I caught this. I said, why is mental healthcare so ethically confusing? And it occurs to me, I don't know, it's confusing.
A kind of category that we can use.
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.
I do mean something more than just complex or more than just contested.
I think I want to say something about mental health care, that of irretrievably complex or irretrievably difficult.
And I think it's irretrievably difficult because some of the things that we might use to try to make sense of ethics,
things like being consistent or being sincere or not being hypocritical, aren't possible mental healthcare.
OK, that's got your interest. Now, the structured possession is.
Gotcha. Okay, so just three little parts, really. What I'm going to do is introduce some ideas about bureaucratic accountability to suggest
that the institutional setting of mental health care is what makes it ethically confusing.
Talk about 10-15 minutes about that. Then I'm going to read a little bit of ethnography.
So this is drawn from my PhD fieldworker. All the people are annonomised
I've concealed kind of where it took place and so on.
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.
So I'm going to kind of suggest, I suppose, two particular ways that we might think through just what is so confusing here.
Why is it that the clinicians and the patients behave in the way that they do?
Because I think it's it's really not obvious. And I think it be very easy to miss.
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.
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.
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,
then are going to raise some concerns about the implications and ask questions.
So bureaucratic accountability. Where would you go to find out about this?
Obviously the Oxford Handbook of Public Accountability, which I just sort of read so you don't have to be honest,
although it's a lot more interesting than you might think. So at heart,
bureaucratic accountability is institutional relational arrangement in which
an agent can be held accountable by another agent or institution not holding to account.
Sounds like a nice thing. But how do you do it bureaucratically? You do it through documentation.
If you're working in a bureaucratically accountable way, whatever it is that you're doing, you'll likely be documenting it.
And then that documentation is likely to be a means by which you're going to be evaluated.
Are you doing the right things? I codings behaving according to norms and so on.
You also need arrangements where the actors can be questioned or investigated and judgements can be made very often.
, there's much more emphasis on negative judgements or sanctions rather than positive ones.
So classically, this is going to apply to all working lives.
It applies to, you know, I mean, kind of across the board, really.
People are increasingly subject to these sorts of mechanisms of bureaucratic accountability.
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.
So where does it come from? Well, it's associated with neo liberal institutional reform.
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.
So kind of reining in health care. And again, there may be people who know more about this than the me in the room.
But in health care, the Tories kind of set up the conditions for these sorts of changes to be made.
But actually, they didn't really kind of manifest until until Tony Blair smiled his way into number 10.
So government creates a distance.
The idea, implicit government creates a distance between itself and service providers rather than governments doing stuff for us.
We kind of have these service providers that do it on the government's behalf and on our behalf.
And that allows the service providers to be reconceived.
They start to be seen as businesses like universities, increase evenings, visiting businesses, perhaps.
And that kind of special businesses, because they're not just trying to maximise profit, but they're accountable.
So they stop. It starts to become if you work for one of these service providers,
you're going to have to stop documenting what you do quite carefully because you're going to be held accountable to stakeholders.
So he said these are new ways of framing work that people do.
The thought might be then that market mechanisms can make things efficient,
whereas consumer choice can make a better fit between what services are being provided and what people really want.
Potentially, people thought that might really kind of change healthcare. And then the role of the government is to monitor and evaluate.
So the government has this kind of hands off from if you're a cynic,
you say it means the government can't be blamed so directly for the failings of the NHS.
But what kind of serious ideas behind this is what to make me. Maybe this is a good idea.
I do know there are certain things that makes it appealing.
I think I mean, this isn't an automatically just take a terrible thing.
It mean it comes really, I think, from a very particular kind of morally maxillary.
I mean, I think this sort of accountability comes from a world where imagining a world is quite knowable and that's quite manipulable.
And you might say, well, look, outputs and inputs can be measured now from unaccountable bureaucracy.
Processes can be standardised and documented. Isn't this really quite a good thing?
Individual actors can be monitored. Again, a good thing.
It's good to stamp out amount practise that people are kind of doing or are able
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.
Work can be evidenced in quality, documented, not very good cases in healthcare of people doing things by customer,
by tradition that actually turn out not to be very helpful. You can kind of can do a trial.
You can work out if it works and then you can change what you're doing. You even measured the efficiencies.
You can think also about safety. So in all this kind of looks, it looks nice.
