Curiosity & Interest and the NHS

Posted by: Philip Stokoe at 16:09, April 1 2013.

In what follows I want to acknowledge my gratitude to my old friend James Fisher who died last year, much too soon. I had assumed that what I am about to say was taken as axiomatic by my fellow psychoanalysts but he pointed out that I cannot assume this, even though I cannot understand how anybody could be a follower of Sigmund Freud without taking this view.

If Richard Dawkins is still searching for the mutation that separated homo-sapiens from the higher mammals, my view is that it is what I would like to describe as curiostiy and Interest. You can see the importance of this trait in other mammals but my contention is that something happened to us such that we have setting in our brains that acts like a computer programme, requiring us continually to explain to ourselves what is happening to us. Sigmund Freud called it the epistemophilic instinct in what has become a characteristic habit of psychoanalysts to invent a completely incomprehensible term where a perfectly survicable one already exists. But enough of this; what does it look like and why do I consider it to be so crucial?

Psychoanalysts have been studying the effects of this ‘computer programme’ for over a hundred years; what they discovered was that we all appear to develop explanations for our experience that take the form of images of ourselves in relation to other people (or parts of people); this investigation is particularly the province of those analysts who belong to the traditions know as object relations or who are studying ‘unconscious phantasy’.

What we have learnt is that these images, developed unconsciously, become modified in the light of further experience in healthy development. Problems arise when such explanations do not get modified (and I shall refer to this phenomenon later when I explain why they can be described as ‘unconscious beliefs‘). This is not the forum in which to describe emotional and psychological development in full detail, but I will give a brief example of what I mean once I’ve defined my terms a little more precisely.

The development of the mind appears to follow the following formula:

1. the engine that builds the mind is a programme that requires us to explain to ourselves what is happening to us (the epistemophilic instinct);
2. these explanations derive from what we already know;
3. these explanations take the form of images in the mind of ourselves in relationship to other people or bits of other people (called ‘objects’ by psychoanalysts);
4. healthy development depends upon the ability of the individual to adjust/modify those beliefs in the light of experience;

Now what this looks like:

1. some sort of stimulation occurs (anxiety is experienced)
2. unconsciously (and instantly) we search for a way to understand this, calling upon what we already know
3. there is a conscious ‘idea’ that appears
4. there is a sense of relief at the arrival of this explanation.

An example of this process from very early on would be…

1. a very uncomfortable physiological experience located in my stomach
2. immediately this triggers the requirement to ‘explain’
3. babies only ‘know’ a very few things:

• Expectation & awareness of another, a ‘not-me’ (represented by the nipple);
• Sharp differentiation of broadly good and broadly bad emotions;
• Defecating – she doesn’t have control but there is no doubt when a baby is doing a poo, there is a rather ecstatic look, isn’t there? She enjoys evacuating;
• Urinating – again there is something pleasurable, I don’t think it is quite so wonderful as doing a poo but it is up there;
• Breathing – no control but a lot of emotions associated with breathing going wrong;
• Touching – she is aware of the pleasures of touch but also the pain;
• Sucking – she has control and it gives her a good feeling (she’s also been doing it in the womb);
• Spitting out or positing – she has control again;
• Blinking – she has control of this and it turns out to be the most important thing;

4. so the explanation arrives: something “not me” is touching me painfully and I don’t like it so I close my eyes to it and all the badness is evacuated “out there”.

In fact this turns out to be the first idea of a relationship, the development of which is that the “other” responds to the eye closing (or denial) by increasing the pain which the baby further ejects, making what I would call the hunger monster appear to grow in size and power which, in turn, increases the baby’s unpleasant feelings, which are then deflected into the hunger monster and so on. We would call this a retaliation model of relationship though my fellow psychoanalysts, true to type, call it “talion” instead.

