Welch, L., 2000. Private Misery, Public Rage and Poor Soundproofing - Seeking Happiness in the NHS. Reformulation, ACAT News Summer, p.x.
I want to start with a story. I work in a psychology and psychotherapy service based in a psychiatric day hospital. One day a week I work in a room next to one used by psychiatrists. The wall separating us gives us physical and visual privacy but its thickness does not extend to the auditory domain. This has lead to two very uncomfortable experiences. Working with clients who have been sexually abused, for example, who have made public to me experiences that have been private for far too long, on occasion I have with horror heard the clearly audible sound of someone else's voice next door. Do I interrupt the flow of revelation from the client, perhaps drawing their attention to something which they seem apparently unaware of, or do I let things proceed, keeping private my experience of this violation of the intimacy between us?
The second experience is the report of a colleague who, sitting in the same room, heard the psychiatrist next-door sectioning a neighbour of hers.
These experiences come up in conversation with colleagues or supervisees but it is very hard to find a forum where they are taken seriously despite the professions’ and the NHS’s’ publicly stated affirmation of the need for confidentiality. The trigger that launched me into preparing this talk arose out of my experience of attempting to have this problem rectified.
I wrote to the relevant manager who sympathetically responded by sending an assistant along to investigate. The assistant agreed there was a problem and someone from the works department actually came along and estimated the cost of adequate soundproofing. How they arrived at the cost of £2000 for a job, which to a layman looked like at the most £500, is another story.
Around this time one of the occasional meetings took place between my service, day hospital staff and area managers in order to discuss issues of common concern with the building. The focus of this one was about how to squeeze two more staff members into a building where the competition over rooms is intense. Related to this was how to deal with the already very crammed car park used by staff. In this context I reminded the managers of the problem of soundproofing. The nurses from the Day Hospital quite rightly pointed out that this was a major issue for them as well. The managers weighed up the £4000 required to extend the car park against the larger cost of tackling the soundproofing problem in the whole building and, informing us that their budget was overstretched already, opted for the car park. My fury at what I felt was the dismissal of a problem that everyone in the room agreed should not be tolerated was compounded when, by chance, I met with a colleague from London an hour later who reported that the newly built NHS premises she was about to be moved into faced exactly the same soundproofing problem.
Reminded that my rather private experience was indeed shared by many, I found myself shifting gear into a rage about the society we live in and the political myths that ensure that the passive acceptance of the unacceptable is the norm.
At this point I should give the only thanks I am likely to give Blair and New Labour. While the Tories grip on power seemed to extend ad nauseam I found my more usual political anger being worn down into despair and quiescence. Alongside this I was disillusioned by the dictatorial control Blair increasingly exerted over my local Labour Party, first in removing our democratically selected prospective parliamentary candidate in 1995, then in suspending the constituency Party in 1997 without any transparent process of hearing. Despite all this I thank Blair for the sight of Portillo’s shock and dismay on television on the Election night. Although from my perspective New Labour has followed the Tories policies on for example anti-trade union laws I prefer their shade of pink to the unadulterated blue that preceded them.
While wishing to be realistic about the possibility and pace of change I began to realize that I faced a dilemma as I saw that my hunger for social change could not be satisfied by the not unimportant crumbs of New Labour. Either I retreated into a private misery where I attacked as adolescent dreams my desire for a world where the collective wealth of society was subordinate to human need rather than towering above humanity, or I more openly placed myself on the side of those who publicly express their rage. Freud’s dictum that the therapeutic task is to transform "hysterical misery into common unhappiness1" came into my mind and I found myself rather unfairly taking against it, feeling that the resources of the world allow the possibility of much more than ‘common unhappiness’.
Three sets of statistics about the distribution of material wealth in Britain and the world provide the context for the assertion that the problems we face in the NHS are not due to a ‘lack of resources’ but to the highly skewed distribution of the resources in favour of the extremely rich
Firstly there is an immense disparity in wealth
"225 individual billionaires in the world are estimated to have assets equal to the combined annual incomes of the poorest 47% of the world’s people, that is 2.5 billion people. The three richest of them have assets that exceed the yearly income of the 48 least developed countries."(pg. 46)
Secondly, this disparity in wealth is increasing
In the poorest regions of the globe 89 countries have lower per capita incomes now than a decade ago. 19 of them are poorer today than they were in 1960. The richest fifth of the world’s population has 78 times the income of the poorest fifth. In 1960 they had 30 times the income
In America "Between 1978 and 1998 the earnings of the country’s highest paid corporate executive are reported to have risen for m to 6m an 11,400% increase2"
In the UK the Dept of Social Security figures
"show that between 1979 and 1995-7, average incomes after housing costs increased in real terms by 44%, but the top tenth of households enjoyed a rise of 70%, while the bottom tenth suffered a cut of 9%" (p 46)
Thirdly, relatively small measures would make a huge difference to the lives of the mass of people in the world.
