1 00:00:00,150 --> 00:00:06,000 I caught this. I said, why is mental healthcare so ethically confusing? And it occurs to me, I don't know, it's confusing. 2 00:00:06,000 --> 00:00:08,970 A kind of category that we can use. 3 00:00:08,970 --> 00:00:13,980 I do have something in mind, and I'm hoping that in the questions you might help me get a bit more clarity on what I mean. 4 00:00:13,980 --> 00:00:18,180 I do mean something more than just complex or more than just contested. 5 00:00:18,180 --> 00:00:26,220 I think I want to say something about mental health care, that of irretrievably complex or irretrievably difficult. 6 00:00:26,220 --> 00:00:31,710 And I think it's irretrievably difficult because some of the things that we might use to try to make sense of ethics, 7 00:00:31,710 --> 00:00:41,930 things like being consistent or being sincere or not being hypocritical, aren't possible mental healthcare. 8 00:00:41,930 --> 00:00:53,630 OK, that's got your interest. Now, the structured possession is. 9 00:00:53,630 --> 00:01:01,100 Gotcha. Okay, so just three little parts, really. What I'm going to do is introduce some ideas about bureaucratic accountability to suggest 10 00:01:01,100 --> 00:01:05,000 that the institutional setting of mental health care is what makes it ethically confusing. 11 00:01:05,000 --> 00:01:10,000 Talk about 10-15 minutes about that. Then I'm going to read a little bit of ethnography. 12 00:01:10,000 --> 00:01:15,140 So this is drawn from my PhD fieldworker. All the people are annonomised 13 00:01:15,140 --> 00:01:17,680 I've concealed kind of where it took place and so on. 14 00:01:17,680 --> 00:01:25,280 And I'm going to kind of read that to to give you some kind of really fine grained data that I'm then going to try to pick apart a little bit more. 15 00:01:25,280 --> 00:01:33,980 So I'm going to kind of suggest, I suppose, two particular ways that we might think through just what is so confusing here. 16 00:01:33,980 --> 00:01:37,700 Why is it that the clinicians and the patients behave in the way that they do? 17 00:01:37,700 --> 00:01:42,800 Because I think it's it's really not obvious. And I think it be very easy to miss. 18 00:01:42,800 --> 00:01:47,720 Actually, you know, it's the sort of thing I think in the earlier part of my fieldwork, these sorts of things are happening all the time. 19 00:01:47,720 --> 00:01:53,060 And I just didn't get it. And then later on, I began to think I'm beginning to kind of see what's going on. 20 00:01:53,060 --> 00:01:59,860 So then so, yes, I'm going to discuss how the ethnography illustrates the problem of ethical confusion and the suggested ways of thinking about it, 21 00:01:59,860 --> 00:02:07,190 then are going to raise some concerns about the implications and ask questions. 22 00:02:07,190 --> 00:02:11,720 So bureaucratic accountability. Where would you go to find out about this? 23 00:02:11,720 --> 00:02:16,650 Obviously the Oxford Handbook of Public Accountability, which I just sort of read so you don't have to be honest, 24 00:02:16,650 --> 00:02:20,000 although it's a lot more interesting than you might think. So at heart, 25 00:02:20,000 --> 00:02:26,630 bureaucratic accountability is institutional relational arrangement in which 26 00:02:26,630 --> 00:02:32,840 an agent can be held accountable by another agent or institution not holding to account. 27 00:02:32,840 --> 00:02:37,500 Sounds like a nice thing. But how do you do it bureaucratically? You do it through documentation. 28 00:02:37,500 --> 00:02:43,730 If you're working in a bureaucratically accountable way, whatever it is that you're doing, you'll likely be documenting it. 29 00:02:43,730 --> 00:02:48,340 And then that documentation is likely to be a means by which you're going to be evaluated. 30 00:02:48,340 --> 00:02:52,910 Are you doing the right things? I codings behaving according to norms and so on. 31 00:02:52,910 --> 00:03:00,000 You also need arrangements where the actors can be questioned or investigated and judgements can be made very often. 32 00:03:00,000 --> 00:03:04,820 , there's much more emphasis on negative judgements or sanctions rather than positive ones. 33 00:03:04,820 --> 00:03:08,210 So classically, this is going to apply to all working lives. 34 00:03:08,210 --> 00:03:11,600 It applies to, you know, I mean, kind of across the board, really. 35 00:03:11,600 --> 00:03:16,370 People are increasingly subject to these sorts of mechanisms of bureaucratic accountability. 36 00:03:16,370 --> 00:03:26,160 A large part of your job isn't. So it's doing what you do, but it's recording what you do in such a way as to show that you've done it properly. 37 00:03:26,160 --> 00:03:30,660 So where does it come from? Well, it's associated with neo liberal institutional reform. 38 00:03:30,660 --> 00:03:40,170 So it's sort of coming out of Chicago. Chicago school economics in the U.K., these sorts of institutional reforms actually arrived in New Labour. 39 00:03:40,170 --> 00:03:44,010 So kind of reining in health care. And again, there may be people who know more about this than the me in the room. 40 00:03:44,010 --> 00:03:49,000 But in health care, the Tories kind of set up the conditions for these sorts of changes to be made. 41 00:03:49,000 --> 00:03:56,820 But actually, they didn't really kind of manifest until until Tony Blair smiled his way into number 10. 42 00:03:56,820 --> 00:03:58,960 So government creates a distance. 43 00:03:58,960 --> 00:04:04,620 The idea, implicit government creates a distance between itself and service providers rather than governments doing stuff for us. 44 00:04:04,620 --> 00:04:10,400 We kind of have these service providers that do it on the government's behalf and on our behalf. 45 00:04:10,400 --> 00:04:13,900 And that allows the service providers to be reconceived. 46 00:04:13,900 --> 00:04:20,060 They start to be seen as businesses like universities, increase evenings, visiting businesses, perhaps. 47 00:04:20,060 --> 00:04:25,530 And that kind of special businesses, because they're not just trying to maximise profit, but they're accountable. 48 00:04:25,530 --> 00:04:29,080 So they stop. It starts to become if you work for one of these service providers, 49 00:04:29,080 --> 00:04:34,530 you're going to have to stop documenting what you do quite carefully because you're going to be held accountable to stakeholders. 50 00:04:34,530 --> 00:04:38,970 So he said these are new ways of framing work that people do. 51 00:04:38,970 --> 00:04:42,990 The thought might be then that market mechanisms can make things efficient, 52 00:04:42,990 --> 00:04:48,990 whereas consumer choice can make a better fit between what services are being provided and what people really want. 53 00:04:48,990 --> 00:04:56,610 Potentially, people thought that might really kind of change healthcare. And then the role of the government is to monitor and evaluate. 