SPEAKER_00: 0:00

We acknowledge Aboriginal and Torres Strait Islander peoples as the First Nations and the traditional owners and custodians of the lands and waters known as Australia and Maori as Tangata Fenua in Aotearoa. We honour and respect the elders past and present who weave their wisdom into all realms of life.

SPEAKER_03: 0:23

Welcome to another Psych Matters podcast from the Royal Australian and New Zealand College of Psychiatrists. Psych Matters is a series of discussions on training and practice issues facing trainees and fellows of the college and other important topics in mental health.

SPEAKER_06: 0:37

Well, hi everyone. I'm Sarah Wilson and really delighted to be here today as part of this special podcast exploring a very complicated issue about power and privilege in psychiatric care in leadership and the experience of those from multiple different perspectives. So today we're going to begin a conversation about the many issues that that bear on this complex topic as a starting point to get us thinking about how this relates to each of us in our everyday work that we do in mental health and well-being. And in no way are we going to come up with all of the answers, but rather hopefully provoke some good questions for each of the listeners to think about how this may relate to your work. So my role currently is as co-CEO of the Collaborative Centre for Mental Health and Wellbeing, we've been set up under the Royal Commission into improving Victoria's mental health and wellbeing system. And a key part of that work is bringing together different perspectives onto these complex types of issues because it's by doing that we that we can begin to experience transformation of the system, think differently, work differently, develop new cultures. So with us today, we have those different perspectives, and I think that's core to having a discussion about power and privilege. We can't understand it without bringing all those perspectives to bear. So my background, I'm a clinical neuropsychologist and could be considered to come from a position of power or privilege in the mental health system. And this is something that I'm always very mindful of. As you walk into a room to speak with someone who might be accessing services, that power balance is automatically there. And I guess from the moment I started in my work, I was really aware of what a privilege it is to go on a journey in treatment with people. I run a functional neurological disorder clinic in addition to my work at the Collaborative Center. And I'm privileged to hear about the amazing journeys and inspiring stories of the people who come to do work with me at the FND clinic. It's truly grounding and it keeps me just constantly in awe of human resilience and and the things that people can journey through, and it's a privilege to go on that journey with them. So that's really where I come at this. But I'm going to pass now to Emily Unity to introduce herself and tell us a little bit about her perspective. Thanks, Emily.

SPEAKER_05: 3:40

Thanks so much, Sarah. My name's Emily, my paranoia's adam. I'm an intersectional and delivering experience advocate. I currently sit on the college's committee for Victoria as the consumer representative, but I also have intersectional experiences of being a carer, as well as being multicultural, queer, disabled, neurodivergent, and a victim survivor. My relationship to psychiatric leadership is both from a personal lens as a help seeker, as well as my professional lens as a co-leader in co-designing mental health systems. And privilege and power are two of my favorite topics to speak about. And I think that they're really opportunities for us to improve the mental health system together. Psychiatrists have often been thought of as the most privileged and the most powerful, as opposed to folks with lived experience, who tend to be the least privileged and the least powerful. But I think that when it comes to privilege, it's something that we don't choose, but we can choose what we do with it. And that can make all the difference in creating really inclusive systems and spaces and power as well. It doesn't have to be used as a tool for control, but it can be a kind of tool for creating meaningful partnerships where everyone is equal. And I think the best leaders that I know use their power and privilege and leverage them to empower others, not to maintain their own status. But yeah, I'll pass on to Karen.

SPEAKER_01: 4:59

Thanks, Emily. My name's Karen Rubin. I'm a psychiatrist. And uh what I'm gonna do is something I don't often do, which is go through all of the various positions I hold because they are part of the power that I bring to this conversation. So I'm the clinical director of uh the mental health and well-being service at Peninsula Health, which is the public mental health service that provides essentially all of the public mental health services to Frankston and the Monaco Peninsula. I'm also an adjunct uh senior lecturer at Monash University, and I have a clinical academic and research role. Um, and I'm the former chair of the uh Victorian branch of the Royal Australian and New Zealand College of Psychiatrists. So all of those things mean that both in a general sense, but in within my profession as well, I I get to sit in one of those really powerful seats and talking about it here and acknowledging it as a is an important step for me because like many people I actually don't like being in a powerful position and yet I am. So I'm hoping that starting off with that acknowledgement helps paint a picture of what power is and those huge power differentials that can exist. My particular passions are around working, you know, with people, and particularly about building a public mental health system that is not about power and control, but is about supporting people, supported decision-making processes, um, creating the least restrictive services. And so I can't help, but I I I stress in every setting I'm in, probably the thing I'm most proud of that that I've done in a professional sense is I work at the only mental health service in Australia where we have eliminated the use of seclusion as a practice in our mental health units. And I'm not going to go into that specifically today, but that is fundamentally about exercising power and control in a manner in which many people, not just people from a lived experience perspective, will say is ultimately harmful for people, not questioning the intentions of why people do it, and the intentions may usually be good, but the importance of recognizing that the exercising of power in and of itself creates a really important experience in the person who is less powerful. So I'm not going to talk any more about that. We'll have lots of time for conversation. I'll hand across to Phyllis.

