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Background: Systems for freedom of choice have been implemented as an organizational structure in public welfare in several western countries. The aim of the market model is to increase citizens’ freedom of choice, conduce diversification in service and providers of service, while contribute higher quality of service and facilitate efficient use of public funds. In Sweden “Act of Free Choice Systems” (2008:962) was introduced in 2009, and optional for municipalities to use. Several municipalities have opened up for both public and non-public providers for citizens’ to choose from in different welfare sectors. Mental health care was one of them. The implemented competitive market logic meant providers needed to promote themselves to attract users to be able to stay on the market.

Aim: The aim of this study is to describe and analyse how public and non-public providers’ of community mental health care use digital pictures during the time of an implementation of a competitive market system in Sweden.

Methods: A case study was conducted. A municipality was strategically selected because a free choice system was implemented in their community mental health care in 2010. Day centres, a common community mental health care support was selected to constitute the focus of the study. All providers had a digital space of their own at the municipality’s website. Digital pictures from each homepage were collected in 2012, when the new system had been running for a while. All pictures were included in the study. Pictures were transcribed using the semiotic model. Transcribed data was analysed with content analyse and categorized into themes. A frequency analysis was conducted to show similarities and differences in content.

Results: Homepages showed between 0 and 88 digital pictures. Public providers displayed less pictures than non-public providers. The content analyse identified three main categories: 1. Presenting pictures 2. Illustrative pictures 3. Emotional intermediating pictures. The frequency analyse showed three main recurring contents: pastries (10 providers), flowers and trees (10 providers) and the building’s exterior (9 providers). Distinguishing pictures were; mountain climber (one provider), dogs at the Coffey table (two providers).

 Analyse/Discussion: Digital pictures seemed to fulfil different purposes; to present activities such as buildings and persons, to illustrate text and to convey feelings of growth, inclusion, participation and friendship. The most recurring picture content was interpreted as follows: pastries, as appealing to the sense of sweetness, something tasting good, homely, attractive; flowers and trees as appealing to growth, literal and symbolic; building’s exterior as representing the place physically. Mountain climber pictures were interpreted as appealing to adventure and excitement, dogs at the Coffey table as appealing to a wish for non-demanding fellowship, a wish for pets.

Conclusion: Most providers used digital pictures in their promotion of themselves. Pictures were used in different ways and with different intentions. Non-public providers displayed more pictures than public providers. This might implicate non-public providers were more adjusted to the new competitive system where promotion was part of the game.

The aim of this study was to describe and analyse structural frames for choice, as well as characteristics of a free-choice market, implemented in community mental health services in Sweden. Day centres were focused. A case study was conducted. Documents were collected and semi-structured interviews were conducted with twenty-eight agents involved in the implementation process. Content analysis of data showed that users’ freedom of choice was influenced by detailed regulation. Freedom of choice was extended, but it was also substantially reduced. The gain or loss of freedom of choice depended on which aspects of the system were emphasised. Features, which could be interpreted as paternalistic, were once again structurally embedded, despite a system addressing individual freedom of choice. Further, the market did not seem to be adjusted for the average user of community mental health services.

This case study investigates the implementation of a free-choice market system in community mental health services using the example of day centres for people with psychiatric disabilities. It was conducted in a major city that was about to implement a free-choice market system due to a new legislation that made it feasible. Eighteen semi-structured interviews were conducted. Agents situated in different parts of the organization were interviewed one year before and two years after the free-choice system was launched in 2010. Data showed a top–down political process. A majority of the intentions of the legislation advocated individual autonomy as the market system's main purpose; only one concerned organizational efficiency. Data reflected, however, that financial efficiency dominated the agents' experiences of the implemented system. The twofold market purpose was clearly reflected in the interviews. Front-line staff hoped for improvements mainly for the users, whereas managers mainly focused on the market as a resource allocator.

Background/Objectives Systems for freedom of choice within mental health has been implemented in several western countries to increase citizens’ freedom of choice, conduce diversification in service and providers of service, reduce inequalities by providing equitable choice to all users while contribute higher quality of service and facilitate efficient use of public funds. In Sweden “Act of Free Choice Systems” (2008:962) was introduced in 2009, and optional for municipalities to use. Community mental health is organized within the municipalities. The aim of this study is to describe the process of designing and constructing a market of free choice within community mental health, and analyse what kind of freedom of choice the citizen in need of community mental health have, in the example of Daily occupation.

Methods A case study was conducted in Stockholm, the capital of Sweden, where free choice was implemented in January 2010. The study consists of semi-structured interviews with twenty-eight actors’ involved in the process, complemented with political documents. Interviews were conducted 2009 and 2012. To analyse the material direct content analysis was used, and theories regarding quasi-markets, market design and regulation of markets were applied.

Results The design and construction of the market of community mental health have determined the degree of clients’ freedom of choice. The volume of the market was regulated by national legislation, but sometimes influenced by the local political budget, and users sometimes appealed their decisions in court to have their rights assessed by law. Admission rules set by authorities concerning management and staff qualifications, financial stability and technical documentation equipment, determined which providers could enter the market. Many user-led organisations were not able to enter due to the admission rules. Quality regulation was developed by authorities to examine providers within the system. The client should be provided neutral and rich information, though full information was hard to access.

Discussion/Conclusion Freedom of choice seems to have been both extended and reduced by the design and construction of the new system. All users theoretically had the same possibilities to choose providers in the system. However the construction limited the actual client choice significantly.

Marketization in community mental health services is a new phenomenon and might be the most comprehensive reform in the field since the deinstitutionalisation that occurred during the second half of the twentieth century. Historically, mental health services have been characterized by discipline and paternalistic practices.There has been an absence ofwhat is now, due to the new organizational model based on individual freedom of choice, is to be introduced.

The aim of this study was to investigate the implementation of a free-choice market system in community mental health services, using the example of day centres for people with psychiatric disabilities. The study was conducted in a major city that was about to implement a free-choice market system due to a new legislation.