54 00:04:56,610 --> 00:04:59,430 So the government has this kind of hands off from if you're a cynic, 55 00:04:59,430 --> 00:05:03,750 you say it means the government can't be blamed so directly for the failings of the NHS. 56 00:05:03,750 --> 00:05:08,740 But what kind of serious ideas behind this is what to make me. Maybe this is a good idea. 57 00:05:08,740 --> 00:05:13,500 I do know there are certain things that makes it appealing. 58 00:05:13,500 --> 00:05:17,780 I think I mean, this isn't an automatically just take a terrible thing. 59 00:05:17,780 --> 00:05:22,020 It mean it comes really, I think, from a very particular kind of morally maxillary. 60 00:05:22,020 --> 00:05:30,690 I mean, I think this sort of accountability comes from a world where imagining a world is quite knowable and that's quite manipulable. 61 00:05:30,690 --> 00:05:35,400 And you might say, well, look, outputs and inputs can be measured now from unaccountable bureaucracy. 62 00:05:35,400 --> 00:05:40,230 Processes can be standardised and documented. Isn't this really quite a good thing? 63 00:05:40,230 --> 00:05:44,610 Individual actors can be monitored. Again, a good thing. 64 00:05:44,610 --> 00:05:48,900 It's good to stamp out amount practise that people are kind of doing or are able 65 00:05:48,900 --> 00:05:54,110 or willing or for some other reason doing what they're supposed to be doing. You're gonna be able to get some hard evidence of that. 66 00:05:54,110 --> 00:06:01,170 Work can be evidenced in quality, documented, not very good cases in healthcare of people doing things by customer, 67 00:06:01,170 --> 00:06:05,190 by tradition that actually turn out not to be very helpful. You can kind of can do a trial. 68 00:06:05,190 --> 00:06:09,940 You can work out if it works and then you can change what you're doing. You even measured the efficiencies. 69 00:06:09,940 --> 00:06:15,390 You can think also about safety. So in all this kind of looks, it looks nice. 70 00:06:15,390 --> 00:06:22,560 And you might think, well, shouldn't this be making mental healthcare not more ethically confusing, but kind of ethically simple? 71 00:06:22,560 --> 00:06:23,070 Should it? 72 00:06:23,070 --> 00:06:31,910 Shouldn't this make it really like a kind of walking in a kind of, you know, evidence park of effectiveness and and sort of streamline efficiency? 73 00:06:31,910 --> 00:06:37,170 You can telling and say no. Now, here's. 74 00:06:37,170 --> 00:06:40,620 Albert Einstein is not normal again, topologies go to authority. 75 00:06:40,620 --> 00:06:47,250 But he did say this nice little thing, which kind of captures part of the problem, not everything that counts can be counted on. 76 00:06:47,250 --> 00:06:53,670 Everything that can be counted counts. This is kind of in a way that's kind the heart of of what I'm concerned about here. 77 00:06:53,670 --> 00:06:58,440 But, of course, anthropologist's, I think quite quick on the scene to start thinking about accountability, 78 00:06:58,440 --> 00:07:04,320 cultures of bureaucratic accountability or the managerial revolutions that sometimes called up. 79 00:07:04,320 --> 00:07:10,590 There's a reason why really anthropologists do kind of long term, immersive, non-invasive kind of fieldwork. 80 00:07:10,590 --> 00:07:16,380 You know, we hang around and watch what's going on. We listen to what people say they're doing and then we watch what we really do. 81 00:07:16,380 --> 00:07:25,140 Always two different things. And so in a ways, it's some it's the methodology that slowest to reach a firm view. 82 00:07:25,140 --> 00:07:28,260 Anthropology can be agnostic an extremely long time. 83 00:07:28,260 --> 00:07:32,610 So if you if you come to the field and want to find out about something, we have preform questions. 84 00:07:32,610 --> 00:07:35,670 You've already made a few assumptions. And the beauty of anthropology, 85 00:07:35,670 --> 00:07:43,520 the strength of it is we don't necessarily do that in the field determines our research questions to a certain extent, at least. 86 00:07:43,520 --> 00:07:48,330 Marilyns to Thurn edited. This is kind of key early. Volume audit cultures. 87 00:07:48,330 --> 00:07:51,960 She she looked at how whether technologies that come from. 88 00:07:51,960 --> 00:07:57,060 She said the concept of the audit has broken loose from its moorings in finance and accounting. 89 00:07:57,060 --> 00:08:05,220 Its own expanded presence gives it the power of a descript or seemingly applicable to all kinds of reckonings, evaluations and measurements. 90 00:08:05,220 --> 00:08:12,990 She was particularly interested in higher education and the way that in a way, what people do is being transformed by this process of documentation. 91 00:08:12,990 --> 00:08:18,000 It's like the carts pulling the horse, Willy. It's like this this stuff that's supposed to be just checking that people are doing what they're 92 00:08:18,000 --> 00:08:24,600 supposed to be doing starts to change what it is that they're doing. there are a particular kind of concerns. 93 00:08:24,600 --> 00:08:28,000 So David Graeber has written recently a book called The Utopia of Rules, 94 00:08:28,000 --> 00:08:34,320 which is a bit of a kind of rant kind of book as some of David Graeber's are. There's high quality ethnography to support this, 95 00:08:34,320 --> 00:08:40,110 but I quite like the punchy statement. He says bureaucratic knowledge is all about schemata ization. 96 00:08:40,110 --> 00:08:46,110 In practise, bureaucratic procedures invariably mean ignoring all the subtleties of real social 97 00:08:46,110 --> 00:08:52,360 existence and reducing everything to preconceived mechanical or statistical formulae. 98 00:08:52,360 --> 00:09:00,270 Whether it's a matter of forms, rules, statistics or questionnaires, it's always a matter of simplification. 99 00:09:00,270 --> 00:09:04,430 I think they should raise the kind of concern if we're thinking about mental healthcare. 100 00:09:04,430 --> 00:09:08,430 Surely that's ignoring all the subtleties of real social existence. 101 00:09:08,430 --> 00:09:11,700 It's a risky thing to be doing in mental health. 102 00:09:11,700 --> 00:09:17,220 It's surely that the subtleties of real socially existence are what, bringing people into their clinic in the first place. 103 00:09:17,220 --> 00:09:28,780 So this kind of a concern about wethers and an accountable bureaucracy is really a very good fit for this kind of mental health work. 104 00:09:28,780 --> 00:09:30,720 There's a lot to that kind of landmark. 