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Reflections from a small land

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Summer holidays are always a good time for reflection. This year we’ve been to Lauterbrunnen in Switzerland, in the heart of the Alps. JRR Tolkien came there in 1911 and this narrow mountain girt valley with its 72 waterfalls it is thought to provide the inspiration for Rivendell, the home of the Elves in the Hobbit and Lord of the Rings.
Our trip has prompted a number of thoughts both about Switzerland and its place in the modern world and about some wider issues.

This was my first extended visit to Switzerland although I have made a few shorter visits in the past. In some ways it was quite familiar. I remember Switzerland being quite in vogue in my childhood with the, then novel, excitements of eating “Swiss style breakfast” cereals and watching Swiss Family Robinson on the television. As ever there is more to Switzerland than that and now, in the light of Brexit, it strikes me there is some considerable value in taking an interest in its affairs as country which sits, in the heart of Europe, but is not a member of the EU.

Reinforced by its geography this not one country but many. This is a federal country in the full sense of the word, “Confoederatio Helvetica” being the Latin name which is reflected in the “CH” stickers on Swiss cars. There are four national languages: German, French, Italian and Romansh and, under the Swiss constitution, the federal Government is an explicit sharing of sovereignty by the 26 cantons rather than a top down imposition of national authority.

National Government is shared through a seven-person National Council, elected for a four-year term, across the political spectrum and the figure of the State President, whom we saw give his traditional address on 1st August, Swiss National Day, rather like the Queen on Christmas Day, is elected by other members of the Council on a one-year basis. The President is primus inter pares with other members of the Council and has no additional power. Swiss politics seems to eschew any focus on personality, a health antidote to the dramas playing out in the Uk while we were away.

All across Switzerland the emblems of cantons and local communities (Gemeinde) were as prominent as that of Switzerland. Managing diversity of interest and working through consensus, not diktat, seems to be hard wired into the Swiss political psyche. The Swiss tradition of direct democracy also has major influence on the shape of Swiss politics.

The other thing which distinguishes public affairs in Switzerland is the country’s deep-seated commitment to neutrality. It has not been at war internationally since 1815 and the principle of neutrality still is at the heart of Swiss foreign policy. As was clear from some of the debate we saw in the Swiss media, that principle comes in two forms, an open and outward looking form which looks for the country playing an active role in international affairs, for instance by taking a permanent seat on the UN Security Council, or one which envisages neutrality being more insular and isolationist in its character.

Both these issues, how we order the relationships within the different parts of the UK and what are the fundamental principles which drive our future relationship with the rest of the world seem to be absolutely central to how we work through the dilemmas around Brexit. It was also salutary to note, that despite its strong sense of independence and the reluctance of the Swiss public to contemplate joining the EU, how central the relationship with the EU is in defining Switzerland’s economic and regulatory policies.

Time in the mountains promoted two other reflections. We enjoyed, like the rest of Europe, two weeks of generally excellent weather but the high temperatures also reminded me of the significance of global warming. Nowhere was this more noticeable than in the shrinking of the Alpine glaciers. There is a lot to worry about in the world at present, but it feels to me also a real risk that, amidst other issues, we fail to take seriously enough the biggest threat to our world. The sight of the mountain rivers in flood with the melted ice of the glaciers was a timely reminder of this issue.

My final reflection was a more serene one. The landscape we were staying and walking in was phenomenally beautiful, with wonderful vistas of some of the most significant Alpine mountains such as the Eiger and the Jungfrau. One of the reasons I have always loved the mountains is the way in which both in scale and timelessness they dwarf our human ambitions and anxieties. Close to where we staying were the spectacular Staumbach falls. At the bottom of the falls there was an inscription of some verses of a poem by Goethe who had visited the valley at the end of the 18th century. They read:

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“The souls men, you are like the water, the fate of men, you are like the wind”

Perspective is very important in life. These words and the sensational beauty of the place offered a sobering perspective for my own petty concerns and anxieties which I will try to take with me as I return to the wear and tear of daily life.

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The will of the people – remember Arginusae

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This has been a profoundly depressing week in politics. The division in British society over the consequences of the Brexit vote continue and there appears to be a frightening willingness to put narrow ideological goals above any wider view of the national interest. Usually I have a strong feeling for the British ability to muddle though but, over Brexit, I beginning to wonder.

