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PSYCHIATRY: LOVE’S LABOUR’S LOST The pursuit of The Plan and the eclipse of the personal by David Zigmond
Attempts to gain greater safety and efficiency in Psychiatric services have led to a redesign which mimics the increasing streaming and fragmentation of Medical Services. The results are, very often, dislocating, depersonalising and demotivating for both staff and patients alike. Human and economic costs are considerable. This article explores by narrative and analysis.
It is a little over thirty years since I gave up my full-time job in Psychiatry. I reduced this work to part-time, became a single-handed Principal General Practitioner and ran a small, private psychotherapy practice. Amidst this busy multivalent work, I turned oblivious and vague from the confusing mosaic of organisational plots and plans gathering around me. The metamorphosis within the NHS would be much different to what I had indifferently supposed. More recently I have awoken to the nature and consequences of changes that incubated and hatched in this last decade, my period of circumspection. The psychiatric service now settling is a much more complex compound of numerous, specialised, boundaried teams. These mostly operate with strict intake criteria and sharply delineated, short-term goals. Algorithmically, such a managed medley may look elegantly precise and machine-like. Such is the likely and wishful perception of managers, policymakers and (increasingly) practitioners. This sharply contrasts with the experiences I hear elsewhere. Frequently I receive patients bewildered and adrift. They attempt to describe a plethora of different teams and formulaic, interrogatory styles of interview. I strive to counter their fatigue and dispiritedness. These often ensue from the recurrent breaking of short-term therapeutic bonds. The engineered neatness of diagnoses and clinical plans does not often correspond to the natural untidiness and inconsistencies of people’s lives and distress. Or their complex and changing needs for reparative contact. Older practitioners, too, talk of their frustration; of being deskilled and disempowered in their fragile endeavours to respond with care that is personally attuned, and with an open view to the longer-term. It is not just patients who may be ‘shrunk-to-fit’. These tribulations derive, paradoxically, from designs and styles of management attempting to address ‘efficiency’ - a Higher Good, a necessary Utilitarianism. This collage of recollections and notions, from both General Practice and Psychiatry, serves both to illustrate and explain some major, current healthcare conundrae. The Law of Unintended Consequences is evidenced from diverse viewpoints. Increasing hegemony and rigidity within and between institutions, at the expense of interpersonal attention and sensitivity, is a central and recurring theme. Inevitable, though inadvertent, losses to our understanding of individuals, and thus our therapeutic effectiveness, are difficult to measure directly. Indirect evidence is plentiful. It signals exponential losses to the kinds of therapeutic benefits that need quality and continuity of human contact as a bedrock. The new services are thus very much more expensive,1 but, in crucial ways, less effective. In the following accounts, events and dialogue are authentic. Usual devices of disguise protect anonymity.
The telephonised voice is unfamiliar. It is bright, young and crisp, with the assurance and pre-set utterances of a corporate officer, officially and well briefed. Amanda tells me she is the Duty Manager for the Community Mental Health Team:
* * * * * * * Three weeks earlier Tessa comes to see me, her GP of twenty years. Now in her late 30s, Tessa enters with a reticent demeanour of bruised trust and flickering hope. I have long known these to lap a larger internal land-mass of bleak fatalism and despair. She offers me a very brief direct look and a hint of a smile of greeting: I imagine she cannot risk more. More than a decade ago I attended the multiple and fresh wounds in, and from, Tessa’s family. The fewer were stark and shocking: a young brother’s violent suicide, in prison; an older brother’s serious residual brain damage, from drugs. Tessa, thereafter, was his Carer. The many were more ‘ordinary’, but cumulatively destructive: chaotic and emotionally illiterate parents, compounding their (family’s) problems with alcoholic oblivion. Then the consequent physical damage. Then came disability and, ineluctably, their dependence on Tessa. As a droning bass-note: the symptoms and trap of endless, ugly, economic poverty. Knowing something of this background and story I understand the meaningful evolution of her psychiatric Stem Cells: her swamp-like poor self-esteem, insecure attachments and default position of helpless depression. Simultaneously, I have long admired the battered and malnourished hulk of her