If workers in the NHS (the area I work in) were able to get more insight into how we all respond to “authority” they would be better able to rely on their own skills and knowledge and be more assertive about resisting the current reforms.
My argument (which could be extended to other workers) is that in order to do this it is vital we extend Marx’s micro analysis of the relationship between the worker and the capitalist in the light of advances in psychological theories and therapies.
The nature of politics requires developing a forcefulness in response to the power of the capitalist system. However real problem on the left is that this forcefulness is not just directed at capitalists but occurs within and between left organisations. The concept of reciprocal roles (developed by Dr A Ryle) provides a means of deepening our understanding of the power of interpersonal conflicts.
From birth we are highly attuned to the other (Kugiumutsakis, Trevarthen) and a wide range of unconscious patterns of relating are; for example, one person can be domineering and controlling while the other is compliant and submissive or sometimes rebellious. It is vital as Marxists that we become alert to these patterns as we can easily slip into them within and between left organisations, undermining our capacity to develop the dialogue and collaboration fundamental to the solidarity vital to sustained revolutionary activity. I want to look at these issues in the context of building solidarity and connectedness amongst those who oppose the privatisation of the NHS.
The commercialisation and privatisation of the National Health Service at the global political level or in local workplace settings triggers feelings of despair and hopelessness, undermining the vital task of building ways of defending a hugely important service.
Whilst a political-economic explanation of the changes is essential to grasp both the profit motivated drivers behind the changes and the social values underpinning opposition, the concept of reciprocal roles offers a valuable additional component for understanding how authoritarian directives lead to a largely compliant response.
The difficulty with exploring reciprocal roles in the NHS is that it means connecting the diverse “domains” which are fundamental to an integrated understanding — at the macro level, the Political-Economic and at the micro level, the Social-Psychological. Each domain on its own provides only a partial understanding. Awareness of the interconnections is vital in considering what actions may be effective in opposing the undemocratic dismantling of the NHS. But each domain draws on a vast range of complex knowledge and it is very easy to interpret another domain within the language of the one we are more familiar with.
From a political perspective, individuals can be portrayed as carriers of social structures and a psychological position can be dismissed as self indulgent, a diversion from the real issues. While from a psychological perspective the social is often seen as the individual writ large and political issues are considered an evasion of real emotional issues.
It is vital to recognise the interrelationship as well as distinction between the different domains: the concept of reciprocal roles is highly valuable in the social-psychological domain and may well provide a fruitful tool in the political-economic but it cannot replace for example, the vital statistical information that is so necessary to grasping how money is exchanged in the financial arena. Lucien Sève expresses the connectedness between the domains: “many political problems consist at least in part of a psychological problem which arises for millions” (Sève, 1978).
The 2012 Health and Social Care Act opened the floodgates for the wholescale privatisation of the NHS, a process started by the creation of the internal market by Thatcher in 1989 and built on by the start of Foundation Trusts by Blair in 2004. The Secretary of State no longer has a duty to provide a national health service, undermining a principle fundamental to the birth of the NHS in 1948.
Neither the Tories nor the Lib-Dems argued for these changes in their 2010 general election campaigns and their initial coalition agreement made no mention. Such a huge change without a public mandate, undermines the notion of democracy, and makes explicit the dominance of the values of those who own and control wealth in society, above those of the mass of the voting population.
The scale of change can easily be experienced as overwhelming, eliciting reciprocal role responses of impotent fury (“it’s outrageous”) followed by despair (“there is nothing I can do about it”) or indifference (“we just have to get on with it”). Building effective opposition is not an easy process but I believe it can be strengthened and enhanced if we can deepen our understanding of where our responses come from.
The macro level of the political and economic is built on dominance at the micro level of relationships amongst the population at large and, in this topic, amongst NHS staff.
It is perhaps useful to give a brief account of how a “cellular” level of relationships operate in a highly simplified form which can then be connected to the political-economic domains.
