Abstract
One of the well known parables on leadership is about geese. When wild geese fly, as each goose flaps its wings it creates an uplift for the bird following. By following in a ‘V’ formation the whole flock adds 71% greater flying range than if the bird flew alone. When the lead goose gets tired it moves back into the flying formation and another goose flies at the point position. The geese in formation cry out from behind to encourage the goose in front to keep up their speed. It is not the cry, but the flight, the movement and air dynamics created that gives the effect of leadership.
I have been interested for some time in the role of psychiatrists as leaders in the delivery and in the development of mental health services, and also as leaders in the wider context of community and society. In this Presidential Address, I will explore whether my interest has a basis in reality, or is just a fantasy. Do psychiatrists make good leaders? Are we in a position to provide leadership? And if so, how should we do this?
First of all, it is important to explore what leadership actually means. It has become a very glib phrase and somewhat popular in recent years. ‘Leadership’ is the catch phrase of the 1990s, just as ‘accountability’ was the catch phrase of the '80s. It is written and talked about greatly in the media. The idea of leadership for a new millennium is much explored: academically, politically and in communities. Indeed, we are in a phase of looking back at the old millennium, at who have been the leaders over the last 1000 years, and seeing what can be learnt from their styles and their achievements to take into the year 2000 and beyond. Unquestionably, our world, our society, our countries, our workplaces and our homes have become much more complex. There is a greater cry for leadership to be shown in organisations and in governments. We all seem to want a sense of direction, someone to guide us, someone to help us find meaning and purpose in the complex lives that we lead, and quite often, someone to tell us what is the right thing to do.
Bennis and Nanus say of leadership: ‘Leadership is a word on everyone's lips, the young attack it and the old grow wistful for it, parents have lost it and police seek it, experts claim it and artists spurn it, while scholars want it. Philosophers reconcile it (as authority) with liberty, and theologians demonstrate its compatibility with conscience. If bureaucrats pretend they have it, politicians wish they did. Everybody agrees there is less of it than there use to be' [1].
Specific university departments have sprung up all over the western world, with titles such as ‘Department of Leadership Studies’. There is now a definitive body of literature and research developed over the last 10 years or so, which has grown out of management research and knowledge. Leadership is comprehensively studied and analysed and much written and discussed.
But what does leadership actually mean in action and what does it mean for psychiatrists as we confront the challenges of changing delivery of mental health services, changing paradigms, expansion in knowledge and therapies and confined funding?
Myths about leadership
There are a lot of myths about leadership. Again Bennis and Nanus outline these [2]. People believe it is a rare skill. It has been said that leaders are born, not made, and that leadership competencies cannot be learnt. Leadership attributes can be learnt: learning to be a leader is like learning to be a parent or a lover. There is a belief that leaders are charismatic. It is true that some are, but most leaders in our community and in our world are not. It is also a myth that leadership exists only at the top of an organisation. There are multiple leadership roles in any organisation and in any community. It is thought that a leader controls, directs, probes and manipulates. This is perhaps the most damaging myth of all. But leadership is about the empowerment of others, not about the exercise of power. The essence of leadership is the capacity to build and develop self esteem of others. In some of the literature, it is thought that a leader's sole job is to increase the shareholder value where, in fact, the leader's first concern is to build and maintain a viable and successful organisation.
Definition of leadership
The word ‘lead’ comes from an Anglo-Saxon root which means path, road or journey, and it has the same derivation in other European languages. In Old English, we encounter ‘load stone’ which means a ‘way stone’, a stone that marks the way or the journey, and ‘load star’ which is the word for the north star, which has traditionally guided people on their journeys. The essence of the derivation of ‘leadership’ is that it is integrally connected with a journey towards something or some place [3].
What is leadership?
There appear to be four key elements of leadership that are best described by Bennis and Nanus [4] but which are consistent in other writings. These are: (i) vision, (ii) communication, (iii) trust and (iv) the deployment or application of oneself.
Vision
First, all leaders have a sense of direction, a vision for the future which can be a vague dream or a definitive goal. Definition of that vision comes from interpreting the environment and the world in such a way to focus on a sense of purpose and direction. All leaders study the past and the present in order to move towards the future, but the future is not – nor should it be seen to be – like the past, but is conceived as a better way and, often, the only way. Within this vision or purpose the leader takes a world view, looks at the international scene, understands the peripheral environment, as well as the core goals and business of an organisation, and is constantly reviewing this to revise the direction and journey.
However, a vision by itself brings little leadership unless this can be communicated to others who can be enlisted to share this as a joint and mutual future. Thus the vision has to be clear, it has to be attractive to others and be attainable.
