The Emperor’s New Clothes 

The anonymous blogger of The Double Life of the Recovered Professional wrote: ‘The good ones leave, the weak ones follow the crowd, and the leaders bully and intimidate’ and I want to add my voice to theirs. This is an anonymised slice of my experience.  

I am an ex-service user turned clinician and this blog is about my experience of working in a re-traumatising and damaging system.  

For me to have been re-traumatised it follows there was an earlier trauma or set of traumas. This is the essence of them. As a child it was my job to keep my parent happy. I had a very unhappy (depressed) parent and they, and neighbours, teachers and God-parents all impressed on me how important it was to ‘look after’ my parent and the way I could succeed in that task was by being a Good Daughter. Being Good itself broke down into more and less tangible concepts, but more often into a paradoxical mess. It turned out the unspoken task of Being Good was to wholly protect the image that my parent had of themselves as ’Ideal parent’ and to NEVER allow the possibility for my parent to confront the reality of themselves as ’Actual parent’. The cost of my not achieving this could, as I experienced on this perilous learning curve, be my parent attempting suicide. The shame and exposure of noticing themselves being less than ’Ideal’ created a powerful force of self-destruction in my parent. The stakes were high. I really did have to protect my parent’s identity as a Sane, Just and Fair Loving Parent even when they were, let’s say, quite far from that. I tried my best to be a Good Daughter and I endeavoured to completely conceal from my parent the chasm between themselves as Ideal parent and themselves as Actual parent. I wholly took responsibility for filling this reality gap. I owned the task and I owned the shame and I cut myself whenever I had not been Good Enough, whenever I had fallen short and failed to uphold my parent’s need to see themselves as Ideal. To summarise, the task was to invisibly, and completely, distort the truth to protect the way my parent needed to see themselves. I had to unwaveringly admire the Emperor’s new clothes; a task based on a definitively crazy-making premise. 

Fast forward 30 years during which time I had some excellent effective help (not from psychiatry) and completed training as a mental health nurse. I went to work in the NHS, eventually landing in a Specialist Service for people diagnosed with ‘Personality Disorder’. 

I was so pleased to be there, so happy to be working in an area where I felt I could relate and where I knew I had something to offer. I was surprised that my caseload (as a full time member of staff) was fewer than 5 people, none of whom I was expected to see or meet. I literally just had to read the notes and report back on them to a regular professionals-only meeting. (In fact, I only ever met one of the clients once.) Also surprising to me was that the work I would carry out only involved seeing (but actually seeing) a further 4 people twice a month. Startlingly the cultural narrative around me was one of ‘busyness’ and ‘stress’ and ‘insufficient resources’. The narrative was that because of the ‘severity and complexity’ of the people we worked with the numbers of people we worked with had to be (very) small, the hours spent in supervision had to exceed the clinical contact hours, and that the work was very ‘difficult and challenging’. I had 4 hours of supervision a week, (that’s 2 hours of supervision for each hour of contact I had with a service user). 

I learned a few other things. The NHS pension is clearly a good thing and no one wants to give that up. Mental Health Officer status is super smashing and you count yourself extremely lucky for the benefits that brings. What this means in reality is that staff who may be completely burned out and may even hold contempt for service users are going to remain in the NHS for the retirement perks no matter what. Bullying (they didn’t call it that) had been tolerated in the service for more than a decade; ‘He’s a law unto himself’. And the formulaic response if I raised an issue to managers was ‘Just because you think/feel this is happening doesn’t mean that what you think/feel is really what is happening’. Who does know what is really happening then? You? But not me? Isn’t that gaslighting? Reality, it seemed, was set by the people with power, and this was familiar and re-traumatising. 

A number of times in a number of different workplaces and roles I have been accused of, or heralded for, ‘telling truth to power’. I commented on the (4 figure) size of the waiting lists for mental health service in our locality. The most honest response I got from one manager when I shared with them the actual number of people waiting for service was, ‘I don’t like to think about that.’ I also commented on the caseload. At least two thirds of our  service’s caseload was people whom we did not directly work with. This was ‘consultancy’ or ‘professionals’ meetings’ that service users were not invited to. (Has anyone heard of ‘Nothing about us without us’?) In fact, the caseloads of individual community mental health clinicians exceeded the number of people our whole service worked with directly. It seemed as though there was a huge investment in the narrative of our service users being ‘severe and complex’ because their severity, complexity and disturbing pathology was the sole justification for this extraordinary state of vacuous busyness.  Might we have been disavowing something about ourselves and drawing on the vulnerability of this service user group to do so? There’s a word for that isn’t there?  Is it ….. projection? Might that make us…… hypocrites? 