SPEAKER_07: 7:25

Thanks, Kieran. So I'm Phyllis Trua. I'm a consultation liaison psychiatrist at the Austin Hospital and Calvary Healthcare Bethlehem. And I've also had an interest in medical education and I was a senior lecturer at Monash University and I've left that role and I'm adjunct there. So I've always been interested in and have been involved at the university in undergraduate and postgraduate courses, as well as at the college registrar training program. So I'm currently the chair of one of the education subcommittees, SEMA. And also have a research interest in neuropsychiatry and medical education. But how I came to be involved in this panel has been an interesting journey. So I have to admit that, like so several years ago, when I was involved in education, the term lift experience was new to me. I'm happy to declare that. And I think it's kind of thrown around now. And at the time I was thinking, oh, this is interesting, because I you know we knew about the you know using the term consumers. But one of the reasons it was interesting to me was that I'm in one of my research and clinical interests in Huntington's disease. And when I first started in this area back, I don't know, over 20 years ago maybe, I remember attending a conference where the clinical presentation was open to people, you know, who had Huntington's inner carers. And I thought this is a very interesting kind of setup. And this is like over 20 years ago, where we have people living with Huntington's inner family who are, you know, who are welcome to attend our meeting. We were also welcome to attend their their day. I remember thinking that, well, one day do you know will this happen in psychiatry? And then fast forward like two or three years ago, I attended another uh meeting where the neurologist and the person who at Huntington's had written a book together and they're both presented on stage together about you know their different experiences as someone who had been tested positive for Huntington's, their journey and the neurologist's experience. So, you know, I think there is potential there. Um we're still not there yet, but I hope that this conversation today is is the start of that kind of thinking about, you know, is that kind of possible for psychiatry? And how I can't be involved is through my education. I I was fortunate in being able to lead the development of a new course, which was done alongside people with lived experience of mental illness and carers. It was very successful and you know, people, the students actually were very engaged with having people with lived experience of mental illness actually facilitating and also helping develop the content. And I've really enjoyed, and in a way, it's kind of felt much more authentic in the education sort of space. And I'm hoping now that I've now moved more to clinical work and that that will also translate to the clinical space where in the mental health sector that we know that the lift experience workforce will also grow. And I'll be interested to hear, you know, Sarah and Emily's thoughts about this as well. So Kira and I being, I mean, he's a director of you know a service, and I have to say, one of the things I wanted to clear also is that I've never had a clinical leadership role. I mean, I've led things in uh academic settings, but what what I'm I want to highlight that because I think this podcast is not just for people who want to be a formal leader. I think as psychiatrists, the minute we get our letters, or even before that, we are kind of leaders in different ways. And even that one-to-one interaction with each patient, sometimes we we we are a leader. And I think this is hopefully this will open for the first conversation topic about how do we get this part and privilege? I mean, what do you the rest of you think about this question? How how do psychiatrists end up being in this position?

SPEAKER_06: 10:55

And yeah, it's a great question, Phyllis. I mean, I think, you know, in our lead up to having this podcast, we were just starting to talk about this idea that this is one of those unspoken things. It's um something when we're doing our work that we don't automatically think about. Psychiatrists, and I think Karen made this reflection, don't often realise that they're in this position of power and nor do they feel comfortable with it. But yet within our current health system, the medical model of care places that power differential or brings it into the room. And so we have to bring that into our conscious awareness if we are in that position, whether we like it or not, and then deal with it. And and so, Emily, I wonder if you can share with us, if you feel comfortable, what it feels like to be in that space when you're accessing a service or or treatment or care or support.

SPEAKER_05: 12:02

Yeah, sure. So I'll speak sort of like how power and privilege have manifested in my personal interactions with psychiatry and then also my professional interactions kind of co-leading. So in my personal interactions, often power and privilege, if it hasn't been checked or understood or addressed, is really present, particularly as a patient seeking help. It feels like a one-way relationship and it feels like I need to fit into a model of care, not the care needs to work around me. I feel like often power can be wielded in a way that reinforces assumptions and bias. I feel like often the system tells me who I am rather than asking and listening to tell my own story. And it's really hard to tell my truth when it's filtered through someone else's bias before I've even spoken. Especially in really crisis moments, power and privilege really can sometimes conflict with compassion if they're not checked. They can really be hindrances to providing effective care and seeing someone for their strengths, not just their weaknesses, um and seeing them as a full person rather than something that needs to be fixed. I think that that has led to many systemic and broader issues, such as inflexible treatment approaches and barriers to general trust and engagement. But I think there have been very positive interactions that I've had in personal settings where power and privilege have been wielded to see who I really am and see my intersectionality, my identity as something to harness and really listen to. And it's that kind of self-determination and the giving back of my autonomy that has shifted the conversation from what's wrong with you to what do you need and how can we work together. I think that that's a brilliant use of power and privilege. As for like professional interactions, um, I'd say that there is a real resistance currently to co-leadership. I think once people get comfortable with a certain way of life, just humans generally, um, it can be hard to change. But I think the resistance co-leadership isn't about taking away power, it's about redistributing it for better outcomes. It's about welcoming in different voices and not seeing them as competition and doing that in a way that's really equitable. So if we're co-leading between psychiatrists and people with lived experience, it's it needs to be really trauma-informed, acknowledging that power and privilege have worked historically in a way that might be really harmful, and to acknowledge that and really leverage people who are privileged to create more equal power balances between everyone that's in the room to ensure that we don't just all have a seat at the table, but we really all have a voice at the table as well.

SPEAKER_07: 14:41

Thanks for sharing Emily. I mean, as I hear you talk about all those points and and your experience of being a um a patient or you know, the experience in interactions of conscious, I kind of say all of them make sense, but then you know, when I think about when I'm actually with a a patient, that I think you do get caught up and you don't realise that. And I think that's one of the you know, discussion, you know, what discussion points here that sometimes you don't realise you have that power and privilege in that individual interaction with a person. You don't realise that's how the person perceives you. Because I think my psychiatrists do try to be compassionate and caring, but you know, I think that relationship's already predetermined in a way. Like before we even walk in the room, you probably kind of think, well, the psychiatrist's coming, and you know, especially um if someone's unwell, I mean, I think we are all vulnerable, whether it's physical or mental illness, just a bit more vulnerable just in general. But the whole setup is already has that kind of puff differential that's somehow defined before we even meet. Does that is that right, Emily?

