Colla Scavenius
Studentnumber 10002612 UvA net ID 6251471 University of Amsterdam Word count: 23.610
University of Amsterdam: master Sociology, track ‘social problems, social policy’ Readers: Loes Jansen Verplanke and Jan Willem Duyvendak.
August 2017 Amsterdam
Policy in everyday professional life
Exploring the experiences of professionals in youth mental health care in the Netherlands.
A macroscopic conceptualization of emotion is possible when not only the experience of emotional feelings, but also the social context in which these arise, is understood as a key element of the emotion itself. Emotion is a social thing, and it is not only formed in but can be conceptualized as a social relationship (Barbalet, 2001: 62).
Table of contents
Foreword 4
Chapter one: Introduction 5
Chapter two: The ‘new’ social context 7
2.1 The Transition 7
2.2 Commodification of care 8
2.3 Citizenship regimes 9
Chapter three: Theoretical framework 11
3.1 Policies 11
3.1.1 Policy translation 11
3.1.2 Logics 12
3.2 Professionals 12
3.2.1 Street-level bureaucrats 13
3.2.2 Feeling rules and framing rules 14
3.2.3 Emotional labour 15
3.3 Coping with policies 16
3.3.1 Different cultures, different policies, different clients 17
3.3.2 Strategies 17
3.3.3 Policy alienation 20
Chapter four: Research 23
4.1 Research questions 23
4.2 Methodology 23
4.3 The interviews 24
4.4 Description of the respondent 25
5.1 Perception and frustration 27
5.1.1 The role of the insurance companies 27
5.1.2 Diagnoses 30
5.1.3 Budget cuts 34
5.1.4 Role of the parents 36
5.1.5 The OKTs 37
5.1.6 One family, one plan, one coach, many participators 41
5.1.7 Clients 44
5.1.8 Pressure to produce 45
5.1.9 Insecurities about the future 50
5.1.10 Right to care? 51
5.2 Coping 52
5.2.1 Strategies 52
5.2.2 Policy alienation 56
Chapter six: Conclusion and reflection 61
6.1 Conclusion 61
6.2 Reflection 63
Foreword
Before you lies my thesis. It has been written for the master Sociology: social problems, social policy.
I would like to thank both of my supervisors, Loes Jansen Verplanke and Jan-Willem Duyvendak, for all the work that they have put into helping me write my thesis.
Especially Loes Jansen Verplanke has been incredibly helpful and patient, and has given me the tools necessary to let me write my thesis in my own way. I would also like to thank both my parents and Casper Siffels, for inspiring me and helping me gather my thoughts. My biggest gratitude goes out to my respondents. I was pleasantly surprised with how open they all were, and how much sociological insights some of them had. I hope that you can read it with the same amount of enjoyment that I had writing it. Colla Scavenius
Chapter one: Introduction
In recent years, there have been a lot of changes in youth mental health care in the Netherlands. The biggest change occurred in 2015. Until then, responsibility for youth mental health care had been in the hands of the national government, and insurance agencies handled the pay out to the mental health organizations. Since 2015,
municipalities are in charge of both the policies governing youth mental health care and also the finances; the amount of care that is purchased for the upcoming year (Hövels, 2015). This change is often referred to as ‘the transition’. The term ‘transition’ is well chosen; Responsibility for policy concerning youth mental health was transferred from politicians at the national level to politicians at the local (municipality) level. And, the execution of the policies was transferred from civil servants at the national level to civil servants at the local level.
I want to write my thesis on how policy affects people working in youth mental health care (jeugd Geestelijke Gezondheidszorg or jeugd GGZ). However, if policies have been stable for a number of years, people are usually not aware how their daily working life is being shaped by policy. Awareness does set in given drastic policy changes, like the transition. This is why the transition offers a unique opportunity to understand how policies affect the daily work of professionals; they are suddenly aware of the (new) policy and the effect it has. The awareness of their subjective experience and the (objective) knowledge of professionals concerning the transition can be accessed through in-depth interviews with these professionals about policy changes.
My focus will be on the experiences that professionals in mental health care for young people and children have with policies surrounding their day-to-day work lives. However, very complicated and dynamic relationships are involved in my research: There is a new, ideologically driven policy (the transition), in which professionals attempt to develop professional attitudes and values to respond to these new policies and they do so in a society in which citizens increasingly are (demanded to be) an active part in their own treatment, therapy, etcetera.
Because of this the main attention of my research will be on how professionals are struggling to develop (new) professional attitudes, values and emotions as they are
confronted with new policies and ‘new’ clients. To catch all this through the eyes of the professionals, the following research steps and social theories will be used. The first step is a sketch of the new social context that the professionals are confronted with; the transition, citizen regimes (the ‘new’ client) and the ongoing marketization of care. These are the main constraints that force the professional to alter their professional work and identity. I will explain the mechanisms that are concerned with this alteration in my theoretical framework. I will discuss theories about how professionals have a measure of flexibility in translating policy into practice (Clarke, Lipsky), the role of logics (Freidson), how emotional labour can be seen as the essential process in inhibiting or developing new professional identities (Hochschild, Kamp), how professionals might develop a certain amount of alienation with respect to policy they do not identify with (Tummers), and how professionals might respond to new policies by developing new work strategies (Tonkens).
In short, I want to see how the policy (and policy changes) from the state trickle down to the everyday lives of the employees of youth mental health care facilities. My main question will be: ‘How do professionals in youth mental health care experience the current policies and the recent policy changes?’
Chapter Two: The ‘new’ social context
There are two main aspects to the new social context confronting the professionals in youth mental health care. At a very concrete level, the new policies of the transition and, also, the ongoing commodification of care. At a more abstract level, how the
professionals are confronted with a new social culture surrounding their work: citizenship regimes. In the following two parts, I will go into more detail concerning these two aspects, I hope it will become clear that in certain ways the concrete and abstract ways are strongly connected and seem to reinforce each other.
2.1 The transition
The main idea behind the transition was that policy-making with respect to care should be closer to the citizen. Simply put: ‘national’ policy is very distant, ‘local’ policy is close to the citizen. This political move to get closer to the citizen is also reflected in the care ideology surrounding the transition. According to Movisie (movisie.nl, 2015), the four main points guiding the new law with respect to youth care all focus on bringing the citizen to the center of care-giving. The citizen is responsible for prevention, for developing their own caring abilities together with their own social network. Other slogans used are ‘demedicalisation’, ‘diminishing care’ (‘ontzorgen’) and ‘normalisation’, in other words, if the citizens (parents and children together) have developed their own responsibility together with their social network, demedicalisation, normalization etc. sets in, and the citizens will not be in need of a professional to solve their own problems. It will become quite obvious that this care ideology is very much part of the citizen regimes that I will discuss in more detail in a couple of pages. On a practical level, to guide the citizens in their process of demedicalisation and normalization, most municipalities chose to use ‘district teams’ (wijkteams) (rijksoverheid.nl, 2017).
