The vision of leaders is often touted as their greatest value to organizations, and perhaps that is true. The ability to imagine a better future, to articulate it clearly, and then to bring others forward in building and attaining that vision is certainly an essential quality of effective leaders. Leaders with extraordinary vision are thus creative, well spoken, and influential, and generate a sense of cohesiveness among individuals who, together, exert purposeful effort toward a foreseen objective.
In academic psychiatry, leaders are people who can help our field generally, and departments of psychiatry specifically, to fulfill their commitments in multiple mission areas. Most traditional academic organizations define three core missions, but I believe we actually assume responsibility for five overlapping areas. The first two areas encompass education, preparing the next generation of physicians-in-training and developing innovative specialty and subspecialty initiatives, as well as research and scholarship, the generation, translation, and application of new knowledge for the benefit of society. A third mission area is clinical advancement and practice, which involves creating new diagnostic and therapeutic approaches and providing state-of-the-art clinical care for patients from all backgrounds and walks of life. We are also responsible for community engagement—working to partner with, serve, and improve the health of our communities, locally and globally. We are charged with fostering professionalism and the companion endeavors of supporting professional development and ensuring the ethical expression of our profession in everyday life. Taken together, these commitments support the growth of expertise and skill among faculty and trainees. What is more, they strengthen the ability of today’s early career leaders to carry the duties to our profession and its stakeholders moving forward. A leader with vision in academic psychiatry, in my view, is one who is able to recognize the interdependent nature of these mission areas and to yoke them together to bring about a better future.
Vision is clearly a necessary attribute of a leader, but what other qualities help define leadership? I was caused to think hard on this question recently, as a lecturer during the University of Toronto Department of Psychiatry Centenary events in June, 2008. I shall describe here a few of the conclusions I reached. Let me foreshadow that I cannot offer up any truly unique insights on the topic of leadership (no matter my desire to the contrary). Still, I did find that the process of exploring the possible answers was itself valuable, and I did arrive at two things that are often overlooked but are, I believe, worthy of greater emphasis as we think on this complex topic.
The dictionary states that to lead is to “go before or with to show the way”; “to influence or induce”; “to cause”; “to guide in direction, course, action, opinion”; and “to take somebody somewhere.” These notions seem to give emphasis to the directive or even control-oriented aspects of leadership, yet most leaders talk about shouldering responsibility wisely and effectively. Moreover, popular quotes about leadership highlight how leaders inspire others and cause others to trust them by virtue of their character strengths. These individuals become recognized as accomplished leaders because others follow them, not because of some proactive effort to “direct” or “manage” others.
So who are these people who exert exceptional leadership, sometimes without specific intent to do so? Recent history offers many men and women who led by example first—and then their influence grew for many reasons. Helen Keller, a woman with nearly overwhelming disabilities coupled with a prodigious intellect, great courage, and human generosity, became a truly inspiring leader. “Although the world is full of suffering,” she wrote, “it is full also of the overcoming of it” (1). She both remembered and urged others to remember the resilience of humanity. Jane Addams conveyed a similarly empathic message in her work and words: “Much of the … hardness of the world is due to the lack of imagination which prevents the realization of the experiences of other people” (1). Martin Luther King, Jr., embodied strength and courage without violence, and he midwived optimism in many. He said, “Nonviolence is a powerful and just weapon which cuts without wounding and ennobles the man who wields it. It is the sword that heals” (1).
Eleanor Roosevelt was another remarkable leader whose impact was felt throughout the world; everyone she met was impressed with her wisdom and hope-instilling nature. She said, “People grow through experience if they meet life honestly and courageously. This is how character is built” (1). Sir William Osler wrote that “the good physician treats the disease; the great physician treats the patient who has the disease” (2), a message of significance for all of medicine. A leader in the health professions as well as in society, Elisabeth Kübler-Ross wrote, “Those who learned to know death, rather than to fear and fight it, become our teachers about life” (3). Rosa Parks became a symbol of strength of character and tenacity in the face of adversity: “The only tired I was, was tired of giving in” (1). And, in one last example, Florence Nightingale had a different concept but a similar constructive stance in life, as reflected in her statement “I think one’s feelings waste themselves in words; they ought all be distilled into actions which bring results” (1).