Eighteen semi-structured interviews were conducted. Agents situated in different parts of the organization were interviewed one year before and two years after the free-choice system was launched in 2010. Data showed a top-down political process. The policy intentions of the new Act were in focus when studying the relation between policy and practice during the implementation process. A majority of the policy intentions of the new Act advocated individual autonomy as the market system’s main purpose, only one intention concerned organizational efficiency. Interview data reflected, however, that financial efficiency dominated the agents’ experiences of the implemented system. The twofold market purpose was clearly reflected in the interviews. Front-line staff hoped for improvements mainly for the users, when managers mainly focused on the market as a resource allocator.

There is broad consensus among policymakers about the urgency of developing healthy, inclusive, and socially sustainable cities. In the Swedish context, social services are considered to have knowledge that needs to be integrated into the broader urban development processes in order to accomplish such ends. This article aims to better understand the ways in which social service officials collaborate in urban development processes for developing the social dimensions of healthy cities. We draw from neo‐institutional theories, which set out actors (e.g., social service officials) as acting according to a logic of appropriateness, which means that actors do what they see as appropriate for themselves in a specific type of situation. Based on semi‐structured interviews with social services officials in 10 Swedish municipalities on their experiences of collaboration in the development of housing and living environments for people with psychiatric disabilities, we identified that they act based on (a) a pragmatic rule of conduct through the role of the problem solver, (b) a bureaucratic rule of conduct through the role of the knowledge provider, and (c) activist rule of conduct through the role of the advocator. In these roles, they have little authority in the development processes, and are unable to set the agenda for the social dimensions of healthy cities but act as the moral consciousness by looking out for everyone’s right to equal living conditions in urban development.

In the governance of housing provision, the public sector is considered unable efficiently to manage such problems through the traditional bureaucratic organizations and associated governing tools. Instead, municipalities are expected to engage in collaborative processes across sectors and with external stakeholders, with the overarching objective to deliver more efficient planning outcomes. As the processes are carried out across sectors, it opens up the opportunity to privilege certain sectors' perspectives and marginalize others. By drawing from Mouffe's agonistic political theories, this article makes an empirical account of the political in organizing cross-sectoral collaborative planning in Swedish municipalities, with the empirical example of developing municipal programmes for housing provision. The article concludes that social service is severely marginalized in what is generally a depoliticized housing provision planning process. Underpinning the collaboration is the conceptualizing of housing provision as primarily a general deficit in constructing housing. Primarily organizing objectivist knowledge, housing provision is constructed as a technical and procedural matter rather than ideological and political. Through such organizing principles, the overarching housing provision problem remains undealt with, e.g. how do we provide housing to 'all' our citizens?

In 2009, the Act on Freedom of Choice Systems (SFS 2008:962) wasestablished in Sweden, and this enabled municipalities to organise services aschoice models. This thesis describes and analyses the implementation of afreedom of choice system within community mental health services. Daycentre services were in focus, and a case study was conducted of a majormunicipality that sought to be a “world-class city” in regard to citizens’ choice.The experiences of policy makers, managers, professionals, and participantswere explored in interviews, and documents on a national, municipal, and citydistrict level, as well as homepages of providers of community mental healthservices, were all part of the study and were analysed using content-analysismethods.

The results showed that the freedom of choice system aimed for two objectives– improvements at the individual level and financial efficiency. In practice,financial efficiency was experienced as the main objective. Increased varietyof services was aimed for by the competitive model, but such variety was notobserved. Instead, services tended to be more similar than specialised.Concerning new providers, they were characterised as committedprofessionals running companies with strained economies. Participantsaffected by the reform expressed anxiety and worries due to theunpredictability and uncertainty embedded in the competitive choice model.Choice within the system concerned where to go, whereas participantsemphasised a wish to be able to influence the choice aspects of who carriedout the service and how much time to attend the services.

The conclusion was that the freedom of choice system was implemented as atechnology of governance to increase financial efficiency of services.Individual choice was not experienced as increased in any aspect except forthe choice of where to go. Instead, freedom of choice actually appeared todecrease due to standardisation and hierarchical structures. Aspects that werefound to be relevant when designing freedom of choice systems aiming toincrease individual freedom of choice were to address predictability andcontinuity, to address sustainable financial premises, to analyse the predictedimpact of administrative systems that are to be used, and to avoid the use of“hidden goals” in the policy-making process.

When addressing child and youth mental health, policy makers around the world call for collaboration between welfare providers. Research shows, however, that cross-sector collaboration is challenging. This article aims to scrutinize the issue of sustainability in the collaborative work undertaken between welfare providers to jointly support and promote child and youth mental health. In a qualitative interview study, 19 key officials involved in collaborative mental health work in three Swedish municipalities were interviewed, 13 individually and 6 in three small groups. Data were analyzed through content analysis and the application of practice-oriented collaboration theories. The results show that informants feel collaboration is beneficial for child and youth mental health. The results also show that five aspects of this collaborative work can affect its sustainability: (1) how the collaborative work was set up: if it was a special project or part of existing organizational structures; (2) what model of funding was used; (3) how many organizational levels were involved; (4) if goals were common, concurrent or contradictive; and (5) if important stakeholders were seen to be 'missing'. Collaboration members felt their collaborative work had caused them to drift away from important non-participant stakeholders. This article concludes that to develop long-term sustainable collaborations addressing child and youth mental health, key features of collaborative work need to be taken into consideration.

Bakgrund: psykisk ohälsa beskrivs som en växande samhällsutmaning. År 2016 initierades något som kan tolkas som ett perspektivskifte i svensk policy inom området.

Syfte: i denna rapport utforskas regionala och lokala aktörers respons på nationell styrning inom området psykisk hälsa. Ett särskilt fokus läggs på samverkansinsatser som rör främjande av barn och ungas psykiska hälsa.