This new legislation should prevent parents and young people from getting lost in the system. It should also be more efficient, because it has only one legal framework and one financing system. Integral care is possible in cases with multiple problems, due to the reduction of regulatory and bureaucratic burdens (movisie.nl). The responsibility of youth mental health care went to the municipalities. Financing youth mental health care is now done through the municipality, instead of through insurance agencies. The
municipalities buy-in the amount of care that they think is needed for the upcoming year.
As mentioned, every municipality organizes the accessibility to mental health care in their own way, but most municipalities chose to use ‘district teams’ (wijkteams). The district teams that I will focus on for my research are OKTs (ouder kind teams). On top of those changes, the amount of money that was spent on youth mental health care has decreased since 2015. The professionals that were interviewed for this research are GZ-psychologists (who are BIG-registered1) who work in youth mental health care2. I
interviewed OKT members and specialized youth mental health care providers.
Every OKT must have at least one GZ-psychologist on their team. The GZ-psychologist in the OKT can refer a client to specialized mental health care. Another big change was that the role of the insurance agencies was taken over by the municipalities: the
municipalities were now in charge of the funding of the treatments for children and deciding which treatments are covered. So it is clear what the purpose of the OKT is; the team acts as a filter, they only allow the very serious cases through to the more
expensive specialized professional, most of the time and energy of the team is spent on guiding and helping parents and their children according to the care ideology as
described above.
2.2 Commodification of care
The municipalities have by and large taken over the working framework of
commodification of care that the insurance companies had developed with the care institutions. This commodification of care strongly defines inside what type of borders the professionals have to work. The commodification of care has occurred due to policy changes, according to Tonkens et al. (2013). She found that professionals use different strategies to cope with policies and the commodification of care. I will examine all these strategies in my theoretical framework (in 2.3.1). First I will describe what
commodification of care means, how the commodification of care leads to these strategies and how it is relevant for my research.
1 Beroepen in de Individuele Gezondheidszorg, officially recognized by the government. 2 Both in specialized youth mental health care facilities and within the OKTs.
The commodification of health care in general can entail marketization, greater consumer-orientation or a combination of the two. According to Tonkens, regulated marketization (‘marktwerking’) is central in the Dutch mental health care. Marketization was made possible by marking care as a product through Diagnose Behandeling
Combinaties (DBCs; a standardized amount and type of treatments for certain diagnoses)3 (Tonkens, 2011: 47). Standardization challenges professional identities,
interdisciplinary collaboration and hierarchical relation (Kamp, 2016). A case could be made, that with the privatization of insurance agencies, greater consumer-orientation was implied, due to the competition between the different insurance agencies (and the competition between the various mental health care organizations and facilities). Not only insurance agencies, but also health care providers have to compete with each other for clientele. The goal was to make health care more consumer-friendly, efficient and transparent; a goal which – according to Tonkens (2011) – was not attained. The transition takes the insurance agencies out of the equation for young people in need of mental health care. However, the municipalities took on the role of the insurance agencies, and applied many of the same policies, especially surrounding diagnosis and DBCs. The health care providers are still in competition with each other, because the municipalities buy in all the care for the upcoming year in advance. We see here that the logic of the market still prevails. The municipality adopted the same level of
standardization, which indicates a commodification of care. For professionals, this means that they are not simply giving a diagnosis, but instead they are selling a product (namely, the DBCs).
2.3 Citizenship regimes
Tonkens describes citizenship regimes within this framework as “the institutional arrangements, rules and understandings, and power relations that guide and shape current policy decisions, state expenditures, framing rules, feeling rules and claims-making by citizens.” (2012: 201). The institutional arrangements, rules and
understandings, and power relations should be understood as being both formal and
3 When professionals want to continue treatment after the DBC has run out, they have to
ask for an extension and explain why. We see here that the standardization inhibits the discretionary space of the professionals.
informal (for example norms and values). These citizenship regimes form policy, and they dictate how we think we should feel when implementing policy and when we’re going about our day-to-day tasks. According to Tonkens, we are faced today with an active citizenship regime. This active citizenship regime encourages informal caretakers and volunteers, while professional organizations experience difficulties maintaining funding. This dominant citizenship regime relies heavily on the individual’s own ability to solve his problems, and the ability of the individual’s social network. In the
Netherlands, this is often referred to as the ‘participatiesamenleving’. We now have discerned different sociological processes on three levels: macro-processes of
commercialization and commodification, the active citizenship regime on a meso-level and the micro-level feeling and framing rules.
We see that the new social context (made by policies) is a very dominant component in the experience of the professional. Professionals have to execute these policies. In my theoretical framework we will discuss all the different parts that are involved with the execution of policies.
Chapter three: Theoretical framework
This chapter has three main parts. I want to find out how these policies affect mental health care professionals. In order to fully get a grip on the mechanisms, I must first understand the relevant theories concerning policy in a broader sense. The first part (3.1) is about policy in general and the logics behind the creation of these policies. These logics can also be used to understand the difficulties that professionals face when
enacting the policies. After that - in part two of this chapter (3.2) - I will go into the role of mental health care professionals and their emotions and emotional labour. Then, I will look at how mental health care professionals deal with policies (3.3). I will discuss which strategies they could have developed to cope with the current policies, how feelings of policy alienation develop, and which techniques they could use to deal with or to influence the outcome of policy in their workplace. The three parts of this chapter are policy, the professional, and the different ways in professionals cope with policies.
3.1 Policy
In order to be able to understand how the youth mental health care professionals
experience these policy, we must first get a greater understand of policy in general. I will start with the subject of policy translation.
3.1.1 Policy translation
Social policy can be seen as a way of dealing with a public issue. However, policy is not a static thing. Instead, it’s always under construction; it is always subject to revisions and inflections (Clarke, 2015: 16). When policy moves from the policy-makers to the
professionals who implement it (through the interpretation of the institutions who first explain the new policy to the professional), policy is always translated; it is made to mean something in its new context. Therefore, policy is (almost) never implemented in the exact way that the policy-makers had in mind because policy is not a singular entity: it is put together – or assembled – from a variety of elements that are always in the
process of being reassembled in new ways (Clarke, 2015: 9). This means that policy can have unintended consequences: it can work out differently in practice than policy makers intended to. This becomes especially true if the executers of the policies do things differently than the policy makers expected or wanted them to. A specific way in which this happens is theorized by Lipsky (1980). He wrote about ‘street-level
bureaucrats’ (the people who actually act out policies), who influence how policy is implemented. I will discuss this phenomenon (street-level bureaucracy) more in depth in 3.2.1, because I will discuss the role of the professional in the second section of the theoretical framework (3.2). First I will discuss another topic surrounding mental health care policies: the commodification of care.
