categories; Influence, response,  Relationship, Organization and care environment, The nurse´s situation and The patient´s situation with each three respective subcategories.  Discussion: The results were discussed based on Kari Martinsens theory about nursing       and other relevant research.

M.A. (Psychology) / The aim of this dissertation is to investigate the services and methods provided by the various medical and psychological professions within an inpatient psychiatric hospital setting. While working at a psychiatric hospital, the researcher was struck by the high readmittance rate of patients. This tended to create a general feeling of disappointment, frustration and impotence amongst the professions. The importance of such an investigation was therefore required, in order to help facilitate and improve current methods. A thorough investigation of the literature with regard to the current treatment methods at psychiatric hospitals, both on an international and national level, were undertaken. An in-depth case study was described and analysed to indicate the recurrent procedures, methods and treatment modalities that were being instituted within the hospital setting. The aim of this thesis was also to propose an alternative method to the current procedures, using an in-depth case study to indicate the use thereof.

D.Cur. (Psychiatric Nursing Science) / Please refer to full text to view abstract

Bakgrund: Hot och våld i psykiatrisk slutenvård är ett vanligt förekommande fenomen. Hot och våld uppstår av en rad olika anledningar. Det är ett störande moment i sjuksköterskans arbete och väcker negativa känslor, vilket kan avspeglas i sjuksköterskornas interaktioner med patienterna. Syfte: Att beskriva sjuksköterskors upplevelser av att vårda hotfulla och våldsamma patienter i psykiatrisk slutenvård. Metod: En intervjustudie genomfördes med åtta sjuksköterskor på två psykiatriska kliniker vid ett större sjukhus i en storstadsregion i västra Sverige. Materialet analyserades genom kvalitativ innehållsanalys. Resultat: Fyra kategorier framkommer. Den första är olustkänslor med underkategorierna att känna oro och ångest, att känna stress, att känna sig ledsen samt att känna sig kränkt. Den andra kategorin är rädsla, med underkategorierna rädsla för den hotfulla patienten samt att känna rädsla för andras skull. Den tredje kategorin är maktlöshet med underkategorierna att förlora kontrollen, att känna frustration samt att arbeta med en tickande bomb. Den fjärde kategorin är trygghetsskapande strategier med underkategorierna att sätta sig in i patientens situation samt att våga stå kvar. Slutsats: Ofta kan det aggressiva beteendet hos patienterna associeras till sjukdomsbild och/eller missbruksproblematik, vilket bekräftades i vår studie. I de flesta fall har sjuksköterskorna en djupare förståelse för patientens beteende och har därmed högre tolerans för hot och våld. Sjuksköterskorna betonar att det är viktigt att alltid vara tillgänglig för patienterna, då det skapar trygghet för båda parter samt är en förutsättning för en god vårdande relation. / Background: Inpatient aggression is common as a phenomenon in psychiatric inpatient care. Inpatient aggression arises for several reasons. It disturbs the nurses in their work assignments and causes negative emotions, which can be reflected in the interaction with the patients. Aim: To describe nurse's experiences of caring for aggressive patients in psychiatric inpatient care Method: An interview study was conducted with eight nurses at two psychiatric clinics at a hospital in a big town in Western Sweden. The material was analysed through qualitative content analysis. Results: The analysis resulted in four main categories. The first category is uneasiness, with subcategories: to feel anxiety, to feel stress, to feel sad and to feel offended. The second category is fear, with subcategories: to feel fear for the aggressive patient and to feel fear for others sake. The third category is powerlessness, with subcategories: to lose control, to feel frustration and to work with a ticking time bomb. The fourth category is work to create security policies with subcategories: understanding the patients' situation and courage to remain in an aggressive encounter. Conclusion: Inpatient aggression is often associated to symtoms and/or drug abuse, which also was confirmed in our study. In most scenarios the nurses had a deeper understanding for the patients behavior and thereby a higher tolerance towards inpatient aggresion. The nurses claimed that beeing available to the patients was very important, since that created an atmosphere of security for both parties and it was assumed a presumtion for a good caring relationship.