Hope, Pride, and Leadership
Pierre AM Beauséjour, MD, FRCPC1
Over the years, presidents of the Canadian Psychiatric Association (CPA)
have focused their addresses on the challenge of change, the need to clarify
our identity as a profession, and a vision for our future. Focusing on
humanism and psychiatry, Dr Jean-Yves Gosselin in his 1993 address commented
that “As physicians, we now have a unique opportunity to reaffirm our traditional
values and our obligation to care for the sick by taking an active role
in health care reform and influencing the decision-makers” (1). Dr William
Bebchuk in 1994 focused on the interwoven concepts of partnership and change,
emphasizing the need for psychiatrists to look at their changing roles
and for psychiatry to take a leadership role in a health care reform driven
by cost containment (2). Dr William McCormick’s 1995 theme of “Meeting
the Challenges” expressed both worry and encouragement about our future
(3). Dr Diane Watson in 1996 asked, “Will psychiatry be a subspecialty
of neurology in the 21st century? . . . We are in the midst of transition,
and major change in the health care system is inevitable. Psychiatry is
a profession with a crisis of identity” (4). In 1997, Dr Renée Roy, redefining
the role of the psychiatrist, said, “I hope that we will find even more
time to make social commitment an integral part of our practice because
this involvement will have an even greater impact on our patients. Our
primary goal remains staying relevant to society” (5).
This preoccupation with the role of the psychiatrist and the future of
psychiatry is not new. In his 1965 Presidential Address, Dr Charles A Roberts
stated that psychiatry was at a crossroads. His insight is equally relevant
today and will remain so. As long as dealing with change remains part of
our daily life, as long as our profession continues to evolve, we will
find ourselves at crossroads and will need to face the challenge of renewing
and reaffirming our professional identity. Dr John J Boronow and Dr Steven
S Sharfstein wrote:
Psychiatry today faces the greatest challenge to its professional identity
since its inception. External economic and social forces have coalesced
in such a way that the very rationale for the existence of the field has
been challenged . . . it is important to keep in mind that although these
forces may dramatically affect the praxis of our profession, they do not
directly bear on its essential medical/scientific knowledge base (6).
I agree with their view that, as long as we focus on the foundations of
psychiatry, that is, our psychiatric knowledge base (medical model), our
biopsychosocial approach (Engel 1977), and the doctor–patient relationship
(Hippocratic oath), this part of our professional identity will remain
meaningful and will survive the impact of social and economic forces.
In contrast, the practice of psychiatry is more vulnerable to and influenced
by social and economic factors. Should psychiatry be seen solely as a product
and its practice as a business enterprise? Should the role of a psychiatrist
be limited to that of a consultant to the mental health system? Should
we define our identity according to what we are paid to do or what we have
expertise and skills to do? These essential questions need to be debated
and the factors influencing our responses closely examined.
The Canadian health system is pressured by social and economic factors.
Health reform was initially needed to improve the system but was too slow
in its implementation. Some would say that dynamic conservatism was at
play. Our national and provincial financial crises created a needed sense
of urgency to implement reform. Unfortunately, the restraint agenda took
the driving lead and has competed with the reform agenda. As a consequence,
our health care system has been undergoing dramatic changes at an accelerated
The principles of universality, accessibility, comprehensiveness, portability,
and public administration of the Canada Health Act (1984) are challenged.
In addition, a more active role of the provincial governments in the management
of the health care system is having its impact. Access to treatment differs
from province to province. If we are not careful, the shift to regionalization
of health services may create even greater regional differences in access
to care and negate its positive consequences. Health Canada recognizes
this, to some extent, as a potential danger in its working paper on “Best
Practices” (7), and it also recognizes the need to harmonize waiting list
management systems across Canada and to establish a national health report
While most stakeholders agree that improvements to our health care system
can and should be made, there are disagreements regarding how to make these
changes, in what sequence, at what pace, and at what human cost. Moreover
and more fundamentally, beyond the veneer of some common language, there
is no real consensus on the underlying goals of and need for change. Our
challenges: how to achieve the best use of decreasing resources in a time
of increasing needs, and how to address this problem proactively while
maintaining our core values. If our goal is to provide quality care in
the most cost-effective way, we need to pay much more attention to the
management of clinical risks. This principle can be stated in a simple
formula: improved quality + decreased utilization = increased clinical
Canadian author Carol Shields is well known for the literary awards she
has received over the years. She is also Chancellor of the University of
Winnipeg, and recently she addressed the Association of Commonwealth Universities
at a conference in Ottawa. She stated that our universities are “no longer
driven by a passion for ideas but by social and economic imperatives.”