Communication
The second key characteristic is meaningful communication. This is more comprehensive and multifaceted than just good systems of information, written or electronic. It can occur by personal commitment or by developing collegial and peer relationships that are non-hierarchical or by developing a personalistic style of being bigger than life or by putting in processes and procedures to ensure communication takes place or, as is often the case, by most or all of these.
Trust
The third key characteristic is trust. This needs to be earned by the way in which the leader behaves, by what the leader says. It incorporates such characteristics as predictability, consistency, honesty, integrity, excellent interpersonal skills, with listening and relationship-building. Such trust comes from actions. It is the ‘knowing’ that the goose which leads the way will continue to fly until it is tired, and that goose trusts instinctively another goose to take its place. It is about credibility and having a track record.
Deployment or application of oneself
Lastly, leadership involves deploying oneself by setting standards or ethics, having values, building a community of mutual trust and common interest, the ability to be persistent, to take risks and accept failures and to challenge and accept challenges. Most importantly, it is about understanding oneself, and continuing to learn. This self-knowledge and learning is one of the most important issues of leadership. It is the ability to incorporate a continual learning process of review and re-evaluation, learning new skills, new methods, learning about new products or new treatments. Application of oneself as a leader is about how one behaves, how one understands one's behaviour and one's own personal characteristics. And, overall, being able to laugh at oneself, being able to joke about one's strength and one's failures.
Leadership behaviours
Underlining these four key elements of leadership, the literature refers to certain behaviours or characteristics which accompany successful leadership [5,6]. These are:
(1) To challenge and take risk
This is the ability to challenge, to step outside into the unknown, to search for opportunity, to experiment, to take risks, to look for new answers, new therapies, new treatments and new knowledge; to have intellectual energy and curiosity.
(2) Being future focused
To be constantly future focused is to be continually reinventing the future; to learn and understand from the past, but not relive or reinvent the past; to have a breadth of vision of what can be achieved.
(3) Collaborating with others
This involves demonstrating the ability to enable others to do, act and achieve, to foster collaboration, to strengthen others and above all, not to alienate people; to have courage in relationships, especially when conflict must be resolved, but also to be comfortable in dealing with ambiguity.
(4) Being a model for others
Being a model, to model the way, is to set an example, to set achievable goals where there are small successes which are seen as the milestones on the way ahead; to show an awareness of the human spirit in understanding the yearnings and struggles of others.
(5) Demonstrating excellent interpersonal skills
Leaders show they care about people by recognising individual contribution, celebrating successes with them, and allowing and respecting their dignity and uniqueness; leaders demonstrate integrity and discernment in decision making and recognising their own vulnerabilities.
All these behaviours are observable and can be learned. There is nothing mystical about them. These are all behaviours that make a good psychiatrist. Within the context of being a good psychiatrist, and with each individual patient and his or her family, to facilitate challenge and risk taking is part of the therapeutic process. As psychiatrists, we are focused on the future well-being of the patient as our goal, we model and celebrate small successes, we collaborate and foster collaboration and we are finely tuned to the nuances of interpersonal relationships. Within our therapeutic relationships we are focused on the future with the patient, and aim to share a vision and pathway. We build trust through meaningful communication and the way we understand and deploy ourselves within the therapeutic alliance. Psychiatrists already learn all these key elements and behaviours within the context of a therapeutic or treatment environment. The question of further developing these and applying them to being leaders in a wider and equally challenging context is considered later in this address.
Leadership styles
The literature suggests there are various ways or styles through which leadership can be demonstrated, of which a number are applicable to the role of a psychiatrist. Adair outlines these well [7].
First, there is leadership through knowledge, perhaps best demonstrated by Plato, Socrates and other ancient Greek philosophers. This includes leadership through the search for, and gaining of, new knowledge, breaking new boundaries and communicating that knowledge to others. Within psychiatry, this is leadership through psychiatrists' demonstrating their knowledge about the complexity of human beings, the bio-psychosocial nature of the human mind, and then communicating evidence about therapeutic interventions.
Second, there is leadership through being a mentor or what one might call a ‘first companion’ in an apprenticeship-type model of learning. The word mentor comes from Greek mythology, from the island, Mentor, on which Odysseus left his son Telemachus entrusted to an old friend. The goddess Athena took on Mentor's shape to help Telemachus in the difficulties which befell Ithaca during his father's absence. Under Mentor's tutelage, the young man eventually became a seasoned leader. Mentorship is fundamental to psychiatry, as it is also to the rest of medicine. Every time a psychiatrist supervises a trainee, the psychiatrist is being a leader. Every time we walk side by side as a ‘first companion’ with a peer in a difficult clinical situation, we are demonstrating a style of leadership.
