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Why community compulsion became the solution: reforming mental health law in Sweden
Umeå University, Faculty of Social Sciences, Department of Social Work.ORCID iD: 0000-0002-4540-5373
Umeå University, Faculty of Social Sciences, Department of Social Work.
Umeå University, Faculty of Social Sciences, Department of Social Work.ORCID iD: 0000-0002-6330-5640
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.

 

Place, publisher, year, edition, pages
2011. Vol. 34, no 6, p. 419-428
Keyword [en]
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: urn:nbn:se:umu:diva-51760DOI: 10.1016/j.ijlp.2011.10.007ISI: 000298905900007OAI: oai:DiVA.org:umu-51760DiVA, id: diva2:488209
Projects
Tvång i frihet
Available from: 2012-02-01 Created: 2012-02-01 Last updated: 2018-04-22Bibliographically approved
In thesis
1. Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
Open this publication in new window or tab >>Tvångsvård i frihet: tillkomst, implementering och rättstillämpning av öppen psykiatrisk tvångsvård
2018 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[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.

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
Keyword
compulsory community care, community treatment orders, mental health policy, policy implementation, patient rights, social control, court rulings, autonomy
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-146889 (URN)978-91-7601-886-6 (ISBN)
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: 2018-05-08Bibliographically approved

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