By Dr Robyn Vesey
Dominating headlines and evoking strong feelings, the Junior Doctors’ strikes between January and April this year have been focused on a new contract the government has been setting up since 2013. Although at the time of writing, the British Medical Association (BMA) is discussing and voting on a new agreed proposal1, it is clear that the depth of feeling and the acrimony in the discussions are likely to leave challenges in the on-going working negotiations around medical staffing. Why has an agreement been so difficult to achieve?
A systems psychoanalytic understanding pays attention to the irrational and powerful emotional forces at play – offering unexplored explanations for the seemingly intractable negotiations and suggesting the likely impact on working relationships between government and Junior Doctors.
Nothing evokes as much passion, anxiety or concern as the national health service – the NHS. And there are good reasons for this. Health services are about our fundamental physical survival and embodied existence – the bottom line: it is a life or death issue. In some important ways therefore, health service organisational issues are like no others: precisely because healthcare services’ particular area of work evokes intense emotions and these emotions impact upon every part of its organisational functioning. The systems psychoanalytic approach to organisations has in its history a landmark case study about the workings of a hospital (Menzies 1960), where the ‘primary task’ of the hospital – to treat, heal and comfort the sick and the dying – is understood as central to the way in which the hospital as an organisation works through the emotions to be dealt with. At a rational level we think we (or others) are managing a team, department or task, but in this analysis it is the task that is managing us – organising our thinking and our behaviours in what have been called ‘social defences’. These social defences allow us to manage the unbearable and unacceptable feelings that are evoked in the work, from disgust and despair to admiration and seduction2.
However, there are ways in which social defences organise thinking that can get in the way of the work, and so any negotiations about change, even change for the better, means threats to the psycho-social structures which manage fundamental anxieties.
Social anxieties in public services
Of course the emotional dynamics of healthcare services can also be understood in the context of shared social concerns about healthcare. Our personal anxieties about our own health take on a broad social-wide level of concern, and we experience what are called social anxieties in relation to the public services on which we depend3. Professor Hoggett, a psycho-social scholar, argues that these social anxieties lead to shared social defences that then impact upon organisations from the outside in – and impact particularly on those at the front line of service delivery – as well as on those in government whose task is to organise public services4. He draws attention to the unavoidable conflicts in public service organisation: the contested issues of how a service should be funded and delivered, what expertise and remuneration should be received, and who is deserving of the service, especially when the reality of service limitations are experienced. The more these questions are not addressed at a social level, the more those on the front line experience the tensions and conflicts in their everyday work, Hoggett claims.
So we can begin to understand an additional layer of context to the current disputes and contractual relations. There are a number of significant contextual factors, including a ten-year history of pay re-arrangements leaving Junior Doctors worse off, staff shortages, and concerns from the frontline about inadequate funding and management (for example decisions that regular staff budgets be cut, only to leave hospitals employing agency staff at higher expense)5. However, a focus on the deeper concerns and tasks of the role of Junior Doctors invites us to recognise what it is in our own beliefs about the state of the NHS and the ‘shoulds’ of healthcare resources, our own investments in having free and good quality healthcare services, and our own anxieties about our health, that is alive in and a part of these disputes.
The reality of death
When it comes to healthcare there is an unavoidable reality: people die. Every day is somebody’s last. We would rather not think about this, and our denial serves us well – we need to not think about our dying in order to live, and to work and to love, to engage in the everyday of living. However, working in a hospital and in the national health services in general, it is not possible to avoid this. The reality of death is seen, somewhere in hospitals and services across the country every day. It is always sad, a source of grief for family and friends. It is sometimes tragic, and sometimes terrible. Very often there is nothing that anyone can do and this brings feelings of despair, powerlessness, anger and protest. The recent campaign by a cancer charity on the London Underground shared a child’s words: ‘Why can’t the Doctors cure my cancer?’, and brings starkly to the foreground the intense and mixed, even contradictory feelings around such life and death issues.
A Doctor might feel compassion and pride for the services that can be helpful, and shame and grief for the cure that cannot be offered, that they themselves do not possess.
On the other side, the patient might feel gratitude for the care that is being offered to them in their suffering, and anxiety and rage at their sickness that cannot be healed. And of course the feelings are the same and sometimes even more complicated for the family, friends and carers of a person who is sick and is dying – the awful combination of love and of powerlessness because death cannot be prevented.
Taking up idealised and entrenched positions
When there are such strong feelings, and survival anxieties that are fundamental to our very being, we can see how quickly irrational arguments and entrenched positions can be taken up. Previous systems psychoanalytic understandings of the NHS can help us to understand what is going on in this current situation. Hughes and Pengelly (1997) highlight the inevitable tension between needs and resources and the importance of the ways this tension is managed. They argue that in the past there was an ideal of universal provision, which was itself a denial and avoidance of the realities of needed rationing6. Arguably, such a denial suits us well as we try to manage our shared social anxiety by believing in the NHS as an ideal and unlimited resource, able to meet our needs and calm our real and understandable anxiety about accessing the healthcare we and our loved ones need. However, this is rightly acknowledged as a delusion – a social defence that is self-defeating. Not only because there have always been limited resources, and because the needs that services are expected to meet have been increasing due to developing medical technologies and demographic changes, but also because the task of healthcare services is complicated, contested and in some important way an impossible task in the face of death4. We can see that it is easy for all of us, both patients, staff and citizens to get caught up in the unconscious wish for death to be forever kept at bay and to act as if it is possible for services to do this for us – and then to feel irrationally let down and blaming when they cannot.