Metod: en fallstudie genomfördes. En policyanalys av 127 nationella och regionala policydokument kombinerades med en intervjustudie där tre exempel på samverkansinsatser strategiskt valdes ut och nitton nyckelpersoner intervjuades.

Resultat: i länsgemensamma handlingsplaner för psykisk hälsa identifierades insatser med ett starkt fokus på individuella faktorer. Beträffande lokala samverkansinsatser för barn och ungas psykiska hälsa visade det sig att den insats som hade stark koppling till den nya policyn hade svag förankring i den egna organisationen. Den insats som var mest integrerad saknade helt koppling till den nya policyn.

Slutsatser: (i) psykisk ohälsa beskrivs som ett problem som ska hanteras genom att påverka individuella faktorer. Detta trots att aktuell forskning visar att även familjerelaterade, samhällsrelaterade och strukturella bestämmelsefaktorer behöver adresseras för att uppnå psykisk hälsa. Fokuset på individuella faktorer kan innebära en risk att människor förstår psykisk ohälsa som ett individuellt problem och ansvar, och (ii) det tar tid att implementera samverkan mellan olika aktörer som arbetar med barn och ungas psykiska hälsa och ohälsa. Långsiktiga styrstrategier behövs.

Background: Sweden faces increasing problems related to mental ill-health. To address this problem, the government recently launched a new mental health policy to cover mental health issues in general.

Purpose of study: This study aimed to explore the implementation process of the new mental health policy.

Methods/Theory: A case study was conducted in which national governance and regional response constituted the main elements of the case. A period of 4 years was chosen. In all, 68 national and regional key documents were selected for the analysis. Theories of implementation processes and governance strategies were used to enhance the understanding of the data.

Findings: The implementation process showed the following the distinctive features: 1) a broad range of target groups were addressed from persons at risk of mental ill-health to persons suffering from severe mental illness; 2) the whole spectra from preventive interventions to treatment interventions were included; 3) the mental health of children and youth was prioritized; and 4) the character of the governance gradually shifted over time from an open to a more targeted approach. A major difficulty associated with the implementation process was the lack of options to systematically follow-up government policy efforts.

Conclusion: The broad definition of mental health care and support meant there were regional variations in the prioritizing of groups, as well as regional variations on the working methods used.

The aim of this study was to explore participants' experiences and opinions about a free-choice system in relation to policy objectives articulated by the national government and local authorities. A case study was conducted. Thirty-five informants participated. Qualitative interviews were undertaken. Results are discussed on how to address different dimensions of choice, not only where, but also what, by whom, how much, and when. They also concern how to design systems that in some ways ensure predictability and continuity to avoid unwanted harm caused by the unpredictability embedded in competitive choice systems. Finally, different aspects of quality need to be addressed.

Finding suitable locations for supported accommodations is crucial both for the wellbeing of individuals with psychiatric disabilities (PD) and to achieve the objectives of the mental health care reform in order to create opportunities for social inclusion. This article explores municipal strategies for localizing supported accommodations for people with PD. In a multiple case study, interviews with 20 municipal civil servants from social services and urban planning were conducted. Three strategies were identified and further analyzed with a public location theory approach: (1) re‐use, i.e., using existing facilities for a new purpose, (2) fill‐in, i.e., infilling new purpose‐built facilities in existing neighborhoods, and (3) insert, i.e., inserting new premises or facilities as part of a new development. The article shows that the “re‐use” strategy was employed primarily for pragmatic reasons, but also because re‐using former care facilities was found to cause less conflicts, as residents were supposedly used to neighbors with special needs. When the “fill‐in” and “insert” strategies were employed, new accommodations were more often located on the outskirts of neighborhoods. This was a way to balance potential conflicts between residents in ordinary housing and residents in supported accommodations, but also to meet alleged viewpoints of service users’ need for a quiet and secluded accommodation. Furthermore, ideas associated with social services’ view of social inclusion and urban planning’s notion of “tricky” tenants significantly influenced localization strategies. Finally, this article is also a call for more empirical research on the decision‐making processes, use of strategies (intended or not) and spatial outcomes, when localizing supported accommodation for people with PD and other groups in need of support and service.

The aim of this study was to explore the longitudinal development of an organisational fieldafter the implementation of a freedom-of-choice system in terms of the range and characteristicsof providers and services as well as the dynamics and professionalism that appeared as a resultof these changes. Our findings suggest that the expected effects of the reform in terms of varietyof providers and services within the organizational field did not materialise due to a lack ofmarket competition. Providers complemented each other rather than competed with each other,and the logics of care, choice, and advocacy challenged each other within the quasi-market. Allinformants described financial conditions in the market as extremely strained. Strong personalcommitment characterized providers entering and exiting the market, and this strongcommitment suggests a nuanced professionalism we refer to as idealistic professionalism. Agap was found between policy goals and experiences among stakeholders, and efficiency wasfound to be the policy goal achieved most often in practice. This raises the questions of howthe Swedish community mental health service market will develop in the future and what theimplications are for the participants.

The aim of this study was to examine changes in an organizational field over time when implementing a freedom of choice model. Main focus was on the range and characteristics of providers and services. Our findings suggest that the expected effects of the reform in terms of variety of providers and services within the organizational field did not materialise due to a lack of market competition. Providers complemented each other rather than competed with each other, and the logics of care, choice, and advocacy challenged each other within the quasi-market. All informants described financial conditions in the market as extremely strained. Strong personal commitment characterized providers entering and exiting the market. A gap was found between policy goals and experiences among stakeholders, and efficiency was found to be the policy goal achieved most often in practice. This raises the questions of how the Swedish community mental health service market will develop in the future and what the implications are for the participants.

För att få behålla de statliga stimulansmedel som delats ut till kommuner och landsting inom området psykisk hälsa 2017 förväntades aktörerna lämna in länsgemensamma handlingsplaner avseende riktade insatser. Forskare vid Umeå universitet fick i uppdrag att sammanställa och analysera dessa planer. Både kvantitativa och kvalitativa sammanställningar och innehållsanalyser genomfördes. Under en forskarpanel bidrog experter inom olika områden med sina kunskaper till att fördjupa och nyansera analyser av preliminära resultat.