Bercusson, Bothwell, and Granatstein echoed her comments in their 1997
book “The Crisis in Canada’s Universities - Petrified Campus” (8). We need
to rethink our academic system. With decreases in federal transfer payments
and provincial funding, students are facing higher fees and lower career
expectations. Tenure, originally designed to protect academic freedom,
has become ironclad job security without effective review. Universities
have become instruments of public policy rather than institutions of change.
We need excellent Canadian universities to provide a system of higher education
that can educate and train our future leaders. But all is not bad. New
knowledge, technological changes, rising public expectations, and increased
demands for public accountability are all having impacts. We need to transform
our universities and to recognize that clinical practice, teaching, and
research are interconnected.
Current trends in mental health care, demographics, and policy are changing
the scope and practice of psychiatry and mental health care. Accountability
for patient-centred services is at the forefront. Here the emphasis should
be more on what, as a psychiatrist, a mental heath care provider, a government,
a patient, a family member, a Canadian, I am accountable for rather than
to whom I am accountable.
Current trends in Canadian mental health care include the following: the
development of more specific and targeted treatments and interventions;
the emergence of psychosocial rehabilitation assessments and interventions;
the importance of interdisciplinary teamwork in the care of severely mentally
ill persons; the emphasis on evidence-based, best practices; the move to
continuous quality improvement and outcome measures; and the goal of an
integrated patient-based approach to care. Early detection, diagnosis,
and treatment together with early functional assessments and rehabilitative,
psychosocial interventions are major keys to better care.
Current trends in mental health demographics include a focus on population-based
needs and mental health human resources. A decade of decrease in the number
of available residency training positions, the aging of psychiatrists,
and the increasing number of women psychiatrists will have a direct impact
on the mental health reform and the practice of psychiatry. Increasing
needs for the care of the elderly and an expanded focus on health promotion
and prevention for children and adolescents are acknowledged. However,
greater attention to mental health as the ultimate productivity weapon
in the workplace is also emerging as a priority. It is becoming obvious
that mental illness and addictions are a business issue and that mental
health is a business asset. The negative economic impact of neglecting
mental illness is enormous. Dr Edgardo Peréz and Mr Bill Wilkerson offer
the following principles or statements of fact, which must anchor business
practices as a strategy of corporate performance (9):
As work stress increases, so do mental illness disability claims. Downsizing
creates an atmosphere of tension in many organizations as workers fear
losing their jobs, feel guilty about keeping their jobs, or are stressed
out about work overload. It is also harder to get away from work, to quit
for a day, even during vacations, thanks to laptop computers, cellular
phones, pagers, and voice mail. Stress leads to depression, loss of self-esteem,
decreased productivity, and increased absenteeism. Short-term disability
stretches into long-term disability. Some estimate the loss to Canadian
business in sick pay and productivity at $15 billion a year.
Current trends are influencing mental health policy: the devolution and
regionalization of mental health services, the changing role of hospital
psychiatry, the shift toward community-based care, primary care reform
and the evolving role of the primary care physician, and the integration
of information technologies. These trends trigger changes, challenges,
and opportunities on the diverse roles of the Canadian psychiatrist. More
than ever, there is a need for cohesive, national mental health strategies
to harmonize our mental health policies.
Our leadership on issues of clinical practice and service delivery, education
and research, and advocacy is therefore more important than ever. But what
is leadership? According to John Kotter, Professor of Leadership at Harvard
Business School, leadership “defines what the future should look like,
aligns people with that vision, and inspires them to make it happen despite
the obstacles” (10). Leadership always coexists with creative thinking.
The current period of profound change in the mental health system requires
innovative solutions. Unfortunately, the process of change can be overmanaged
and underled. We can resist change, manage change, or lead change.
As Derm Barrett, author of “The Paradox Process,” puts it, “The more change
there is, the more innovation we need; and the more innovation there is,
the more change we will get” (11). Allowing innovation is in itself a strategy
for change. Change triggers diversity. A major pitfall of our current emphasis
on evidence-based best practices is that it may prevent innovation and
diversity from occurring. Yet, our patients have a diversity of needs and
a one-size-fits-all solution will not work. Change can also trigger unintended,
undesirable, and disruptive consequences. I have a lot of respect for the
law of unforeseen consequences. However, the problems produced by change
will not disappear if we decide to stop being creative and innovative.
Two men were laying bricks. A passerby asked the first man, “What are you
doing?” “I’m laying bricks,” was the reply. The passerby asked the second
man, “So, you’re laying bricks?” “Not me,” replied the second man, “I’m
building a house.”
We need leadership. Peter Urs Bender writes that leadership starts from
within ourselves, that there are skills we can learn to develop leadership,
and that the biggest obstacle to leadership is fear and not believing in
ourselves (12). Many people believe that leadership is leading someone
else. I believe it begins with leading ourselves.