will to survive and connect. These are the germinators of her health: I encourage them in myriad ways. Over many years I have offered her, piecemeal and compressed, refuge, reflection, and asylum. Often we have needed expedient, intermittent bolstering from others; from Psychiatrists, Social Services, Day Centres and Counsellors. Like the Asthma and Diabetes she has ‘inherited’, her Mental Distress is not decisively curable, though it (she) is responsive, ameliorable and containable. Mostly I guide and I palliate. Often, I help her perceive and act in ways that do not make difficult situations worse. I may sometimes help her succeed. Far too late to make major reversals of Fate, I offer valued morsels of parenting that were tragically lacking in her biological family: safety and reliability. Then space and sensitivity, for respectful, imaginative dialogue; sometimes, even, wisps of play. All have been necessary, but rarely sufficient. To alleviate some of the insufficiency, I welcomed synergy from like-minded colleagues. * * * * * * * One such was Dr M, a senior psychiatrist at the local (Teaching) hospital. A little short of twenty years ago I am meeting Dr M every few months. Our conversations generate mutual interest, guidance and clarification. We share care for many puzzling, distressing or enervating patients. Our roles, locations and periods of contact are different, sometimes disparate. It is the exchange of these that may enlighten work that is so often uncertain and uncompleteable. Sometimes it will not: then there is support and affiliation from a trusted colleague; a humble balm for long-term professional goodwill and morale. The cordiality and informality of our meetings is framed by a light lunch or early evening meal. There are no recorded agendae, bullet-points, power-points, or action-plans. This is learning by mutual enquiry; Education at its most feral and refined. Over many years I had several such alliances with Senior Psychiatrists from this hospital. Although the style varied with the individual, the pattern of commonality endured: we were fortified by a pragmatic rapport of uncertainties. Such extemporised dialogue made us a little more able to perceive and address the chimeric complexity of people’s lives. * * * * * * * I remember a conversation with Dr M about Tessa, early one summer evening. As usual, we each brought our samplings of newly garnered notions and reports. Again, his perceptive compassion and imagination freshened my own efforts, sometimes lost and stumbling. Thus enriched through our fallibilities, we grew an implicit bond of gentle, ironic affection. Tessa, too, benefited from this unplanned but now deliberate and fertile overlap of ‘multi-agency care’. I thought of the secure and happy child who senses good contact and connection between her parents, but does not necessarily know (or care) what they are talking about. Tessa partially articulated this, shortly after her brother killed himself:
Later that evening Dr M told me of mooted plans to reorganise Psychiatric Services. He was not directly involved, but had heard:
It all sounded good to me. My hesitations were trivial, brief and personal: I rather liked the system as it was, and my relationships within it. Also, I’d never really been interested in that kind of Grand Planning … I soon stopped my timorous muttering. I assured him I would look forward, with alacrity. * * * * * * * Twenty years later I am struggling to learn the language and etiquette of this ‘community-based’ system. The current consultant, Dr Q, has been in post five years, but has had only essential and remote contact with myself and the few other GPs similarly interested and motivated. I once attempted to speak with him, about an obscured and worrying patient-situation: I hoped for the kind of dialogue I had, fruitfully and repeatedly, many years ago, with Dr M and his contemporaries. Dr. Q's response was stiff in formality and cautious to the point of inertia. He quickly demonstrated (to himself) that there was little to discuss. As he spoke, I remembered old monochrome newsreels of the 1950s: the veteran Soviet Foreign Minister, Gromyko, and his stern monosyllabic camouflages, neutralising western journalists’ eager questions. This opaque gravitas seemed both comic and threatening. The threat is felt because the (Non) Spokesperson may foreshadow an enigmatic and concealed multitude, not a mere (and maybe) curmudgeonly individual. Silence can be interpersonal darkness, in highly vulnerable territory.
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Other Practitioners are having similar problems. Dr K, a Local Medical Committee member. She is a warm-hearted, sharp-witted woman with a reputation for intelligent but humorous persistence. In an unscheduled encounter we briefly discuss my Doldrums with local psychiatric services. Her initial receptivity soon dissolves with gestures of thwarted aggravation.
