The Impossible Task: Are Irish CMHTs set up to fail?

MDT Picture 1

Pádraig Collins

 

Abstract

Tensions within the functioning of Irish Community Mental Health Teams (CMHTs) have been alluded to in the small body of published literature on teamwork in Irish mental health services. Such literature commonly recommends a range of measures to enhance teamwork, but fails to explore how issues of power and how the conflicting paradigms that underpin different practitioners’ work may preclude the implementation of such measures. This paper discusses how the conflicts that can arise in CMHTs may often be framed as between particular personalities but may be better understood as primarily arising from profound philosophical differences, and therefore preferred praxis within teams. Key amongst these issues is that of defining the team’s ‘task’, along with the structure, processes and governance required to complete such a ‘task’. It is argued that understanding the differing forces that operate when different ideologies clash, including that of how power is exercised, may help illuminate the nature of these conflicts and empower us to find better solutions.

 

Background

It has been almost a decade now since the Mental Health Commission published its key document on teamwork: “Teamwork Within Mental Health Services in Ireland” (2010)1. Since then a small body of Irish published literature, including one large study, has attended to this topic. In essence, these discussions have focussed on issues such as resourcing, mainly the under-resourcing of certain disciplines, disciplines’ satisfaction with their role and the impact of blurring or stereotyping of roles2,3 and the challenges of integrating a recovery ethos in multidisciplinary teams (MDTs)4. Deady5 noted that of 32 MDTs studied “none agreed on structure, formulation, and practice of their MDT”. A paper by Twomey, Byrne & Leahy6 re-iterated the key points in the MHC document around the key need for the correct ethos, structures and processes for positive teamworking. An earlier large-scale study by De Búrca, Armstrong and Brosnan7 had similarly highlighted the reality that the majority of teams did not have a full multidisciplinary complement, did not measure performance/outcomes, that ‘reflexivity’ was rare in busy teams, and that the majority of team activity occurs at a unidisciplinary level primarily by biomedical (nursing/medical) practitioners. The authors made a range of recommendations amongst them an emphasis on the need for ‘clarity of purpose, shared goals and performance capability […] that translate into key performance indicators’(pg.8).

The review by Maddox2 of the broader international literature highlighted the many diverse challenges experienced by practitioners in multidisciplinary mental health teams. The majority of Irish papers, however, have focussed more on certain key drivers of positive teamwork (e.g. having a ‘Shared Vision and Goal’ – as recommended by De Búrca et al.) while highlighting the absence of these features in teams across the country. It seemed important, therefore, to explore in greater detail why it may be that many Irish teams continue not have a ‘Shared Vision & Goal” and consequently struggle to develop the resulting agreed structures and processes that are necessary for effective teamwork. An analysis that explores the issues of power (defined simply as ‘influence over the actions of others’8) and contested paradigms within CMHTs may provide some helpful understandings in this regard, and illuminate the nature of the challenges inherent in bringing about the changes promoted by previous documents. The focus therefore of this paper is less on the already acknowledged deficits in teamworking highlighted by previous research or on recommending additional measures to foster positive teamwork, as the original MHC document more than adequately highlights these. The focus here is rather a further critical analysis of the some of the key forces that continue to preclude such teamworking and may continue to do so unless directly understood and faced.

 

A Contested Task

The ingredients for highly effective teams have been well discussed within the broader organisational literature (e.g. Mickan & Roger, 20009). One commonly accepted feature of such teams consists of having a consensus on what is the ‘task’ (‘shared mission’) of the team. Having a shared sense of what is the ‘job’ or ‘common goal’ of the team is crucial to the creation of processes and structures by which this task can be achieved. However, where the ‘task’ is contested –where no consensus exists of what is the key job of the team, then the legitimacy of any leadership or structure or processes put in place to achieve such a task will invariably come under challenge.

