Authoritarianism, Conformity and Compliance

I started training as a direct entry student midwife in 1978. Unusually for those times I was already a graduate. My first degree was in social psychology and I also had a masters in psychopathology. So when I started I had a body of knowledge which made me understand my experiences in a particular light. Midwifery training is different now and I think that a lot of the structures are less rigid and authoritarian, but I still think much of what follows applies, not only to training but also to practice, certainly in hospitals. Hospitals are hierarchical institutions and hierarchy always implies a certain degree of authoritarianism and competition which is often explicit. In the case of the maternity services the hierarchy works like this: obstetricians are superior to midwives, qualified midwives are superior to students, and health professionals are superior to their clients (however much this may be denied: just observe the behaviour). And this hierarchy applies even if it is not an accurate reflection of reality. A midwife has a realm of expertise which the doctor doesn't; a student may make a correct observation which a qualified member of staff misses; a mother may say that she needs to push and the midwife tell her that this can't possibly be the case (a scenario which happens frequently). I think that the reduction in rigidity and authoritarianism is good, but I do think that the old system had advantages in the very focused, apprenticeship style nature of the training.

During my first degree I had learnt that after the Second World War certain social psychologists focused their research on conformity and compliance because they wanted to understand how it was that four European countries, Spain, Portugal, Italy and Germany, had been enthralled by fascist ideology during the late 1920s and 1930s. I do not want to include the Soviet Union because, however lethally oppressive it may have been in reality, its expressed ideology was concerned with egalitarianism and nondiscrimination, unlike that of fascism. One central aspect of fascist ideology is that an outgroup, or more than one, is defined, differences from the outgroup are emphasised, and the outgroup is actively oppressed. This active oppression allows authorities to keep the majority cohesive and obedient, and enable the authorities to hold on to their power. Under fascist regimes when people comply with authority they find that they are colluding with oppression. They may do this because they are frightened of the consequences of non-compliance, or because they agree with the reasoning of the regime; they may even find that they enjoy oppression.

I should like to concentrate on three classic and well-known experiments by Asch, Milgram and what has come to be known as the Stanford experiment by Zimbardo et al, to give examples of what I brought to my training.

Solomon Asch did his experiment in 1951. Each experimental subject was told that they were participating in an experiment on perception. They entered a room where there was somebody leading the experiment and two other participants. What the subject did not know was that the other participants were stooges who were going to give false answers. The leader showed a card with a line of a particular length on it and another card with three lines, one of which was the same length as the single line and two others which were notably different. All of the ostensible subjects were told to say which of the three lines matched the original in length. Both of the two stooges chose as their answer one of the evidently different lines. And Asch found that the true experimental subject in a statistically significant number of cases agreed with his two fellows. When I was first taught about this I had imagined that the difference would be barely noticeable, a couple of millimetres. It was some years later when I saw examples of the cards and was astounded that the difference was at least two centimetres. The difference was so noticeable that the experimental subjects must have made a conscious decision to lie in order to agree with the majority. And Asch concluded that conforming with the majority was a powerful and common drive.

In a post-experimental debriefing session most of the subjects said that they had known they were not telling the truth, but that they conformed for fear of ridicule. Some had said that they really believed the lines were the same. It is possible that their perception might have been distorted. It is equally possible that they were lying in the debriefing session. I remember thinking as a student midwife that when I qualified I would be able to practise in a way that was more woman centred than I could as a student, because as a student I felt I had to do what I was told to some extent. But then when I qualified I found I was still too frightened to go against the grain. It was only when I worked outside the hospital, as a community midwife, that I was comfortable enough in my own skin to do what I felt was right.

Stanley Milgram's experiment was carried out in 1961 and was specifically designed to see whether ordinary people (most subjects in psychology experiments tend to be psychology students, so there is this specific deviation from the norm) would perpetrate ostensible harm to others if ordered to do so. In this case the experimental subjects were not students but had been enrolled by an advertisement and told that the object of the experiment was to investigate how people learn. The stooges in this case were being given a learning test by the experimental subject and then, when they gave a wrong answer, were subjected to pretend electric shocks. The experimental subject could see a dial which showed what appeared to be measures of the intensity of the shock and at one point the dial explicitly showed the word 'danger' in red. The experimental subject was ordered to give progressively stronger shocks to the point where the stooge was demonstrating what appeared to be the experience of pain, and the marker on the dial had moved beyond the word 'danger'. The stooges were strapped down and unable to escape.