I think of Dr M’s metaphor of the previous psychiatrists working in The Castle on the Hill, and how we have somehow, at great expense, replaced it with local armed garrisons of foreign soldiers, who speak only their own language. I share these evolutionary images with Dr K. We laugh heartily at this vignette of The Law of Unintended Consequences, but it is the manic, displacing laughter of doomed respite. As our laughter falls away, I am aware of a sadness; a grieving, a realisation that valued activities and contacts are gone. Relinquished for those that seem (to me) to lead to such misalignment and derogated contact. Is the problem, mostly, that in my fortieth year of practice I am too rigid to mould to the cusp of change? Or is this more a Cultural Grief, for the passing of a Colleagueial culture that was more responsive in its informality, pluralist and ‘organic’ in its growth. Replaced by a managed culture of sharply boundaried and structured Multidisciplinary Teams, themselves issuing and receiving ‘Information’ and ‘Action Plans’; where any ‘development’ is engineered and sanctioned by official diktat and now, increasingly, ‘Market Forces’? * * * * * * * I try to get Amanda beyond her templated telephone ‘management’ of Tessa and I. I am becoming impatient. I feel obstructed by an armoured inflexibility. These colleagues seem immured and impermeable. Most worrying, they seem unstoppably confident in making remote, procedural decisions about a complexly troubled person who they have never met. Clearly, there is little precedent, capacity or inclination to engage with me: an observant, thoughtful practitioner (I like to think) who has known the patient twenty years. I need to inject (my) reality into this surreal impasse. I can do this by talking collegueially with Dr Q. I ask to speak to him.
Her crisp voice now seems edged with reprimand. I am being managed. I imagine the bright, brittle shell of a mollusc, a protective exo-skeleton. An Executive Persona. * * * * * * * Thirty-five years ago I worked with Carl in a large Victorian Mental Hospital. As young, trainee psychiatrists we enjoyed a friendly network of peers and older mentoring consultants. The ancient institution’s heavy, forbidding architecture was, paradoxically, home to a warmly personalised ‘village’ within the NHS. In my two years there, friendly colleagueial relationships extended far beyond my closer professional ‘family’ (psychiatrists, psychologists, PSWs); I developed affable and effective alliances with Art Therapists, Rehabilitation Officers, the Laboratory Manager, even the Hospital Telephone Switchboard Operator. All these were known by name, face, voice, styles of banter. Reminiscing, Carl and I remember them with surprising precision. Beyond our individual memories, this says a great deal about that old institution and its connection to people. Carl and I were mostly blessed by similar personal continuity and attention in our Clinical Apprenticeships. We both were guided by Consultants who (often) had known their patients for many years. This knowledge was likely to be quite as much ‘In Vivo’ as ‘In Vitro’. Individuals were ‘known’ not just by questioning in the consulting room. Often they had been seen, over many years, in their homes, with parents, partners, children, friends, neighbours, even the (then) ‘Family’ Doctor. Our mentoring consultants thus taught us a kind of ‘Field Psychiatry’. Here was a long time-span, and a wide matrix of human connections and understandings. By example as much as theoretical formulation, we learned to be imaginative about the unspoken, respectful of the complexity of attachments (including our own). We were gently shown creative discipline amidst inevitable uncertainties. Likewise, a pragmatic scepticism of the incompleteness of our consensual psychiatric language and tools. We discussed how many individual exceptions there are to our theoretical generalisations. “The more you see of somebody, the more of somebody you see” was an anchoring, guiding principle. For many years, after he became senior, Carl continued this trajectory; he managed and delivered a service that got to know well its many kinds of sufferers, often over several years. For those whose problems were longstanding and variable, he was unhampered in his experienced choice of approach. In calm times, he would offer accessible, gentle interest. When trouble brewed, he could fast-track to a more interventive and urgent out-patient appointment. When serious trouble impacted, he would admit the patient, to be cared for by the staff he knew well; another part of his therapeutic family. Amidst the stresses and tensions inevitable in Psychiatry, he grew a quiet love for the satisfactions of his role as a kind of Pater Familias and patient gardener. During these two decades, I did not hear him speak of ‘Holistic Practice’, but recognised the radiation of these values. * * * * * * * In recent times, Carl and I are talking of our individual and common travails. At this august stage of a diligent and creative career, he is disheartened and despondent. Not from his marathon contact with the anguished, but with the ever-tightening structures and strictures of management.
I raise my hands limply in surrender: my comprehension is coagulating. He continues in angry jest:
Carl seems a little self-surprised by the size of this bolus of professional frustration, and the force, though ease, with which he has expelled it. Knowing my kindred experiences, we are, both, more emboldened than embarrassed. How has a practitioner of Carl’s calibre, experience, and personal qualities become so restricted, deskilled and impoverished in his work? I want to know the hidden organisational history.
