Management of authority and responsibility

A Brief Note:

• The presence of psychosis in the life of a person acts as a major constraint on service delivery/clinical practice because it seriously limits the individual patient/client‘s ability/capacity (at certain critical points in time) to accept and take responsibility for themselves; and equally, to share or relinquish authority over their own life, situation and treatment. 

• This makes it very difficult for the treating practitioner to establish any agreement with the patient/client over congruence in relation to decision making and management of authority and responsibility. 

• Coherent and effective service delivery requires congruent decision making and management of authority and responsibility to be invested in the practitioner; in the patient/client; in relevant others; or shared between practitioner, patient/client and relevant other parties/stakeholders. 

• The presence of psychosis (and any other difficulty that has a major impact on cognition) creates an unequal relationship between the patient/client and the treating practitioner that is difficult or impossible to remediate. 

• Psychosis also creates an unequal relationship between patient/client and most other parties/stakeholders to the matter, that is also difficult to remediate (not so with patient/clients with some other conditions e.g. depression). 

• This may be true of other conditions such as substance abuse/addictions, BPD, bipolar mood disorder, brain injury, etc. 

• Medication compliance appears to be a fair indicator of successful treatment in terms of major mental health; and this is also an indicator or measure of congruence in terms of decision making and management authority and responsibility over medication i.e. either the patient/client retains authority over their own life and exercises congruent responsibility by taking the medication as agreed or directed OR the State takes that authority from the patient/client and exercises direct responsibility over the patient/client in relation to medication and perhaps other treatment processes. 

• The micro-political struggle between practitioner and patient/client over decision making and management authority and responsibility often creates or leaves an authority/power vacuum; fertile ground for a struggle between the various interested parties/stakeholders (family, NGO’s, GP’s, Parole Officers, Ministers of Religion, self-help groups, statutory office holders, and other treating practitioners etc.) over who is possessed of what authority over whom, when, where, how, and in relation to what responsibility. 

• Often the human system around the practitioner and patient/client fragments and fractures when such a power/authority vacuum appears, competing with each other for a slice of that power/authority (or competing to absolve themselves of such) further constraining the appropriate exercise of decision making and management responsibility by that practitioner and/or the patient/client, and any other party/stakeholder. 

• Long standing major mental health matters appear to attract numerous treating and support systems, with a significant proclivity to fracture and fragment over decision making and management authority in relation to the client/patient, treatment etc. 

• Cooperation and collaboration, so clinically prized in this field, are very difficult to achieve in whilst such fracture and fragmentation remain. 

• The primary clinical task is to establish congruent decision making and management of authority and responsibility through the prudent remediation of inequality wherever possible and the management of systemic fragmentation and fracture.