Governing by commissioning services - Implementing alcohol screening and brief interventions in hospital settings in Norway.

Norwegian health services have undergone marked logistical changes in organization and funding over recent decades. One significant change was the new public management-inspired commissioner's document, first issued in 2013 by the Norwegian Ministry of Health and Care Services, to establish medical and surgical departments' identification of patients with underlying substance abuse problems (Ministry of Health and Care Services, 2013). Herein, we investigate how multiple stakeholders and actors, who bear responsibility in regional and local health trusts, have responded to the commissioned services to establish routines for identifying alcohol and substance abuse problems among patients admitted to medical and surgical wards. First, an extensive literature search was conducted. Second, we conducted qualitative interviews with informants who have responsibility for applying the commissioner's document in regional health authorities and local hospitals. The study results demonstrate that responsible actors at all levels take establishing alcohol routines seriously, and that hospitals' self-assessment of their achievements on internal goals indicate that they have made satisfactory progress. Nevertheless, improvement is needed to meet the goal of discussing alcohol use with all patients admitted to medical and surgical wards within local health trusts. Recommendations for the next steps, based on these findings, include further research and training priorities.

Not talking about illness at meeting places in Norwegian community mental health care: A discourse analysis of silence concerning illness-talk.

Research on the topic of not talking about psychosocial hardships describes the presence of 'house rules' against illness-talk in common areas in 'meeting places' ('day centres') in community mental health care. The aim of this article was to explore the complexity of not talking about psychosocial hardships ('silence') in meeting places in Norwegian community mental health care. The research team consisted of first-hand and academic knowers of community mental health care (participatory research team). We performed two series of focus group discussions with service users and staff of meeting places. The focus group interviews were analysed within a discourse analytic framework, and five discursive constructions were identified: (1) biomedical colonization of illness-talk, (2) restricted access for biomedical psychiatry and problem-talk in the common spaces of meeting places, (3) censorship of service users' civil and human rights to freedom of speech, (4) protection from exploitation and burdens and (5) silent knowledge of the peer community. Based on the analysis, we suggest that not talking about illness (silence) entails a complexity ranging from under-privileging implications to promoting the interests of people who 'use' meeting places. For instance, restricting biomedical psychiatry may imply the unintended implication of further silencing service users, while silently shared understandings of hardships among peers may imply resistance against demands to speak to legitimize one's situation. The discussion illuminates dilemmas related to silence that require critical reflexive discussions and continuous negotiations among service users, staff and policymakers in community mental health care.

Treating symptoms or assisting human development: Can different environmental conditions affect personal development for patients with severe mental illness? A qualitative study.

BACKGROUND: Recent research suggests that a basic anomaly in self-experience may be a core factor in patients with severe mental illnesses. Given the importance of sense of self, the traditional treatment of symptoms might not be the most effective for these groups of patients. This qualitative study examines how differences in social environmental conditions, organized as education or treatment, might affect personal development in patients with severe mental illness. METHODS: A qualitative hermeneutical design was used. Data were collected through qualitative interviews. Informants included 14 patients in psychiatric treatment and 15 students at schools for adults with mental illness. Most informants were interviewed on two occasions, 6-8 months apart, totaling 47 interviews. All participants had been diagnosed with severe mental illness with pronounced impact on daily functioning (most often psychoses or personality disorders) for a minimum of 2 years. RESULTS: Findings and interpretations showed that the students experienced a supportive environment focused mostly on education. They described personal and enduring development in areas such as capacity for relationships, regulation of symptoms, subjective well-being, and integration in society. The patients experienced an environment focused more on treatment of their illness and less on personal development and interests. They described little development, much loneliness, a poor quality of life, an objectifying attitude of themselves and others, and hopelessness. CONCLUSIONS: Even if more research is needed, findings indicate that for this group of patients, problems may be closely related to identity development. Therefore, instead of solemnly focusing on specific symptoms, it might be more effective to support patients' personal and social development by offering intensive and lasting social environmental conditions. This includes stable and mutual relationships, intrinsically motivated activities, and an environment that supports personal choices, acceptance, and development.

Medicine's perception of reality - a split picture: critical reflections on apparent anomalies within the biomedical theory of science.

Escalating costs, increasing multi-morbidity, medically unexplained health problems, complex risk, poly-pharmacy and antibiotic resistance can be regarded as artefacts of the traditional knowledge production in Western medicine, arising from its particular worldview. Our paper presents a historically grounded critical analysis of this view. The materialistic shift of Enlightenment philosophy, separating subjectivity from bodily matter, became normative for modern medicine and yielded astonishing results. The traditional dichotomies of mind/body and subjective/objective are, however, incompatible with modern biological theory. Medical knowledge ignores central tenets of human existence, notably the physiological impact of subjective experience, relationships, history and sociocultural contexts. Biomedicine will not succeed in resolving today's poorly understood health problems by doing 'more of the same'. We must acknowledge that health, sickness and bodily functioning are interwoven with human meaning-production, fundamentally personal and biographical. This implies that the biomedical framework, although having engendered 'success stories' like the era of antibiotics, needs to be radically revised.