SPEAKER_05: 15:43

100%. I think uh privileged psychiatry often manifests through dominant, unseen cultural norms that shape the profession and it can really lead to a hierarchical structure that is not necessarily explicit but often implicit. And this re really reinforces one-directional flows of communication where people lived experience feel like our experiences are being dictated rather than explored. And I think that if power and privilege go unchecked in psychiatric settings, it can really create barriers to trust, um, barriers to meaningful outcomes and more marginalization and harm. I think that these sort of structural systemic issues need to be brought into the light and spoken about, um, acknowledge that everyone has power and privilege. Lived experience have their own power and privilege in their own way. Whilst I come from a number of different backgrounds, identities that might be termed as underprivileged or marginalized, I still have a lot of privilege and power in different ways. English is my native language, I'm well educated. Um, I think that there's ways that I can leverage that power to amplify voices that are less heard than mine. Um, and I think that psychiatrists, just like any other person, can also do the same.

SPEAKER_07: 16:58

Yes, I agree. Because I think palm privilege does come from like some individual characteristics that we all have, whether it's gender or race. You know, as you were saying that I was thinking that within under medical hierarchy, there is this hierarchy that we all kind of adhere to. It's just part of our training. That, you know, we train with trainee, then as a consultant, then we have the you know, the lead clinician. And I guess that's how we uh do our training, it's just automatic for us. But I I hope that you know, being more aware, and I think that's part of that leadership framework to kind of lead ourselves and be that that self-awareness. So to acknowledge that we do have that power or privilege, how is that kind of affecting this relationship that we're having with whoever we're interacting with, whether it's the person with lived experience or the consumer, and just kind of be aware of how maybe it might impact on on the care that we're trying to give to the person. So I think just kind of acknowledging it, perhaps is the first step. And and and as you said, like it's sort of there. So it's not like we want to get rid of it, it's just more being aware of it and how it's impacting on on this particular relationship. Would that be alright?

SPEAKER_05: 18:07

Absolutely. I I think the first step in all of this is just awareness and education and understanding. It it often is one of the biggest barriers is people just unaware of the privilege that they carry. Um and that's not necessarily their fault. But I think for me, a lot of harm can be really unintentional if it's not checked. But I think we all have a responsibility to check our own privilege and power and understand the way in which it's being wielded, whether it's on purpose or not.

SPEAKER_07: 18:35

Can I just ask, I mean, when you say harm, can you I mean, is there anything that you can think of that we I mean, you don't have to talk about anything that you don't want to, but yeah.

SPEAKER_05: 18:43

So coming from many different backgrounds, my lived experience is difficult to understand for most folks, just as it's hard for me to understand other people's lived experiences. But I think there have been a lot of times where I've been inadvertently harmed by someone not understanding their power and their privilege, not understanding how, for example, our differences in culture, our differences in education biases can affect the way that I'm being labelled or diagnosed and therefore being treated. I have been handled between services, misdiagnosed, mistreated, and it has resulted in some things including seclusion and restraint that could have been avoided. I think that there's a lot of inadvertent harm that comes from people who are doing things with the best intentions, but not with a lot of curiosity, if that makes sense.

SPEAKER_07: 19:31

Yeah, I can see I'm sorry to hear about your experience. And I know personally, like now that I'm trying to be more self-aware and um Asian background and being female. Um I'm I guess more sensitive to some of the intersectionality kind of issues that that you've kind of referred to. But recently I was aware that I had made these assumptions about a refugee and you know, came with PTSD and depression. I thought, yes, it's all kind of war-related. But then when I spoke to them, it was just the trauma you might see, you know, the experience anywhere else. But you know, I was kind of horrified in a way that I hadn't made that assumption, even though I was trying to be, you know, to deliver holistic care and kind of um be empathetic and compassionate. And but I had come with that lens or thinking, oh, you know, this is a person's refugee. And so it is very easy, I think, sometimes to just fall in that trap. But rather than beat myself for it, you know, I think it's part of what the framework talks about, that kind of being aware, the self-reflection, and you know, you we're always kind of learning along the way, and we we can't learn everything, and and things are dynamic and changing. And you know, this was the first time I met someone from that background, and now I know not to kind of make assumptions about people that I see. Definitely, like when you know better, you can do better.

SPEAKER_06: 20:43

I think this conversation is so great because what it does is it puts the onus of power sharing on on each of us, right? So understanding our privilege, as Emily has so beautifully described, and then making a decision about how we use that, are we going to use it for good or not? And of course, we never intend not to use it for good, but if we're not aware, then that might be the outcome. And so as you were talking, I was thinking more broadly. So, what does this mean for reform or transformation of the mental health and well-being system in Victoria? Because we know that a lot of harm has happened under the traditional models of care. And the whole point of the Royal Commission was to really stop that from continuing to happen. Once we become aware, we need to do something about it. Uh, we can't just keep repeating those patterns. And here I'm talking about a change in our mental models, a cultural change in the way we work and practice and bring that reflective practice into all of our conversations. But also the importance of the lived and living experiences, perspectives and workforces in the system to be present with us, to be having those conversations and pointing those things out for us. And for us to have an open mind and not to feel too threatened by that or intimidated by that, because of course the flip side is that often if we've been in these positions of unaware power, then if someone points that out, we might feel defensive about that. Um, because of course that was never our intention, but that serves to exacerbate the problem rather to rather than come to a point of problem solving or changing how we work. And so I'm going to pick up this idea that, well, we're in this system and we can't do anything about it, because I actually think we do have some things we can do about it, and I actually think we must if we're going to bring transformation and to really change this fundamental dynamic which sits at the heart of our challenge for reform. So, Karen, I'd be interested to hear what you think about that.

