Relationship and dependency in the public sphere: the importance of relationship is devalued in contemporary culture - even in health and welfare systems, where people are necessarily dependent.
The trend away from dependency is embedded in a contemporary culture whose view of the self can be encapsulated as 'I feel therefore I am'. Far from being a triumph of the therapeutic, however, this view of the self is expressive of an individualism that denies the central value of relationships. Its shallow conception of individuality creates an opportunity for offering quick fixes (for example the claim that a short period of CBT can turn someone's life around). The obvious attractions of therapeutic self-help are mobilised to justify reforms of health and social care that are based on offering people 'opportunities' to organise their own support or recovery; while the idea that people can be whoever they want is a cover for the resort to increasingly behaviourist forms of intervention.
The social policy agenda is now focused on opportunities for self-help rather than on trying to understand the underlying structures and relationships that provide the basis for more intransigent resistances to change-such as inequality, or complex dynamics of envy or hate. Such an agenda can be concrete and positive in its promises about outcomes, and it also serves to distract from the importance of inequalities. If we can be anything we want, it does not matter so much that we or anyone else starts at a disadvantage.
This thin view of relationship can be seen in our everyday experience of being greeted by shop-workers or told to 'have a nice day': the appearance of relationship is used to achieve a business objective. 'Person-centred added value' is used to sell products or services. But to act as if we care is not a relationship, and the pervasiveness of such management techniques only further undermines our understanding of social relations.
The post-dependent therapeutic approach in mental health can be seen in the language of 'recovery'. For example: 'recovery is about people seeing themselves as capable of recovery rather than as passive recipients of professional interventions'; 'Self management may help you! Take part in the expert patients programme'. And the promise is often explicit: 'Just two and a half hours a week, for six weeks, could change your life ...'. This emphasis on self-management has many strengths - but it also involves a diminishment in the importance of relationships to others, including a reduced respect for the authority derived from the competence and experience of others. Why should I think that anyone knows better than me about anything? Isn't the customer always right?
One area where the weakness of the post-dependent approach is revealed is in discussion of what is now called the parenting deficit. The current approach to issues of parenting is constrained by the language of (children's) rights and (parental) responsibilities. This is silo thinking: look at the child over here, the parent over there. The focus is not on the relationship between them. But, as the psychoanalyst Donald Winnicott said, there is no such thing as a baby on its own, it is always in relation to its mother. Children grow within the conscious and unconscious relationships and communications of their parents and family. They cannot be separated from them. Understanding this is crucial to debates on parenting. For example, in discussing an issue such as underage drinking a psychoanalytic approach might ask about the authority of the parent in relation to the child. Instead there tends to be a - seemingly attractive - focus on mutuality: what is good for me is good for you. But this mutuality tends to be understood narrowly, in terms of exchange rather than relationship.
A culture of measuring
Public services have become caught up in this instrumental and economically driven approach, as patients and service users become customers of health and social welfare. A social policy culture that emphasises the need for measurable outcomes is a powerful managerial constraint on relationships within public service. One example of the effects of such practices can be seen in the management of care workers in relation to service users. A home care team, working in the community, is employed by the local authority; and the staff are contracted to work for a specific amount of time with each service-user, with technology allowing for each home visit to be timed to the minute. The management argues that this is a way of introducing some flexibility: the carer can give the service-user more time on a specific occasion if she needs it, and this can be monitored, with the extra time being taken from the next visit. In this way, from a management perspective, the system is being more responsive to client need and offering more flexibility-surely a good thing. But in fact this is a way of asserting more control (this is the essence of New Labour managerialism, as evidenced on a larger scale by the seemingly independent but closely regulated NHS Foundation Trusts). And somewhere along the way during this monitoring exercise the human relationship between the carer and the service-user vanishes.
