Does anyone realise…the lunatics actually are in charge of the asylum?

In 1959 Isabel Menzies-Lyth – psychoanalyst and organisational consultant, published a study of a teaching hospital in London. The study, initiated by senior staff at the hospital, was expected to underpin institutional change given concerns that the system was under significant strain. Essentially, senior nurses were worried about their capacity to provide adequate practical support for trainee nurses whilst at the same time maintaining patient care. Something was wrong: Sickness rates amongst staff were worryingly high as was the drop out rate from training.

Menzies -Lyth spent time in the hospital, talking to people and carefully noticing the issues, diagnosing the problems. What she describes in her seminal paper is an odd, brittle culture where nurses were more automatic than compassionate, efficient rather than kind; a culture within which the nurses were given a diverse range of tasks which meant that they had little contact with any one patient. A culture which allowed them to refer to patients not by their names but by their symptoms (“the liver in bed 10”).

Despite the fact that the nurses presumably had different skills and interests, it was not supposed to matter in this place who you nursed or what their symptoms were. Brisk professionalism was prized as was a way of working characterised by detachment and routine. Complex, challenging issues and decisions were avoided by ritual and rendered silly through grim tradition. There was nothing special about anyone.

One assumes, from reading the paper that there was little humanity in the way that the nurses approached their tasks. They do not appear to work with humility or in a way that allows them to be known by their patients as individuals. One imagines that gentleness and humour were killed by this strangely dispassionate culture, that clever minds had to be put away. The paper describes a place full of people but with obstacles to all the lively, kind and happy stuff that should happen between them.

Why did they work like this? Were they monsters? Psychopaths? Power crazed harridans? We already know they weren’t as just asking the question illuminates how ridiculous those angry assumptions are: These nurses would have been normal, nice people; people driven by vocation and by wanting to look after others, by wanting to do something that matters. By reminding us that this dour, uninspiring, vaguely embattled culture would have emerged for very good reasons, Menzies Lyth introduces us to an important discourse: She directs our gaze away from condemning the practices themselves and towards the urgent task that the nurses were faced with and for which these practices presented a solution.

All human beings act badly when we’re anxious or afraid and we act even worse when we have no reason or space to reflect on the fact that we are anxious or afraid. Instead we pretend we know things, we avoid people or cling to people, drink too much or take drugs or drive too fast or shout too loud.  Menzies-Lyth reminds us about the nature of the task for these nurses; the anxiety inherent in caring jobs – the anxiety (or, to be more specific, the fear, shame, incompetence, envy….) that every one of us feels in all our interpersonal encounters. She spells out the things that make nursing particularly difficult: the bloody, messy, disgusting bodies, the frustrated, suffering patients who act badly themselves. Then she goes further and helps us to see how awful this would be – to hate the people you are supposed to care for, to face illness that can’t be cured, to be uncertain that you can make a difference, to be an expert who sometimes doesn’t know and can’t really help. She helps us to understand the envy an exhausted nurse would feel towards the patient lying prone, being served and the dreadful dilemma faced by all of us paid to care for people who irritate us, harass us, bore us, overwhelm us, love us…how to manage the relentless tumult of emotions that we are faced with when we look after humans? How to manage our guilt and our shame at feeling all the “unprofessional” things we’re not supposed to feel and can’t possible voice?

Menzies-Lyth concluded that the curious culture at the hospital emerged as a way of helping to manage the tension and distress associated with the job. The nurses had unconsciously ‘requested’ that the hospital sanction various practices which worked to help them manage their own anxiety. Intimacy and individuality were avoided meaning that loss (when people died or worsened) could also be avoided. Relationships, humour, gentleness and kindness would have been eradicated through the singular efforts that this organisation made to avoid disgust and fear and the pain associated with not always knowing or being able to make people well. Strange ‘cliques’ within the nursing team would have allowed the nurses to discharge their anger and blame their colleagues rather than confront their own limitations.

The practices, or “social defences” would have emerged subtly and insidiously, masquerading as ‘good practice’, or ‘professional conduct’. They were practices which would have felt normal, clear and dutiful when in fact they worked to ‘rescue’ the nurses while undermining the very purpose of the organisation. The workers themselves collectively, subconsciously agreed to sacrifice their capacity to care humanely for humans who were suffering in order to manage the intrusive, disturbing stuff in their own minds.