3.1.2 Logics
A change that professionals cannot influence in a street-level way, is the fact that there has been a commodification of care. We can now understand how the commodification of care has continued in spite of the transition from insurance companies to
municipalities, and Freidson gives a clear theoretical framework to understand this. He differentiates between three ways of thinking and talking about health care, which he calls the logic of professional, the logic of the bureaucracy and that of the market. The logic of the professional entails looking at policy from the point of view of the
professional, who wants the best type of care for their clients. The logic of the bureaucracy uses an approach where bureaucratization is central. The logic of the market involves using the mechanics of the market onto health care policies. The logics have not changed, only the agents have (from national government to local
government). The logic of the market is just as prevalent. This is illustrated by the encouragement of competition between health care organizations and health care professionals, and the usage of DBCs. According to Freidson (2001), the logics of bureaucratization and marketization are overpowering the logic of the professional (Tonkens 2009b, Duyvendak 2006). I argue that the same process can be found in the new policies, especially when we consider the usage of the DBCs; a standardization in order to adapt to a competitive market environment. The commodification of care can thus still be found when examining youth mental health care policies.
Having dealt with the concept of policy and commodification of health care, I will now take a closer look at the role of the professionals. We saw that standardization and the commodification of care can make it difficult for professionals to translate policy and to enact their role as street-level bureaucrats. Standardization can thus endanger
professional identity. In order to understand the experience of these mental health care professionals, we must first understand the sociological mechanisms that they are subjected to. First I will discuss their role as street-level bureaucrats a bit further, and then I will discuss the emotional aspects of their work.
3.2.1 Street-level bureaucrats
As mentioned, these youth mental health care professionals can be seen as ‘street-level bureaucrats’; they have to interpret a policy and translate it in order to apply it to their day-to-day tasks and interactions with clients. According to Lipsky (1980), the policy-implementing role of a street-level bureaucrat is built upon two interrelated parts of his or her position. The first is a relatively high degree of discretion in determining the nature, amount and quality of benefits and sanctions provided by their agencies. The second is the relative autonomy from organized authority, which means they have room to implement policy in different ways (including different ways than intended by the policy-makers) (Lipsky, 1980). Discretion and autonomy impact how an employee feels about his or her work. Discretion and autonomy also affect how the employee feels about the level of influence he perceives to have. This determines how important they feel they are. Lipsky identifies three factors that shape street-level bureaucrats’
experience of discretion: (1) the degree of freedom given to them by the agency that is necessary to be able to do the job, (2) the unclear ways policy is formulated, which means the street-level bureaucrats have to make their own decisions regarding
implementation and (3) the ability of street-level bureaucrats to subvert policy (Evans, 2004). The amount of discretion professionals think they have, affects which of the strategies (Tonkens et al. 2013) the professionals choose to apply when coping with policies. I will elaborate on this process in 2.3.2.
Lipsky wrote his book on street-level bureaucrats in the 1980’s. A lot has changed since then. New management systems have used standardization and created more rules and more bureaucracy that requires professionals to show that they have achieved
particular targets. This leads to less discretion and less autonomy (Taylor, 2006).
However, according to Evans, greater elaboration of rules and guidelines can make them more unclear and uncertain, which would lead to more discretion of the second factor (Evans, 2004). Some professionals might enjoy being able to follow specific rules (for example because standardization and bureaucracy gives them less responsibility when something goes wrong) while others might feel imprisoned by the same rules; emotion plays a big part in how policy is experienced4. There has been an increasing amount of
media attention focused on the waiting lists and the time that mental health care professionals have to spend on administration. We now understand how they
implement policies and how the level of autonomy and discretion affect them, but to be able to fully understand their experience, we must also discuss feeling and framing rules. Following the logic of the market has decreased the discretionary space of the youth mental health care professionals. The commodification of care (driven by the logic of the market) has lead to standardization, which constrains the ways in which street-level bureaucrats can exert their power. We see here that policy instructs professionals how to act, and – depending on the amount of discretionary space they have -
professionals can alter the outcome of policy. This whole process impacts the emotional state of the professional. We will now discuss how emotions play a big part in this process.
3.2.2 Feeling rules and framing rules
Feelings are an important part of everyday life, and people manage these feelings in various different ways. They actively construct and reconstruct their own emotions. However, emotions are always embedded in a social environment. An environment can dictate which emotions we should feel: there are certain rules about feelings. According to Hochschild, “Feeling rules define what we imagine we should and shouldn’t feel and would like to feel over a range of circumstances” (2003: 82).
Ideas about what good care entails, bring their own framing rules and feeling rules with it. What are these rules? How should an employee at a youth mental health organisation feel about his or her work? Feeling rules can be seen as guidelines for the assessment of
4 The experience depends on which logic the professional believes in, as we saw with the
fits and misfits between feeling and situation; the difference between what we can expect to feel in a given situation and how we should feel in that situation. Framing rules are described as rules according to which we ascribe definitions or meanings to
situations (Hochschild, 1979: 566). An example of a framing rule can be that a first line mental health care professional tries to solve as many problems by himself or herself, and the corresponding feeling rule would then be to be happy if you haven’t given any referrals. Hochschild uses these constructs to highlight the social (re)construction as well as the social and moral complexity of emotions. She writes: “We do not simply feel, we think about our feelings, both individually and collectively. The way we think about them also influences our feelings. We experience feelings in tango with feeling rules, the social guidelines that direct how we want to try to feel” (Hochschild, 2003: 97).
A feeling rule creates an area within which one has permission to be free of worry, guilt or shame with regards to certain situated feelings (Hochschild, 2003: 98). However, if there are conflicting emotional demands, employees will actively try to reconcile their conflicting emotions (Tonkens, 2012). A change in the relation of a feeling rule to a feeling itself and a lack of clarity about what the rule actually is, leads to conflicts and contradictions between contending sets of rules (Hochschild, 1979). Hochschild
combines macro-processes of commercialization and commodification with micro-level feeling and framing rules. In order to better understand and apply these concepts, Tonkens (2012) added a meso-level step: citizenship regimes. All these sociological mechanisms affect the ability of professionals to be the professional that they want to be, and thus influence the emotions of the professional in different ways. Below, I will describe in which way emotions are a vital part of the work of mental health care
professionals, and I will combine this with the sociological theories on Freidsons logics.
