I’ve got a bit of a theory about multi disciplinary teams. It’s this. The more people in a multi disciplinary team, the smaller the concentration of power. In fact, I believe there’s quite a bit of evidence that shows that although the team may consist of dozens of professionals, the power is often held by just one person. And often that person is the responsible clinician. You hear professionals bang on about “flattened hierarchies” but that’s normally a fog hiding a lethal, centralised power base. I remember the uncomfortable hour in court when the social care manager, armed with four A4 landscaped charts stapled together, trying to explain to Justice Jackson how the decision making process worked. After an incomprehensible narrative, Justice Jackson threw his arms in the air and cried “this is impenetrable”. The Judge voiced what everyone in that courtroom was thinking – the explanation, rather than illuminate, clouded.
A couple of examples. I’ve written recently about the plight of Jack Smith, trapped in an ATU in Birmingham. Jack had been looking forward to some home leave over the Easter weekend. Understandably, his hope carried a huge anxiety and on Wednesday he found that anxiety impossible to contain. The Responsible Clinician, the psychiatrist, immediately cancelled Jack’s home leave. Her rationale? ” To teach him about boundaries”. Eve’s posts became increasingly heartbreaking as she reported how Jack went into a cleaning frenzy, (his room, the communal dining room) in an attempt to win the psychiatrist over. At the time of writing, this hasn’t been successful. Despite the recent support Eve has received from NHSE, everyone shrugged their shoulders and said they couldn’t intervene. The CCG, the LA, the social worker, all bowing to the power of the psychiatrist. I find this incredible. When the 15 odd members of Jack’s multi disciplinary team turn up for the next review meeting, do none of them question the wisdom, or psychological validity of this decision? It would appear not. One person’s decision is final.
I sat in court at LB’s Inquest for the tail end of Dr Valerie Murphy’s evidence. She was the psychiatrist and responsible Clinician. It was Dr Murphy, who had decided that Connor hadn’t been having seizures and she was clinging onto that position in court. Her position led directly to Connor’s death. She was followed in court by another psychiatrist from the MD team, although she didn’t carry the power of Dr Murphy. Despite the obvious coaching she’d received from Southern Health’s consultants, her evidence was both deeply uncomfortable and infuriating. It was clear that she disagreed with the responsible Clinician but didn’t have the bottle to challenge her. Another position that led directly to Connor’s death.
During his time in the ATU, Steven didn’t have a responsible Clinician. It wasn’t run by the NHS. Justice Jackson expressed his constant frustration in not being able to unravel who made the decisions. The Hillingdon witnesses tried to present a united, clouding front. That somehow things moved along with a momentum that had nothing to do with any one individual. I’ve never bought into that presentation. Clearly, decisions were made. Hundreds of them. The two big ones were, (1) Steven must be held in the ATU and not come home, and (2), he would be moved to the hospital in Wales. Somebody, at a MD meeting, must have spoken those words, made those suggestions. One thing is clear from the social care records, is that if anyone in the MD team disagreed with any of the decisions, they were removed from the team. The learning disability nurse, the support agency manager show up in the many minutes as challenging decisions. They then mysteriously disappeared from future meetings. My belief is that all the major decisions were made by the social worker.
But this throws up two different propositions. Dr Valerie Murphy was obviously an egotist, with a terrifying self belief. Plus, in terms of her hierarchal position, she held an enormous power. People speaking up against her would have a lot to lose. She could end careers. It was quite different with Steven’s social worker. She was a long way from being the most senior member of the MD team. But I know other members of that team, both above and below her, and they were very weak individuals. I’m not just talking about people prepared to compromise their integrity. It’s something more basic than that. Fundamental human weakness. You may remember my dream about the social worker on her pink inflatable, sailing down The Thames. Now, a pink inflatable is not exactly the most robust material on which to build your power base, but if your followers are weak, it serves its purpose.
I had a client who I saw for several years. He was a lovely bloke who had collected several mental health labels over the years. He had an MD team “working” for him. I saw him, first and last, as a survivor. Medicated to the eyeballs, he continued to hold down a full time job. His Responsible Clinician didn’t see him that way at all. She saw him as an “unstable, manipulative man”. From her reports, she obviously didn’t like him. My client was terrified of her. Every encounter he had with her brought on a dreadful threat of being sectioned, of losing his job, of losing his independence. She once told him, ” I have more say than your manager over whether you keep your job”. When it came to his three monthly appointments with the psychiatrist, my client would meet me the day before for some “coaching” (I’d hear myself saying – “You can’t tell her that. She’ll have your guts for garters) and we’d meet the day after for a debriefing. In the end, she won. He swore at her. She doubled his medication. This made driving unsafe. He couldn’t get to work. An example of the Responsible Clinician acting totally irresponsibly.
I don’t know the answer. But as they say, power corrupts. And when all the power is in the hands of one individual, we are in very rocky waters. The Mental Capacity Act is no help in these situations because the Responsible Clinician will be using the full clout of the Mental Health Act to wield power and silence dissenters. And we can’t seem refuge in Carl Rogers and person centred powers.
My client believed in karma. It was one of the things I used to try and dissuade him from discussing with the psychiatrist. Perhaps he was right. Perhaps, we just have karma as our only hope for equalisation.