A couple of months ago I attended a conference where there were professionals, Families and carers and service users all in the audience. I was struck by some of the dialogue that came out of the presentations, workshops and groups. The conference was about a pretty new way of working and most of the professionals attending, a mix of clinicians, therapists and other workers, were pretty insistent that they were already working in a way that was in line with what the conference was all about. However this was not the experience of the service users, families and carers. They very clearly and very articulately and almost universally, said that none of them had experienced anything remotely like what was being described, despite coming from the same, or similar, geographical areas. This got me thinking about some of the training I deliver and how often there is a real belief on the half of the people attending that they are already doing what I’m talking about. Like many of these things, as I’ve become aware of this, the more I’m noticing it.
The scary part is that there seems to be a genuine belief that people are doing things, which often they aren’t, and that thing the thing they believe they are doing is, in some way, clinically justified and done for the greater good. It’s strange how, when you get your teeth into something, it seems to develop a life of its own and you feel yourself drawn to things you may not have been drawn to previously. This happened recently when someone recommended a book to me about public shaming. The book is by Jon Ronson, the guy who wrote the psychopath test, and is called so you’ve been publicly shamed. In the book Ronson examines the history of public shaming, how it has become a massive internet phenomena and, to extent, why it happens. As I read it, it became very apparent that there are lots of parallels in public shaming and professional cognitive bias. For example the Zimbardo experiment that took place at Stamford University in the 60s revealed some surprising truths following more recent scrutiny whilst researching this book. Philip Zimbardo is a psychologist and professor emeritus at Stamford University. In the experiment he was trying to test his hypothesis that the inherent personality traits of prisoners and guards are the chief cause of abusive behaviour in prisons. He selected 24 males out of 75 respondents to invites to participate in the experiment. They were deliberately selected to have no criminal background and be psychologically stable. They were predominantly white and middle class. He split the group into two designating them the role of 12 “guards” and 12 “prisoners”. Pretty soon the experiment appeared to get out of hand, the guards started to appear to be belittling, disrespecting and de-humanising prisoners. The prisoners appeared to become submissive, conforming and soon began to lose any kind of rebelliousness. In fact the experiment had to be called to a halt when Zimbardo’s then partner came on site and was horrified by what she saw.
Zimbardo thought, and still does, that the whole thing confirmed his initial hypothesis. This behaviour was, in fact, inherent and manifested, almost naturally, as and when the right social circumstances were put in place. In fact he thought that these drives were so strong and so deeply ingrained that he himself had been drawn into the spirit of the experiment, lost his objectivity and had encouraged the guards to be even more cruel and harsh. Whilst researching his book Ronson tracked down some of the participants and, despite his old age, managed to interview Zimbardo. Ronson started with a hypothesis not unsimilar to Zimbardo’s that most examples of mob rule, including public shaming, followed a process, identified by French physician Gustav Le Bon in his 1895 book the crowd, involving a kind of mass contagion of emotions. The crowd, in effect, becomes a homogenous unit where every sentiment and act becomes contagious. In a crowd we become impulsive, irritable, irrational, like a grain of sand amid other grains of sand, which the world stirs up at will and infects everyone around us. (Le Bon 1895, the crowd). Ronson started to question this hypothesis as began to recognise something that Zimbardo really hadn’t taken into account. Zimbardo, in Ronson’s opinion, had failed to realise the importance of his own participation. As he interviewed participants he began to realise that, far from being some kind of mindless victims of mob rule, they were in fact scheming, manipulating and acting their way into Zimbardo’s favour. Participants simply wanted to please him and make, what he was trying to achieve, work. Now this began to put a different slant on this blog and my attempt to make sense of the professional cognitive bias so obviously endemic in health, social and criminal justice care.
What I encounter time after time are people and systems involved in health, social and criminal justice entirely convinced that they are working effectively and productively and they have little or no culpability even when the evidence says something very different. It would be so easy to put this down to the ignorance, laziness, lack of vision, and lack of ambition which I myself have in the past. But what if it were something entirely different? What if it was none of that and it was just simply people trying to please and comply with systems and a management style that was neither pleasable nor indeed compliable? What if the “professional cognitive bias” has become so entrenched in the system and culture that we simply cannot keep trying to fix it and we need to develop a completely new way?
Recently it was all over the news that almost every aspect of the NHS is grossly over spent, as far as I can understand this represents an overspend on an overspend on an overspend. Politicians will adopt the same strategy, blame individuals, root out fraud and corruption but avoid the bloody obvious that the poor decisions, fudging of targets, massaging figures probably has very little to do with mal-intentions and has everything to do with people trying desperately to please. They are, in effect, doing almost exactly the same as the students in Zimbado’s basement experiment, much the same as any nurse, medic, manager will do when confronted by an unworkable system with unrealistic targets. Everyone involved will probably know that it’s the system and the way it’s managed that’s at fault but goes along with it because they don’t want to be seen to go against it.