The 1998 United Nations Development Programme Report3 states that:
"It is estimated that the additional cost of achieving and maintaining universal access to basic education for all, basic health care for all, reproductive health care for all women, adequate food for all and safe water and sanitation for all is roughly billion a year. This is less than 4% of the combined wealth of the 225 richest people in the world." (p 30, in, p47)
In Britain, an increase in the contributions made by employers to National Insurance to the level that the French pay would produce £70 billion. This is the amount by which total social expenditure in the UK falls behind the average in the major EU countries4
The resources are clearly there when the government decides they are needed5. If we return to the NHS funding for example, a study in 1994 argued that the "newly imposed market processes have doubled the administrative running costs of the NHS. This represents an additional administrative expenditure of at least £1.7 billion a year at current prices6"
The so-called 'fact' of limited resources narrows our consciousnesses and hides the highly charged political and economic interests that lie behind the ‘fact’. I believe that these statistics reveal that the most problematic form of attachment in the world today is the attachment of the very few to their private wealth. These are the real sociopaths who demonstrate a complete incapacity to empathise with the needs of the world’s population.
An example of the strength of this pathological grip on private wealth is the response of the pharmaceutical company, Pfizer, in 1998 to the Thailand Government’s attempt to resolve their massive HIV problem. They issued a compulsory licence to a non-profit making company to produce a drug that helps in the treatment of HIV related illness. This move would have reduced the cost of the production of the drug to a mere 4% of Pfizer’s price. Pfizer lobbied the US Administration who in turn threatened Thailand with trade sanctions and the plan was squashed7.
These problems are of course structural problems and not psychological problems and I am also aware that no amount of therapy will liberate the very wealthy from their compulsion to increase their possession of an ever-larger number of digits after the dollar sign. My purpose here today however is not to stay at the very general level and deliver a diatribe against capitalism but rather to consider what meaning this can have for us as psychotherapists. While my own political inclinations lead me along the path of desiring revolutionary democratic and socialist change in the global system of property relations I am aware that this current is not the one in greatest popular favour at present.
Instead I would like to focus on three areas in our work as psychological therapists.
The first is to do with the broad interests we can choose to identify with as therapists. The Salvadorean psychologist, Martin-Baro, murdered by a death squad in 1989 has stated this clearly in the context of a country devastated by civil war sustained by the USA:
"If it is not the calling of the psychologist to intervene in the socio-economic mechanisms that cement the structures of injustice, it is within the psychologist’s purview to intervene in the subjective processes that sustain those structures of injustice and make them viable. If the psychologist is not called upon to make peace for the forces and social interests at war, he or she is competent to help find paths for replacing violent habits with more rational ones; and, if the definition of a project for national autonomy does not lie within his or her competence, the psychologist can contribute to the formation of a personal and collective identity that responds to people’s most real demands8."
His phrase "it is within the psychologist’s purview to intervene in the subjective processes that sustain those structures of injustice" takes me to my second point. How we understand the complex relationship between the political and the psychological is central to how we intervene with clients and understand their problems. Case examples might illustrate the point here. I have recently had the opportunity to work with a number of clients who are in administrative and clerical positions in the NHS who have all spoken of the great stress they feel under to work hard and to please their employers, though they have varied in their capacity to name the problems clearly.
Some have turned their anger inwards into a diffuse angry depression; others have worked themselves into exhaustion. It is easy to formulate their problems in terms of the historical development of their individual trying to please traps and the constraint they experience in expressing their feelings.
Their individual reciprocal roles can be seen as variants of controlling, demanding and dominant, to striving to please, controlled and dominated. However, in order to help them in their struggles with these roles I have felt it important to be aware of the enormous uncertainty and pressure that is the common experience of working for the NHS. I have found myself advocating joining a trade union to one, while with another I acknowledged my own feelings of anger at the insensitive way she was being treated by a manager, aiming to facilitate the development of her rather weak sense of injustice. It has felt important to talk realistically about the risks of asserting basic needs to an unsympathetic management without adequate support or clarity about goals.
The third area I would like to address very briefly is the concept of reciprocal roles itself.
While there is a danger in psychologising the political by over extending the understandings gained in the interpersonal terrain, I feel the concept of reciprocal roles can provide us with a connecting tool, giving us an insight into one of the threads which weave together our experience as apparently isolated individuals with an overarching sense of participation in collective experience. Marx, in one of his critique of Feuerbach powerfully argues, "the human essence is no abstraction inherent in each single individual. In its reality it is the ensemble of the social relations9." The concept of reciprocal roles helps fill out some of the micro level content of what is meant by social relations, giving us a foothold into understanding the personal level of experience of social relationships.