Menzies-Lyth and her colleagues introduced a discourse that situates organisations as part of a dynamic process. She shows us that, far from being benign practitioners, all of us who work in caring professions are thrown fully into a daily, complex interpersonal reality. She helps to position our bad practice as threat responses and reminds us that none are immune. The impact of the work (of caring for humans) is inevitable….how could it be otherwise for social beings designed to be sensitive in relation to others?

This is a discourse which helps us to understand that the work that we do caring for others makes us mad. It renders good, diligent, caring people capable of creating stupid services that work badly and fail the people who use them. This is a discourse which makes sense of rigid, meaningless targets and dehumanising language, of bureaucracy and neglect and our sheer inability to remember that our ‘patients’ are, quite literally, people we can know.

And I think we need it more than ever as you just have to listen to the news to know how lost we are….In August last year SkyNews reported that investigations into abuse in mental health services have  nearly doubled in three years. Reports peppered the news towards the end of 2017 about a crisis in mental health service provision: not enough staff (The Independent, 30th Sept 2017); long waits for treatment (The Guardian, 7th July 2017); leading charities urging the Government to address a crisis given that so many people in need are ‘locked out of services’ (The Independent, 4th November 2017); services for people who self harm or are wanting to kill themselves are under “unprecedented pressure” (BBC news, 27th July 2017).

People continue to be excluded from, made worse, stigmatised, blamed and hurt by services. The service user movement on social media is vociferous and raging – justifiably angry at our crass, dumb attempts to create services which alleviate distress and mental anguish. Outraged at the fact that we sometimes – often – make things worse through an inability to create services which are, at their core, simply humane.

The point of the discourse introduced by Menzies-Lyth and her colleagues is that this is all of us…not just the ‘bad’ ones. There are no ‘bad’ ones…there are just ones who haven’t noticed what has happened to them. The ‘bad’ ones are simply services which have made no provision for helping the staff, leaders who are too caught up in their own anxiety to create space for noticing or to model a helpful approach. More worryingly (and less hopefully) they are services which are ill served by political agendas that ramp up the anxiety and make it harder, or even impossible, to notice. The ‘bad’ ones are simply those who lack the space to think, or refuse the space to think because they are too afraid, too threatened to be inexpert.

Last year a friend and colleague undertook training in dealing with complaints in her NHS Trust. They worked through a real life, anonymised example which centred around rude, dismissive conduct from a staff member over the phone. My friend had the complainant in her mind – a relative with a recently admitted, highly distressed son. This was a woman who, presumably, in the midst of being terrified and desperate, asked the responsible NHS Trust to notice that they had acted badly. Notice, perhaps, a social defence which had emerged…a way of working which allowed the worker to put the phone down a little quicker, discharge a little irritation.

The group worked through the example, worked through the process and discussed the outcome which would be – and had been in real life – disciplinary proceedings. My friend expressed surprise…wasn’t this behaviour the result of someone stressed, someone managing anger or annoyance? Someone who was maybe overworked or under pressure? Maybe, just before the call, this staff member had been yelled at or attacked or had cut someone down, been the first on the scene, witnessed something terrible that they would never really forget.

The tutors, according to my friend, had no answer. There was no narrative about why this staff member had behaved the way they had. Only that they shouldn’t. My friend was confused – how would disciplinary proceedings (in the absence of anything more exploratory about why this behaviour occurred) help? If there were good reasons for this poor behaviour, then how would sanctions help? Would this not add to the stress, blame, shame?

Menzies Lyth would no doubt argue that this complaints process emerged as another social defence: An organisationally sanctioned process which works (crudely) to manage the institutional anxiety at the expense of a more restorative process which ultimately would serve the people who use the services much better but which would require more of the organisation.

Talking about the stress that we experience as workers who strive to make lives better for some of the most distressed/distressing, frightened and frightening people in our society is, I think, considered bad form. We are supposed to be unrelentingly compassionate, unproblematically kind and giving. But caring for people who are scared and damaged is scary and damaging. It can’t (and shouldn’t) be any other way. It is what we signed up for. But we need institutions that help us manage this properly so that we can stay thoughtful and kind in the midst of the struggle and the feelings of overwhelming incompetence.