The third kind of leadership is one often shown by explorers, adventurers and the early men who led the fight for new territory, for example Alexander the Great. These are leaders who challenge boundaries, who search for new lands or ideas and have a quest for conquering almost impossible barriers. Many wars have been fought, victories won and territories defended by such people, and many lands and much knowledge discovered.
The fourth style of leadership, and the one that perhaps is most common in the Western world, is endowed by power or position, either by status through birth or elected status or gained status. This can be from the most famous rugby player who inspires the nation, right through to the Prime Minister or the local community priest or the principal of a school. Such leaders may bring other personal styles and strengths which are instrumental in them acquiring such status, but ‘leadership’ is also bestowed on them by their position.
Leading by example is a further style of leadership that uses influence rather than power. This influence is usually by the deployment of oneself, using knowledge with certain personality strengths and interpersonal skills. Such an example was demonstrated by Ghandi in India. And most psychiatrists will know a wise senior psychiatrist in a department who also uses such an approach.
Last, there is the leadership style best described by the ancient Chinese philosopher Lao Tzu, where leadership focuses on enabling others, which can be paraphrased as: ‘The best leader doesn't say much but what he says carries weight. When he is finished with his work, the people say “we did this ourselves” '. This is the ‘servant/leader’ concept which is embodied in several religions. It is the concept of leading from behind, like being a shepherd of sheep, or the concept of the ‘shepherd/king’ parable. De Pree has [8] likened this kind of leadership to that of a jazz band. The leader of a jazz band brings the best out of other musicians and combines the unpredictability of the future of the music with the gifts of individuals. The jazz leader is also a follower.
No style is pure and many leaders have more than one, but all will be showing the four key elements of leadership, that is, vision, meaningful communication, trust and applying and knowing oneself.
What does this all mean for psychiatrists and for the College?
What vision do we have for the future?
Any vision is influenced by what we know of the environment internationally and in Australia and New Zealand, and what appear to be the sociopolitical influences on the health of our nation and on our health services delivery.
In reviewing international and Australian–New Zealand trends in psychiatry and the role of psychiatrists within mental health service delivery, it seems clear that psychiatrists will be far more grounded in medicine in the future. Psychiatrists will be much more like physicians than like psychologists or other mental health professionals, and will probably operate much more as consultants and highly specialised doctors working collegially with others, rather than predominantly as sole or direct care practitioners. From trends seen internationally and in New Zealand, it is very likely that within 20 years, maybe sooner, nurses and probably psychologists will be able to prescribe a limited range of medicines. Already some professional groups are being trained in specific and targeted psychotherapies. Much of these international trends is associated with obtaining the best outcome for consumers or the community within the funding available. Although these trends are relatively new, there is no evidence thus far that outcomes for patients are any worse for these changes, and may in fact be somewhat better, as consumer surveys reveal that they feel less stigmatised by other professions compared with psychiatrists.
It is important not to expect that the healthcare system we have today is necessarily that which will be here tomorrow, nor to stay wedded to the past or present because it seems to have worked well for us or for our patients. We must be open to new ideas, new thinking, new models of funding and of delivery so long as the outcome for patients and the community is as good or better. White et al. [9] compare the challenges of leadership today and in the future with steering in a ‘white water’ environment where there is little certainty, except the turmoil of the water, and where we are riding on the hurling and swirling rapids. In such a changing world we too have to change and develop to survive, but the act of changing increases the risk that we may not survive and stay above the rapids. It can be exciting and exhilarating if we choose it to be.
As White et al. put it, ‘we have no choice, but to operate in this new world shaped by globalisation and information revolution, and the new environment dictates two rules. First, everything happens faster, and secondly, anything that can be done will be done, if not by us, then by someone else, somewhere. These changes do lead to a less kind, less gentle and less predictable workplace and world.’ [10]
Leaders in such a world need to develop a high tolerance of disorder and that, after all, is an integral part of the training of psychiatrists: a high tolerance for ambiguity, ambivalence and disorder. That is why I believe that if psychiatrists are trained and skilled, we can make good leaders.
In terms of being leaders, it is important that psychiatrists take note of the international trends and build into our vision for psychiatry understanding and interpretation of these trends, even accommodating them. We could try to fight these trends, but my view is that we will not win. We need to build a vision that focuses on a role for psychiatrists as leaders, as coordinators, working collaboratively with others; a role which demonstrates that because of our knowledge and skill as psychiatrists, we carry the integrated picture for each patient, or for services. Psychiatrists see the whole picture: the medication required, the kind of psychotherapy needed, what life skills training is needed, how the person's cultural or spiritual beliefs will assist them, how the social and political policies of the day affect them, and what assistance can be given because of these or despite these.
