Patients' basic needs have to be met, and patient-staff interaction has to also continue during seclusion/restraint. Providing patients with meaningful activities, planning beforehand, documenting the patients' wishes, and making patient-staff agreements reduce the need for restrictions and offer alternatives for seclusion/restraint. Service users must be involved in all practical development.

The use of patient restrictions (e.g. involuntary admission, seclusion, restraint) is a complex ethical dilemma in psychiatric care. The present study explored nurses' (n = 22) and physicians' (n = 5) perceptions of what actually happens when an aggressive behaviour episode occurs on the ward and what alternatives to seclusion and restraint are actually in use as normal standard practice in acute psychiatric care. The data were collected by focus group interviews and analysed by inductive content analysis. The participants believed that the decision-making process for managing patients' aggressive behaviour contains some in-built ethical dilemmas. They thought that patients' subjective perspective received little attention. Nevertheless, the staff proposed and appeared to use a number of alternatives to minimize or replace the use of seclusion and restraint. Medical and nursing staff need to be encouraged and taught to: (1) tune in more deeply to reasons for patients' aggressive behaviour; and (2) use alternatives to seclusion and restraint in order to humanize patient care to a greater extent.

ObjectiveThe role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association.MethodTowards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017.ResultsFrom the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations.ConclusionsAlliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.

Risk factors for suicidal ideation and attempts may diverge both qualitatively and in terms of dose response. When effects of risk factors from multiple domains are concurrently examined, proximal clinical characteristics remain the most robust. All risk factors cluster into the group of repeated attempters.

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Though some empirical and anecdotal accounts can be located in the extant literature, it remains the case that little is known about how secluded/restrained (S/R) patients perceive their overall treatment. The purpose of this study was to explore patients' perceptions of their hospital treatment measured after S/R. The data were collected with a Secluded and Restrained Patients' Perceptions of their Treatment (S/R-PPT) questionnaire from S/R patients aged 18-65 years. Ninety completed questionnaires were analysed. Patients perceived that they received enough attention from staff, and they were able to voice their opinions, but their opinions were not taken into account. Patients denied the necessity and beneficence of S/R. Women and older patients were more critical than men and younger patients regarding the use of restrictions. There were also statistically-significant differences in responses among patients at different hospitals. It is concluded that patients' opinions need more attention in treatment decisions. To achieve this, psychiatric treatment needs genuine dialogue between patients and staff, and individual care should have alternatives and no routine decisions. Therefore, the treatment culture must improve towards involving patients in treatment planning, and giving them a say when S/R is considered.

Mental health services (MHS) have gone through vast changes during the last decades, shifting from hospital to community-based care. Developing the optimal balance and use of resources requires standard comparisons of mental health care systems across countries. This study aimed to compare the structure, personnel resource allocation, and the productivity of the MHS in two benchmark health districts in a Nordic welfare state and a southern European, family-centered country. The study is part of the REFINEMENT (Research on Financing Systems’ Effect on the Quality of Mental Health Care) project. The study areas were the Helsinki and Uusimaa region in Finland and the Girona region in Spain. The MHS were mapped by using the DESDE-LTC (Description and Evaluation of Services and Directories for Long Term Care) tool. There were 6.7 times more personnel resources in the MHS in Helsinki and Uusimaa than in Girona. The resource allocation was more residential-service-oriented in Helsinki and Uusimaa. The difference in mental health personnel resources is not explained by the respective differences in the need for MHS among the population. It is important to make a standard comparison of the MHS for supporting policymaking and to ensure equal access to care across European countries.

Delayed perceptions and proposals resembled the proximate ones. Perceptions may persist for years. Such perceptions and proposals, if taken into account from the beginning of treatment, may prevent negative long-term consequences of witnessed or experienced aggression/violence. Humane, interactive nursing models should be studied and disseminated.