Readers of this blog will know the value I attach to looking at what history has to teach us about the events of the present. On this occasion I am drawn to thinking about one of the most traumatic episodes in the history of early Athenian democracy, the vote to condemn to death the victorious generals at the Battle of Arginusae.

This happened at the end of the fifth century, in the last years of the Peloponnesian War between Athens and Sparta. After the disastrous expedition to Sicily, Athens had been on the backfoot in the conflict with Sparta. They had flirted with Alcibiades as a potential saviour, but he had gone into exile in Persia. Slowly, they had made a come back and in a naval battle off the cost of what is know Turkey had inflicted a significant defeat at the Battle of Arginusae.

There had been, however, been a sting in the tail. A storm which had blown up at the end of the battle had prevented a pursuit of the defeated Spartans but, more significantly, it had prevented the rescue of Athenian sailors whose ships at been sunk and who were left stranded in the water. When the generals in charge of the action returned to Athens, instead of facing a heroes’ welcome, they were confronted with public anger at the loss of Athenian life. In anticipation, two of the generals decided not to return to Athens but went into self-imposed exile.

The issue was taken to a special meeting of the Assembly, the ultimate body of Athenian democracy in which every male, freeborn Athenian citizen was entitled to take part. The president of the Assembly was chosen, each day, by lot and, as it happens, the president for this momentous day happened to be the philosopher Socrates. The Assembly debated an extraordinary proposal for all the Generals to be tried together by the Assembly itself. If found guilty, the penalty would be death.

The debate raged fiercely between emotion, fuelled by the testimony of a survivor from Arginusae who had survived clinging onto a wooden flour tub and rationality as others tried to point out the genuine difficulty of rescuing the men given the weather conditions. Socrates, as President and himself to fall foul in later years of the anger of the populace, tried to keep the debate in order and to resist the call to put the proposal to put the Generals on trial to the vote. In the end, thinking at last that a rational outcome would prevail, he allowed the vote to proceed. The vote went against him and subsequently the generals, who included the son of Pericles, the most famous statesman of Athenian democracy, were sentenced to death.

Remorse came quickly, and the populace turned on those political leaders who had led them onto to take this regrettable decision. It was, however, too late. A year later the Athenians were defeated at the battle of the Aegispotami. Unable to defend their grain supply from the Black Sea, the Athenians were brought to a final and humiliating defeat. Although it later recovered one of the long-term consequences of Arginusae was the reluctance of people of talent to serve in position of public responsibility, knowing that they, like the generals at Arginusae could be victim to the whims of public anger.

There are many features of these dramatic events form the past which resonate with current events. The triumph of emotion over rationality, the contempt for traditional politicians and people in roles of leadership, the ignoring of the views of experts, the manipulation of procedure, so central, in all times, to the operation of democracy.

With the advent of social media modern democracy has moved closer to the paradigm of its ancient predecessor with more riding on the moment and ordinary citizens closer to the action. Democracy, no less than other forms of Government, has always been vulnerable to the manipulation of the anxieties and other emotions of the populace. Those feelings have to be acknowledged but they should never be the basis for rationale decision making about complex issues of national strategy.

Had Socrates prevailed and there had been a moment for reflection it is possible that the Assembly would have repented of their anger against the generals. In our current national debates about Brexit there is a crucial need for such a moment of reflection.

The Open Society

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One of the most powerful things I read when I was studying history at University was the philosopher Karl Popper’s “The Open Society and its Enemies.” Written at the end of the Second World War it made the argument, starting with Plato’s Republic, against the closed ideologies of totalitarianism. Popper’s argument is that in trying to order society and insulate it from external change, totalitarian regimes inevitably fall into abuse: suppressing the truth and oppressing their citizens. Manipulation of the historical narrative is one of their principal tools.

I read this work through the lens of the mid 1980s and the latter days of the Soviet hegemony. Popper’s argument appeared a self-evident truth as the communist regimes of Eastern Europe staggered towards their eventual decline. Recent events have made me think, once more, about these arguments as, again, liberal democracy appears to be under threat, a narrow nationalism is on the rise and the principles of the open society challenged and subject to question.

