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

Resonances in a spring-pendulum: algorithms for equivariant singularity theory

A spring-pendulum in resonance is a time-independent Hamiltonian model system for formal reduction to one degree of freedom, where some symmetry (reversibility) is maintained. The reduction is handled by equivariant singularity theory with a distinguished parameter, yielding an integrable approximation of the Poincaré map. This makes a concise description of certain bifurcations possible. The computation of reparametrizations from normal form to the actual system is performed by Gröbner basis techniques.

Mutual powerlessness in client participation practices in mental health care

Background  Client participation has become a dominant policy goal in many countries including the Netherlands and is a topic much discussed in the literature. The success of client participation is usually measured in terms of the extent to which clients have a say in the participation process. Many articles have concluded that client participation is limited; professionals often still control the participation process and outcomes. Objective  The objective of this study is to gain insight into (i) the practice of client participation within a quality improvement collaborative in mental health care and (ii) the consequences of a Foucauldian conceptualization of power in analysing practices of client participation. Design  We used an ethnographic design consisting of observations of national events and improvement team meetings and interviews with the collaborative’s team members and programme managers. Results  Contrary to many studies on client participation, we found both clients and service providers frequently felt powerless in its practice. Professionals and clients alike struggled with the contributions clients could make to the improvement processes and what functions they should fulfil. Moreover, professionals did not want to exert power upon clients, but ironically just for that reason sometimes struggled with shaping practices of client participation. This mutual powerlessness (partly) disappeared when clients helped to determine and execute specific improvement actions instead of participating in improvement teams. Conclusion  Recognizing that power is inescapable might allow for a more substantive discussion concerning the consequences that power arrangements produce, rather than looking at who is exerting how much power

Circular dichroism of cholesteric polymers and the orbital angular momentum of light

We explore experimentally if the light's orbital angular momentum (OAM) interacts with chiral nematic polymer films. Specifically, we measure the circular dichroism of such a material using light beams with different OAM. We investigate the case of strongly focussed, non-paraxial light beams, where the spatial and polarization degrees of freedom are coupled. Within the experimental accuracy, we cannot find any influence of the OAM on the circular dichroism of the cholesteric polymer.Comment: 3 pages, 4 figure

Mutual powerlessness in client participation practices in mental health care

Background Client participation has become a dominant policy goal in many countries including the Netherlands and is a topic much discussed in the literature. The success of client participation is usually measured in terms of the extent to which clients have a say in the participation process. Many articles have concluded that client participation is limited; professionals often still control the participation process and outcomes. Objective The objective of this study is to gain insight into (i) the practice of client participation within a quality improvement collaborative in mental health care and (ii) the consequences of a Foucauldian conceptualization of power in analysing practices of client participation. Design We used an ethnographic design consisting of observations of national events and improvement team meetings and interviews with the collaborative's team members and programme managers. Results Contrary to many studies on client participation, we found both clients and service providers frequently felt powerless in its practice. Professionals and clients alike struggled with the contributions clients could make to the improvement processes and what functions they should fulfil. Moreover, professionals did not want to exert power upon clients, but ironically just for that reason sometimes struggled with shaping practices of client participation. This mutual powerlessness (partly) disappeared when clients helped to determine and execute specific improvement actions instead of participating in improvement teams. Conclusion Recognizing that power is inescapable might allow for a more substantive discussion concerning the consequences that power arrangements produce, rather than looking at who is exerting how much power

Exponentially small heteroclinic breakdown in the generic Hopf-zero singularity

In this paper we prove the breakdown of an heteroclinic connection in the analytic versal unfoldings of the generic Hopf-Zero singularity in an open set of the parameter space. This heteroclinic orbit appears at any order if one performs the normal form around the origin, therefore it is a phenomenon "beyond all orders". In this paper we provide a formula for the distance between the corresponding stable and unstable one dimensional manifolds which is given by an exponentially small function in the perturbation parameter. Our result applies both for conservative and dissipative unfoldings

Vergrijzing, aanvullende pensioenen en de Nederlandse economie

De vergrijzingsproblematiek betreft alle Westerse landen. De gecombineerde effecten van een lager geboortecijfer, een lager sterftecijfer en de naoorlogse geboortegolf leiden ertoe dat de bevolkingsopbouw aan het veranderen is. Volgens het CBS zal het bevolkingsaandeel van ouderen (met een leeftijd van 65 jaar of hoger) de komende jaren stijgen van 13% naar ruim 22%. Deze verandering zal zijn weerslag hebben in de hele economie, en bijzonder gevoeld worden in de pensioensector

Multi-site breathers in Klein-Gordon lattices: stability, resonances, and bifurcations

We prove the most general theorem about spectral stability of multi-site breathers in the discrete Klein-Gordon equation with a small coupling constant. In the anti-continuum limit, multi-site breathers represent excited oscillations at different sites of the lattice separated by a number of "holes" (sites at rest). The theorem describes how the stability or instability of a multi-site breather depends on the phase difference and distance between the excited oscillators. Previously, only multi-site breathers with adjacent excited sites were considered within the first-order perturbation theory. We show that the stability of multi-site breathers with one-site holes change for large-amplitude oscillations in soft nonlinear potentials. We also discover and study a symmetry-breaking (pitchfork) bifurcation of one-site and multi-site breathers in soft quartic potentials near the points of 1:3 resonance.Comment: 34 pages, 12 figure

Nanoplasmonic electron acceleration in silver clusters studied by angular-resolved electron spectroscopy

The nanoplasmonic field enhancement effects in the energetic electron emission from few-nm-sized silver clusters exposed to intense femtosecond dual pulses are investigated by high-resolution double differential electron spectroscopy. For moderate laser intensities of 10 14Wcm -2, the delaydependent and angular-resolved electron spectra show laser-aligned emission of electrons up to keV kinetic energies, exceeding the ponderomotive potential by two orders of magnitude. The importance of the nanoplasmonic field enhancement due to resonant Mie-plasmon excitation observed for optimal pulse delays is investigated by a direct comparison with molecular dynamics results. The excellent agreement of the key signatures in the delay-dependent and angular-resolved spectra with simulation results allows for a quantitative analysis of the laser and plasmonic contributions to the acceleration process. The extracted field enhancement at resonance verifies the dominance of surfaceplasmon-assisted re-scattering