Inför länens arbete med handlingsplanerna uppmanades kommuner och landsting att länsvis, liksom 2016, presentera en aktuell gemensam analys och handlingsplan med tillhörande budget för att arbeta med befolkningens psykiska hälsa utifrån ett gemensamt ansvarstagande. År 2017 förväntades länen även presentera en fördjupad analys och handlingsplan med fokus på barn och unga 0–24 år, samt en uppföljning av arbetet 2017.

Liksom 2016 fanns det även 2017 en stor variation i länsplanerna, både beträffande struktur och innehåll. Det framstår dock som att varje län funnit en form för det egna arbetet under detta andra år med gemensamt handlingsplansarbete. Handlingsplanerna 2017 påminner mycket om handlingsplanerna 2016, med tillägget att de 2017 inkluderar uppföljning av insatser samt särskilt fokuserar barn, unga och unga vuxna. Några handlingsplaner visar att den statliga satsningen inneburit att länen under 2017 kunnat utvecklat nya strategier för att arbeta länsgemensamt med insatser inom området psykisk hälsa. Andra handlingsplaner visar att länsnivån inte heller 2017 varit en naturlig plattform för kommunerna och landstingens arbete på området. I anslutning till länsplanerna 2017 har länen skickat in ett flertal dokument som de anser är relaterade till handlingsplanen, exempelvis regionernas egna handlingsplaner för utveckling av insatser inom området psykisk hälsa.

Alla län följer upp insatser genomförda 2017. Uppföljningarna tenderar att vara instrumentella i meningen att man mäter om insatser är genomförda eller inte, snarare än att man följer upp resultaten av insatserna. Några län problematiserar uppföljningen av specifika indikatorer, samt länsnivåns möjligheter och svårigheter i relation till uppföljning och utvärderingsarbete.

I de delar av handlingsplanerna som presenterar insatser riktade till den vuxna och äldre delen av befolkningen kunde följande iakttagelser göras:

• Det fanns en balans mellan generella insatser för psykisk hälsa riktade till en bred målgrupp i termer av hela befolkningen och specifika insatser riktade till en mer specifik målgrupp i termer av personer med långvarig psykisk ohälsa.
• Insatser riktade till både en bred och en snävare målgrupp befann sig i ett spektrum från främjande insatser, till tidiga insatser och slutligen behandlande och långsiktigt stödjande insatser.
• Den breddade policyn tycks ha påverkat med vilka perspektiv man betraktar även den traditionella målgruppen, lämpligast uttryckt som ett helhetstänkande som inte bara omfattar stöd och behandling utan även prevention och hälsofrämjande arbete.
• Handlingsplanerna presenterar även ett antal utvecklingsområden som är av övergripande karaktär. De två teman som förekommer i flest planer är: brukare och närståendes delaktighet samt samverkan och samordning. Detta resultat kan tolkas som områden där hierarkier och maktrelationer, olika gruppers handlingsutrymme och olika syn på uppdrag och professionalitet aktualiseras.

Sammantaget så är det en mycket jämn fördelning mellan de olika målgrupperna; den breda målgruppen medborgare, och den snävare målgruppen personer med etablerad psykisk ohälsa.

I de delar av handlingsplanerna som presenterar insatser riktade till barn, unga och unga vuxna kunde följande iakttagelser göras:

• Sammanställningen av planerna visar att det har varit ett trevande arbete i flera län, samtidigt som det i vissa län varit en fortsättning på ett sedan flera år redan påbörjat arbete.
• Länen har gjort analyser utifrån elevhälsodata, folkhälsodata, riktade enkäter, intervjuer och fokusgrupper. I samband med analysarbetet har SKL gett länen 58 nyckelindikatorer att genomföra sina analyser utifrån. Dessa indikatorer har påverkat länens sökljus, och i förlängningen innehållet i länens handlingsplaner.
• Handlingsplanerna för barn, unga och unga vuxna präglas av att riskgrupper för psykisk ohälsa identifieras. Tio olika riskgrupper nämns. Asylsökande, nyanlända och ensamkommande, ”hemmasittare” som varken studerar eller arbetar, personer med annan funktionsnedsättning, barn som anhöriga till personer med psykisk funktionsnedsättning och barn i samhällsvård är de riskgrupper som flest län nämner. Dessa fem riskgrupper finns med bland nyckelindikatorerna.
• Bland övriga utvecklingsområden, förebyggande, tidiga, behandlande insatser samt övergripande teman, syns tydliga spår av de 58 nyckelindikatorerna. Det finns dock även en lokal variation beträffande riskgrupper, insatser, målgrupper och övergripande teman.
• Samverkan och delaktighet utgör de viktigaste övergripande utvecklingsområdena även när det gäller övergripande områden med fokus på insatser för barn och unga.

Länen formulerar sig med några få undantag, ofta svepande kring frågan om kunskapsbaserade arbetssätt. Det finns generellt en lyhördhet för nationella initiativ, där man i planerna kan referera till Socialstyrelsen, Folkhälsomyndigheten, SBU eller SKL med innebörden att sådana statliga satsningar utgår från bästa tillgängliga kunskaper.

Trots en breddad policy i den nationella satsningen, är många av de specifika arbetssätt och interventioner som nämns i planerna riktade till personer med allvarliga tillstånd eller funktionsnedsättningar. Oaktat den uppmärksamhet som ägnas åt psykosociala interventioner vid allvarlig psykisk sjukdom, är suicidprevention det enskilda insatsområde som dominerar handlingsplanerna.