We need this discourse because a lot of the (subtle, normal) stuff we do is very bad indeed. We need this discourse to help us examine the governance and accountability structures around organisations that are tasked with alleviating human suffering. We need a discourse which asks: ‘what are we doing”? and “why”?….a discourse which makes it okay for us to notice that we, as workers, are struggling.

Reference

Menzies Lyth, I (1959) The Functioning of Social Systems as a Defence Against Anxiety Human Relations (13) pp 95-121

The PTM framework: Where do we go from here?

So, the Power Threat Meaning (PTM) framework has burst into my mental health/psychology focussed world. It is rather glorious – outraged, strutting, purposeful: An ideology founded in the certainty (which I share) that something is terribly wrong.

I love the explicit references to power and I love the way it dissolves the boundaries between ‘those who are ill’ and ‘those who are well’. I love the fact that sitting in a large, naturally lit lecture hall in Euston, I was allowed a glimpse of insight into my own fracturing many years ago. I love that I had a moment to think about how the assumed truth, the familiarity and normality embedded into the expectations around me at that time obscured their oppressiveness. For the first time I entertained the thought that maybe it wasn’t solely my idiocy, my youth and my fault that, for one awful year, my mind became my enemy.

The PTM framework is inclusive and bold and impressive and – despite accusations to the contrary – is, in my view, infused with humility. And this is good. It is right that something so ambitious and righteous is also cautious; the authors know that this is just the beginning, they know it needs testing and critiquing and that it will take many people working together to move it forward, to make it work. Like a road map the PTM framework offers us a whole lot of routes but not necessarily the destination. We’re going to have to work out where it takes us and what on earth that looks like.

So, my worry is that we could take a wrong turn. The PTM framework makes it perilously easy to divide the world into those wedded to diagnosis (traditional, unthinking, oppressive) and those who are anti diagnosis (radical, critical, enlightened, empowering).  Or – the other split – those who use diagnostic categories (evidence based, rigorous, scientific) and those are opposed to them (dangerous, emotional, polemical). There is the danger of alienation, division and of little or no progress being made to actually help those who don’t have a voice. There is, I fear, the danger that the the PTM framework could be used to further entrench individuals who should be focussed on creating safe cultures and harmonising care.

I know what I’m talking about…I have been that person. I have been infuriated by the attitudes of my colleagues and I’ve been the one bitching to others (who share similar views to mine) about the ignorance and callousness around me. I’ve viewed the practices around me through a lens of righteous indignation believing that I understand, I know better. I have believed that I’m on the side of compassion whilst my dim witted colleagues are, clearly, the man. I’ve been the person who is speechless with outrage at the decisions made by others. Incandescent and inarticulate with fury….I have been comfortable in my indignation doing nothing positive to bring this shit together.

I’m not stupid. But I have been stupid. Plenty of times.

And the PTM framework is far from stupid but I worry that it may be used in a dumb way to justify opposing views and adversarial positions doing nothing to further debate and put a little compassion out there into the universe.

Which brings me to what I think might be a massive opportunity sat right there in its pages….

The PTM framework, rightly in my opinion, positions the behaviour normally associated with a psychiatric classification as understandable threat based responses. It goes further and argues that these behaviours constitute responses to threat which stem from restricted access to conventional or approved forms of power.

So what if we use the PTM framework to understand the more toxic forms of control and abusive power that  organisations and workers use as responses to threat (or social defences)?  What if the ideological power that infuses coercive care is also understood as organisationally sanctioned responses to fear? How would it be if we understood all those problematic, unthinking, often damaging practices as understandable reactions to aversive emotional events associated with…yes I know how this sounds…with disempowerment, with shame and with anxiety.

I am arguing that workers and, more importantly, organisations are traumatised. I am arguing that these professionals and institutions respond coercively because they often don’t know what to do, don’t know how to help. I’m arguing that they are frightened by what they see and hear and read. They are angry at those who have hurt the people in front of them and ashamed by the impossibility of the task, by their inability to take away the pain.

While we fail to acknowledge our own (as workers) emotional responses to the work, we will continue to oppress, to denigrate, blame and even abuse those who confront us with our inadequacies or make us feel afraid. Whatever words we use, whatever frameworks we have will be weaponised. And while we fail to acknowledge our own emotional responses to the work it will remain easy to accuse our colleagues of stupidity, to fail to understand their struggle and to work supportively, restoratively to create compassionate, therapeutic cultures.

