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The walls within: working with defenses against otherness

Online Conference 5-11 July 2021

Facing Facts what's the good of change?

What kind of practice am I talking about? The clinician is highly paid, because there are not many of them. He turns up at the clinic and sees the patients in appointments organised for him by the administrator. He reads the case notes, speaks with the patient, examines her condition, makes a prescription, sends her on her way, and completes the paperwork. And what is wrong with that?The clinician will tell you that he has no time to think, has no chance to discuss cases with colleagues, and is on an endless treadmill as he tries to do his best for each patient as she appears in front of him in the limited time available. But what can he do about it? There have been many reports pointing out that patients are not getting the quality of treatment that they need, and that the focus on managing the costs by increasing throughput makes it impossible for the clinician to sustain a focus on outcome, beyond the moments in which the patient appears in front of him. But nothing seems to have happened as a result. The system grinds inexorably on with its priorities, in a way that seems oblivious to the actual suffering of his patients.So he continues to do his best by the patients he sees. He is grateful for the living he is able to make. And he waits for the powers that be to change things for the better. After all, there are only so many times he can point out what is wrong, and have nothing be done about it. Better to get on with doing what you can where and when you can.What am I going to be talking about? My colleague Tom Flynn and I have been working within the British National Health Service (the NHS) since 2000, examining the way orthotic clinics treat their patients. Orthotists are a type of clinician who prescribe 'orthoses', working not only with orthopaedic and paediatric patients, but also preventatively with diabetic patients, osteo-arthritic patients, and so on. These orthoses are artificial external devices, such as a brace or a splint or special footwear, which prevent or assist relative movement in the limbs or the spine. And the characterisation I gave you of the orthotist's experience within the NHS is not an unfair one, including the gender characterisation. To cut a long story short, we found that focussing on the early and sustained treatment of conditions involved initial investment and a significant increase in orthotic budgets, but within five years saved more than five times the initial investment in reduced need for the acute care and social costs associated with immobility in later life; and a great deal more than that over the longer term. And, of course, an enormous gain in the quality of patients' lives. It was as if the system had been set up to deal with acute conditions, if necessary by waiting until conditions became acute!iWhat kind of challenge did this face the clinicians with? I want to talk about a kind of Faustian pact that clinicians enter into with their host systems that, while not explaining why change does not happen, does highlight something about what makes change difficult. The Faustian pact is an unholy alliance between the clinician and the system, in which the deal is'As long as you give the system what it needs, you can do pretty much as you like, so long as the patients don't complain.' A kind of 'we'll leave you alone if you leave us alone'. And of course there is the other side of this the clinician going to great lengths to keep obscure what he or she is actually doing for his or her patients not only because he or she considers it to be no-one else's business, but also because the less anyone else knows, the less likely they are to find a basis for interfering with their practice, something that he or she would always consider to be for the wrong reasons or against the patient's interests.I want to argue that the alternative to this involves the clinician having to take up a kind of double challenge. This double challenge, on the one hand involves clinicians questioning the nature of their own practices in relation to their consequences and outcomes in the patient's life. And on the other hand it involves challenging the host system, insofar as that system creates contexts that act against the needs of the patient - a kind of constructive disobedience not only given force by the challenge of the case, but also supported by the evidence of the case. This is what is implied by the idea of 'facing facts'.What is the relevance of this to us all?What has this got to do with us, I hear you say? The way of the clinician stands for a particular desire to address the needs of the patient, however cynical we may become about how clinicians fall short of this in practice (Boxer and Palmer, 1997). I want to extend this ethic from the 'clinician' in particular to the 'professional' in general. In some sense we all of us here are professionals who will have had some direct experience of this double challenge. Furthermore, as members of ISPSO, we are uniquely placed to understand it because of the nature of the Freudian insight. So in unpacking something of what this double challenge might mean for us, I will also be saying something about the form of leadership it implies. And in not taking up this double challenge? I will be arguing that failure to do so leads to a kind of evacuation of the public realm, which is to the detriment of us all. By this I mean that there comes to be no way of speaking about, let alone protecting the public good. Everything is rendered 'private'. What is the plan for the paper? The paper is in two halves. The first half starts with the case itself, what we tried to do in response to it, and what kind of double challenge the case represented for the orthotists. It will then talk about the wider context of the NHS system itself, and how the double challenge facing the orthotists could be taken as being symptomatic of the difficulties facing the state itself in its approach to reforming its public services. This will lead me to the question of what appears to be happening to our relationship with the state as citizens, and the way in which the double challenge at the level of the orthotist is repeated at the level of the state as a question of what properly belongs in the public realm. The point about the Faustian pact is that it describes the process by which the evacuation of the public realm takes place. The first half concludes by considering what kind of dilemma this double challenge presents us with as clinicians or as citizens. The second half then looks more closely at what is happening at the individual level in all of this. Firstly, it looks at how we approach the question of our own authorisation as citizens; then at what is going on when we 'face facts', in particular the role ideology plays in this, insofar as the force ideology has for us is derived from the valency it has with our own unconscious phantasies. This leads me to consider how anxiety gives us the clue for what happens when this valency is put into question, how anxiety strikes us personally, and where we can then find ourselves looking for the good of change.