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Twenty academic psychologists and neuroscientists, with an interest in autism and based within the United Kingdom, were interviewed between 2012 and 2013 on a variety of topics related to the condition. Within these qualitative interviews researchers often argued that there had been a ‘turn to infancy’ since the beginning of the 21st century with focus moving away from the high functioning adolescent and towards the pre-diagnostic infant deemed to be ‘at risk’ of autism. The archetypal research of this type is the ‘infant sibs’ study whereby infants with an elder sibling already diagnosed with autism are subjected to a range of tests, the results of which are examined only once it becomes apparent whether that infant has autism. It is claimed in this paper that the turn to infancy has been facilitated by two phenomena; the autism epidemic of the 1990s and the emergence of various methodological techniques, largely although not exclusively based within neuroscience, which seek to examine social disorder in the absence of comprehension or engagement on the part of the participant: these are experiments done to participants rather than with them. Interviewees claimed that these novel methods allowed researchers to see a ‘real’ autism that lay ‘behind’ methodology. That claim is disputed here and instead it is argued that these emerging methodologies other various phenomena, reorienting the social abnormality believed typical of autism away from language and meaning and towards the body. The paper concludes by suggesting that an attempt to draw comparisons between the symptoms of autism in infant populations and adults with the condition inevitably leads to a somaticisation of autism. [ABSTRACT FROM AUTHOR]

The need to focus on patient safety and improve the quality and consistency of medical care in acute hospital settings has been highlighted in a number of UK and international reports. When patients on a hospital ward become acutely unwell there is often a window of opportunity for staff, patients and relatives to contribute to the ‘rescue’ process by intervening in the trajectory of clinical deterioration. This paper explores the social and institutional processes associated with the practice of rescue, and implications for the implementation and effectiveness of rapid response systems (RRSs) within acute health care. An ethnographic case study was conducted in 2009 in two UK hospitals (focussing on the medical directorates in each organisation). Data collection involved 180 h of observation, 35 staff interviews (doctors, nurses, health care assistants and managers) and documentary review. Analysis was informed by Bourdieu's logic of practice and his relational concept of the ‘field’ of the general medical ward. Three themes illustrated the nature of rescue work within the field and collective rules which guided associated occupational distinction practices: (1) the ‘dirty work’ of vital sign recording and its distinction from diagnostic (higher order) interpretive work; (2) the moral order of legitimacy claims for additional help; and (3) professional deference and the selective managerial control of rescue work. The discourse of rescue provided a means of exercising greater control over clinical uncertainty. The acquisition of ‘rescue capital’ enabled the social positioning of health care assistants, nurses and doctors, and shaped use of the RRS on the wards. Boundary work, professional legitimation and jurisdictional claims defined the social practice of rescue, as clinical staff had to balance safety, professional and organisational concerns within the field. This paper offers a nuanced understanding of patient safety on the front-line, challenging notions of the ‘quick fix’ safety solution. [ABSTRACT FROM AUTHOR]

Abstract: This paper provides a consolidated overview of public and healthcare professionals' attitudes towards vaccination in Europe by bringing together for the first time evidence across various vaccines, countries and populations. The paper relies on an extensive review of empirical literature published in English after 2009, as well as an analysis of unpublished market research data from member companies of Vaccines Europe. Our synthesis suggests that hesitant attitudes to vaccination are prevalent and may be increasing since the influenza pandemic of 2009. We define hesitancy as an expression of concern or doubt about the value or safety of vaccination. This means that hesitant attitudes are not confined only to those who refuse vaccination or those who encourage others to refuse vaccination. For many people, vaccination attitudes are shaped not just by healthcare professionals but also by an array of other information sources, including online and social media sources. We find that healthcare professionals report increasing challenges to building a trustful relationship with patients, through which they might otherwise allay concerns and reassure hesitant patients. We also find a range of reasons for vaccination attitudes, only some of which can be characterised as being related to lack of awareness or misinformation. Reasons that relate to issues of mistrust are cited more commonly in the literature than reasons that relate to information deficit. The importance of trust in the institutions involved with vaccination is discussed in terms of implications for researchers and policy-makers; we suggest that rebuilding this trust is a multi-stakeholder problem requiring a co-ordinated strategy. [Copyright &y& Elsevier]