3.2.3 Emotional labour
Hochschild has written a lot about the emotional labour of stewardesses. The feeling and framing rules are at the basis of emotional labour. With stewardesses, emotional work is part of your job in an external way (e.g. smiling at costumers). With mental health care professionals, emotional work is part of your job in an internal way (Kamp, 2016). Experience is always defined and interpreted by emotion. Regulating emotions was explicitly part of the policies that stewardesses had to adhere to. Regulating emotions is
a big part of the work of mental health care professionals, but is (to my knowledge) never explicitly mentioned in the policies. However, regulating emotions is incredibly important for a professional’s identity and is needed in order to be able to be the professional that that person wants to be. According to Nancy Chodorow, emotions at work must be understood as cultural mediations between an internal reality and an external social reality (Chodorow 1999). Theodosius (2008), whose work particularly concerns emotional labour in healthcare, argues that emotions in the context of work and organizations are culturalized. She discusses how professionals develop emotional rules and scripts as part of establishing professional identities. Health care professionals carry out emotional labour in order to support the execution of tasks, such as setting diagnoses or giving treatment. She also discusses the emotional labour involved in dealing with colleagues. Kamp describes how the emotional labour of mental health care professionals becomes even more invisible due to standardization (Kamp, 2016). This can be interpreted as a clash of logics.
As mentioned earlier, Freidson (2001) describes a conflict of different cultures or logics; that of the professional, that of the bureaucracy and that of the market. These logics all have their own set of feeling rules and framing rules Tonkens (2009b). We already saw how Lipsky’s ideas on autonomy and discretion are connected with feelings and
emotions, and the different logics that they are subjected to. Sambeek, Tonkens and Bröer (2011) suggest that these three types of logics are so different from each other that they are not compatible and that this can lead to frustration and difficult dilemmas for the professional. They also found that professionals are made more conscious of the financial situation of their organization and the way they could improve it. However, this knowledge could also have an opposite effect; they can strategically use their knowledge of a system to be able to give a client a more extensive therapy that is reimbursed for a longer time, which they would not have done otherwise (Sambeek et al, 2011). Here we also find their influence as street-level bureaucrats: they are actively interacting with the policy. The way in which they do this and how they feel about it, is dependent on which logics they adhere to. In the last part of this chapter, we will look even more closely on how policy and professionals interact and we will discuss how professionals cope with the emotional aspect of these clashes of logics.
3.3 Coping with policy
In this part of my theoretical framework, we will discuss ways in which professionals can cope with policies. First I will describe Tonkens’ strategies. Which strategies they use is influenced by the amount of discretion and autonomy that they think that they have. This choice is also dependent on which logics they feel comfortable with. After that I will describe what happens if they can’t cope; they experience policy alienation. I will discuss how this occurs and what can be done about it. Before I go into these ways of coping and not coping with policy, it is essential to show how the discussed policy changes affect the day-to-day lives of youth mental health care professionals.
3.3.1 Different cultures, different policies, different clients
As we already saw, culturally and policy-wise, there has been an increasing focus on citizenship participation and the strength of the individual (Tonkens, 2009a). This notion of the participation society is parallel to the changes for the youth mental health care professionals, and it influences the policies surrounding the transition and the way these policies are implemented. An active citizenship regime means a focus on self-reliance. This can have the effect that clients get referred to specialized mental health care professionals much later than they did before, or in a different state of mind than before, since they (were) expected to solve their problems by themselves or at least without specialized care, which is no longer a right due to the recent policy changes. Getting treatment later can worsen the state that they are in when they arrive at the mental health care professional’s office. On top of that, pre-purchasing specialized health care can lead to a situation where someone who gets molested in January might receive better care than someone who gets molested in August, because the municipality has bought-in a limited amount of DBCs for the entire year. It can be argued that these changes transformed the role (or at least the experiences) of the youth mental health care professional. The active citizenship regime (participation society) will not be a central part of my thesis, but you can find traces of this idea throughout my writing.
3.3.2 Strategies
We already saw that the street-level bureaucrats can experience policies differently based on which logics they adhere to. We also saw that the amount of discretion they believe they have influences how they feel about policies. Tonkens (2013) writes about
different ways that professionals cope with commodification and policy. The five strategies that Tonkens et al. described are entrepreneurialism, activism, pretending, bureaucratization and performance. These strategies are ways in which mental health care professionals cope with policy.
A professional that uses the first strategy, entrepreneurial professionalism, uses the policies to gain profit, to diversify his/her work and to find new sources of recognition. An entrepreneurial professional is generally more concerned with efficiency,
competition and patient-friendly behaviour. This strategy is inspired by both the market logic and the professional logic. Many professionals are critical of the policies that led them to their entrepreneurial strategy, but feel forced to adopt these entrepreneurial styles of professionalism. Tonkens et al. (2013) call this ‘involuntary
entrepreneurialism’. Within my research, this applies to the specialized youth mental health care professionals who have decided that they were not going to participate with the municipalities, but instead only take on clients who can pay for their treatment out of their own pocket. This strategy is fitting with the logic of marketization.
The second strategy is called activism. A professional that follows this strategy openly challenges certain policies and is opposed to the goals and values that underlie these policies. This professional uses the traditional professional logic and defends
professional autonomy and discretionary space. An activist can refuse to do certain obligatory procedures and often tries to influence public opinion. Sometimes they legally challenge policies. According to Tonkens et al. (2013), psychoanalytic activism is especially concerned about the autonomy of the professional and the privacy of the client. This strategy comes about by the logic of the professional.
The third strategy is pretending; pretending to work by the rules, while secretly
following your own rules in order to protect the quality of your work. Professionals who use this strategy solve policy-related problems individually and covertly. Pretenders distinguish between their real work and how they report their work to insurers, in order to protect their professional discretion and the interests of their client. They view the insurance companies as driven exclusively by financial interests. They are driven by all three logics: they distrust the insurance company due to market logic, they formally go
along with the policies due to logic of the bureaucracy but they decide to secretly do things differently due to the professional logic. They present this strategy as a form of resistance instead of fraud. The system’s shortcomings remain invisible within this strategy. A very clear way of ‘pretending’ is “being creative with diagnoses” in order to give a client better or more affordable treatment (even after the budget of certain DBCs is already reached). This strategy adheres to the logic of the professional.
The fourth strategy is called bureaucratization. Bureaucracy is used to reduce risks and to secure the professional’s position. Safety and security are seen as more important than autonomy by the professionals who employ this strategy. They feel that the assertiveness of clients and the state limits their autonomy, and bureaucracy is used to protect them from such assertiveness (e.g. law suits) and to justify their actions. I expect that I will find this strategy more often be found with people who have just started working in specialized mental health care, because they are more insecure about their own assessment of a situation. This strategy is associated with the logic of the
bureaucracy.
