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What leads to innovation in mental healthcare? Reflections on clinical expertise in a bureaucratic age

  • Neil Armstrong (a1)

Summary

This paper considers a witness seminar in which healthcare professionals discussed working on an acute admissions ward run along therapeutic community lines from the 1960s to the 1980s. Participants remarked that older styles of working are ‘unimaginable’ today. This paper discusses why. Literature from the humanities and social sciences suggest healthcare is reactive, reflecting wider cultural changes, including a preference for a more bureaucratic, standardised, explicit style of reasoning and a high valuation of personal autonomy. Such a reflection prompts questions about the nature of professional expertise, the role of evidence and the importance of the humanities and social sciences.

Declaration of interest

None.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Correspondence to Neil Armstrong (neil.armstrong@anthro.ox.ac.uk)

References

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4Atran, S. Cognitive Foundations of Natural History: Towards an Anthropology of Science: 269. Cambridge University Press, 1990.
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7Porter, TM. Trust in Numbers: The Pursuit of Objectivity in Science and Public Life. Princeton University Press, 1995.
8Graeber, D. The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy. Melville House, 2015.
9Harrison, S. Street-level bureaucracy and professionalism in health services. In Understanding Street-Level Bureaucracy (eds Hupe, P, Hill, M, Buffat, A): 6178. Oxford University Press, 2016.
10Turner, J, Hayward, R, Angel, K, Fulford, B, Hall, J, Millard, C, et al. The history of mental health services in modern England: practitioner memories and the direction of future research. Med Hist 2015; 59(04): 615.
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What leads to innovation in mental healthcare? Reflections on clinical expertise in a bureaucratic age

  • Neil Armstrong (a1)

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What leads to innovation in mental healthcare? Reflections on clinical expertise in a bureaucratic age

  • Neil Armstrong (a1)
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eLetters

Psychiatry, expertise and existential angst

Brendan Kelly, Professor of Psychiatry, Trinity College Dublin
20 November 2018

Armstrong’s article about ‘an acute admissions ward run along therapeutic community lines from the 1960s to the 1980s’ is facinating (1). But then, anthropology often is.

I am especially intrigued that anthropologists tend to ascribe a high level of confidence to psychiatrists that is often at odds with reality. Armstrong suggests that ‘it appears to be an essential part of the role of mental healthcare clinicians that they do not merely reflect or reproduce everyday ideas and assumptions about mental disorders and their treatment, but bring something distinctive to the table. This distinctive contribution is the result of intensive training, painstaking clinical experience and robust scientific research.’

In fact, many psychiatrists see their training as considerably less than ‘intensive’, their clinical experience as invaluable but scarcely ‘painstaking’, and much ‘scientific research’ as anything but ‘robust’.

Obviously, every argument needs a good straw-man and Armstrong, for the most part, mercifully spares us from medical anthropology’s most beloved fantasy, ‘biomedicine’, with which many anthropologists persist, despite the enormous disconnect between the monolithic construct of ‘biomedicine’ in the academic literature and the messiness of the real world. (Confession: I sometimes wish that ‘biomedicine’, as conjured up by anthropologists, really did exist; life would be so much simpler.) In fact, psychiatrists, above all others, are only too aware that ‘rather than being the sole active agent, mental healthcare professionals as a group are acted upon by wider social and cultural forces’.

Armstrong argues that ‘a widespread loss of confidence in mental healthcare would mean an existential challenge for the discipline as a whole.’ In fact, psychiatry has a distinctly rocky relationship with confidence to begin with; psychiatry’s fiercest critics are generally psychiatrists ourselves. As a result, a whole-scale loss of confidence in psychiatry would not trigger significant existential angst among psychiatrists (we are hardened veterans of existential angst) but would ‘mean an existential challenge’ for the population more generally, which would lose a convenient mechanism for dealing with complex social issues and complex people that society has always sought to ‘other’.

Armstrong’s points about our ‘highly bureaucratised times’ are well-made and well-taken, and Porter’s views about ‘improvised, intuitive exchanges between staff and patients’ are intriguing (2). While the Phoenix Unit that Armstrong describes was undoubtedly a very special place, such ‘exchanges’ have actually been a recurring feature of psychiatry for centuries. As early as 1810, Dr William Saunders Hallaran, an asylum-doctor in Cork, recommended routinely speaking with each patient on any topic of their choosing and described the benefits resulting from such exchanges as ‘almost incredible’:

‘Maniacs, when in a state to be influenced by moral agents, are not to be subdued ex officio, by measures of mere force… I have in consequence made it a special point on my review days, to converse for a few minutes with each patient, on the subject which appeared to be most welcome to his humour…The mental exertion employed amongst the convalescents by this species of address is very remarkable, and the advantages flowing from it are almost incredible’ (3).

Brendan D. Kelly, Professor of Psychiatry, Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin, D24 NR0A, Ireland; email brendan.kelly@tcd.ie

1 Armstrong N. What leads to innovation in mental healthcare? Reflections on clinical expertise in a bureaucratic age. BJPsych Bulletin 2018; 184-7.

2 Porter TM. Trust in Numbers: The Pursuit of Objectivity in Science and Public Life. Princeton University Press, 1995.

3 Hallaran WS. An Enquiry into the Causes Producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons. Edwards and Savage, 1810.
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Conflict of interest: None declared

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