The Values of Psychotherapy: Attachment and other science perspectives on public health

services ‘malaise’

Jeremy holmesUniversity of Exeter, UK

Has the snake become venomous?

Plan of talk

• Psychoanalytic approaches to social systems• Commodification, inequality and health• Fostering altruism: the gift relationship• What money can’t buy• Importance of primary care• Mentalising, secure and insecure attachments

in healthcare• What is to be done?

Healthcare in Greece 2007

Greece OECD averageRank• Health expenditure as % of GDP 9.6% 9.5% 15th

• Change in health expenditure (2000–2007) 6.9%4.0%

• Life expectancy (years)80.3 79.5

• Daily smokers among adults 39.7% 22.3% 1st

• Obesity rate 18.1% 15.1%

Lancet 2014

• Public spending for health now less than any of the other pre-2004 European Union members

• Population 11 million people -- 800,000 no

access to unemployment benefits, entitling them to free health care.

Lancet papers 2014

Kentikelenis et al: 120% increase in the use of mental health

services; funding cuts 20% in 2010-2011; 55% in 2011-2012

Vlachadis et al 2014: 25% increase in deaths in older people

Lancet continued

Cost of health care deliberately shifted onto patients leading to reductions in health-care access

User fees increased from €3 to €5 for outpatient visits (exemptions for vulnerable groups), co-payments increased by 10 percent or more

New fees for prescriptions (€1 per prescription)

Rise in maternal death rates

From 2014 to 1944: WOSB

Isabel’s Menzies-Lyth

• ‘Presenting symptom’ of an institution reflects deeper underlying conflicts.

• Understood in terms of unconscious needs, fears, and defenses

• ‘What is not being said’: cabals and gossip = institutional analogues of repression and free association.

‘Social systems as a defense against anxiety’

• ‘Exporting’ anxiety in an institution to the weakest members: trainee nurses

• Struggling with fundamental issues of illness, death, bodily function, sex

• C.f. current socio-political system: ‘blaming the victim’

Social systems defenses

• Evasion of these unconsciously driven anxieties:

• Task fragmentation, short-term placements, authoritarianism

• Basic assumption rather than work-group mentality:

• fight/flight, dependency, pairing

UK: mid-Stafford scandal

Mid-Stafford

• Excess deaths; long waits; uncaring staff• Staff: culture of fear• Management - failure to meet targets, cuts in

funding • Department of Health: escalating costs

Commodification of health care

Underlying problems

• Social isolation of elderly leads to excessive hospital admissions

• Commodification of life quantity, versus quality

• Insecure attachment (Government, management): ‘exporting’ anxiety to most vulnerable (patients, nurses).

Menzies-Lyth theraputic principles• Bionic ‘not-knowing’ stance.• Reflective space: institutional hierarchies

temporarily set aside; members of a team speak equally and openly.

• Change feels catastrophic unless contained by institutional commitment/leadership.

• Cultural change plus structural change needed

Nye Bevan

NHS as an institution

• Innovative and enduring because both practical and ideological

• Egalitarian: rich and poor: equal access to good care

• ‘Free at the point of access’ – removes money from the health equation…

• …but n.b. compromise: Bevan’s ‘stuff their (i.e. top doctors) mouths with gold’

Is health a commodity?

What’s wrong…

• Commodification, industrialisation of health • Perverse effects of target-driven management • Need for cultural change• Over-diagnosis, over-treatment

What’s wrong…

• Treating indices not illnesses or patients (e.g. dementia & depression check-lists, cholesterol levels)

• Role of big pharma• Rising costs• Need to integrate medicine and social care

Staff…

• Cynicism and waiting for retirement• Disempowerment• Breakdown of trust • Top-down control• Stifling creativity• Tyranny of the computer and data-gathering• Silo-ism• Blame culture

Patients…

• Fragmentation• No whole-person medicine• Here-and-now rather than family-oriented,

developmental perspective• Reading the computer, not the face• ‘Customer/consumer’ ethos• Lack of personal relationship with doctor• Illusion of ‘choice’

But…

• Medical arrogance & maverickism• Non evidence-based practice• Under-investment• Mediocre outcomes• Neglect of prevention• Patient disempowerment

The fisherman and his wife

Be careful what you wish for…

• Fisherman’s wife• Removing money from the health equation

opens the doors to unfettered desire…• Hence, to Bevan’s surprise, health costs went

up not down once NHS established

Psychoanalytic caveats….

• With ‘free at the point of access’ is contact barrier phantasy/reality dissolved?

