Dr Neil Armstrong – Why is Mental Healthcare so Ethically Confusing

Co-authored with Daniel D’Hotman de Villiers

In the first St. Cross seminar of the term, Dr. Neil Armstrong talked about ethical challenges raised by mounting bureaucratic processes in the institutional provision of mental healthcare. Drawing on vignettes from his ethnographic fieldwork, Dr. Armstrong argued that the bureaucratization of mental healthcare has led to a situation in which the provision of care involves conflicts of the sort that make it irretrievably morally confusing. The podcast will follow shortly here.

Bureaucratic Accountability

Armstrong begins by detailing the growth of what he calls ‘bureaucratic accountability’, that is, the instigation of institutional relations and arrangements by which agents can be held accountable. In the context of mental healthcare provision, such arrangements include, amongst other things, the increasing need for psychiatrists to document and justify their clinical practice, and increased government monitoring and evaluation. Armstrong notes that increasing bureaucratic accountability marks a shift towards a model of healthcare provision that views service providers as businesses, and patients as customers.

There are some benefits of such accountability – the measurement of performance and the standardization of clinical practice can clearly have some beneficial effects on patient care. However, Armstrong contends that bureaucratization is ill-suited to the complexities of mental healthcare. There are 4 reasons for this: (i) bureaucratic mechanisms are a poor fit for mental healthcare, which often calls for patient-specific psycho-dynamic approaches, (ii) bureaucratization often leads to a reductive and simplistic understanding of mental disorders, (iii) it prioritises understandings of mental health care that are congruous with a bureaucratic approach (such as those favouring pharmacological treatment), and (iv) the psychiatrist’s clinical expertise must blur with the representational skills of a bureaucrat in the institutional setting of mental health care provision.

Jill, Giles and Viv

To further explicate this view, Armstrong appeals to some of his previous ethnographic fieldwork in the institutional setting of mental healthcare provision. Of course, much of the force of an ethnographic approach relies on the intricate details of particular cases. Since this is intended to be only a short summary of the talk, I urge the interested reader to listen to the podcast of the talk for full details.

Although I cannot hope to do justice to Armstrng’s detailed ethnography here, the case study can, all to briefly, be summarised as follows. It concerns, ‘Viv’, whose son is awaiting trial having performed serious sexual offences. Viv appears to be depressed & anxious, but her clinician, Jill, does not believe that she is suffering from a psychiatric disorder – Rather, she believes that Viv’s symptoms are proportionate to her distressing life circumstances, although she also believes that Viv could have an undiagnosed personality disorder. However, after Viv details the extent of her depressive symptoms, and some significant risk factors for suicide, Jill consults ‘Giles’, a consultant psychiatrist. Giles describes several rationales for prescribing anti-depressants to Viv but appears somewhat flippant; it appears that he has no expectation that anti-depressants will benefit Viv, but nonetheless issues a prescription.

Two Questions

Armstrong suggests that this case raises two questions about the conflicts that can arise in institutional settings of mental healthcare provision, in which healthcare professionals may feel compelled to approach their practice in a manner that is incongruous with their own clinical understanding of the situation. He suggests that it forces us to ask two questions: First, how would Jill and Giles approach Viv if the institutional setting were changed (but Viv remained the same)? Second, how would Viv approach Jill and Giles if the institutional setting were changed (but her predicament remained the same)? Armstrong contends that this sort of clinical encounter would differ quite significantly if it had occurred outside of the institutional setting of mental healthcare provision.

Indeed, he makes the provocative claim that it may be impossible for those who provide mental healthcare in an institutional setting to do their job well whilst maintaining sincerity. In part, this is because the moral perception of the healthcare professional in this setting must often become overly narrow and specialised, because they are expected to act in somewhat stereotyped ways to fit the requirements of bureaucratic accountability, and where there can be bureaucratic reasons for making particular psychiatric diagnoses.

In turn, this can lead healthcare professionals to adopt a ‘double morality’, whereby they feel compelled to betray values that they nonetheless profess to maintain. Armstrong illustrates this by drawing an analogy with the cheating spouse who professes to love their partner whilst at the same time fundamentally betraying them in a manner that bespeaks an utter lack of meaningful moral concern.

Armstrong’s discussion of an ethnographic approach to ethics in mental healthcare provision is an illustration of how this approach can reveal new dimensions to ethical questions in this area. In addition to questions about how we should weigh the costs and benefits of bureaucratic accountability, Armstrong’s discussion also raises questions about which of costs of bureaucratization are specific to mental healthcare provision, as opposed to general bureaucratization of healthcare more broadly. Furthermore, at the level of the individual clinician, we may also wonder whether the phenomenon of double morality is a moral sleight of hand that is necessary for them to continue virtuous clinical practice, or whether it is a form of specious ex post rationalization that prevents them from adequately engaging with the problems that the culture of bureaucratic accountability evinces, problems that give rise to the phenomenon of double morality in the first place.