We have immediate “fast brain” quick reactions and thoughtful, slow brain responses to each other and to objects in the world (Kahnemann 2012). These lead to actions, on which rests the possibility of reflecting and learning. The strength of the understanding of reciprocal roles lies in focussing especially on their development within early and childhood relationships.
What is absent from the analysis however is the importance of human labour, the creation and exchange of products, to understanding the development of humans. The wages we receive in exchange for our work are vital in enabling us to sustain our lives; anxieties about loss of wages can powerfully shape our responses to changes in the workplace. The ownership and control of the objects humans produce or the services delivered, however, lies in the hands of the rich and powerful whose financial judgements about how to increase their wealth makes them deaf to the needs of the workforce and to the general population. It usually takes acute crises for the working population to begin to assert their own needs independently from those above them who direct their activities.
“Cellular” relationships operate primarily at the level of personal, family relationships, friendships, local community, colleagues at work where our actions and responses usually effect one other person, or a small group. We experience political reciprocal roles at a deep unconscious level, often unaware of the power of the super-rich. A very narrow view of the world is presented to us by those in positions of authority over us or through the media, subtly shaping the language we use and our concepts and knowledge of the world. This “primes” (Kahnemann 2012) us to think using our fast brain responses rather than encouraging us to think slowly and see how power relationships play a fundamental role in the workplace.
This highly intricate web of relationships is shaped by those in positions of power in the NHS who cascade downwards the directives they receive from those above, demanding acceptance of edicts by those in the lower echelons. The fast brain reciprocal role responses all too often trigger an unthinking compliance, a sense that this is the world we have to accept.
Two meanings come together in one phrase: “we’re in this together” gives an appearance of connectedness, equality, the feeling that differences between us are insignificant when faced with difficulties of the economy. The complete emptiness of the phrase is demonstrated by pivotal differences in wealth where the rich and super-rich are only too happy to avoid paying tax while demonising those on benefits.
“Patients’ choice” is something we would all support on the surface but the real meaning for those in power is about creating competition amongst hospitals, not providing open accessible care to all. The hollowness of the rhetoric of putting GPs and frontline staff in charge of commissioning is quickly revealed when private companies are brought in to administer the complex, expensive bureaucracy required by this new system. The dual meanings are powerfully demonstrated by Circle’s ex-banker boss, Ali Parsa, who says “we believe our partners — the doctors, nurses and healthcare professionals — should run their own hospitals” (Hamer, 2012). After Circle took over the Hinchingbrooke Healthcare Trust in February, they went on to make cuts in nursing posts and the cleaning budget. Can it really be believed that the staff would agree with this?
Increasingly the deeply human service provided in health care is reduced to the language of numbers as the addiction to performance indicators becomes the central driver for judging the services delivered; a key factor in these numbers is the language of finance and money. The imperative for managers in the NHS is to drive, control and criticise the workforce to work more “productively” for less pay. Their focus is on numbers: finance, statistics, and targets directing their immediate, non-thinking responses to those below them. Private independent consultants are brought in to reconfigure services largely ignoring the intimate knowledge the workforce has of how the service operates in practice
All too often the reactions to commands from above range from conscious agreement to unthinking compliance (“this is how the world is, get on with it”). This merges into resigned acceptance or silent protest of something experienced as disturbing. It is very easy to experience the instructions as just that and to feel impotent.
NHS management increasingly promotes a sense that dialogue and discussion present unnecessary delays; managers become focused on ensuring that the directives they are carrying out are complied with by those beneath them. Genuine discussion amongst adults about complex issues is dismissed as time wasting. Generally the views of the workforce are seen as irrelevant though at times changes are given the gloss of “consultations” (see also Jones & Childs, 2007), the majority of which are meaningless exercises though at least they can slow the process down.
Becoming assertive in the face of this is not an easy process for the workforce and probably more so for those who work therapeutically as the nature of the work requires listening to the views of others and responding sensitively in a way that aims to help the patient to think about themselves.
