Guest Editorial
Reason, Commonsense and Imagination in the Service of our Shared Humanity
Kenneth Walsh
Nursing Practice Development, South East Sydney and Illawarra Area Health Service; School of Nursing, Midwifery and Indigenous Health, University of Wollongong, Wollongong NSW
PP: 1 - 3
Article Text
In preparing this editorial, like all good academics I began by searching the literature. I quickly found myself buried in a mountain of papers on; innovative projects and programmes for consumer participation in mental health services; government policies to ensure consumers have a voice in service planning, care delivery and service evaluation and many research articles about how consumers view mental health services. These papers reflected many things but some of the issues that came through to me were that, whilst the consumer voice is now being heard more loudly, many consumers still feel disempowered and marginalized; there is still a need to find new ways of including consumer perspectives in mental health services; and the issues of the 'who', 'how' and 'when' of consumer involvement are still not clear. One paper, which reported on consumer views of consumer participation in mental health services, cogently summed up what were for me the key messages (Lammers and Happell 2003). This paper states that mental health service providers need to:
...view consumers as heterogeneous and respond to individuals' needs and interests regarding consumer participation. Despite variations in experience there is a clear need to develop mechanisms to support consumer involvement and to influence the attitudes of health professions to become more valuing of a consumer perspective (Lammers and Happell 2003:385).
So it would seem that we have made much progress but there is still a long way to go. In the pages of this special issue, you will find some excellent papers which will discuss consumer perspectives and practical issues of consumer involvement. So I do not wish to address these issues directly in this editorial. What I would like to do is ask the question; how did we find ourselves where we are? I have a sneaking suspicion that the answer is linked to something more fundamental in our society and by association, in our health services. It was while I was pondering this that serendipity stepped in and I found myself picking up a book in an airport bookshop called On Equilibrium by the Canadian philosopher John Ralston Saul (2001). In it, I found what I think are the key elements of an answer to my question. I will touch on some of these elements in what follows.
Discussions on consumer participation in mental health services to be found in the literature point to the fact that, to a lesser or greater extent, the health system often fails the people it is designed to serve. How can this be so? I certainly do not think it is because it is filled with uncaring people. Perhaps there is another explanation: that we have become reliant on narrow, rigid ways of thinking of, and viewing, the world. The continuation of the dominant role of hospitals in our health systems over the last 150 years is perhaps an illustration of this.
Hospitals are useful and an important part of our health services. Hospitals continue to dominate our health services yet hospitals, as we know them today are a 19th century invention. Today we struggle to keep these behemoths alive in a rapidly changing environment. Hospitals were and are a product of the enlightenment and the industrial revolution, which have both been so influential in our Western ways of thinking and being. These ways of thinking and being pervade everything we do and are mostly reliant on one of our human qualities - Reason (Saul 2001). When speaking of Reason, one thinks of the famous dictum of Rene Descartes 'Cogito ergo sum' - 'I think therefore I am'. I rather prefer the Czech writer Milan Kundera's take on this. He says 'I think therefore I am' is the statement of an intellectual who underrates toothaches and that 'I feel therefore I am' is a truth much more universally valid (Kundera 1991: 225). In suffering, we are reminded of our individuality. This humorous little quip is relevant. It reminds us that Reason is but one of our human qualities, but it has become the quality most (almost exclusively) relied upon to be all things to humanity - a big ask really. Reason, according to Saul (2001), has become less about thought and argument and has been used more and more as an instrument in the service of economics and corporatism.
So we see hospitals operate in instrumental ways and these ways pervade all areas of health care, including community care. Hospitals are still the centre point of our health services. We may have closed many a large psychiatric hospital but in these cases we find that the centre point of the health service is a general hospital with a mental health service as ancillary to that. This is of course a generalisation and I am sure most readers can think of an exception. Nevertheless I think it is generally true. It may also help to explain why the move towards primary health care and prevention has been so difficult. This instrumental use of Reason has seen the systems and processes of the health organisation become more important than the purpose for which they were established in the first place - to serve the public. It has also seen our ways of treating people largely narrow to mechanistic views of disease and illness and, for psychiatry, this has meant a reliance on medications.
Mostly we work and are cared for within these services without much conscious thought about these things. The breaking up of common knowledge into ever-smaller specialisms and silos further enhances this lack of consciousness. In this way, many issues can be seen as the province of someone else - an expert. And so we vaguely know things are not as they could be, but who are we to say? After all, we are not the experts and so we muddle along. Oh, we might bluster a little but then that vague sense of helplessness creeps back when the statistics are produced or the clichés trotted out: 'user pays', 'personal responsibility', 'the bottom line', 'we have to be fair to everyone', 'the figures speak for themselves', 'there can't be rules for one and different rules for others'.
So what are we to do? Saul's advice is to reinvigorate our other human qualities and see Reason for what it is, an important quality, but only one of many and not superior to the others. And what are the others? They are, according to Saul (2001), memory, intuition, ethics, commonsense and imagination. For reasons of brevity, I will make mention of just two of these here: commonsense and imagination.
The knowledge in the excellent papers that follow in this section of this special issue are only as useful as our individual will to use this knowledge to work in better ways with each other. We as individuals need to be responsible for building bridges across narrow specialisms and siloed ways of working in order to engage with others, be they consumers or service providers, around that which we share - our humanity. We need to temper our use of Reason in the service of institutions and systems with Reason in the service of dialogue and debate. We need to bring to bear our commonsense, or what the Romans called our Sensus Communis (Saul 2001) - our shared knowledge, shared humanity and sensibility - in order to undermine rigid ways of thinking and 'objective' Reason that is sometimes used to argue against our right to human dignity. We also need to support the excellent work that is being carried out by individuals, health services and consumer groups and to build on these and support good people doing good work.
But most of all we need to use our imagination. Imagination has gotten a bad press. We say 'You are imagining things' or 'Don't let your imagination carry you away' but imagination is the key to developing new ways of working together and new innovations.
And what is it that allows us to reach beyond our personal comfort to support ... public programs...? Not pity or noblesse oblige or charity. Rather it is our ability to imagine the other (Saul 2001:128).
Imagination then is the first step to a new future. It is that which allows us to reach beyond ourselves and to a sense that 'they' are to a large extent 'us'. It is the first step of responsible individualism and it is the antidote to dehumanisation.
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