Many believe that leadership is about finding ways to accomplish tasks
more effectively. For example, they may talk about downsizing, restructuring,
and reengineering. These are only tools to reach a goal. “If you do not
know where you are going, any road will get you there,” or better still,
“If you do not know where you are going, you may end up somewhere else.”
I believe leadership is about creating a vision of what should be, getting
others to share it, and putting it into action with passion and integrity.
Vision stimulates energy. Energy is contagious. Leadership is about having
Like the first bricklayer, some people are so task-oriented that they fail
to see the big picture of what they do, what they are participating in.
I believe that leadership is about pride. Pride about what we do and about
ourselves. Pride about our accomplishments. Pride about our profession.
Leadership is not about being first, about having the highest position.
Leadership is not about managing systems. Leadership is about people. Leadership
is not about command and control. Leadership is about coaching and empowering.
As Abraham Lincoln said, “Am I not destroying my enemies when I make friends
of them?” Leadership is about partnership.
Leadership is not about “dynamic conservatism.” Leadership is about change,
about making choices to bring about positive change. Leadership is not
about being perfect. Leadership is about continuous quality improvement.
Creating a vision is important, but not enough. Leadership is about creating
results, but not at any cost. Results must be reached with respect, care,
and integrity. Credibility is our major asset.
In times of change, we need to grieve the loss of what we are leaving.
We also need to deal with the anxiety provoked by transition and the uncertainty
of the future. How change is implemented is as important as creating results.
Leadership is about reducing fear and increasing hope.
Bender, in his book “Leadership from Within,” explains that the best leaders
demonstrate 5 key attributes (12):
Employees are a quantifiable capital asset, not a liability.
Health is a strategic issue in asset planning, not a cost.
Research tells us that Canadians strongly identify with their workplace.
In business terms, the stigma of mental illness is expensive and counterproductive.
The structure, culture, and governing processes of corporate organizations
can cause, aggravate, or prevent mental illnesses.
Human capital, the skills and output of people, is the most important
form of capital in the world today.
We need leadership to address mental illness and to meet the mental health
needs of Canadians. The 1997 National Forum on Health recommended focusing
on national homecare, pharmacare, information technologies, and child programs.
One in 5 Canadians at some time in their lives will need access to mental
health services. Mental health must be part of these initiatives. Mental
health must be on the political agenda. Health Minister Allan Rock showed
leadership when, at the 1997 annual meeting of the Canadian Medical Association
(CMA), he asked our colleagues to show him the needs in health care. We
supported the CMA’s access to quality care response. During the CPA’s 1997
annual meeting in Calgary, we also called for federal government leadership
to develop a national strategy on mental health. Our call is even more
relevant today. Health Minister Rock recently stated that “the fundamental
challenge we face is to make the health system more responsible and more
responsive to Canadians.” The CPA fully supports this goal but emphasizes
that mental health must be given more priority. In a recent press conference,
the CPA called again for the government’s leadership in mental health,
urging that the debate on reinvestment in health consider more strategically
the state of Canada’s mental health system. CPA initiatives over the past
year have been converging toward the development of a vision and building
blocks for a national strategy on mental illness and health, for the roles
of psychiatrists in that vision, and for how organized psychiatry and mental
health partners can work together to put this vision into action. We must
continue to provide our leadership.
I have had a unique privilege this past year to serve our association as
president and as chairman of its Board of Directors. I met colleagues from
across the country and feel very confident that we can work together to
improve the mental health of Canadians with a united voice at the national,
provincial, and regional levels. Thank you for the opportunity to participate
in the strategic planning that is leading our profession into the 21st
demonstrating to others how to reach a goal, and
achieving progress that benefits others, not just themselves.
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Advisory Network on Mental Health, 1997.
Bercuson D, Bothwell R, Granatstein JL. Petrified campus: the crisis in
Canada’s universities. Toronto: Random House of Canada; 1997.
Peréz E, Wilkerson B. Mindsets - mental health: the ultimate productivity
weapon. Guelph: The Homewood Centre for Organizational Health at Riverslea;
Kotter JP. Leading change. Boston: Harvard Business School Press; 1996.
Barrett D. The paradox process: creating business solutions, where you
least expect to find them. New York: AMACOM; 1998.
Bender PU. Leadership from within. Toronto: Stoddart Publishing; 1997.
This paper was presented at the 48th Annual Meeting of the Canadian Psychiatric
Association, September 15–18, 1998, Halifax, Nova Scotia.
1Associate Professor of Psychiatry, University of Ottawa; Clinical Director,
General Psychiatry, Royal Ottawa Hospital, Ottawa, Ontario; Immediate Past
President, Canadian Psychiatric Association.
Address for correspondence: Dr PAM Beauséjour, 5th Floor, Carmichael Building,
Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, ON K1Z 7K4
Can J Psychiatry, Vol 43, December 1998