Across all health care settings, certain patients are perceived as ‘difficult’ by clinicians. This paper’s aim is to understand how certain patients come to be perceived and labelled as ‘difficult’ patients in community mental health care, through mixed-methods research in The Netherlands between June 2006 and October 2009. A literature review, a Delphi-study among experts, a survey study among professionals, a Grounded Theory interview study among ‘difficult’ patients, and three case studies of ‘difficult’ patients were undertaken. Analysis of the results of these qualitative and quantitative studies took place within the concept of the sick role, and resulted in the construction of a tentative explanatory model. The ‘difficult’ patient-label is associated with professional pessimism, passive treatment and possible discharge or referral out of care. The label is given by professionals when certain patient characteristics are present and a specific causal attribution (psychological, social or moral versus neurobiological) about the patient’s behaviours is made. The status of ‘difficult’ patient is easily reinforced by subsequent patient and professional behaviour, turning initial unusual help-seeking behaviour into ‘difficult’ or ineffective chronic illness behaviour, and ineffective professional behaviour. These findings illustrate that the course of mental illness, or at least the course of patients’ contact with mental health professionals and services, is determined by patient and professional and reinforced by the social and mental health care system. This model adds to the broader sick role concept a micro-perspective in which attribution and learning principles are incorporated. On a practical level, it implies that professionals need to look into their own role in the perpetuation of difficult behaviours as described here.
This article presents the life stories of four older women in Vienna in order to better understand the role of occupation in the course of ageing. A qualitative life-story method in the narrative tradition was used as a design of this multiple case study. The stories presented extend beyond an illness or deficit narrative and contribute to a more multifaceted narrative of the subjective experience of ageing in occupational terms in connection with identity. The women did not perceive themselves as old or sick despite problems in mobility, the presence of chronic disease and advanced age. This was associated with their engagement in occupation that was meaningful and linked to their identity. Engaging occupation is the means to continue, test, and adapt to the ageing self. Because occupation is like a litmus-test of one's identity and capacities, the women used it as a measure of change while ageing. Using Atchley's continuity theory, the attempt of the four older women to maintain a balance between adapting and struggling to continue their occupations is discussed in relation to their identity. The results expand Atchley's continuity theory by adding an occupational perspective.
Urban farming projects often involve the (temporarily) redevelopment of urban space by local co-productions of citizens and/or entrepreneurs. To realize their ambitions these coalitions often need support of public (government) resources such as time, money, space and regulation (Green Deal Stadslandbouw, 2013). This paper asks the question to what extent the development of urban farming projects can be understood as an example of planning through direct citizen participation/ participatory governance (e.g. Cornwall, 2004; Roberts, 2004) and what this means for the role of the municipal planning professional or civil servant in making these projects successful. Literature on the role of the municipal planner or civil servant in urban farming projects mainly concerns the role as enabler of projects given the many difficulties for projects. However, when looked at the development of urban farming as an example of citizen participation/ participatory governance and the transfer of social functions towards society other roles and tasks of planners seem to be important to make urban farming successful. This discussion paper looks to the role of planners and civil servants in some related government domains such as landscape (e.g. Van Dam et al. 2008, 2010, 2011) and neighbourhood development (e.g. Frieling et al., 2014) to complement our understanding of the role of planners in making urban farming projects successful. With this analysis the paper sets the scene for further research into tools for the planning professional or civil servant to support urban farming. In the paper the situation in Amsterdam serves as an example.