I believe that psychiatrists are and should be the most broad-banded of specialists, in the sense that Mant [11] uses this term, meaning that intelligent leaders are knowledgeable and skilled across many ‘bands’ or areas. Psychiatrists need to be highly knowledgeable and skilled in multiple paradigms: biological paradigms, the psychological paradigms, the whole spectrum of social sciences, economics, ethics and political science. We would also be wise to understand the spiritual dimension of human beings and how this differs enormously between cultures. Psychiatrists are the only medical professionals who are required to be knowledgeable in all of these areas in order to integrate them into the assessment and treatment of all individuals and their families. It is clear that all that knowledge cannot be obtained in the short few years before qualifying for Fellowship of the College, so it behoves us to continue our learning in all of these paradigms in order to be the kind of leaders that we will need to be.
Additionally, psychiatrists need to develop a vision for how we will work in an integrated world where specialty mental health services will have a greater interface with primary health, not just with general practitioners, but other primary practitioners such as advanced nurse practitioners, community providers and ethnic health services, and with consumer workers, carer workers, community workers and cultural workers, as well as other medical specialists. We will increasingly be working within a system whose major driver is the empowerment of individuals away from a model of dependency on psychiatrists as doctors or dependency on the medical system. This is not any different from the model existing for people with diabetes, cancer or many other chronic physical illnesses, including major disabilities.
Some might say, ‘but mental illness is different’; it is a ‘different kind of beast’ that saps people's independence, requiring them to enter into intense professional relationships such as that which psychotherapy demands, in order to start to rebuild some of their damaged personalities. Some aspects of this will be true, but the assumption that this is the only model is currently being challenged, and will continue to be challenged, as there is, as yet, little evidence that this therapeutic dependence can encourage, enable and empower individuals towards recovery and independence. These views might be seen as heretical and challenging one of the very fundamental principles of psychiatry, but I believe that we need to re-examine the complex issues embodied in the doctor–patient relationship, so that this can be perceived to be more healing and less creating of dependency.
We are moving to a future where in 20–30 years there may be fewer psychiatrists, although perhaps not in New Zealand where current numbers of psychiatrists are too low and too few; but in both New Zealand and Australia, we will be challenged to look at how psychiatrists will work differently, and by the knowledge that much of what psychiatrists do now could be done just as well or better by other and less costly professionals, or by other models of health care delivery. On this issue much more open and informed debate is needed. We are in the midst of a revolution in mental health care, one that is moving us away from an institutional or hospital-based form of treatment to a variety of treatment models based in the home involving family or community support, or in day treatment settings or in supervised accommodation. We are still in the middle of this revolution in the developed world. Some developing countries have managed this much better than we have, although they may have not been confronted to the same extent with moving through a difficult transition from detaining people in hospitals to caring more appropriately for them within our own communities, these cultures may be more used to seeing mental illness as part and parcel of every day life, just as physical illness is.
Within 20–30 years psychiatrists will need to relinquish the sole privilege of the doctor–patient relationship, except for a small number who will have highly developed skills to work intensively with a very few patients. Psychiatrists will be seen much more as professionals who have the overview of the patient care, who coordinate the care, who advise and consult. There will always be a number of patients for whom psychiatrists will be the prime and even the sole therapist, but our principal role will be one of a specialist consultant.
The role of psychiatrists can be likened to that of the unifying theme of a musical symphonic work which integrates the whole composition. All of this means psychiatrists' building strong relationships with other professions, and with consumers and their organisations, and accepting that community groups, consumers and carers also bring skills to this therapeutic model. It will be most unusual for any psychiatrist to be working alone in 20 years time. Rather, the psychiatrist will be working alongside and with other people, including consumer workers who will be part of the team. Telemedicine, computers and other information technologies will be readily used to assist in ensuring greater access to treatments.
Vision is one of the key elements of leadership for the psychiatrist as leader, and without this element there is no leadership. In order to build and maintain a vision for psychiatrists and psychiatry in 20 years time, we need to:
Continue to analyse and understand the environment and future trends.
Focus on being broad-banded, knowledge and skill based experts.
Collaborate with other professionals, consumers, carers and the community.
Be the integrators of knowledge and skill for each patient and for mental health service delivery, and
Strongly and solely focus on maintaining standards of mental health practice and achieving the best outcome for patients, consumers and the community.
