The psychiatrist as archaeologist and architect

A colleague and I recently proposed a model to guide the description and reform of mental health services and to clarify service evaluation (Tansella & Thornicroft, 1998). The model, which we call the ‘mental health matrix’, consists of two dimensions, one temporal and one geographical. The temporal dimension comprises three phases: input (phase A), process (phase B) and outcome (phase C). The geographical dimension has three levels: regional/ national (level 1), local or catchment area (level 2) and individual, meaning a patient or a group of patients (level 3). Nine cells are created by the intersection of these two dimensions (Table 1). The matrix can be used not only to deal with problems in the description of mental health services, but also to interpret accurately treatment outcomes. For example, to look for the possible causes of an episode of violence committed by a patient (which would be located in cell 3C, at the intersection of phase C, outcome, and level 3, the individual), one would refer not only to the process and input variables relevant to that level, the patient level (i.e. what was done before the episode of violence and what resources were available for the treatment of the patient), but also to the process and outcome on the two higher levels (how well the service responsible for the patient functions and what resources – inputs – it has at its disposal). In other words, to understand what has happened in cell 3C, we have to analyse the data and relevant facts in cells 2C and 1C and any relevant information in the other six cells of the matrix. More information on this matrix model and its possible applications is available elsewhere (Tansella & Thornicroft, 1998; Thornicroft & Tansella, 1999). We can also use this matrix as a framework for studying the professional characteristics and attitudes of psychiatrists. Although it is difficult to classify members of a professional discipline on the basis of their attitudes, preferences and the choices they make in the practice of their work, one cannot deny that these exist into various clusters common to many professionals. Psychiatrists, for example, could be classified in many subtypes, but the ones most relevant to this model are, in my opinion, these two – the psychiatrist as archaeologist and the psychiatrist as architect. The first, the psychiatrist–archaeologist, shows a predominant interest in the single patient (the individual level of our matrix). Members of this group devote most of their efforts to understanding the deepest origins of the symptoms and behaviour of their patients. Before deciding on an intervention, Editorial The psychiatrist as archaeologist and architect