And you might think, well, shouldn't this be making mental healthcare not more ethically confusing, but kind of ethically simple?
Should it?
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?
You can telling and say no. Now, here's.
Albert Einstein is not normal again, topologies go to authority.
But he did say this nice little thing, which kind of captures part of the problem, not everything that counts can be counted on.
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.
But, of course, anthropologist's, I think quite quick on the scene to start thinking about accountability,
cultures of bureaucratic accountability or the managerial revolutions that sometimes called up.
There's a reason why really anthropologists do kind of long term, immersive, non-invasive kind of fieldwork.
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.
Always two different things. And so in a ways, it's some it's the methodology that slowest to reach a firm view.
Anthropology can be agnostic an extremely long time.
So if you if you come to the field and want to find out about something, we have preform questions.
You've already made a few assumptions. And the beauty of anthropology,
the strength of it is we don't necessarily do that in the field determines our research questions to a certain extent, at least.
Marilyns to Thurn edited. This is kind of key early. Volume audit cultures.
She she looked at how whether technologies that come from.
She said the concept of the audit has broken loose from its moorings in finance and accounting.
Its own expanded presence gives it the power of a descript or seemingly applicable to all kinds of reckonings, evaluations and measurements.
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.
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
supposed to be doing starts to change what it is that they're doing. there are a particular kind of concerns.
So David Graeber has written recently a book called The Utopia of Rules,
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,
but I quite like the punchy statement. He says bureaucratic knowledge is all about schemata ization.
In practise, bureaucratic procedures invariably mean ignoring all the subtleties of real social
existence and reducing everything to preconceived mechanical or statistical formulae.
Whether it's a matter of forms, rules, statistics or questionnaires, it's always a matter of simplification.
I think they should raise the kind of concern if we're thinking about mental healthcare.
Surely that's ignoring all the subtleties of real social existence.
It's a risky thing to be doing in mental health.
It's surely that the subtleties of real socially existence are what, bringing people into their clinic in the first place.
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.
There's a lot to that kind of landmark.
Ethnography of mental health by Tanya Nermin, published in 2000, which I can recommend for people who are interested.
She's really writing about how psychoanalytic and psychodynamic psychiatry and mistakes was superseded by more biological,
pharmaceutical driven psychiatry.
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,
but she does nonetheless notice is that part of what's going on is that you have a lot of
psychiatrists having to make phone calls to the insurance providers to pay for treatment,
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.
Call the insurance company if they've been if they've declared six days in a ward.
But you think that the patient is a suicide risk and want to stay another six days, you have to make a phone call.
There's an awful lot of liaison between the psychiatrist and other responsible clinician and the insurance company.
And she writes like this. She says, The more time date the psychiatrists spend on the phone with insurance agents negotiating
for six day admission to be extended to nine days because a patient is still suicidal.
The more administrative interviews they need to do, the more discharge some risk they need to type,
the less the way support an experience of psychodynamic psychotherapy fit in,
the less they seem relevant or even real on the more psychiatrists are willing to fall back on the
ideological position that the cause and treatment of mental illness is biological and psychopharmacological.
And this is a really interesting observation.
So the first thought we you know, we think of bureaucracy as a kind of iron cage, that kind of Iberian idea.
You know, you put the clinician or at you any other worker,
But since we're talking about mental health, we're putting them into an accountable bureaucracy that would constrain the choices that they make,
perhaps perhaps that will force them to behave in ways that they wouldn't like for them not to behave.
But still, that's it's still the bureaucratic frame. What Learmont suggesting is a bit more than that, really.
She's saying the sorts of the ways of imagining the world, the ways of thinking.
Mental illness. The ways of treating mental illness. The best fit form filling documentation.
The mechanisms of accountability start to feel more real.
There's lots of kind of anti psychiatry people would say, oh, big Pharma has completely taken over and corrupt psychiatry.
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.
It's the institution itself. It's just quite difficult to be psychodynamic and produce notes which don't expose you to risk.
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.
She's really talking about government institutions in the Himalayas.
But one of one of the kind of centres of what she's writing about is how very often clinicians being at clinicians,
these are government bureaucrats are being asked to do things that aren't quite doable.
And you begin to realise what bureaucratic expertise is, is something representation quite so much what you do.
It's about learning to be very good at representing what you may or may not have done.
