The organization of mental healthcare in laboratory: life and death of an assessment tool

 

 

 

 

Under reconstruction for about the last thirty years, mental health in Belgium started in the second half of the years 2000 a new reconversion phase. Aiming at de-institutionalizing the existing institutions by promoting network practices, the upcoming reform had to be preceded by an ambitious experimentation phase to test the new care model. This experimental policy, which was often called « therapeutic projects in mental health», was actually made of two large aspects. On the one hand, therapeutic projects as such, or primary dialog, aimed at locally organizing care workers from different origins around a group of patients. On the other hand, transversal dialog was organized to draw conclusions from the experimentations to prepare the future care system reform. While the latter foresaw an « empirical » dialog process between the different stakeholders, a scientific study of the experimentations was assigned to a specialized agency. In addition to a qualitative study about the different projects organizational processes, a quantitative assessment tool was built in order to collect the different types of data about the patients involved in projects. It is that tool that will be analyzed in this report.

If among all the existing mental health projects in Belgium, therapeutic projects have a significant place due to the importance of the perspective change they had to initiate, the quantitative study is worth talking about. Close to the « evidence-base » approach, this research is among the first to be conducted in mental health in Belgium. After it was announced, this tool quickly generated major controversies and the opposition of different actors more or less involved in projects. Initially planned to start right after the launch of therapeutic projects in the spring of 2006, this study will definitely be withdrawn in the fall of 2009 due to the many delays observed.

The strength of controversies about this tool reveals the significant issues crystallized by this assessment. Whether professional, managerial or clinic, these issues can reflect some of the main progresses of our care system and even go beyond the strict framework of mental healthcare. By starting with a context overview in order to understand the tool’s birth, this enabled us, after going through the history, to understand the meaning of the tool and the issues it brings for the different actors involved. In fine, we saw that the building and use of such tools based on scientific knowledge is not politically neutral but is in the center of many issues and power relationships for the different actors who have to work with it.

What does this assessment teach us about mental health evolution in Belgium? The history of this tool can be seen, through the negotiations that were conducted about it, as a succession of framing made by the evaluating agency that would limit the scope of its research to the organization of care networks, and overflowing by participants who related its existence to many stakes which are external to therapeutic projects policy, as examples : willingness to reduce costs or to impose a new care model, impact on the therapeutic relationship, medical secrecy, status of the patient or the practitioner…

What can we say about that at the end of this research about this tool? If the importance of controversy that went along with this assessment tool helped us identifying issues it generated for the involved actors, its early death and therefore the fact that its results were not used, doesn’t allow us to definitely determine its real consequences on the issues that were raised.

This specific tool has however some original characteristics that must be emphasized so that the tool can be positioned among the other healthcare tools of the same type which were developed. So, the tool developed by the federal agency seems to be positioned in a different configuration than those studied by Castel and Dalgalarrondo (2005). Indeed, these authors demonstrated that if the development of evidence-based medicine had significant consequences on the medical area internal relationships, care managers were not ready to use the data collected to control the medical profession. However, unlike the works about the development of evidence-based studies with research purposes and the objective to rationalize practices through the profession itself, the present assessment was aimed at supporting the political decision of external actors.

Replacing the work of the agency into the context of mental health evolution in Belgium and based on its promoters objectives, allows shedding another light on it. By « imposing » a reconfiguration of mental health, its promoters wish to position this kind of tool in « a collective action aimed at change » (Setbon, 2000 : 65, free translation). However, the « powers redistribution » (Ibidem) that this kind of tool can potentially generate in favor of managers and patients is an issue. Indeed, the example developed in this report reveals that even in this case where the assessment is addressing care organization and not therapeutic actions of professionals, the involvement of professionals into the project would be very helpful. On the other hand, the fact that patients and their associations were not very concerned about the assessment is revealing that they could not find their « spokesman » (Callon, 1986) in a study that was intended to represent their interests.