Participatory leadership in addressing mental health crises: If not now,when;if not you,who?

‘Once more unto the breach, dear friends, once more …’, Shakespeare, Henry V

Around 1513, having been arrested, tortured and exiled; Niccolo Machiavelli wrote ‘The Prince’, in the last chapter of which he exhorts the seizure of Italy to free the country from barbarians. In the face of similar systemic challenges, we exhort psychiatrists to provide leadership in freeing us from the crises of mental healthcare in Australia (Looi and Kisely, 2018). In the context of the challenges facing the mental health system, our profession may feel besieged. However, psychiatrists, as expert medical specialists, can and should cleave to the broad role of leadership in policy, service delivery and collaborative care with patients and their communities. Our conception of leadership in day-to-day practice is achievable within the context of ongoing personnel, morale and material resource shortfalls, but is not limited to administrative or managerial roles. We outline practical developmental steps for psychiatrists to reclaim leadership in the mental health system.

Developing leadership

It is a normal human reaction in times of crisis to focus on survival, which in the clinical setting for psychiatrists entails continuing to care as best we can for our patients with what little resources are available, often at great personal cost in terms of role strain. If psychiatrists are to seize back leadership of the metaphorical Italy of mental health services, we must find ways to cast our view beyond mere day-to-day survival.

We discuss aspects of leadership most relevant for psychiatrists. In its simplest definition, leadership is the act of leading people or an organisation. The contribution of psychiatric expertise to policy, planning and delivery of mental healthcare is a key role for psychiatrists as leaders. The education and mentoring of colleagues and health professionals, as well as supporting patients and the community, is another important dimension of leadership for psychiatrists. In the context of crises in mental healthcare, morale is often impacted in our profession, and across the health sector. Psychiatric leadership can assist individually or collectively with a sense of agency and contribute to effective morale. Providing leadership entails responsibility, yet, as medical specialists we are already responsible for the quality of care that we provide.

Leadership very rarely arises fully formed like Athena erupting from Zeus’s forehead. Neither can we simply don an Aegis to signify our prowess. Mostly our quotidian leaders are mentored, seize at opportunities, or in times of crisis are thrust into their roles. Therefore, we advocate for developmental leadership according to the stage and experience of a psychiatrist.

Initially, a psychiatrist must develop skills to lead the multidisciplinary team with which she provides care, and can seek mentoring from experienced colleagues. Such skills include, but are not limited to communication, collaboration, analytic, strategic, organisational and diplomatic skills. Psychiatrists can learn leadership skills via formal peer review and formal/informal mentoring. To further develop leadership skills, psychiatrists may undertake formal university or professional education such as courses in Health, Public, Policy and/or Business Administration, especially for analytic, strategic and organisational skills. A psychiatrist can serve an apprenticeship in the Royal Australian and New Zealand College of Psychiatrists (RANZCP), American Medical Association (AMA) and/or on non-governmental organisations (NGOs) in voluntary capacities or more formally work in administrative or advisory roles in private or public mental health services to hone communication, collaboration and diplomatic skills.

There are also roles that afford managerial as well as leadership responsibilities such as service clinical director roles. Line management alone encompasses limited aspects of leadership. Optimism was previously expressed for clinical psychiatrists to act in collaborative leadership roles with allied health and non-clinician managers, which would be ideal to effect change (Callaly and Minas, 2005). However, it seems the pendulum has swung such that there is a dearth of psychiatrist leadership and that allied health and non-clinician managers occupy the senior leadership roles in public sector mental health services at least.

Policy

Psychiatrists, on the basis of their broad and deep learning and experience as medical specialists (Looi and Cartledge, 2018), are needed in leadership of mental healthcare policy. Within the Australian context, mental health policy is promulgated at federal, state and local governmental levels. The policy cycle involves a feedback cycle: problem identification, option development, political decision, implementation and evaluation (Whiteford, 2005). The avenues through which psychiatrists can and should be involved in these levels of development of policy include, but are not limited to expert advisory service via peak professional bodies, universities and NGOs. The expertise contributed can be general or specific, across the lifespan and communities.

Examples include the following:

• An old-age psychiatrist might volunteer, via nomination of the RANZCP, to provide advice to the Commonwealth Department of Health in relation to the Aged Care Royal Commission.

• A general private practice psychiatrist might volunteer via the state AMA to assist with the development of Visiting Medical Officer contracts across public and private psychiatry.

• A psychotherapist psychiatrist might volunteer to review the development of e-therapy services funded by a local NGO.

Service delivery and collaborative care

Outside of formal line managerial roles, such as, for example, Chief Psychiatrist or Clinical Director roles, psychiatrists can and should provide expert leadership in the planning, design, delivery and evaluation of mental health services, as well as providing appropriate supervision and education of medical, nursing, psychology and allied health staff/students. Indeed, the skills of psychiatrists can be catalysts for effective change to improve care (Callaly and Minas, 2005). Examples include the following:

• A liaison psychiatrist may design, together with other junior medical officer educators and the local AMA/RANZCP, a mental health support programme for junior doctors.

• A private practice psychiatrist, specialising in care of veterans, might convene a multidisciplinary veteran’s care peer supervision group to encourage interest and expertise in caring for this particular population.

• A perinatal psychiatrist may be interviewed on local radio advocating for better postnatal home visiting services.

Developing further skills

In a broader conceptualisation, psychiatric leadership, management and administration may be properly contextualised as distinct but overlapping roles. An educational curriculum is required (Saeed et al., 2018). Such education has begun through the RANZCP training programme and may benefit from expansion to Fellows via continuing medical education, including, but not limited to, the expertise of the RANZCP Special Interest Group on Leadership and Management and formal education as described above. However, such leadership skills need to be applied in the field, in an apprenticeship as we have highlighted above.

Conclusion

Psychiatrists demonstrate their daily dedication to collaborative clinical care of their patients: it is our collective raison d’etre. Developing leadership skills through apprenticeship in leadership and managerial roles, in private, public and the NGO sectors, combined with formal education, will allow for more effective engagement in mental healthcare. Providing leadership in policy, service design and delivery can enrich, inform and ultimately improve our practice, to better serve our patients and their communities. The time has come for psychiatrists to again lead, in the spirit of Machiavelli’s call for liberation, sallying forth from a besieged system to free mental health services from the shackles of poor policy, planning and practice.