SPEAKER_01: 23:14

Look, I've really been listening with interest, and particularly that conversation with, you know, Emily and Phyllis there about those experiences. And I think one of the things that makes it hard for people to recognise their own power and privilege is people, we don't talk a lot about power and privilege, and people don't understand what the things are that contribute to power and privilege. And and they often think about very limited things. And I think Phyllis touched on that, that you don't feel powerful when you see yourself as junior in a hierarchy, but actually you're not seeing yourself in a much broader sense. So the the the concepts that we often think about, and I'm acutely aware of that in in this room and in most rooms I go into, you know, there's some primary things that exist across all parts of our society: gender, race, country of origin, cultural or religious issues. But then there are the other things that factor into the power that people have. And Emily's touched on some of those things, such as one's educational background, um, income, social capital. But then particularly importantly for psychiatrists, and even more so for psychiatrists in leadership positions, there is role, and roles come with inherent power. And as psychiatrists in all parts of Victoria, and I'd say in all parts of Australia, there are actually also the legal structures that invest you with very special, incredible powers that almost nobody else in our society has. And if you don't recognize that, that automatically means that you generate the kinds of experiences that Emily was talking about, not just with um people who are coming to you seeking care, but you create those experiences in multidisciplinary teams when you're working with people. You create those experiences of power, unacknowledged power differentials in people's families, supporters, carers. Um, I extend that up again. I was talking about I sit in a powerful role. In Victoria, the Mental Health and Wellbeing Act has a position of an authorized psychiatrist, which I also am. I should have listed that um in my list of titles. I have legislated powers, and I'm referred to specifically in legislation as having all of these incredible powers that, except for Phyllis, none of you have. Phyllis has those powers because an authorised psychiatrist delegates them to her in her public role. So wow. It doesn't matter. You could create a person with my roles who didn't have that sense of power from their upbringing, you know, from their background in terms of gender. Education's a tricky one. You don't get to this kind of job without ultimately having had privilege around education, regardless of where you started. Social capital, all of those things, the very nature of your role means you're normally the most powerful person when you walk into a room, up until really you you kind of get into my jobs where you then start to engage with that level of power that sits above you. And suddenly you you you often aren't the most powerful person in the room. And then the problem with that is you take that into the other rooms you go into. If you spend all your time in rooms where you're not the most powerful person, you forget that when you walk into a room where you are the most powerful person, you don't think of yourself that way. And so, you know, a lot of junior or mid-career psychiatrists who don't see themselves in leadership positions and don't recognize the most junior psychiatrist as a leader, don't feel that sense of power and wonder why other people respond to them as if they have power. So self-reflection and insight around what is power and what is privilege, I think is the real starting point. That's kind of what I take out of this. I can't help myself. It says something about my background. This is where I quote Spider-Man. Um, with great power comes great responsibility. Um and the first responsibility is recognizing your power so that you don't harm people with it. Unintentionally, with the best of intentions, unaddressed power is harmful in clinical relationships, but it's harmful in leadership structures as well. And you can't do good co-production that puts lived experience at the center of what you do without without an acknowledgement of power in each and every interaction you have. So that's kind of where where I sit around this. And I'm really interested, Sarah, with your role, how this fits into, you know, your understanding of, you know, what what you're trying to do from both inside and outside the power structures to address these things.

