Abstract
Objective
To review the concept, purpose, and subjects of Position Statements of the Royal Australian and New Zealand College of Psychiatrists since their inception in 1971, and to consider changes to enhance their value.
Method
We scrutinised the procedure in producing, revising, and rescinding Position Statements, and the nature of the subjects covered.
Results
Position Statements were initiated by the College Board, various College committees and members. The format and procedures of revising and rescinding them varied considerably. We identified 11 subject areas encompassing professional practice and research, their association with societal developments, and the implications for College policy.
Conclusion
Position Statements have proved to be a dynamic vehicle to keep abreast of significant changes in psychiatry. Methodical appraisal is required to optimise their objective in conveying College policies to members and relevant stakeholders.
Position Statements (PSs) have been an intrinsic feature of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) since their launch in 1971. But uncertainty surrounds their provenance. They were evidently introduced to guide clinical practice, reflect on the interrelationship between psychiatry and societal developments, and to help formulate mental health policy. A systematic assessment of the process that has been used to produce them, and the issues focused on, has not been carried out hitherto. Given the significance of PSs for College policy contributions in several vital areas, we believe an historical review is timely.
Methodology
The College’s electronic record of all PSs created since 1987 enabled them to be readily identified. Those that were not digitised (between 1971 and 1986) were retrieved through a thorough examination of the minutes of Council/Board meetings. An archival tool, Wayback Machine, was used to supplement traditional archival research methods. The 114 statements found from both sources were analysed with the aim of extracting information germane to conducting our historical perspective. Limitations to data collection include uncertainty from non-digitised records as to whether the statement was ever formally published or accepted by the College, as well as limited information on decisions related to rescindment.
The process for producing position statements
The objective of producing a PS, namely the ‘presentation of the College’s stance on issues’, has always been couched in relatively vague terms.1,2 In the early 1970s, generally the committee whose remit was to deal with ‘social issues’ was given the task of devising PSs (after polling members) on a variety of topics such as abortion and homosexuality. During the 1980s, the College established several new committees, which were consulted by General Council (the governing body) in order that it could determine its view on issues it considered relevant to psychiatry, but no longer by polling the general membership.
In 2007, a Committee concerned with College policy (Board of Practice Standards; subsequently renamed Practice, Policy and Partnerships Committee) was assigned by General Council to manage the process. This was deemed necessary as ‘Statements have numerous inconsistencies in their content, context, length, and format… [and] many have subsequently become out-of-date.’ (Kirkby K, pers. comm., 2008). An additional step was introduced shortly thereafter - requiring the Corporate Governance and Risk Committee to envisage and mitigate any risks stemming from the PS.
This procedure of oversight has continued, with the Practice, Policy, and Partnerships Committee (PPPC) judging whether issues identified by the Board, College committees or members warrant the production of a PS. The PPPC drafts a scoping paper, assisted by experts with clinical or research knowledge in the subject under consideration; this document is converted into a PS after a consultative process involving members and relevant internal and external stakeholders, and is submitted to the Board for final approval.
Assessing an issue does not always result in a PS, alternatives such as a media release may be deemed more appropriate.
Revising and rescinding a PS?
Hitherto, a PS has been assigned a date to review its utility at the time it is created, commonly 3 years. For a proportion, the review period is much longer, based on its purpose or the judgement of the Board or relevant committee.
Rescinding a PS is a Board decision exclusively, but in consultation with relevant groups within the College. Rescission has occurred in the wake of substantial changes in the issue or in legislation, or because the statement is regarded as obsolete, inaccurate, contentious, or may bring the College into disrepute.
What issues have position statements focused on?
An overview of all 114 PSs over half a century provides an interesting perspective on how psychiatrists as a professional body have addressed societal issues and clinical practice.
Most statements have demonstrated a commitment to promoting social justice such as criticising laws that discriminate against members of the LGBTIQ+ community or calling for better services for migrants, refugees, and asylum seekers.
Regarding practice, the College has questioned the adequacy of services, first in the mid-1970s when shortage of ‘manpower’ became a matter of considerable concern (Manpower needs for psychiatrists, 1978), followed by appeals for an expanded workforce and defining the role of psychiatrists in multidisciplinary mental health teams.
The College has also used statements to influence optimal application of treatments, like condemning the employment of discredited interventions such as Deep Sleep Therapy (adopted 1992), or dispelling stigma associated with effective evidence-based treatments, for example, Electroconvulsive Therapy (2019). These positions have had a different focus to other types of College documents on treatment (e.g. professional practice and clinical memoranda) that guide psychiatrists on how to deploy best possible treatments.