The last strategy is performance. Performance is a way of ‘doing professionalism’. This can occur when professionals are uncertain about their front stage behaviour. When they feel watched and evaluated, they adjust their conduct accordingly. They try to appear professional in the eyes of the other. This often happens when professionals don’t (feel like they) have a back stage. There is a pressure to perform, and the ‘output’ of care is partly judged by criteria that are not defined by the professionals themselves or other professionals. On top of that, patients frequently challenge the decisions of professionals (and are encouraged to do so by the active citizenship regime). Tonkens (2013) describes how ambulance personnel sometimes runs faster to a victim to reassure the crowd, even if they think (in their professional opinion) that running is unnecessary. An example in specialized mental health care could be that a client was given ten therapy sessions by their insurance, and the professional gives the client all ten, even if their professional opinion is that eight would be more than enough. Since the time of specialized mental health care professionals is very carefully monitored (and they only see their clients when they are scheduled), this will probably only happen within the OKTs.
I want to find out if these strategies can be recognized within BIG-registered youth mental health care professionals. As mentioned, there could be more strategies to cope with policy. However, ‘not coping’ should also be taken into account. If professionals experience a clash of logics, and are not content with any of the alternative ways to deal with it, they can experience policy alienation. Policy alienation can be understood as a way to ‘not cope’ with policies.
3.3.3 Policy alienation
The concept of policy alienation originates from Karl Marx’ work alienation. He focused on objective work alienation: workers are alienated when they do not own the means of production of the resulting project. Later sociologists (like Blauner, 1964) focussed on subjective work alienation: alienation as perceived by the worker. Tummers (2009) linked this concept to policy. He defines policy alienation as ‘a general cognitive state of psychological disconnection from the policy programme being implemented, here by a public professional who regularly interacts directly with clients’ (Tummers, 2009: 688). His theory of policy alienation is focussed on the public, it considers professionals (instead of manual workers), and it looks at alienation from the policy being
implemented instead of the job being done. So how does policy relate to the people who have to implement it?
Policy involves social processes that are intertwined with people’s lives (Clarke, 2015). People create a relationship with a policy, which means that they structure their own behaviour, discourse and ideas to the way a policy is formulated (Sambeek, 2011: 62). Public professionals can also have trouble identifying with policy programmes they have to implement, especially when they have to consider several output performance norms that conflict with their own professional standards or with the demands of increasingly empowered clients.
The first dimension of alienation is powerlessness. According to Tummers, powerless workers feel like they are objects that are being controlled and manipulated by others or by an impersonal system. When it comes to policy making and implementation,
have) in shaping the policy programme they have to implement (Tummers, 2009). Tummer describes three types of levels (strategic, tactical and operational) in which feelings of powerlessness can take place. Powerlessness on the strategic level refers to the inability to influence general managerial policies, powerlessness on a tactical level refers to a lack of control over employment conditions, and powerlessness on an operational level is about the lack of control over the immediate work process. The second dimension of alienation is meaninglessness. Meaninglessness refers to a professional’s perception of the contribution the policy has to a greater purpose. Meaninglessness can also occur at the strategic, tactical and operational levels. At the strategic level, meaninglessness refers to a professional’s perception that policy is not actually dealing with specific societal problems. At the tactical level, meaninglessness reflects the professional’s perception of their own contribution to societal goals. At the operational level, meaninglessness refers to the professionals’ perceptions of their own contributions to concrete, individual cases as manifestations of broader societal
problems. Do they feel like they are really helping people? If this is not the case, they will probably experience policy meaninglessness, according to Tummers.
Tummers describes isolation as role conflicts. He writes about two types of role conflicts, which contribute to feelings of policy alienation; institutional-client conflict and organizational-professional conflict. This relates to the three different logics of Freidson (2001), which were also used by Tonkens (2009b) (market, bureaucracy and professional). According to Tummers (2009), the first role conflict (institutional-client conflict) emerges from the tension between the rules of the organization (which can be seen as driven by bureaucratic logic and/or market logic) and the demands of the clients (which can be related to the logic of the professional). The professional is often the one blamed by the client for the decisions of the organization. A second role conflict emerges from the tension between managerial demands, which focuses on output and getting the work done as efficiently as possible, and the professional norms. These theories suggest a clear conflict: the market logic and bureaucratic logic versus the logic of the
professional. Asking about role conflicts will help me to determine if a professional is experiencing policy alienation, but role conflict can also exist without feelings of policy alienation. The main question here is: Can the professional be the kind of professional
that (s)he wants to be? In other words, what is the experience of the professional? This brings us to my research questions, which are formulated in the next chapter.
Chapter four: Research
In this chapter I will expand on my research questions, discuss my methodology and introduce my respondents.
4.1 Research questions
The goal of this research is to find out how the professionals experience the (new) policies and how they deal with the current situation after the transition. I want to find out which strategies they use to cope (or not cope) with the new policies, and I am interested in the emotional labour concerning these policies and strategies. Therefore, my main question is:
‘What is the experience of GZ-psychologists in youth mental health care with respect to the transition?’
My subquestions are:
1. How do professionals in youth mental health care perceive the current policies and the recent policy changes?
2. Do they encounter problems related to the current policies, and if so, what kind of problems?
3. Can we identify clashes of logics (Freidson, 2001)?
4. Which strategy/strategies do they use? (What kind of discretionary space do they have and do they implement the policies in different ways? How do they feel about it?)
5. Do they experience forms of policy alienation (and if so, to what extent)?
Before we can answer these questions, we must first take a look at the methodology.
4.2 Methodology
I have used a symbolic interactionist framework, because the interviews I will be conducting will be done using a constructivistic approach. I want to find out which strategies my respondents use to deal with the current policies, and I want to learn how they view colleagues with different strategies. I will keep in mind that the accounts are part of the world they describe (Silverman, 2001). For this reason, I will do qualitative research. I will conduct semi-structured in-depths interviews. This means that I will use
an interview guide, to make sure I cover the same questions and topics with each
interviewee. I will be able to be flexible and go more in depth when a respondent has an interesting reply or an unexpected point of view. I will make sure that I am familiar with the setting in which the interviewee works and I will also ask for ‘facesheet’ information in order to provide a context to the answers that people give me (Bryman, 2008). While analyzing, I will try to paint a clear picture of their experience, and I will keep in mind that I am taking a constructivistic approach. My outcome will not be representative for people working in the GGZ. I have used a snowball method to get in contact with (possible) respondents. I have included people who have quit their job at a specialized youth mental health care facility in the last year. I hoped that this would help provide me with a clear picture of the processes that people go through when dealing with policy, policy changes and policy implementation in the GGZ.
I used roughly the same topic list with all the respondents, and I will give a clear picture of how I analyzed and interpreted the data, which will ensure transferability. I have made notes of any changes that occurred in the setting and how these changes could affect the way a respondent approaches the study. This way, I made my research dependable (Bryman, 2008).