Within mental health teams starkly different conceptual paradigms of mental distress co-exist which naturally result in often different understandings of what is the ‘task’ of the team. Within a standard biomedical model mental disorders can be best understood as biological illnesses of the brain and nervous system, of largely genetic origin, at times triggered in the individual by environmental stressors. In such a model such diseases are best understood and treated at a biological level (commonly through the use of psychotropic medication but also by in certain cases through ECT or surgical intervention). The task is to diagnose through categorising the reported cluster of symptoms into the correct diagnostic category and ‘treat’ using the best evidence-based treatments for this disorder resulting in the alleviation or elimination of symptoms.

Certain psychological models (e.g. trauma-focussed understandings of mental distress10, 11) would reject the concept of the ‘diseased brain’ conceptualising the behaviour, and reported affect and cognitions, as the natural consequences of a brain acting as it’s designed to do in response to specific environmental experiences. I.e. an individual traumatised by childhood physical abuse, bullying in school and assaults as an adult may naturally develop high levels of anxiety and hypervigilance around others, which could be construed as ‘paranoid thinking’. The ‘task’ then becomes one of fostering healing and the development of more positive and beneficial patterns of thinking through therapy and fostering more benign and interpersonally supportive environments within the person’s life.

Certain social models12, 13 of mental disorders point to the ever changing nature of diagnoses and how marginalised individuals consistently have differences construed as pathology e.g. the presence of homosexuality in previous diagnostic manuals, the admission of unmarried mother in Irish asylums, the placing of political dissidents in psychiatric institutions abroad. They would look at the disproportionately high level of ‘mental illness’ among the poor and disadvantaged and challenge whether these difficulties are best understood as occurring within the individual, rather than the natural consequence of individuals suffering from social, economic and power inequalities in unjust societies. The ‘task’ then becomes one of highlighting injustice more broadly, de-pathologising the individual, supporting them acquire basic resources (housing and money) and subsequently the power (both individually and collectively) to materially alter their well-being and live a freer life.

These differing paradigms may be understood as partially a natural consequence of different training systems wherein different understandings are privileged and different identities formed. Such identities may be less crucial in CMHTs were not the very legitimacy of the practitioner’s actions and beliefs, and therefore their value to the team, dependent on their separate identity.

 

The problematic nature of biopsychosocial / holistic approaches

Attempts to bridge these quite different understandings of mental distress (with the resulting different ‘tasks’ that follow) have arisen through the promotion of a ‘biopsychosocial’ or ‘holistic’ approach (the latter commonly including spiritual needs in addition to biological, psychological and social) to service delivery. Such models have commonly taken an ‘additive’ approach to mental health services i.e. support for ‘biological’ needs and support for ‘psychological’ needs and support for ‘social’ needs. An ‘all must have prizes’ approach, which superficially appears to attend the diversity of need with which service user presents. However, two difficulties immediately arise with this: (1) Conceptually defining a need as either biological or psychological is highly problematic. Without subscribing to Cartesisan dualism (that the mind exists in a separate space from the brain) then effectively such models could be seen as making a philosophical ‘category error’. I.e. it holds that the mind and brain are physically different objects rather the same entity viewed through two different paradigms (one psychological and one biological). Rather than the sparking of neurons causing thinking, the sparking of neurons being thinking. If therefore we are talking about how two paradigms conceptualise the same difficulty, rather than two separate areas of need, then this leads to the second difficulty. (2) The question of power. If the same entity can be understood in different ways (e.g. anxiety as the phenomenological experience of fear and frightening thoughts, and simultaneously as the hyperactivation of the sympathetic nervous system) then which understanding is privileged? Discourses dominated by biological understandings may naturally lead to biological interventions and the prioritisation of resources to facilitate this.  Different paradigms can certainly co-exist and enrich each other in teams. However when attempting to understand why certain decisions are made about resource allocation or treatment type, it seems necessary to acknowledge that the paradigm espoused by the practitioners with greatest power within a team commonly triumphs. Consequently helpful discussions on the use of “biopsychosocial’ models by CMHTs may need to explicitly attend to the conceptual difficulties therein as well as consider how power operates within the team.

