The Intrusion of the Discourse of Economics Into the Clinical Space III: Economic Rationalism and Clinical Effects

ECONOMIC RATIONALISM AND MENTAL HEALTH SERVICES

In recent times, the language and policy documents that emanate from our health ministries reiterate the type of discourse used in the commercial sector. This is not at all to suggest that the public servants who use terms derived from the corporate world have undertaken studies in economics or are deliberately implementing neo-liberal policies. These people at the level of policy implementation, after all, are often drawn from clinical disciplines. Rather, it is a case of the ethos of economics filtering down from above. And, more specifically, the managerial-speak that emanates from government departments is, at least in part, a legacy of the economic rationalist policies and practices that have marked both the public and private sectors, particularly in the past 15 years or so.

This has, of course, been a global phenomenon. The management practices promoted by In Search of Excellence ⁵ were echoed by the economic rationalist policies that were initiated at the same time in the United Kingdom under Margaret Thatcher (1979–1990) and in the United States under Ronald Reagan (1981–1989). Similar changes were introduced in Australia under Paul Keating (1991–1996) and here in the Victorian state government under Jeff Kennett (1992–1999). While governments have changed, the economic approach has not, even if it has softened a little. ^2,6,7

Economic rationalists take their inspiration from the English economist Adam Smith, who in 1776 proposed that the free market is guided in the production, consumption and distribution of goods by the ‘invisible hand’, a notion akin to the then scientific idea that the natural world was a great machine designed by God. Thus the political mantra of the last two decades has been that of ‘unleashing market forces’ and ‘freeing up the market’. It implies that there is a natural order lying dormant under layers of government regulation. ⁶ Dufour ² cites Karl Polanyi from his 1944 work, The Great Transformation, in a citation which currently seems quite prophetic:

Of course we can view the recent collapse of the deregulated market as being the logical consequence of these policies being applied in their reductio ad absurdum. But nonetheless these policies, as we know, have been applied, at times ruthlessly, in the public sector. In fact, the very notion of ‘public service’ has been weakened and now we are concerned about the ‘bottom line’, different hospital departments now being in the hitherto incongruous position of ‘making a profit’, or ‘being in the red’.

Not only have the names of our patients been changed to ‘consumers’, but the names of our services have also changed. Whereas previously each department of psychiatry was named after the hospital in which it was located, and according to the particular orientation of that department, now, according to government policy, the names of services have become standardized as Mental Health Services, seemingly all offering the same ‘product’. The term ‘mental health’ also does away with our traditional name of psychiatry which combines the psyche with the iatros, or doctor, thus nominally de-medicalizing our services.

In mental health the notion of ‘health’ is no longer just a norm, it is an ideal or a utopia (pp. 8–11). ⁸ Charles Melman in fact goes a step further, proposing that mental health is now “an object of satisfaction” (p. 17), ⁹ in other words a product of consumption. In any case, what is implied in this terminology is that there is no longer any psychiatric or mental illness, only differing degrees of ‘mental health’. We could propose that these terms are yet another way in which the dimension of suffering has been eliminated from the clinical encounter. Ironically, despite the euphemism of ‘mental health’, many patients and their families complain about this term on the ‘signage’ of our services as they do not like to be called ‘mental’.

In the late 1990s, following the advent of vigorous economic rationalist policies here in Victoria, came a series of consumer satisfaction surveys which were conducted by private consulting firms at the behest of our funders. As we have already noted in the first article of this series, ¹⁰ a ‘survey’ which seeks ‘opinions’ is not essentially a clinical tool – it is a marketing strategy such as exists in every part of the commercial sector. Our experience with dinner-time telephone surveys, as well as faxed surveys from pharmaceutical companies and the firms engaged by them to target psychiatrists regarding medications, adequately testify to this.

In the questions posed, the surveys had already formulated and thus imposed a particular view of the clinical encounter. One of the questions posed to parents at child and adolescent psychiatry services, for instance, was: ‘Was the advice you received helpful?’, here construing the consultation as a giving of advice, which, depending on the orientation of the clinician, might be a ‘strategy’ that is scrupulously avoided in order to allow the parents to appropriate their own means of resolving their dilemmas. Other questions were plainly trivial, such as: ‘How easy was it to find a car park?’ Of course, the inevitable sequelae to such surveys were the bonuses received by the services with the best ‘outcomes’ obtained through the surveys. Clearly, those in our Ministries of Health are not unfamiliar with behavioural techniques, at least in their crudest form.