Metasynthesis and bricolage: an artistic exercise of creating a collage of meaning.

During the past decades, new approaches to synthesizing qualitative data have been developed. However, this methodology continues to face significant philosophical and practical challenges. By reviewing the literature on this topic, our overall aim in this article is to explore the systematic and creative research processes involved in the act of metasynthesizing. By investigating synthesizing processes borrowed from two studies, we discuss matters of transparency and transferability in relation to how multiple qualitative studies are interpreted and transformed into one narrative. We propose concepts such as bricolage, metaphor, playfulness, and abduction as ideas that might enhance understanding of the importance of combinations of scientific and artistic approaches to the way the synthesizer "puzzles together" an interpretive account of qualitative studies. This study can benefit researchers by increasing their awareness of the artistic processes involved in qualitative analysis and metasynthesis to expand the domain and methods of their fields.

Emotional, self-conceptual, and relational characteristics of bullies and the bullied.

AIMS: To clarify distributions of emotional and somatic symptoms among different groups involved in bullying behaviour during early adolescence; to explore differences in social integration and self-perceptions; to explore how different cut-off limits for bullying behaviour may affect the impact of these measures; and to interpret our findings in the light of theories of identity that may suggest directions for interventions against bullying in schools. METHODS: A cross-sectional study, based on self-completion questionnaire, of 1237 pupils aged 11-15 years in autumn 2000 in Alesund, Norway. RESULTS: Bullies and their victims reported similar and greater emotional impairments and psychosomatic complaints, lack of self-confidence, and pessimism than students not involved in bullying. With increasing involvement, bullies differed from non-involved students only in regard to depressive complaints and pessimism. The bullied group reported more depressive, somatic and anxiety complaints, and self-reproach with increasing victimisation. Both bullies and the bullied reported problems relating to school, parents, and teachers. Bullies enjoyed friendships to the same degree or better than their peers not involved in bullying, whereas the bullied group reported impaired peer relations and increasing problems with more serious involvement. Bullies, the bullied, and bully-victims reported diminishing peer support in their class with increasing involvement. CONCLUSIONS: Both the bullied and bullies share relational, emotional, and self-conceptual problems, but they also differ in whether they succeed in social arenas and to what extent they are affected by different emotional and self-conceptual problems. They are, however, fellow sufferers in many aspects.

The negotiation of identity among people with mental illness in rural communities.

Integration and normalization are goals within the community-based care of people with mental illness. The implementation of this care policy has led to increased contact between people with mental illness and so-called normal people and society at large. But we know little about how this change affects the former patients' identity and experience of stigma and stereotyping. This study is based on qualitative interviews with people with mental illness (N=15) living in rural communities in four different municipalities. The focus in the study is on the informants' subjective experiences and the results show that they adapt in different ways, depending on how they negotiate their identity. Those who accept their role as "mental patients" seem to have easier access to services, they experience less stigmatization and fewer conflicts with their surroundings than those who oppose the patient role. Seem from our informants' perspectives there seems to be a simple definition of integration: Being integrated is feeling accepted as yourself. Some implications for policy and mental health services are discussed.

[Teenagers with piercing and tattooing]. / Tenåringer med piercing og tatovering.

BACKGROUND: The search for social identity seems important to young people's efforts at finding a social practice that fulfills their own needs. "Body art", i.e. tattoos and piercing, could be understood as a way of demonstrating a personal identity, though it is doubtful whether this practice over time could fill such needs in a modern society. This study addresses the question of whether young people that acquire tattoos or piercings have special characteristics in terms of social integration and behaviour. MATERIAL AND METHOD: A cross-sectional questionnaire was administered to junior high school students (6th, 8th and 10th grade, age 11-15) in a Norwegian town (population: 40,000). A total of 1237 students filled in the questionnaire. The social integration and health-impacting behaviour of those with body art was compared to those without. Adjustments were made for age and sex through linear and logistic regression analysis. RESULTS: Teenagers with body art are just as active in their spare time as their peers without such decorations and they are just as close to and trusting of their friends (relational quality), but they are more integrated with their friends in terms of time spent with them (relational quantity). Teenagers with body art see themselves as less well integrated in school than their peers. Moreover, they assess the support they get from their parents and their closeness to them lower than do those without body art. Having body art is strongly associated with health-compromising behaviour. INTERPRETATION: Health-promoting efforts in schools would benefit from recognition of young people's need for expressing their personal identity and that so-called risk behaviour may be an expression of personal identity. A focus on mastering experiences and inter-generational dialogue could be as fruitful as a focus on risk behaviour.