Policymakers at global level recognise that household biomass use in developing countries has significant health consequences. However, it is unclear how local-level health professionals perceive and respond to such health effects. This paper which is derived from the findings of a larger study on perceptions and responses to the harmful health effects of carrying heavy firewood loads and to smoke from cooking fires is based on a study conducted in South Africa among managers of health programmes and community nurses of Qaukeni and Mhlontlo municipalities in rural Eastern Cape. Interviews and participant observations were conducted in 2009 using ethnographic grounded theory approaches. In addition to a 10-month period of ethnographic fieldwork, ten programme managers and nurses in two villages were interviewed about health patterns in the villages that they serve, their perceptions of, and responses to the health effects of carrying heavy firewood loads, and inhalation of smoke from wood and dung cooking fires, their professional qualifications and experience, their own household energy use; and observations made as they served clinic clients. Results show that these programme managers and nurses perceive the health effects of carrying heavy loads of firewood and of cooking smoke as minor. Sometimes, nurses give women symptomatic relief for musculoskeletal pain resulting from carrying heavy loads. We posit that their perceptions are derived from customary neglect of work-related health and non-communicable diseases, cultural interpretations of womanhood, limited access to relevant information, and limited interactions between health and energy sector professionals. We conclude that culturally and gender-sensitive awareness programmes are needed for local-level health professionals to effectively address health effects of biomass collection and use. This paper provides new insights into overlooked differences between globally-driven initiatives to address health effects of biomass use and local perceptions. [Copyright &y& Elsevier]

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of ‘persons’ are exercised through ‘technical safety’ measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain ‘places’ within the hospital where risks are seen to be ‘located’. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to ‘Panopticist’ theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice. [Copyright &y& Elsevier]

This paper reports on research framed by theories of therapeutic landscapes and the ways that the social, physical and symbolic dimensions of landscapes relate to wellbeing and healing. We focus especially on the question of how attributes of therapeutic landscapes are constructed in different ways according to the variable perspectives of individuals and groups. Through an ethnographic case study in a psychiatric hospital in the North of England we explore the perceived significance for wellbeing of ‘smoking spaces’ (where tobacco smoking is practiced in ways that may, or may not be officially sanctioned). We interpret our findings in light of literature on how smoking spaces are linked to the socio-geographical power relations that determine how smoking is organised within the hospital and how this is understood by different groups using the hospital building. We draw on qualitative research findings from discussion groups, observations, and interviews with patients, carers and staff. These focused on their views about the building design and setting of the new psychiatric hospital in relation to their wellbeing, and issues relating to smoking spaces emerged as important for many participants. Creating and managing smoking spaces as a public health measure in psychiatric hospitals is shown to be a controversial issue involving conflicting aims for health and wellbeing of patients and staff. Our findings indicate that although from a physical health perspective, smoking is detrimental, the spaces in which patients and staff smoke have social and psychological significance, providing a forum for the creation of social capital and resistance to institutional control. While the findings relate to one case study setting, the paper illustrates issues of wider relevance and contributes to an international literature concerning the tensions between perceived psychological and psychosocial benefits of smoking vs. physical harm that smoking is likely to cause. We consider the implications for hospital design and the model of care. [Copyright &y& Elsevier]