My clustered questions are insistent, but softly spoken. Carl looks disarmed and discomfited by them: shards of freshly realised but compromised ignorance. “Ah!” I exhale, now canny in recognition. I imagine a stage-curtain descending. The Triumph of Bureaucracy-become-Culture: The Dictatorship of Everyone by No One. “It’s fiendishly clever”, I say with affected, boyish lightness. “I mean, how can anyone ever undo it …?” * * * * * * * We decide we cannot discern the persons behind the plans, those behind the unplanned drift into depersonalised care. Our attention turns now to more generic influences: culture, economics, new technologies, the media … We rummage in this attic-full of tangled puppet strings, previously unheeded. Carl and I, veteran cohorts, rejuvenate our fading energies with regenerated language and questions. “If you’re writing about this new, skewed rigidification of Psychiatry, you really should include these undiscussed influences”, Carl says. “But there are so many, and they’re so subtle … the article will be far too long …” I falter, daunted. “Well, condense it and offer it as an Appendix. You can always write it up more fully, later,” proffers Carl, saturated, succinct and prescriptive. I agree. Herewith.
1. Industrialisation/Mass Production Now determining influence in most human activities and their objects. May be the most important and difficult to counter. Leads to standardisation and pre-packaging. Loss of individual input: craft, attention and interest. ‘Factory sizes’ only: no bespoke. Difficult to prevent anomie. Best only when human variables are minimal, e.g. Cataract extraction, Vaccination, Acute and severe physical illness. Least good with complex, changeable processes and atypia. (As 2 +3) 2. A(na)tomisation Medical Model = MM= best when dealing with localised physical macropathology. (Much less effective in other areas.) Psychiatric services now very dominated by MM. Anato-atomisation = AA = Multiplying and confining specialisations according to smaller body areas. e.g. General Orthopaedics > Hip/Knee/Shoulder etc. GI Surgery > Upper GI/Hepatobiliary/Colorectal etc. AA and MM lead to limiting analogy of ‘Mental Disorders’ being generic ‘states’, rather than individual ‘processes’. AA and MM are structural and mechanistic models. Thus v. compatible with Industrialisation/Mass Production/Management Hegemony/Goals and Targets (see later). Recent massive attempts to mimic AA in Psychiatry, by mixing patient behaviour with organisational expedience, e.g. CMHT, Dual Diagnosis, Assertiveness Outreach, Eating Disorders, Alcohol Dependence, Emergency Psychiatric, Home Treatment, Early Discharge … Medieval Theological Problem = How many Angels can sit on a single pin-head? Current NHS problem = How many Clinics can medicalize human anguish and be paid for by one PCT? Such designed complexification generates its own problems. Akin to fitting a 117-speed gearbox to a vehicle: gears will tend to miss or jam, power is lost in propelling the larger bulk of machinery, which is much more expensive to produce … 3. Computers and IT Based on binary code: 0 or 1. Difficult medium for creative uncertainty. Algorithmic processes/choices coded as clear and definite. Incompatible with ambiguity, multiple meanings etc. Likely to lead to reification: Mental illness seen as a ‘thing’ rather than an organising concept for complex, evanescent processes: leads to Knowledge as a ‘commodity’ rather than ‘activity’; a ‘product’, not a ‘creation’. 4. We know how to work things, but not how things work Objects of our use increasingly maintenance – free, disposable, sealed-for-life. A growing conundrum and syndrome in our Hi-Tech world. Few users now understand the innards of their car or computer. Leads to widespread mastery-without-understanding mindset. e.g. Psychiatrist who follows ‘correct’ (decreed) Treatment Pathways, but has little understanding of/interest in the unique experience and ‘innards’ of each patient. Management without personal understanding. 5. NHS Commissioning: Territoriality and Commodification Commissioning conceived (presumably) to tighten and sharpen working awareness and performance. Does it? Model derived from Corporate Competitive Commerce. Many unintended side-effects: Practitioners frequently more boundaried = affiliation to Trusts’ short-term, measurable, G & T (Goals and Targets) rather than patients’ longer-term, less measurable, health and welfare. Increasing resources spent on window-dressing, PR/’Spin’, legal process. Officious Practice = adhering to ‘Letter of the Law’, not cleaving to values underlying it. Rules devoid of jurisprudence. G & T very compatible with MM + AA (above). Fosters competitive, territorial behaviour, rather than cooperative, colleagueial alliances. 