'It has gotten a lot better, but it is still bad': Experiences with the police among marginalized PWUDs in a context of depenalization.

Based on a survey (n = 249) and qualitative interviews (n = 38) with marginalized people who use drugs (PWUDs) in Copenhagen, Denmark, we investigate the experiences of this group with the police in a context where drug possession had been depenalized in and around drug consumption rooms (DCRs). Our findings point to positive experiences with the police, especially with the local community police in the depenalization zone, who refrained from drug law enforcement and practiced 'harm reduction policing.' However, marginalized PWUDs also reported that they were still targeted for drug possession by other sections of the police despite the depenalization policy. Specifically, the drug squad of the police would continue to confiscate illicit drugs for investigatory purposes to counter organized drug crime, as well as continue to target user-dealers who were not formally included in the depenalization policy. The findings illustrate how marginalized PWUDs still found themselves in a precarious legal situation without any legal rights to possess the drugs that they were dependent on, even though possession of drugs had been depenalized in and around DCRs.

Perceived advantages and disadvantages of substance use in a dual diagnosis population with severe mental disorders and severe substance use disorder. Considering the self-medication hypothesis.

AIM: Based on a large cohort of dual diagnosis patients, the aim of this study was to quantify the patient-perceived problems and advantages of their substance use and relate the quantity of problems to the substance type and psychiatric diagnosis. MATERIAL: Data comes from a naturalistic cohort admitted to an in-patient facility in Denmark specialized in integrated dual diagnosis treatment. We included 1076 patients at their first admission to the facility from 2010 to 2017. Participants completed 607 DrugCheck and 130 DUDIT-E questionnaires. METHOD: we analyzed the questionnaires and included admission diagnosis by use of t-test and ANOVA to depict the patterns in substance use in relation to psychiatric diagnosis. RESULTS: The three most common substance related problems according to the DrugCheck questionnaire were: feeling depressed, financial problems, and losing interest in daily activities. From DUDIT-E, the highest-ranking negative substance related effects were financial ruin, deterioration of health, and problems at work. Effects on social life relationships were also evident with more than 40% of participants. The top three positive substance related effects reported were relaxation, improved sleep, and control over negative emotions. The number of problems listed varied significantly with the type of preferred substance. Patients using pain medication, sedatives, central stimulants, and alcohol reported most problems. Diagnosis did not differentiate the problems experienced. Results partially support the broad self-medication hypothesis for patients with severe mental illness, but also points out that patients are well aware of negative effects.

Past, Present, and Future Labor Market Participation Among Patients Admitted to Hospital With Concurrent Substance Use and Mental Health Disorder, and What We Can Learn From It.

OBJECTIVE: The aim of the study is to investigate the labor market participation of patients with concurrent substance use and mental health disorder before treatment, as well as the strength of the barriers to re-enter the labor market. METHODS: The study population is composed of individuals with concurrent substance use and mental health disorder at a psychiatric unit in 1996, 2001, 2006, 2011, and 2016. The number of self-supported years 20 years back in time, as well as present and subsequent employment, was calculated. RESULTS: From 1996 to 2016, there was a decrease by 43.8% in self-supported years before treatment and by 36.4% in the fraction of patients working at the time of admission. CONCLUSIONS: The results point to increasing difficulties with regard to labor market attachment among individuals with mental illnesses.

What kind of science for dual diagnosis? A pragmatic examination of the enactive approach to psychiatry.

The recommended treatment for dual diagnosis - the co-occurrence of substance use and another mental disorder - requires seamless integration of the involved disciplines and services. However, no integrative framework exists for communicating about dual diagnosis cases across disciplinary or sectoral boundaries. We examine if Enactive Psychiatry may bridge this theoretical gap. We evaluate the enactive approach through a two-step pragmatic lens: Firstly, by taking a historical perspective to describe more accurately how the theoretical gap within the field of dual diagnosis initially developed. Secondly, by applying the Enactive Psychiatry approach to data from a longitudinal study on the trajectory of cannabis use in psychosis disorders. By applying the theory rather than simply presenting it, we position ourselves better to evaluate whether it may assist the purpose of achieving a more expedient pragmatic "grip" on the field of dual diagnosis. In our discussion, we suggest that this may very well be the case. Finally, we consider the enactive approach as one of a small handful of new theories of mental disorders that draw on systems thinking and ecological psychology, and discuss whether they have the potential for a wider progressive problemshift within psychiatry. The case in favor of such potential, we argue, is less strong unless the role of complexity, similar to that seen within the dual diagnosis field, may be demonstrated for other fields of clinical practice.