105 00:09:30,720 --> 00:09:37,800 Ethnography of mental health by Tanya Nermin, published in 2000, which I can recommend for people who are interested. 106 00:09:37,800 --> 00:09:46,470 She's really writing about how psychoanalytic and psychodynamic psychiatry and mistakes was superseded by more biological, 107 00:09:46,470 --> 00:09:50,130 pharmaceutical driven psychiatry. 108 00:09:50,130 --> 00:09:56,700 And she's in a way, she offers a kind of subtle, quite a multifaceted kind of account and something that she doesn't develop, 109 00:09:56,700 --> 00:10:01,170 but she does nonetheless notice is that part of what's going on is that you have a lot of 110 00:10:01,170 --> 00:10:05,890 psychiatrists having to make phone calls to the insurance providers to pay for treatment, 111 00:10:05,890 --> 00:10:11,100 to have to justify everything they do. You've got a patient. You think they need to be hospitalised, you've got to be stopped. 112 00:10:11,100 --> 00:10:16,020 Call the insurance company if they've been if they've declared six days in a ward. 113 00:10:16,020 --> 00:10:21,400 But you think that the patient is a suicide risk and want to stay another six days, you have to make a phone call. 114 00:10:21,400 --> 00:10:28,090 There's an awful lot of liaison between the psychiatrist and other responsible clinician and the insurance company. 115 00:10:28,090 --> 00:10:35,670 And she writes like this. She says, The more time date the psychiatrists spend on the phone with insurance agents negotiating 116 00:10:35,670 --> 00:10:40,800 for six day admission to be extended to nine days because a patient is still suicidal. 117 00:10:40,800 --> 00:10:46,260 The more administrative interviews they need to do, the more discharge some risk they need to type, 118 00:10:46,260 --> 00:10:51,870 the less the way support an experience of psychodynamic psychotherapy fit in, 119 00:10:51,870 --> 00:10:57,840 the less they seem relevant or even real on the more psychiatrists are willing to fall back on the 120 00:10:57,840 --> 00:11:05,570 ideological position that the cause and treatment of mental illness is biological and psychopharmacological. 121 00:11:05,570 --> 00:11:07,500 And this is a really interesting observation. 122 00:11:07,500 --> 00:11:13,000 So the first thought we you know, we think of bureaucracy as a kind of iron cage, that kind of Iberian idea. 123 00:11:13,000 --> 00:11:16,820 You know, you put the clinician or at you any other worker, 124 00:11:16,820 --> 00:11:22,500 But since we're talking about mental health, we're putting them into an accountable bureaucracy that would constrain the choices that they make, 125 00:11:22,500 --> 00:11:26,160 perhaps perhaps that will force them to behave in ways that they wouldn't like for them not to behave. 126 00:11:26,160 --> 00:11:32,040 But still, that's it's still the bureaucratic frame. What Learmont suggesting is a bit more than that, really. 127 00:11:32,040 --> 00:11:36,210 She's saying the sorts of the ways of imagining the world, the ways of thinking. 128 00:11:36,210 --> 00:11:41,700 Mental illness. The ways of treating mental illness. The best fit form filling documentation. 129 00:11:41,700 --> 00:11:46,500 The mechanisms of accountability start to feel more real. 130 00:11:46,500 --> 00:11:52,360 There's lots of kind of anti psychiatry people would say, oh, big Pharma has completely taken over and corrupt psychiatry. 131 00:11:52,360 --> 00:11:58,540 I think what a different case that is making here. What is giving us the resources to talk you here so much is Big Pharma. 132 00:11:58,540 --> 00:12:05,800 It's the institution itself. It's just quite difficult to be psychodynamic and produce notes which don't expose you to risk. 133 00:12:05,800 --> 00:12:16,910 As a clinician, this is a kind of very important idea to just just wrote nine Akhmatova's in a really lovely book about bureaucracy. 134 00:12:16,910 --> 00:12:20,660 She's really talking about government institutions in the Himalayas. 135 00:12:20,660 --> 00:12:28,270 But one of one of the kind of centres of what she's writing about is how very often clinicians being at clinicians, 136 00:12:28,270 --> 00:12:33,160 these are government bureaucrats are being asked to do things that aren't quite doable. 137 00:12:33,160 --> 00:12:38,740 And you begin to realise what bureaucratic expertise is, is something representation quite so much what you do. 138 00:12:38,740 --> 00:12:43,330 It's about learning to be very good at representing what you may or may not have done. 139 00:12:43,330 --> 00:12:48,570 She puts it like this. Agents of the state know that rules can never be followed to the letter, 140 00:12:48,570 --> 00:12:56,850 that energies are directed instead at making it appear as if the alleged abilities are being overcome, as if orders are being followed. 141 00:12:56,850 --> 00:13:00,220 So, you know, this is a kind of really striking thing, 142 00:13:00,220 --> 00:13:07,650 because presumably it's slightly similar remarks made by David Moss in this account of development work that successful 143 00:13:07,650 --> 00:13:13,530 development projects are the ones you can represent according to current trends and what a successful project looks like. 144 00:13:13,530 --> 00:13:22,020 What happens on the ground? So the substance I think the reason for this quiet I'm trying to be polemical, too, is you can tell. 145 00:13:22,020 --> 00:13:25,230 So I'm hoping we're going to get some nice questions now. 146 00:13:25,230 --> 00:13:30,210 So I suggest that I think kind of foolish reasons why accountability might be a source of ethical confusion. 147 00:13:30,210 --> 00:13:35,310 And I'm wanting to be heavy handed. Just gonna remind you of them before I meet my bit of ethnography. 148 00:13:35,310 --> 00:13:40,780 So this report that imported bureaucratic mechanisms don't necessarily fit mental health care, 149 00:13:40,780 --> 00:13:46,410 that even if we think these are good things, that might be the root problem of how well do these things fit together? 150 00:13:46,410 --> 00:13:54,930 Bureaucratic mechanisms are associated with accountability. A reductive and simplistic mental health care is complex and nuanced understandings 151 00:13:54,930 --> 00:13:57,870 of mental health that are suited to accountable practise a favourite loss. 152 00:13:57,870 --> 00:14:06,600 Others lose ground or seem less real, and expertise as a condition blurs with a representational skills of a bureaucrat. 153 00:14:06,600 --> 00:14:13,430 So I am hoping that it starts to look, if not ethically confusing, at least very complex. 154 00:14:13,430 --> 00:14:19,470 Okay. Now, I'm going to talk a little bit about Jill Charles. 155 00:14:19,470 --> 00:14:25,690 I'm going to read this out because I said that the detail is the key thing. 