Before the experiment Milgram thought that only between one and three per cent of the subjects would persist beyond the point where the stooge was showing ostensible pain. In fact 65% never stopped, and none stopped even when the stooge said that he had heart trouble.

The object of this experiment was to demonstrate how people obeyed authority figures, even when the authority figures were telling them to do something which caused what seemed to be evident harm to others. Those subjected to pain in this experiment had not been named and derided as an outgroup. In Nazi Germany, for example, the overriding ethos was that certain groups of people, Jews, Gypsies, Slavs, gay people, people with disabilities, were intrinsically inferior and causing harm to them was therefore to the greater social good. It is difficult to know how many people colluded in the institutionalisation of lethal persecution of these people because they believed the propaganda. And in a way I find this less dishonourable than colluding because you are frightened of the consequences. But Milgram's experiment showed that people are prepared to harm others without any kind of systematic belief, just because they were told by an authority figure to do so.

(I have recently found out from my son who is teaching psychology in a secondary school that a number of replications of this experiment have been made in different cultures. All of these replications confirmed the abusive compliance with authority except the Australian. Maybe a heritage of criminality has its advantages...)

The Stanford experiment was so called because it took place at Stanford University in the USA in 1971. A number of psychology students were randomly selected to be either prisoners or prison guards. The hypothesis was that those allocated as prison guards would behave in an authoritarian manner; those allocated as prisoners might either becomes submissive or might rebel. The experiment took six days and was terminated because the actual behaviour of some of the participants became so extreme, far beyond that expected by the experimenters. The roles that the participants were allocated were heightened by certain symbols. The prison guards had batons which they were not supposed to use; they were intended as marks of authority. The prisoners were required to wear demeaning clothing and ankle chains. Some prisoners initially rebelled but others were submissive and some even identified with the prison guards, a phenomenon which has been much observed and is now known as the Stockholm syndrome. The 'prison guards' were more than authoritarian. They were abusive. One member of the university staff, Philip Zimbardo, had been designated prison supervisor and he found himself becoming more involved than he had intended. Batons became used to punish prisoners. Some prisoners needed to be removed for their own safety, either physically or psychologically. The conclusion drawn was that people, to some extent, derive their sense of identity and behaviour not from anything intrinsic to themselves, but from their roles.

It also, like the Milgram experiment, demonstrates the extent to which people are prepared to be violent to others.

This is what I brought to midwifery training. It seemed to me that the concepts of conformity and compliance to authority demonstrated in these experiments were very relevant. To some extent they were what we were being explicitly taught as student midwives, but the lesson I had learnt as an undergraduate was that conformity and compliance were never to be accepted without question

When I first started training I felt as though I had joined the military. We wore uniforms, were addressed by our last names and expected to obey orders. I only survived my training because of my fellow students, who were unusual and two of whom had undertaken the training for explicitly feminist reasons. Otherwise I felt infantilised. I thought the women were patronised. I was extremely shocked by the way in which we were expected to learn. Even my primary school in the 50s had not treated its pupils like this, never mind university. As student midwives we were not taught to question anything, in fact we were taught specifically not to question what was told us, but rather to accept everything we were told as indisputable fact, because those who were teaching us were our superiors. University education had explicitly taught me to be critical, to check out the sources of statements. But also my specific upbringing, as the daughter of two parents whose politics were not those of the majority where we lived, had taught me from a very early age that different opinions exist, and that these differences are legitimate, and that I could decide which of the alternatives was more congenial to me for intellectual, political or simply capricious reasons.

I know that midwifery education is now university-based, so I assume that this mode of learning no longer applies. I hope that people are no longer referred to by their surnames. I don't know to what extent the necessary protective clothing which nurses, midwives and doctors wear designate their roles and status nowadays, but if they do then there is still this somewhat military quality whereby clothing represents rank. I do not know, but I doubt very much that staff working in the health service are treated as people with different roles all of which are equally valuable. I would imagine that the old hierarchies still exist. Much of what I read currently on the ukmidwifery e-group supports this.