SPEAKER_06: 27:47

Yeah, and and I love the way that you've reflected, Karen, on the fact that your power shifts depending on what context you're in. And Emily, you touched on that too, that um in different ways you recognise you also have that power. And so the onus, again, is on all of us to understand how that plays out in a given context and to be ever mindful of that for all the reasons we've spoken about. I mean, that was really one of the reasons that I was so attracted to the co-CEO role at this newly established Victorian Collaborative Centre. It is a completely different model, and the Royal Commission were very brave in putting it forward, and I think showed great vision, but also set us all a huge challenge. Because, again, in reflecting on what we've been talking about, it really calls upon us to start and practice and work very differently. If we start from this basis of power and privilege and inadvertent harm that can arise from that if we're not keeping it at front of mind, what it's really calling us to do is question the model of care that we're in and and and how we do that and to move away from these more traditional hierarchical models where there's someone who needs, as Emily said, you know, to come in and say, What's wrong with you? And someone else to say, Well, this is how I'm gonna fix you. So the fixer and the the fix-e, if you like, and to start and think about relational models of care. And relational models of care are all about the human relationship that exists between two people and understanding where they are, each in their own lives, you know, and they're both gonna bring perspectives and pearls of wisdom to bear on whatever it is that they're interacting to work on, and they're gonna learn from each other. It's not just ever one way. And this is where even the therapist role, I think Emily has an inbuilt um power in it as a as a uh psychologist who does. Does therapy, you get to know a lot about the person, but they get to know very little about you. So there's an imbalance in that therapeutic relationship. And that was kind of traditionally set up to avoid there being a scenario where the therapist just goes on and on and about themselves, and you that actually becomes unhelpful. But at the same time, it also creates this opaqueness, which again leads to a power difference for therapists and clients or consumers of therapy. And so how I like to think about it, and I kind of alluded to this when we started, is working together, being on a journey together. There's a reason that the relationship works, and not all therapeutic alliances do, but fundamentally what sits underneath it is that human relationship of two people exploring issues at a time and in a place that is hopefully going to help both of them move forward and learn and reflect. And so at the collaborative center, relational models of care and lived experience are at the heart of all of our work. And promoting innovative ways of working that reduce or eliminate, in fact, seclusion and restraint are all about what we're here to do and to encourage across the system. And so important for us at the collaborative centre is to walk the walk, not just talk the talk, because it's easy to say these things and much harder to do them. So the Royal Commission built this co-CEO model into the collaborative centre structure. It also put a board in place that has a chair who is non-lived experience, but a co-chair who's lived experience and many people with lived experience around the board table. This is quite an atypical thing. You're not going to see this on standard boards in organizations in the community. It has at every level of the center's work embedded lived experience, shared decision making, shared reflective practice. And then it has the lived experiences advisory panel, or leap, as we very warmly refer to it, the leapsters, who provide advice to the board and to the team in all of our work, and this is core to the way we think and do things. So what this means in real time as a co-CEO is that you really change the way you work. You don't come in and make decisions and just write, we're going to do it this way. There's this stepping back from that, what might be a traditional leadership model and a deliberate seeking space for discussion and reflection and taking time to confer. And Carolyn Gillespie, my co-CEO, Lived Experience, who can't be here today, but I do my best. I don't do it well, but I do my best to channel her thoughts. She would talk about our real-time discussion and decision-making and how we're kind of doing that just in the daily work. And that really brings this constant reflection about the power and make sure, you know, that that relational way of working, reflection, decision making, shared power is caught of the model. And we have to really work hard to do that because it's easy for us to be very busy and go, we'll split and conquer and divide. But actually, as soon as we step away and do that, we've lost the essence of what we're there to be doing. And so what it means is that we have to be deliberate, we have to be intentional and conscious about it, and we have to build in extra time because you know the pressures of the clinic or the the organization or the leadership role or what wherever you find yourself mean that you you naturally get pulled away from that.

SPEAKER_02: 34:03

I hope that you're enjoying this podcast. If you have a topic suggestion or would like to participate in a future episode of Psych Matters, we'd love to hear from you. Please contact us by email at psychmatters.vback at ranzcp.org.

SPEAKER_06: 34:21

So, Emily, I'd be interested to hear about your reflections of LEAP and how that's gone in terms of the structure more broadly for the collaborative center, given your core involvement as the deputy chair.

SPEAKER_05: 34:34

I think one of my favorite things about the LEAP is that I often forget I'm deputy chair not because of the responsibility, but because it is very much shared leadership and acknowledging that everyone has something to bring and learn. I think that's something that I really enjoy about being in that space is the humility that everyone practices, the curiosity that everyone brings, and how we're always working towards the same goal of improving the system. We're hard on the system but gentle on the people. And I think that that's something that I hope to see more in reform spaces. The leap is something that I definitely value as a space that's representative of intersectional lived experience leaders. And it's really an amazing opportunity to be able to work with people who do not identify with lived experience or predominantly haven't worked in those sorts of designated roles and to really challenge and disrupt power and privilege in a way that is curious rather than punitive. Because I think that conversations around power and privilege, they don't need to be scary. I think that some people are really uncomfortable engaging in these conversations because they feel that it's going to end up as a personal attack or fear that it's going to be giving up control or diminishing their role. But I think it's about an opportunity to grow and to learn and to improve with more perspectives, especially to make room for people who historically have not been heard but have a human right to be involved in decision making that affects them. I think my kind of main message to people who might be hesitant to engage in these sorts of conversations, it's important to highlight that addressing privilege isn't a one-time, immediate radical change. It's small reflective actions and remaining curious about not just the people around you, but also about yourself. And I think it's maintaining that active care towards you and the world around you that can really build a system and a society that's really for everyone, not just for the only people who have decision-making power currently.