• Healthcare as ‘transformational object’ – an intermediate zone between phantasy and reality

• (Out)rage at the vicissitudes of fate – man-made and inherent in the human condition

Social science contribution

• Wilkinson & Pickett: health implications of inequality

• Marris: ‘exporting’ of insecurity• Boehm: egotism & nepotism v altruism• Haidt: oxytocin and the ‘hive’ switch• Sandel: what money can’t buy• Mikulincer & Shaver: social role of attachment

W & P: ‘The Spirit Level’

• Above a certain level not GDP but inequality best predictor of indices of social disruption – in 21 most advanced industrial countries, & between states in the US

• Equality can be achieved via taxation (Scandinavia) or modest wages for managers, minimum wage for employees (Japan)

• ?Mechanism: lack of identification, envy

Publically funded healthcare…

• Expected to redress inequality…• But society highly unequal…• Leading to rationing…• Leading to growth of private medicine…• …therefore healthcare cannot be considered

in isolation

Cymbeline

Golden lads and girls all must,As chimney-sweepers, come to dust

--------------------------------------------------------------But n.b.: chimney sweepers die younger,

especially if mentally ill

Peter Marris: link between insecurity and inequality

• Politics of uncertainty• The powerful buffer their security by

exporting to weakest and most vulnerable• In health: privatised medical system… • …means that insecurity no longer shared

through mutual insurance

Thomasello: cooperation

• Through joint attention…• Collaboration and cooperation (sharing,

helping informing) is integral to human psychology (c.f. great apes)

• Collective intentionality • Adaptive action

Boehm’s hunter-gatherer egalitarianism

• Egotism (= narcissism)• Nepotism (= paranoid/schizoid)• Altruism (= depressive position)

Boehm continued

• Role of gossip, blushing & conscience as antidotes to egotism, nepotism and free-loading

• Democracy an alliance of the many weak against the few strong

• Altruism is ‘weak’ – ‘golden rule’ needs boosting by containing institutions, familial, religious or political

Subliminals

Mikulincer and Shaver

• Role of subliminal messages from the environment shapes attachment dispositions

• With subliminal secure attachment messages v neutral, insecure subjects’ narratives indistinguishable from secure subjects

• Therefore the contextual messages, including in healthcare vitally important

Vassily Grossman: The Old Teacher

‘The Nazis were a great falsehood, life’s greatest falsehood. Wherever they passed, up from the depths rose cowardice, treachery, murderousness, and violence against the weak. The Nazis drew everything to the surface, just as a black spell calls up the spirits of evil…

Grossman continued

Fawning speeches of disavowal were taking shape in the hearts of the poor in spirit. Thoughts of revenge…were being conceived. Hearts were being infected by callousness, pride and indifference. Murk rose up from the beds of lakes and rivers; toads swam up to the surface; thistles sprang up where wheat had been planted.’ (The Road 2010)

Implications

• Culture of cuts, • Blame, • Deprofessionalisation, • Mistrust,• Envy…• Reinforces egotistic/narcissisitic vector,

downgrades altruism

Haidt: institutions and intuitions

• Political and religious beliefs rationalise intuitions…

• …no matter whether ‘intuitions’ (?affective dispositions’) come from genes (Haidt), class (Marx) or unconscious (Freud)

Haidt’s ‘5 foundations’

• Care/harm • Fairness/cheating • Loyalty/betrayal • Authority/subversion • Sanctity/degradation

Haidt continued

• Left: care/fair; Right all 5• Devil has more rather than better tunes:

egotism, nepotism, punishment and gossip just as powerful and valid as sharing & altruism

• ‘Combined parent model’ needed: desire + realism, Yin/Yang

McGilchrist: ‘Master & his Emissary’

• L brain: detached, analytic, manipulative, ‘re-presentational’

• R brain: social, wholistic, connected, present, contextual

• Ideally R-L-R• But runaway L brain – something vitally

important in danger of being lost – intuition, individualism, relationship, context

Lawson’s jibe

• NHS ‘closest thing the English have to a religion’• Intended as a debunking of a sacred cow, but…• …although etymology disputed…probably• …Religare, to bind, or connect, as in rely• So NHS binds an unequal, disparate, class-ridden

society together• E.g. Titmus – blood transfusion, the ‘gift

relationship’

Richard Titmus

Ernest Rutherford

We've got no money, so we've got to think.

Sandell – the perverse impact of financial incentives

What money can’t buy…

Sandell

• The Haifa nursery story• ‘Skyboxification’• Money is an exchange mechanism – but some

things are ‘inexchangable’ – friendship, love

Sandell implications

• Paying GPs to measure BP, give smoking advice, administer depression surveys etc devalues the unmeasurable -- long-term knowledge of patient and his family etc.

• Graveyard of bonus culture: money not main motivator

• But – n.b. Priebe study: medication compliance in schizophrenia

Parashutes evidence-based?

Limitations of evidence based medicine

• Good doctors use individual clinical expertise and best available external evidence; neither alone enough.