How would it be if we used the PTM framework to look at ourselves first? To notice our own threat responses and the practices which have emerged as a consequence. How about we work collaboratively with service users to examine what we do and find out which practices failed to serve the primary task of alleviating their distress. How about we then ask ourselves why?

 

 

 

 

It’s all about the relationship, dammit!

How about this…instead of thinking about changing language and the words we use, how about we re-think what those words mean? What if ‘personality disorder’ meant something that existed in relation to services. And what if it didn’t exist in isolation? Away from services people are distressed or lonely, afraid… but, in relation to services, ‘personality disorder’ is born. It can’t exist outside of services because services themselves work to create it.

Again, as before, I’m not claiming to like or agree with the term ‘personality disorder’ but I believe that noble efforts to overturn medically dominated and blaming terminology can only go so far.

To do something different – to create and maintain wise mental health services  – we need to better understand the dynamic between workers/organisations and those they work with. So many initiatives designed with the best intentions somehow fail to make a difference because, I think, we refuse to notice what we need to – that workers feel afraid, incompetent, ashamed in their work and organisational practices emerge to manage those anxieties at the expense of those who use the services. Many of us – often the best of us – in subtle, almost unnoticeable ways maintain a lie that ‘personality disorder’ (or however you want to describe the ‘symptoms’ that could lead to its diagnosis) is somehow stable within individuals. We refuse to notice that it is dynamic. That it exits in relation to other humans – can be ‘treated’ only in relation to other humans.

For example, ‘personality disorder’ isn’t a fixed and stable problem for the man who is confused and lonely after 20 years in prison but it is the moment when I ask him for a bus ticket to reimburse his travel and he thinks I don’t trust him. Personality disorder is the anger that emerges when I – foolishly, clumsily, defend myself because I’m angry at his furious accusations and what feels like his stubborn refusal to understand something perfectly reasonable. ‘Personality disorder’ is the gulf that widens between us; a cavernous gap filled with the ghosts of those who hurt him, lied to him, refused to trust him and my self righteous inability to see that I have become one of them.

The woman from years ago who carried a knife because she was so scared was just that without me (or someone else) – scared. She ricocheted around our town terrified, lost. But with someone – with me – personality disorder emerges as she screams and laughs at me because I try to help using therapy words which have no meaning for her. It is the moment I fall away from her because I don’t know what to do and I don’t know how to help. I get paid to help people and I don’t know how to help her. She is so frightened and she has nothing and I can’t make it better. I’m lost and confused and probably ashamed. I struggle onwards within my frame of professionalism – expecting these words to click as much with her experience as they did with me when I studied them and wrote them in essays and used them to explain myself to other professionals. Her ridicule and desperation push me further away into my shame. It would be easy to blame her for this moment and I could walk away, intact. It almost comes to me – “this is your problem, not mine”, “if you don’t want to be helped”….

‘personality disorder’ is the moment when X allowed me to see that she hated the man she was sleeping with. It’s the moment when I stopped listening – and she noticed – because I was immediately frightened by her hatred and panicked about what she might do. It’s the moment I didn’t understand and asked for clarification and received a torrent of abuse for not listening and then felt angry – and stopped listening. It’s when I turned up for an appointment to find the other person bloodied from self harm, stomach distended with medical dressings, disorientated and sad. The enormous well of her need unreachable, incomprehensible, overwhelming for me. Where to start?

This is what it is….it is one person (with less power) screaming at another (with more power) in outrage. Outrage because that person is supposed to help but their words and their faces and their body language and this room and everything make the pain worse. And it is the helper at a loss because their tools (the things they have been given, taught to use) are useless. It is a helper frantically using those tools more bluntly, more haphazardly, more cruelly, more rigidly, more angrily.

‘Personality disorder’ is our shitty, worst interactions. That’s what it is. It is no more or less than that.

And, if that’s where it lies, that’s where it can be relieved, soothed, made better. All it requires is that we sink our professional selves into a scary place of not knowing. A place where we rely on intuition and humanness and – yes, admittedly, a reasonably sophisticated understanding that people always have very good reasons for everything that they do. Personality disorder is cured moment to moment by brave, authentic workers who allow themselves to get it wrong in the pursuit of getting it properly right.

