Chapter 1. Psychiatric Leadership

Physicians often find themselves in leadership positions not necessarily because they set out to become leaders but through “good luck” or “being in the right place at the right time.” In survey research conducted by the Group for the Advancement of Psychiatry Committee on Administration and Leadership, Merlino et al. (2015) reported that many psychiatrists in leadership positions did not actually seek out leadership opportunities and were often appointed to such positions by others in their organization. Some of these leaders have trouble trying to determine what the leadership role requires, whereas others rise to the top to become superstars in their field. Leadership requires skill sets for a psychiatrist to succeed, whether serving as the medical director of an outpatient clinic, chairing an academic department, or acting as the CEO of a psychiatric hospital or organization.

Effective leadership is the process that mobilizes people and resources to achieve a common goal (Saeed et al. 2018). Leaders are visionaries who focus on the overall picture in a quest to create a better tomorrow for their organizations. Successful leaders share their vision and passion to connect with and motivate others in their organization to achieve common goals. At its heart, effective leadership is a dynamic and mutually beneficial relationship between followers and leaders, which enhances and supports a team’s ability to perform well. Good leadership is developed through a never-ending process of self-study, education, training, and accumulation of relevant experience (Bass and Bass 2008).

Leadership is critically important to a team or organization. Leadership is typically made and learned, which means that people can develop the skills to become tomorrow’s effective leaders. Leadership requires proficiency in several competencies that can be divided into 1) personal attributes, 2) managerial and administrative competencies, and 3) leadership competencies; see Tables 1–1, 1–2, and 1–3 (Saeed et al. 2018).

The terms psychiatric management, psychiatric administration, and psychiatric leadership are often used interchangeably and without any distinction by many, but others believe they differ and do have a different focus (Saeed et al. 2018). Psychiatrists in leadership positions usually function in all three domains. Administrative psychiatry entails collaboration within and outside health care systems, which requires working relationships with diverse professionals, including other clinicians, patients, insurance companies, community organizations, and fiscal managers.

Psychiatric management means day-to-day oversight ensuring that operations run well and everyday problems are addressed. Psychiatric leadership requires the formulation of a vision for an organization, comfort with giving directions to others, and motivation of others to achieve such vision.

The leadership theory has evolved over decades. Here we provide a succinct review of the history of leadership theory. Although some of these theories were established years ago, they continue to inform what leadership is and how it comes about.

Until the late 1940s, the prevailing belief was that leaders were born and not made, and they had particular traits such as intelligence and extroversion. From the late 1940s until the late 1960s, the core belief was that leadership was a question of style, and as such, it could be learned. From the late 1960s until the early 1980s, the dominant theory was that leadership depended on the situation in which leaders found themselves (i.e., some leaders would be good for some circumstances but not for others). Since the early 1980s, leadership theory has focused more on vision and charisma at the core of leadership, and it has also differentiated leading from managing.

Great man theory assumes that the traits of leadership are inherent or intrinsic, meaning that great leaders are born and not made. The term great man is a reminder of the times when leadership was thought of primarily as a male quality, especially military leadership. Bass wrote that “the history of the world, according to [William] James, is the history of Great Men; they created what the masses could accomplish” (Bass 1990a, p. 37).

Trait theory asserts that leaders should possess qualities that are evident to those around them. It suggests that people are either born or made with these qualities that make them excel in leadership roles. These qualities are intelligence, a sense of responsibility, creativity, and other traits, as discussed earlier. The conceptual framework for these theories of leadership has been further developed by Bernard (1926), Tead (1929), and several others, who defined leadership in terms of traits of character and personality (Bass 1990a).

Behavioral theory asserts that leaders are made, not born. It identifies the observable behavior of leaders that can change the behavior of followers. In other words, it focuses on how leaders behave and assumes that these traits can be learned by other leaders or that leaders can decide what actions they want to implement to become the kind of leaders they want to be. This theory assumes that anyone is capable of becoming a leader.

Behavioral theories of leadership focus heavily on the actions of a leader and assert that the best way to predict leadership success is by viewing how a leader acts rather than focusing on the qualities or attributes that a leader brings to the table. As discussed in the next section, behavioral theory categorizes patterns of observed behavior as “styles of leadership.” There are several of these leadership styles, but the behavioral theory does not suggest that there is a right style for every circumstance.

Exchange theory, also known as leader-member exchange theory or vertical dyad linkage theory, is a relationship-based approach to leadership that focuses on the two-way (dyadic) relationship between leaders and followers. It assumes that leadership consists of several dyadic relationships that connect the leader to the members of the group. The measure of the quality of these relationships is through the level of trust, respect, support, and loyalty. Leader-member exchange theory conceptualizes leadership as a process that is centered on the interactions between the leader and the followers, and the focal point of the leadership process is the dyadic relationship rather than the traits, style, or skills of the leader. Exchange theory is also referred to as transactional leadership given its focus on the transactions made between the leader and the followers.

Contingency theories assert that there is no single way of leading and that the success of a leader hinges on the specific situation at hand. This signifies that certain people would perform at the maximum level in certain places but at a minimal level when taken out of their element. How effective a particular leader or leadership style will be for the given situation depends on certain factors such as the situation itself, the personality of the leader, and the composition of the group that is being led. The basic assumption of the contingency theories is that leadership success or failure is situational.