In addition to this research which I had learnt as part of my formal university teaching, I had long been interested in psychoanalysis. I regard psychoanalysis not as scientific theory but as an imaginative discourse which is relevant to midwifery because it expresses the way in which psychic processes are learnt as the result of early relationships; midwifery deals with the mother-child relationship from about as early as anybody can. It therefore hypothesises a link between midwifery and psychology which could be profound.

I don't think the unscientific nature of psychoanalysis is a problem. I think an imaginative discourse is a good basis on which to justify practice. It is scientific in so far as testable hypotheses can be generated. I think it is evident that much of what is popularly seen as scientific is not so: much of scientific development is driven by commercial or political concerns and the way in which scientific discourse is popularly described depends largely on journalists not educated scientifically.

Psychoanalysis has, since Sigmund Freud focused on sexuality and aggression, tried to articulate and bring into the discourse that which has been previously shunned as unacceptable. One thinker who seemed particularly pertinent was Melanie Klein because she tried to articulate (albeit in rather bizarre phraseology) the mindset of babies. This seemed relevant to me as a midwife, but I also identified with much of what she was saying for personal reasons. She focused on envy, particularly in the book Envy and Gratitude. She described a number of defence mechanisms such as splitting and projection, and they seemed to me to describe much of the behaviour I saw around me generally, not only in hospitals or international events. It seemed as though she had described the interpersonal aspects underpinning fascism. With splitting individuals deny in themselves that which they find unacceptable, such as aggression or sexuality, while with projection they then ascribe these attributes to an outgroup. It has always seemed notable to me how racists think that black people are oversexed and likely to do them damage. People are particularly prone to these psychological processes when they feel under resourced and/or are reluctant to recognise such attributes as their own sexuality and propensity to aggression.

One book which I read after qualifying as a midwife which described processes particularly relevant to midwifery was the Mass Psychology of Fascism by Wilhelm Reich. Wilhelm Reich went through many phases during his life, but this book was written before the Second World War when he was both a communist and a psychoanalyst, for which he was derided by both institutions. Unlike orthodox psychoanalysts he maintained that human beings were marked not only by unconscious processes, but by material conditions such as their social class, and that both the material and the unconscious were mutually influencing. The book is written in a particular jargon which might make it quite difficult to be read nowadays. Its focus is on the attractions of fascist ideology for the lower middle classes. He describes how people from this stratum are desperate to differentiate themselves from the proletariat, but are riddled by self-doubt because they know that they are not in the upper echelons of society. The proletariat has the strength of solidarity, but this strength is denied the lower middle classes by their snobbery. Fascism has an appeal for these people because by defining an outgroup they, by contrast, feel as though they are important and by positively oppressing this outgroup they release the anger caused by the knowledge of their own real lack of importance or quality of relationships.

My partner at that time was a nurse and we used often to talk about how relevant this book seemed for both nurses and midwives. Nurses and midwives know that they are not among the upper echelons of the health profession: those are the doctors. And it seemed to us that they often took out their frustration on their patients/clients. They were certainly very conscious of their status. When I first started training we had five weeks in the maternity department before we joined the new set of student nurses for six months training in general nursing. After an initial week in school learning some fairly basic stuff we were allowed on the wards to observe. At one point I was observing a staff midwife looking after a woman expecting twins. It was her first pregnancy. She was not in established labour and so we were talking quite sociably. At one point the topic of conversation came round to home births and the woman said that if she had not been expecting twins she would have liked the idea of giving birth at home. At this point the staff midwife said that there was a law against women having their first babies at home. I was aghast at this misinformation and spontaneously rebutted this. To which the staff midwife responded 'argue with me when you are a staff midwife'. I have never forgotten this incident because it seemed so emblematic of the strange circumstances I found myself in.

There is a television programme called One Born Every Minute. It has been widely praised in the press as giving a realistic and unsensational view of childbirth. Recently it showed a midwife saying to a young woman 'I'm just going to examine you down below and then break your waters'. I think this is indicative of a mindframe where the professional is unnecessarily using euphemisms to a client and is assuming that she, as a professional, has the right to make a decision which ought really to be solely the province of the woman. The use of euphemisms is patronising and it serves the purpose of enhancing the status of the professional. And, essentially, to undertake a procedure such as artificial rupture of membranes without fully informed consent except in life and death emergency is assault. And if this statement seems extreme it is counterbalanced by my sense that women are routinely not given the information to give proper consent; they are told what will be done to them, and it is assumed that the experts know best.