'Not everything that can be counted counts. Not all that counts can be counted.' Albert Einstein 6. Governmental Modelling: Less Conscious influences a) Since 1997 the previous (New Labour) government has had more lawyers in Cabinet then any previous. Hence accelerated tendency to rules, regulations, prescribed procedures in most difficult human problem areas, especially Health and Social Care, Education. Intelligent and creative flexibility initially displaced, eventually proscribed. b) In recent years a very influential senior Minister of Health2 has been a Laparoscopic Surgeon. His expertise re: illness and treatments is via well-defined (mostly successful) procedures to very confined body areas. (Where MM and AA are most effective.) His perspective on planning and funding derives from these. Problem = if too dominant, leads to impoverishment of more holistic approaches. Especially important re: syndromes that are chronic, incurable, fluctuating or non-localisable = much (most?) of Elderly, Primary, Psychiatric Care. Much more than MM/AA required with these. 7. The Climbié-Clunis Factor:3 The ratcheting of Defensive Practice In our media-dense world, we now mass-produce and sustain interest in the most extreme enactments of ‘madness’ and ‘badness’, as never before. These sporadic horrors are rare, through perennial. New (and understandable) government initiatives to assert ‘authority’: systems for early identification and sequestration of perpetrators. 'Never again.' Resulting mass Micromanagement is doubtfully effective. May be less effective, due to secondary inflexibility. Services dominated by ‘worse case scenario’ become anxiously and narrowly focused: like phobic patient with rigid and controlled relationships. Another analogy: the over-armoured Medieval Knight who cannot walk, mount his steed, or respond dextrously to attack, when it comes. Lesson: too much caution creates new hazards. Practitioners strangulated by Procedure lose capacity for reception, perception and reflection. 8. Not only but also: unintended multiplications and extrapolations AA will tend to fragment holistic care and its long-enough healing attachments. Increasingly, ever more numerous and boundaried teams then have to be staffed and trained for. Trainees (who may provide most consultations) are then necessarily rotated more frequently between these many teams. Q: How will doctors learn about the power and subtlety of Caring attachments? Are we already losing arts and crafts in these? How can the emotionally vulnerable connect, trust and heal by submitting to a carousel of professional ‘strangers’, united largely by the managerial designation of a Team? This discontinuity recently and coincidentally amplified by EC Working
Hours legislation. ‘Rationing’ of working-time necessitates even more complex rotas and teams.
Intentions and consequences can be very different. In the early 1930s few realised how long and dense would be the shadow cast by the sinewy and virile youth of Totalitarianism. Giovani Gentile ghost writes for Mussolini, with Olympian righteousness, The Doctrine of Fascism: “Anti-individualistic, the fascist conception of life stresses the importance of the State and accepts the individual only in so far as his interests coincide with those of the State, which stands for the conscience and the universal will of Man as a historic entity. It is opposed to classical liberalism which arose as a reaction to absolutism and exhausted its historical function when the State became the expression of the conscience and the will of the People …” About 75 years later in the National Health Service of our liberal democracy, Dr Steven Ford, a medical practitioner, writes to The Independent newspaper:3
Few have claimed to design this new legacy, but many, already, are clearer about its effects. Whoever redesigns this redesign will have much to draw from.
References and footnotes 1. NHS expenditure shows an accelerated increase in the last two decades, far beyond any inflation. Statistics published in Hansard show this to be nearly 300% in the period 1995-2007 (c. 220% when inflation-adjusted). GDP fractional expenditure shows a similar trend in this period, from c. 6% to 8%. Some of this increase is due to factors inevitable, widespread and desirable, e.g. more people getting relief or cure from more conditions, greater longevity, more sophisticated and effective investigations, interventions and medications. Psychiatric services share most of these. Where the new design of such services is exceptional is in its generation of complexity, with all the more and less obvious additional costs. 2. Lord Ari Darzi 3. Victoria Climbié was a child murdered by her aunt and partner in 2000. Christopher Clunis, known to be disturbed and labelled ‘Paranoid Schizophrenia’, murdered a stranger ‘randomly’ in 1992. Both cases led to castigation of relevant professions (Social and Psychiatric Services respectively). Followed by demand for more management, supervision, documented procedures. 'Never again.' Major historical influences in current overgrowth of ‘defensive practice’. 4. The Independent, Letters, 13/12/08 At the time of writing Tessa has been lost to contact. This followed my rejected referral. The connection seems significant, and I fear the gravity of the consequences. More positively, after many initiatives I have arranged a meeting with my CMHT. _________________
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