umu.sePublications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Umeå University, Faculty of Social Sciences, Department of Social Work.
2018 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Coercion in freedom : genesis, implementation, and legal rights in compulsory community care (English)
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.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2018. , p. 94
Series
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 90
Keywords [en]
compulsory community care, community treatment orders, mental health policy, policy implementation, patient rights, social control, court rulings, autonomy
National Category
Social Work
Identifiers
URN: urn:nbn:se:umu:diva-146889ISBN: 978-91-7601-886-6 (print)OAI: oai:DiVA.org:umu-146889DiVA, id: diva2:1199752
Public defence
2018-05-18, Hörsal B, Samhällsvetarhuset, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-25 Created: 2018-04-22 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Why community compulsion became the solution: reforming mental health law in Sweden
Open this publication in new window or tab >>Why community compulsion became the solution: reforming mental health law in Sweden
2011 (English)In: International Journal of Law and Psychiatry, ISSN 0160-2527, E-ISSN 1873-6386, Vol. 34, no 6, p. 419-428Article in journal (Refereed) Published
Abstract [en]

The aimof this article is to understand how compulsory community care (CCC) has become a solution in mental health policy in so many different legal and social contexts during the last 20 years. The recent introduction of CCC in Sweden is used as a case in point, which is then contrasted against the processes in Norway, England/Wales and New York State. In Sweden, the issue of CCC was initiated following high-profile acts of violence. Contrary to several other states, therewas agreement about the (lack of) evidence about its  effectiveness. Rather than focusing on dangerousness, the government proposal about CCC was framedwithin an ideology of integrating the disabled. The new legislation allowed for a broad range ofmeasures to control patients at the same time as itwas presented as a means to protect positive rights for patients. Compared to previous legislation in Sweden, the scope of social control has remained largely the same, although the rationale has changed — from medical treatment via community treatment and rehabilitation, to reducing the risk of violence, and then shifting back to rehabilitation in the community. The Swedish approach to CCC is similar to Norway, while New York and England/Wales have followed different routes. Differences in ideology, social control and rights orientations can be understood with reference to the general welfare and care regimes that characterize the four states.

 

Keywords
mental health policy, mental health law, outpatient coercion, community treatment orders, outpatient commitment, compulsory community care
National Category
Social Work
Research subject
Sociology
Identifiers
urn:nbn:se:umu:diva-51760 (URN)10.1016/j.ijlp.2011.10.007 (DOI)000298905900007 ()
Projects
Tvång i frihet
Available from: 2012-02-01 Created: 2012-02-01 Last updated: 2018-06-08Bibliographically approved
2. Translating coercion policy into inter-organisational collaboration: the implementation of compulsory community care for people with mental illness
Open this publication in new window or tab >>Translating coercion policy into inter-organisational collaboration: the implementation of compulsory community care for people with mental illness
2016 (English)In: Journal of Social Policy, ISSN 0047-2794, E-ISSN 1469-7823, Vol. 45, no 4, p. 655-671Article in journal (Refereed) 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.

National Category
Social Work
Research subject
Sociology
Identifiers
urn:nbn:se:umu:diva-127186 (URN)10.1017/S0047279416000040 (DOI)000384335500006 ()
Projects
Tvång i frihet – tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2008-0955
Available from: 2016-11-01 Created: 2016-11-01 Last updated: 2018-06-09Bibliographically approved
3. The compliant court: procedural fairness and social control in compulsory community care
Open this publication in new window or tab >>The compliant court: procedural fairness and social control in compulsory community care
2014 (English)In: International Journal of Law and Psychiatry, ISSN 0160-2527, E-ISSN 1873-6386, Vol. 37, no 6, p. 543-550Article in journal (Refereed) Published
Abstract [en]

Compulsory community care (CCC) was introduced in Sweden in 2008. This article investigates all written court decisions regarding CCC over a 6 month period in 2009 (N = 541). The purpose is to examine how the legal rights of patients are protected and what forms of social control patients are subjected to. 51% of CCC patients are women and 84% are being treated for a psychosis-related disorder. In the court decisions, only 9% of patients are described as dangerous to themselves, while 18% are regarded a danger to others. The most common special provisions that patients are subjected to are medication (79%) and a requirement that they must maintain contact with either community mental health services (51%) or social services (27%). In the decisions, both the courts and court-appointed psychiatrists agree with treating psychiatrists in 99% of cases. Decisions lack transparency and clarity, and it is often impossible to understand the conclusions of the courts. There is considerable variation between regional courts as regards the provisions to which patients are subjected and the delegation of decision-making to psychiatrists. This means that decisions fail to demonstrate clarity, transparency, consistency and impartiality, and thus fail to meet established standards of procedural fairness. Surveillance techniques of social control are more common than techniques based on therapy or sanctions. Because of the unique role of medication, social control is primarily imposed on a physical dimension, as opposed to temporal and spatial forms. The article concludes that patients are at risk of being subjected to new forms of social control of an unclear nature without proper legal protection.

Place, publisher, year, edition, pages
Elsevier, 2014
Keywords
compulsory community care, community treatment orders, outpatient coercion, court hearings, legal rights, social control
National Category
Other Social Sciences not elsewhere specified
Identifiers
urn:nbn:se:umu:diva-96401 (URN)10.1016/j.ijlp.2014.02.027 (DOI)000345542000002 ()2-s2.0-84909980797 (Scopus ID)
Available from: 2014-11-19 Created: 2014-11-19 Last updated: 2018-06-07Bibliographically approved
4. Tvingad till autonomi: en teoretisk analys av öppen psykiatrisk tvångsvård i Sverige
Open this publication in new window or tab >>Tvingad till autonomi: en teoretisk analys av öppen psykiatrisk tvångsvård i Sverige
(Swedish)Manuscript (preprint) (Other academic)
Abstract [sv]

Utifrån tidigare forskning om öppen psykiatrisk tvångsvård har två paradoxer i förhållande till lagstiftningen identifierats: Öppen psykiatrisk tvångsvård (ÖPT) innebär både mer och mindre autonomi för patienten. ÖPT innebär att autonoma individer tvångsvårdas till autonomi. Syftet med artikeln att tydliggöra vilka normativa ställningstaganden som ligger till grund för tvångsvårdsformen genom att de två paradoxerna belyses utifrån fyra perspektiv på autonomi.

