Having just left my role as a clinician in the Tavistock after some 30-plus years, I have been reflecting on some changes I have experienced over those decades.
I have two abiding memories of my early days at the Tavistock. One is that, in those days before email even existed, my first official communication within the Clinic (there were no Trusts back then just clinics!) was a piece of paper in a tray with my name on it. This was how communication took place then, handwritten bits of paper, and this first missive was inviting me to vote for the new chair of the child and family department. In those days every senior position, including the role that nowadays would be called the Chief Executive, was appointed via the votes of staff members. The same went for the roles of Deans, and heads of discipline, such as the lead in child psychotherapy, elected by discipline members. The sense was that we had a stake in how the place was run and that our opinion and input was valued. I certainly felt that I belonged in a way that no longer feels the same.
The other hard-to-believe memory is that there was almost no management, and indeed only a tiny proportion of the budget was spent on managers, admin, communications or computer systems. The main costs were clinical and teaching time,, people who were helping others, and there was a lot of freedom to be innovative and set up new services and courses. I remember soon after I arrived I had an idea for a new school’s service that was a little radical. I felt a degree of trepidation that there were no committees to go through, and my then ‘manager’, the lovely late Hamish Canham who tragically left us so young, simply said ‘well that all sounds good, you can do your own thing here, there is no controlling management’. This was a service called the Tavistock Outreach Project in Schools (TOPS) which lasted 20 years until funding very recently ceased, and it helped countless teachers, children and families
Indeed, historically, it was the Tavistock’s atmosphere of innovation and indeed pioneering radicalism, that gave rise to some of the best things that came out of it. The workshop system, whereby clinicians interested in an area of work, such as eating disorders, infant mental health, autism or fostering and adoption, set up workshops and invited other clinicians and trainees to join, and from each workshop there ensued a wonderful melting pot of ideas that gave rise to multiple papers, books, conferences and genuinely new ideas. Personally, I have been able to set up several services spanning over 50 schools, as well as set up new courses and lecture series. Yet this path has got harder and harder as more control came in, and more fear of innovation. The risk is that places like this lose their reputation of being on the cutting edge, and appear conservative at best.
What we have seen in fact in so much of the public sector is a huge increase in layers of management, audit and overseeing/checking up, which leaves me both nostalgic for the good old days and sad about the loss of freedom for and trust in clinicians. Its replacements, audit, ongoing scrutiny and outcoming, have also of course left many of us increasingly anxious, especially those like me who have powerful superegos!
This shift to command and control, such as seen in CQC in the NHS and Ofsted in Social Care, has, I believe, had a really bad effect on services, even if the original motives have been good. Layers of bureaucracy have been added leaving much less room for innovation and spontaneity, let alone reducing hugely the proportion of budgets spent on clinicians who actually see people. Instead there is so much more time form filling and back-covering and making sure everything ‘looks’ ok. Of course, the inevitable dynamic of all institutions tends to be, as Max Weber (Weber and Eliaeson, 2000) long ago saw, a move from lithe open flexible systems to more bureaucratic increasingly ossified ones, and this tendency is exacerbated in the contemporary world.
I have long followed the work of Iain McGilchrist (Mcgilchrist, 2010) who has been arguing that that we are in danger of living in an increasingly mechanistic, fragmented decontextualised world which he links to growing left hemisphere dominance. He has suggested with powerful research evidence that the left hemisphere is used to control and manipulate, to organise, be logical and analyse with a calculating mind-set. This is a great advantage for financial planning, for technological advance, for bureaucratic control, but not for encouraging innovation, new thinking, nor for achieving what the Greeks called eudaemonia, sometimes translated as a good life or as human ‘flourishing’.
For example, McGilchrist suggests that probably the technology that most affected hemispheric balance was the clock. With its appearance suddenly time was broken up into small pieces, allowing days to be divided into regimental units, very different from more circular rhythms of time in hunter gatherer and agrarian societies. This facilitated more abstract thinking, relying less on other ways of being, which again would have changed the very way our brains were wiring.
Richard Sennett (2012) has painstakingly described the shift away from lives lived with a profound sense of community, stability, continuity of belonging, with clear rituals, where work was stable if hard, whether down a coal mine or as a craftsman or in a school. Previously cooperation and mutual obligations were a given. Life was marked by ways of associating which allowed differences but ensured respect. Bauman’s analysis of contemporary society as ‘Liquid Life’ (Bauman, 2005) suggests a similar loss of intrinsic values in the face of materialism and a speeded up, less secure world. For Sennett, as for Bauman and McGilchrist, contemporary life is marked by people being treated less as real, alive emotional beings, and more as consumers, or units of labour. Here technocratic efficiency, devoid of right hemisphere emotion and ritual, alongside the quest for profit and success, are increasingly important motivators.
The Tavistock was, at its inception, a genuinely radical organisation, a beacon of innovation. That was the vision that its founder Crichton-Miller , a towering figure in his day, his thinking being at the cutting edge, and it is not goiong too far to say that the Tavistock was then a centre of radicalism. Its early days spawned extraordinary developments, whether the theories of Ian Suttie, Bion’s extraordinary legacy, Bowlby and attachment theory, the first child therapy trainings, new ideas and trainings in systemic family theory, and so much more, let alone the radicalism of the infamous R.D. Laing. We saw extraordinary innovation with projects decades ahead of their time, going back to the work of Bion, with groups, trauma sufferers and new psychoanalytic ideas, with organizational consultancy by the likes of Obholzer, the new thinking in the Portman from Glasser, Weldon et al, , new thinking about autism from Anne Alvarez and SDue Reid, about infant mental health by Dilys Daws and Juliet Hopkins, the rich Tavistock book series spearheaded by Margot Waddell, the innovations of the likes of John Byng-Hall and Chris Dare in family therapy, trauma projects such the trauma unit led so incredibly bravely by Jo Stubley, as well as child trauma work such as Judith Trowell’s sexual abuse project, the Monroe Family Centre, and so much more.
It is with great sadness that I leave the NHS and the Tavistock, an institution that has made such a huge difference to generations of clinicians and professionals in multiple disciplines, from psychiatry, social work, educational psychology, family therapy, schools professionals, child and adult psychotherapy, as well as to tens of thousands of patients but also the patients of the people who have trained there. Its legacy is long and deep.
In this short blog I have written here about my misgivings about the changes in the UK public sector but I sincerely hope that I have not just become a curmudgeonly old man (!). I hope to urge people to aim to carve out a space for genuine innovation, curiosity and uncertainty, and indeed radicalism, to help make a difference at multiple levels, in the way we have for so long seen at the Tavistock. For myself, I never liked the word retirement, with its etymologies of pulling back and retreating. I hope to maintain my own interest, passion and curiosity, and as the mindfulness people suggest, keep activating the left prefrontal areas of the brain, keep looking forward and ahead, and, as the great Donald Winnicott said of his own hopes, be alive until I die. That might mean less time than I thought for cogitating quietly. In fact, much as I admire Mcgilchrist, I don’t expect to actually get through much of his new and incredible sounding (and 1500 page!!) book all that quickly, although the ambition is there and it is by my side. Thanks to anyone reading this who was part of this journey and I look forward to the next stages.