Because compensation policies have critical implications for the provision of health care, and evidence of their effects is limited and difficult to study in the real world, laboratory experiments may be a valuable methodology to study the behavioural responses of health care providers. With this experiment undertaken in 2013, we add to this new literature by designing a new medically framed real effort task to test the effects of different remuneration schemes in a multi-tasking context. We assess the impact of different incentives on the quantity (productivity) and quality of outputs of 132 participants. We also test whether the existence of benefits to patients influences effort. The results show that salary yields the lowest quantity of output, and fee-for-service the highest. By contrast, we find that the highest quality is achieved when participants are paid by salary, followed by capitation. We also find a lot of heterogeneity in behaviour, with intrinsically motivated individuals hardly sensitive to financial incentives. Finally, we find that when work quality benefits patients directly, subjects improve the quality of their output, while maintaining the same levels of productivity. This paper adds to a nascent literature by providing a new approach to studying remuneration schemes and modelling the medical decision making environment in the lab. [ABSTRACT FROM AUTHOR]

When a life is lost or severely impaired during childbirth, the midwife and obstetrician involved may experience feelings of guilt in the aftermath. Through three empirical cases, the paper examines the sense of guilt in the context of the current patient safety culture in healthcare where a blame-free approach is promoted in the aftermath of adverse events. The purpose is to illustrate how healthcare professionals may experience guilt without being at fault after adverse events, and Gamlund's theory on forgiveness without blame is used as the theoretical framework for this analysis. Philosophical insight has proven to be a useful resource in dealing with psychological issues of guilt and Gamlund's view on error and forgiveness elucidates an interesting dilemma in the field of traumatic events and medical harm in healthcare, where healthcare professionals experience that well-intended actions may cause injury, harm or even death to their patients. Failing to recognise and acknowledge guilt or guilty feelings may preclude self-forgiveness, which could have a negative impact on the recovery of midwives and obstetricians after adverse events. Developing and improving support systems for healthcare professionals is a multi-factorial task, and the authors suggest that the narrow focus on medico-legal and patient safety perspectives is complemented with moral philosophical perspectives to promote non-judgemental recognition and acknowledgement of guilt and of the fallible nature of medicine. [ABSTRACT FROM AUTHOR]

Abstract: Building on social science research examining the relationship between genetic knowledge, identity and the family this paper takes the cultural context of Cuba as a site for critical ethnographic engagement. The paper makes use of research working with a range of Cuban publics and genetic professionals as part of a collaborative research project exploring the social and cultural context of health beliefs about breast cancer. It illuminates the contrasting ways in which genomic knowledge linked to an increased risk of breast cancer is perceived, communicated, and acted upon. It is argued that the particular meaning and significance of genetic risk linked to breast cancer in this context must be examined in relation to long standing institutional practices relating to public health care provision. The focus on ‘the family’ in the provision of Cuban health provides a particularly viable foundation for the expansion of what is described as ‘community genetics’, including the collation of family history details for common complex diseases such as breast cancer. Nevertheless specific public perceptions of risk related to breast cancer and the difficulties of discussing a diagnosis of cancer openly in the family point to the very specific challenges for the translation and application of predictive interventions in Cuba. In summary the dynamic interrelationship between public health, perceptions of risk or health beliefs about the causes of the disease and attitudes towards cancer diagnosis within the family point to both continuities and discontinuities in the way that genomic interventions linked to breast cancer are unfolding as part of a dynamic yet still ostensibly socialist project of health care in Cuba. [Copyright &y& Elsevier]

The “rightness” of a technology for completing a particular task is negotiated by medical professionals, patients, state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain technologies may challenge the meaning of the “job” they are designed to accomplish. Manual vacuum aspiration (MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion, known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is legally prohibited. Although state health authorities have championed MVA as the “preferred” PAC technology, the primary donor for PAC, the United States Agency for International Development, does not support the purchase of abortifacient technologies. I conducted an ethnography of Senegal's PAC program between 2010 and 2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC. While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and digital curettage. Anxieties about MVA's capacity to induce abortion have constrained its integration into routine obstetric care. This capacity also raises questions about what the “job,” PAC, represents in Senegalese hospitals. The prioritization of MVA's security over women's access to the preferred technology reinforces gendered inequalities in health care. [ABSTRACT FROM AUTHOR]