Reciprocal roles can be seen as having a dimension where millions of people respond to the broadest problems of their psychological existence in a relatively common way. This most general and overarching level can be seen to be a complex and rich web of patterns of relating where for example the dominance of the current inhuman and brutal social order is perceived to be the only possible order. In response to this we can adopt roles of despairing passivity, of angry and rejecting cynicism about the possibility of collective change, of striving to carve out a comfortable personal space, or of a rather self-righteous cut off anger about the state of the world.
However, by the very fact of focussing on human relatedness rather than object relatedness we are carving out an arena of existence that can offer hope for change. Although there is no necessary progression into political activity through doing psychotherapy we are working in an area that is one of the many countervailing forces to the dominant ethos of valuing profit above people. However, if we are to protect and extend our work within the NHS I believe this requires of us that we do not sink into a private misery about the apparent impossibility of changing the circumstances in which we find ourselves. To finish the story where I began, my union reps have told me that my concern about my working conditions is a Health and Safety issue and I am now waiting to see what results the next inspection brings, hopeful that soundproofing can occur before socialism. Perhaps I wasn’t right to take against Freud’s dictum. He went on to say, "With a mental life that has been restored to health you will be better armed against that unhappiness". Perhaps by discovering the courage to making public our apparently private miseries we can begin collectively to transform the conditions giving rise to our common unhappiness.
1 Breuer & Freud (1895) p305 Studies in Hysteria In J Strachey (Ed & Trans) The standard Edition of the Complete Psychological Works of Sigmund Freud (Vol 2) London Hogarth Press, quoted in Wolfenstein, Eugene Victor, p 39 Psychoanalytic-Marxism. Groundwork 1993 Guilford Press, NY
2 Elliott, Larry, The Guardian 12/2/00
3 United Nations Development Programme (UNDP) Human Development Report 1998 in Barratt Brown, Michael Young Persons Guide to the Global Crisis 1999 Nottingham Spokesman
4 Action for Solidarity Vol 2 No 18 27 January 1999
6 Appleby et al ‘Monitoring Managed Competition’, in Evaluating the NHS Reforms, edited by Ray Robinson and Julian LeGrand, Newbury 1994, cited in Griffith, B Competition and Containment in Health Care New Left Review No 236 July/August 1999
7 Action for Solidarity Vol 2 No 15 Nov99 pg 11
8 Pg 46 Martin-Baro, Ignacio, Writings for a Liberation Psychology ed Aron, Adrianne & Corne, Shawn Harvard University Press Cambridge Massachusetts 1994
9 p285 in Marx & Engels Basic writing on politics and philosophy ed Feuer, LS Collins The Fontana Library 1969
Action for Solidarity Vol 2 No 18 27 January 1999
It is true that income tax on high incomes in the UK is lower than in Germany, France, Italy etc. So is corporation tax (ie tax on profits) – but not by very much. On the other hand, NI falls behind its equivalent in other EU countries by a huge amount.
The Financial Times (19/1/00) reports the figure for French NI as £164 billion. The UK equivalent is less than £100 billion. This is also approximately the amount by which total social expenditure in the UK falls behind the average in the major EU countries (around 8to 10% of GDP) … In the UK it is around 9% of wages, in Germany over 20%, in France over 40% and in Italy 50%. An increase in the contributions made by employers to National Insurance to the level that the French pay would produce £70 billion, the amount by which total social expenditure in the UK falls behind the average in the EU.
Action for Solidarity Vol 2 No 1 5 March 99 pg 8 .
