State autonomy, policy paralysis: paradoxes of institutions and culture in the French health care system

In this article, we assess the recent performance of the French state at containing costs in health care using political science concepts such as path dependency and incentives, which are central to an economic approach. The article focuses on institutional capacities and cultural immobilism and attempts to lay bare the tensions at play in seizing (or not) opportunities for structural change. In particular, we attempt to delineate what constitutes real change in this policy arena (big reforms versus the accumulation of many small policy movements) and to understand the variables at play in the coming together of conjunctures that provide for the big, as well as the underlying structures that allow the accumulation of the small. Except in cases of favorable conjuncture, the analysis bodes very ill for nonincremental reform and, indeed, for significant change over the long term.     

Community mental health and prisons: A model for constitutionally adequate care in correctional mental health

The establishment of judicially acceptable standards of mental health care within a prison setting requires the adoption of a service-delivery model and a constant evaluation of that model in relation to individual and civil rights. This article reviews the experience of the department of corrections in one state in developing a constitutionally adequate mental health system. The report outlines the programs established, the legal basis for decisions, and recent constitutional challenges. Future trends in correctional mental health are also discussed.     

Potential legal protection problems in the use of compulsory commitment in mental health care in Norway

Compulsory commitment in mental health care represents a dramatic infringement on an individual's life. In Norway, this deprivation of liberty is based on a professional medical assessment that does not require a court verdict. This article presents possible changes that may increase legal protection for the mentally ill. The concept of legal protection has at least two definitions: the state's protection of the individual's legal rights (including the right to health care) and the protection afforded to citizens from abuse and arbitrary actions by the state. Infringements on personal liberty without consent require such legal authority as is found in the Human Rights Conventions. These Conventions have precedence over national laws. Norwegian legislation is based on confidence in psychiatry as a profession. This confidence allows professionals to treat patients against their will. In some countries, initial court action is necessary before compulsory mental health care can be implemented. This should also be possible in Norway in most cases, with the exception of life-threatening situations.     

Compulsory mental health care in Norway: The treatment criterion

The Norwegian government has chosen to retain a treatment criterion in the Mental Health Care Act despite the opposition of several user organizations. From a critical user perspective, the only reason for using coercion to require mental health treatment is that the individuals are in a state where they are an immediate danger to themselves and/or their surroundings. This articles aims, first, to provide an overview of research studies concerning the benefits or harmfulness of involuntary treatment after coerced admission and, second, to evaluate studies that try to compare involuntary with voluntary treatment. A systematic overview of studies of compulsory mental health care with regard to treatment criteria, coercion in mental health, and involuntary admission published over the last decade was examined in detail, along with a secondary manual search of references cited in identified publications. Few studies have been conducted on the effect of compulsory mental health care, and the results have been contradictory. More randomized studies are needed to document the kinds of effects that the use of compulsory treatment has on treatment results. Another issue that needs further examination is whether the use of coercion should be transferred to legal bodies with an adjudicatory process.     

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. AIM: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. METHOD: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. RESULTS: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. DISCUSSION: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.     

A tale of two cultures: examining patient-centered care in a forensic mental health hospital

Several questions remain unanswered regarding the extent to which the principles and practices of patient-centered care are achievable in the context of a forensic mental health hospital. This study examined patient-centered care from the perspectives of patients and providers in a forensic mental health hospital. Patient-centered care was assessed using several measures of complementary constructs. Interviews were conducted with 30 patients and surveys were completed by 28 service providers in a forensic mental health hospital. Patients and providers shared similar views of the therapeutic milieu and recovery orientation of services; however, providers were more likely to perceive the hospital as being potentially unsafe. Overall, the findings indicated that characteristics of patient-centered care may be found within a forensic mental health hospital. The principles of patient-centered care can be integrated into service delivery in forensic mental health hospitals, though special attention to providers' perceptions of safety is needed.     

Diversion in youth justice: a pilot study of effects on self-reported mental health problems

As part of a larger study to evaluate the effects of a Liaison and Diversion scheme in community youth justice services, staff of newly established Youth Justice Liaison and Diversion (YJLD) teams undertook observational ratings and administered self-report mental health and risk measures to young people referred to this pathway. The overall objectives of the YJLD project were to divert young people from the criminal justice system and to coordinate other services in order to reduce their likelihood of reoffending and the extent of their mental health problems. Data were collected from five local authority areas in different parts of England. Young people thereby referred had an average of 5.4 h of contact with youth justice staff. For a sample of young people on whom data were available at the beginning and end of that process, there was evidence of a significant reduction in problems and a small but significant correlation between the amount of individual contact time with YJLD staff and the extent of change observed. Absence of a comparison sample limits the drawing of firm conclusions; however, recommendations are made for future controlled experimental studies.