Några ”tystnader” som identifierats i materialet är följande: 1, avsaknaden av insyn i det reguljära arbetet, som en följd av att handlingsplanerna fokuserar länens utvecklingsarbete 2, unga vuxna, och specifikt unga flickor och kvinnor utgör inte en prioriterad riskgrupp i länsplanerna, trots att aktuell statistik pekar ut denna grupp som utsatt 3, avsaknaden av familjeinterventioner i länens praktik, trots hög evidensgrad och prioriteringsnivå i nationella riktlinjer 4, avsaknaden av att systematiskt arbeta med brukarerfarenheter på länsnivå.

I rapportens avslutande del lyfts ett antal reflektioner upp till diskussion. Några saker som diskuteras är:

• Länsnivåns legitimitet när det inte finns någon politisk nivå att förankra planerna i, eller instans att utkräva ansvar från.
• Tillitsstyrningens dilemma på länsnivå – staten ingår en överenskommelse med vem?
• Materialet visar att den breddade folkhälsopolicyn kompletteras med ett perspektiv på ohälsa och sjukdom som värnar om personer med långvarig psykisk ohälsa eller funktionsnedsättningar.
• Det breda uppdraget landar i en struktur som tidigare skapats för att arbeta med en specifik målgrupp: personer med psykiska funktionsnedsättningar. Denna tradition påverkar vilka aktörer som är delaktiga även när det gäller den breddade policyn. Det tycks vara svårt att förankra delaktighet hos en breddad aktörskara i länen, t.ex. skolan, så länge det inte finns ekonomiska incitament för att delta.
• Innebär den breddade policyn ett ”förfrämligande” hos specialistpsykiatrin i arbetet med handlingsplanerna?

För att få del av de statliga stimulansmedlen inom ramen för överenskommelsen mellan Regeringen och Sveriges Kommuner och Landsting (SKL) 2016 var kommuner och landsting skyldiga att länsvis sammanställa en handlingsplan med avseende på området psykisk hälsa. Forskare vid Umeå universitet fick i uppdrag att analysera dessa planer. Både kvantitativa och kvalitativa sammanställningar och innehållsanalyser genomfördes. Under en forskarpanel bidrog experter inom olika områden med sina kunskaper till att fördjupa och nyansera analyser av preliminära resultat. Preliminära resultat presenterades under en seminariedag i Stockholm där representanter för länen samt företrädare för SKL, Socialstyrelsen och Folkhälsomyndigheten samlats. I samband med denna presentation inkom kompletterande uppgifter som innebar att vissa revideringen av rapporten genomfördes. Inför länens arbete med handlingsplanerna föreslog regeringen i överenskommelsen med SKL att kommuner och landsting skulle beakta fem fokusområden: 1, förebyggande och främjande insatser 2, tillgängliga tidiga insatser 3, enskildas delaktighet och rättigheter 4, utsatta grupper och 5, styrning, ledning och organisation. Dessa fem områden är aktuella för barn och unga, vuxna och äldre. I samtliga handlingsplaner förhåller sig länen till dessa fokusområden. I 18 av 21 län har man strukturerat sina handlingsplaner i relation till fokusområdena. Tre län förhåller sig friare till de angivna fokusområdena. Sveriges län skiljer sig åt på många sätt, vilket återspeglas i handlingsplanerna som varierar till form och innehåll. Vissa län har gjort behovsanalyser utifrån ett folkhälsoperspektiv på psykisk hälsa, medan andra behovsanalyser undersöker faktorer som är mer relaterade till ett perspektiv på manifest ohälsa och sjukdom. I vissa län finns detaljerade målsättningar som specificeras i långsiktiga mål och kortsiktiga delmål. I andra län har målformulerandet just påbörjats. I en del handlingsplaner finns detaljerade åtgärdsförslag medan det i andra län presenteras mer övergripande och generella åtgärder. Variationsrikedomen i handlingsplanerna är mycket stor. När det gäller beskrivningen av arbetsprocessen i samband med att handlingsplanerna utarbetats varierar graden av insyn i hur arbetet gått till. I vissa handlingsplaner beskrivs processen i detalj, och personer som deltagit är namngivna. I andra handlingsplaner går det inte att utläsa vare sig hur arbetsprocessen har gått till eller vilka som varit delaktiga. I ett län har ett ägarskap skrivits in i handlingsplanen som innebär att instanser utsetts som ansvariga för att handlingsplanen i sin helhet omsätts i praktik. I några län utses ansvariga inom respektive insatsområde, medan vissa län inte berör ansvarsfrågan alls. I såväl den nationella policyn som i handlingsplanerna finns en komplexitet när det gäller den tredelade målgruppsbeskrivningen om ”allas” psykiska hälsa, utsatta gruppers psykiska hälsa och personer med omfattande psykiatrisk problematik.

Hur kommuner och landsting hanterat frågan om brukarmedverkan i arbetet med planerna varierar; alltifrån att inte ha någon brukarmedverkan dokumenterad alls, till att en brukarorganisation är en av tre jämbördiga parter. I ett län anläggs ett folkhälsoperspektiv på brukarmedverkan genom att representanter från ett brett spektrum av brukar- anhörig- och patientföreningar finns representerade, liksom representanter för skola. Att använda sig av länsnivån som avsändare för planerna innebär utmaningar. Vilken grad av struktur som finns varierar mellan länen – se Länsinventering Psykisk Hälsa (SKL 2015). Det finns ingen självklar politisk struktur vilket innebär att det är svårt att förankra handlingsplanerna i en politisk kontext. I 9 län beskrivs politisk förankring av varierande grad. I återstående 12 län framgår det inte om handlingsplanerna är politiskt förankrade eller inte. Graden av politisk förankring påverkar möjligheten att omsätta handlingsplanen i praktiken. En annan utmaning rör tillgången till tjänstemän på länsnivå som kan arbeta med länsgemensamma uppdrag. Även detta skiljer sig åt mellan länen och påverkar arbetet med länsgemensamma planer och målsättningar. När det gäller målsättningar presenteras det i drygt hälften (12 av 21) av handlingsplanerna långsiktiga mål som är nedbrutna i kortsiktiga delmål. I fyra län är långsiktiga och kortsiktiga målsättningar fristående ifrån varandra. Målsättningar strukturerats antingen utifrån de fem fokusområdena eller tematiskt utifrån prioriterade områden i länen. I fem av länen har man hanterat målsättningar på andra sätt. De slutsatser som dragits utifrån analysen av de 21 länens handlingsplaner är följande:

• Strukturer för att arbeta på länsnivå ser mycket olika ut i länen. Därför skiljer sig handlingsplanerna åt, både till form och innehåll. I vissa län tycks arbetet med länsplanen innebära ett mervärde för de inblandade aktörerna, i andra inte. Om principen från regeringen och SKL att använda sig av länsnivån i kommunikationen ska bestå, bör strategier för stöd till länen övervägas.