She puts it like this. Agents of the state know that rules can never be followed to the letter,
that energies are directed instead at making it appear as if the alleged abilities are being overcome, as if orders are being followed.
So, you know, this is a kind of really striking thing,
because presumably it's slightly similar remarks made by David Moss in this account of development work that successful
development projects are the ones you can represent according to current trends and what a successful project looks like.
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.
So I'm hoping we're going to get some nice questions now.
So I suggest that I think kind of foolish reasons why accountability might be a source of ethical confusion.
And I'm wanting to be heavy handed. Just gonna remind you of them before I meet my bit of ethnography.
So this report that imported bureaucratic mechanisms don't necessarily fit mental health care,
that even if we think these are good things, that might be the root problem of how well do these things fit together?
Bureaucratic mechanisms are associated with accountability. A reductive and simplistic mental health care is complex and nuanced understandings
of mental health that are suited to accountable practise a favourite loss.
Others lose ground or seem less real, and expertise as a condition blurs with a representational skills of a bureaucrat.
So I am hoping that it starts to look, if not ethically confusing, at least very complex.
Okay. Now, I'm going to talk a little bit about Jill Charles.
I'm going to read this out because I said that the detail is the key thing.
OK, Vivint, a family, were widely described as being well known to services.
It's an ominous phrase.
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.
We've recently came to the attention of a mental health team that I was working with
following the arrest of one of her sons for a string of serious sexual offences.
The case was locally notorious and received extensive media coverage.
Five was briefly admitted to a psychiatric ward as an informal or voluntary patient.
She was discharged a few days later and was due to come and see a CPA called Jill, who I worked with quite long.
I asked Jill about what kind of person is she? What kind of care did the team provide?
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.
She talks about wanting to kill herself. And in the view of the team, she presents a substantial suicide risk.
But Jill stressed they want to provide the minimum care possible for her.
If I asked why, you replied, We don't believe Viv has a mental illness, she explained.
They think that Viv was depressed, but she doesn't suffer from a depressive disorder.
She's anxious, but she doesn't suffer from an anxiety disorder.
The reason for this is that her distress seems broadly proportionate to the environment.
Joe describes it as normal depression. She added that Viv has plenty to feel depressed and anxious about.
How would we feel? Jill asked if we were in her position. Jill articulate this in terms of stressors.
The level of stress is very high and so the level of distress is very high.
However, Jill also explained that Viv's personality is being taken into account.
Jill said that the team feels that V.F. has personality issues or definite personality traits.
This is coded language.
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.
That's kind of what that means.
She says that the team take the view that these personality issues are important when thinking about appropriate treatment.
We'll put it to me this way. Mental illness is something that could happen to anyone.
To me and to you who you are. Does it make any difference?
It can just come and take your life away. But with personality is you.
Who's the problem? She went on to say that personality problems have their origin in childhood, either an abuse or neglect.
As I understand it, she recalls vivid childhood as causing dysfunctions or pathologies that are distinct from mental illnesses,
but of the same order of magnitude.
She says that these problems go on to shape character such that the patient finds it hard to lead a functional or fulfilling life.
To talk more about how his depression and anxiety are caused in part by her personality,
she has poor coping skills, for example, at a time when she has a lot to cope with.
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.
She goes on, but she talks in a rather cautious way, almost like a politician in a tricky interview, choosing her words carefully.
I felt unsure how sincere Jill was about this personality issues.
She was able to talk convincingly in a way that would be required for team meetings or medical documentation.
But I thought her heart wasn't really in it. This gave some of her words a slight, ironic edge.
Now a timestream field work. I sense the rhetorical power of a particular variety of understatement.
On one occasion during a team meeting,
which a female CPM community psychiatric nurse described to the team how a male patient had been sexually aggressive towards a very
sexually aggressive and norm in the normal world had been incredibly sexually aggressive towards the world of mental health care.
They have to get used to a lot of stuff. So let's say a sexually aggressive towards her.
She used phrases when describing it to the team like, oh.
He had a really poor sense of personal boundaries, and I did detect some impulse control issues.
These anodyne, non judgemental, bureaucratise terms acquire rhetorical force through understatement, though immensely effective.
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.
I don't think she accepted the personality disorder model, but neither did she reject.
With regard to VIFF, her stance was undefined.
Jill went on to say that instead of looking to her own resources, which might already have become dependent on services.