As a service our processes were vague, incomplete, changeable, erratic, disordered and in some instances nonsensical. Some items on our ‘inclusion’ criteria also appeared on our ‘exclusion’ criteria: Has to have symptoms that are severe enough to jeopardise accommodation; and on the exclusion criteria: Instability in accommodation!  This madness gave the service extraordinary flexibility to justify quite arbitrary and contradictory decisions. Additionally people would be told something would happen, and frequently, but not always, something quite different did happen. The discrepancy would not be acknowledged or would be re-directed at such length one might fear drowning in a sea of irrelevant verbal diarrhoea, eventually losing hope for an answer and just settling for the stinking flow to cease. Service users would be treated noticeably differently for unknowable and therefore unchallengeable ‘clinical’ reasons. Their accurate perceptions and warranted accusations of favouritism were turned back on them as ‘their issues to work on’. I found myself unable to be in meetings with certain managers and service users as I felt professionally compromised, silenced and sick. I gained a reputation for bringing the missing voice of the service users and this was reflected back to me with contempt by some senior staff -but not, of course, within earshot of staff senior to them.  

The fragility of some senior managers’ egos in the service was bolstered by secrecy and by control. The rationale was always one of protection of the weak or the lesser, of anyone lower in the hierarchy, staff or service user. The needs and fragmentation of management, whilst evident, were denied, since it was believed that it would be too frightening for the underling staff to think that managers might not be completely in control. Like tiny children we might become paralysed with fear if we suddenly realised ‘our parents’ were out of their depth, confused, uncertain, divided. Dazzled by their good intentions, glowing with complacent glory of working with this ‘most severe and complex’ group of patients and deaf to dissent from your voice or mine, they WERE in their own eyes and in yours too if you knew what was good for you, the IDEAL managers.  

It turns out I am not a Good Employee in the way that I used to be a Good Daughter. I didn’t distort the truth and fill the chasm between the Ideal Service and the Actual Service. I didn’t protect the image of the Ideal Service. I pointed out the lack of numbers of service users, the lack of process, of order, of transparency, of service user feedback, of our collective ‘othering’ and at times denigration of both service users and other parts of the service which seemed to operate from different value frameworks. I made visible the lack of integrity that exists everywhere that professed values are not matched by the values practised. ’We care about what service users think’. Do you? Show me where. I didn’t protect the image of those more powerful than me. I didn’t let myself become infantilised or seduced by cooing, secretive managers who wanted to blow smoke and compliments to distract attention away from needing to be accountable for their actions. I didn’t clap and cheer and admire when the naked Emperor strutted past. I said: ‘He’s not wearing any clothes, he doesn’t practise the values he professes to have, I think our projections might be in this mix too, and we aren’t doing the work we are paid for.’ I am not a Good Employee by their measure, but I reckon I can live with that. 

Don’t get me wrong; I don’t mind working in an Actual Service, one that is naked, struggling, and overwhelmed, is imperfect, vulnerable and makes mistakes and misjudgements but is steadfastly honest and accountable for itself, seeks change and improvement, power with and not power over relationships and has the humility to listen and learn from, and apologise to, the people it exists to serve. These are ‘subjectifying processes ….. that stand in contradistinction to the objectifying narcissistic processes of coercive projection and belittling diminishment’ (Shaw 2014). However, I cannot prop up or carry a sham of integrity of us being an Ideal Service. I cannot cover up where we fall short, or pretend that we haven’t done anything that needs to be acknowledged or accounted and apologised for. As a child I was not there to meet the needs of my parent by distorting reality, and, encountering a parallel situation in my workplace, as a mental health professional I’m not there to meet the needs of the service by distorting reality and pretending we don’t fail service users often. I won’t participate in that.  

I’ll finish with a question to any clinicians reading this. Consider everything I have said here. What stops you being able to tell the truth of what you see to the Emperors of management? 

References:

Shaw, Daniel (2014) Traumatic Narcissism Relational Systems of Subjugation. Routledge 

https://www.theguardian.com/society/2019/may/19/mental-health-nursing-numbers-6000-fall-nhs-england