Bakgrund: Patienter med långvarig ländryggssmärta upplever ofta funktionsnedsättning, utan att där finns en tydlig koppling till vävnadsskada. Funktionsnedsättning kan delvis vara skapad av vården, av att patienter har fått kontraproduktiva råd av vårdgivare. Syfte: Att undersöka attityder och attitydskillnader mellan studenter i termin 1 och 6 på fysioterapeutprogrammet vid Uppsala Universitet gällande kopplingen mellan långvarig ländryggssmärta och funktionsnedsättning, samt om den egna upplevelsen av smärta påverkar resultatet. Metod: Studenter i termin 1 respektive 6 på fysioterapeutprogrammet vid Uppsala Universitet svarade på Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). HC-PAIRS mäter i hur stor utsträckning vårdpersonal associerar funktionsnedsättning med långvarig icke-specifik ländryggssmärta. Resultat: Termin 6 svarade signifikant lägre än termin 1, vilket betyder att studenterna i termin 1 har mer negativa förväntningar på funktionsförmågan hos patienter med ländryggssmärta (55 mot 46). Signifikanta skillnader fanns inom områdena “förväntningar på funktion”, “förväntningar på social förmåga” och “behov av bot”, men inte inom “projicerad kognition”. Egen upplevelse av smärta påverkade inte resultatet. Slutsats: Studenter i termin 6 har ett mer positivt synsätt på funktionsförmågan hos patienter med långvarig ländryggssmärta än studenter i termin 1. Spridningen är dock stor i båda terminerna. / Background: Patients with persistent spinal pain often experience a loss of function, without a clear association with tissue damage. Loss of function may partly be healthcare caused, after patients being provided counterproductive advice by their caregiver. Purpose: To investigate the differences in attitudes among first term and last term physical therapy students at Uppsala University, in regards to persistent spinal pain and loss of function and to investigate if student’s own experience of persistent pain influences these attitudes. Method: The students answered the Health Care Providers Pain and Impairment Relations Scale (HC-PAIRS) Questionnaire. HC-PAIRS measures to what extent health care providers link loss of function to persistent spinal pain. Results: There was a significant difference between the semesters. The students in semester one having a higher overall score compared to the students in semester six (55,5 compared to 46). There were significant differences regarding “functional expectations”, “social expectations” and “need for cure”, but not in “projected cognition”. The students’ own experiences of persistent pain did not affect their scoring. Conclusion: Students in semester six had a more positive outlook on the functional ability among patients with persistent spinal pain than students in semester one. However, there was a vast spread of results within both semesters.

The process and outcome of psychoanalytic psychotherapy have been studied for a long time. However, the experiences of patients, particularly in therapies where goals were not met, have not yet been the target of extensive research. Psychoanalytic psychotherapy with young adults might face particular challenges. The overall aim of this thesis was to explore the experiences of young adults in psychoanalytic psychotherapy, with a particular focus on differences between suboptimal therapies and therapies with generally good outcome. The setting was naturalistic, and perspectives of the patient, therapist and observer were combined. Qualitative and quantitative methods were used. Study I explored experiences of psychotherapy process and outcome among seven patients in psychoanalytic psychotherapy, who expressed dissatisfaction. Interviews at termination and 18 months later were analysed using grounded theory and compared to therapist experiences. Patients experienced abandonment with their problems in and after therapy, since therapy according to the patients lacked connections to daily life, as well as flexibility, activity and understanding from the therapist. Therapists presented a different picture of the same therapies, mainly focused on the difficulties of the patients. Study II analysed the experiences of 20 non-improved or deteriorated young adult psychotherapy patients at termination of therapy and 36 months later. Non-improvement and deterioration were calculated based on the reliable change index on self-rating scores. The grounded theory analysis of interviews established spinning one’s wheels as a core category. The relationship to the therapist was described as artificial, although at times helpful. Participants experienced their own activity in life and active components of therapy as helpful, but thought focus in therapy was too much on past experiences. Study III explored the experiences of 17 young adult patients, in psychoanalytic individual or group therapy, overcoming depression. The analysis of interviews from therapy termination and 18 months later indicated that finding an identity and a place in life were perceived as intertwined with symptom relief. Negative experiences included difficulties to change oneself, fear of change, and problems in therapy, such as too little activity on the therapist’s part. The results were discussed in relation to young adulthood, therapeutic alliance, mentalization, and attachment. The conclusion was expressed in a comprehensive process model of suboptimal therapy with young adults, with suggested ways to prevent such a development. The therapist’s meta-communication and correct assessment of the patient’s mentalization capacity from moment to moment are proposed as crucial. Regarding clinical implications, therapists of young adult patients need to establish meta-communication on therapy progress, as even experienced therapists might be unaware of dissatisfaction or deterioration. Meta-communication could be considered part of the treatment itself, as it may foster mentalization and good outcome. Further, the period of young adulthood entails decisions and developing an adult life, and therapists need to make room for this by active interventions.