She wanted to be in contact with Jill every day, either by phone or in person.
Jill seemed wary. She thought this might need to Viv losing skills where she might benefit from improving them.
I know it's hard to joke. But life is hard. You have to learn how to cope.
She said she didn't want exaggerating her distress to secure attention.
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.
Losing her autonomy and self-reliance. In their dealings with VIFF,
Jill said the team had made sure not to prescribe any medication that aims to restrict the scope
of any dependency that may create by basing her treatment on generic support offered by Joe.
Now, I was quite excited to meet. By this stage, I have to say.
But before without me just may say what a strange man I am. But let's stop before before we go to the meet.
Joe steps into the waiting room to introduce me and to ask if it's okay for me to be present in the appointment.
I stand behind her as she introduces me as a researcher in medical anthropology.
Vivi sitting with a sister who we understand will stay in the waiting room, which seemed slightly expectant.
So excited. Joe Stressless, I don't have to be there that the appointment can go on without me.
But a tone suggests there's no reason why not. Viv seems pleased on that.
She asks what medical anthropology is. I explain. Oh, as a research student and actually I thought she's a little disappointed.
I wasn't more senior, but nonetheless, he was pleased that I was around.
So having established, I'll join them if rises quickly.
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.
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.
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.
This starts to talk about how depressed she's been. She says she can't sleep and she finds it painful to be alive.
Jill notes, listens and a simple questions is having contact with her son.
Remember that? Who's committed the offences currently being held on remand?
She says no. Is she in touch with the other children? She says yes.
Jill is supportive, but without offering opinions or advice,
she tends to repeat back what Jill says or make remarks such as that must be very painful.
I can see how difficult that is. If starts to discuss how she feels that her husband is supportive but doesn't understand.
She also says she's getting forgetful at work. She presents itself, was overwhelmed by her feelings.
Most are kind of baffled by them as well as she talks.
She scans Jill quite carefully. She says it's all too much to cope with.
She describes how she comes downstairs in the night, unable to sleep, tormented by intense, overwhelming feelings.
Hours go by sitting alone on the sofa, not knowing what to do.
We've continued saying, oh, no. She's thinking of killing herself.
She very much wants to do it. But she's held back by concern for her younger children.
There's a pause as Jill offers me assurance and comfort. Life goes on.
No, drinking doesn't help. You've told me about that and I don't do it.
And I feel terrible. But she starts to cry. She says, I can't manage.
It's all too much. Hunched over the table, her body tenses and shakes.
She hooks herself and grass gasps for breath. Jill hands her a box of tissues.
She wakes her Viv to compose herself, sitting perfectly still. Take your time.
It's OK. There's no hurry. Just take your time. Viv returns to the topic of medication.
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.
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?
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.
She said yes. We got up and went to find Giles, the consultant psychiatrist, as we were leaving.
Jill said, you'll be all right. What you for a few minutes while I speak to the doctor.
We've agreed that you'll be fine. Now, Charles's office is further down the corridor, which explains to Giles what's happening.
She says Viv seems very depressed and is talking of suicide. The risk seems to be real.
So might it be worth giving her antidepressants? Joe says he can see the might be a justification for describing antidepressants.
Then he asked me what I think. Now I'm out of my depth. I don't know what to say.
So he talks through a possible rationale that she's very distressed that antidepressants might help a bit,
that she's at risk of both suicide and of developing a depressive illness.
And anyway, antidepressants won't do any harm. Just find several ways to justify prescribing antidepressants.
But his tone suggests he's slightly flippant. I don't think he has any expectation that the medicine will be effective.
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.
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.
There might be safer to put her on medication.
So the three of us returned to the room, which seems much calmer, visibly brightens when she sees Giles.
There's no room for another chair. So he has to crouch down in front of her.
She's almost flirtatious. You're a very tall doctor, aren't you? When?
Later. She writes down her date of birth on the prescription. She jokes coquettishly about her age.
Shouldn't be telling you that, should I? Giles is unreflected, an impassive.
He talks a few options. His role is to impart him.
Information is clear from the outset that she's getting the tablets she wants.
He says there shouldn't be any side effects. We can never be sure. He gives her a leaflet, writes out a prescription.
The meeting's over. So I want to ask two questions about.
Maybe you're going to have more questions. I'm going to ask two questions about deal jobs.