SPEAKER_01: 36:41

I'm really interested, Emily, listening to you and Sarah. And I've got a bit of a question for you in this one, Phyllis, but I kind of want to put this to all of you. I think we're we're talking about that personal responsibility people have in checking power and privilege, in self-awareness. But for psychiatry as a profession, I think there's also that responsibility for the profession to be self-aware about the impact of power and privilege on our leadership structures within psychiatry and and within health services. And so I I come back to kind of that same rough list I sketched before. Worry that when power structures and leadership structures are not reflective of, you know, the members of a group, when they're not respective of the broader society that they're part of, that's that's another way in which power and privilege manifest more subtly. So you know, I can meet the most lovely, reflective leader and always thoughtful about power and privilege in my personal interactions with people. But if I don't recognise I don't just have power and privilege in those spaces, I have a professionally, and I'll use the example of, and and I mean no offense to any of my colleagues who will be able to identify themselves for what I'm about to say. But I spoke about one of my previous roles, which is the chair of the Victorian uh branch of the College of Psychiatry. And so when I first joined that Victorian branch committee, I'm gonna say maybe 16 or 17 years ago, there was not a female on the committee. And uh certainly nobody uh was identifying as uh non-binary, uh, so it was both binary male, not not heteronormative, but certainly very cisnormative. And when you look back on it, that had just been how it always was. And there were ways, my experience of it coming on as a very young person back then, that the ways of conducting that committee propagated that. So the times of day that it was held at created imbalances in who who would nominate because they could or they couldn't attend. I do remember when a, you know, a female colleague of mine joined and she eventually left that committee, and one of the things she said was it was an overwhelmingly masculine environment. It was just eventually too toxic and unsustainable. Predominantly a mixture of, you know, when we looked at racial background, it was men, most of them much older than I was at the time, sadly the age I probably am now, and a mixture of predominantly European and Indian background men, which are the two groups that seem to be represented in power structures within psychiatry in Victoria. And there was nothing being done to actually change that or address that. Um, before I was the chair of the branch, there were some other, you know, much more forward-thinking people who went, There's a problem here and we need to do something about it. I'm going to talk about my personal approach, not to big note myself, but as an example of it, like how we have to approach these things broadly, was there was a recognition that there were issues with this. There was a recognition that when we looked at who'd been the uh speakers at conferences over the last decade, it was disproportionately weighted towards men, when in fact our membership was closer to 50-50. Um and when you looked at trainees, um, there were more women than men, and there were more people identifying as non-binary than you know, that hadn't existed well uh for people uh up until a certain point in something that you could identify with. People still identified that way, but not openly and not in in more public settings. So we were not representative of that as all. So one of the we you know, we put in place clear policies that said you have to have even distributions when you run a conference. And we put in when we put in place a succession uh strategy, we were really clear that the next chair of the branch was not going to be another man. Because until your positions of power are representative of the people you're representing, you you're perpetuating those power imbalances that exist within our society each and every day. So I think it's lovely that I'm interested, uh talking a lot to kind of his background, but I'm interested in how you've seen that play out or not play out in how you approach things at the collaborative center. And I'm really interested in Phyllis's and Emily's experiences of how that's played out in the psychiatry leadership settings, because both of you in different ways um interact with psychiatry leadership all the time. And hopefully it's not as quite as toxic as it appeared to me 20 years ago.

SPEAKER_05: 41:24

Understanding power unpacking it, um especially in the way that you've described it, Karen, to understand that it's kind of societal and the individual and the formal and informal. There are kind of two axes. So if you imagine like the y-axis going from like informal at the top to informal down the bottom, and then the x-axis from the left to be individual and the right to be societal, that kind of creates four quadrants of where power can kind of manifest. The first quadrant of like consciousness, which is like individual and informal, it that's that sort of like checking your own power and privilege. It's understanding it, being empowered in your own self and be able to do that at the individual level, in at the informal but the societal level. There's like culture and the representation, the visibility of who is actually in leadership, whose expertise is being valued, and what is actually being counted at as expertise. There's also like individual but formal, which is stuff like resources, who's being paid to actually be giving their expertise, who has access to opportunities to provide their expertise or technology or information, and then uh formal societal, which is those kind of formal rules and policies such as like governance and procedures that dictate things such as who needs to have certain qualifications in order to attend meetings or be good enough in order to give their expertise. I think interrogating the different ways that power can manifest is really important to addressing them. And it is very much sometimes really explicit, um, such as like policies and governance or representation at board levels. But sometimes it can be really implicit and at at societal and both individual levels. So yeah, I I love the way that you kind of unpack that, and I hope that my verbal explanation of this framework kind of helps a little bit.

SPEAKER_01: 43:14

That's been lovely. I I kind of tend to have a brain that thinks along those lines, but probably not as um structured as as you were. So that's that's really given me something lovely to think about. I'm interested, Sarah Phyllis, as well, your your understandings and how this has played out for the two of you.

SPEAKER_07: 43:31

So it's interesting. So I I don't want to point this out to you, Karen, but you're the only you're male in the panel, and you are also not uh Australians. But I mean I was just thinking about you know how you kind of were able to transform, you know, the Vic branch and the community. You started from a place of power. You know, you were part of that the the group that held the power. Just to highlight it is hard for the people you know who who might be at the other at other end of that spectrum that Emily kind of outlined. And and and it's great to have this collaborative centre now and some other changes in the kind of role that the World Commission has initiated because it's very hard for one person, particularly the person that's at the bottom of that hierarchy, to try and make you know, do transformation, which is what you're talking about, Sarah. And like for me, like I am just a clinician on the ground, and although I'm trying to do my best of the patients that I see, you know, the thought of trying to you know transform the whole system. I mean, that's just impossible. And one of the things you've highlighted is that by legislation, I have the most power. So as much as I try not to do restrictive practice and everything, the law has given me that responsibility. And I think it's something a lot of psychiatrists, clinicians struggle with that we have this ultimate power and responsibility, because power does come, you know, with responsibility and it does sit with us. And it is very, very difficult, therefore, to share that because unfortunately the responsibility doesn't get kind of passed on. Like legislation, we are the ones who sign off. So if anything happens, like is it possible that maybe in the future that could be more than that psychiatrist who has input into making an assessment order and you know the TTR? You know, is that gonna be legislated? I know we're supposed to take into consideration different people's you know points of views and including the you know the the patient, but but someone who's really unwell and who's been deemed to have you know don't have capacity and if it it is very difficult. So I have to kind of I guess kind of n not defend as a role of psychiatrist, but it is uh one of the big challenges, like in terms of co-leadership, that as well as giving the side the power, do we also share that responsibility? And I mean I think that is a slight shift, the idea of dignity of risk and sharing that risk. But at the end of the day, it is always in my head that you know we are the one who's signing off, and if anything happens, then I'm the one who's gonna be you know caught up in court. That's there are challenges at the kind of systemic level still. I mean, and hopefully that might change with time. So from my perspective as a as a psychiatrist on the ground, even though I might have the power at that practical level, that that you know, there's some challenges that we face.