At the heart of the debate is our attitude to the movement of ideas and of people and how we embrace change in our world. Whether, as default position, we are open to change and new developments or whether we wish to look back and lock down the world, in some sense, in a paradigm of a personal, sectional or national past.

All of this appears to be playing out in a large way in current events whether over Brexit, the rise of Donald Trump or the emergence of different shades of nationalist and popularist politics across Europe and elsewhere. The impact of globalisation, the shift of economic and political power from the West, the scale of migration and economic pressure and public austerity all seem to be fuelling a shift against the values of liberal democracy and towards a more inward facing creed of nationalism. History never repeats itself exactly but the parallels with the 1930s are far too close for comfort.

My experience and study of history would teach me to side with Popper. That is that human development and progress has usually been linked to open societies and the free interchange of ideas of people and the creative energy that this unleashes. Nowhere epitomises this more than ancient Athens, the single most brilliant example of human development, in the Western world at least, which in a period of less than 200 years created the building blocks of western intellectual, political and cultural activity and whose legacy can be profoundly felt today.

In saying this it is important not to discount the anxieties which have fuelled the emergence of popularist and nationalist feelings nor is it necessarily wrong to value and want to cherish the past or defend traditional values or activities. The 20th century might have succeeded in condemning the Welsh language and the cultural traditions it embodies to the scrap heap of history. It has taken a significant act of national will to resist that secular trend and to preserve a crucial part of the DNA of the Welsh nation and people. Many people can very legitimately see change as a threat to aspects of life they value, and which have constituted an important part of their own identity.

I think in our own times three factors exacerbate the tension between the new and the old. The first is the ever-accelerating pace of technological and social change and, now, the increasing level of interaction between them. The Internet as mass phenomenon is no older than my children and there is every possibility that the next generation of technological change around robotics and Artificial Intelligence will happen even more quickly. This puts an enormous strain on our powers of adaption.

The second is the shifting balance of generations in our society with the growing numbers of older people and the declining proportion of younger people in society. In 2020 it is estimated there will be, for the first time in history, a greater number of people aged 65 and above than under 5. While there have always been tensions between younger and older generations these are made sharper by the change in the profile of society.

Finally, there is the sense that the hegemony of the west, as we have known it, and the sense of privilege which has gone with that is coming to an end. This creates particular issues and the politics of decline at a time when overall resources are challenged are never easy to manage.

The quality which, for me, is most important, in managing the tensions of these times, is tolerance. In supporting an open society, it is crucial we do so in a way which is respectful of the past and is understanding of those who are left behind by change. While we must always call out hatred and discrimination towards others we must do so in a way which is, in its own turn, measured and free of hatred and intolerance. In an increasingly divided world that is not an easy ask but is an essential if we are to avoid a return to some of the horrors of totalitarianism which Karl Popper was motivated to write about in 1945.

 

The kindness of strangers

 

 

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As some of you will know from my posts on Twitter my mother-in-law, who has been developing dementia, went missing on Thursday night. Fortunately, she was alright but, in the hours, until we discovered that on Friday morning, it was a deeply anxious time for my wife and I and for the rest of her family.

One of the compensations was receiving a torrent of messages of concern, advice and best wishes on Twitter after I had posted her picture on Thursday evening. Some of these were from friends and people I knew, some were from total strangers. They were a great source of comfort and reminded me, once again, of how much decency and kindness there is in the world. From the news and some corners of social media it is n’t always possible to get that same message.

Having grown up with a disabled brother, the kindness of strangers has always been something I have been aware of. Ironically, blindness is a very visible disability and over the years I have witnessed countless acts of kindness towards him. Even in London, with its all rush and bustle, I am always struck by how readily people will give up a seat on the Underground for him.

Such acts of kindness go much wider. Just before I left Rethink Mental Illness I had the privilege of being involved in the events surrounding “Find Mike”. The charity worked with the campaigner and expert by experience, Jonny Benjamin to try find the person who, several years previously, had helped him when he had been on Waterloo Bridge about to attempt suicide. Jonny didn’t know his name but had a recollection he was called Mike. After a week or so the person was found, not called Mike at all, and Jonny and Neil’s story has been rightly celebrated ever since.

