Academic journal article Social Alternatives

Gatekeeper versus Concierge: Reworking the Complexities of Acute Mental Health Care through Metaphor

Academic journal article Social Alternatives

Gatekeeper versus Concierge: Reworking the Complexities of Acute Mental Health Care through Metaphor

Article excerpt

Gatekeeping is a term associated with the intake function of acute mental health services and involves making key decisions about provision of service to clients. The term can also be seen as a powerful metaphor, invested with both functional and symbolic connotations epitomising the challenges and dilemmas faced by acute care workers. The gatekeeper metaphor is explored and juxtaposed against an alternative metaphor, that of the concierge, which presents a more constructive and inspiring vision of clinical practice. Defensive, self protective and aggressive practices are challenged whilst clinicians are urged to empower themselves by moderating a growing focus on administration, control and risk management through renewed perspectives based on clinical judgment, compassion and care. Intake is redefined as a client focused service and the 'Concierge' a way of envisaging a more satisfying professional role for mental health nurses and other acute care clinicians.

'The gatekeepers are vulnerable though they pretend to stay in control'

(Excerpt from Gatekeepers by Henry B Stevens, 2004)


The author has over thirty years experience in mental health nursing; much of that time in acute care settings. A participant observation approach (Douglas 1976) provides the basis for critical analysis of contemporary mental health acute care practice based on the author's professional journalling along with the reflections of other acute care clinicians. This ethnographic material is supplemented by content analysis of relevant literature.

Australian public mental health services utilise a single point of entry based in acute care teams; with the intention being to streamline intake processes and expedite initial determinations about service provision (Sands 2007: 243). Clinicians working in this role are required to weigh clinical and risk considerations against consumer perceptions of need (Vine 2011), societal (Mental Health Council of Australia [MHCA] 2005: 33) and organisational expectations (New South Wales [NSW] Auditor General 2005: 2). Add to this, constraints on time and resources, ethical and medico-legal considerations, along with a raftof documentation and accountability requirements (Mullen et al. 2008: 85; Deutsch and Rosse 2009) and the process starts to become quite complex. Although all health care decision making is influenced, or hindered (Forster 2005: 56) by non-clinical factors to some degree, tensions arising from these competing considerations converge most noticeably during mental health intake. It is during mental health intake that first impressions are made, the relationship with the consumer begins and the interface between the mental health service and the community is at its most public. In this context, acute care workers come to be viewed as gatekeepers deciding the 'who', 'how' and 'what' of service provision.

Lessons learnt from clinical practice should inform the theories that drive organisational mental health reform (Nolan 1993). Nearly ten years ago a discussion between acute care colleagues about the implications of the gatekeeper function sparked a reflective process that eventually resulted in this article. The conclusion of that original discussion was that the term 'gatekeeper' conveyed an administrative, service-based orientation rather than a clinical or consumer focus. The language we use as clinicians not only frames our self view but can limit our functional capacity and construct consumers in ways that support unhealthy paradigms (Summerfield 2001: 148; Hamilton and Manias 2006: 86; Wand 2013: 287); even contributing to the stigma of mental illness (Sartorius 2002: 1470; Hocking 2003: 47). Acute care intake workers faced with competing pressures, ideological and clinical dilemmas and without adequate support and governance, can resort to defensive practices designed to serve and protect themselves and the service, rather than the consumer (Lakeman 2006: 396; Mullen et al. …

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