 

The challenge of contested leadership

Socio-historical influences may help explain why certain professions currently occupy positions of leadership within CMHTs but they may also help our understanding of why such leadership invariably remains contested. At a paradigmatic level, the legitimacy of leadership based on biomedical expertise will necessarily be challenged by professions for whom biomedical understandings and knowledge do not trump psychosocial (and vice versa). It is in keeping with this to note (as reported by De Búrca et al.)7 that conflict between nursing and medical practitioners is reported as less pronounced than between psychological and psychiatric.

Clinical hierarchies are ubiquitous in healthcare delivery (e.g. a consultant physician overseeing a junior doctor). However, the legitimacy of such hierarchies derive from a consensus that the individual in the superior position has greater knowledge and expertise in a domain that the individuals in the inferior position. When such a consensus does not exist in a cross-disciplinary context e.g. a psychiatrist attempting to clinically oversee a social work intervention, the legitimacy of such a hierarchy and consequently the adherence to such a hierarchy falls. A managerial system which attempts to implement clinical hierarchies without the consent or agreement as to its legitimacy, from those involved, invariably gives rise to problematic team functioning.

Such tensions also operate within a broader social and legal setting of importance, given the role of ‘public protection’ historically held by mental health services. The organisational attempt to exclusively place one discipline as ‘clinical leaders’ within CMHTs poses significant challenges as a consequence of disciplinary conflicts already discussed. In addition any attempt to hold clinical leads as exclusively clinically responsible for service users clashes with the legal reality that all disciplines remain personally responsible for their own clinical actions. I.e. at any disciplinary hearing, civil case or criminal proceedings, no one discipline has no legal power to grant immunity from prosecution to other disciplines. Consequently, regardless of their wishes in this regard, all professionals remain personally, ethically and legally clinically responsible for their own actions with service users. The impact of this legal reality is that professionals of all disciplines cannot simply defer to clinical leads and thereby dispense with any personal clinical responsibility but need, in contrast, to act at all times in keeping with their ethical, professional and legal responsibilities. However, in multidisciplinary CMHTs, individual professional’s determination of what is appropriate (ethically and professionally) will again be largely determined by their disciplinary background, and their definition of the ‘task’ of the service, returning us once more to areas of potential conflict for the team.

 

Contested Structure and Processes

It unsurprisingly follows from the above, that the structures and processes that teams put in place necessarily will be both (a) an expression of where power between competing paradigms currently exist within the team and (b) a forum within which these contested perspectives will play out. Furthermore, in the absence of accepted broader forces to adjudicate decisively on these conflicts, in one direction or another, individual teams will be left to largely battle this out separately in each area. However, the individual solutions that particular teams may come up (whether functional or otherwise) will continuously be open to question when professionals come into to contact with colleagues in other teams. This may leave professionals in the invidious position of operating in teams where no sustainable conclusion to the phase of ‘storming’ (cf: Tuckman14) can ever by fully arrived at, given the competing forces both internal and external to the team.

 

How we got here and the forces that support the ‘status quo’

