Robert Nozick and Axel Honneth: An attempt to shed light on mental health service in Norway through two diametrical philosophers.

This article aims at giving insight into Norwegian mental health service by exploring the ideologies of two diametrical philosophers, the American Robert Nozick (1938-2002) and the German Axel Honneth (1949-). Nozick proposes as an ideal a minimal state in which citizens have a "negative right" to the absence of interference and to follow their own interests without restriction from the state. On the other side, Axel Honneth claims that there is no freedom without state interference. In his view, governmental involvement is understood as a prerequisite for personal freedom. We may call this state an opposite of the minimal state; a maximal state. To get a better understanding of these opposite philosophies, we use texts written from conversations with people suffering from mental health problems, nurses and other caregivers in four Norwegian municipalities. Nozick's notion of the minimal state and Honneth's political philosophy of freedom and recognition were used as analytical tools. Among patients and helpers, there were different opinions about good care and how much caregivers should intervene. Some emphasized autonomy, independency, minimal involvement in human contact by nurses and other caregivers, similar a minimal state. Others perceived good care as bonding between helpers and service-users. They underlined equal and personal relationships, as well as helping with practicalities, similar a maximal state. In the discussion, we focus on how people with chronic illnesses are supposed to transform themselves into self-cared individuals, able to manage their own condition successfully with minimal help from public welfare and at a lower cost. Finally, we express concerns about who will care for disempowered patients without family and other resources in a minimal state.

Fear, danger and aggression in a Norwegian locked psychiatric ward: Dialogue and ethics of care as contributions to combating difficult situations.

BACKGROUND: Fear and aggression are often reported among professionals working in locked psychiatric wards and also among the patients in the same wards. Such situations often lead to coercive intervention. In order to prevent coercion, we need to understand what happens in dangerous situations and how patients and professionals interpret them. RESEARCH QUESTIONS: What happens when dangerous situations occur in a ward? How do professionals and patients interpret these situations and what is ethically at stake? RESEARCH DESIGN: Participant observation and interviews. PARTICIPANTS: A total of 12 patients and 22 professionals participated. ETHICAL CONSIDERATIONS: This study has been accepted by the Regional Committee for Medical and Health Research Ethics in Norway. FINDINGS: (a) Both atmosphere and material surroundings were interweaved within dangerous situations, (b) the professionals applied stereotypes when interpreting dangerous situations and (c) the professionals and the patients had different interpretations of what triggered dangerous situations. DISCUSSION: The discussion centres on how care ethics and a dialogical practice might contribute towards combating difficult situations and the ways in which change is an ongoing ethical process of becoming. CONCLUSION: The ethics of care and a dialogical approach are suggested as ethical frameworks for preventing fear, danger and aggression in psychiatric wards. Both frameworks can be understood as patient-driven, including the relational and contextual perspectives. It means a shift from professionally driven processes to patient-driven dialogue.

The locked psychiatric ward: hotel or detention camp for people with dual diagnosis.

BACKGROUND: The concepts of autonomy and liberty are established goals in mental health care; however, involuntary commitment is used towards people with mental health and substance abuse problems (dual diagnosis). AIMS: To explore how patients and staff act in the context of involuntary commitment, how interactions are described and how they might be interpreted. METHOD: Ethnographic methodology in a locked psychiatric ward in Norway. RESULTS: Two parallel images emerged: (a) The ward as a hotel. Several patients wanted a locked ward for rest and safety, even when admission was classified as involuntary. The staff was concerned about using the ward for real treatment of motivated people, rather than merely as a comfortable hotel for the unmotivated. (b) The ward as a detention camp. Other patients found involuntary commitment and restrictions in the ward as a kind of punishment, offending them as individuals. Contrary, the staff understood people with dual diagnoses more like a generalized group in need of their control and care. CONCLUSION: Patients and staff have different perceptions of involuntary commitment. Based on the patients' points of view, mental health care ought to be characterized by inclusion and recognition, treating patients as equal citizens comparable to guests in a hotel.