This paper examines the process of professional resocialization among internationally educated health care professionals (IEHPs) in Canada. Analyzing data from qualitative interviews with 179 internationally educated physicians, nurses, and midwives and 70 federal, provincial and regional stakeholders involved in integration of IEHPs, we examine (1) which aspects of professional work are modified in transition to a new health care system; (2) which aspects of professional practice are learned by IEHPs in the new health environment, and (3) how IEHPs maintain their professional identity in transition to a new health care system. In doing so, we compare the accounts of IEHPs with the policy stakeholders' positions and analyze the similarities and the differences across three health care professions (medicine, nursing, and midwifery). This enables us to explore the issue of professional resocialization from the analytical intersection of gender, professional dominance, and institutional/organizational lenses. [ABSTRACT FROM AUTHOR]

The paper investigates whether, how and in what circumstances boundary blurring or boundary maintenance is productive or destructive of sense in collaborative research based on a case study involving researchers from two universities and two principal organisational stakeholders in a local healthcare system in England between 2009 and 2012. Adopting a narrative method, using meeting observation, document analysis and interviews, we describe two key sets of activities in the evolution of collaboration, which allows us to tackle the question at two levels. Studying the production of documents and their use as boundary objects in project management meetings, we show how these were used to enable cooperation by establishing a truce between worldviews, giving participants a better feel for the game and a clearer perception of its stakes. Studying how the partnership expanded to take in other organisations besides the two formal partners, we show how the project accommodated pre-existing organisational interests but thereby sacrificed its experimental ethos. In showing how actors needed to subvert their experimental script to enact collaborative partnership, we argue for understanding and evaluating the latter as the co-produced outcome of disputes and co-orientations towards a practical ideal, not as an organisational format for knowledge co-production. [ABSTRACT FROM AUTHOR]

Globally, attacks on and interferences with health workers and healthcare delivery, including targeted violence towards providers, attacks on hospitals and delays and denial of health care, represent a serious humanitarian and human rights issue. However, gaps in research about these events persist, limiting the evidence base from which to understand and address the problem. This paper focuses on experiences of local health workers in eastern Burma's chronic conflict, including their strategies for addressing security and ensuring access to vulnerable ethnic communities in the region. Face-to-face in-depth interviews were conducted in June and August 2012 with 27 health workers from three health organizations that operate throughout eastern Burma, with their operational head quarters located in Mae Sot, Tak Province, Thailand. Qualitative analysis found that health workers in this setting experience violent and non-violent interferences with their work, and that the Burmese government's military activities in the region have severely impacted access to care, which remains restricted. Data show that innovative security strategies have emerged, including the important role of the community in ensuring securer access to health care. This study underscores health workers' concern for improved data collection to support the rights of health workers to provide health care, and the rights of community members to receive health care in conflict-affected settings. Findings will inform the development of an incident reporting form to improve systematic data collection and documentation of attacks on health in this setting. [ABSTRACT FROM AUTHOR]

Abstract: This paper explores the performance dimensions of Italian teaching hospitals (THs) by considering the multiple constituent model approach, using measures that are subjective and based on individual ideals and preferences. Our research replicates a study of a French TH and deepens it by adjusting it to the context of an Italian TH. The purposes of this research were as follows: to identify emerging views on the performance of teaching hospitals and to analyze how these views vary among hospital stakeholders. We conducted an in-depth case study of a TH using a quantitative survey method. The survey uses a questionnaire based on Parsons' social system action theory, which embraces the major models of organizational performance and covers three groups of internal stakeholders: physicians, caregivers and administrative staff. The questionnaires were distributed between April and September 2011. The results confirm that hospital performance is multifaceted and includes the dimensions of efficiency, effectiveness and quality of care, as well as organizational and human features. There is a high degree of consensus among all observed stakeholder groups about these values, and a shared view of performance is emerging. Our research provides useful information for defining management priorities to improve the performance of THs. [Copyright &y& Elsevier]