Le soin est indissociable de la relation de confiance et de la mobilisation de la capacité du patient à exprimer librement ses décisions, aptitude centrale dans la relation de soins. Si les objectifs d’accès aux soins et de protection des droits du patient sont clairement posés, la question de la liberté de choix du malade mental reste sujette à caution. En France, les textes législatifs ne spécifient pas de claire délimitation de l’incapacité à consentir aux soins et il revient au médecin d’en authentifier le bien fondé. Le consentement, valorisé par notre moderne démocratie sanitaire, est contesté par le besoin de sécurité mentale mais conforté par la recherche d’alliance thérapeutique. La permanence d’une telle situation conflictuelle rend compte d’un affrontement entre la défense des droits de l’homme, ici et maintenant, et l’affirmation du « libre choix » de la société. / We cannot separate a relationship’s care based on trust from the raising of patient’s ability to freely express his decisions, the core capability of health relationships. If the goals in access of care and patient’s rights protection are clearly laid down, the issue about the freedom of choice of the mentally ill person is still subject to caution. The French legislative texts do not specify a clear boundary about the inability to consent to the care and it is up to the doctor to approve of its validity. The consent, valued by modern sanitary democracy, is disputed by the need for mental security but is consolidated by the search for a therapeutic alliance. The permanence of a conflicting situation explains the confrontation between a defense of the human Rights, hic and nunc, and a free choice assertion by the society

Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format. Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT. / Depression is a debilitating disorder that affects a large part of the adult population every year. Yet there is still a lack of access to effective care for people in need. Cognitive Behaviour therapy (CBT) is an evidence-based method for treating depression that together with the increased availability of Internet services provides an opportunity to increase access to effective treatment. Internet-based interventions can be effective in the treatment of depression, but there is a lack of knowledge concerning which formats of delivery that can be used and if therapeutic alliance is of equal importance when providing treatment over the Internet. The overall aim of this thesis was to examine the effects of different treatment formats (email therapy, guided self-help, and blended treatment) in internet-based CBT for depression and to further examine the role of alliance in these treatment modalities. Findings from this thesis show that email therapy and internetbased treatment programs were effective methods for treating depression. Alliance ratings were high, showing that a positive therapeutic alliance can be achieved in internet-based treatments. Patient-rated alliance could not predict outcome in any of the different treatment formats. However, therapist-rated alliance predicted change in depression during blended treatment. This thesis includes the first randomized controlled study on CBTbased email therapy, and the first internet-based behavioral activation program with ACT-components, for adult depression.