All position statements from 1971 to 2023 identified using the methodology described
Parents, infants, children, and young people
The very first PS supported Abortion Law Reform in response to the political battles waged during the 1970s. Highlighting the College’s early interest in the changing role of women in the workforce, statements were produced on ensuring adequate provision of support for children of employed parents (Family day care, 1974; Substitute childcare in the community, 1976). The need to develop apposite clinical services for women and children was also emphasised around this time (Admission of mothers and babies, 1971; Child psychiatric services in Australia and New Zealand, 1972).
In the early 2000s, attention turned to vulnerable children (Child sexual abuse, 2003; Children of parent with mental illness, 2005; Children in care, 2005), and the need to advocate on their behalf. Conversely, other statements (Sexualisation of children in the contemporary media, 2008; Addressing the needs siblings of children with disability or chronic illness, 2011) were rescinded after only a few years when it was determined that their focus was overly narrow.
Older people
The centrality of holistic and age-appropriate approaches to addressing mental illness in older people has been recognised for over 30 years in the College’s longest standing currently active statement (Psychiatry services for older people, 2019). First published in 1987, and repeatedly revised, the PS has demonstrated advances in mental health care in accordance with principles of promoting recovery, fostering independence, respecting dignity, and recognising cultural and linguistic needs. The value of a multidisciplinary approach has been consistently stressed, particularly the interface between mental health and general practice (Relationships between old age psychiatry and geriatric medicine, 2022).
Aboriginal and Torres Strait Islander people
Respecting the special needs of Indigenous communities in light of the College’s commitment to culturally sensitive care has been highlighted in a series of statements. The role of the psychiatrist in Aboriginal and Torres Strait Islander mental health (adopted 1980) called for better integration of services, including the place of Aboriginal and Torres Strait Islander mental health workers. In 1999, the College apologised for the role psychiatrists had played in perpetuating the Stolen Generations tragedy (Acknowledging the Stolen Generations, 1999). Another focus has been the Recognition of Aboriginal and Torres Strait Islander peoples in the Australian Constitution (adopted 2011) as part of rectifying past unjust practices.
What form have position statements taken?
The substantial variation in the format of PSs is striking. Their length has ranged from one to 11 pages, with little evidence to suggest that shorter statements have been less relevant. Sub-titles have covered summary, purpose, recommendations, key messages, resources, provenance, record of revisions (if any), and date of a review.
Other sections, among them background, evidence, research, and definitions of terms, have overlapped substantially. There are notably differing levels of detail. For instance, some have provided an extensive list of definitions, others none. The inclusion of research findings from literature review in the document has sometimes been extensive, and at other times less so.
The purpose of a PS, essentially why the College has considered it relevant, has oriented us to the subject in most cases, but not always explicitly. A clear statement of purpose and context for all PSs is likely to help the reader understand their utility and reason for adoption in the first place.
Recommendations for action and key messages, inevitably covering the same terrain, have been presented in diverse ways. In some PSs they are merely a couple of points; in others an extensive list (20 or more). Although this degree of detail has proved illuminating, the links between the components have sometimes been tenuous and short of integration.
Finally, three technical points: • The heading entitled Resources, essentially a guide to further reading, appears at the end of most PSs. They assume a broad range of forms, among them, other College statements, references of journal articles, and titles of governmental reports. It appears to be an arbitrary choice as to the number and type of resources cited. • Reference to a review is rarely mentioned, conveying the impression that the PS is envisaged as a ‘one-off’ exercise. When a review period is defined, this is not made publicly available. • The provenance of a statement is not always explicitly stated; we are thus left ignorant about who raised the need for it and how their initiative was pursued.
Recommendations
Based on our findings, we propose that the role of the PS should be appraised systematically with the aim of optimising its utility for members and relevant stakeholders. We recommend that the following five aspects would benefit from a fresh look: • A transparent process in how a decision is made to create a PS to deal with a specific issue – who proposes the idea, and how is it expedited. • Creation of a template to maintain consistency of what is covered as well as to minimise the risk of omitting a salient feature. • An explicit articulation of the purpose of the PS at the outset in order to orient the reader. • Determination of when it should be reviewed made publicly available, with a degree of flexibility to conduct an earlier review if necessary. • Share the reasoning with all members following a Board decision to rescind a PS.
Conclusion
The PS has proved to be a dynamic vehicle to keep abreast of significant changes in psychiatry and society and their interrelationship, and to draw attention to their implications for College policy, clinical practice, and conduct of research.
However, we surmise that consideration of our recommendations has the potential to enhance its impact on members and other stakeholders.
Footnotes
Disclosure
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