Abstract: In England from 2002 to 2013, Primary Care Trusts (PCTs) were responsible for commissioning healthcare for their local populations. The NHS has recently undergone rapid organisational change whereby clinicians have assumed responsibility for local commissioning decisions. This change in commissioning arrangements alongside the current financial pressures facing the NHS provides an impetus for considering the use of technical prioritisation methods to enable the identification of savings without having a detrimental effect on the health of the population. This paper reports on the design and implementation of a technical prioritisation method termed PBMA applied within NHS Plymouth, an English PCT responsible for commissioning services for a population of approximately 270,000. We evaluated the effectiveness of the process, the extent to which it was appropriate for local healthcare commissioning and whether it identified budget savings. Using qualitative research methodology, we found the process produced clear strategic and operational priorities for 2010/11, providing staff with focus and structure, and delivered a substantial planned reduction in hospital activity levels. Participants expressed satisfaction with the process. NHS Plymouth adhered to the PBMA process, although concerns were raised about the evidence for some priorities, decibel rationing, and a lack of robust challenge at priority-setting meetings. Further work is required to enhance participants' understanding of marginal analysis. Participants highlighted several external benefits, particularly in terms of cultural change, and felt the process should encompass the whole local health and social care community. This evaluation indicates that the prioritisation method was effective in producing priorities for NHS Plymouth, and that PBMA provides an appropriate method for allocating resources at a local level. In order for PBMA to identify savings, cultural and structural barriers to disinvestment must be addressed. These findings will interest other healthcare commissioners in developing their own approaches to priority-setting. [Copyright &y& Elsevier]

As intuitive and inviting as it may appear, the concept of patient-centered care has been difficult to conceptualize, institutionalize and operationalize. Informed by Bourdieu's concepts of cultural capital and habitus, we employ the framework of cultural health capital to uncover the ways in which both patients' and providers' cultural resources, assets, and interactional styles influence their abilities to mutually achieve patient-centered care. Cultural health capital is defined as a specialized collection of cultural skills, attitudes, behaviors and interactional styles that are valued, leveraged, and exchanged by both patients and providers during clinical interactions. In this paper, we report the findings of a qualitative study conducted from 2010 to 2011 in the Western United States. We investigated the various elements of cultural health capital, how patients and providers used cultural health capital to engage with each other, and how this process shaped the patient-centeredness of interactions. We find that the accomplishment of patient-centered care is highly dependent upon habitus and the cultural health capital that both patients and providers bring to health care interactions. Not only are some cultural resources more highly valued than others, their differential mobilization can facilitate or impede engagement and communication between patients and their providers. The focus of cultural health capital on the ways fundamental social inequalities are manifest in clinical interactions enables providers, patients, and health care organizations to consider how such inequalities can confound patient-centered care. [ABSTRACT FROM AUTHOR]

Abstract: This paper addresses the gap in health services and policy research about the implications of everyday weather for health care work. Building on previous research on the weather-related challenges of caregiving in homes and communities, it examines the experiences of ‘seasonal bad weather’ for health care workers in long-term care institutions. It features a hermeneutic phenomenology analysis of six transcripts from interviews with nurses and personal support workers from a qualitative study of institutional long-term care work in rural Canada. Focussing on van Manen's existential themes of lived experience (body, relations, space, time), the analysis reveals important contradictions between the lived experiences of health care workers coping with bad weather and long-term care policies and practices that mitigate weather-related risk and vulnerability. The findings contribute to the growing concern for rural health issues particularly the neglected experiences of rural health providers and, in doing so, offer insight into the recent call for greater attention to the geographies of health care work. [Copyright &y& Elsevier]

