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Book Reviews   |    
Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment
Reviewed by Thomas A. Simpatico, M.D.
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.3.423
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by Teresa L. Scheid; Hawthorne, New York, Aldine de Gruyter, Inc., 2004, 198 pages, $24.95 softcover

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As I read Teresa L. Scheid's aptly titled Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment, I knew that if I were Amazon.com, I would pair it with Jared Diamond's Collapse: How Societies Choose to Fail or Succeed. The latter makes the argument that failed human societies of the past often shared the flaw of not even attempting to remedy perceived social problems; the book argues that such failures to act fall under the heading of what economists and other social scientists term "rational behavior," arising from clashes of interest between people. Tie a Knot and Hang On describes the real-world consequences of what the author refers to as "the logic of commodification," whereby mental health care providers have lost power, their work increasingly being subjected to efficiency criteria. The result is a clear conflict between professional logic and the demands for efficiency and cost containment.

Scheid is an associate professor at the department of sociology at the University of North Carolina at Charlotte. In Tie a Knot, she helps us look through a sociologist's lens at the work of providing mental health care in this first decade of the new millennium. More precisely, she describes and analyzes the theoretical and empirical linkages between environmental pressures and the activities of organizations and individuals who conform to these pressures.

Scheid has collected, over the past ten years, in-depth data from mental health care providers in diverse settings about their work and treatment practices. She gives many examples of how the inevitable arrival of managed care methodologies in the world of public-sector psychiatry has resulted in a sea change in the way care is conceptualized and conducted. She focuses on the inherent conflict between clinicians' need to bring a high degree of emotional and personal involvement to their work zeitgeist of public-sector bureaucracies, with too few resources and myriad demands from the community, including increased service provision, outreach to diverse populations, and protection of the community from disruptive and unwanted behavior. She argues that the rational business ethics and corresponding systems of bureaucratic control are now imposed on organizations that had previously operated on the basis of a professionally determined moral foundation.

Scheid understands the business of caring for persons with serious mental illness; she is genuinely passionate about the importance of the work, for the plight of both the clinicians in the trenches and the organizations they work for, and for the all-too-often lost potential of people they serve. Despite this passion, she somehow manages to maintain the objectivity of a scientist. This book makes the powerful argument that although the advent of the managed care ethos in the world of public-sector psychiatry is completely understandable, its methodologies represent an extension of bureaucratic control over clinical work that is a direct threat to the professional autonomy and discretion of providers. There's a chilling Orwellian subtext that the behavior of medical professionals is largely a reflection of the immediate situations in which physicians find themselves.

Scheid has provided us with a well-researched and compelling look at ourselves and the arc of our profession. This book should be required reading for mental health care providers and administrators who want to be reminded of the important role they play in society and the ease with which clinical ideals can be corrupted by fiscal and political expediency. Here's hoping that Henlee Barnette's admonition that "you can judge the character of a society by how it treats defenseless persons" does not turn out to be a harbinger of our social decline.

Dr. Simpatico is associate professor of psychiatry and director of public-sector psychiatry at the University of Vermont College of Medicine in Burlington as well as medical director of the Vermont State Hospital in Waterbury.

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