Another programme that followed soon after was the Consumer Information Project. ¹¹ Here the idea was again to give bonuses to the winning services in demonstrating their availability of printed information regarding disorders according to the Diagnostic and Statistical Manual (DSM) and medications and other forms of management, pitting mental health services against each other. This was regardless of the fact that, so far as many Child and Adolescent Mental Health Services are concerned, such diagnoses have limited usefulness and medications may be infrequently prescribed. That is, this ‘project’ projected a particular conception of clinical difficulties and their treatment from a policy, not a clinical, point of view.

I make mention of this because it appears to conform to a very economic rationalist view of the world. For the economic rationalists, imperfect information is one of the four recognized forms of market failure, barring consumers from being able to weigh up what they are getting for their money (p. 126). ⁶ That is, we might view a consumer information project as a direct imposition of an economic rationalist worldview upon the clinical field. It assumes that the giving of information is an adequate strategy to address the imbalances in the market in order to redress this ‘market failure’. ⁶

In any case, despite all the market research of the consumer satisfaction surveys referred to, in none of the surveys was there a question asking our patients by what name they would like to be called. This is one point upon which these market surveys are silent. Here we might propose that the place which is allocated to the so-called ‘consumer’ is a place that is fixed in advance, a place determined by the contemporary economic discourse.

SOME EFFECTS UPON THE THERAPEUTIC RELATIONSHIP

If, as we are proposing, the economic discourse penetrates into the clinical space from the side of our funders and administrators, as well as through us, the clinicians, it is also brought in by our patients. That is, within our political and social milieu, we are all subject to the prevailing economic discourse. What we need to consider here is not whether any particular mode of speaking, theory or treatment modality is valid or invalid, but rather what might be the effects of such modalities of speech.

From my perspective as a child and adolescent psychiatrist, we can find instances of the effects of the discourse of management and economics by those who might present to our clinical services recounted in the media. The following is an excerpt from an article by the writer Maria Tumarkin ¹² :

We are then not surprised to find such parents presenting both themselves and their children to our clinical services, given the impossible demands that such modes of being impose upon them, as well as a certain alienation from the particularity of their own suffering and that of their children. This situation is exacerbated by the tendency to conceive of the individual to be but an example of a generalized phenomenon. This is exemplified by parents wanting to find out what they ‘should do’, as promoted by a plethora of self-help books, but also by psychiatric thinking moving away from the individual towards a normative approach. Here again, we can cite Maria Tumarkin:

The notion of ‘parenting’ is already removed from the specificity of what it is to be a mother or a father, being operationalized into a kind of task or ‘skill’. ‘Parenting style’ then takes one step further away again from the immediacy of one's experience in becoming a supposed sub-type of a generalized phenomenon. Again, there is a move away from the particular towards generalities. We now hear clinicians say that there are difficulties in a family because the two parents have different ‘parenting styles’, akin to the generalized notions of ‘personality style’ of the individual. This can become a type of theory of hopelessness as the conception of the parent's struggle as a ‘style’ takes it as something innate or fixed. However, it is only in addressing the particularities of each of the parents with respect to their histories that we have a chance of assisting them in resolving the difficulties that assail them and impinge on their ability to be a mother or a father.

We have already alluded to the promotion of ‘strategic responses’ in the economic discourse, but this has permeated the clinical field such that there has arisen an insistence on ‘strategies’ in our clinical work. Such strategies tend to put the emphasis on a technique, somehow conceived of as being outside the therapeutic relationship. Again, we find a type of imposition of a generalized technique on the individual. Don Watson ¹³ gives a citation from Richard Bandler, the co-founder of Neuro-Linguistic Programming referred to below, a technique on the fringes of clinical practice. Many of us would be aware that some of our patients have had such techniques used upon them. Here the parroting of the word ‘strategy’ (as well as the term ‘creative’) gives an indication of the vacuousness of this term:

An homologous notion inherited from the commercial domain which attempts to operationalize a certain function of the individual and hence of the clinical work is that of ‘skills’ or ‘skill sets’ (p. 343). ¹³ In doing this, the particular function or skill can simply be learned with the right ‘strategies’. Thus, the complex field of social relations can be addressed by ‘social skills training’, the parenting we spoke of above can be learned by a ‘parenting skills programme’, and an excessive passivity can be addressed by ‘assertiveness skills training’. In other words, each of these aspects of our patients can be taken at this superficial level, split off from their history and other difficulties, and always remedied by the right ‘information’.