156 00:14:25,690 --> 00:14:31,840 OK, Vivint, a family, were widely described as being well known to services. 157 00:14:31,840 --> 00:14:33,640 It's an ominous phrase. 158 00:14:33,640 --> 00:14:41,670 It means they received input from a wide range of sources, social services, mental health care and the police, as well as a local charity. 159 00:14:41,670 --> 00:14:45,490 We've recently came to the attention of a mental health team that I was working with 160 00:14:45,490 --> 00:14:50,470 following the arrest of one of her sons for a string of serious sexual offences. 161 00:14:50,470 --> 00:14:55,030 The case was locally notorious and received extensive media coverage. 162 00:14:55,030 --> 00:14:59,740 Five was briefly admitted to a psychiatric ward as an informal or voluntary patient. 163 00:14:59,740 --> 00:15:06,880 She was discharged a few days later and was due to come and see a CPA called Jill, who I worked with quite long. 164 00:15:06,880 --> 00:15:11,740 I asked Jill about what kind of person is she? What kind of care did the team provide? 165 00:15:11,740 --> 00:15:20,980 Joe said that she was depressed and anxious. She's feeling guilty about her son and his crimes and hated by the other members of the local community. 166 00:15:20,980 --> 00:15:27,070 She talks about wanting to kill herself. And in the view of the team, she presents a substantial suicide risk. 167 00:15:27,070 --> 00:15:31,670 But Jill stressed they want to provide the minimum care possible for her. 168 00:15:31,670 --> 00:15:39,010 If I asked why, you replied, We don't believe Viv has a mental illness, she explained. 169 00:15:39,010 --> 00:15:43,190 They think that Viv was depressed, but she doesn't suffer from a depressive disorder. 170 00:15:43,190 --> 00:15:47,440 She's anxious, but she doesn't suffer from an anxiety disorder. 171 00:15:47,440 --> 00:15:52,390 The reason for this is that her distress seems broadly proportionate to the environment. 172 00:15:52,390 --> 00:15:58,900 Joe describes it as normal depression. She added that Viv has plenty to feel depressed and anxious about. 173 00:15:58,900 --> 00:16:06,040 How would we feel? Jill asked if we were in her position. Jill articulate this in terms of stressors. 174 00:16:06,040 --> 00:16:11,120 The level of stress is very high and so the level of distress is very high. 175 00:16:11,120 --> 00:16:17,760 However, Jill also explained that Viv's personality is being taken into account. 176 00:16:17,760 --> 00:16:25,650 Jill said that the team feels that V.F. has personality issues or definite personality traits. 177 00:16:25,650 --> 00:16:27,360 This is coded language. 178 00:16:27,360 --> 00:16:35,220 Maybe I should just insert four were hinting that we think she has a personality disorder, but we haven't diagnosed with a personality disorder. 179 00:16:35,220 --> 00:16:37,710 That's kind of what that means. 180 00:16:37,710 --> 00:16:45,230 She says that the team take the view that these personality issues are important when thinking about appropriate treatment. 181 00:16:45,230 --> 00:16:49,050 We'll put it to me this way. Mental illness is something that could happen to anyone. 182 00:16:49,050 --> 00:16:52,770 To me and to you who you are. Does it make any difference? 183 00:16:52,770 --> 00:16:56,700 It can just come and take your life away. But with personality is you. 184 00:16:56,700 --> 00:17:05,150 Who's the problem? She went on to say that personality problems have their origin in childhood, either an abuse or neglect. 185 00:17:05,150 --> 00:17:12,200 As I understand it, she recalls vivid childhood as causing dysfunctions or pathologies that are distinct from mental illnesses, 186 00:17:12,200 --> 00:17:15,080 but of the same order of magnitude. 187 00:17:15,080 --> 00:17:23,240 She says that these problems go on to shape character such that the patient finds it hard to lead a functional or fulfilling life. 188 00:17:23,240 --> 00:17:28,850 To talk more about how his depression and anxiety are caused in part by her personality, 189 00:17:28,850 --> 00:17:34,130 she has poor coping skills, for example, at a time when she has a lot to cope with. 190 00:17:34,130 --> 00:17:43,520 Joe says that like many people with personality traits, if his poor self soothing, I noticed that Joe's reticent when talking about these issues. 191 00:17:43,520 --> 00:17:51,770 She goes on, but she talks in a rather cautious way, almost like a politician in a tricky interview, choosing her words carefully. 192 00:17:51,770 --> 00:17:56,210 I felt unsure how sincere Jill was about this personality issues. 193 00:17:56,210 --> 00:18:01,860 She was able to talk convincingly in a way that would be required for team meetings or medical documentation. 194 00:18:01,860 --> 00:18:08,030 But I thought her heart wasn't really in it. This gave some of her words a slight, ironic edge. 195 00:18:08,030 --> 00:18:14,440 Now a timestream field work. I sense the rhetorical power of a particular variety of understatement. 196 00:18:14,440 --> 00:18:16,340 On one occasion during a team meeting, 197 00:18:16,340 --> 00:18:23,360 which a female CPM community psychiatric nurse described to the team how a male patient had been sexually aggressive towards a very 198 00:18:23,360 --> 00:18:29,060 sexually aggressive and norm in the normal world had been incredibly sexually aggressive towards the world of mental health care. 199 00:18:29,060 --> 00:18:32,930 They have to get used to a lot of stuff. So let's say a sexually aggressive towards her. 200 00:18:32,930 --> 00:18:37,680 She used phrases when describing it to the team like, oh. 201 00:18:37,680 --> 00:18:44,730 He had a really poor sense of personal boundaries, and I did detect some impulse control issues. 202 00:18:44,730 --> 00:18:52,970 These anodyne, non judgemental, bureaucratise terms acquire rhetorical force through understatement, though immensely effective. 203 00:18:52,970 --> 00:19:00,570 Know the room goes quiet when someone says things like that. But with Jill, I felt we witnessed some sort of grey area as well. 204 00:19:00,570 --> 00:19:04,710 I don't think she accepted the personality disorder model, but neither did she reject. 205 00:19:04,710 --> 00:19:08,460 With regard to VIFF, her stance was undefined. 206 00:19:08,460 --> 00:19:16,170 Jill went on to say that instead of looking to her own resources, which might already have become dependent on services. 207 00:19:16,170 --> 00:19:20,730 She wanted to be in contact with Jill every day, either by phone or in person. 208 00:19:20,730 --> 00:19:27,100 Jill seemed wary. She thought this might need to Viv losing skills where she might benefit from improving them. 209 00:19:27,100 --> 00:19:31,800 I know it's hard to joke. But life is hard. You have to learn how to cope. 210 00:19:31,800 --> 00:19:36,240 She said she didn't want exaggerating her distress to secure attention. 