What makes the leadership of these individuals so immediately apparent? It is striking that each of these individuals overcame challenges, offered an honest appraisal of difficult aspects of human experience, and yet remained positive, forward looking, and strong. Moreover, they often gave meaningful and effective “solutions,” believing in humanity, imagining the experiences of others, being ennobled, meeting life honestly and courageously, not relenting when discouraged, knowing to what one should assign importance in life, and endeavoring in the ways that bring about good for others, often more than for themselves. In other words, they believed in something that mattered, they communicated this well to others, they made personal sacrifices in supporting their beliefs, they conferred hope, and they gave a prescription for what many characterize as “right action.”
These exceptional individuals are heroes and often seem larger than life. Yet, every community has natural leaders—the individuals to whom others turn for guidance and for models of the behavior that is most socially valued within that community. These natural leaders, sometimes referred to as “opinion leaders,” have great effect on others.
In a remarkable and novel study of such leaders in a unique and vulnerable population, Kelly, Amirkhanian, and colleagues (3) documented just how influential these individuals can be. The Roma (“gypsies”) are the largest ethnic minority group in Eastern Europe, and they experience very serious health problems related to social disadvantage, including HIV/AIDS. The life expectancy for the Roma is 10–15 years less than that of the majority population living in the same geographic areas. It is a marginalized community, untrusting toward outsiders, and very difficult to reach from a public health perspective. A 2-arm, randomized, controlled trial involving 286 Roma men from 52 social networks in the Fakulteta settlement in Bulgaria was developed, focusing on the influential role of natural leaders, that is, persons who others would “most like to spend time with, talk to, felt close to, and trusted.” These individuals were identified in small social circles, usually five to six people who interacted closely in a positive way and appeared cohesive. A number of baseline assessments were performed. In both groups, individual counseling on HIV risk reduction was provided, and people with sexually transmitted diseases received treatment at the start of the study.
In one arm of the study, the opinion leaders participated in eight small-group training sessions, giving attention to accurate information on disease transmission; positive attitudes toward protected sexual behavior; strengthening friends’ healthy behaviors; and self-efficacy/self-confidence. Three months later, the intervention resulted in a significant decrease in high-risk sexual behavior, greatest among those with the highest risk behavior, and a decrease in the development of new infections. Enduring positive attitudes related to health and self-efficacy emerged as well. More important, there was an even greater impact after 12 months, indicating that social norms were substantively shifted by the intervention involving natural leaders.
The “Givens” and Natures of Leaders
Impressions of great people in recent history, as well as this unusual study of a special present-day community, underscore two linked leadership concepts that, in my view, receive too little attention. First is the concept of how the fundamental assumptions, expectations, and values—that is, the “givens” of a leader regarding what is essential in everyday life—are highly influential aspects of his or her leadership. Second is the idea that a leader’s basic character or nature becomes an important factor, a key “active ingredient,” in his or her leadership style.
What are the “givens” of a particular leader? How does one’s basic character or nature affect one’s ability to serve as a leader? I have often commented that the “givens” and the natures (good, neutral, and bad) of leaders are amplified across the systems they shepherd, with the predictable consequences (good, neutral, and bad). On one hand, if a leader believes that competition, not cooperation, and individual excellence result in the best possible work, then this leader will, in time, build an organizational culture that reflects this set of assumptions. On the other hand, a leader who prizes collaboration, mutualism, and teamwork will build a strikingly different organizational culture. A leader who treasures honesty will foster this quality, while a leader who sees the need for an occasional “sleight of hand” will support a different ethic within his or her group. A leader who sees sexual boundary crossings as completely unacceptable will communicate this clearly in words and in actions, while another leader may not. Moreover, if a leader is ambivalent and conflicted by his or her nature, then, in the absence of ameliorating pressures, his or her team will feel ambivalent and conflicted regarding their positions, their responsibilities, and their goals within the organization. The values governing their decisions will also become increasingly unclear under such a leader. If a leader is intuitive and quick to decision in the absence of much or diverse data, his or her organizational culture will differ greatly from that of one led by a more deliberate, analytical, and evidence-driven individual.