Fundamentally health care will always be stuck in a finite resources-infinite need continuum but the NHS was set up on some kind of assumption that we could somehow muster infinite resources and make need finite. What it didn’t take into account was the culture of dependency and entitlement it would create and the ever increasing costs of fighting illness in a population that is ever increasing and living longer. When the labour government in 1947 devised the NHS they could not have imagined the dependency on medical interventions and subsequent costs of the drugs involved that they were about to create. They could never have imagined life expectancy almost doubling and infant mortality reducing so dramatically. They probably couldn’t even contemplate the erosion of the human condition into diagnosable medical problems needing ever more expensive pharmaceutical solutions. But by far the biggest and, in many ways, most damaging and destructive force that almost forces people into professional cognitive bias, is a kind of paranoid mistrust that seems to permeate the system from top to bottom. It’s sold to workers, and people using services, as “improving patient care”, or “ensuring excellence”. It’s probably driven by an almost phobic reaction to things like fear of litigation, fear of missing targets or just simply losing face in the current quartile you find yourself being compared with. It hits people in the way they spend almost every working hour justifying their existence, pointlessly risk assessing anything that moves, aimlessly ticking boxes, counting and producing ever increasing amounts of meaningless data.
On the whole almost everyone entering the caring professions will be, by definition, a caring person. Some may be quite broken themselves, finding their healing in helping others but caring also attracts probably more than its fair share of very broken people who care for, shall we say, less than altruistic reasons. In the current climate of paranoid mistrust, pointless paperwork and unattainable targets, those amongst us with a more narcissistic/sociopathic/psychopathic slant tend to become very plausible and percolate towards management positions. What they may lack in things like empathy and emotional intelligence they more than make up for in arbitrary decision making, autocratic management style and simply appearing to get things done. Their inability to see the others perspective becomes an asset and organisations employ more and more like them. Because their core values are more Machiavellian, power seeking and self-centred, caring values like empathy, compassion, dignity, hope and connection become secondary. Whole strata of management and organisations become perpetrator, with workers and service users flipping between rescuer and victim. Everything takes on a must do now dynamic, explanations for why being rarely given, and new ways of doing things are imposed all too frequently.
Most people who work in the caring professions are highly qualified, motivated, experienced and innovative. To help them maintain this, and retain them, they need some very simple conditions in place. Once qualified, competent and confident, they need to have a level of autonomy that allows them to practice independently. Within this autonomy they need to feel free to make decisions commensurate with their level of skills, qualifications and experience. They need to feel free from intrusive management and have confidence that if they do make a mistake it will be treated sensitively within a culture that is, as far as possible, not seeking blame and/or retribution. They need to feel part of something that makes sense to them and that they believe in. They need to feel that the organisational values align with their values and see all the managers as a manifestation of all those values. They need to feel they are part of something that gives them a sense of purpose and affords them the time and space to reflect on practice, take risks, build evidence, challenge old paradigms and grow. The working environment needs to be a more level playing field and truly reflect holistic multi-disciplinary working practice. Cognitive bias needs to be accepted for what it is, part of the way we have evolved and an essential component of being human.
Cognitive bias is, quite simply, how our brains have evolved to work. The brain receives bits of information, almost instantaneously puts its own spin on it based on past experience, and comes up with a position, possibly requiring action. Sometimes we need to undertake this process fairly rapidly, often from a perceived position of self-preservation, but mostly we need to slow down the process, think things through and not act out on our first thoughts. Our first thoughts are, almost always, brought about from a position of uncertainty. Uncertainty makes us feel threatened and uncomfortable and the cognitive bias involved is the overriding urge for control, comfort and certainty. All too often we seek this solace in the, so called, robust systems we create and the person who seems to be most adept and most confident in applying them. When it appears to go wrong, which it often does, it’s never the system or the person calling the shots that becomes accountable, it’s always some poor individual who probably made a poor decision. Not because they weren’t qualified or, indeed, out of any kind of malice, but because they were trying to make an unworkable system work and, in some way, please the person managing it.
Finally I want to try to illustrate this whole scenario by using the latest Joseph Helleresque catch22 situation that I have personally come across. I see Mental Health nursing as a very noble profession. It’s quite possibly the only branch of nursing where everything is really about the relationship between patient and nurse. A good MH nurse knows the people they are working with intimately, based on strong therapeutic alliances. Often we are working with people who not many other people would work with, helping them deal with unpredictability on a daily basis. Unfortunately not all areas of mental health care are like this with many labouring under a collective biomedical illusion with its over-emphasis on psychopharmaceutical solutions. As a mental health nurse I want to be an advocate for the people I work with, when they are unable to advocate for themselves, and I want to be able to help them to broker the best possible treatment plan available. I consider myself well qualified, I have over forty years experience, I am very well read and have a really high skill set, yet I find myself constantly trumped, in multi-disciplinary decision making formats, by consultant psychiatrists and medics. Often this comes from a very paternalistic, we know best, position and, more often than not, it involves a decision to medicate or medicalise. Although many of these have involved direct breaches of at least three of the Nurses and Midwives code of conduct, I have found myself reluctantly complying and, a bit further down the line, helping the person to deal with the consequences of that decision. It’s Zimbardo all over again, it’s the systems we continue to create from a position of cognitive bias, uncertainty and control and it’s the people that seem to gravitate to positions of authority and plausibility we seem to appoint.