211 00:19:36,240 --> 00:19:48,150 Manipulative behaviour like that is expensive and it diverts us from our real job could easily become a burden on services while in the same process. 212 00:19:48,150 --> 00:19:52,910 Losing her autonomy and self-reliance. In their dealings with VIFF, 213 00:19:52,910 --> 00:19:59,300 Jill said the team had made sure not to prescribe any medication that aims to restrict the scope 214 00:19:59,300 --> 00:20:06,780 of any dependency that may create by basing her treatment on generic support offered by Joe. 215 00:20:06,780 --> 00:20:11,000 Now, I was quite excited to meet. By this stage, I have to say. 216 00:20:11,000 --> 00:20:16,940 But before without me just may say what a strange man I am. But let's stop before before we go to the meet. 217 00:20:16,940 --> 00:20:22,730 Joe steps into the waiting room to introduce me and to ask if it's okay for me to be present in the appointment. 218 00:20:22,730 --> 00:20:27,240 I stand behind her as she introduces me as a researcher in medical anthropology. 219 00:20:27,240 --> 00:20:33,540 Vivi sitting with a sister who we understand will stay in the waiting room, which seemed slightly expectant. 220 00:20:33,540 --> 00:20:38,930 So excited. Joe Stressless, I don't have to be there that the appointment can go on without me. 221 00:20:38,930 --> 00:20:43,530 But a tone suggests there's no reason why not. Viv seems pleased on that. 222 00:20:43,530 --> 00:20:49,820 She asks what medical anthropology is. I explain. Oh, as a research student and actually I thought she's a little disappointed. 223 00:20:49,820 --> 00:20:54,500 I wasn't more senior, but nonetheless, he was pleased that I was around. 224 00:20:54,500 --> 00:20:57,380 So having established, I'll join them if rises quickly. 225 00:20:57,380 --> 00:21:05,720 When we walked together down a long corridor and into a tiny room seems too small and it's made worse, frankly, by my presence, airless and cramped. 226 00:21:05,720 --> 00:21:13,460 There's barely enough space for a table, and three chairs were forced into physical proximity to salts on the other side of the table. 227 00:21:13,460 --> 00:21:25,350 And I sit next to VIFF as if I'm I'm sort of her ally. Jill begins by asking, but talking quite neutrally about how things been going. 228 00:21:25,350 --> 00:21:31,220 This starts to talk about how depressed she's been. She says she can't sleep and she finds it painful to be alive. 229 00:21:31,220 --> 00:21:36,530 Jill notes, listens and a simple questions is having contact with her son. 230 00:21:36,530 --> 00:21:41,900 Remember that? Who's committed the offences currently being held on remand? 231 00:21:41,900 --> 00:21:46,760 She says no. Is she in touch with the other children? She says yes. 232 00:21:46,760 --> 00:21:50,420 Jill is supportive, but without offering opinions or advice, 233 00:21:50,420 --> 00:21:55,220 she tends to repeat back what Jill says or make remarks such as that must be very painful. 234 00:21:55,220 --> 00:22:02,840 I can see how difficult that is. If starts to discuss how she feels that her husband is supportive but doesn't understand. 235 00:22:02,840 --> 00:22:08,210 She also says she's getting forgetful at work. She presents itself, was overwhelmed by her feelings. 236 00:22:08,210 --> 00:22:12,560 Most are kind of baffled by them as well as she talks. 237 00:22:12,560 --> 00:22:18,330 She scans Jill quite carefully. She says it's all too much to cope with. 238 00:22:18,330 --> 00:22:25,680 She describes how she comes downstairs in the night, unable to sleep, tormented by intense, overwhelming feelings. 239 00:22:25,680 --> 00:22:30,010 Hours go by sitting alone on the sofa, not knowing what to do. 240 00:22:30,010 --> 00:22:34,690 We've continued saying, oh, no. She's thinking of killing herself. 241 00:22:34,690 --> 00:22:40,230 She very much wants to do it. But she's held back by concern for her younger children. 242 00:22:40,230 --> 00:22:44,310 There's a pause as Jill offers me assurance and comfort. Life goes on. 243 00:22:44,310 --> 00:22:47,420 No, drinking doesn't help. You've told me about that and I don't do it. 244 00:22:47,420 --> 00:22:52,680 And I feel terrible. But she starts to cry. She says, I can't manage. 245 00:22:52,680 --> 00:22:56,760 It's all too much. Hunched over the table, her body tenses and shakes. 246 00:22:56,760 --> 00:23:03,240 She hooks herself and grass gasps for breath. Jill hands her a box of tissues. 247 00:23:03,240 --> 00:23:08,230 She wakes her Viv to compose herself, sitting perfectly still. Take your time. 248 00:23:08,230 --> 00:23:13,950 It's OK. There's no hurry. Just take your time. Viv returns to the topic of medication. 249 00:23:13,950 --> 00:23:20,760 She says she doesn't want tablets because she knows they don't help. But she knows she needs something because nobody could bear what she's buried. 250 00:23:20,760 --> 00:23:28,110 Nobody could be go through what she's going through. Might there be some tablets that could help something that help her cope to take the pain away? 251 00:23:28,110 --> 00:23:38,910 Otherwise suicide. So with that. Jealous still might want to go as if she might want us to go and speak to the doctor about antidepressants. 252 00:23:38,910 --> 00:23:45,300 She said yes. We got up and went to find Giles, the consultant psychiatrist, as we were leaving. 253 00:23:45,300 --> 00:23:49,790 Jill said, you'll be all right. What you for a few minutes while I speak to the doctor. 254 00:23:49,790 --> 00:23:57,180 We've agreed that you'll be fine. Now, Charles's office is further down the corridor, which explains to Giles what's happening. 255 00:23:57,180 --> 00:24:02,490 She says Viv seems very depressed and is talking of suicide. The risk seems to be real. 256 00:24:02,490 --> 00:24:09,930 So might it be worth giving her antidepressants? Joe says he can see the might be a justification for describing antidepressants. 257 00:24:09,930 --> 00:24:14,580 Then he asked me what I think. Now I'm out of my depth. I don't know what to say. 258 00:24:14,580 --> 00:24:21,270 So he talks through a possible rationale that she's very distressed that antidepressants might help a bit, 259 00:24:21,270 --> 00:24:25,560 that she's at risk of both suicide and of developing a depressive illness. 260 00:24:25,560 --> 00:24:34,010 And anyway, antidepressants won't do any harm. Just find several ways to justify prescribing antidepressants. 261 00:24:34,010 --> 00:24:40,160 But his tone suggests he's slightly flippant. I don't think he has any expectation that the medicine will be effective. 