Governing Ideals of Good Care: Quality improvement in mental health care

In the spring of 2008 I attended a conference on the use of coercion in mental health care. A healthcare worker who was also a “practicing patient”, as the program told us, held an impressive lecture that captured the audience from the moment the woman walked to the front. She referred to herself as “difficult patient” and questioned certain care practices in her lecture, mainly those on the use of coercion within psychiatry. “How free are you actually?” she asked the audience. “Your life is made up of constraints.” But the difference is, she said, that in normal life constraints agreed upon by partners or created institutionally lead to bonds, whereas in care they often lead to marginalization. The conference also featured some interactive workshops. One of the workshops was on the subject of how to deal (differently) with situations in which coercion is needed. It was mainly professionals who engaged in the discussion and one of them told about a client who maintained she would be able to live independently. Her care givers, however, were less convinced. “To what extent can we force her to live in the institution?” the care professional brought up. Eventually someone remarked: “if we continue with coercion [in this case] we win the war but loose the peace”. It became clear that coercion would endanger the (caring) relationship with this client. This conference taught me how difficult it can be to provide and to receive mental health care. There are no easy solutions. At the end of this coercion workshop one of the organizers concluded that the discussion had rendered no tips that would help provide care in a better or less difficult way. Attending conferences like these therefore made me wonder: how do professionals go about providing good care? What is good care? What values are deemed important? How are these values defined and enacted? How do different actors decipher what is ‘best’ in a given situation? What do they see as (moral) problems in providing and improving care? These are the questions I explore in this thesis.

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