And then the first one is, how would deal in China's approach if if the institutional setting changed, VIFF remains the same.
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?
People hate to kind of understand why some did really terrible things.
And he's got a life sentence for what he did. But she can't.
You don't treat you have psychotic services are not there to treat guilt.
So it has to be depression and anxiety. So it has to be reframed.
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.
And then there's this peculiar category of personality, personality issues, personality traits.
It's a category surely that's all about lessening what it dealing with risk.
Really, it's all it's all about how do we take steps so that we handle two particular risks could really very risky,
very risky of committing suicide to have disengaging with services they don't want either.
Basically, they don't also want to become dependent on services and the category of personality disorder or these Veiga personality traits.
I think he's organised around those institution needs, but those institution needs are derived from the from the institution.
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,
that their work is being bureaucratised, remember, so that we can have market mechanisms in the NHS.
So I would suggest more if the institutional setting with different things could look really quite different.
But likewise. How would approached Jill and Giles if the institutional setting changed with her predicament remain the same?
Because I think it's quite easy to to look at how Viv interacts.
I mean, really, I'd very much like Jill and John was that really committed professionals and they do jobs.
I couldn't do I just could not put myself through the things that they put themselves through.
It is also clear they don't like this. Actually. And it has very, very few cards to play.
And in a sense, she's very astute. She is exactly what people told patient.
And it just patient should be in that she's seeking the best you can get in her situation.
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.
I do follow your advice about drinking.
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?
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?
I mean, this kind of kid, you want the best treatment, you've got the most important people.
And she knows how to do it. And she does escalator. I don't think it's very tight.
I mean, Jill has a sense of this, I think and I understand it's annoying for her.
But I also think vis a vis her position is defined by this position.
I could imagine know she may be wholly differently if if the stakes were different,
if she didn't present a risk, if there were different ways of talking about her distress.
Everything is being kind of set up. I think by.
By the institution is like everything. I'm exaggerating a little, but you can see what a decisive influence it's having on this.
So I got to say, it suggest two ways now of thinking about this,
about why this is all now so morally confusing from kind of recent publications really
seem to think about whether you think these ideas help clarify what's going on.
So the first book published couple of years back by an aunt in Xhaka,
is a political scientist who did ethnographic work in a government office and in the States,
and he's interested in the moral consequences of impossible situations.
So the bureaucrats that he he observed were constantly they have a certain amount of
discretion in making decisions about access to benefits and things of that sort.
So they're constantly having to exercise judgement. They can't just follow the rules or organs.
But, you know, in lots of cases have lots of uncertainty and ambiguity.
So she says that that kind of torn between wanting to do the best for each individual kind, trying to be fair,
to treat clients equally, but also be efficient so that you don't start to behave in a way that isn't sustainable.
You know, you have other clients, you have colleagues, you have submental resources and so on.
And these different kind of interests or these different kind of sentiments,
cash that they're just not that there's no kind of consistent way of dealing with it.
So he says that if the risk is that people move towards one of these things,
they start to become like either an M4 slot, which is kind of following the rules,
or they become excessively good for certain kind of favoured clients or, you know,
they become like a team player, but kind of screw the clients, he says.
Because that place to me is impossible positions, that kind of erosion of the most kind of moral subjects.
He says the problem is not that bureaucrats lose their capacity for sound more reasoning,
but that their moral perception and role conception that feed into such reasoning become overly narrow and specialised.
Now. In other words, like what? So so only in Ireland specialise precisely means just just ACTIMMUNE, these kind of stereotyped ways.
So it's as if they lose sight of the job necessarily being impossible, necessarily involving contradictions.
They resolve the contradictions, but it makes them bad bureaucrats. I think actually that Giles and Jill don't do this.
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.
So sure, they start out by thinking, don't give Viv antidepressants.
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.
They then say, I mean, just in a matter of minutes. No, actually, she's probably got a kind of depressive disorder.
So they come. But that's because not much has changed really.
And if the other things are in play, you can't really understand their decisions.
Just thinking about it. Lives, health needs. Neither should you. Because you have to always be thinking about the bigger picture.
That's what that's what a life of a bureaucrat is. You shouldn't be thinking about only one kind of thing.
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.
That would be problematic. All these meetings are set up. I mean, Jonas is having meetings with the police,
coordinating in all sorts of ways to make sure that the families kind of move one piece until they get to trial.
