Mid Sweden University

Therapists’ ability to build strong therapeutic alliances is essential to patients’ self-confidence and motivation for change. Therapists who trust their own alliance competence also improve their professional and personal satisfaction. Enhancing competence in alliance development contributes positively to the patients’ and therapists’ mental health, and ought to be a priority in mental health work. This study examines whether acquiring Motivational Interviewing education affect therapists’ own confidence in their ability to build therapeutic alliances. The study employs the questionnaire Working Alliance Inventory – short version (WAI-s) and a semi-structured interview in a triangulated mixed method design. The results show that training in Motivational Interviewing can help therapists feel more competent in their role as mental health professionals and more confident in their ability to establish therapeutic alliances.

In this study, 10 former patients' experiences of hospitalization are described using a qualitative approach. The informant group consisted of three men and seven women with different diagnoses and each with his or her individual experience of life as an inpatient. The aim of this study was to extend our understanding of former psychiatric inpatients' experience their time of admission to a psychiatric inpatients unit.

Data were collected and analysed using a content analysis approach. From the former patients' descriptions, the following five themes emerged: being seen as a disease, striving for a sense of control in an alienating and frightening context, succumbing to repressive care, meeting an omniscient master, and care as a light in the darkness. In conclusion, the experience of psychiatric inpatient care could be interpreted and understood from former patients' narratives as a struggle for dignity in the face of discrimination and rejection.

I samband med industrialismens framväxt inrättades institutioner i större skala. Den ökade mängden omhändertagna på institution vid 1800‐talets slut kan förklaras med fler medicinskt diagnostiserade, en ökad utstötning, lägre tolerans för avvikande beteende, läkarintresse för ett nytt revir, låg utskrivningsfrekvens och hospitaliseringseffekter. Antalet vårdplatser inom den psykiatriska vården minskade under 1900‐talets sista hälft. År 1992 tillsatte regeringen den så kallade psykiatriutredningen som slog fast att personer med kronisk psykiatrisk sjukdom utgjorde en grupp i samhället som karaktäriserades av allvarligt handikappade personer som berövats sina medborgerliga rättigheter och som hade få resurser till sitt förfogande. Psykiatrireformens intentioner genomsyras av bland annat begreppen normalisering och autonomi. De psykiskt funktionshindrades levnadsvillkor skall normaliseras för att öka deras möjligheter att leva som andra, vilket betyder att de ska delta i besluten om sin egen vård och behandling.

Avhandlingen har sin grund i ett hermeneutiskt perspektiv, det vill säga att människor aldrig kan förstå något helt fördomsfritt eller förutsättningslöst. Förförståelse kan förstås som en form av föraning/förkänsla och första idé om det sökta fenomenet, vilket leder förståelsen i en viss riktning. Perspektivets innebörd är att ingen förståelse kan växa fram förutsättningslöst, dvs. växa fram utan någon på förhand given inställning från forskarens sida. Studiens övergripande syfte är att belysa vårdares attityd till personer med psykiska symtom. Avhandlingen består av fyra delarbeten med såväl kvantitativ som kvalitativ design. Data har insamlats med hjälp av frågeformulär, skattningsskalor samt narrativa intervjuer.

Resultatet i delstudie I visar att fyra typologier som upptäckts i en tidigare kvalitativ intervjustudie existerade (god, ond, tokig och osynlig). Delstudie II visar att vårdarnas syn på inneliggande deprimerade patienter i hög grad bestäms av diagnosen. Syftet med delstudie III var att klargöra om patientens och vårdarens bild av patientens historia, nutid och framtid överensstämde med varandra. Resultatet visar på en tydlig skillnad mellan parterna. I delstudie IV var syftet att belysa före detta patienters upplevelser av att vara inlagda på en psykiatrisk avdelning. Studien visar att de tidigare patienternas upplevelser mestadels var negativa och att de kan tolkas som om det under sin sjukhusvistelse varit utsatta för ett subtilt förtryck.

För att förstå vårdarnas syn på den drabbade personen kommer resultatet i studien att tolkas utifrån en teoretisk referensram inspirerad av den franske filosofen Michael Foucaults och den ryske filosofen Mikhail Bakhtins texter. Tolkningen visar att vårdarna har en tendens att undvika “annanhet” (otherness) och därigenom se patienten enbart som en karaktär, en typologi. Härigenom kommer patienten att placeras i ett ”ingenmansland”, i en kontext där han/hon inte tillhör vårdargemenskapen samtidigt som kontakten med den gamla privata gemenskapen upphör. Genom att se patienten som ett enskilt fall undviker vårdarna att se det lidande som finns i ”rummet” och därigenom blir det ”rum” som skapas till en ”isvärld” som inte är livsbejakande och därför ohälsosam för patienten. Att förändra vårdarnas attityder är en långvarig samhällelig process som kräver inte bara resurser i form av utbildning och handledning utan kanske främst utrymme för kontinuerlig diskussion och debatt. Grunden för förändringen finns redan idag i psykiatrireformens ideala normaliseringsbegrepp. Kravet är dock att politiker och tjänstemän inom vård och omsorg börjar leva upp till lagens intentioner. Detta kräver dock att synen på en person med psykisk sjukdom psykiskt handikapp måste ändras på samma sätt som till exempel synen på homosexuella ändrats från att de varit marginaliserade och levt i ett utanförskap, till att bli sedda som fullvärdiga samhällsmedborgare. För att bryta det strukturella maktmönstret behövs en total samhällelig attitydförändring. Endast en politisk förändring är inte tillräcklig.