262 00:24:40,160 --> 00:24:48,740 Perhaps even that you'll even take the pills. He went on to say the notoriety of his son's crimes make her a very high profile case. 263 00:24:48,740 --> 00:24:57,550 And the team needs not to take unnecessary risks because they'll be looking after it for the next six months, at least as they wait for the trial. 264 00:24:57,550 --> 00:25:00,320 There might be safer to put her on medication. 265 00:25:00,320 --> 00:25:06,350 So the three of us returned to the room, which seems much calmer, visibly brightens when she sees Giles. 266 00:25:06,350 --> 00:25:10,100 There's no room for another chair. So he has to crouch down in front of her. 267 00:25:10,100 --> 00:25:15,000 She's almost flirtatious. You're a very tall doctor, aren't you? When? 268 00:25:15,000 --> 00:25:19,490 Later. She writes down her date of birth on the prescription. She jokes coquettishly about her age. 269 00:25:19,490 --> 00:25:24,200 Shouldn't be telling you that, should I? Giles is unreflected, an impassive. 270 00:25:24,200 --> 00:25:27,620 He talks a few options. His role is to impart him. 271 00:25:27,620 --> 00:25:32,600 Information is clear from the outset that she's getting the tablets she wants. 272 00:25:32,600 --> 00:25:38,300 He says there shouldn't be any side effects. We can never be sure. He gives her a leaflet, writes out a prescription. 273 00:25:38,300 --> 00:25:48,400 The meeting's over. So I want to ask two questions about. 274 00:25:48,400 --> 00:25:52,510 Maybe you're going to have more questions. I'm going to ask two questions about deal jobs. 275 00:25:52,510 --> 00:26:02,980 And then the first one is, how would deal in China's approach if if the institutional setting changed, VIFF remains the same. 276 00:26:02,980 --> 00:26:12,310 I think it would make a huge difference. I mean, you think of have Jill started to talk to me about if she's guilty and isolated? 277 00:26:12,310 --> 00:26:16,030 People hate to kind of understand why some did really terrible things. 278 00:26:16,030 --> 00:26:19,960 And he's got a life sentence for what he did. But she can't. 279 00:26:19,960 --> 00:26:23,530 You don't treat you have psychotic services are not there to treat guilt. 280 00:26:23,530 --> 00:26:26,860 So it has to be depression and anxiety. So it has to be reframed. 281 00:26:26,860 --> 00:26:35,110 It's not really, really what what Vivia is talking about is very understandable kind of human responses, but it is being reframed in health terms. 282 00:26:35,110 --> 00:26:39,790 And then there's this peculiar category of personality, personality issues, personality traits. 283 00:26:39,790 --> 00:26:46,270 It's a category surely that's all about lessening what it dealing with risk. 284 00:26:46,270 --> 00:26:53,170 Really, it's all it's all about how do we take steps so that we handle two particular risks could really very risky, 285 00:26:53,170 --> 00:26:58,960 very risky of committing suicide to have disengaging with services they don't want either. 286 00:26:58,960 --> 00:27:06,880 Basically, they don't also want to become dependent on services and the category of personality disorder or these Veiga personality traits. 287 00:27:06,880 --> 00:27:14,890 I think he's organised around those institution needs, but those institution needs are derived from the from the institution. 288 00:27:14,890 --> 00:27:22,630 This isn't really all that much now about what Vivi's like. It's about the position that Jill and Giles are put in, by the way, 289 00:27:22,630 --> 00:27:28,620 that their work is being bureaucratised, remember, so that we can have market mechanisms in the NHS. 290 00:27:28,620 --> 00:27:35,490 So I would suggest more if the institutional setting with different things could look really quite different. 291 00:27:35,490 --> 00:27:45,500 But likewise. How would approached Jill and Giles if the institutional setting changed with her predicament remain the same? 292 00:27:45,500 --> 00:27:50,910 Because I think it's quite easy to to look at how Viv interacts. 293 00:27:50,910 --> 00:27:57,120 I mean, really, I'd very much like Jill and John was that really committed professionals and they do jobs. 294 00:27:57,120 --> 00:28:01,200 I couldn't do I just could not put myself through the things that they put themselves through. 295 00:28:01,200 --> 00:28:08,530 It is also clear they don't like this. Actually. And it has very, very few cards to play. 296 00:28:08,530 --> 00:28:13,270 And in a sense, she's very astute. She is exactly what people told patient. 297 00:28:13,270 --> 00:28:17,710 And it just patient should be in that she's seeking the best you can get in her situation. 298 00:28:17,710 --> 00:28:25,570 She's got one currency and that's her risk and she knows that. So she nishu when she's talking to Jill, she should give feel a kind of gift. 299 00:28:25,570 --> 00:28:27,790 I do follow your advice about drinking. 300 00:28:27,790 --> 00:28:36,910 You know, I'm doing what you're saying, but she gradually escalates her sense demands because why shouldn't she go for the most that she can get? 301 00:28:36,910 --> 00:28:43,390 And the most that she can get definitely is the big tall psychiatrist to come in the room because the hierarchy is like my mom, you know? 302 00:28:43,390 --> 00:28:46,720 I mean, this kind of kid, you want the best treatment, you've got the most important people. 303 00:28:46,720 --> 00:28:50,590 And she knows how to do it. And she does escalator. I don't think it's very tight. 304 00:28:50,590 --> 00:28:54,440 I mean, Jill has a sense of this, I think and I understand it's annoying for her. 305 00:28:54,440 --> 00:29:02,140 But I also think vis a vis her position is defined by this position. 306 00:29:02,140 --> 00:29:06,490 I could imagine know she may be wholly differently if if the stakes were different, 307 00:29:06,490 --> 00:29:10,750 if she didn't present a risk, if there were different ways of talking about her distress. 308 00:29:10,750 --> 00:29:15,340 Everything is being kind of set up. I think by. 309 00:29:15,340 --> 00:29:22,900 By the institution is like everything. I'm exaggerating a little, but you can see what a decisive influence it's having on this. 310 00:29:22,900 --> 00:29:27,490 So I got to say, it suggest two ways now of thinking about this, 311 00:29:27,490 --> 00:29:34,030 about why this is all now so morally confusing from kind of recent publications really 312 00:29:34,030 --> 00:29:38,530 seem to think about whether you think these ideas help clarify what's going on. 313 00:29:38,530 --> 00:29:42,280 So the first book published couple of years back by an aunt in Xhaka, 314 00:29:42,280 --> 00:29:48,060 is a political scientist who did ethnographic work in a government office and in the States, 315 00:29:48,060 --> 00:29:52,930 and he's interested in the moral consequences of impossible situations. 