The other three key elements of leadership; communication which is meaningful, building trust and ‘just doing it’ (i.e. the deployment of oneself) are all embodied in these five aspects. It is a colourful weave of skill and knowledge that is required in what we bring, not just to the care we give each patient, but the leadership we need to show.
These issues are not new and no doubt have been expressed more eloquently by others. Like the continually changing first goose in the geese parable, leaders in the College have been saying and talking about these issues for some years; not just current or previous Presidents, but leaders right throughout the College, at Branch level and in other bodies. Like the geese flying in formation, leadership in the College and in psychiatry at the front or top is only as good and effective as leadership right throughout the group. What is important is the collegial and collaborative approach and, most importantly, the direction that we are heading.
I have referred to ‘not fighting these trends’. This will seem anathema to many Fellows who see around them a much less kind and less predictable world which adversely affects us as psychiatrists and, most of all, those whom we serve: our patients. In saying this, what I mean is that psychiatrists are most effective if we develop what Mant calls a ‘ternary’ relationship with power-brokers (governments, funders etc.) to create a win-win solution [12]. Like psychiatrists, the governments in both New Zealand and Australia usually want the best for people, and it is imperative that we work with them for the same ultimate goal. We are more likely to be successful and to influence the direction and outcome with this approach. A binary relationship, in Mant's terminology, or a win-lose approach, will mean that psychiatrists will be more frustrated and much less likely to influence the direction. Such a ternary approach is a hallmark of Mant's ‘intelligent leadership’ where psychiatrists bring vision, knowledge and expertise and, with leadership, influence the direction of change by focusing on standards of care and what is the best outcome for patients and the community.
Such leadership will ensure that psychiatrists are the protectors of, and the protagonists for, the standard of care and treatment for individuals, based on best evidence and best practice to achieve the best outcome. While psychiatrists are the protectors of standards, this must not be seen as being ‘protectionist’ of ourselves. The approach must also be seen as being inclusive of others. The principal aim is the application of best knowledge and evidence, and the quest for better knowledge and evidence. In this relationship, psychiatrists are seen as teachers and those who impart knowledge to others. As researchers, scientists and mentors, psychiatrists carry the vision for the best outcomes and the best service, also focusing on what we know will prevent mental illness and promote better mental health care.
Psychiatrists are trained to focus on mental illness. Very few psychiatrists have opportunities to think about the prevention of illness or the promotion of better mental health care for individuals. There is a growing body of evidence suggesting a relationship between the increasing prevalence of depression, substance abuse and anxiety disorders, and complex social issues such as poverty, unemployment, increased violence, alienation and disempowerment of individuals, of cultures, of nations and of other groups. The College and, indeed, individual psychiatrists, have been very tardy in speaking out about these relationships, partly because as yet they lack a rigorous scientific evidence base and the links are complex and multifactorial. However, if psychiatrists are truly to be seen as leaders, understanding all the broad paradigms and the complexities and interactions that go into making up human beings, families and societies, we should be developing a larger role in discussing the relationship of some mental disorders to the wider social issues.
We need to lift our aim and vision, we need to be focused on the kind of future that we are facing and the outcomes we expect for patients, for families and for the community. For example, we cannot avoid being involved in the debate on rationing of health care; we cannot avoid aiming at the best results or the best value for money, and looking at how these decisions should be implemented to the best advantage in both New Zealand and Australia. We need to be seen not only to be interested in this debate, but to be actively involved and to provide leadership on the difficult ethical aspects of those issues.
Jaques defines levels of authority, complexity and talent [13]. Levels 1–3 focus on quality, with ‘hands-on skill’ and the systems supporting this for good practice. Levels 4 and 5 focus on modelling new futures, repositioning and having an overview of the purpose in the context of the organisation or issue. Levels 6 and 7 deal with the international context and sustaining long-term viability. Psychiatrists largely operate at levels 1–3. My advocacy to College Fellows is that we need to also be operating at levels 4 and 5 and, at best, levels 6 and 7.
It is a complex and difficult challenge to lift our thinking to a systems level, while maintaining focus on quality and best outcomes for patients.
Conclusion
Leadership is about pointing a direction for the future, at the same time as developing an idea, issue or organisation for that future. It is about building and maintaining trust with clear communication and, above all, increasing the knowledge about ourselves and the world so we can develop ourselves intelligently and wisely in the pursuit of attaining a mentally healthy society. Similar concepts of leadership occur in different cultures. In this paper I have used the parable and visual imagery of geese in flight, but the Chinese talk of wild ducks. There is an old Chinese proverb which says: ‘Not the cry, but the flight of the wild duck leads the flock to fly and follow’. As a College of Psychiatrists, we have much to do to improve and master our flying!