The Cultural Formulation Interview-Generating distance or alliance? A qualitative study of practice changes in Danish mental healthcare.

This article presents provider experiences with the Cultural Formulation Interview (CFI) in Danish mental healthcare for migrant patients. Semi-structured interviews with 17 providers and 20 recorded CFI sessions were analyzed with a constructivist grounded theory approach. Based on our empirical material, we endorse the CFI's ability to facilitate working alliance and a profound and contextually situated understanding of the patient. Further, the CFI supported less-experienced providers in investigating cultural issues. Conversely, we found that CFI questions about cultural identity and background evoked notions of distance and 'othering' in the encounter. Nine providers had felt discomfort and professional insecurity when the CFI compelled them to introduce explanatory frameworks of culture in the mental health assessment. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which had limited analytical value. We describe the contradictory CFI experiences of alliance versus distance at three levels: 1) at the CFI instrument level; 2) at the organizational level; and 3) at the contextual and structural level. We demonstrate benefits and pitfalls of using the CFI with migrants in Denmark, which is an example of a European healthcare context where cultural consultation is not an integrated concept in health education programs and where the notion of culture is contentious due to negative political rhetoric on multiculturalism.We suggest that the CFI should be introduced with thorough training; focus on fidelity; and supervision in the clinical application and understanding of the concept of culture.

Negotiating Engagement, Worthiness of Care and Cultural Identities Through Intersubjective Recognition: Migrant Patient Perspectives on the Cultural Formulation Interview in Danish Mental Healthcare.

This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.

Negotiating the Practical Meaning of Recovery in a Process of Implementation : An Empirical Investigation of How a Participatory-Inspired Research Approach to Implementation Might Facilitate a More Recovery-Oriented Practice: The Case of RENEW-DK.

As implementation of recovery-oriented practices has proven difficult, this study investigates whether a participatory-inspired approach to implementing and adjusting a recovery-oriented model, RENEW-DK, might facilitate a more recovery-oriented practice among the professionals in public sector services. Ten narrative interviews with professionals was analyzed from a Science and Technology Studies perspective, and special attention was devoted to the concepts of distortion and stigmatization. Despite a one-year participatory process of model adjustment and implementation, professionals experienced RENEW-DK as a distortion and thus shaped their practice of RENEW-DK according to organizational requirements and professional beliefs instead of making their practice more recovery-oriented. The study calls attention to the need to acknowledge contradictions between intentions in general models and values in specific organizations with local norms and practices.

Satisfaction with mental health treatment among patients with a non-Western migrant background: a survey in a Danish specialized outpatient mental health clinic.

BACKGROUND: Global migration increases ethnic and cultural diversity and demands mental health services to adapt to provide all patients with equal access to good quality care. Patient satisfaction surveys can inform this service delivery, thus we explored patient satisfaction among non-Western migrants receiving treatment in a Danish specialized outpatient mental health clinic [Competence Centre for Transcultural Psychiatry (CTP)]. METHODS: We used multivariate logistic regression models to estimate associations between 'Overall treatment satisfaction' and treatment-related items plus potential confounders from a cross-sectional patient satisfaction survey (n = 686). The satisfaction questionnaire was a self-report measurement tool developed locally at CTP. Participants were non-Western migrants above 18 years with Post-Traumatic Stress Disorder (PTSD) or depression diagnoses according to ICD-10. RESULTS: Most participants (n = 497; 82.6%) reported overall satisfaction with their mental health treatment, but less than half (n = 311; 48.8%) reported an improvement in health and situation after end of treatment. Participants who experienced a subjective improvement in their health and situation had significantly higher odds of being satisfied with their mental health treatment [odds ratio (OR) = 8.5, 95% confidence interval (CI): 4.0-18.1]. Perceptions of influence on the treatment course (OR = 4.7, 95% CI: 2.4-9.2), and of understanding and respect for one's cultural background (OR = 3.4, 95% CI: 1.5-7.6) were significantly associated with treatment satisfaction. Age and sex were insignificant in the final regression model. CONCLUSIONS: Implications for practice based on our findings are to enhance person-centred care and shared decision-making with all patients regardless of cultural background and to prioritize pre- and postgraduate training in cultural competences and cultural humility for healthcare providers.