Before I move on, it might be comforting to know that another kind of relationship presents itself to the baby in these first days of life outside the womb. If the baby has a good enough carer who can detect the distress and (eventually) provide the necessary milk, the baby has experience of some “other” who has magically turned the bad experience into something good that baby takes back inside herself. In contrast to the hunger monster, I call this yummy, yummy, mummy.

Unconscious Beliefs

It is probably immediately apparent that healthy development requires a capacity to modify early explanations in the light of further experience. I like to give the example of my daughter, Willow, a little before she was one, taken in her pushchair by her grandmother to the park. Which is what grandmothers do with their grandchildren. And, in the park, was a pond, just as there is supposed to be when grandmothers take their grandchildren to the park and, of course, there were ducks. One of these ducks came out of the water and walked in that familiar way with its bottom swaying from side to side and grandma said, “duck” and Willow said, “duck”. The next day found them back at the park throwing bread at the pond when a little old lady came by walking in such a way that her bottom swayed from side to side and Willow said, “duck”. I am happy to report that Willow now knows the difference between a duck and an old lady.

It was Ron Britton[i] who first came up with the concept of unconscious belief to explain what happens to those “explanations” that do not get modified in the light of further experience. I think that all of us hold unconscious beliefs which inevitably interfere with our capacity to perceive reality but for some of us the handicap consequent upon our unconscious belief can be massive.

The little boy who grows up in a household where his father is frequently violent towards him can be forgiven for developing the belief that all men are potentially dangerous. Of course the problem with unconscious beliefs is that we don’t know that we hold them (they are unconscious); instead, if we are aware of them at all, they appear to be facts of life with the same quality that the sun will always rise every morning. If I am like this little boy, then I am certain that men are dangerous and so I will misinterpret perfectly innocent behaviour as evidence of malign intent. My consequent behaviour is liable to stimulate an aggressive response in the other, which only serves to “prove” my assumption about the dangerousness of men. When we know that we have a belief, we know that this is a concept that remains unproven; one that is available for testing against reality. Ron Britton’s example of his first awareness of unconscious belief was the discovery that there is no Father Christmas. Only when it was made clear that it was his parents who produced the pillowcase (or stocking), did he realise that what he had taken to be a fact was, after all, only a belief. One of the problems of fundamentalism is that fundamentalists do not hold beliefs, they are “certain” about “facts”. (In a future blog I shall be describing the problem of conducting a conversation with somebody in a fundamentalist state of mind.)

I think that one might say that most of the work that psychotherapists do is to help people to become aware of their unconscious beliefs. This is also true of the particular approach to organisational consultancy that I espouse. I know that an awful lot of organisations believe that the best form of consultation is “motivational”; this is based upon an interesting unconscious belief that the reason my organisation/Department/team are doing badly is because of the individuals. It therefore follows that I can improve my productivity by making them climb mountains together or be inspired by a successful sportsman. A friend of mine who runs an EAP (Employee Assistance Program) describes the difficulty of realising that the organisations which employ his services do so so that they don’t have to look at problems within the system. His counsellors find that they are often dealing with several members of staff from a particular team but, because each member of staff is being counselled “confidentially”, it is not possible to point out to the organisation that there is clearly a problem with the management of this particular team. I think that my friend’s discomfort reflects the sad truth that organisations employ EAPs precisely to avoid looking at their own internal dysfunction.

Unconscious Belief and the NHS.

When Mrs Thatcher first came to power, a senior civil servant told me that he had been briefed that she would not take kindly to civil service reports based on “… the advice of the so-called professionals”. Successive governments appear to have taken the extraordinary assumption that people who have trained for years in a particular profession are less able to run that profession than politicians who apparently have some innate and extraordinary management capacity. At the heart of the attack on the NHS is a belief that medics are unable to ration. It is for this reason that successive governments have been committed to bringing managers into the system who have no clinical expertise or experience.

The development of that concept frequently described as “the internal market” seems to me to indicate another unconscious belief namely that health care can be organised by market-based capitalism.