Specialized mental health care professionals have experienced less ‘demystification’ within their profession than other health care providers (Tonkens, 2013). I hope that this will give me a clearer picture of the amount of discretion the mental health professionals’ experience.
4.3 The interviews
In the beginning it was very difficult to find respondents. Almost everyone told me that they were too busy. I think that this has to do with the workload that most
GZ-psychologists experience (which will be discussed later). I often had to send several e-mails before we could find a date, and it often took several weeks before they could fit me in.
In the end, I was able to interview 11 different people. As mentioned, everyone I interviewed is a BIG-registered GZ-psychologist who works with children.
Unfortunately, two were only able to talk on the phone. Respondent #5 was cycling the entire 40 minutes that we spoke, and respondent #11 suddenly had a small time frame in between meetings. I noticed that these interviews were less long and less in-depth than my other interviews. However, due to the busy schedule of my respondents, this was the only way that I was able to do an interview.
I made it clear to my respondents that my goal is not to change policies and that I am not in the position to do so; I am simply interested in their experiences. I am hoping that stressing this will eliminate politically correct answers or strategic answers (for example, exaggerating a financial shortage). I will try my best to make sure that they (and the institution they work for) are kept anonymous. I hope that this will compel them to be honest with me, which ensures credibility.
4.4 Description of the respondents
All my respondents had a different story, and a different background. I used a snowball method, which means that some of my respondents knew each other. My first
supervisor and I are the only ones who have access to the entire interviews, and we are the only ones who know the names of all my respondents. Because I used a snowball method, there is a slight chance that one respondent might be able to recognize another respondent, but I have tried to minimize the chance of this happening. When it’s
necessary to understand a quote, I will of course give a short description of the
respondent. I decided not to share which specific respondent I’m referring to when I had to go in-depth, in order to ensure anonymity. The numbers my respondents were
assigned are not necessarily in any type of order. Because some of their stories are so distinct, I will not go into detail about either of my respondents. However, I can describe the respondents as a group.
As mentioned, all of my respondents are GZ-psychologists except for one respondent who is in training to be a GZ-psychologist.This means that she works four days a week as a GZ-psychologist (but has to get a lower production percentage than the rest), and is in training for one day a week. Unfortunately, her training was in a different municipality than the municipality of the other respondents, but she did work in a specialized mental health care institution in the municipality of my other respondents during the transition.
All work or have worked in specialized youth mental health care, including the OKT members. Of my eleven respondents, two worked full-time in an OKT, and one worked part-time in an OKT and part-time as a specialized youth mental health care
professional.
Five of my respondents were in their 30s, one was late 20s, two were between 40 and 50, and three were 60 years or older. Four respondents worked at the same
organization and two had started their own practice. One respondent used to work as a head of treatment (‘hoofdbehandelaar’5), then asked to continue working at the same
organization but without the extra title, and after a while this person went to work at an OKT. Three of my respondents were head of treatment during the interview.
Chapter five: analysis
I’ve compartmentalized the analysis into two main sections: First, my respondent’s perception and frustration with the policies, and second, their coping strategies. I will keep a semi-chronological order when discussing these topics: at the beginning of this chapter I will discuss how the policies before the transition influence the way it is now, and what that means for the GZ-psychologists, and I will end 5.1 with the influence that their ideas about the future have on their lives. In the second part of this chapter (5.2) I will describe the way they cope (or don’t cope) with the current policies, using Tonkens’ strategies and Tummers’ concept of policy alienation.
5.1 Perception and frustration
In this part of the chapter, I will describe their perception of the policies, why they think that the policies have come about, and their experiences with the policies. I will describe their experiences with the three main changes that happened with the transition. The three main changes are (1) the professionals in youth mental health care no longer had to deal with the insurance companies, but instead with the municipality, (2) the fact that the municipality buys in the care for the upcoming year and (3) the introduction of the OKT teams.
5.1.1 The role of the insurance companies
Before the transition the insurance companies covered the treatment directly. They would be heavily involved with the treatment, which raised privacy concerns. This meant that insurance agencies were heavily involved with the treatment itself, which decreased the discretionary space of the professionals. Because of this, the professional was not free to give the treatment the way that they wanted to. This can be interpreted as a clash between the logic of the professional and the logic of the market. The biggest problems that were mentioned by my respondents concerning the insurance companies were these privacy concerns and the power the insurance companies had over the diagnoses. In this section, I will first focus on the similarities and the differences between the municipalities and the insurance companies, and how they affect privacy and the diagnoses that are being made.
When asked about privacy concerns, a lot of respondents first started talking about the insurance companies. The insurance companies have no direct interference in the youth mental health care since 2015, but the policies the insurance companies had made before 2015 still have a lingering effect in the experience of the respondents. The following respondent talks about the way that the insurance companies used to work with specialized youth mental health care (and how it still works for clients over 18): “Nu [voor mensen boven de 18, maar voor 2015 ook voor mensen onder de 18] is het eigenlijk zo dat de zorgverzekeraar een overeenkomst sluit met de hulpverlener, en dat de cliënt daar een hele gekke positie in krijgt. Want die denkt ‘ik heb een goede polis’, maar toch zijn er allerlei afspraken over dat trajecten maximaal zo lang mogen duren, of wel of niet die vorm van interventie mogen bevatten […][ik vind]die hele inmenging van die zorgverzekeraars met het hulpaanbod heel ongewenst.” (Respondent # 6)
All my respondents had ideological problems with the insurance companies. The biggest concern of my respondents with regards to the insurance companies was the invasion of privacy. Due to the system of the DBC’s (Diagnose Behandeling Combinatie), insurance companies knew exactly which treatment a person was getting, and they demanded access into the personal files of clients. One respondent described how agents of the insurance companies came in and demanded to sit behind the respondent’s computer, look into all the files, and ask questions about everyone. If they didn’t agree to this, the insurance companies would cut the funding for the organization. This also meant that management would question every extension of a DBC, in fear that the funding would be cut if the insurance agencies did not agree with the extension. This clearly shows that it is difficult to determine who is to blame, which can create a feeling of powerlessness. The logic of the market is pushed upon the professional by the management, who are in turn pushed to follow this logic by the insurance companies (which is made possible by the national governmental policies of the DBC). This disturbs the ability of professionals to follow the logic of the professionals, and it infringes on the autonomy and
discretionary space of the professionals.