Bakgrund Att leva med de psykiska sjukdomarna schizofreni eller bipolärt syndrom innebär stora utmaningar i det dagliga livet, då det sociala livet är inskränkt och stigmatiserade uppfattningar leder till en känsla av diskriminering och ytterligare utanförskap för denna patientgrupp. Symtomen behandlas i första hand farmakologiskt, men det räcker inte med enbart läkemedel för att personen ska uppnå god psykisk hälsa. Alla individer har rätt till adekvat och personcentrerad omvårdnad för att öka välbefinnandet och livskvaliteten, vilket i sin tur påverkar det psykiska måendet. Syfte Syftet med studien var att beskriva hur omvårdnad kan främja den psykiska hälsan hos personer med schizofreni eller bipolärt syndrom. Metod Det utfördes en icke-systematisk litteraturöversikt, där totalt 16 vetenskapliga originalartiklar utgör grunden till resultatet. Sökning av relevant litteratur har gjorts i databaserna PubMed, CINAHL och PsycINFO. Genom tydliga inklusions- och exklusionskriterier har artiklarna granskats och valts ut för resultatet. Med hjälp av tematisk analys av artiklarnas innehåll har följande sex kategorier utarbetats: den terapeutiska alliansen, copingstrategier för ökad livskvalitet, ökad självkänsla, stigmatisering av patienter med schizofreni och bipolärt syndrom, samarbete mellan olika vårdgivare samt hälso- och sjukvårdens kunskap i ämnet. Resultat Resultatet tyder på att byggandet av en terapeutisk allians mellan sjuksköterskan och patienten är grunden till personcentrerad vård. Personer med schizofreni eller bipolärt syndrom måste hitta strategier för att hantera sina sjukdomsepisoder med stöd från sjuksköterskan. Detta leder till ökat välmående och främjar den psykiska hälsan. Individanpassad omvårdnad baseras på utbildning och kunskap, samt ett samarbete mellan olika vårdgivare. Slutsats                                                                                             Som legitimerad sjuksköterska är det viktigt att inneha kunskap om bemötande av personer med schizofreni eller bipolärt syndrom för att kunna ge adekvat omvårdnad och stödja utsatta patientgrupper till god hälsa och ökad livskvalitet. Detta innefattar att främja empowerment hos patientgruppen för att ge möjlighet till önskvärd egenvård. / Background Living with the mental illnesses schizophrenia or bipolar disorder involves major challenges in daily life, as social life is restricted, and stigmatized perceptions lead to feelings of discrimination and further exclusion for this patient group. The symptoms are primarily treated pharmacologically, but medication alone is not enough for each person to achieve satisfactory mental health. All individuals have the right to adequate and person-centered care to increase well-being and quality of life, which affects the mental state. Aim The purpose of the study was to describe how nursing care can promote mental health for individuals with schizophrenia or bipolar disorder. Method A non-systematic literature review was accomplished, where a total of 16 Scientific original articles form the basis for the result. Searches of relevant literature were performed in the databases PubMed, CINAHL and PsycINFO. Through precise inclusion and exclusion criteria, the articles have been carefully reviewed and selected for the result. Using a thematic analysis for the content of the articles, the following six categories were developed: the therapeutic alliance, coping strategies for increased quality of life, increased self-esteem, stigmatization of patients with schizophrenia and bipolar disorder, collaborative care and health care knowledge within the subject. Results The results indicate that the establishing of a therapeutic alliance between the nurse and the patient is the basis for person-centered care. People with schizophrenia or bipolar disorder need to find strategies for managing their episodes of illness with the support of the nurse. This leads to increased well-being and promotes mental health. Individualized nursing is based on education and knowledge, as well as a collaboration between different care providers. Conclusions As a licensed nurse, it is important to possess knowledge about treating individuals with schizophrenia or bipolar disorder, in order to provide adequate care and support vulnerable patient groups to good health and increased quality of life. This includes promoting the empowerment of the patient group to provide the opportunity for desirable self-care.

This paper aims at therapeutic relationship of adolescents, specifically at therapeutic alliance, which is factor often connected to successful outcome of therapy. The main research goal of this study was to explore therapeutic alliance with adolescents within the Day care centre for adolescents with mental health difficulties and understand how they perceive therapists and their work. The first part of this paper is describing concept of alliance from historical perspective, types of alliance are presented as well as factors on both side of therapeutic process involved in forming of the alliances. Further it presents specifics of alliance in group therapy and in adolescent patients. For research purposes, we chose to use semi structured interview. We were inspired by official tools for measuring this concept. The FIRO-B inventory was added to see, how adolescents form their relations with others, and what do they expect from others in terms of relationships. The purpose for using this tool was to see how their interpersonal orientation could be connected to forming of alliances with therapists. 7 adolescents participated in this study and their data were processed by qualitative approach, specifically by repeating themes analysis. The result of this analysis showed two main categories: "Goals" and...