• Without clinical expertise, practice risks becoming tyrannised by evidence

• Excellent external evidence may be inapplicable to, or inappropriate for, an individual patient.

Barbara Starfield 1932-2011

Barbara Starfield: Increasing numbers of GPs:

• Lowers all cause mortality• Increases life expectancy and better self-

reported health• Lowers rates of hospital admission• Lowers infant mortality• Reduces health inequalities• Reduces costs

Starfeild

• Good relationship with a freely chosen primary-care doctor, preferably over several years…

• …associated with better, more appropriate care, better health, and much lower health costs.

Starfeild continued

• US health system takes pride in its specialty care.

• Half doctors in industrialised countries work in the primary sector, in the USA only a third.

• Main cause of the US's poor showing in international league tables of health

• Privatised Secondary care inescapably money-driven

Relevance of Attachment Theory to the debate

• We need a theory of doctor-patient relationship• AT explains interpersonal dynamics of threat,

distress and illness• NHS institutions (hospitals, health centres, clinics)

& health professionals as Secure Base for patients and families when threatened by illness…

• But threatened care-givers = insecure attachments

Interpersonal sensitivity

• Sensitivity necessary but insufficient.• Sensitivity has to be focused, appropriate,

person-centered, this entails…• Mentalising

Burns’ Ode to a Louse

Oh wad some power the giftie gie us To see oursel's as others see us! It wad frae monie a blunder free us, And foolish notion

Reflexive Function/Mentalising:

• ‘To see ourselves from the outside and others from the inside’

• Arousal: Threat and anxiety drives out mentalising

• ‘Mind-mindedness’ (Meins)

Strathearn et al’s babies

Strathearn et al (2009)

• fMRI study; mothers divided into secure and insecure on AAI; shown images of their infants’ smiling or crying faces

• Secure mothers’ reward-response centres activated equally with crying or smiling faces;

• Insecure respond to smiling, but insula and other disgust centres activated by crying; + lower oxytocin levels.

Conditions fostering mentalising: triangulation

• Clinician and client together ‘triangulate’ the the client’s feelings

• Triangulation = pointing, naming, storying, makes/creates meaning

• creates ‘illness’ out of dis-ease

Insecure attachments

• Avoidance – clinician appears to resent intrusion -- affectless consultation

• Hyperactivation – clinician appears distracted and hard to engage – exaggerated affect

• Disorganisation – clinician a) paralysed and frightened, or b) patient-blaming – bizarre chaotic consultation; role reversal; perversity and iatrogenesis

Secure attachment

• Enhanced by subliminal social messages• Less xenophobic• More able to to take risks and trust that things

will turn out alright• Learn from their mistakes via mentalising• Are more self- and other-forgiving• Tolerate negativity

A safe space…for love and fear and hate

In an unsupportive environment…

• Unsupported carers will: • distance themselves from clients/patients, • see them as importuning and demanding,• need to keep them at a distance and • confine themselves to technical rather than

emotional engagement

Donald Winnicott

Winnicott: how to kill creativity

• … the environment that makes [for] good-enough active adaptation enables personal growth to take place…

• The self-processes then may continue active, in an unbroken line of living growth.

• If the environment behaves not well enough, then the individual is engaged in reactions to impingement, and the self-processes are interrupted…

• … the core of the self begins to get protected; • there is a hold-up, the self cannot make new progress

unless the environment failure situation is corrected.

Importance of institutions

• Importance of containing, holding environment• Vital importance of reflective space• Both structural and cultural change needed• Institutions both shape and are shaped by their

members (see Winnicott)• Flexibility and appropriate responsiveness• Discussion not evasion• Long-term perspective

What is to be done?

What’s to be done? Role of mega-data

From Luke 3: 10 to Lenin!

• The people ask John the Baptist: • “What are we to do?” • And John answered, “If you have two coats,

give one to the person who has none; and if you have food, do the same.”

--------------------------------------------------Egalitarianism,yes, but how far does that get us,

and does it inevitably mean leveling down…?

What’s to be done?????

• Reflective space• Champion General Practice (Starfeild)• Insist on the primacy of care-giver/care-seeker

relationship• Create stable safe institutions• ‘Render unto Caesar…’

????? (continued)

• Third force: voluntary sector: resist privatisation and bureaucracy

• Creativity, experiment, innovation• Ecological (v commodification) perspective:

environment, institutions, heath, relationships• Foster altruism: ‘intelligent kindness’ =

combined parent (Realism + love)

Public healthcare

• A fundamental part of social capital, • Contributes to a good society, • Embodies and sustains connectedness,

equality and generosity

But…dangers of liberal motherhood and apple pie

Thanks for listening…

• If you want slides:

• j.a.holmes@btinternet.com