316 00:29:52,930 --> 00:29:58,360 So the bureaucrats that he he observed were constantly they have a certain amount of 317 00:29:58,360 --> 00:30:03,460 discretion in making decisions about access to benefits and things of that sort. 318 00:30:03,460 --> 00:30:07,510 So they're constantly having to exercise judgement. They can't just follow the rules or organs. 319 00:30:07,510 --> 00:30:12,310 But, you know, in lots of cases have lots of uncertainty and ambiguity. 320 00:30:12,310 --> 00:30:19,140 So she says that that kind of torn between wanting to do the best for each individual kind, trying to be fair, 321 00:30:19,140 --> 00:30:24,980 to treat clients equally, but also be efficient so that you don't start to behave in a way that isn't sustainable. 322 00:30:24,980 --> 00:30:29,100 You know, you have other clients, you have colleagues, you have submental resources and so on. 323 00:30:29,100 --> 00:30:32,230 And these different kind of interests or these different kind of sentiments, 324 00:30:32,230 --> 00:30:36,790 cash that they're just not that there's no kind of consistent way of dealing with it. 325 00:30:36,790 --> 00:30:41,890 So he says that if the risk is that people move towards one of these things, 326 00:30:41,890 --> 00:30:45,430 they start to become like either an M4 slot, which is kind of following the rules, 327 00:30:45,430 --> 00:30:50,650 or they become excessively good for certain kind of favoured clients or, you know, 328 00:30:50,650 --> 00:30:54,670 they become like a team player, but kind of screw the clients, he says. 329 00:30:54,670 --> 00:30:59,680 Because that place to me is impossible positions, that kind of erosion of the most kind of moral subjects. 330 00:30:59,680 --> 00:31:04,360 He says the problem is not that bureaucrats lose their capacity for sound more reasoning, 331 00:31:04,360 --> 00:31:12,740 but that their moral perception and role conception that feed into such reasoning become overly narrow and specialised. 332 00:31:12,740 --> 00:31:20,540 Now. In other words, like what? So so only in Ireland specialise precisely means just just ACTIMMUNE, these kind of stereotyped ways. 333 00:31:20,540 --> 00:31:26,920 So it's as if they lose sight of the job necessarily being impossible, necessarily involving contradictions. 334 00:31:26,920 --> 00:31:37,630 They resolve the contradictions, but it makes them bad bureaucrats. I think actually that Giles and Jill don't do this. 335 00:31:37,630 --> 00:31:45,190 I think what you can see is throughout the ethnography, they haven't just collapsed into a single kind of frame, a single kind of way of doing it. 336 00:31:45,190 --> 00:31:51,100 So sure, they start out by thinking, don't give Viv antidepressants. 337 00:31:51,100 --> 00:31:58,240 And then they say, oh, no, let's get on with antidepressants. They start out saying, oh, she's got a personality disorder type problem. 338 00:31:58,240 --> 00:32:03,940 They then say, I mean, just in a matter of minutes. No, actually, she's probably got a kind of depressive disorder. 339 00:32:03,940 --> 00:32:09,340 So they come. But that's because not much has changed really. 340 00:32:09,340 --> 00:32:13,150 And if the other things are in play, you can't really understand their decisions. 341 00:32:13,150 --> 00:32:19,720 Just thinking about it. Lives, health needs. Neither should you. Because you have to always be thinking about the bigger picture. 342 00:32:19,720 --> 00:32:26,050 That's what that's what a life of a bureaucrat is. You shouldn't be thinking about only one kind of thing. 343 00:32:26,050 --> 00:32:32,950 They have to maintain relations with with with. If if you said, well, screw this, I'm not going to come and see my psychiatrist anymore. 344 00:32:32,950 --> 00:32:38,620 That would be problematic. All these meetings are set up. I mean, Jonas is having meetings with the police, 345 00:32:38,620 --> 00:32:44,160 coordinating in all sorts of ways to make sure that the families kind of move one piece until they get to trial. 346 00:32:44,160 --> 00:32:51,190 I think that that just can't happen. If I was being polemical, I would say that's why they've now has depression. 347 00:32:51,190 --> 00:32:55,240 I mean, you know, if we think that clinical depression, this means a psychiatrist saying you have depression, 348 00:32:55,240 --> 00:33:00,310 she's now got depression, but she's got it for these institutional reasons. 349 00:33:00,310 --> 00:33:07,300 And I think, you know, what I think looked at from this point of view, Giles and Jill are being entirely honourable. 350 00:33:07,300 --> 00:33:17,060 They're doing their job really well. It's just that it looks weird if you think that their job is just health care. 351 00:33:17,060 --> 00:33:22,820 Here's my second. Kind of taken on kind of what's going on. This is more a book by Paolo Heywood. 352 00:33:22,820 --> 00:33:28,580 It's about queer activism in Bologna. This is super interesting field. 353 00:33:28,580 --> 00:33:33,390 But Heywood talks about quite, quite a lot of the people he works with. 354 00:33:33,390 --> 00:33:41,960 They say they are critical of but also do themselves a certain sort of hypocrisy that he gets quite interested in. 355 00:33:41,960 --> 00:33:44,810 And this is he calls it a double morality. 356 00:33:44,810 --> 00:33:52,390 So this is an example of this is where somebody in public is very loving to their spouse and upholds a kind of 357 00:33:52,390 --> 00:33:58,280 a sort of ethical we must be faithful to each other and must always be kind of loving and attentive and so on. 358 00:33:58,280 --> 00:34:05,480 But then when they go home Cappucci cheating on their spouse, they behave in a different way. 359 00:34:05,480 --> 00:34:10,930 So there's a kind of two to apparently two forms of behaviour and hate which says, well, 360 00:34:10,930 --> 00:34:14,660 look, kind of classic way of dealing with this is to say you've got two ethics going on. 361 00:34:14,660 --> 00:34:19,970 You've got in the ethics a home in the ethics and public people as is jumping between the two. 362 00:34:19,970 --> 00:34:24,740 And I think there are situations where that's, you know, actually that's a case where people decide these kind of multiple worlds. 363 00:34:24,740 --> 00:34:29,390 I mean, it leads to some intellectual problems, I think. But but still, it kind of makes sense. 364 00:34:29,390 --> 00:34:37,250 It's a coherent thing that he would struggle to maybe something slightly different really is happening, at least some of the time. 365 00:34:37,250 --> 00:34:42,080 He's saying that that and he had maybe the quotes helpful people might have a relationship, 366 00:34:42,080 --> 00:34:46,010 ethical injunctions in which adherence is not always expected, 367 00:34:46,010 --> 00:34:50,390 which does not have over negation of the universal applicability of the moral conventions. 