Dual diagnosis and mechanical restraint - a register based study of 31,793 patients and 6562 episodes of mechanical restraint in the Capital region of Denmark from 2010-2014.

OBJECTIVE: To investigate whether patients with dual diagnosis have a higher risk of being mechanical restraint compared to patients with only psychiatric diagnoses. METHODS: Data on all patients admitted to a psychiatric ward from 2010-2014 in the Capital Region of Denmark was linked with information from the register of coercive measures. Patients were based on diagnosis divided into six groups. The three main patient groups were: only psychiatric diagnosis defined as all ICD-10 F-diagnosis except F10-F19, dual diagnosis (co-occurrence of diagnoses of harmful use or dependency and psychiatric diagnoses) and only other substance use diagnosis (i.e. other than harmful use or dependency). The risk of mechanical restraint was investigated by analyzing all first-time admissions in the period using Cox-proportional hazard models. RESULTS: In the crude rates patients with dual diagnosis were more often mechanically restrained compared to patients with only psychiatric diagnoses or only other substance use diagnoses. However, this was attenuated when the characteristics of patients were accounted for. Patients with only other substance related diagnoses had the highest risk of being mechanically restrained. CONCLUSION: When preventing mechanical restraint, the focus should be on actual use of substances or withdrawal effects and not on the dual diagnoses patients in them-self.

"Caught Between a Rock and a Hard Place"-Between Discourses of Empowerment and Solicitude: Danish Public Sector Service Professionals' Discourses of Nonattendance.

Nonattendance constitutes a profound challenge in public sector services targeting young adults with mental health difficulties. Therefore, researchers and practitioners are occupied with trying to resolve this. For clinicians to be aware of their own naturalized and perhaps inappropriate communicative practices, we investigated the established normative organizational logics behind explanations and strategies related to nonattendance. We performed a critical discourse analysis on material collected through participatory research throughout 2015. Three discourses were identified: solicitude, responsibility, and youth discourse. Although the discourses were complex and entangled, they were used by all practitioners. Furthermore, some of the discourses, especially the responsibility and the solicitude discourses, were inherently tension filled, and practitioners experienced frustration in dealing with these tensions. The youth discourse can be understood as a coping mechanism to deal with these tensions because it distributes responsibility for nonattendance to general social and cultural processes.

Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes.

AIM: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. METHOD: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. RESULTS: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. CONCLUSIONS: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

Dual diagnosis and psychosocial interventions--introduction and commentary.

Treatment of patients with concurrent mental illness and substance abuse represents a challenge to the traditional treatment systems. This article gives: 1) an introduction of the concept and frequency of dual diagnosis (DD), 2) a presentation and discussion of the latest guidelines on DD treatment, 3) status on the current situation in the DD field in Denmark, and 4) potentials for future research. The article is based on systematic examination of evidence-based research and popularized latest guidelines on DD treatment. Methodologically, both treatment and research is challenged by the diversity in DD combinations. Although integrated treatment with the inclusion of cognitive-behavioural therapy, motivational interviewing and family intervention in DD treatment show promising results, it remains to establish which treatment programme is the most qualified in improving mental health and reducing substance use. A future priority is the development of DD treatment that targets specific co-morbid combinations and treatment needs.

[Patients with non-Danish background? Citizenship, nationality, ethnicity or culture]. / Patienter med anden baggrund end dansk? Statsborgerskab, nationalitet, etnicitet eller kultur.

The ethnic and cultural background of patients in the Danish health care sector has gained increased attention in research as well as in clinical practice. Often the only available information concerning these patients is their citizenship. It is, however, problematic to use citizenship as proxy for other background variables. This article presents definitions of citizenship, nationality, ethnicity and culture from a social scientific perspective and discusses how these categories should be used in order to obtain the most precise information about the patient's background.