Respondents complained that (management and) the insurance companies should not be concerned with the substance of the treatments, due to privacy concerns. This got so bad that one organization decided that they could no longer allow patients of certain insurance companies because of the immense invasion of privacy:
“Maar op een gegeven moment wilden ze [verzekeringsmaatschappijen] toch iets meer over de inhoud van de behandeling weten, en toen heeft [organisatie] gezegd, we nemen
gewoon geen klanten meer aan van [enkele specifieke verzekeringsorganisaties] […]toen hebben we gezegd we nemen die klanten niet meer aan, en als je zorg wil, en wij
weigeren je dus, meld je maar aan bij het zorgloket, maar dat vond ik toen wel heel goed van [organisatie], dat de privacy van de cliënt ook echt heel belangrijk is.” (Respondent # 2)
This respondent was happy that her organization denied children with certain insurance companies care, because that was the only way that she could ensure that the privacy of her clients was being secured. We see here that the policies based on making care affordable and accessible, sometimes end up denying certain people their right to care. We clearly see a clash of the logic of the market with the logic of the professional. The logic of the market needs to check if treatment is covered, and therefore they invade the privacy of the client. The logic of the professional wants to protect the privacy of the client.
We also find a clash within the logic of the professional itself. Following the logic of the professional can go one of two ways: denying care can be seen as a good thing because the privacy of all of their clients is being secured, or it can be seen as a bad thing because some children don’t get any care. An important aspect of the logic of the professional is guaranteeing the privacy of the clients, but this leads to denying care to certain clients because the policies surrounding privacy are being applied within the framework of other (more dominant, according to Freidson) logics. This situation has been made possible by bureaucratization, which dictates that everything should be written down and accounted for6. Nobody (under 18) gets excluded based on their choice of insurance
company since the transition to the municipalities in 2015.
The respondents who work within an organization prefer to deal with the municipality7
instead of the insurance companies:
“Het is wel makkelijker geworden qua vergoedingen, dus dat de gemeente 100% betaalt. En de gemeente is tot nu toe in ieder geval iets minder moeilijk met betalen […] met dossiercontroles enzo, dat heb je ook niet. […] tot nu toe nog niet, geloof ik. Ik merk er nog niks van in ieder geval. […] Tot nu toe is de gemeente vrij coulant, hoor.”
(Respondent # 5)
6 This should ensure fair and equal care, but we see here that it can have an opposite
effect.
We see here, that this respondent seems insecure about the future (‘tot nu toe nog niet’). At first glance, it seems like the right to specialized care seems to be the same for every person under 18, since it is no longer based on where a client is insured. We will come back to this later. The fact that insurance companies do not have direct access to the files does not alleviate the privacy concerns. The following respondent addresses his
uneasiness with the depth of the knowledge some people at the municipality have about his clients:
“Wat wel nieuw is, is dat de gemeente wel vaker druk uitoefent dat ze iets willen weten, of dat zij dingen weten over een jongere, terwijl je denkt, ja een gemeente zou dat niet hoeven weten. […] bijvoorbeeld dat er dan een gemeenteambtenaar met toenaam en naam precies een jongen weet, en wat er aan de hand is, en binnen het gezin, en noem maar op, terwijl je denkt van ja dat moet niet mogen. Want daar hebben ze [de cliënten] helemaal geen toestemming voor gegeven. En dat zie je natuurlijk wel gebeuren, dus dat […] die ambtenarij vinden dat ze het recht hebben om ook alles te weten, terwijl jij denkt van, ja waarom eigenlijk?” (Respondent # 3)
We see here that the privacy of a client can also be invaded by the municipality. This could be seen as a lingering effect of the system that the insurance companies had put into place. We also find the influence of the policies the insurance companies used to have when we’re discussing diagnoses. Deciding which diagnoses would be covered is another role that used to be filled by the insurance companies, but is now done by the municipalities. This is another example of how the policies of the insurance companies still have an effect.
5.1.2 Diagnoses
An important role of the insurance companies was how they used their powers to redefine one of the professionals’ core work instruments: the use of diagnoses. The system of the DBCs means that a diagnosis needs to be made during the first meeting with a new client. A lot of respondents expressed concern about this; it can be difficult to get a grasp on all the problems that are going on, and a client often only starts opening up after a couple of meetings. This can have an impact on how the mental health care professional can function:
“[…] dat je vindt dat je hem [diagnose] snel moet stellen, terwijl je eigenlijk vindt dat het wel heftig is om iemand een sociale persoonlijkheidsstoornis te geven, terwijl je denkt, ja zo goed ken ik hem nog niet. Maar vaak moet je wel een diagnose hebben om verder te kunnen. Dat is soms gewoon, wat niet goed voelt als hulpverlener.” (Respondent # 3)
Here the professional is clearly concerned with how their professional autonomy in making a diagnosis is undermined, thus undermining their discretionary space and professional identity; ‘it does not feel good’. Another problem with setting a diagnosis can also be traced back to the insurance companies. What a certain diagnosis entails, was also decided by the insurance companies, and can have a big effect on treatment:
“Als het economisch slecht gaat, dan gaat het IQ voor bijvoorbeeld verstandelijk beperkten gaat naar beneden. Waarom? Dan vallen er minder mensen onder waar speciale zorg voor nodig is.” (Respondent # 1)
The insurance companies decided when a certain diagnosis can be given. On top of that, they could also change which diagnoses were covered. A lot of my respondents
complained that the insurance companies decided a couple of years ago that they would no longer cover ‘aanpassingsstoornis’, ‘ouder-kind relatie probleem’ and
‘hechtingsstoornis’. These are all relatively low impact diagnoses, and they are often temporary (unlike, for example, the diagnosis of autism). According to my respondents, children with these same problems would often get a ‘heavier’ diagnosis after these ‘mild’ diagnoses were no longer covered. Most professionals expressed that they were not satisfied with the diagnoses that they could give (both before and after the
transition). They described pressure from management to only give diagnoses that are covered. Management would send around a list containing the diagnoses that weren’t covered anymore, “En dan word je dus eigenlijk wel verzocht om je diagnose zo te maken dat die wel in de vergoeding komt“ (respondent #4). The respondents realize that they are being overpowered by the logic of the market
“En dat het [wat wel en niet vergoed wordt] willekeurig wordt heeft toch ook te maken met de marktwerking. En met een waanzinnige behoefte aan controle op wat de mensen doen.” (Respondent # 1)
The professionals have to develop a diagnosis that’s part of a DBC, and are therefore ‘selling’ a care product. Obviously, this is a major invasion of the professional autonomy, and of the professional emotional labour involved.
A diagnosis determines how the treatment is done, and it can affect the child’s
perception of himself. A label can be something that a child carries with him for the rest of his life. The diagnosis also determines how the professional has to do the treatment. The following respondent shows how her autonomy is affected by setting certain diagnoses.
