Who’s missing from Inside Out’s internal family?

Where Riley’s writers could go next.

Henna Cundill

Henna is a researcher with the Centre for Autism and Theology at the University of Aberdeen.

Cartoon characters of emotions at a control desk.

Inside Riley's head.

Disney.

Once upon a time a man got angry. Then he got angry at himself for the fact that he got angry, which of course didn’t help. As the Buddhist monk Thich Nhat Hanh would say, “If we become angry at our anger, then we will have two angers at the same time.” Similarly, there was an occasion when he got really nervous that he might make a mess of giving a speech, and his nerves became so overwhelming that he delivered the speech badly. A self-fulfilling prophecy, one might say.

These are not my examples; they are examples given by psychologist Richard Schwartz in his introduction to Internal Family Systems (IFS). This therapy (sometimes also called “parts therapy”) is a form of self-analysis in which participants learn to resist supressing or controlling their difficult thoughts or emotions, the different “parts” of their inner world, and instead adopt a posture of curiosity towards each of them. This posture allows people to be in a beneficial relationship to their emotional lives, rather than being ruled by them.

Fundamentally, the relationship that emerges is one of compassion, understanding that our thoughts and emotions have a job to do, even the uncomfortable or shameful ones. So, anxiety, for example, guards us from committing social faux pas, whilst joy helps us to keep hold of a sense that life is ultimately worth the living, no matter how hard things get. Even sadness and grief, as much as we fear being overtaken by such emotions, have an important role to play, for example by helping us to define what things and people are most valuable and important to us.

For those who haven’t seen the Inside Out films, the writers cleverly take this idea of the “internal family” of emotions and create five relatable characters that embody them – Joy, Fear, Sadness, Anger and Disgust. In the first film, we see how these characters interact inside the head of a little girl called Riley. They are helping her to hang on to her sense of self despite the upheaval she experiences in her outside world, when her family relocate to a new city, and she must settle in to a new home and school. In the sequel, we rejoin Riley as she enters the turmoil of puberty, and the five initial characters are abruptly forced to work alongside some new arrivals – the “teenage” crew of emotions: Anxiety, Ennui, Envy, and… the biggie… Embarrassment.

This Self is transpersonal – it exceeds the boundaries of who we each are as an individual person and connects us to something large.

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When he first developed IFS in the 1980s, Richard Schwartz was, by his own confession, a committed atheist, with what he describes as “a distain for religion”. Schwartz writes of the frustration he felt at that time when several Christians got excited about IFS in its early stages of development. His peer, Robert Harris, even went so far as to publish a book that set out a Christian version of the therapy. Initially, Schwartz felt the biggie – embarrassment – that his therapy was being taken up by Christians. However, as time went on, and as much as Schwartz tried to push aside the spiritual dimension of IFS, he increasingly found that spirituality could not be eliminated from the picture:

“As I used the model with clients through the eighties and nineties, increasingly they began having what can only be described as spiritual experiences. These vicarious encounters with the mystical profoundly affected my own spirituality and I became interested in Buddhism, Hinduism, Taoism, shamanism, Kabala – everything but Christianity.”

Over time, Schwartz’s antipathy to the relationship between IFS and Christianity began to wane. He saw how much he had been working on the basis of prejudice, limiting his own exploration of Christian ideas in response to some unhelpful encounters he’d had with a few heavy-handed fundamentalists. He made deliberate moves to engage with Christian dialogue partners across the breadth of the tradition and began to see how congruent IFS was with the teaching of Jesus. The posture of curious compassion towards oppressive and uncomfortable emotions that Schwartz was encouraging his clients to adopt was mirrored perfectly in the attitude that Jesus advocated towards “enemies” in the outside world: do not judge, instead seek to engage them with kindness, and work towards their healing.

In recent decades, Schwartz has come to rethink IFS as an integration of psychology and spirituality, rather than as a form of psychotherapy. He speaks of “spirituality” as an innate essence at the core of each person, which he calls the “Self”, and acknowledges that many of his more religious students prefer to think of this essence as “the soul” or “Atman” (the eternal self within Hinduism). And, whilst he still describes himself as fundamentally agnostic and is wary of making his own definitive religious commitments, he has come to agree that this Self is transpersonal – it exceeds the boundaries of who we each are as an individual person and connects us to something larger.

Screenwriting for a popular audience of all-faiths-and-none, it is perhaps unsurprising that the makers of Inside Out have thus far eschewed the deep and fascinating spirituality of IFS. Riley’s “sense of self” is at the centre of both films, but the way it is depicted implies that it is something that only comes into being at birth and exists entirely to regulate Riley’s engagement with the outside world. So far, there has been no exploration of more existential questions such as faith and eternity. However, the concept of the film is so brilliant, and for a complex idea it is so well executed, that I am sure we can look forward to many more Inside Out films to come. If that is the case, then just as Schwartz found himself going on an unexpected journey of spiritual exploration, the writers of Riley’s may well find themselves doing the same. I, for one, look forward to finding out what Riley discovers.

Article

Care

Change

26 July 2024

6 min read

Are we forgetting how to care?

The profound act at the heart of nursing.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient

Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care. Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions?

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers.

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’.

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care.

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?”

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness.

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.”

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.