SPEAKER_06: 46:02

Yeah, and Phyllis, you've touched on that dilemma or that tension that exists really beautifully, and you've captured that that even in a position of power you feel powerless because this system change seems to be um above and beyond where individual capacity lies. And and and Emily beautifully described it in her, you know, two axes model. One of the new models of care that we're trying at the Collaborative Center, and as part of the strategy that we have, we have a translational research strategy for Victoria that we're rolling out to support new models of care that are built around these relational models. One of them is the open dialogue model that we're doing in partnership with the Royal Melbourne Hospital. And I know there are other services across the state who do variants of this type of model. But it gets to this nub of the tension that you were talking about, Phyllis, that what does it mean to deliver care for someone when they're perhaps in a position where they can't make informed decisions when they're acutely unwell? And then how do we address that so that we can ensure that we do make decisions that they would approve of or that they have, you know, had direct input into so that the decisions that are made when they're not in that perhaps state of mind to be able to contribute, nonetheless, the decision reflects what they would want. And so the open dialogue model is all about these models of community-based care where discussions are had around that as part of the model. So, how is it that you want to be cared for in the different phases or states of your condition? At certain points, your well-being will be higher, at other points your psychological distress will be higher. And how is that to be best managed? And talking through that and really having a shared model of care that comes out of that that that reflects the needs and wants of the consumer, that also hears the voices of carers and supporters and kin and brings the team together so that power sharing is held across the team. And Phyllis, in a sense, that actually is better then for the psychiatrist as well, because it what we haven't spoken about is the moral injury experienced by clinicians as well. So these practices are not just harmful to consumers and families and carers and supporters and kin, they're also harmful to clinicians and psychiatrists. Because the last thing that certainly I ever want to be doing is creating these scenarios where, you know, seclusion or restraint might be the option that we end up in, as I'm sure exactly your same experiences, Phyllis and Karen's. And when we get into the system as it currently works, kind of leads us into these scenarios where that seems to be, you know, we we're led down this path and the moral injury, the the the distress, how can this be happening? This is not what I signed up to do. I signed up to go on journeys with people and to experience the highs and the lows and the joys and the dismay with them and to learn and to to walk alongside. I didn't sign up for other types of experiences, and yet here I am now finding myself doing this or having to do this. And we know a lot of clinicians have left the system because of this, right? Because of the moral injury and that the harm that they've had out of it. So I think before when I reflected on this is a necessity that we all have to work towards for all of our benefit collectively, because we know at the moment getting people to stay in the workforce is one of the biggest challenges, the retention rates, the burnout, the psychological impact. And then again, that leads to even worse experiences for people who are then accessing services. So we get into this downward spiral rather than stepping back and taking a completely different approach. So it's kind of radical at one level, but I guess it's what the Royal Commission saw, the point that the system had come to and is asking us all now to grapple with. I don't think it's an easy answer and I don't think it's a quick fix. I think it's complex, it's hard work and it's going to take a long time. And the best way to do it is with all the voices in the room and and from really elevating the lived experience so that we we don't repeat the same mistakes.

SPEAKER_07: 50:47

Um, thanks for that, Sarah. I think that it it's it's reassuring to hear that there are sort of like models, alternative models of care being trialed. Um and you know, that incorporates that co-leadership element and it is true, it it is a bit of a relief, you know, because it is one of the things that makes the job quite hard when you've got someone who doesn't have the capacity to make decisions and you know, um if they especially don't have carers, like what do you do? And we know we don't want to come to work and do restrictive practices. Um that's not why we signed up to do psychiatry. So that it's nice to have that validated. Um because I think the picture of psychiatrists in public is often often the opposite. And I think with a framework, you know, that's why we're hoping that that psychiatrists would sort of reflect on their own practice, but also how their own role within the system. And you know about Karen, I if we do see that there are issues and how do we as individuals well not like take on the whole Vic branch, but maybe just make more changes. And it could just be a simple thing like that, you know, like how we to participate, are the opportunities maybe just start sharing that that power. Karen, would that be all right?

SPEAKER_01: 51:56

Yeah, look, uh so there's always opportunities. And but I want to pick up kind of connecting what you've said and and some of the things Sarah said to what Emily was saying about the you know the assumptions that dominant cultures make. And so one of the things that bothers me, I'm going to use that specific example because it's come up a few times and it's dear to my heart, restrictive interventions. The dominant culture in Victoria, both inside and outside of the health system, dominant culture supports some kinds of practices as necessary in making sense in certain situations, and therefore people feel, as you've described, feel less like there's no other option. But frequently the dominant culture is wrong. The dominant culture doesn't mean that something's right. It means it's what everyone believes is right, or it's what everyone has, you know, developed to a point of thinking makes sense. But but from an evidence base and from other perspectives, it's often really wrong. And I think this is some of the stuff the Collaborative Centre is teasing out with different models. For me, it's it's that obvious thing around, you know, restrictive interventions. There is nothing from a medico-legal perspective that says you should be doing restrictive interventions, and if you don't do them and something goes wrong, you did the wrong thing. But that has been the culture, and I'm not saying from just within psychiatry, but the way coroners and a medical culture, so both medicine and and legal cultures, have examined when things go wrong. Um and that comes right down to the fact that some of the methods that are used to analyze things look to find a cause and essentially to lay blame whether they see it that way or not. But there are other approaches to this. And, you know, you know, there are restorative justice cultures that take a really different look at what it means when something has occurred. And so there are things that are really deep within our culture that lead us down the wrong path. And so I think power and power structures and not being aware of them is really one of those things. Um they often lead in the wrong direction because they assume that the people with the power have the knowledge and therefore what they want to do is right. I was in a co-leadership position for a few years, Sarah, and I always used to say I feel like a fraud here because one of the principles was that I was meant to be developing leadership in people with lived experience as part of co-leadership, but I learned far more than I imparted, I always thought, that actually I I it changed the way I work both clinically and as a leader, working in co-leadership. Again, I think that's one of those dominant assumptions that it's uh it's more one way than the other because of the power differentials.