368 00:34:50,390 --> 00:34:59,170 But it does provide for certain ways of relating to such conventions, which the possibility of their betrayal in certain form is already allowed for. 369 00:34:59,170 --> 00:35:02,630 So thought, maybe in a way. OK, if you're cheating on your spouse, 370 00:35:02,630 --> 00:35:10,520 you kind of know that that is part of who is still tied to the fact that that's might be a bad thing because 371 00:35:10,520 --> 00:35:17,840 you're contradicting those that you may you may kind of uphold certain values once consistently breaking. 372 00:35:17,840 --> 00:35:26,360 I mean, I don't know. I what take what I like about this is I think this is what happens if you conduct if you're gathering data 373 00:35:26,360 --> 00:35:31,520 and you keep on gathering data and you're very slow to reach a judgement about what's really happening, 374 00:35:31,520 --> 00:35:38,800 you start to capture how kind of messy and ambiguous and confusing potentially kind of human lives are. 375 00:35:38,800 --> 00:35:44,900 But I think it's safe for Charles and Jill. Their equivocation is perhaps it could be understood in this way. 376 00:35:44,900 --> 00:35:49,720 I'm not quite sure what they think some of the time, but maybe that's right. 377 00:35:49,720 --> 00:35:58,640 Make maybe that there's a certain advantage. Maybe there's something better about not being entirely sincere all the time, about being a hypocrite. 378 00:35:58,640 --> 00:36:06,440 Some other time the situation requires it in a sense. I think they still have some fidelity to kind of to their understanding of medicine. 379 00:36:06,440 --> 00:36:12,350 I think, Giles, you know, if you meet him in the pub after, he's he will give an account of what's going on, 380 00:36:12,350 --> 00:36:16,610 which suggests that these are all medical decisions, kind of knows a lot as well. 381 00:36:16,610 --> 00:36:25,750 But I think to someone, I think they also I think that, you know, this is this might be might be possible that they're simultaneously both. 382 00:36:25,750 --> 00:36:33,930 So, OK. I would. So I can a few questions for you to ponder. 383 00:36:33,930 --> 00:36:43,420 If, as I hope you going to leap in with with questions that are both furious, but also help bring me intellectual clarity. 384 00:36:43,420 --> 00:36:50,970 I mean, what I'm trying to suggest, really, is that for all three players in the ethnography that I'm describing, 385 00:36:50,970 --> 00:36:54,600 which I want to present, really is this is a common situation. 386 00:36:54,600 --> 00:36:57,090 This is an extreme version of something that's happening all the time. 387 00:36:57,090 --> 00:37:03,300 So so most clients, if you're a psychiatrist, think they don't have a son who's just done a massive crime. 388 00:37:03,300 --> 00:37:09,810 But I can assure you, psychiatrists constantly talk about what's this going to look like on the front page of the Daily Mail tomorrow morning? 389 00:37:09,810 --> 00:37:15,480 I mean, they're constantly aware of in a field be scrutinised full of risk of reputational damage. 390 00:37:15,480 --> 00:37:25,170 So this is this is just an extreme form of day. That's why I think it's a good, good, good, opportune, good moment to try to describe and and analyse. 391 00:37:25,170 --> 00:37:32,100 And I think it's the is ethically confusing because it just isn't possible to be consistent. 392 00:37:32,100 --> 00:37:37,690 It isn't possible for them to do their job well and behave consistently and with sincerity. 393 00:37:37,690 --> 00:37:43,230 They have to have sort of half engage with ideas and ikarus fairly strong feeling 394 00:37:43,230 --> 00:37:46,950 that Joe basically thinks the idea of a personality disorder is rubbish, 395 00:37:46,950 --> 00:37:52,810 to be honest. I mean, I, I know I know both these people really quite well socially and patients does. 396 00:37:52,810 --> 00:37:56,780 Know she doesn't really think this is true. But but her job requires that to do it. 397 00:37:56,780 --> 00:38:03,810 And I'm sure it's the right thing, you know. So her engagement with this kind of thing is this isn't isn't a fixed thing. 398 00:38:03,810 --> 00:38:08,660 It's not like she believes or she doesn't. Sometimes she does. Someone she half does when she goes home. 399 00:38:08,660 --> 00:38:18,320 Copy a little bit less. You know, it's kind of all over the place. And I think that this potentially has kind of wider thoughts, I think. 400 00:38:18,320 --> 00:38:25,820 I don't see how if I'm not quite sure how any of them can be good in a circumstance in a situation of such ethical confusion. 401 00:38:25,820 --> 00:38:31,970 I don't necessarily slightly screwed. I necessarily always going to go home feeling they probably done the wrong thing and they 402 00:38:31,970 --> 00:38:37,280 probably also always doing the wrong thing because that's how you also do the right thing. 403 00:38:37,280 --> 00:38:40,220 I mean, I think that's what ethical confusion probably means. 404 00:38:40,220 --> 00:38:44,960 Anthropologists have ethics often like to present it as a way of orienting yourself in the world. 405 00:38:44,960 --> 00:38:48,860 You have a kind of ethical schema or you have certain kind of technologies of self ethics, 406 00:38:48,860 --> 00:38:54,290 some kind of self-improvement, or changing yourself to try to make sense of things. 407 00:38:54,290 --> 00:38:59,480 I'm not quite sure in this case. I think actually this is more like the fallout from a very complex situation. 408 00:38:59,480 --> 00:39:06,410 I don't think the ethical intuitions are ever going to bring clarity to any of these plans and including as well. 409 00:39:06,410 --> 00:39:12,080 And I think this kind of leaves potentially questions about to what degree to epistemic movements like evidence based 410 00:39:12,080 --> 00:39:18,950 medicine or clinical categories such as personality disorder or mental disorder and clinical projects like patients, 411 00:39:18,950 --> 00:39:24,560 self management or the recovery model arise out of the institutional setting of mental health care. 412 00:39:24,560 --> 00:39:29,370 And who would have jumped up at any of these things, perhaps if the institutional demands were different? 413 00:39:29,370 --> 00:39:37,960 Could we continue to assume that the ethics and ethics theme of accountable bureaucracy are consistent with the clinical interests of patients and. 414 00:39:37,960 --> 00:39:43,890 How do we how should we weigh the costs and benefits of accountability? 415 00:39:43,890 --> 00:39:50,198 Thank you.