The NHS is anti-family and this is institutionalised (The Case of Ashya King et al)

Institutionalised attitudes are covert, entrenched and generally undetected by staff who mediate them.  As the saying goes, you can’t hear the music if you are one of the notes.  They persist because they have an important, systemic function – that is, of preserving the status quo.  And they become intractable when they fall in step with the prevailing mind-set of the organisation. Thus, institutionalised racism in the police is consonant with and legitimises the paranoid stance that brings many people into the work in the first place.  Aggressive, retaliatory and fearful impulses are released and endorsed when they alight on those who for historical and cultural reasons are felt to enact the stereotype of the threatening, untameable black man.  The collective, institutional mind, like the radio hunting for a signal to tune into, scans those on the outside until it finds what appears to it to be a match for what it is seeking.

The NHS, especially (but not exclusively) in its mental health work where ancient fears and fantasies are fertile ground for messy, unconscious projections and prejudices, pushes families to the margins, first because they are a potential threat both to status and to exclusive and prized relationships with patients; and secondly because of the power of the stereotypical picture of relatives as over-involved, troublesome, uninterested, abandoning, negligent and – this a persisting vestige of 1970s anti-family ideology – even schizophrenogenic, or causing psychotic illness.

Individual staff, in particular managers, will always respond to such observations by saying they are unfair and untrue – because subjectively they generally are. Apart from a very small minority, those who work in the NHS are conscientious, altruistic (secondarily if not primarily) and wanting the best for patients and their significant others.  Policies on consulting and assessing the needs of carers will be cited as evidence of organisational determination to make sure that a collaborative approach is actual and not just wishful.  But this apparent attentiveness in practice protects stasis and wards off real change because it doesn’t impinge on the cognitive DNA of the organisation which infiltrates individual behaviour and day-to-day clinical practice.

Once this premise is accepted, anti-family practices can be seen as ubiquitous, their pervasiveness and familiarity paradoxically meaning they go unnoticed. Almost every report into a homicide or suicide demonstrates the culture of exclusion and, even at times, denigration graphically. Confidentiality is the weapon of first resort in justifying the exclusion of relatives from clinical discussion, exploration and decision-making even when – and maybe, strangely, because – families know well the antecedents, course and dangers of whatever illness or disorder is being treated. Confidentiality, of course, applies to the giving of information rather than receiving it but staff apply it to mere contact which often has the self-fulfilling effect of driving relatives to live up their stereotypes – which in turn leave staff permanently anxious about complaint, criticism or challenge.

What breathes life into these behaviours are negative and hostile feelings towards one’s own parents which haven’t been resolved or just laid to rest.  Just as there is always an element of treating oneself in the patient, so relatives become tinged with the resentments and fears we harbour about our own families. This leads in part to the long, tunnelled focus on pathology which characterises much of mental health practice, with the patient seen as a container of defining symptoms and disease rather than as someone with essentially normal roles, relationships and experiences who needs support in managing some abnormal and troublesome aspects of this life. This means that the primary or determining relationship which staff develop is with symptomatology and deficit rather than with the person in and with his or her context.

The parents of Ashya King may well recognise this dynamic as would, I have no doubt, the relatives of almost every patient who has become tangled up with the mental health system – many of whom, such is the narrowness of focus and vision, may well not be known to exist.  What staff do may be within the reach of procedure, training and legislation but attitude and culture rarely are.  They can only be changed by, first, subscribing to the hypothesis; secondly by supporting and championing leaders who espouse its implications for day-to-day clinical practice; and finally by ruthlessly only recruiting those who have signed up for it. There is hope.