The reality is that, left to themselves, some carers would do a lot more than they are contracted to do, because they get into a relationship with the service-user. Equally, other carers may exploit any lack of surveillance in the system to do less than they should. That, you might say, is human nature - the good egg/bad egg syndrome. The problem lies in the response, which has been to make them both the same: to contain the good and coerce the bad to a single standard of a National Vocational Qualification within a National Service Framework. This may be benign in its intent but it is also Orwellian in its process. In practice, it is only if it is applied in an inefficient and incomplete way that the system works with any humanity and respect for people's relationships. Some very good care is provided, but this is in despite, not because, of these safeguards. And some bad care may also remain undetected by the monitoring system.
Having tried to squeeze the life out of the relationships between carers and cared for, social policy now thinks to introduce targets for compassion. But regulation does not sit easily with the complex task of making relationships: if you allow carers to have relationships of any significance with service users, things will get messy. That which is spontaneous, idiosyncratic and uncertain in its outcome does not fit with an agenda of national standards. Thus one NHS mental health trust, taking a global view of its recruitment needs, decided to employ a significant number of staff from a country whose caring had impressed a senior manager, only to be disappointed when the caring culture did not successfully transfer into the NHS Trust. We need the remarkable competence of ordinary people to care for others; we must not be frightened of that competence and seek to impose mechanisms of control. What is needed, rather - in the supportive psychological sense - is containment.
In modern organisational life it often looks as if relationships are all important, but this is usually expressed through networks rather than through sentient one-to-one communication. And networks have the dynamics of speed-dating - they offer a quick and ready way of seeing who might suit our immediate needs. This is 'just-in-time' management applied to relationships. In public services the just-in-time-system can be seen in the increased reliance on 'bank' staff who work shifts as required - more evidence of the collapse of respect for the value of relationships.
A more relational or psychodynamic perspective is concerned with our capacity to connect with others, but the therapeutic ideal has become self-sufficiency. Some of the dysfunctional consequences of this approach can be seen in the case of one resident in an independent living scheme who was forced to carry out tasks to demonstrate her progress in being independent - by, for example, doing the washing up while two care workers stood over her. Her daughter saw this as patronising and insulting - more punishment than support - and complained to the manager. The response was that the services had to be able to show outcomes to justify their funding. On the ground, it seems that this meant standing over an old lady doing the washing up. In a care system of this kind, if a significant relationship does develop it is likely to deviate from such unthought-out protocols.
Recognition of relationships of dependency is a major casualty of the new systems. In order to play down dependency and maintain the appearance that all concerned are autonomous beings, patients and clients of public services have been re-allocated the role of service users - the therapeutic equivalent of customers, assumed to know their own needs. This has its attractions, as an attempt to ensure some parity in what is otherwise an unequal power relationship. But once patients become customers their needs can be redefined as wants. And at this point the realities of power re-enter the calculation: the providers of services are in a position to subject these 'wants' to cost benefit analysis, and to substitute alternative products. This is particularly problematic at a time when illnesses are increasingly being linked to life-style choices - obesity leading to diabetes, diet and stress being associated with cardio-vascular diseases, alcohol's association with disease, etc. Assessment processes fit uneasily in this process: assessment of need is in fact inextricably tangled with the management of resources.
The service user has to fit the criteria for the provision of the service according to a rights and responsibility framework: for such-and-such a reason the user has the right to a service, and the provider agency is commissioned to provide it. Interventions are delivered and monitored as short-term interactions. Cases are opened, shut and re-opened according to externally determined criteria. The apparent offer - the promise of a relationship - is a shallow pretence.
In this kind of regime psychoanalysis does not fare well, though in the past psychoanalytically informed thinking was part of the professional training and practice of many health service professionals. Psychoanalysis is founded in a therapeutic relationship that can last years. Its emphasis on continuity, regularity and a close attentiveness to thoughts and feelings runs counter to the modern reality of managers who are looking for 'quick wins'. From the perspective of its critics it does not seem a very efficient technique, and in a system dominated by market values of productivity it is hard to defend as best value. But at the core of this work there is a respect for the patient's own capacity for learning, and for the real human difficulties of learning and changing, which contrasts with the urgency of time-limited interventions.