In contrast to an idealised public sector, an alternative form of organisation of the NHS emerged in the 1980s, concerned with the management of resources and introducing a market model. And yet for all the narratives about austerity and limited resources that this approach is concerned with, Halton (1995) argues that the market model replaces one delusion with another
– a focus on self-reliance, and a sense of manic triumph over neediness, as if the market will somehow fix everything, make sure everyone will survive unscathed7 – or at least everyone who deserves to. Again, through the need for a social defence to manage social anxieties about death, suffering and unmet needs an unrealistic and idealised position is taken up. In this delusion it seems as if it is possible to work harder to make everything better and so avoid the realities of suffering and death. Hoggett (2010) calls such a delusion a perverse defence, because it is self-defeating: accepting a ‘virtual reality’, for example reporting the meeting – or not meeting – of a particular target, without engaging with the more complicated reality that might lie beneath8. The worst case scenario is that this psychological approach creates an out of touch and unrealistic ‘as-if’ relationship between the government managing the services and the suffering of people receiving healthcare.
A consequence of social defences
One reading of the current dispute between the government and the BMA is that Junior Doctors have become caught in the distortions that social defences against the anxiety of death and dying have created. At an unconscious level they are asked to fill the gap between the rhetoric of improved services and the reality of inevitable suffering.
Caught up in the difficulty of meeting our deepest wishes for care and for safety, alongside the challenges of incurable illnesses and the distributing of finite resources, Junior Doctors are in danger of being seen as the heroes who must strive to defeat death…
– and if they do not, then it is because they are not efficiently meeting the demands of the task in hand, and so be made to be more efficient.
This reading – at an unspoken, unconscious and deeply emotive human level, can offer a new understanding of the positions taken by both the government and the BMA and their inflammatory nature leading up to this seeming resolution. Each side has been making strong claims for their concern for patient safety, the common good, and casting the other side as irresponsibly putting patients at risk. The implicit message behind the government claims that the new contract and seven-day working would prevent deaths evokes the social anxieties of death and inadequate care, directing blame and mistrust at medical professionals. The BMA and Junior Doctors have responded to this by claiming the government’s position is undermining patient safety, re-directing the social anxieties that are shared by the public towards the government, casting them as inadequate overseers of the NHS. It is as if both sides are defending against the limitations of their capacities to offer the idealised service that – in subtly different ways – both the historic post-war view of the NHS and the market-structured NHS offer. Both sides are attempting to reassure the population that services will be able to make all things well, and if they do not they will be changed until they do.
Of course the reality is more challenging, and personal accounts by individual Doctors9 reveal a sense of feeling overwhelmed by the service’s demands and feeling concerned about failing to meet patients’ needs – a tragic position that chimes with the complexity of the systems and the emotions of healthcare services outlined above.
The question is whether this reality can be engaged with by both sides in order to find a way through the powerful defences and entrenched positions. The revised new contract has already been accepted and endorsed by BMA negotiators, and will be voted on by Junior Doctors between 17th June and 1st July. Whichever way the vote goes, there is an on-going set of complex factors in working relations of medical staffing, set within wider NHS challenges and change10. Whether or not the dispute leaves a ‘toxic legacy’, a systems psychoanalytic view suggests that bringing Doctors and government together to reach agreement requires a shared facing of the social anxieties and social defences, with all of the primitive emotional forces behind them. Most crucially it requires undertaking a shared project to face the reality of limited resources and impossible tasks that healthcare services inevitably consist of. And this requires something of all us. Perhaps not least that we face a little more directly the reality of our own deaths, the tough decisions about services that are, and are not provided, and that we find ways for the anxiety this evokes to be recognised and held.
- Menzies, I. (1960) A case-study in the functioning of social systems as a defence against anxiety. Human Relations Vol.13 N0.2, p95-121
- Obholzer, A. (1994) Managing social anxieties in public sector organisations. In A. Obholzer and V. Roberts, (Eds) The Unconscious at Work: Individual and Organizational Stress in the Human Services. London: Routledge
- Hoggett, P. (2006) Conflict, ambivalence, and the contested purpose of public organizations. Human Relations Volume 59(2): 175–194
- Hughes, L. & Pengelly, P. (1997) Staff supervision in a turbulent environment: Managing process and task in front-line services. London: Jessica Kingsley
- Halton, W. (1995) Institutional stress on providers in Health and Education. Psychodynamic Counselling 1, 2, 187-198
- Hoggett, P. (2010) Government and the perverse social defence. British Journal of Psychotherapy Volume 26, Issue 2, pages 202–212