In contrast, responding to managers requires a very different mental state of assertion not accommodation, expressing an independent viewpoint rather than seeking to reach a shared conclusion as there is a fundamental divide between the participants in this debate. At a minimum, discovering how our own micro level reciprocal roles interfere with our capacity to speak as adults to those in authority over us can at least build our understanding of why it can be so difficult for others to be effectively assertive.
Any change starts with forming a new awareness of reality as it presents itself to us.
This requires fostering a belief that the views held in our own workforce have legitimacy and that the deep unconscious parent-child or teacher-pupil reciprocal roles which can so easily be triggered by the latest management directive need to be brought into conscious awareness.
Awareness alone is of course insufficient to bring about change though it is the essential beginning. Discussion with family, friends and colleagues is vital to deepening the awareness that the “modernization” of the NHS must be opposed. Fortunately as the “modernisations” dig more deeply into the NHS, we are beginning to get expressions of disagreement and dialogue with colleagues. Occasionally there is even a refusal to comply in solidarity with others as in the recent NHS strike for fair pay.
In the further future we need ways of articulating alternatives to how the NHS is currently run by financial targets set by those at a great distance from the workplace. This requires that we deepen our knowledge of what collaboration looks like in order to construct democracy in the workplace. Democracy has to be asserted and regained in the political domain but we also need to think about how it can be a powerful tool in the workplace, engaging those who do the work in the task of developing and improving the services we offer.
Chief executives should be elected, not appointed by representatives of those above them; salary scales should be proportional so that the highest paid have limits placed on what they earn, determined by the wage received by the lowest paid. This could be, say, 10 times or, at the most, 20 times the lowest paid worker. The “reward” of hard work should surely be the satisfaction that it is successfully helping patients, not the number of zeros achieved in a pay package.
For democracy in the workplace to be successful, many tools would be needed. The problems can be seen particularly in the way the political left is organized where differences between individuals often become large barriers in building up effective links between different political groupings.
While there is probably general agreement among the left that the wealth divide (e.g. 1210 global billionaires owning $4.5 trillion of wealth compared with $8.5 trillion owned by the 3.01 billion adults with net worth less than $10,000) has to be broken for serious social change to take place, there are inevitably many different viewpoints on how this should be challenged and what the world might look like in the future.
These divisions are hardly surprising given the complexity of the problem and the unknown nature of the future but the left needs to be able to discover ways of hearing each other’s viewpoint rather than losing sight of commonalities and focusing solely on the differences.
While it is possible for those in authority to hear the views of those beneath them, the likelihood of this will be much less, particularly at middle management level which is subject to powerful commands from above.
The concept of reciprocal roles could form a strong basis for the development of democracy through awareness that our fast emotional reactions to others can easily over-ride our capacity to hear clearly what the other is saying. Our assumed knowledge of an area can make us super confident so that we quickly dismiss another’s differing viewpoint.
Developing “observing selves” could open up space for dialogue between those who are working at a broadly equal level.
An earier version of this was published in Reformulation: theory and practice in Cognitive Analytic Therapy Issue 39 Winter 2012/13 pgs 14-18
Hamer, T 2012 Stop these parasites! Solidarity 22 August no 254
Jones, A & Childs, D 2007 Reformulating the NHS reforms Reformulation Summer pp 7-10
Kahneman, D 2012 Thinking Fast and Slow Penguin
Kugiumutzakis, G. 1998, "Neonatal imitation in the intersubjective companion space," in Intersubjective Communication and Emotion in Early Ontogeny, S. Braten, ed., Cambridge University Press, Paris, pp. 63-88.
Ryle, A. 1990, Cognitive-Analytic Therapy: Active Participation in Change Wiley, Chichester.
Sève, L 1978 Man in Marxist Theory and the Psychology of Personality Harvester Press
Trevarthen, C. 2004, Learning About Ourselves, From Children: Why A Growing Human Brain Needs Interesting Companions.