Beyond these effects, the leader also serves as a potent role model. Perceptions of his or her character or nature become the template for comparison by others in the group. If a new leader is by nature very industrious, the industriousness of his or her people increases appreciably and very quickly. For instance, if a leader is seen as a “triple-” or “quadruple-threat,” individuals with this portfolio of strengths in an organization will rapidly succeed, whereas others with narrower scope (even if they are excellent) may begin to wonder if they “measure up.” As another example, a leader whose personal life, language, and actions support commitment to family as well as professional obligations will have an organization rich with thriving families and professional successes. Finally, and more worrisome, as Lister Sinclair said, “A frightened captain makes a frightened crew” (1). An organization led by someone who has lost a positive sense of the future will soon have a new leader or will sink.
In the language of professionalism, effective leaders will possess certain virtues and adhere to ethical principles, and taken together, these will define leaders of integrity. This deep and all-encompassing sense of integrity combined with expertise, generosity, self-sacrifice, and beneficent intent ensures that the trust placed in ourselves by individual people and in our field by society as a whole is well earned. This is possible only when “the talk” and “the walk” of our field are tightly tethered.
Bringing it Back to Academic Psychiatry
This essay started with the idea that exceptional vision was essential for leadership. In our field of academic psychiatry, vision involves braiding together the missions of education, scholarship and research, clinical innovation and service, community engagement, and professionalism to create a better future to serve the very society that has entrusted us with this special and distinct work. Such a vision is critical. This said, I have suggested that vision is not sufficient for authentic leadership in our field. So what else is needed? We have touched on examples in the words of individuals from such diverse walks of life as Helen Keller and Sir William Osler, Eleanor Roosevelt and Rosa Parks in an effort to remind us that leadership is about belief, meaning-making, honesty, optimism, and action. The illustration of the intervention study with the Roma, further, was intended to suggest that all communities have leaders and that the influence of natural leaders can be strengthened and directed to bring about significant good that endures and grows. The anecdotal impressions pulled together here regarding the effects of leaders’ fundamental assumptions, “givens,” and natures were meant to emphasize the inextricability of an individual’s values and character from his or her ability to lead others.
Why does a better understanding of leadership of this sort merit our attention? It matters for two reasons, and neither is insubstantial in nature or in consequence.
First, the burden of suffering associated with mental illness is so great that we must find ways to lessen this burden in the near future, using all of our mission areas in concert to do so. Our organizations exist to design a better tomorrow for our patients. It is a matter of professionalism and integrity that we live up to the expectations with which society has entrusted us. Neuropsychiatric disorders affect all ages, both genders, all cultures—and these illnesses are severe, disabling and life threatening, poorly understood, inadequately treated, and by any measure profoundly costly. Indeed, the illness burden associated with these diseases and conditions is surpassed only by pandemic infectious diseases. The diseases cared for by the profession of psychiatry, in addition, are terribly stigmatizing. Disease stigma interferes with appropriate illness recognition and care-seeking and worsens quality of life and health outcomes considerably. Moreover, the scientific basis of our profession has been underdeveloped and under-resourced, further disadvantaging people living with mental illness. Relatively few individuals enter the field of psychiatry, although physicians in all areas of medicine carry extensive responsibilities for the care of people with mental illness and coexisting conditions.
The second reason for examining the topic of leadership in academic psychiatry is that we need more and more skilled and diverse leaders in our field. A recent study documented that chairs of psychiatry remain in their positions an average of 5–7 years (William Rayburn, personal communication). This is a very short timeline for accomplishing what needs to done in a field with few resources, critically important imperatives (e.g., in education, research, clinical innovation, community outreach, professionalism), and immense and growing patient needs. Furthermore, psychiatry leaders often help guide and stabilize their systems. In academic psychiatry, our organizations are typically medical schools and, to a lesser extent, affiliated academic institutions—these organizations are charged with significant responsibilities in our society and are themselves under great duress. Psychiatric leaders quickly become exhausted, and relatively few efforts are in place to help with suitable succession planning in academic psychiatry. Finally, the skill set and qualities needed to lead academic psychiatry programs found in very diverse settings, with very different financial structures, and wildly varying responsibilities in the private and public sectors are seldom fostered in traditional medical training and faculty experience. There is a need to be much more intentional about helping to foster the careers of potential leaders who have the kind of vision, “givens,” and natures that our field needs.
Understanding, nurturing, and supporting genuine leadership is an important commitment in our profession. Our leaders require vision, and their fundamental assumptions and natures matter in building a future in which people living with mental illness will be better cared for, stigma will be diminished, the public health burden of neuropsychiatric disease will be lessened, and a new generation of effective, forward-looking, virtuous, and positive leaders will help guide the way.