SPEAKER_06: 54:36

Yes, absolutely. And and in fact, I would be thinking that going forward this should be the model, you know. It we should have co-leadership in all our mental health services from the top and all the way through the system. And uh that's what we mean by really putting lived experience at the heart. It has to mean something and have impact and really change the way the system works, and and that's the way we're gonna move towards this, I think, better place. Is there anything more, Emily, you'd like to reflect on, or would you uh like to sum up some key points?

SPEAKER_05: 55:14

It's been a really amazing conversation. I absolutely loved it. But I I think um something I'd like to point out about this conversation is that uh privilege and power, it's not a conversation about blame. Each of us in this conversation have different types of privilege, different types of power, and I think it's about being curious about yourself and the people around you, how systemic structures can influence our privilege and power. And I think we've really role-modeled that, and I hope that that kind of is the flavor that other people take on into their conversations. They're really big things, privilege and power, but it I think each and every single one of us can do things to address that at an individual level, and that can really ripple out. And my kind of favorite three steps that I like to give folks when like first talking about privilege and power is to first learn about yourself. So understand how systems affect you. Everyone has their own experience of gender, sexuality, race, education, employment, and a whole lot of other intersectional factors. So learn about how those factors affect you. And then second, learn about other people. So I think it's important to step on first because otherwise we will leak over our experiences into other people's experiences. So we need to hold ourselves apart from other people and really learn about who they really are without ourselves being put over them. And then the third step is to speak up and show up. So really leveraging your power and privilege where you can speaking not for other people, but with other people, and really amplifying voices that aren't often heard. Yeah, I will throw it over to Karen.

SPEAKER_01: 56:51

I have a view or a perspective that the best leaders are leaders who don't want power. The problem with being somebody who doesn't want power and being in a position of power is it feels really uncomfortable. Sharing power is the best way to address that. And be that in your day-to-day clinical practice, be that in leadership positions, sharing power, there is uh there's wonderful evidence that, you know, a group of competent people will generally come up with better solutions than one really smart person. Um so sharing power, sharing privilege where you can ultimately leads to better outcomes. That's kind of my key take home. It's a more sensible way forward to get better outcomes that are actually more pleasant to achieve. If you're like me, I do much better reading things than listening. Um, though I do listen to a lot of podcasts, so happy to do one. Um if you want to have co-leadership, you need to make sure that you're investing in people developing into leadership positions. And so I think that is one of the things we haven't spoken about here is that there has to be both a systemic and a personal investment in consumer leadership from psychiatrists and leaders. Um I'll throw it across to you, Phyllis.

SPEAKER_07: 58:03

Thanks, Karen. I think those two words that I think Emily mentioned as well about humility and curiosity. And although that's not kind of part of the framework, I think that is something to kind of think about. I mean, it's not something that comes naturally to everyone. I think doctors in general tend to be curious, but you know, not all humble in all situations. But I think, you know, to be able to share power, you need to think about being a bit humble and and curious and and where this could lead you. And certainly at a on a personal level, I mean, it's been very enriching from going not knowing what lived experience meant to then the last few years being actually throwing myself into it in educational and in my clinical space, it's been very enjoyable and sort of more authentic and you know it's what I signed up for originally when I wanted to be a psychiatrist. And I Emily was one of the people I've worked with with the frameworks. But I I I think, you know, like being curious about what the opportunities there are and having the difficult conversations, because it always does start with difficult conversations, but I mean hopefully this podcast enable people to think about it and have that conversation. You know, when everyone doesn't know where we're gonna end up, but the fact that we can actually openly, honestly, and respectfully have that conversation is I think, you know, is a good starting point. So that I think that's the main message I like to people to take from this podcast. Thank you.

SPEAKER_06: 59:20

Yeah, and just just to finish off and uh tie all of that together, that hopefully the listeners today have heard that you have the authorizing environment to do this wherever you are in the system. The really important thing to remember that a system is just a set of humans, and it's the humans who ultimately, if we work collectively and collaboratively, can start to make the system work for us rather than us working for the system. And we have the authorizing environment to do that, and we have heard at large from the lived and living experiences communities how important it is the Imperative to do that. And so to take away that inspiration, enthusiasm, or sense of purpose from this discussion that this is where we we need to be headed. We do need to grow the lived experience leadership in our community and opportunities and workforces and really have them integrated into our clinical practices and service deliveries. We haven't yet, I don't think, fully perfected that, so we need to continue to do that. And as we do this, we all need to recognize we're on a learning journey and we're going to learn from each other. We're going to make mistakes, but we can be courageous and open to acknowledging that and then learn in an iterative way to do better as we go and have that compassionate approach. So show up as humans to do the work together to make the places that mental health treatment, care and support is delivered better for all of us. So on that note, I'll thank everyone for tuning in to Psych Matters and the discussion. I've certainly enjoyed it. I hope others have too. And to thank the other people in this podcast for all these amazing insights that we've shared.

SPEAKER_04: 1:01:13

We hope you enjoyed this episode of Psych Matters. Feel free to share it with others and keep an eye out for future episodes. Psych Matters is produced by the Royal Australian and New Zealand College of Psychiatrists.