The Denial of Shit and the Impossibility of Institutional Compassion

Since Robert Francis’ report the importance of compassion in healthcare, and the risk of catastrophe when it is lacking, have been repeatedly highlighted. Healthcare Trusts now offer training in compassion to employees and include compassion in their mission statements, corporate values, and letter-heads. And yet staff and patients appear to be fighting a rear-guard action to maintain their own compassion towards one another, as though our national structures and institutions are pushing in the opposite direction.

What we witness is an imperious demand for compassion hand-in-hand with a persistent modelling of its opposite. Take, for example, the way that the anchors of news and current affairs programmes interview their guests, senior and middle-ranking executives are held to account at board meetings, or the word “compliance” flourishes in mass mailings of health service organisations.

We are drip-fed the message “We value compassion highly and we shall censure without compromise anyone who demonstrates anything less than excellence in their compassion towards others”.

This cannot be simply because we operate in reduced circumstances. The UK, despite current efforts to the contrary, is still one of the richest nations in the world and, in any case, wealth and compassion are, if anything, inversely related .

My belief is that this incongruent relationship between talking the compassionate talk on the one hand and walking the compassionate walk on the other stems, not from lack of material resources, but from emotional immaturity at a societal level.

Melanie Klein described a stage in individual human development which she called the paranoid schizoid position. We need not be put off by this language if we can distance ourselves from diagnostic labels. Schiz and paranoia refer, respectively, to a split and a sense of persecution. The individual (perhaps an infant) finds it intolerable that something good (like the breast) could do something bad (like not be there when required). Only a bad breast would do such a thing. We categorise things into either good or bad, and cannot accept what we all believe we know which is that nothing is either wholly good or wholly bad.

In order to develop a tolerable relationship that endures across time, we have to grasp the fact that the good thing might be temporarily not so good, and develop the capacity to experience some concern for its welfare. You will see where I am going with this.

Generally speaking, this realisation that there are no purely good things, and that what good there is typically doesn’t last forever, is a rather depressing one. Melanie Klein called it the depressive position. Welcome to grey.

The depressive position is a difficult place to be. Even the guru who beams broadly whilst explaining this to you is liable to be slipping back into a pre-depressive notion of Nirvana. Generally we are drawn to escape to a place where good people look cool and win in the end.

When we place ourselves next to someone and acknowledge their suffering, we must acknowledge also the fact that we may be unable to alleviate it. We acknowledge and live with the fact that we are not perfect. Nor were our teachers, or the service we work for. As a clinician I have to acknowledge that my patients, also, are not perfect or without a degree of responsibility for their suffering. But neither my own limitations, nor the failings of my patient should prevent me from sitting with them and doing what I can.

It is not so easy to be compassionate when you are in a hurry, or are worried about professional revalidation, but it is utterly impossible if you are unable to accept, as Milan Kundera so eloquently put it, the existence of shit.

The problem is that the depressive position does not sell. Practically everything we are currently offered belongs a pre-depressive universe; perfect holidays, faster downloads, Snapchat, smile smile smile (and attack deviation). We don’t get a lot of practice or encouragement in living in the depressive position. Even this blog post invites the idea that it is the answer to something.

When it comes to our electoral system, first-past-the-post is the very embodiment of Klein’s paranoid-schizoid: We split the politicians into two huge camps, employ a three-line whip so that there is no diversity in the ranks, and then vote yes or no. It is a digital-binary process. The in are in, and the out, out.

The party, in order to get or to stay in power, will write a manifesto full of absolutes. The current-affairs interviewers will press their guests to a binary answer; “Will you or will you not? Is that a yes or a no? You are clearly not going to answer my question” (pulls lever to room 101).

To accept someone, whether they are friends, political leaders, or passers-by, is to accept that they will fail at some point. Compassion is easy to say, but not so easy to do. Paranoid-schizoid is harder to say, but a) comes more naturally to us, and b) is hell in the long-run. Perfection and the total segregation of glory from grime may be attractive as a notion, but it is impossible to achieve. We have to live with that reality, too.

Much of therapy involves effectively helping people to accept a situation that is frequently far from ideal, and to move forwards from there. Aspirational language is exciting and may be, for a while, invigorating, but first we have to know where we stand. Indeed, at an individual level, many people do manage to get their heads and hearts around this. As collectives we find it harder. The mob, in particular, seems to find it impossible. Our institutions really ought to be able to embody, in the language they use, something more mature – more compassionate: Embrace me and my failings, and I will find it easier to embrace you, yours, and others.

As long as the country, the media, the health service, and such-like persist in labelling everything either good or bad and encouraging the eradication of bad, individuals working and living in the system will struggle to show compassion. As well as exhorting us to it, our institutions need to model compassion. They need to be more ready to admit to the existence of shit.

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