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This study intends to examine the psychotherapist`s experience of videotherapy and therapeutic relation and alliance in videotherapy. Earlier studies show that videotherapy is a positive contribution to healthcare systems and increases accessibility for patients, but there are technical issues and limitations in non-verbal communication. The therapeutic alliance between patient and therapist is not negatively affected. The experience of the patient tends to be more positive than the experience of the therapist. This study´s approach is qualitative and inductive. Data are obtained from interviews with five licensed psychotherapists. The study shows that videotherapy is a good flexible alternative, but therapist attitude towards it, varies. A good therapeutic relation and alliance is possible and depends on both patient and therapist factors, though the quality is deepened in face-to-face sessions. The psychotherapists describe that some therapeutic interventions need to be modified and amplified, due to the unique settings.

The purpose of this clinical case study was to compare clients’ and an Educational Psychologist’s experiences of a psychometric feedback from a traditional perspective with feedback from the perspective of positive psychology. The study consulted relevant literature and integrated readings to design frameworks to guide the two modes of feedback. A mixed-method research approach was applied, with a dominant focus on the qualitative aspects of this study (Qualquan), guided by an interpretivist epistemology. Four adolescent girls and an Educational Psychologist were conveniently selected to participate, with two girls participating in the pilot phase and two in the data collection phase. After the pilot the interview frameworks were adapted. Psychometric profiles were used to generate quantitative data, while audio-visual recordings of the feedback interviews, interview transcripts, field notes , the researcher’s and Educational Psychologist’s reflections, and participants’ pre- and post-feedback narratives contributed to the qualitative data for the study. Following thematic analysis it emerged that the clients’ experienced four similarities between the two modes of feedback interviews. Both feedback interviews were experienced as satisfactory and positive experiences; both modes provided self- and career knowledge to the participants; both were experienced as comprehensive feedbacks and the Educational Psychologist highlighted both strengths and weaknesses of the client in each mode. However, the participant who experienced the positive psychological feedback interview received an additional strength-building opportunity. The lack of significant differentiation between the two modes of feedback interviews may be indicative of the value of the therapeutic alliance between therapists and client. This study’s main contribution to Educational Psychology theory and practice is a framework for a positive psychological feedback interview, which may create opportunities for strength-building discussions. / Dissertation (MEd)--University of Pretoria, 2010. / Educational Psychology / unrestricted

Syftet med studien var att undersöka behandlares upplevelse av terapeutisk allians vid sessionvia digitalt format. En kvalitativ metod har tillämpats och datainsamlingen har gjorts via semistrukturerade intervjuer. I studien deltog sju respondenter varav fem var kvinnor och två var män. Studiens insamlade material har analyserats utifrån Braun och Clarkes (2006) Tematiska analys. Den Tematiska analysen genererade tre teman: Första temat: Osäkerheten i vad som sker, och vad man inte ser eller hör, vilket beskriver respondenternas upplevelse av hinder i kommunikationen via det digitala mötet. Andra temat: Begränsat handlingsutrymme,beskriver respondenternas känsla av att det digitala formatet minskar deras verktygslåda som behandlare. Det tredje temat: Avsaknad av fysisk närhet, beskriver hur respondenterna saknar den fysiska närheten i det digitala formatet men upplever det digitala formatet vara ett gott komplement till det fysiska rummet, dock ingen fullgod ersättning. / The purpose of the study was to investigate therapists' experience of therapeutic alliance in therapy through digital format. A qualitative method has been applied and data collection has been done through semi-structured interviews. The study involved seven participants, five of whom were women and two were men. The study's collected material has been analyzed based on Braun and Clarke's (2006) Thematic analysis. The Thematic Analysis generated three themes: The first theme: The uncertainty in what happens, and what one does not see or hear, which describes the participants' experience of obstacles in communication through the digital meeting. Second theme: Limited room for maneuver, describes the participants' feeling that the digital format reduces their toolbox as a therapist. The last theme: Lack of physical proximity, describes how the participants lack the physical proximity in the digital format but experience the digital format as a good complement to the physical space, however, no adequate replacement.