The Tavistock Century

2020 Vision

Waddell, Margot, Kraemer, Sebastian

• Publisher: Phoenix Publishing House
• Year: 2020
• ISBN:
  9781912691722
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

The Tavistock Century traces the developmental path taken from the birth of a progressive and inspirational institution. From their wartime and post-war experience, John Rickman, Wilfred Bion, Eric Trist, Isabel Menzies, John Bowlby, Esther Bick, Michael Balint, and James Robertson left us a legacy of innovation based on intimate observation of human relatedness.

The book contains entries across the full range of disciplines in the lifecycle, extending, for example, from research to group relations, babies, adolescents, couples, even pantomime. It will be of enormous value to anyone working in the helping professions; clinicians, social workers, health visitors, GPs, teachers, as well as social science scholars and a host of others who are directly or indirectly in touch with the Tavistock wellspring.

Part I

The Tavistock legacy

CHAPTER ONE

Challenge, change, and sabotage

Anton Obholzer

There has been no shortage of inquiries, working parties, recommendations, reports, and executive letters from on high as to what is to be done about improving the mental health of the nation. Yet, despite all our best efforts, progress has been painfully slow and disappointing. This chapter [from a conference presentation given in 1997] is an attempt to look at some of the issues that in my view slow down and, at some times, completely sabotage the process of change and, in the case of mental health, ensure that we continue to be trapped in the present day mix of swamps and logjams.

I do not believe that the fundamental problem is shortage of staff or lack of money. This might come as a surprise to some of my colleagues and a pleasant relief to the NHS Executive. I believe that we have more than enough staff engaged in the mental health field in the widest sense, but that the vast majority of them are poorly trained and ill-supported in their work. This covers both the formal and voluntary sectors. Until we make better use of our existing staff we cannot tell whether there is enough money in the system or not.

So if we have enough reports, executive letters, staff, and money why is the system not working? I believe that many of the reports and recommendations to managers and workers alike are no better than telling someone who is distressed to “pull themselves together”. This form of treatment, whether applied to a child, an adolescent, an adult, a professional, or mental health workers in the broadest sense, does not work. Even if it takes the form of action paragraphs, deadlines, or penalties of how, and by when, one has to pull oneself together, it does not work.

In order to improve the situation one has to understand it not only in its conscious manifestation (as most reports do) but also in its unconscious manifestation in terms of the underlying and unspoken nature of the problem. I am not talking about some mysterious or esoteric approach peddled on behalf of one or other sectarian point of view, be it psychiatry, psychoanalysis, or whatever. I’m talking about what we all know but don’t, and often dare not, speak about, about: the fact that working with the mentally ill drives us to despair and into dark and seemingly hopeless places; that making progress, or even just maintaining one’s sanity and morale, can be a full-time occupation; and that taking flight from the pain of the work accounts for much of the difficulty experienced in the field.

I am not saying that it is hopeless, or that nothing can be done: I am saying it makes us feel hopeless and despairing. This can often not be spoken about. We then fall into denial of the very existence of the problem, and in that state of mind we then find it difficult to help ourselves, our colleagues, and our organisation. The process can go one step further by what, in my field, is called projective identification, a technical way of describing the mote in one’s brother’s eye when one does not see the beam in one’s own. It is at this stage that the mechanism of blame enters the equation; blaming lack of money, lack of workers, the government, the profession, and so on. It makes for a state of self-righteous comfort but does nothing towards making progress in improving mental health.

But is it true that working in the mental health field is more painful than other work? I think it is. Occupational health teaches us that there are occupational hazards to all forms of work. “Mad as a hatter” is a good example from the past. Silicosis, farmer’s lung, for example, are well known. Radiographers carry a disk on their lapel that measures the degree of radiation that they have been exposed to. There is similar risk of “radiation” in the mental health field. Working with mental distress causes the distress to be communicated to the workers and for the workers to become stressed and distressed in turn.

In the past—in recognition of the stress of the work—psychiatrists were allowed to retire at fifty-five (instead of sixty-five) and draw their pension. Of all medical workers psychiatrists have the highest suicide rate. You may think that this is because the profession draws the most unstable doctors, but that instability—if it is true—may also be an asset for doing the work. As the Baptist minister John Martin proclaimed of his contemporary William Blake’s alleged madness, “If Blake is cracked, his is a crack that lets in the Light.” The real reason is the stress arising from the work. I have been speaking about psychiatrists, but it must be understood that they should be seen as only one of the many professions that work with the mentally disturbed and ill, and that the processes (and the historic retirement rights) I describe apply equally to all professionals in the field.