Abstract: High expectations for new technologies coexist with wide variability in the actual adoption and impact of information technology (IT) projects in clinical settings, and the frequent failure to incorporate otherwise “successful” projects into routine practice. This paper draws on actor–network theory to present an in-depth, sociotechnical analysis of one such project – a computer kiosk designed to diagnose and expedite treatment of urinary tract infections (UTI) in adult women. Research at a hospital urgent care clinic demonstrated the kiosk program''s effectiveness at diagnosing UTI and reducing patient wait times, and the kiosk was subsequently adopted by the clinic for routine patient care. However, a study promoting the adoption of the device at emergency departments (ED) was characterized by persistent staff resistance and lower-than-expected patient eligibility for kiosk-assisted care. The device was ultimately abandoned at all but one of the new sites. Observations and interviews with ED staff and the design/research team were conducted at four California EDs between April and July 2011 and point to conflicting understandings of evidence for the device''s usefulness and reasons for its (non)adoption. The kiosk program''s designers had attempted to “rationalize” medical work by embedding a formal representation of triage practices in the kiosk''s software. However, the kiosk''s “network” failed to stabilize as it encountered different patient populations, institutional politics, and the complex, pragmatic aspects of ED work at each site. The results of this evaluation challenge the persistent myth that a priori qualities and meanings inhere in technology regardless of context. The design and deployment of new IT projects in complex medical settings would benefit from empirically informed understandings of, and responses to, the contingent properties of human–technology relations. [Copyright &y& Elsevier]

Abstract: The subject of death denial in the West has been examined extensively in the sociological literature. However, there has not been a similar examination of its “opposite”, the acceptance of death. In this study, I use the qualitative method of discourse analysis to examine the use of the term “acceptance” of dying in the palliative care literature from 1970 to 2001. A Medline search was performed by combining the text words “accept or acceptance” with the subject headings “terminal care or palliative care or hospice care”, and restricting the search to English language articles in clinical journals discussing acceptance of death in adults. The 40 articles were coded and analysed using a critical discourse analysis method. This paper focuses on the theme of acceptance as integral to palliative care, which had subthemes of acceptance as a goal of care, personal acceptance of healthcare workers, and acceptance as a facilitator of care. For patients and families, death acceptance is a goal that they can be helped to attain; for palliative care staff, acceptance of dying is a personal quality that is a precondition for effective practice. Acceptance not only facilitates the dying process for the patient and family, but also renders care easier. The analysis investigates the intertextuality of these themes with each other and with previous texts. From a Foucauldian perspective, I suggest that the discourse on acceptance of dying represents a productive power, which disciplines patients through apparent psychological and spiritual gratification, and encourages participation in a certain way to die. [Copyright &y& Elsevier]

Abstract: While attempts are being made to improve health promotion by following a linear Evidence-Based (EB) approach, the actors involved are aware that the quality of health promotion is not just a matter of supplying ’evidence-based’ interventions to local practitioners, but the result of a situated coproduction process that depends on many factors. This paper explores what constitutes an intervention that works from the perspective of health promotion professionals (HPP), and how, according to them, the development and implementation of interventions should be improved. We interviewed 81 HPPs about the use of 10 health promotion interventions at 30 Municipality Health Services in The Netherlands. The HPPs described an intervention that works as something that produces its intended effects after being realized in a local situation. Interventions are realized by combining elements of a supplied intervention (e.g. a theory, artefacts) with elements that are situated in the local context (e.g. funding, local network). Interventions that are transferred contain implicit assumptions about local contexts, but it is often unclear what precisely constitutes an intervention and what is assumed of local contexts. An intervention that works is a situated configuration of aligned elements. A linear EB approach depends on the realization of the local circumstances in which ’evidence based’ interventions can work. Various strategies are possible for approximating such circumstances, but the core assumption that the configuration that is realized in practice is similar to the ’evidence based’ intervention seems unrealistic for most health promotion in the Netherlands. Under such circumstances, attention should shift from central quality assurance to the system of actors and the distributed actions and heterogeneous learning processes that together add up to interventions that work. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]