One of things that struck me in hearing about what had happened to find the real “Mike” was how many people had come forward. At first, this seemed somewhat disturbing, was there no limit that people would go to for a few moments of celebrity. In reality, it reflected that this was a relatively common situation and that were many “strangers on the bridge” whose intervention made the crucial difference when someone was thinking of taking their own life. On Thursday night the police told me that in cases of missing people, especially older people with dementia, it is usually ordinary people in the street, noticing someone who is distressed, who ensure that missing people are found.

In suicide prevention, the role of ordinary people, whether strangers or wider family and friends, has been recognised. There is an excellent resource which has been developed by the Zero Suicide Alliance and Relias which is designed to help give ordinary people the confidence to support someone who is in distress and maybe thinking of attempting suicide.

Ordinary people of course can also be experts. On Thursday night, as well as messages of concern and best wishes, there was some powerful good advice from those who had been in the same position, both on what was best to do and, just as importantly, how to cope psychologically with the anxiety of the situation.

As we battle to work out, in a time of limited resources, how best we can meet the level of need in society, it is crucial that work out new approaches to make the best use of the role of ordinary people, communities and experts by experience. This needs to be a partnership, not an abrogation of responsibility by the state. There were some positive aspects in the idea of Big Society but it’s juxtaposition with massive cuts in public services negated these and associated the brand with a cynical attempt to cover for the withdrawal of state support.

We’re not always very good, in statutory services, at establishing and nurturing these partnerships. We get too absorbed in our own system and its pressures to look outside and, at times, we can see such initiatives as threatening to our professional identity and worth. Yet as individuals, organisations and systems we desperately need to find effective strategies to harness this dispersed community capital to provide support to individuals in need. Volunteering and the voluntary sector has an enormous role to play in this but the same austerity which has challenged public services has also reduced its resources and capacity.

It is worth remembering that this is not a level playing field. Some individuals and groups will always be more of the subject of acts of kindness and others, whether for reasons of stigma, fear or prejudice, more likely to be shunned. The journey which mental health has gone though in the last 10 years, has, no doubt, impacted positively on the willingness of people to interact and support someone in obvious mental distress.  Other groups still have that more negative experience.

But the biggest challenge is to ourselves. Whether or not you are religious, the story of the Good Samaritan remains one of the most special parts of the Christian tradition. We can all be too busy, too self-important, too frightened  not to stop to help someone in distress but when we do, we do something very special.

 

The frank acceptance of all experience

 

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Last Saturday I went to see the production of Oscar Wilde’s “An Ideal Husband”, currently playing at the Vaudeville Theatre. An excellent cast, led by father and son, Edmund and Freddie Fox and the timeless Susan Hampshire, did full justice to Wilde’s unique combination of wit and pathos. It was a welcome reminder of how much I have always enjoyed his work.

Wilde remains a very accessible figure for a modern audience and, while, in one way, firmly set in his own era, he also manages to speak very clearly to our own. Next to Shakespeare he is one of those writers whose best lines are instantly recognisable and whose wit has a timeless quality. While less well known than “The Importance of Being Earnest”, “An Ideal Husband”, a story of political corruption and blackmail and the eventual triumph of friendship and love, is an excellent play.

It is all the more poignant, as a piece of theatre, knowing that it was first performed when Wilde was on the edge of his own disgrace and eventual imprisonment. It is hard not to sense the feeling of anxiety in Wilde’s authorial voice. His characters speak of their fear of public humiliation and disgrace and the emotional power and genuine pathos of their words is reinforced by what we now know, with hindsight, of Wilde’s predicament.

In part we revere Wilde for his wit, in part as man who became a victim of prejudice and hypocrisy on account of his sexuality. Personally, I admire Wilde for both of these things but, more than anything, I admire him for his love of beauty, his humanity, and his non-judgemental acceptance of his own fate.

Born in Dublin in 1854, the son of a successful Anglo-Irish family, his father Sir William Wilde was an ophthalmic surgeon. After first attending Trinity College Dublin, Wilde came to study in Oxford in the 1870s and later established himself as part of the English aesthetic and intellectual scene. A man who could literally live of his wit, famously telling the American immigration authorities on a trip to America in the early 1880s “I have nothing to declare except my genius, there is no doubt he would have thrived in our own age as a darling of chat shows and television game shows.