• Generellt sett rör länsplanerna utvecklingsarbete och endast i liten utsträckning organisationernas kärnverksamhet.

• Länsplanerna handlar främst om kommunerna och landstingens gemensamma arbete och om samverkan mellan organisationerna. Detta innebär att de enskilda huvudmännens verksamheter endast uppmärksammas i mycket liten utsträckning. Följaktligen saknas en stor del av den reguljära kärnverksamhet som bedrivs av kommuner och landsting var för sig, som till exempel den specialiserade psykiatrins behandlingsarbete eller primärvårdens insatser. Inriktningen är särskilt tydligt under fokusområdet ”ledarskap och organisering” där handlingsplanerna företrädesvis rör samordning och samverkan.

• Det finns en hög ambition i länen att främja psykisk hälsa hos barn och unga, och att samarbeta mellan huvudmännen kring barn och unga som har utvecklat någon form av psykisk ohälsa.

• I länen finns en hög ambition att samarbeta huvudmän emellan och tillsammans med det civila samhället för att bli bättre på hälsofrämjande insatser riktade till asylsökande och nyanlända, samt att bli bättre på insatser som riktas till asylsökande och nyanlända som utvecklat någon form av psykisk ohälsa.

• Två insatsområden som återkommer frekvent i länen är arbetet med suicidprevention och arbetet med att erbjuda dem som får stöd från de båda huvudmännen en samordnad individuell plan (SIP) samt att utveckla formerna för SIP.

• I handlingsplanerna finns en ansats att främja den psykiska folkhälsan i länen. Detta sker parallellt med att insatser riktas till riskgrupper och grupper där psykisk ohälsa redan utvecklats. Detta innebär att kommuner och landsting tagit emot de nationella styrsignalerna, och fortsatt vidga sitt fokus från PRIO-satsningen till att omfatta folkhälsoperspektivet inom området psykisk hälsa. Dock sker detta endast i mindre utsträckning för grupperna vuxna och äldre personer.

Avslutningsvis ges exempel på några aspekter utifrån vilka ”en lyckad plan” kan förstås. En lyckad plan kännetecknas av ett tydligt ägarskap, systematisk analys, realistiska mål och ett val av tydliga aktiviteter som kan implementeras och följas upp. Vi ger även tre rekommendationer till länen i det fortsatta arbetet med att formulera länsgemensamma handlingsplaner: 1, att skriva planerna för sin egen skull 2, att öka genomförbarheten i planerna genom aktiva prioriteringar mellan de breda och olikartade målsättningar som staten lanserat 3, att ta frågan om ansvar för planerna på allvar genom att klargöra vem eller vilka som ansvarar för handlingsplanen och dess implementering.

Background

Art therapy could benefit couples.

Aims

This article explores art therapy used by couples in relational crisis from a professional perspective.MethodsSeven art therapists working in family counselling participated in the qualitative study.ResultsThe results showed that, through non-verbal communication, art making facilitated clarification of situations, handling non-talkable concerns, and added playfulness to the relationship. Three crucial dimensions were identified in the family counselling context: (1) outer frames, i.e. room and material; (2) some special conditions, i.e. that they trusted each other and both wanted to repair their relationship, and the therapist’s ability to assess this; and (3) art work techniques that all couples could master.

Conclusions

Art therapy could benefit couples in relational crisis, given appropriate prerequisites were ensured. Implications for practice: suitable rooms and appropriate materials have to be arranged if the social services want to offer couples in relational crisis art therapy as a tool in their work to reduce marital distress and prevent separations.

Plain-language summary

This study explores art therapy used by couples in relational crisis, from the viewpoint of art therapists. Seven art therapists were interviewed. The results showed art therapy could benefit couples in relational crises. Couples could understand each other better and they could get in touch with positive sides of the relationship. Three factors were experienced as important when using art therapy with couples in relational crisis: (1) to have access to an appropriate art therapy room and sufficient art therapy materials, (2) that the persons in the couple wanted to repair their relationship and that they trusted each other, and (3) that art therapists use easy art therapy techniques that all couples could master. Limitations, research recommendations and clinical implications are discussed.

BAKGRUND  Denna folder är framtagen inom det fyra-åriga tvärvetenskapliga forskningsprojektet LEX-projektet. Hållbara livsmiljöer för psykiskt funktionshindrade. Att integrera bostadsplanering och välfärdsservice genom nya kollaborativa praktiker. Projektet startade startade 2019 och finansieras med medel från de två statliga forskningsråden Formas och Forte. Vi som jobbar i LEX är forskare inom fysisk planering, byggd miljö och socialt arbete från fyra olika lärosäten i Sverige - Blekinge tekniska högskola, Högskolan Dalarna, Sveriges Lantbruksuniversitet SLU samt Umeå universitet. Till projektet hör även en referensgrupp med företrädare från Boverket, Socialstyrelsen, Sveriges Kommuner och Regioner (SKR) och Nationell Samverkan för Psykisk Hälsa (NSPH) samt forskare från Karolinska Institutet (KI) och Kungliga tekniska högskolan (KTH).