I think that that just can't happen. If I was being polemical, I would say that's why they've now has depression.
I mean, you know, if we think that clinical depression, this means a psychiatrist saying you have depression,
she's now got depression, but she's got it for these institutional reasons.
And I think, you know, what I think looked at from this point of view, Giles and Jill are being entirely honourable.
They're doing their job really well. It's just that it looks weird if you think that their job is just health care.
Here's my second. Kind of taken on kind of what's going on. This is more a book by Paolo Heywood.
It's about queer activism in Bologna. This is super interesting field.
But Heywood talks about quite, quite a lot of the people he works with.
They say they are critical of but also do themselves a certain sort of hypocrisy that he gets quite interested in.
And this is he calls it a double morality.
So this is an example of this is where somebody in public is very loving to their spouse and upholds a kind of
a sort of ethical we must be faithful to each other and must always be kind of loving and attentive and so on.
But then when they go home Cappucci cheating on their spouse, they behave in a different way.
So there's a kind of two to apparently two forms of behaviour and hate which says, well,
look, kind of classic way of dealing with this is to say you've got two ethics going on.
You've got in the ethics a home in the ethics and public people as is jumping between the two.
And I think there are situations where that's, you know, actually that's a case where people decide these kind of multiple worlds.
I mean, it leads to some intellectual problems, I think. But but still, it kind of makes sense.
It's a coherent thing that he would struggle to maybe something slightly different really is happening, at least some of the time.
He's saying that that and he had maybe the quotes helpful people might have a relationship,
ethical injunctions in which adherence is not always expected,
which does not have over negation of the universal applicability of the moral conventions.
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.
So thought, maybe in a way. OK, if you're cheating on your spouse,
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
you're contradicting those that you may you may kind of uphold certain values once consistently breaking.
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
and you keep on gathering data and you're very slow to reach a judgement about what's really happening,
you start to capture how kind of messy and ambiguous and confusing potentially kind of human lives are.
But I think it's safe for Charles and Jill. Their equivocation is perhaps it could be understood in this way.
I'm not quite sure what they think some of the time, but maybe that's right.
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.
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.
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,
which suggests that these are all medical decisions, kind of knows a lot as well.
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.
So, OK. I would. So I can a few questions for you to ponder.
If, as I hope you going to leap in with with questions that are both furious, but also help bring me intellectual clarity.
I mean, what I'm trying to suggest, really, is that for all three players in the ethnography that I'm describing,
which I want to present, really is this is a common situation.
This is an extreme version of something that's happening all the time.
So so most clients, if you're a psychiatrist, think they don't have a son who's just done a massive crime.
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?
I mean, they're constantly aware of in a field be scrutinised full of risk of reputational damage.
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.
And I think it's the is ethically confusing because it just isn't possible to be consistent.
It isn't possible for them to do their job well and behave consistently and with sincerity.
They have to have sort of half engage with ideas and ikarus fairly strong feeling
that Joe basically thinks the idea of a personality disorder is rubbish,
to be honest. I mean, I, I know I know both these people really quite well socially and patients does.
Know she doesn't really think this is true. But but her job requires that to do it.
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.
It's not like she believes or she doesn't. Sometimes she does. Someone she half does when she goes home.
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.
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.
I don't necessarily slightly screwed. I necessarily always going to go home feeling they probably done the wrong thing and they
probably also always doing the wrong thing because that's how you also do the right thing.
I mean, I think that's what ethical confusion probably means.
Anthropologists have ethics often like to present it as a way of orienting yourself in the world.
You have a kind of ethical schema or you have certain kind of technologies of self ethics,
some kind of self-improvement, or changing yourself to try to make sense of things.
I'm not quite sure in this case. I think actually this is more like the fallout from a very complex situation.
I don't think the ethical intuitions are ever going to bring clarity to any of these plans and including as well.
And I think this kind of leaves potentially questions about to what degree to epistemic movements like evidence based
medicine or clinical categories such as personality disorder or mental disorder and clinical projects like patients,
self management or the recovery model arise out of the institutional setting of mental health care.
And who would have jumped up at any of these things, perhaps if the institutional demands were different?
Could we continue to assume that the ethics and ethics theme of accountable bureaucracy are consistent with the clinical interests of patients and.
How do we how should we weigh the costs and benefits of accountability?
Thank you.