I. Transversal dialog: a hybrid expertise-generating system
In 2005, a reform aiming at reorganizing Belgian mental health supply around networks and care circuits organized along the needs of mentally ill persons has begun. The working conditions in mental health networks are experimented through the therapeutic projects, i.e. local projects that regularly bring together the mental health practitioners likely to be involved in the reinsertion of patients suffering from chronic and complex mental disorders. While the INAMI (National Sickness and Disability Insurance Institution) fulfills the role of administrative authority, checking the projects’ compliance with its own regulation standards, the transversal dialog is in charge of both scientific and empirical assessments. Actually, transversal dialog is a complex system (a) in which three main actors categories are involved (b) and are invited to interact in order to perform a consistent work (c); i.e. to produce a hybrid expertise based on scientific and empirical knowledge issued from the therapeutic projects.
a) Transversal dialog is made of two main parts: one is scientific and the other is empirical.
The first part is homogeneous. It has only one actor, the KCE (Belgian Health Care Knowledge Centre), which is in charge of delivering a scientific knowledge based on the data it will collect from care providers, or from the second part. The second part is split between transversal projects and the participation project. These two projects are assigned to different bodies that respectively represent mental healthcare providers (Dialog Platforms in Mental Health) and care users (Users and Relatives Associations). These bodies are provided with a mandate to summarize in empirical recommendations the data they collect from the actors they represent. Eventually, the Mixed Work Group is a coordination body of these three institutions, so that their respective mandates can be articulated in a consistent initiative that would generate a hybrid expertise.
b) The three institutions involved in the system are the KCE, Dialog Platforms in Mental Health, and Users and Relatives Associations. These institutions can be distinguished by their missions and expertise.
The mission of the KCE is to independently produce an evidence-based scientific knowledge which would help public authorities to make efficient decisions in public health. By involving the KCE, public authorities seem to be willing to acquire a « scientific » or « explicit » knowledge of mental health, that is to say a knowledge that can be « transmittable in formal systematic language » (Bartunek et al., 2003). The production of an expertise is also part of the two other institutions concerns, but it is not their primary mission. The mission of Dialog Platforms in Mental Health is to improve care quality and care consistency with people’s needs by organizing a dialog between member institutions of the associations. Moreover, they can be mobilized along with mental health public policies implementation, or to communicate empirical data to public authorities. Unlike the KCE, platforms generate an empirical knowledge which does not claim any total autonomy regarding political power. Users and relatives associations are places where experiences and information related to care services can be exchanged and aggregated in order to help users in their actions and to inform them about the services and rights they have. The knowledge that can be generated by the associations is therefore empirical, as platforms knowledge, but it is coming from users and is intended for them. By involving Platforms and Associations, the authorities seem to be willing to acquire a « tacit » knowledge of mental health, that is to say a knowledge based on experience, « specific and rooted in action » (Ibidem). This knowledge is the knowledge of professional and amateur users.
c) The Mixed Work Group is made of delegates of the previous bodies.
II. The transversal dialog between knowledge production and power conflicts.
Despite the scenario designed by policy makers –according to which knowledge owners have to interact during three years within the framework of the transversal dialog with the aim of producing a hybrid knowledge- the whole process will be regulated by conflicts hindering the knowledge production.
We have identified three main types of conflicts between the above knowledge types.
a) Administrative rationality and professionalism.
Many conflicts arose about the INAMI’s administrative requirements that had to be respected by therapeutic projects to get funding. The requirements are known to be incompatible with the professionals work. Practically, these conflicts put the INAMI’s frame rigidity against the flexibility imposed to professionals by the patients’ clinic rhythm. Indeed, if the bureaucratic regulation of the INAMI aims at enhancing public action forecast-ability, the actors who take part to it must manage the lack of forecast-ability of therapeutic work. More generally, the controversies reveal a discrepancy between local and global action methods. Indeed, each therapeutic project is generating a local contingency with specificities related to criteria such as the project objective, the target group and so on. But these criteria simultaneously involve specific needs that can be incompatible with the global action method of public action: a bureaucratic way of working that relies more on certainty about public funds allocation and realization of related projects rather than a focus on local, random or individual needs.