It may seem extreme to be talking about fascism in this particular context. But I believe that fascism is something written on a national scale which occurs universally on a smaller scale. And it occurs particularly in circumstances where there is a hierarchy and where there is a sense of being under resourced, like the NHS. D.G. Myers writing of Jean Améry, who survived a number of concentration camps and after the war lived in Belgium until his suicide in the sixties, wrote ‘Perhaps better than any other Holocaust writer, Améry shows that the liberal pillars upon which Western civilization rests are not dug very deep; they are merely taken for granted’. I am not sure to what extent this statement is specific to Western civilisation. There are plenty of brutal regimes outside the West. If the invocation of fascism seems extreme something which is much more everyday is the way that institutions such as workplaces develop cultures of bitchiness and bullying. I would maintain that most institutions include these ways of relating; they are probably more normal in statistical terms than openness, non-defensiveness and good humour.

Isabel Menzies, as she was known before she married, worked for the Tavistock as a psychoanalyst specialising in the way that unconscious motives work in institutions. In the 1950s she was commissioned by a London teaching hospital to look at their programmes of teaching student nurses, because their rates of retention were so low. The 1950s was a long time ago, but I don't think this work has ever been superseded nor have its conclusions being fully taken on board. She described the work that student nurses were learning to do as intrinsically anxiety provoking for a number of reasons. It was concerned with people who were sick and therefore involved dealing intimately with people in ways which were generally taboo outside the sexual and parental realms, dealing with naked bodies, excrement and bodily fluids such as vomit and sputum. The people in hospital were themselves anxious about their condition, as were their relatives and nursing therefore involved either engaging with this anxiety or actively refusing to acknowledge it. She described how a system of working with patients had evolved which meant that emotional contact was minimised as much as possible. So nurses developed systems such as task allocation which put the emphasis on the task which must be fulfilled rather than the individual patient; their interpersonal relationships with other staff members were formalised and this was emphasised by uniforms which designated their place in the hierarchy and very formal ways of addressing each other. This was described as professionalism. She also (and I think this is particularly relevant for midwives) described how staff did not take on all the functions for which they were formally trained and tried as far as possible to delegate responsibility to those above them in the hierarchy.

She concluded that this way of working reduced anxiety by minimising the extent to which the staff had to empathise with their patients. Institutional structures were created precisely to facilitate this distancing. As a psychoanalyst Isabel Menzies-Lyth accepted the concept of unconscious processes, so there is no suggestion here that these structures were created deliberately. But the unconscious nature of their creation means that they are more difficult to uproot. However this reduction of anxiety in the professionals implied that their clients were to some extent dehumanised, which had deleterious implications for their mental health and had a parallel effect on the professionals, hence the poor retention rates. In order to remain working in this environment it is easier to adopt the mores and this can be observed in both professionals and patients/clients. Social psychology uses the process it describes as cognitive dissonance to explain how it is that people will adjust attitudes if circumstances cause a conflict between them. This is another process which I have found useful. For example, I think it explains the much quoted remarks that women do not mind who looks after them in labour: I think that women actually do mind this very much, that continuity of known and trusted carer is crucial, but because they do not believe that this is likely they do not have allowed themselves to recognise how valuable it is.

I think that these processes still continue. Degrees of formality have been reduced in the intervening decades, but it has been extremely difficult to eradicate task allocation. During my awareness of professional practice there have been two major attempts to create a more holistic approach to patient care. They were known as direct patient care and primary nursing. Neither succeeded because it was decided that these modes of relating were not cost effective and the concept of 'skill mix' was developed. I think that with the major restructuring of nursing and midwifery education which came with Project 2000 this has to some extent been further consolidated. Sick people in hospitals still need basic care and those who regard themselves as university graduates are less inclined to provide this care. There have been recent examples of failures of basic care in the media which to some extent represents staff shortages but which I think embody the sense that ensuring that people are clean, comfortable and fed is very low status work however intrinsic it is to good health.

All this is hypothetical. Social scientific premises cannot be tested in the way that those of physics can. However there is a word used in social science which I think is applicable here: heuristic. I find these hypotheses helpful. I think they explain a lot.