This study is part of a larger project, the aim of which is to elucidate “mental health nurses” attitudes towards their patients'. In this study, nurses' and patients' attitudes are described from the perspective of both parties using a qualitative approach. The informants were selected from a rehabilitation unit for young adults, below 40, suffering from psychosis at a psychiatric clinic that provides acute psychiatric care. The informant group consisted of three dyads: three patients with various diagnoses and three nurses with primary responsibility for the patients' daily care. The aim of this particular study was to extend our preliminary understanding of nurses' attitudes towards psychiatric patients in the context of psychiatric in-patient care, by elucidating the patient's “inner” picture of her/his past, present and future and the nurse's picture of the same patient's past, present and future. Data were collected and analysed using a phenomenological-hermeneutic approach and the narrative picturing technique. For each picture and group, 15 related sub-themes emerged, on the basis of which six themes were formulated. The findings show that the nurses overrate their own importance when it comes to the patient's well-being on the ward. All the nurses emphasize confirmation and safety as the basis of their nursing care, while in the patient's picture the nurses represent a replication of childhood demands, which probably means that nursing care risks becoming a continuation of the patient's childhood estrangement.

People suffering from depressive disorder are affected by one of the western world's largest medical groups of disorders in both psychiatric and general medicine. Drug treatment is usually the first-line intervention and has been shown to be an effective treatment. Other therapies, including nursing interventions that could be implemented in care, are infrequently used. It is therefore important to understand whether nurses' perceptions of depressed people could be explained from the medical model by defining the nurses' view of psychiatric inpatients. Therefore, the aim of this study was, with the clinical picture as the starting point, to investigate the nurses' view of hospitalized patients with a diagnosis of depression. In this prospective study, 155 nurses' opinion of depression among depressive inpatients was assessed using a questionnaire based on the Montgomery-Asberg Depression Rating Scale. To elucidate the relationship between the variables in the questionnaire, factor analysis rotated by the Varimax method with Kaiser's normalization was used. The factor analysis identified five factors. The number of variables was reduced from 61 to 34. Based on the factor interpretation, an initial factor structure for the depressive inpatient was defined. The identified factors were interpreted and labelled to create the nurses' fused 'picture' or meaning of the depressed inpatient as an individual who experienced feelings of annihilation, alienation, fatigue, emptiness and affliction, an individual who is disconnected from the whole of temporality.

Nurses' attitudes towards psychiatric patients can be expressed in terms of either a symptom-oriented approach or a personhood-focused approach where the latter is characterized by the ambition to establish a genuine and lasting relationship, while the former places the emphasis on correcting 'defective' patient behaviour. To study whether previous typologies found in a qualitative in-depth interview study exist in a larger quantitative investigation and, if so, to identify and describe a structure for the nurses' attitudes connected to each of the identified typologies. Six psychiatric group dwellings and six acute psychiatric hospital wards participated in the study. In all, 2700 assessments of 163 patients were sent out to 160 respondents and 2436 answers were returned, that is, the external dropout rate was 9.8%. The semantic differential technique was used. This is a method for quantifying the meaning that is attached to an identified phenomenon through series of bipolar pairs of adjectives. The scale has 57 bipolar pairs of adjectives, which estimates an unknown number of dimensions of nurses' attitudes towards an identified patient. The respondents' answers were analysed through entropy-based measures of association combined with structural plots. The analysis revealed that the four typologies existed as a delimited group, especially the groups of 'good' and 'evil' patients, while the 'crazy' and 'invisible' patients existed in a more blurred form. The analysis also revealed that the two groups, 'good' and 'evil', were connected to the nurses' ethical and aesthetic attitude structure, while the 'crazy' patients were linked to the cognitive structure and the 'invisible' patients to the empathetic structure. The study indicates that the two typologies, 'good' and 'evil', could be seen as each other's antithesis and, together with the other two typologies, 'crazy' and 'invisible', they touched upon a structure of the nurses' attitudes that was closely connected to a negative view of the patient except in one case -'the good' patients, which was probably based on his/her exterior symptoms.