Despite this, during the 1880, Wilde struggled to establish himself as a serious intellectual figure. He was versatile in a number of artistic forms, but it was, as a playwright, in the 1890s that he really made his name and it is through these plays which he is largely remembered today.

Wilde was much idolised by society but he also made enemies, none worse than the Marquess of Queensberry, the father of Wilde’s lover Lord Alfred Douglas. With relentless hatred and prejudice, fuelled, in part, by his pathological relationship with his own son, he pursued Wilde to his eventual conviction for “gross indecency”. In a fall from grace of epic proportions, Wilde turned overnight from the society darling to a common convict sentenced to two years hard labour.

Though Wilde’s charm and wit remain a source of delight it is in the Wilde of the years of disgrace that I find the most to admire, captured in his two final works, “The Ballad of Reading Goal” and “De Profundis”, both works of great beauty but written in a very different key from what went before.

In the “Ballad of Reading Gaol” Wilde gives a profound and moving account of the horror and pointlessness of prison, made all the more poignant because its base is not self-pity but, rather, a deep sense of empathy for his fellow prisoners.

In De Profundis, the subject of the very first of my blogs, Wilde makes a reckoning of what has happened to him. In doing so, he recognises not only the horror of what has happened to him, but also, this own role, in those events. “I turned the good things of my life to evil”. Most beautifully it acknowledges his gratitude to those, such as the man who greeted him with respect when he was standing outside the Court of Bankruptcy in his prison garb, who were prepared to show kindness to him in his darkest hour.

One of my favourite pieces of music is Tchaikovsky’s Pathetique Symphony. It contains a gripping shift of mood between the third and last movements which resounds with an enormous sense of sadness. It is a piece of the same era and days after its first performance Tchaikovsky, himself a troubled man, was dead. There is a striking resemblance to the mood of Wilde’s last works.

There is a line in De Profundis where Wilde talks of the humility as the “frank acceptance of all experience. It is a deeply moving definition which I have often thought about. Wilde was a man who experienced the heights and depths of the human condition and was in the end, capable of looking both in the eye. It is that for which I most love him.

And the greatest of these is empathy – a series of reflections on the NHS at 70

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It is one of the most amazing things about being human that we can find ways of communicating, verbally and non-verbally, about how we feel. At its best, our sense of emotional connectedness is our great strength as, as a species. Its absence lies at the heart of many acts of neglect and cruelty.

Nowhere is that quality more important than in the relationship between caring professionals and those they care for. An empathy which can see, listen too and feel another person’s distress and provide support, reassurance or just a sense of being there. In mental health, but also in physical health, it is the quality, more than anything else, distinguishes outstanding care. It can not be prescribed or, necessarily, planned for but its absence is felt profoundly.

Empathy is a quality which we learn at our mother’s breast. Supported by early parental love and support we learn to make the good attachments which are so fundamental to our sense of wellbeing. So many later problems of mental distress and emotional development can be dated back to early difficulties in making attachments.
Yet empathy is often a quality we neglect in the planning and management of healthcare at the expense of more tangible things such as technical knowledge or the narrow counting of activity and outputs. Yet, to use the words of the poet R.S. Thomas it is “the pearl of great price, the one field that had treasure in it.”

I spent a fascinating evening, last week, with one of our clinical teams which works with children in local primary schools. The team is largely drawn from trainee child psychotherapists, who have come from a wide range of professional backgrounds, clearly motivated by a desire to help children experiencing distress and other emotional and developmental difficulties. They were talking about some of the cases they were dealing with and, in particular, the feelings of both children, families and therapists in dealing with endings. I was humbled by the commitment of the group and by their recognition of the need to make an empathetic connection with the children they were trying to help. When they succeeded in doing so it was for them indeed “the pearl of great price” but it often required great patience and thoughtfulness to reach that point.

It has long been a tenet of the Tavistock clinic, where I work, that you can not see the needs and emotions of those being cared for from those of the individuals who are attempting to provide care. Caring, while being surrounded by distress, is an emotionally demanding task. However willingly people come into working in healthcare the fact needs to be recognised alongside the conflicting emotions relating to a sense of the recognition that it is not always possible to provide more than “good enough” care.