Different subtheories fall under the general contingency theories, including Fiedler’s contingency theory, the Hersey-Blanchard situational leadership theory, House’s path-goal theory, and the decision-making theory. Although they are all similar on the surface, each offers its own distinct views on leadership. For example, Fiedler’s contingency theory suggests that leaders’ success requires placing individuals in situations that are aligned with their skills. Hersey-Blanchard’s situational leadership theory emphasizes that the most effective leaders are those who are able to adapt their style to the situation and look at cues that might contribute to getting the job done. Such cues may include the nature of the task at hand, the nature of the group, and other factors. House’s path-goal theory of leadership describes a process in which leaders select specific behaviors that are best suited to the employees’ needs and the working environment so that they may best guide the employees through their path to achieve their daily work goals (House 1971). The decision-making theory is an interdisciplinary approach that helps in arriving at the decisions that are the most beneficial to the organization given an uncertain environment.

McGregor postulated two types of theories still prevalent in organizations. Theory X and Theory Y attempt to describe how people relate to some organizations today. Theory X states that people are directed and will not produce unless coerced or made to produce in an organization. Theory Y is based on an assumption that followers will fulfill the needs of the organization because they are already motivated to do so (McGregor 2006).

In transformational or relationship leadership theories, followers are transformed through the leader’s inspirational nature and charismatic personality. Burns (1978) identified two types of leadership: transformational and transactional. He based this on a qualitative analysis of the biographies of political leaders and viewed the transformational leader as one who “engages with others in such a way that the leader and the follower raise one another to a higher level of motivation and morality” (Burns 1978, p. 20). Transformational theories focus on the connections formed between leaders and followers. In these theories, leadership is the process by which a person engages with others and is able to “create a connection” that results in increased motivation and morality in both followers and leaders. Relationship theories are often compared with charismatic leadership theories in which leaders with certain qualities, such as confidence, extroversion, and clearly stated values, are seen as best able to motivate followers. Relationship or transformational leaders motivate and inspire people by helping group members see the importance and higher good of the task. These leaders are focused on the performance of group members as a unit but also on each person in fulfilling his or her potential. The four factors of transformational leadership, at times referred to as the “four I’s,” are 1) idealized influence (charisma), 2) inspirational motivation, 3) intellectual stimulation, and 4) individual consideration. Bass (1990b) argued that through training, managers can learn the techniques and obtain the qualities they need to become transformational leaders.

The attribution theory of leadership suggests that a leader’s judgment about employees is influenced by the leader’s attribution of the causes of employees’ performance. To understand the leader, one must first understand his or her behavior, along with his or her thought process in regard to the situation he or she is experiencing at the time (Pfeffer 1977). The origins of attribution theory can be traced to the work of Fritz Heider (1958), which stated that attributions are the result of the fundamental cognitive processes by which people ascertain cause and effect so that they can solve problems and become more efficacious in their interactions with their environments. In other words, attribution theory provides the framework necessary to understand individuals’ explanations for why events in their environment happened.

As the previously summarized theories of leadership suggest, leadership requires using distinctive styles to motivate followers. These leadership styles are selected—and often adapted—to fit the individual, group, situation, or organization. It is helpful to understand the different styles of leadership. In this section, we summarize several leadership styles that have been described in detail in the literature (Amanchukwu et al. 2015).

There are many ways to define attributes of successful leaders. One such conceptualization from Saeed et al. (2018) enumerated leadership competencies in psychiatry in three groups: personal attributes, managerial and administrative competencies, and leadership competencies. These qualities individually are innate, developed, or honed. When someone is a follower or mentee, the personal attributes that Saeed et al. (2018) described as important leadership competencies relevant to psychiatric leadership exist in various embryonic states. It can take years to optimize each of these skills, depending on the setting or task at hand. As new responsibilities are given to a developing leader, these competencies grow from preexisting characteristics. By the time a developing leader is fully invested in a position of authority, his or her leadership competencies are crystallized.

Dr. B was a psychiatric resident turned residency director early in his career. Many experiences in residency prepared Dr. B for aspects of academic psychiatric leadership. He developed leadership skills from clinical experiences and time serving as a chief resident assigned to assist his program in scheduling and the development of new educational rotations. He was given the opportunity to serve as director of the program from which he graduated. Reflecting on his recent experience as a member of the residency allowed Dr. B to guide his residents using many leadership competencies.

Saeed et al.’s (2018) first category of competencies relevant to leadership is personal attributes. These competencies are the ones most evidently nurtured by psychiatric residency. They are initiative, creativity and innovation, emotional intelligence and self-awareness, drive, ethics and integrity, reliability, judgment, flexibility, and fairness. Saeed et al. (2018) described the process by which these attributes develop as being a combination of “rearing, religion, culture, education, professional and lived experiences, and the vicissitudes of interpersonal transactions” (p. 321). Many of these experiences were central to Dr. B’s time in residency. They led to competencies he uses to serve as an effective psychiatric residency director.

Effective leaders can mobilize people and resources to achieve a common goal. Although in the past it was believed that leaders are simply born with innate characteristics and attributes, today’s belief is that effective leadership skills can be learned and acquired. In general, leadership competencies can be divided into 1) personal attributes, 2) managerial and administrative competencies, and 3) leadership competencies. Over decades, different leadership theories have evolved in an attempt to explain how leadership works, such as the great man theory, the trait theory, behavioral theories, exchange theories, contingency theories, relationship or transformational leadership theory, and the attribution theory. In addition, different leadership styles have been identified, including the autocratic, democratic or participative, bureaucratic, charismatic, laissez-faire, transactional, and coach-style leadership styles.