Why does this process matter? It is a minor problem affecting some individuals, so what! But I would say that far from being a minor problem it is a major problem, and addressing it holds the key to shifting the mental health logjam. In spite of our best efforts there is severe bias and fear in the public’s mind about mental illness. All of us present at any of our conferences will know that this is irrational, but for all that, it is a fearsome reality in how our society functions.

All “threats” in our society have been “allocated” office bearers and institutions whose task it is to deal with these threats and to remove them from society and from our conscious concerns.

The same applies whether we are talking about physical, medical, or emotional threats.

It is no coincidence that the mentally ill were incarcerated in institutions on green field sites away from the centres of population. “Out of sight, out of mind” was the policy. That policy has now been changed, and we have “care in the community”, but the state of “out of sight, out of mind” is still with us, exactly as before, only it takes a different form. The most pernicious form is now the state of mind of the workers in their approach to the patients. Because repeated daily exposure to the mentally ill is draining, the workers fall into a state of mind of not being in touch with their patients. This can take a variety of forms. At its most concrete it can mean that workers lose contact with patients. You have all seen the statistics and read the multiple recommendations about how this is to be avoided. But, whatever the recommendations, if you want to “lose” a patient you will.

I need to make quite clear what I am saying. I am not saying that workers consciously and wilfully lose patients. Far from it. The vast majority of workers are dedicated and hard working, and would rightly protest at such an outrageous suggestion. And yet a great many patients are lost—I believe for unconscious reasons. Just as one is inclined to “forget” unpleasant appointments and deadlines, so workers forget patients. And if they are working in a system in which there is little training and no awareness of these processes, they themselves feel forgotten. When that happens, the likelihood of patients—particularly the most troubling ones—being forgotten is ever higher.

Another equally concrete way of losing contact with patients is either to become ill yourself as a worker (illness rates in care in the community workers are high) or to leave (staff loss and turnover is equally high and, of course, expensive). But these are only the most visible manifestations of the process of distancing yourself from the work. There are more subtle and thus pernicious ways of distancing yourself from patients. For example by not having your mind on the job, by being distracted, taking flight into other activities that fall into the orbit of the work but enable escape from the discomfort of the work at the emotional “coalface”. Keeping the patient and his or her needs in mind in the context of their family and social systems means being in touch with all the distressing and, at times, hopeless aspects of being mentally ill in often very unsatisfactory personal, social, economic, and housing conditions. Working with other agencies and other workers, in social, housing, finance, and the like, only compounds the experience of difficulty. And so it is understandable that liaison does not happen and people fall into the gaps between the various professionals and institutions that are supposed to look after them.

I am not justifying this state of mind in workers, nor their professional conduct, but I believe that what they are doing in everyday layman’s language is turning a blind eye to discomfort, pain, and threats, and that executive letters and their ilk make no difference to the situation whatsoever. You can tum a blind eye to an executive letter and bin it, just as you can to any other painful situation. If bombarded by deadlines and threats you will feel persecuted and find ways around them, or have a breakdown or leave, but you are unlikely to comply with the injunction to face something that is unbearable. I should reassure you that I am not by character depressive, negative, or cynical in my approach. I believe that a lot can be done to change the situation, but before we change it we need to understand what the problem is. In many instances we have attempted to address the symptoms without understanding the underlying problems.

I should also say that the foregoing ideas about how workers relate to stress and how it affects their work and the institutions in which they work comes from a long and honourable tradition of research that by and large has had very little influence in the health and mental health fields. This is because the message is unwelcome and defended against, a case of “shooting the messenger” if he brings unwelcome news or brings ways of understanding that do not fit into the “regulation” way of seeing things. In this regard I, too, as messenger run a risk, not of being shot, but of being politely welcomed and then completely forgotten, for the message I bring is a disturbing one.

Why is working with the mentally ill so upsetting?

There are several interrelated factors. If one is to work with an open mind in this field one has to ask oneself about the causes of mental illness. In doing so it is clear that there are many genetic, biological, psychological, sociological, and economic factors that affect human development and mental health and the onset of mental illness. It is hard to think about these issues “out there”—as affecting only others or patients. It is natural that one should also have thoughts about one’s own upbringing and about how our behaviour affects our own children. At that level the situation becomes a lot more difficult and close to the bone.

This, in part, explains why all concerned seem to make so little connection between child and adolescent development and adult behaviour. Quite understandably, we fall into a state of mind of “it did me no harm, so why should it affect my children?”, failing to take into account that perhaps we are least best placed to judge whether or not “it” has done no harm. Parenthood, in any case, is about a degree of regret. How much more so if our child has become mentally ill. At times like that we may well fall into finding an explanation that makes sense to us, often one that helps us move away from our own unspoken and unacknowledged sense of guilt. Sometimes this generates a “crusading” state of mind that can be very helpful in raising money and providing support, but at the price of pursuing a particular approach. Nothing gives a better boost to one’s identity than having an enemy, preferably an unreasonable and hateful one. This may explain why mental health—unlike, say, surgery, paediatrics, or professions outside the health sector—is riven with strife and factionalism. There is a greater “personal invasiveness” factor in working with mental states than there is with other treatment “products” that are processed as part of the work.