When we look at the use of resources in the health and care services it is essential that we factor in sufficient time and support to allow the impact of caring responsibilities to be processed and the capacity for empathy to be restored. There are a variety of approaches for how this time can be organised: Schwartz Rounds and Balint groups are some of the best known. However, what ever approach is taken, there must be mainstream ownership and proper recognition of this activity in the allocation of resources. This is so crucial at a time, when rightly, there is a focus on issues of productivity and the proportion of time which is spent on the delivery of care.
The voice of service users and carers is also crucial. It provides the narrative for understanding what it means to live with the distress of illness and disability and should set our benchmark of what constitutes good and bad care. In essence, it helps set a common language of empathy.

I have long believed that stories, as much as quantitative facts and data, is an essential ingredient of education for health and care practitioners. They always form for me the most important part of Board meetings, setting the tone and context for other discussions. When things go wrong it is the story of what happened and the emotional impact it has had on all concerned which makes the biggest difference in defining what needs to change.

As we approach the 70th birthday of the NHS let us remember more than anything else the sense of empathy which motivates our collective desires to set up and maintain a health service for all. A sense of empathy which can feel out for the suffering of others, knowing that, at some time, we too will needs its support and care.

Death in Leamington

 

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On Thursday I attended the funeral of an old family friend who had died recently in Leamington at the age of 98. As she had no close family of her own, the task fell to me of organising the funeral. It was the first time in my life I have been so closely involved in the practical arrangements surrounding a death and it made me reflect on that hidden, but most inevitable of, human experiences.

The funeral itself passed off well and I am full of admiration for the undertakers and the vicar whose combination of sympathy, dignity and attention to detail was exemplary. There can be no more difficult work than supporting strangers at a time of bereavement. It is immensely important.

Our friend had died peacefully after a long life. She had gone to university before it was at all common for women to do so, she had been a capable and devoted teacher in a secondary school in the North West. She was a woman of intelligence, of strong values and strong views. On retirement, she had moved back to our roots in Warwickshire where, amongst other acts of kindness, she had supported my great uncle, her former teacher, at the end of his life.

In the last couple of years her health had declined, and she had had to leave her own home and move into a nursing home. Like an increasing number of people surviving to a great age, she had lived out a tail to her life marked by physical frailty, some psychological distress and a growing withdrawal from the world. There was some sense of relief in her eventual passing from this life.

Reflecting on the funeral, I was struck by how awkward we are with death these days. To start with we have drifted away from a common narrative of what death means and what might be expected to happen after death. There is no right or wrong to this, and maybe behind the front of collective religion, it was more the case in the past than we suspect. However, it means that we have allowed ourselves less space to talk about death and less of a common language in which to express that conversation.

The events of death also used to be something which happened in the heart of communities and which we have now moved to the margins in hospitals or crematoria where they are not visible. Unless we are clinicians, few of us are familiar with the physical patterns and processes of death. When somebody dies we are, unless they are celebrities, less aware of the fact, less drawn into the ritual of marking their parting, which in the past, would have impinged on the whole of the community. Our more rootless existence and the more drawn out nature of life, mean more people are dying in loneliness and isolation.

It has also been interesting to observe the process of drawing someone’s earthly affairs to a conclusion. In a way I am very grateful that it is so straightforward, and, in any case, our friend’s affairs were in very good order. Nonetheless it has been striking to see how simple it is to make the transition.

I was struck, in preparing for the funeral, in looking at a poem by John Betjeman of the same name as this blog. It describes the quiet and lonely death of an elderly women in Leamington and the matter of fact reaction of her nurse, bringing her afternoon tea, and realising that her patient has passed away. It could have been written for our friend.

Death should be higher in our public consciousness. Facilitating a good death should be a more prominent purpose of health and care services, recognising the psychological, practical as well as the medical aspects of this. We should be more bothered about this, at times, than we are about our obsession to lengthen life beyond its natural limits. The circumstances of death of so many people should be a further reminder of the bitter consequences of loneliness and social isolation. Above all else we should make sure, as individuals, we are prepared to look ahead and consider ourselves what constitutes a good death.

It is in the nature of the human condition that it is hard to understand or reconcile ourselves to ultimate ending of our days. It is not helpful though, to ignore the issue.