Jeremy holmes University of Exeter, UK

1. The Values of Psychotherapy: Attachment and other science perspectives on public health services ‘malaise’ Jeremy holmes University of Exeter, UK

2. Has the snake become venomous?

3. 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?

4. Healthcare in Greece 2007 Greece OECD average Rank • 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%

5. 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.

6. 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

7. 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)

8. Rise in maternal death rates

9. From 2014 to 1944: WOSB

10. 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.

11. ‘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’

12. 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

13. UK: mid-Stafford scandal

14. 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

15. Commodification of health care

16. 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).

17. 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

18. Nye Bevan

19. 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’

20. Is health a commodity?

21. What’s wrong… • Commodification, industrialisation of health • Perverse effects of target-driven management • Need for cultural change • Over-diagnosis, over-treatment

22. 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

23. 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

24. 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’

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

26. The fisherman and his wife

27. 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

29. 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

30. 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

31. 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

34. 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

35. Cymbeline Golden lads and girls all must,
As chimney-sweepers, come to dust -------------------------------------------------------------- But n.b.: chimney sweepers die younger, especially if mentally ill

36. 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

37. Thomasello: cooperation • Through joint attention… • Collaboration and cooperation (sharing, helping informing) is integral to human psychology (c.f. great apes) • Collective intentionality • Adaptive action

40. Boehm’s hunter-gatherer egalitarianism • Egotism (= narcissism) • Nepotism (= paranoid/schizoid) • Altruism (= depressive position)

41. 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

42. Subliminals

43. 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

44. 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…

45. 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)

46. Implications • Culture of cuts, • Blame, • Deprofessionalisation, • Mistrust, • Envy… • Reinforces egotistic/narcissisitic vector, downgrades altruism

47. 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)

48. Haidt’s ‘5 foundations’ • Care/harm • Fairness/cheating • Loyalty/betrayal • Authority/subversion • Sanctity/degradation

49. 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

50. 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