Programme for reform: If all private hospitals and health facilities were nationalised the NHS’s hospital beds would increase by one third and its staff by one third. Further proposals include: nationalising the big banks, pension funds and insurance companies; authorising the banking and finance unions to impose workers control; putting £2 billion extra into the NHS in this year; putting £10 billion into a building programme; taking over the 900,000 houses and flats lying empty and offices standing idle; building new houses and renovating schools and hospital buildings; building new nurseries for the under fives; £2 billion for meet the running costs for an extra 400,000 places for under fives; £4 billion to introduce decent staffing and class sizes in schools and further education; £4 billion on higher education to restore student grants; upgrade the minimum wage to half male median earnings (£5 an hour); legal maximum normal working time of 35 hours per week; legislation for trade union rights; new jobs in the public services and the reduced working week will cut at least £20 billion from the social security budget to be put straight back into increasing pensions and benefits. The total increase in government spending will be around £28 billion; nationalise the land and the utilities; introduce a maximum wage law of £35,000; make MP wages linked to the average skilled workers wage; this gives control of the £50 billion paid to the rich in rent, dividends and interest; £30 billion paid in vast salaries; and £70 billion of the economy’s total £106 billion per year in profits. Halve military spending by scrapping nuclear weapons; change from a standing army to citizens defence and convert arms industries to peaceful purposes. – saves £15 billion per year in the long term, but conversion costs in the short term. This would produce a total revenue of £150 billion extra in the short term, £165 in the long term. Subtract £20 billion lost from income tax on high incomes; £32 billion of public spending and £98 remains; slash VAT
Action for Solidarity Vol 2 No 15 Nov99 pg 11
AIDS. " 90% of the world’s HIV+ population – (20.8 million people in sub-Saharan Africa, 6 million in south and south-east Asia) have no access to combination therapy because they – or their governments – can’t afford to pay for the drugs." In Uganda, Kenya, the Republic of Congo, Zambia and Zimbabwe, one in 13 adults between the ages of 15 and 49 is now HIV positive. There are 8 million orphans as a direct result of the AIDS epidemic. "The pharmaceutical company Pfizer …in 1998 … had a net income of .35 billion. Its income has risen by an average of 38% a year over the past five years. Pfizer holds the patent (that is, the exclusive right to manufacture, or licence the manufacture of) for flucanazole, a drug used to treat cryptococcal meningitis, a common and deadly infection which is often HIV-related. In 1998 the government of Thailand decided that the spread of HIV was at such a level that it would issue a ‘compulsory licence’ to a non-profit making organisation, allowing it to produce flucanazole at just 4% of Pfizer’s price. Compulsory licences are recognised under international law as a means for countries to deal with national emergencies.
Pfizer, seeing a big threat to profits … sent it lobbyists along to complain to President Clinton about this… The US administration threatened Thailand with trade sanctions to protect the drug companies’ profits. The Thai government backed down, and amended its own statutes to prevent itself repeating the error
Action for Solidarity Vol. 2 No I2. 21 September 1999
In the last decade over 20,000 companies have been convicted of breaking Health and Safety laws.
There were 46,000 major industrial injuries reported to the H&SE in the last two years alone. Only 12% of these injuries were investigated by the HSE. Of this 12% 10% were prosecuted.
The HSE claim that 70% of all accidents in the workplace are the result of management negligence.
Britain has the most restrictive list of occupational illnesses qualifying for compensation under the Industrial Injuries Scheme in the European Union.
Only a very small percentage of workplace deaths result in prosecution (not imprisonment) - 16%
IN I997/98, there were 268 workplace deaths. The figure for work-related deaths is thousands of times higher with over 3,000 deaths a year from asbestos- related diseases alone. Capitalism kills!
There were 46,000 major injuries reported to the Health and Safety Executive (HSE) in I997 and I998.
Over the last 30 years only 5 company directors have faced manslaughter charges. Of the company bosses involved in the Kings Cross fire, the Piper Alpha oil platform, the Clapham rail crash and the Zeebrugge ferry disaster none were successfully prosecuted for manslaughter despite being found to be at fault
Action for Solidarity Vol 2 no 13 15 Oct 1999 1986-96
UK rail-passenger deaths was three times that for Italy, Belgium Sweden and Spain; 1998 Railtrack made £398 m profit, rolling stock companies made £387 m Train operators £124, freight operators £63 Total ex-British Rail profits for 1998 were £1072
Every day at least one person in Britain is killed doing their job
13 million days are lost each year due to work-related ill health
People in a trade union are 50% less likely to have an accident than those not in a trade union
Working over 48 hours a week doubles your risk of heart disease
Shift workers die younger and are 40%more likely to get cardiovascular disease than people in comparable day jobs.
Tony Blair's speech the 1999 Trades union Congress: ''I make no apology for saying that New Labour does strongly support business.’’ There would be no further lessening of the Tories anti-trade union laws, he said, no legalisation of secondary action. ''Business and employees... are not two nations divided''... They have ''common interests''...We are all ''one nation’’. A newly published Joseph Rowntree and Cambridge University survey of workers found that only 26% agreed that ''in this organisation management and employees are on the same side’’.
Action for Solidarity Vol 2 No 10 5 August 1999 pgs 8-9
130 million children will be born this year. 3 in 10 will be born into extreme poverty ie basic need for food and shelter is not met on a regular basis. Less than 1 in 10 can expect to have access to computer technology. Half of the world’s poor are children
A third of children in Britain (4.3 million) live in households with below half average income in 1995-6
% of population living in poverty in industrialised nations (UN Human Development Report 1998): US is top of list with 16.5%, Ireland 2nd with 15.2%, Britain third with 15%.
Richest one fifth of British pop have 10 times the wealth of the poorest
Since 1979 the incomes of the top 1% of US earners have risen by 80%,
Richest one fifth of humanity has 82 times the income of the poorest fifth
Every year nearly 12 million children under the age of five die from a handful of easily preventable childhood diseases
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