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Translating coercion policy into inter-organisational collaboration: the implementation of compulsory community care for people with mental illness
Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.ORCID-id: 0000-0002-6330-5640
Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.ORCID-id: 0000-0002-4540-5373
2016 (Engelska)Ingår i: Journal of Social Policy, ISSN 0047-2794, E-ISSN 1469-7823, Vol. 45, nr 4, s. 655-671Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

In 2008, compulsory community care (CCC) for people with severe mental illness was introduced in Sweden. CCC requires co-operation between psychiatric and social services, thus further complicating the longstanding difficulties with service coordination in the mental health field.

This article investigates what happens when a new policy is introduced that assumes complex co-operation of two organisations bestowed with high degrees of discretion. The process of institutionalisation will be analysed in terms of how an idea is translated and materialised on local levels. This has been investigated by interviewing key informants within psychiatric and social services at three different locations.

The implementation was perceived as relatively successful and occurred without major conflict. The main effect of the new legislation was improvement in the coordination of services, where designing a template form for a coordinated care plan was central. The inter-organisational discussions about service coordination that arose had a spill-over effect on services for other patient groups.

In essence, respondents describe CCC as a pedagogical reform to promote the coordination of services, rather than a reform to increase coercive powers over patients. This raises concerns about the legitimacy of the reform.

Ort, förlag, år, upplaga, sidor
2016. Vol. 45, nr 4, s. 655-671
Nationell ämneskategori
Socialt arbete
Forskningsämne
sociologi
Identifikatorer
URN: urn:nbn:se:umu:diva-127186DOI: 10.1017/S0047279416000040ISI: 000384335500006OAI: oai:DiVA.org:umu-127186DiVA, id: diva2:1044074
Projekt
Tvång i frihet – tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Forskningsfinansiär
Forte, Forskningsrådet för hälsa, arbetsliv och välfärd, 2008-0955Tillgänglig från: 2016-11-01 Skapad: 2016-11-01 Senast uppdaterad: 2018-06-09Bibliografiskt granskad
Ingår i avhandling
1. Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Öppna denna publikation i ny flik eller fönster >>Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
2018 (Svenska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Alternativ titel[en]
Coercion in freedom : genesis, implementation, and legal rights in compulsory community care
Abstract [en]

This thesis aims to analyze compulsory community care (CCC) as a social and normative practice in different contexts in the Swedish welfare system. The research questions are:

- How can the motives to introduce CCC in Sweden and other Western countries be understood?

- What happens in and between psychiatric and social service organizations when CCC is implemented?

- How are the legal rights of patients protected and what forms of social control of patients is discernible in written court decisions regarding CCC?

- What normative positions regarding autonomy is the CCC legislation based on?

- How can CCC be understood from steering, historic and power perspectives?

The four first research questions corresponds to the four research studies included in the thesis and the fifth question relates to the material as a whole.

The empirical material for the first study mainly consists of documents from the parliamentary process. For the second study, 15 interviews with employees in psychiatric and social services were conducted. For the third study, all written court decisions over a 6 month period (N=541) were investigated. In the fourth study, the analysis is primarily based on the current legislation and its history.

Community care has already taken over most tasks of the old institutions. With the adoption of CCC, even the coercive measures are now formally found in community settings. CCC was adopted despite lack of evidence supporting its effectiveness. Although the policy process started in the aftermath of high-profile crimes, the government bill was focused on integration and rehabilitation with the stated intention to reduce coercive powers. While CCC entails an actual expansion of coercive powers, those coercive elements are downplayed in the bill. CCC allows for preventative restrictions on non-violent civilly committed patients. The CCC example shows that political steering is not something that automatically restricts discretion over the medical profession. Earlier political steering strategies had failed to reduce the excessive clinical use of use of temporary leave. The introduction of CCC meant that politicians adapted legislation to previously undesired practices.

In psychiatric and social services, CCC is materialized as a physical object in the coordinated care plan. The interviewees talked about the template form for the coordinated care plan as almost synonymous with CCC. It helped clarify responsibilities and facilitated coordination between the organizations. These changes extended even beyond services for the targeted patients under CCC. The requirement of a coordinated care plan thus served as a political steering strategy for enhancing collaboration.

In the written court decisions about CCC we found deficiencies in procedural fairness in all four requirements for a fair trial that were investigated: transparency, clarity, consistency and impartiality. For example, more than 99 % of the decisions were made in favor of the claims of treating psychiatrist and a substantial minority of courts routinely delegated decision-making authority to treating psychiatrists. The special provisions often involved surveillance controlling techniques. The control is mostly physical, because of the unique role of medication, but also spatial and temporal. Even though no formal coercive measures are allowed, the special provisions as controlling measures seem to have real impact on patients. CCC may therefore be understood as disciplinary power.

A legal requisite for coercive care is that the patient oppose care. However, in practice it is assumed that a patient under CCC will accept the coercive elements (i.e. special provisions). The legal requisites for allowing and discharging from CCC are thus met at the same time. Restrictions of patient autonomy in the legislation is often motivated in terms of enhanced autonomy in the future, for example through avoiding relapse. Another rationale for the restriction of autonomy is to safeguard the health and quality of life of patients. There is no research evidence that compulsory community works. Accordingly, it is hard to identify what benefits CCC provide that can trump the autonomy of the patient.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet, 2018. s. 94
Serie
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 90
Nyckelord
compulsory community care, community treatment orders, mental health policy, policy implementation, patient rights, social control, court rulings, autonomy
Nationell ämneskategori
Socialt arbete
Identifikatorer
urn:nbn:se:umu:diva-146889 (URN)978-91-7601-886-6 (ISBN)
Disputation
2018-05-18, Hörsal B, Samhällsvetarhuset, Umeå, 10:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2018-04-25 Skapad: 2018-04-22 Senast uppdaterad: 2018-06-09Bibliografiskt granskad

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Zetterberg, LivMarkström, UrbanSjöström, Stefan

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