The socio-historical background to the development of community mental health teams in Ireland bears briefly alluding to. As discussed in more comprehensive detail elsewhere (e.g. Bentall15, 16, Pilgrim and Rogers17, 18) societal beliefs that mental distress represented ‘moral failure’ -with those involved therefore needing to be hidden or punished – were displaced by ideas of mental disorders as ‘medical ailments’. These therefore required ‘care and treatment’ by medical practitioners, aided in this task by nurses, predominately in large asylums (for most of twentieth century). An informal ‘social contract’ whereby medical practitioners took on the role of ’public protection’ (acquiring legal power to detain individuals to ‘protect’ the public from those deemed ‘mad’) facilitated this process and was further reinforced when ‘care in the community’ became the norm for mental health service delivery.  Concurrently, broader societal forces over the last 50years continued to shape our understandings of mental distress with psychological and social understandings gaining greater credence. This in turn led to the emergence of different disciplines, informed by such paradigms, and the insistence of their presence in community mental health teams. However, the emergence of teams with social workers, psychologists and OTs is a relatively recent phenomenon (cf: Vision for Change19) and has brought with it the natural contesting of the ‘task’ of the team as explored above. However the preponderance of biomedical staff in mental health services, has resulted in a biomedical culture (medical hierarchies, medical paradigm of mental distress) remaining the dominant culture within teams7, even while broader society embraced more diverse social and psychological ideas.

 

The broader ‘push-and-pull’ forces towards change faced by CMHTs

A sociological power-based analysis (cf: Pilgrim, 2003)20 would argue that professional ‘guilds’ naturally develop in healthcare domains. In this perspective guilds focus on the promotion of the interests of their own discipline first.  In practical terms this would mean that as new interventions gain credence then particular disciplines will argue that they, and they alone, can safely oversee or provide such interventions, and demand the need for additional resources, or colleagues of their discipline, to achieve this. The more powerful the discipline within a system the more able it is to make this argument and protect pre-existing power structures. Similarly competing disciplines will attempt to use the introduction of new initiatives/interventions as a means of enhancing their own standing and power within the system. Consequently, from this analysis, individual CMHTs will constantly face external disciplinary forces placing tension on the cohesion of the team.

Other forces impacting on teams would include the changing nature of the service user’s relationship with the mental health service provider. The Recovery movement has challenged the relatively disempowered nature of service users within the system and demanded a great say for service users and those that support them21. This has included insisting on representation on management teams and a greater emphasis on particular types of interventions (e.g. talking therapies and family engagement).  These forces of change again may challenge pre-existing relationships and power structures within the mental health system.

Similarly, as Irish society’s views of mental distress and its alleviation continue to develop so does its expectations from its mental health services. It remains, therefore, to be seen whether the current system can successfully adapt within its current power structures to these evolving demands, potentially through implementing relatively minor adaptations in the type of service provided. Or, in contrast, whether these broadening paradigmatic understandings within society will see more radical changes (in leadership, in definitions of the ‘task’ of CMHTs, in the use of resources, in the nature of responses to mental distress) to the structures of, and services delivered by, CMHTs.

 

Conclusion

This paper outlines how differing perspectives of mental distress exist within Irish CMHTs. It argues that while these different perspectives can enrich each other they also naturally give rise to conflict and tensions within teams. It explores how attempts at developing common conceptual overarching models have been problematic and have been insufficient to resolve these tensions. The result being that the issue of power and how it’s exercised within a CMHT comes to the forefront. Consequently an analysis of power and its manifestations, including the ideas and belief systems – the ‘paradigms’ – that underpin the exercise of such power, is crucial to understanding the current functioning of mental health teams within Ireland. It also explores how these tensions have invariably resulted in the key foundations of functional teamwork i.e. an agreed task, and consensus around the nature of authority and leadership within the team, remaining highly problematic.

Tensions within community mental health teams are often viewed by those within teams as unique to that region or to the constellation of personalities within the particular team. However, many of the sources of such tensions may be much broader than the specific teams and lie in fundamental existential questions about the nature of mental distress, the nature of our response to this, the ‘task’ of CMHTs and in the distribution of power broadly with mental health services in Ireland. An open acknowledgement of these ‘structural fault lines’, how such unresolved tensions may mean that CMHTs can be ‘set up to fail’, may liberate individual practitioners from personalising the difficulties they face. It may also make them more powerful to affect real change where required

 

Author

Dr. Pádraig Collins, Senior Clinical Psychologist, Roscommon.

Email: padraig.collins@hse.ie

 

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