“Nou ik denk wel, als die diagnose [ouder-kind relatieproblemen] betaald zou worden bijvoorbeeld, zou je wel een stuk minder autisten hebben, eigenlijk. […] we zien ook wel dat het met die ouders niet helemaal klopt […], ouder-kind relatieprobleem krijgen we
niet vergoed, dus we doen maar PDD-NOS8. En dan ga je wel vervolgens in je
behandeling, ga je dus […] aansturen alsof het autisme is. Dus ga je autisme protocollen opdoen, ga je ouderbegeleiding vanuit een autisme afdeling doen waarbij je dus een heel ander perspectief krijgt. En ik, wat ik het kwalijkst daaraan vind, is dat je kinderen gaat aanspreken [als autistisch] […] ja dat is wel voor de beleving van het kind is dat een heel groot verschil. […] Maar goed, ja, wat ik al zei, het is gewoon geaccepteerd dat we dat zo doen.” (Respondent # 8)
We see here how consequential this redefinition of the professionals’ use of diagnoses is for the whole treatment trajectory of the child. Following the logic of the professional means helping the child in the best way possible. If this professional wants to help a child with autism-like symptoms which in the professionals opinion is caused by ‘ouder-kind relatieproblemen’, she needs to give the child a diagnosis of autism. Following the logic of the market and the logic of the bureaucracy, a child with a diagnosis of autism gets a specific type of treatment (DBC), which decides how the professional can help the child (“dan ga je dus aansturen alsof het autisme is. Dus dan ga je autisme protocollen doen”).
We also find Hochschilds framing and feeling rules; “wat ik het kwalijkst daaraan vind, is dat je kinderen gaat aanspreken [als autistisch]”, versus “het is gewoon geaccepteerd dat we dat zo doen”.Treating the child differently, and knowing that this has a big effect on the child (“voor de beleving van het kind is dat een heel groot verschil”), means that this respondent is doing emotional labour due to the difference in framing and feeling rules. The respondent is not able to be the professional that she wants to be, because she can’t give the treatment that she finds more fitting. This is another way in which
standardization reduces the professional autonomy, intrudes on the professional identity and makes the emotional labour more invisible (Kamp, 2016).
Setting these diagnoses does not only influence the treatment trajectory, but it can also influence a child’s future in different ways:
“[…] [Pragmatisten zeggen] ‘ja, nou, dan noem ik ze maar allemaal posttraumatische stress, want dan wordt het ten minste vergoed.’ Maar het is wel vervelend voor die kinderen, want je zou maar posttraumatische stress [als diagnose krijgen, dan] kan je later geen piloot worden. Dus het heeft best wel veel consequenties.” (Respondent # 1)
Many professionals felt insecure about the future ramifications of setting certain
diagnoses. Some respondents said that they could not say with certainty how diagnoses will affect a child’s future, for example:
“[…] [Ik vind] dat je het allemaal wel moet weten, maar niemand weet hoe het zit. Net als dat ouders nog steeds vragen, ja, zo’n diagnose autisme, kan het later mijn kind in de weg staan als hij later een huis wil kopen? Dat weet ik nog steeds niet. En ik zit al weet ik hoe veel jaar in het vak hier.” (Respondent #2)
Not knowing how a diagnosis will influence the future, makes it difficult for a
professional to be the professional that (s)he wants to be; “ik vind dat je het allemaal wel moet weten, maar niemand weet hoe het zit”.
When the municipalities took over, these concerns were not addressed. They did not make any clear promises about how certain diagnoses would affect a client the future. We will talk more extensively about these insecurities about what the future will bring in 5.1.9.
The municipality where this research was conducted decided to cover (and not cover) the same diagnoses as the insurance companies, and still uses the same system of the DBCs. However, decentralization does have its upsides according. A respondent who works with delinquent children told me that the municipality does learn better and quicker than the national government and insurance agencies used to, concerning the top (youth) delinquents in Amsterdam. One could argue that due to the size of the municipality, it is better able to keep an overview of this group and its specific mental health care needs than the national government would be able to for the top criminals of every city and town combined.9 Decentralization seems to make the work of this
9 Given my limited research data, it is unclear how big a role this has had in influencing
the municipalities’ overall approach to their mental health sector, but it does exemplify how a municipality can use their newly-won power in influencing the mental health care sector in a way to pursue their own general policy aims - not necessarily in the interest of the aims of the mental health care of the child. Ethically, this raises questions on whether or not it is desirable if the people who are responsible for fighting crime have personal data on the home situation of a delinquent child. We will not discuss these issues in this thesis.
respondent more meaningful because his work has a larger impact and it’s easier to influence policy makers.
5.1.3 Budget cuts
So far I have argued that the system before the transition has a lingering effect on the day-to-day lives of these professionals. Before we go further into the situation as it is now, I will first discuss the effects of the budget cuts. Together with the implementation of the transition, the amount of money that the national government spent on mental health care went down. A lot of my respondents experienced budget cuts within their organizations right before the transition. The consensus among the interviewees was that the (then) upcoming transition was at fault for these budget cuts, and this was viewed as part of the commodification of care. A problem that many of my respondents experienced, was that the budget cuts within their organization were often led by someone who was mostly knowledgeable about the financial aspects, and necessarily knowledgeable about the substance of the organization. Some respondents described that (upcoming) budget cuts led to a culture of fear, which was so severe that one respondent decided to quit her job over it.
“[…] er heerste eigenlijk eenzelfde [angst]cultuur, dus dat er niemand z’n mond open trekt, […]dus ik zei dingen, en dan vroeg die directeur van ja, ehm.. staan jullie
hierachter, en dan stak niemand z’n vinger op. En dan liep ik weg, en dan zeiden ze ‘oh, ik vond het wel goed hoor, dat je dat zei’, of mailtjes ‘ik ben zo blij dat je dat gezegd hebt’, ja potverdomme, zeg dat dan gewoon daar. Wat heb ik daaraan? Om dat dan tegen mij.. nou ja, het is gewoon angst, want ze durven gewoon niet. Ja, toen dacht ik, ik wil het gewoon niet. Ik ging [er] met zoveel weerstand op een gegeven moment heen, en het werk vind ik dan leuk, maar als je het zo moet doen… nee. En toen dacht ik nou, ik hou er mee op.” (Respondent #4)
A culture of fear means that people are afraid to speak out. It was clear that people wanted someone to speak out (‘ik ben zo blij dat je dat gezegd hebt’). This had a big impact on the emotions of this respondent. She also states that enjoys the work, but the framing and feeling rules of the organization made the emotional labour too much for her to continue her job.
“Mensen zijn bang, bang voor hun positie, bang voor hun baan. […]ik wil zo niet werken. Ik doe het gewoon, ik wil het gewoon niet. Ik word daar ziek van, ik ga het gewoon niet doen. Dus ja, dan ga ik weg. Heb ik misschien ook een luxepositie, dat ik daar niet zo bang voor ben en ook wel een beetje weet wat ik in huis heb.” (Respondent #4)
This respondent seems to think that she was able to speak up and could afford to quit her job due to her experience. The question is if people who don’t have a lot of