En framtidsverkstad är en metod som syftar till att förändra genom att kartlägga och diskutera hur en situtation ser ut idag, vad problemet är med den, hur det skulle kunna vara på ett annat sätt, dvs vad krävs för att nå detta andra sätt samt hur ansvaret för att genomföra förändringen bör fördelas.

Den här framtidsverkstadens bestod av en stadsvandring och en workshop med tjänstepersoner från olika förvaltningar från Umeå kommun  De bilder och citat som presenteras i denna folder hade vi med som inspel till den första dagens stadsvandring. Dessa är framarbetade genom metoden PhotoVoice tillsammans med tolv personer med egen erfarenhet av psykiskohälsa, psykiatri och socialtjänst i tre grupper från tre olika städer. Deltagarna förmedlade erfarenheter av sin livsmiljö genom att fotografera olika platser och berätta om dem. Under den andra dagen träffades framtidsverkstadens deltagare föratt genomföra en workshop kring problem och möjligheter kringboende och livsmiljö för personer med psykisk ohälsa. Även samverkansfrågoroch stödinsatser behandlas.

This editorial addresses social infrastructure in relation to urban planning and localisation, drawing together the themes in this thematic issue on “Localizing Social Infrastructures: Welfare, Equity, and Community.” Having contextualised social infrastructure, we present each of the 12 contributions by theme: (a) the social consequences of the localisation of social infrastructure for individuals, (b) the preconditions for localising social infrastructure in the urban landscape, and (c) the social consequences for the long-term social sustainability of the wider community. We conclude with the openings for future research, such as the need to continue researching localisation (for example, the ways localisations of social infrastructure support, maintain, or hinder inclusion and community-building, and which benefits would come out of using localisation as a strategic planning tool); second, funding (the funding of non-commercial social infrastructure and who would take on the responsibility); and third, situated knowledge (the knowledge needed by planners, architects, social service officials, decision makers, and the like to address and safeguard the importance of social infrastructure in urban development and regeneration processes).

In this report, we have presented the first part of two in the interdisciplinary research project LEX - sustainable Living Environments for people with psychiatric disabilities. Aligning housing planning and social services through eXperimental collaborative practices. 

Our starting point was to find out more about what characterizes support measures aimed at people with mental disabilities and how these are organized, and to investigate cross-sectoral collaboration in terms of planning for housing and inclusive living environments. 

Our material shows that the target group for housing and support initiatives has changed. People with disabilities due to long-term psychological disabilities still constitute a central group, often in need of interventions with a high level of service. However, the target group for the initiatives is changing and this has in some municipalities led to a development towards a more general organization for the support initiatives without specialist functions. Housing initiatives decided in accordance with SoL dominate, but a mixture of approaches can be seen, from individual exceptions where LSS is applied to a municipality where all decisions about housing with special services are made according to LSS. When it comes to the types of activities for support measures, traditional group housing and housing support dominate. Some believe that group housing as a type will eventually disappear, and among those responsible for operations, there is a consensus that the field is generally moving towards a direction to work towards increased independence and autonomy for the users within the operations. 

The ways in which social services and community building administrations work together with issues that affect the target group differs between the municipalities. The work is sometimes organized in networks, sometimes it is about coordination, in some cases cooperation or collaboration. In some municipalities, there are forums for continuous joint work, in others it is not considered necessary at all. How meetings between the two administrations are organized, on whose initiative and responsibilities are handled in different ways. It is a complex picture that emerges where issues are raised in different instances and at different levels within the own administration as well as between the administrations. 

When it comes to municipal housing provision responsibility, the work of developing the housing provision program is an important part. Officials from different administrations are involved in various ways in this work, from coordination and coordination to long-term strategic collaborations. Different types of roles are produced, such as initiators, information providers, experts or spokespersons with different areas of action. The social services' experience-based knowledge of the current situation for different groups is not always used. In the material, the issue appears to be politically sensitive and is presented as a broad goal of 'housing for all', but with limited concretization. 

The municipal strategies for locating housing with special services are about converting existing premises, building new housing in already built-up housing areas and planning for new housing in urban development processes. The overall pattern for the location of housing is in the outskirts of  residential areas, a compromise between the social administration's ideas about social inclusion and the community building administrations' ideas about integrity. However, users' opportunities to acquire positive neighborly contacts may be hampered by such peripheral locations. 

What an inclusive, ‘good’, living environment could be for people with mental disabilities turns out to be a new issue for our interviewed officials. Several informants from the social services have not previously thought about how housing and employment relate to each other geographically and in what way it affects experiences of the living environment. Considering inclusive living environments for our target group as part of the broader community planning was not obvious to the planners. It also emerged that it is more difficult for the municipality to make architectural demands to those who build housing with special services and other similar care housing than what it is to those who construct other public buildings such as city halls, libraries or swimming pools, something that is reflected in location and architectural quality.

This article focuses on the stock of accommodation service units for people with psychiatric disabilities in Sweden and the classification of supported accommodation. We examined 122 units in 12 municipalities in Sweden and classified them according to the Simple Taxonomy for Supported Accommodation (STAX-SA). We found an obvious variation in the field and a movement into a recovery-oriented direction and towards individuality. There is an emphasis on Move-On that seems to expand into and beyond floating outreach support, and there is a relaxation of service units’ boundaries concerning commitment and target groups. The correspondence to STAX-SA was quite low (48%), and the applicability to ‘real world’ services was not satisfactory. When capturing variation and change in a rich dataset, STAX-SA is too reductive. However, STAX-SA was a successful point of departure in the analysis that opened up for identifying diversities and movement. We suggest some adjustments to increase its applicability.