Den första paradoxen förklaras genom att lagstiftaren förhåller sig till både en liberal och en medicinsk-etisk autonomidefinition. I ett liberalt perspektiv är öppen tvångsvård en inskränkning av individens rätt till frihet. I ett medicinsk-etiskt perspektiv kan öppen tvångsvård öka autonomi genom att det ökar eller skyddar patientens autonomi i framtiden. I ett medicinsk-etiskt perspektiv kan andra värden, som hälsa och livskvalitet, också motivera inskränkningar i patientens autonomi.

Den andra paradoxen kan förklaras genom att lagstiftaren blandar proceduriella och substantiella rekvisit för autonomi. Patienten förutsätts vara autonom enligt proceduriella rekvisit eftersom patienten inte anses vara beslutsoförmögen. Samtidigt är utfallet av patientens val avgörande för om det respekteras. Om patienten vill avstå vård förutsätts detta inte vara patientens autentiska önskan, vilket är ett uttryck för en substantiell syn på autonomi. Vården ska istället återge patienten dess substantiella autonomi. Vid ÖPT förutsätts patientens i praktiken frivilligt medverka till vården. Det betyder att patienten uppfyller även autenticitetsrekvisiten. Men eftersom syftet med tvångsvården är att återupprätta just den autentiska viljan genom att patienten blir i stånd att frivilligt ta emot tvångsvård är autonomikraven för öppen tvångsvård uppfyllda samtidigt som autonomikraven för vårdens upphörande också är uppfyllda.

Om ÖPT ska kunna motiveras utifrån ett medicinskt-etiskt perspektiv krävs att tvångsvården faktiskt ger mer autonomi senare eller andra vinster. I dagsläget finns inget vetenskapligt stöd för att tvångsvårdsformen fungerar. Mot denna bakgrund är det svårt att se vilket värde som tillförs som väger tyngre än patientens autonomi.

Abstract [en]

In earlier research about compulsory community care, two contradictions related to the legislation have been identified: First, compulsory community care (CCC) means both more and less autonomy for the patient. Second, it means that autonomous individuals are being coerced to autonomy. The aim of the article is to clarify the normative underpinning of the law in light of four perspectives of autonomy to that help understand the two contradictions.

The first contradiction can be explained by the fact that the legislator operates with two different definitions of autonomy: liberalistic and bioethical. In a liberalistic perspective, CCC restricts the right to autonomy. From a bioethical perspective, CCC potentially increases autonomy since it may enhance or protect the future autonomy of the patient. According to this perspective, other values, like health and quality of life, can also motivate restriction of autonomy.

The second contradiction can be explained by how the legislator confuses procedural with substantial conceptions of autonomy. Since the patient is not assumed to be incompetent, the patient is assumed to have procedural autonomy. At the same time, whether or not the patient’s will is accepted depends on the eventual outcome of the patient’s choice. If the patient refuses care, her opinion is not presumed authentic, which is an expression of a substantive conception of autonomy. The coercive care provided is supposed to re-install the patient’s substantive autonomy. When it comes to the practice of CCC, the patient is assumed to voluntarily accept the coercive elements. This means that the patient is also autonomous according to a substantive conception of autonomy. Since the objective of compulsory care is to enable the patient to accept care voluntarily and thus restoring her/his authentic opinion, the legal requisites for allowing and discharging from CCC are met at the same time.

If compulsory community care is to be acceptable from a bioethical perspective, it must provide the patient with actual benefits or more autonomy. 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.

National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-146888 (URN)
Available from: 2018-04-22 Created: 2018-04-22 Last updated: 2018-06-09

Open Access in DiVA

fulltext(906 kB)63 downloads
File information
File name FULLTEXT01.pdfFile size 906 kBChecksum SHA-512
e8f1b36760316c94b5eeb44fab5cb74a181d9ac99d1e846237ad807e9483a79ac6ccdd43d3875f6ff27329ddf37749fd43d3ec450237ee43f60d3cf99c38aab0
Type fulltextMimetype application/pdf
spikblad(312 kB)9 downloads
File information
File name SPIKBLAD01.pdfFile size 312 kBChecksum SHA-512
d613b8444b55b8d334a6354cb9fb612eda80d97a9672e9027ba6ecb0adc0cf0637f5a9dfb1b50632aa0f6318eb1fe22e27fccbaa1ab7caf05468487ae795cc1b
Type spikbladMimetype application/pdf
omslag(338 kB)202 downloads
File information
File name COVER01.pdfFile size 338 kBChecksum SHA-512
2fd99bfd7a141e0791c7fba75a01069f774ee44309bb12044e3df23c2e29c7a5bf96aca782bd85d90b32729e2b2edf490bcf6ddf58dc4374706f309c5103252a
Type coverMimetype application/pdf

Authority records BETA

Zetterberg, Liv

Search in DiVA

By author/editor
Zetterberg, Liv
By organisation
Department of Social Work
Social Work

Search outside of DiVA

GoogleGoogle Scholar
Total: 63 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 332 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf