Pathways to antisocial behavior: a framework to improve diagnostics and tailor therapeutic interventions.

The Antisocial Personality Disorder (ASPD), and antisocial behavior (ASB) in general, is associated with significant impact on individuals themselves, their environment, and society. Although various interventions show promising results, no evidence-based treatments are available for individuals with ASPD. Therefore, making informed choices about which treatment can be applied to an individual patient is complicated. Furthermore, contradictory findings on therapy effectiveness and underlying factors of ASB, such as cognitive impairments and personality traits, fuel the debate whether the conceptualization of ASPD in the DSM-5 is accurate and whether this population can be seen as homogeneous. A conceptual framework, based on the reciprocal altruism theory, is presented in which we propose different pathways to ASB. These pathways suggest underlying dynamics of ASB and provide an explanation for previous contradictory research outcomes. This framework is intended to serve as a clinically relevant model that provides directions for improving diagnostics and matching treatments to underlying dynamics in the antisocial population.

Explaining the willingness of clinicians to work with patients with antisocial personality disorder using the theory of planned behaviour and emotional reactions.

Many clinicians seem to experience negative emotions towards patients with antisocial personality disorder (ASPD), resulting in the exclusion of patients in many treatment programmes. The behaviour of individuals with ASPD has a significant impact on society, which affects ASPD patients and their environment, and therefore, the exclusion from programmes is a serious concern. Relatively, little is known about why some clinicians are willing to work with ASPD patients and others are not and what factors contribute to an increase in the motivation to do so. In this study, clinicians (n = 130) working in a regular and forensic mental health service in the Netherlands completed a questionnaire based on the theory of planned behaviour (TPB) and the Feeling Word Checklist and questions about the relevant experience gained and education received. The current study confirms the limited willingness to work with ASPD patients, especially in regular mental health care. Experience working with ASPD patients, education on cluster B personality disorders and having experienced verbal and/or physical violence in clinical practice did not fully explain whether or not clinicians were motivated to provide treatment to ASPD patients. TPB appeared to predict the intention to provide psychological therapy to ASPD patients adequately. The impact of positive emotions towards ASPD patients on providing treatment appeared to be stronger than negative emotions. This study provides more insight into why so few clinicians are willing to work with ASPD patients and what may increase motivation to include this group in treatment programmes.

Demand-oriented and demand-driven health care: the development of a typology.

In most European countries, there is an increasing demand for demand-oriented and demand-driven approaches in the development of health care policy and the organization of health care services. Both approaches, in which the main focus is on 'the demand', are seen as counterparts of the supply-oriented approach, that has 'the supply' as point of departure. However, there is much confusion about the definition of the concepts. To identify the different views, and to examine to what extent there is consensus in the Netherlands about the concepts of demand-orientation and demand-driven care, a Delphi study was done among 26 experts; scientists, health care insurance companies, health care suppliers, the government, independent advisory bodies and client interest groups. The study resulted in a typology. The similarities and differences between the two concepts were demonstrated in five dimensions; responsibility, control, need-determination, formal embedment of vision in organization and choice. Furthermore, the typology was used to identify existing types of services as being either demand-oriented or demand-driven services. The typology provides an understanding of the similarities and differences between the two concepts, and appears to be a useful tool in identifying services to the extent that they are demand oriented or demand driven.

A clients' perspective on demand-oriented and demand-driven health care.

BACKGROUND: In many Western European countries, there is an increasing request for demand-oriented and demand-driven approaches in health care. In these approaches, the emphasis is on the clients' perspective on healthcare policy and healthcare services. A study was conducted to gain insight into the clients' view of health care. METHODS: In 2004 a survey was conducted in the Netherlands among 4250 ambulatory mental health clients, by means of a postal questionnaire. To include clients with different experiences of mental health care, the sample was stratified according to the length of the treatment history. A total of 865 clients responded to the survey. RESULTS: Elements that are found to be important to most clients are that 'needs are determined in consultation with the client', that 'the client is treated in a pleasant manner' and that 'the professional informs the client about the possibilities in his/her situation'. Significant differences were found between groups with different background factors: income, education, age, sex and treatment history all had significant correlations. CONCLUSION: Most clients in ambulatory mental health care appreciate the demand-oriented and demand-driven approaches. However, not all the elements are appreciated in the same manner. In general, clients do not seem to care much about who makes the decisions, but they care much more about the way the decision-making process is carried out. Clients especially value being heard and being involved in the process as a serious party.

Reflections on demand-oriented and demand-driven care within the current health care system.

The authors describe models for the approach to demand-orientated and demand-driven health care as experienced in the Netherlands. The practical operation of the scheme is discussed including implications for financing and other aspects of regulation. The paper concludes that at present a demand-orientated system is feasible, but changes of a fundamental nature would be necessary to institute a successful operation of demand-driven health care, at least in the country the subject of this study.