The need to acknowledge dependency
The intimacy of a relationship that is respectful of dependency requires an open-ended commitment, when you don't know exactly what you are getting into, or what you will get out, but you have the capacity to stick with it. We recognise dependency in the nursery and the hospice, but not in between-though there is not a time in our lives when we are not dependent on others for our survival and comfort.
The human need for relationship is not of course lost or destroyed in all these processes. As already mentioned, careworkers may demonstrate very powerfully a capacity for creating an intimate relationship outside of kin, even when the protocols do not allow it. However, the current system reinforces the capacity we all have to act all the time as if we are on our own in our achievements, and to do everything we can to defend ourselves against the sure and certain knowledge that this simply is not true, that we are truly inter-dependent. But hatred of dependency is different from denial. The hatred we can do little about, but the denial is something for us to work with in the development and management of human systems. And though we may at times deny our dependence, the entrepreneurial culture promoted by the government only suits a small minority of people - or a small part in each of most of us. The majority of us remain risk averse, having neither the stomach nor the skill to make the best of every opportunity according to a resourceful evaluative maximising model, beloved of neoliberal economic theory. Continuous effort is required to mould our interactions into instrumental forms.
The voluntary sector, with its not-for-profit organisations created and developed to give expression to deeply-held values and commitment, is also continuously suborned by an insistent demand that it becomes efficient and competitive. Chief executives move from one cause to another without noticing any conflict of interest, and having successfully competed for government funding go on to become government advisers. But below that opportunistic leadership, people continue to act on their enthusiasms as much as their interests. A partner from one of the major consultancies once explained to me how the voluntary sector did not understand the employer-employee relationship. Volunteers, local committees, ideologically driven workers, have a tendency to do what they think right, and managing them requires an empathy with the other's desires that can only be carried through by relationship. It is when that breaks down that there will be trouble and conflict. Modern management systems find it difficult to co-exist with an ethos that resists instrumentalisation.
The current approach to working relationships attempts to realise a relationship without dependence; it aims for a relationship of independent operators - who are nevertheless managed by surveillance and audit and a performance-related reward system. Qualities of loyalty and trust are no longer needed if their advantages can be achieved by technicalities of performance management. The quality movement introduced the concept that nothing has meaning unless it can be measured. But the concept has developed even further - so that anything that can be measured will be, even if the measurement is meaningless. This robotic tendency in human relations - to see the individual as a productive unit that can be made to run at near optimum efficiency - has led to a thriving new therapeutic culture at work, which addresses the needs of the human-in-the-robot. There are counselling services funded by employers, and - for more important people in the organisation-executive coaching. Employees who are downsized are offered out-placement services. Remuneration is increasingly linked to performance bonuses, as if the individual is a sole trader in a competitive enterprise.
The relationship of customer and provider, in so far as it exists, is instrumental - a defensive contract rather than a real engagement of identities. The power of contracts and protocols to impose behavioural norms has replaced the authority of personal relationships to develop appropriate behaviours. In the place of the uncertainty of relationship, we have got stuck in a new therapeutic culture that indulges the fantasy of personal salvation. This provides a very necessary defensive environment, psychologically speaking, where we can live without the necessity for a committed relationship: in helping us to live with the freedoms of a market economy that leave us feeling entrapped it makes the resultant world of targets and audit sort of tolerable. The freedoms of the market are, arguably, good for us as customers for cheap computers or shoes, but get us anxious, overworked or excluded in our working lives as suppliers of goods and services. Nor is it all good news for the customer. In health and social care, as we have seen, even the most vulnerable people also have to live up to the expectations of the market. In a world in which we feel increasingly impotent, the therapeutic fantasy offers the consoling prospect that we are still free men and women.
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|Date:||Jun 22, 2009|
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