Leif Hugo Stubrud

Foto: Malin Sveinsdotter Lystad

Hvordan etablere gode tjenester?

Tilsyn med tjenestene til mennesker med utviklingshemming avdekker svakheter i stort mon. Antallet personer med tvangsvedtak vokser fra år til år. Til tross for dyster statistikk, mener psykologspesialist Leif Hugo Stubrud at det ikke er spesielt krevende å peke på de sentrale faktorer for gode tjenester, men mer krevende å etablere og opprettholde gode tjenester.

Leif Hugo Stubrud jobber i habiliteringstjenesten i Østfold. Erfaringen med mennesker med utviklingshemming går tilbake til tidlig på 1990-tallet. Han var sentral i utarbeidelsen og oppfølgingen av de første tvangslovverkene overfor mennesker med utviklingshemming og jobber fortsatt både akademisk og klinisk med problematikk knyttet til mennesker med utviklingshemming. Det er naturlig å spørre Leif Hugo Stubrud om hvordan en etablerer gode tjenester for mennesker med utviklingshemming og hvordan en kan unngå eller minimalisere bruken av tvang.

- Det er noen få suksessfaktorer som går igjen. Ingen av suksessfaktorene er spesielt krevende å etablere og opprettholde. For det første må tjenestemottaker være godt kjent med og trygg på tjenesteyterne, noe som tilsier små og stabile personalgrupper og tjenesteytere som trives i jobben slik at de blir værende. For det andre må aktivitetene være individtilpasset og i samsvar med tjenestemottakers ønsker og vilje. En bør unngå kollektive tjenester og heller ikke tvinge alle inn i de samme rutinene. For det tredje kreves en god samhandling og kommunikasjon mellom tjenesteytere og tjenestemottaker. En må prøve å forstå den utfordrende væremåten. Ofte er den utfordrende væremåten uttrykk for vansker med å regulere følelser. En kan vel kanskje si at når en lykkes med å skape trygghet og trivsel, så har en lykkes med å legge grunnlaget for gode tjenester.

Når tid er det nødvendig å benytte tvang?

- En må gripe inn med tvang dersom det oppstår farlige situasjoner. Hvis en person er i ferd med å gå ut på en trafikert vei, så må en stoppe personen slik vedkommende ikke blir påkjørt. Det kan også være nødvendig å benytte tvang for å forhindre alvorlig selvskading eller angrep på andre. I tillegg er det noen få som har en slik oppførsel at selve oppførselen er til hinder for dem, de makter f.eks. ikke å gjøre annet enn noen ensformige gjentakende bevegelser. I slike situasjoner kan en måtte bryte inn på en skånsom måte slik at personen kan delta i mer varierte aktiviteter som den finner interessant. Tvangstiltak må ikke benyttes som straff.

Hva kan en gjøre for å unngå eller å minimalisere tvangsbruken?

- Vanligvis bør en fokusere på levekårene til personen, tjenestene som personen får, at tjenestemottaker er trygg og trives. Når folk mistrives eller ikke har det bra på andre måter, så blir ofte oppførselen deretter.

Ser du noen fellesnevnere mellom bofellesskap hvor det er store utfordringer?

- Ofte er det snakk om utydelig eller manglende ledelse og ukritisk bruk av tvang. Slike situasjoner gir også utslag på ansatte i form av sykemeldinger og høy gjennomtrekk av ansatte. Knappe budsjetter kan gjøre det vanskelig å etablere gode levekår og gode tjenester. Stramme budsjetter forplanter seg raskt fra kommunestyret og ned over i systemet.

Omfanget av tvang og makt synes å være svært ulikt fordelt mellom fylkene. I Østfold er det rundt 2 prosent av voksne med utviklingshemming som har tvangsvedtak, i Hedmark er det rundt 13 prosent. Mellom disse to fylkene ligger de andre fylkene, utenom Finnmark hvor rundt 1 prosent har tvangsvedtak. Hva kommer disse store forskjellene av og hva skyldes det lave antallet tvangsvedtak i Østfold?

- Variasjonen kan nok ha noe med geografisk variasjon i erfaringer og forståelse både i kommunene, habiliteringstjenesten og mellom fylkesmansembetene. Variasjonene synes å være relativt stabile over tid, noe som tilsier at de er knyttet til tradisjoner. Andre forklaringer kan være forskjeller knyttet til hvordan en skal forstå og forhindre problematisk oppførsel, hvordan lovverket skal forstås og forskjeller i registreringspraksis. Vi vet lite om årsakene til de store geografiske variasjonene. Bruk av tvang er et alvorlig inngrep. Årsakene til den store variasjonen i tvangstallene burde vært forsket på. I Østfold har vi i lang tid lagt mye vekt på problemforståelse og vi har prioritert andre måter å gripe inn på enn med tvangstiltak.

Du har fulgt nøye med på tvangsbruken overfor mennesker med utviklingshemming siden tidlig på 1990-tallet og har vært med på utformingen av tvangslovverket. Er du fornøyd med situasjonen og dagens lovverk?

- Jeg var tilhenger av tvangsreguleringene, nå er jeg mer usikker. Antallet personer med tvangstiltak vokser år for år og slik har det vært lenge. Det synes f.eks. å bli stadig vanligere med tvangstiltak overfor mennesker med lett utviklingshemming, en gruppe som det var svært lite fokus på da lovverket ble utarbeidet. Tvangsreguleringene synes også å bli brukt overfor situasjoner som de ikke ble utformet med tanke på, f.eks. det å forhindre kriminell virksomhet. Tvang er et alvorlig inngrep i folks selvstendighet. Det er svært viktig å begrense tvangsbruken, avslutter psykologspesialisten fra habiliteringstjenesten ved Sykehuset Østfold.

Jens Petter Gitlesen

16 januar 2019

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