PD In the middle

So, I work in a service which has the term “personality disorder’ in its title. And…this feels risky…but I’m not advocating to change it. Not because I like the term. I don’t. I think it’s rude (at best), abusive, stigmatising and re-traumatising at worst.

I’m passive about it not because I like it or believe in it but because I feel in the middle of two camps: This is crude. I know it is more nuanced than this but, for simplicity…Those in the first camp argue that no service and no intervention which uses the term has any value or credibility. People in this camp hate the term for very good reasons and are alienated by the services which use it.

The second camp defends the term because it has validated their distress and provided relief by opening doors. Or because it makes sense to them, because it fits with a medical framework that situates distress as ‘disorder’, as intra psychic failure, as non normal. Potentially as something you can fix, recover from, take pills for. A chemical imbalance that can be treated. They may like it because it is part of an expert professional lexicon that validates them.

I agree with those in the first camp but I don’t belong there. I’m glad there are people in the second camp who have been helped but I don’t belong there either.

Now, I know language is important. I know it can create and uphold structures that oppress and abuse as much as it can create art and song. I know language has the capacity to make bad things happen and to stop better things from happening. I know language frequently works to serve those in power and that efforts to change damaging discourses are bold and brave and radical and important.

But, I believe language will continue to be weaponised while workers are afraid, incompetent, ashamed and traumatised themselves by the work that they do. I’ve heard so many terms over the years (“it’s behaviour”, “she’s sabotaging”, “he’s kicking off”) that work to position the user of the service as malign, as other, as disordered, infantile, malicious, hateful. So many words – some good ones, some powerful, useful words (not all stupid words like ‘personality disorder’) – all used damagingly, sometimes cruelly, always thoughtlessly.

Emotion makes us thoughtless. It doesn’t matter who we are. When we’re afraid or ashamed we act badly, carelessly, instinctively to protect ourselves often by controlling or hurting another. And when we work for organisations that are unable to process and manage anxiety, cultures emerge which sanction and support those practices. Words are routinely used in a way that damages other people by obscuring the personal meaning of their circumstances, denying the trauma they have experienced, refusing to allow them to be known and understood. In this way workers, professionals are validated and safe – we are different, sane, sorted. Inured to the traumatic stories that people have to tell.  We can confidently locate the ‘problem’ within the users of our services and hide behind words that protect us  from the realisation that we are the same. That ‘there but for the grace of God’…. That what we see before us are entirely rational responses to a society which has failed to protect, failed to rescue from or condemn abuses that we find unbearable. A society we belong to and which is overwhelming to change.

So, no..I’m not advocating to change the term. When the paradigm shift that I am advocating for finally happens, the term will change. Or it will not longer have any power, will no longer be used to hate. This is where my activism is focussed – in working to notice and name the defensive practices which serve us as workers and the anxious organisations we work for at the expense of our clients. In working to make it safe for workers to be afraid, to not know, to be inexpert. To be more authentically human and kind.

 

 

Stupid services and wise women

Tonight I signed up to write a blog about mental health (or, rather, “distress”). I wanted to write about how those of us who provide services to distressed (and, in my world, violent) people provide those services stupidly. I signed up after years of working for a large mental health Trust and my growing sense of despair about the lack of a public narrative which links distress with social context and the fact that our stupid services are largely irrelevant and work badly.

Anyway, it turns out that -surprisingly – I had started a blog two years ago and I never published my first post. It’s just been restored for me and my younger self has sprung into life. It turns out that, two years ago, I was bothered about…”envy and threats, bewilderment and a gradual sense that, if you’re a reasonably bright woman who has a vision or just some good ideas and who leads people well and with compassion….you can’t really be allowed to exist”. Two years ago I believed that “feelings of pride and pleasure and achievement (of feeling on top of the world) can only last if you work at it yourself because most people won’t feel happy for you”.

It strikes me now that these are good and relevant things to be bothered about so this blog is about people whose distress makes them frightening and it’s about how – because we are frightened – we provide stupid, mindless services. It’s about how our anxiety makes us brutal, neglectful and dumb.

And it’s also about being a woman in a position of leadership and about noticing the subtle stuff (from other people and ourselves) which probably stops us from leading wiser, better services.

Thanks for reading!