One of the main professional activities of the clinician is to make decisions about the form of treatment most appropriate to the patient and which patients should be offered what kind of treatment in the context of a team of limited resources. These are all rationing decisions. They have been made by clinicians since clinicians were first invented. It is complete nonsense that clinicians cannot ration; what is worrying is an idea that a manager without clinical experience can make judgements about which type of patients should receive which type of treatment.

In a free market, I produce a service or a product and you decide whether you want it or not and part of your decision-making will be based on whether you can afford it or not. If my product is particularly attractive (an iPad for example), you might go to some trouble to try to get hold of one. If my product is successful I can make more, this might enable me to reduce the price, I can sell more and both of us are happy; you have your iPad and I am rich. If you cannot afford my product, you might feel motivated to work harder to get more money. And this is the capitalist model.

In the NHS, the people requiring the products do not have the money to buy them (that is you and me, otherwise known as ‘patients’). The people buying the products are called commissioners and are employees of the NHS. The money they use to buy the products is given to them by government and is limited. The commissioners are controlled by government through requirements and expectations for how they manage the business of buying products. During the period of the Labour government this system was described as “world-class commissioning” (much in the way that American baseball is described as the “World Series”). In those days commissioners were employed by Primary Care Trusts (PCT’s) and usually had no clinical training or experience. In order to get around this rather worrying problem, the world-class commissioning briefing included quality control known as clinical governance delivered as a series of tick boxes. This served as the site for the expression of one of the unconscious beliefs I have just been describing. Clearly what was missing was the clinical voice however, and this is tragic, the PCT’s were coming to terms with this and many of them had begun to make clinical advice an essential part of the commissioning process. The reason why I say this is tragic is because the mad people from the current government who have dismantled the NHS have done so without realising that the only thing they bring that sensible (making clinical expertise central to the commissioning process) was already happening.

The unconscious belief that clinicians cannot ration leads to the “perceived truth” that, unless they are rigorously controlled, clinicians will simply go on and on spending. In this way the systems of clinical governance easily become the site of the conflict around this unconscious belief. Commissioners, who cannot trust these greedy clinicians, use the tick boxes of clinical governance to keep them controlled. Clinicians, who are dismayed at the lack of clinical understanding amongst commissioners experience the tick boxes as mechanisms to limit their clinical expertise. The sad truth is that clinical governance can be a support to both sides when it is based in best practice because it acts as a means for clinicians to monitor their own practice as well as providing commissioners with a mechanism for ensuring that patients are getting the best deal.

Finally, and I think this is the most important paragraph of this blog, the two unconscious beliefs (that the NHS can be a market-run organisation, and that clinicians are financially irresponsible) has led to the most destructive economic intervention. This was started during the Labour government and is maintained now. It is the requirement on the providers to cut their expenses by 4% year on year. Successive governments have explained to the public that these “efficiency savings” are aimed at reducing unnecessary management expenditure. The truth is that expenditure is mostly on staffing so in efficiency savings are going to be mostly on staffing. Since the issues of finance have become the most important ones in the organisation, addressing financial, “efficiency savings” requires a large management service, therefore the staffing that gets cut are the front line services. When patients complain that psychotherapy services have disappeared from their local area or that other front-line services have ceased to operate, they are not imagining this, it is really happening and it is the result of an insane idea that you can go on making “efficiency savings” indefinitely.

The NHS is not a marketplace, cannot be a marketplace and will be destroyed if people go on believing that it can be run like a market. Clinicians are not irresponsible, greedy and uncaring; the fact that the system has not collapsed in spite of the destruction going on right now is entirely and only because of the good will of clinicians who continue to provide the best service they can in spite of the madness of politicians who seem to have lost track of the original notion that their job is to be the honest broker on behalf of the voter and, instead, have decided that they are the only people who can run complex services.

[i] BRITTON, R. 1998 Belief and Imagination. London, Routledge