Thursday, 27 October 2011

Multi-disciplinary teams, VBP, psychiatry and getting things right

Gloria and I had dinner in Preston with Prof John Cox, our out-going external examiner and ex-President of the Royal College of Psychiatry. John is a keen promoter of medicine for the person (and the work of Paul Tournier) and a humane and spiritually aware form of psychiatry. But about such a form of psychiatry, he is very positive. That is, he emphasises the positive virtues of psychiatry so construed rather than, by contrast, taking those broader values to support the end of psychiatry since it has often failed to embrace them in the past. (I say that because I have also heard people argue for the end of psychiatry precisely because they hold some of those same values: about the importance of the person, meaning, recovery etc.)

One reason for that is this. Increasingly in the UK, mental healthcare is provided by other professions (GPs, nurses, clinical psychologists, neurologists) as well as psychiatrists, acting either individually or in multi-disciplinary teams. On John’s view, psychiatrists are uniquely positioned within such teams to provide a broad overview, spanning the biological to the social, evaluative and spiritual. Thus the diminution of the role of psychiatry threatens loss of that overview.

That suggests an underlying question about what one thinks is the nature and aim of discussion in multi-disciplinary team meetings. A first thought is that the different teams are there for a non-accidental reason. As Fulford and Colombo argued some years ago, different roles within mental healthcare typically hold different views about, or models of, the nature of mental illness and the aims of healthcare. So to omit a discipline is to omit an approach or model and thus to miss the understanding of the situation it might bring to bear. Even if one thinks that such approaches or models are merely pragmatic devices – useful rather than true – that provides a rationale for the multi-disciplinary team. A discipline with an overview of the various approaches would have an overview of their pragmatic virtues.

But there is a more metaphysically charged thought also available. One might think that somehow balancing or accommodating the different views could be done ideally so as to lead to the right answer in the circumstances. The right thing to do would be to look at this situation in this! way. This contrasts with an idea – closer to the spirit of Fulford’s values-based practice – that it is not a matter of aiming at a right answer as rather having a good process. On this less charged view, having a good discussion (with a variety of views) just is as good as it can be. Whatever result emerges as seeming right is as right as right gets (to echo a comment of Wittgenstein’s for the opposite purpose).

On the metaphysically charged view, psychiatry is a kind of master discipline which sees best the facts available (with the other disciplines as intellectual prosthetics). On the less charged view, there is no sense of a right answer to be tracked and, in so far as psychiatry has a special role, it is to organise a fair discussion: a kind of choreographer.

So it seems the view that one takes of the role of psychiatry, the nature of multi-disciplinary teams, values-based practice and the metaphysics of what a correct judgement aims at are all deeply tied together. This leaves me wondering: how should we assess the two broad options for thinking about what getting things right involves?