Additionally, we grow up in a culture where we are supposed to be able to deal with everything that life throws at us with “a stiff upper lip”. While that culture is undoubtedly changing, the fallout from it is still with us. Then there is the peculiar situation where the expertise that goes with working with the mentally ill is not recognised. No one would claim to know as much of their field as an engineer or a scientist or a lawyer. But when it comes to mental health we’re all “experts”. This is partly for the reasons mentioned above—the divisions and “enemy” states in the mental health professions—but also because we have all been children and have grown up and thus have a degree of expertise, simply from our own experience. Besides mental health the only other fields where this applies are education and social services, for similar reasons. We are in the grip of flight and defensive processes from painful work and are divided amongst ourselves.

I haven’t told you anything that you don’t know, though perhaps I have cast some light on why it is happening. And I’ve repeatedly said that I don’t believe that change by fiat or injunction works.

What is to be done?

The first is that the splitting process that creates gaps between departments and budgets—the gaps into which patients fall—needs to be narrowed and closed if at all possible. We need the best possible conditions for human development. Today’s patients are a generation ago’s babies. We need a better integration of health, social, educational, and fiscal policy. At present we have separate empires with their office bearers who pay lip service to cooperation, but jealously guard their power and their budgets. We need to address this fragmentation which not only serves to maintain the status quo, but embodies a denial of the importance of people as the world’s and nation’s most important asset. The present arrangement also embodies a sense of “no can do” which is based on a sense of hopelessness about ever making improvements in mental health.

The present green paper on cooperation between health and social services and the appointment of a minister for public health1 give some hope, but the risk of these developments being caught up and bound in the process of hopelessness mentioned above are enormous. The social process of change is inexorably geared in favour of no change unless we build “addressing resistance to change” in as an integral part of the process. The risk of the round of conferences to which we go is that, having serviced our sense of guilt by attending and giving views, we all go our separate ways. Acknowledgement of the difficulty of mental health work should be addressed in both mental health training programmes and in staff support (see, for example, Hale, Chapter 35) and continuing education systems, which too many workers don’t have. Around half the workers in the mental health field have had either no training at all, or no adequate training. Staff development systems (see many other chapters in this volume) are either completely absent or else unclear in what they are trying to achieve, and by what means. It is for these reasons that what is required is not more staff but better trained and better supported staff. And that does not necessarily mean more money—it is too early to say—but it surely requires a change in training—in training organisations, and in the commissioning of training. The present system of commissioning training in the mental health field is in desperate trouble, partly because it is caught up in a doctrinaire policy designed by the previous government [in the mid-1990s2]. While on paper the policy makes sense, in practice it is so out of touch with reality that I sometimes wonder whether it is not an unconscious attack on both the patients and the workers in the mental health field. This is not as bizarre an idea as it might seem to be at first glance. It is not uncommon for people to be resentful of, and hostile towards, those that drive one into despair. And what is the despair about? In spite of the civil servants’ best intentions, it is about our frustratingly slow rate of change in the field. Doctors get angry and frustrated with patients that don’t respond to their therapeutic ministrations and turn away from them, or fall into punitive therapeutic regimes. It would be surprising if civil servants did not fall into a similar state of mind.

Be that as it may, the way mental health training is supposed to proceed is as follows: there are separate systems for medics and non-medics—so much for multidisciplinary work—and these are then to come together at some stage in the future. So much for history. And training is supposed to be commissioned by consortia. The fact that these consortia have hardly got their act together as regards basic nurse training, never mind mental health work, is not mentioned. And then mental health training is to be commissioned by these mechanisms. It may be a brave attempt to empower purchasers (now known as commissioners) and to wrest the baton from crusty training organisations that keep on producing what suits them. But it takes no account of the fact that mental health has always been a Cinderella area, for reasons of personal and social discomfort. The chances of success following this approach to commissioning training I believe are nil, because the commissioners are quite out of touch with the needs of mental health professionals.

Summary

Even within existing staff resources, ...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Contents
• Preface
• Foreword: The Tavistock enigma
• Part I: The Tavistock legacy
• Part II - Pregnancy and under-fives
• Part III - Children and adolescents
• Part IV - Couples and families
• Part V - Working with adults
• Part VI - Psychology, social work, and nursing
• Part VII - Consultation, court, and organisations
• Part VIII - Performance, publications, and policy
• Afterword
• References
• Index