This trivialization and fragmentation of critical aspects of the psyche are perhaps best exemplified by Charisma Enhancement, now available with Neuro-Linguistic Programming. ¹⁴ As these are trademarked, however, Charisma Enhancement does not come cheaply. Charisma Enhancement, though, has not yet become a mainstay of psychiatric treatment.

In a similar way to which there has been a slippage in the use of the term ‘consumer’, the word ‘management’ now encompasses both the traditional medical concept of clinical management, including case management, as well as the sense of ‘managerialism’ which has crept into clinical services. This slippage perhaps facilitates, and is a result of, the incursion of managerialism in the clinical field, transforming the meaning of the word ‘management’. Thus, our staff is now ‘performance managed’. This latter sense has also acquired a similar semantic scope to that of ‘skills training’, for instance in referring to ‘anger management’.

We need to mention in this regard the modern preoccupation with ‘goals’ and ‘goal-setting’ in which such notions have been directly transplanted from the field of management. In the corporate domain, and also in our public service and hospitals in so far as they now emulate the corporate sector, goal-setting is done with Key Performance Indicators (KPIs): “KPIs are to modern managers what the stars were to early navigation. They set their course by strategic goals and mark them off against results” (p. 31). ¹⁵

As we know, the goals imply that the ‘outcomes’ can be specified in advance, as one might determine the goals for the productivity of a manufacturing firm, something that is not so evident in the clinical field. The demand for goal-setting is now so widespread that it seems heretical to even put this into question. Nonetheless, we could say that the individual service plan in which the treatment goals are specified, is to the individual patient what KPIs are to the organization.

CONCLUSION

What is troubling in the extension of the economic discourse into the clinical domain is that it has occurred in a subtle and unintentional manner, at least on the part of clinicians. And yet the intrusion of this discourse is very tangible and, as I have argued, has a real impact on how the clinical encounter is construed, and therefore has insidiously altered the therapeutic relationship.

It is also of concern that critiques of the effects of the economic discourse and the practices of managerialism have had to come from outside our field. One of the arguments I have put forward is that the advent and extension of population-based approaches have made us more sensitive to the influence of funding and resource-distribution issues in our clinical practice. Such a change in psychiatry, with a heavy emphasis on normative data, which we can date to the middle of the last century with the introduction of the Diagnostic and Statistical Manual, comes with a hefty price tag.

I have put forward that the renomination of our patients as ‘consumers’ is archetypal in the redefinition of the clinical space in economic terms. If we are ‘providers’ who supply a service to a so-called ‘consumer’ then we may not so easily be able to address ourselves to the suffering of the patient, something different to providing a service. When the patient is in our consulting room, he or she is not just an instance of a generalized phenomenon who seeks to pay for a service. He or she is a patient who presents wanting to speak of their suffering in the context of their history and their account of themselves.

I have raised the question of which master we are serving by using the terms derived from the corporate sector. It is not simply a question of serving the policies of the government ministries and functionaries who promote certain policies or privilege managerial modes of thinking. Beyond this, the question I am posing is, whether in unwittingly promoting the commercialization of the clinical space, are we serving the ‘invisible hand’ of market forces along the lines that Dufour describes of the transformation of our society, each one of us included?

In this paper and the previous two in this series, ^10,16 we have begun to discern some of the ways in which the language and thinking of economics has instilled itself into our profession. If we do not allow ourselves to consider these questions, then we become party to the insidious reshaping of the clinical space. To address these changes, we need to study these phenomena as closely as the clinical phenomena of our work. Indeed they are the clinical phenomena of our work.