The movement towards deinstitutionalisation of mental health services has created a space for new and community-based solutions in western countries, but the field still seems to lack coherent ideological and practical features. This is also evident for issues related to housing. The aim of this article is to examine the characteristics of supportive accommodation services for people with psychiatric disabilities in Sweden, according to the experiences of local service providers. The focus is placed on the services’ organizational setting, main orientation, and conceptual content. This article is based on a multiple case study of ten Swedish municipalities, purposely selected regarding size, location, and demographic features. Data mainly consist of interviews with key informants in the social service organisation. The results indicate the emergence of a new generation of service users with complex needs, who challenge both the organisation and the content of the service offered. Group homes and mobile housing support appeared as pillars in the service supply, but several local and pragmatically oriented solutions were also identified, as well as ambitions to scale down the extent of institutional settings. The guiding idea present at most sites is a strive towards increased autonomy among service users. 

I denna rapport presenteras resultaten av en studie som genomförts på uppdrag av Barnahus i Dalarna. Barnahus i Dalarna startades 2007 med målsättningen att erbjuda barn som misstänks vara utsatta för våldsbrott i nära relationer och sexualbrott ett behovsanpassat omhändertagande. Verksamheten utgörs av tvärprofessionell samverkan mellan Åklagarkammaren i Falun, Polismyndigheten Dalarna, socialtjänsten i Dalarnas samtliga kommuner, Barn- och ungdomsmedicin i Dalarna och Barn- och ungdomspsykiatrin i Dalarna. Under 2021 uppmärksammades en minskning av ärenden som aktualiseras för samråd i Barnahus och det uppfattades viktigt att öka kunskapen om socialtjänsternas perspektiv på polisanmälan och tvärprofessionell samverkan. Det uppdrogs därför till Sara Quarles van Ufford, Högskolan Dalarna, att genomföra en intervjustudie med representanter för de socialtjänster som ingår i barnahussamverkan. 

Syftet var att undersöka socialtjänsternas perspektiv på polisanmälan av misstänkta vålds- och sexualbrott mot barn och identifiera upplevda hinder, möjligheter och förbättringsområden för tvärprofessionell samverkan, samt belysa socialtjänsternas utgångspunkter vid utredning av våld mot barn. Studien baserades på semistrukturerade intervjuer med första linjens arbetsledare inom socialtjänsten som analyserades kvalitativt med hjälp av tematisk analysmetod. 

Resultaten visade att socialtjänsterna delvis har olika utgångspunkter och strategier för att utreda våld mot barn vilket påverkar inställningen till att polisanmäla brottsmisstankar – och som leder till att våld mot barn handläggs på olika sätt. Det framkom att bedömningar av om en polisanmälan ska göras kraftigt skiljer sig åt, liksom den upplevda nyttan och konsekvenserna av en polisanmälan. Medan vissa betonar vikten av att barnet synliggörs som brottsoffer menar andra att en polisanmälan försvårar samarbete och stöd till familjen. Generellt uppfattas socialtjänstens utredningsprocess försvåras när brottsutredningen drar ut på tiden med negativa konsekvenser för barn och familjer – och vetskapen om att förundersökningar tenderar att dra ut på tiden kan upplevas som ett hinder för att göra en polisanmälan. Samtidigt menar flera informanter att en utebliven polisanmälan kan innebära risker för att våld och intressekonflikter mellan barn och föräldrar förminskas och inte utreds på djupet. Vidare framkom att tvärprofessionell samverkan ofta uppfattas upphöra efter det initiala samrådet och att barnpsykiatrisk kompentens inte upplevs tillgänglig vid behovsbedömningar som aktualiseras i ett senare skede av processen. Det uppfattas också vara svårt för barn som aktualiseras i Barnahus att få hjälp via Barn- och ungdomspsykiatrin. Generellt uppfattas det finnas flera vinster med att göra en polisanmälan – men också flera förbättringsområden för tvärprofessionell samverkan som kan sammanfattas i fem övergripande områden: 

• Tydliggöra, stärka och jämställa barnahusaktörernas roller 
• Ökad snabbhet i brottsutredningen och synkronisering med socialtjänstens utredning
• Förbättrade möjligheter för fortsatt tvärprofessionell samverkan i Barnahus med fokus på stöd och behandling
• I större utsträckning beakta geografiska aspekter i barnahussamverkan
• Ökat fokus på ”barnets bästa” i barnahussamverkan 

Background: Suicide is a serious public health problem. All 194 member states of the World Health Organization have signed the Comprehensive Mental Health action plan 2013–2030 which tasks governments with implementing evidence-based interventions in community settings to prevent suicide at all stages of life. This study aims to map the priorities in suicide prevention policy in community-settings in Sweden, one of the World Health Organization's member states. Method: A document study, using data from suicide prevention policy documents in the 21 counties in Sweden. Data was analyzed using qualitative content analysis. Results: Suicide prevention interventions at the universal, selective and indicated prevention levels were prioritized. Most of the suicide prevention interventions intended to be implemented at each prevention level was evidence-based. Most of the suicide prevention interventions at all prevention levels did not prioritize any specific age group, however when age groups were targeted there were some emphases on children and adolescents. Conclusion: There is a need to improve suicide prevention interventions prioritizing age-groups who have high suicide rates. As educational interventions that encourage young people to develop their ability to face life challenges related to adolescence are found to be appropriate suicide prevention interventions, so too could educational interventions aimed at other age-groups be developed, to enable them to develop their ability to face life challenges related to their age. © 2023

The internet has become very central to today’s society. The aim of this scoping review was to map internet use among people with an intellectual disability (ID) in Sweden, and to scrutinise the phenomenon from a critical perspective. The concepts of digital divide, digital inequality, social construction of intellectual disability, and power relations were applied to conceptualise the empirical material. The results showed that people with ID have limited access to the internet. A discrepancy in approaches towards internet use was identified. Generally, people with ID subscribe to a positive view of the internet. Among professionals a generally pessimistic view was instead identified. People with ID are described as a vulnerable and naive group, who presumably cannot protect themselves from the risks the internet entails. From a critical perspective, control of internet access could strengthen asymmetric power, and human rights of social participation are withheld from people with ID.