b) Professional versus amateur expertise
The collaboration between dialog platforms (professional empirical expertise) and users associations (profane empirical expertise) has generated two types of issues. First of all, the professional’s delegates challenged the systematic participation of associations to meetings. Professionals indeed thought that associations were not involved in all aspects of information sharing. Their argument was to emphasize the fact that beyond some limits, the medical secrecy communication could jeopardize the therapeutic relationship, and that the transversal dialog requirements could not harm clinic work. Then, as the associations were accepted and took part to all the meetings, their « real practice » experts were able to speak out, which could be an issue. There is indeed a real gap between the subjective living of a situation by a user and the objective therapeutic requirements that professionals are associating to it. Also, despite the work performed by associations to support dialog between real practice experts and professionals, what professionals said generated users anger which in turn led to professionals surprise and irritation as they were not prepared to such sudden and sometimes violent way of talking. So, if a professional can be happy to involve patients in therapeutic dialog, he will have to go beyond his certainties to answer the real practice experts who wonder why it cannot just be « as simple as that »?!
c) Scientific knowledge and quantitative investigation versus empirical knowledge and qualitative investigation (or from experimentation to assessment)
The conflict between scientific knowledge, held by the KCE, and empirical knowledge, held by dialog platforms, is hiding two additional types of tension. The first one is due to the opposition between quantitative and qualitative research, and the second one is due to the confusion between assessment and experimentation. Practically, the KCE performed its scientific work based on a series of indicators that according to field actors were not sufficient to understand the complexity of the experimentation they were conducting. They were therefore opposed to the complexity decrease implied by the KCE’s work, as they wished to generalize the results. Then, field actors criticized the nature of the indicators selected by the KCE, which required them to submit intrusive questionnaires to patients, and which as such were threatening the therapeutic relationship. Also, the combination of these two elements – (1) quantitative indicators (2) related to patients and not to networking- gave field actors the feeling that their projects, which were designed as experimentation, were actually submitted to an efficiency assessment.
d) Conflicts management
As mentioned above, the Mixed Work Group is made of delegates of each knowledge holders. It is a body that is specifically designed to control the compatibility and consistency of action methods involved in transversal dialog. It should therefore at least handle the incompatibilities between these methods, and at most be able to manage diversity in order to bring an added value, that is to say so that the final product is more valuable than the sum of all parts. However, the Mixed Work Group did not manage to achieve this mission. Dialog actors provide three reasons for this: decisions related to the system functioning and evolution were made outside of the group; each actor was defending his own interests; the group did not have a sufficiently powerful mandate to overcome these difficulties, that is to say to replace bilateral exchange with collective negotiation, and to impose collective interest –building a hybrid expertise– to the stakeholders respective interests. These interests bring us back directly to the macro-context, i.e. the power relationships which govern mental health.
e) Relationships between macro-context and knowledge conflicts
Most of the knowledge conflicts seem in fine to be related to the power relationships that govern mental health ex ante, and to how actors feel ex post about these. All stakeholders have a specific ex ante position in mental health, with specific relationships with political authorities. From this viewpoint, mental health dialog platforms have a strong institutional position. On the other hand, the KCE has a strategic position in health in general, but not in mental health. However, such essential role as the one played by platforms is assigned to the KCE by political and administrative actors for transversal dialog. Besides, dialog platforms are requested to collaborate with users and relatives associations, which are also involved in dialog. Now, this involvement provides the associations with an opportunity to institutionalize their participation to mental health policy, which is also an objective for public authorities which were under international pressure.
Each institution involved in transversal dialog has interest either to achieve some legitimacy in mental health or to protect its own legitimacy. Now, it seems that the strategies implemented in this way replaced the formal and collective mandate assigned to transversal dialog.
Eventually, from an analytical viewpoint, the reflection about knowledge seems not to be able, in its links with public action, to evolve without a refined analysis of power relationships that govern mental health. In the same way, as far as public action is concerned, the design of such system aimed at performing cognitive activities, cannot be considered outside of the strategic work that actors will potentially perform.