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Subject: paper for PSYCHOMEDIA
A CULTURE OF ENQUIRY: LIFE WITHIN A HALL OF MIRRORSby Peter Griffiths and R D Hinshelwood
written for the conference of the Internationa Society for the Psycho-Analytic Study of Organisations, July 1995 in London
In this paper we describe work within a therapeutic community dedicated to a culture of enquiry. We describe this work in order to link it with psycho-analysis, the general tradition of therapeutic community work, current notions of reflective practice and the metaphoric reflective space of groups and organisations. Placing psycho-analytic ideas at the hart of the primary task makes the notion of internal consultancy central to therapeutic community work. However any institution has to mount a struggle to maintain a space in which the culture of enquiry can adequately function; and psycho-analysis itself can be used in a perverse way to close off enquiry.
We look at the development of the Cassel Hospital from the point of view of Tom Main's approach to the therapeutic community. It is, in part, a history of the struggle to maintain a culture of enquiry. We describe briefly the socio-technical system based on the dyadic nature of psycho-analysis and its implications for an organisation that seeks to maintain an enquiry into its organisational dynamics. We detail many other interconnected processes which function as social defences, and which the culture has to withstand in order to keep such a space for reflection and enquiry open.
A unique property of therapeutic communities and many in-patient psychotherapy units is a psychodynamic awareness of the organisation itself. The concept of a 'culture of enquiry' has grown up in recent years as the hallmark of the therapeutic community (Main 1967, 1983, Norton 1992). Working within such an institution dedicated to insight, might seem entirely enviable. In fact it is, like all organisations, beset by its own problems. There are dilemmas in attempting to work in an internal consultative way and this paper is a case study of how such a culture can be generated, lost and found in a psychoanalytic therapeutic community. Within this struggle, between the opening of a space for enquiry and its closing off, psycho-analytic understanding itself is a discourse which both contributes to, but also distracts from this enquiry.
The Institution - A Psychoanalytic Therapeutic Community.
The institution which is the basis for this study was developed by Main (1946, 1983) from 1946 to 1976 to create a model hospital that was self exploratory of all its systems.
Main had worked on the problem of high and low morale in combat units and in individuals during the Second World War, and emphasised the importance of group influences and mutuality in the development of group-psychological defence systems against personal depression, disaffection and panic.
-In the field one met well-run units of high group morale which carried significant numbers of men with manifest personal breakdown who refused to report sick, and who would soldier on effectively; and other units which combined to make an unhappy and inefficient whole with generalised reactive miseries, complaints, delinquencies and psychosomatic disturbances, even among men with records of stable personal health... What was it about battalions which made the difference. It had nothing to do with the social structure... It seemed to be something both more vague and more important; it was the culture, the human folkways by which the system was operated- (Main 1977, p. **).
This mutuality between real people led Main to the importance of real representations as much as instincts and the internal phantasies that are expressed in them. At Northfield, Main set about an exercise in systems thinking before the term had been coined (Main 1946, 1983, Rickman 19**). He applied his thoughts about combat units to the hospital setting and recognised how an ordinary hospital operates various socially accepted defensive structures. For instance: -[...] only roles of health or illness are on offer; staff to be only healthy, knowledgeable, kind, powerful and active, and patients to be only ill, suffering, ignorant, passive, obedient and grateful... In most hospitals staff are there because they seek to care for others less able than themselves, while the patients hope to find others more able than themselves. The helpful and the helpless meet and put pressures on each other to act not only in realistic, but also fantastic collusion... [The] helpful will unconsciously require others to be helpless while the helpless will require others to be helpful. Staff and patients are thus inevitably to some extent creatures of each other- (Main 1975, p. 61).
Main thought that whilst this basic assumption might be valid for some purposes in a general hospital it was certainly not appropriate for a hospital treating patients with neurotic disorders.
It is particularly the insight into this mutual projecting system to which Main devoted his psycho-analytic thinking.
Main believed that this way of thinking and linking was an application and development of Freud's method (Main 1983). As a community of interdependent systems Main recognised that, from the human individual to the hospital as a whole, the institution's own health needed care and monitoring:
-every higher-order system [the hospital] is related hierarchically to the lower-order system [a patient] and has to be studied and helped in its own right if it is to understand and support the work of the lower-order system- (Main 1983, p. 206).
That gave birth to the concept of the Therapeutic Community (Main 1946, 1983).
He was aware of the need for clarity of the structure and roles at each level; that this enhances efficiency and minimises anxiety and conflict. He believed the culture, the folkways operating in any organisation, were decisively influenced and informed by the way the organisational heads related to one-another. Main (1983) suggested the hallmark of such an organisation was -not a particular form of social structure but a culture of enquiry. It both requires and sanctions instruments of enquiry into personal and interpersonal and inter-system problems, the study of impulses, defences and relations as these are expressed and arranged socially- (Main 1983, p. 217).
Through the ongoing development and application of therapeutic community principles, (Main 1946 and Barnes 1968), the hospital developed what it called a culture of enquiry (Main 1983) which set out actively to use the totality of the daily domestic and recreational aspects of living, in the service of the therapeutic work, so that the reasons for failures in these everyday situations could be explored and discussed.
Psycho-analysis is not practised within the hospital. Treatment comprises of at least three inter-related aspects:
1. Individual psychoanalytic psychotherapy;
2. in conjunction with this, psycho-social nursing (Barnes 1968, Kennedy 1986) which takes place in the context of the Therapeutic Community; and
3. patients working actively with each other in the living community.
The hospital's residential living and working environment, forms the basis of a therapeutic milieu and the framework within which nurses work with patients.
Patients are expected to become active participants in the life of the hospital throughout their stay, sharing work, domestic and social activities and joining with others (colleague-patients and nurses).
The hospital is organised around this task:
i. Patients take on real responsibilities for many everyday tasks: cooking, cleaning, gardening etc. They graduate to elected positions of responsibility for managing the many groups that perform these kinds of activities.
ii. All patients are supported by nursing staff; firstly with a key worker (or, 'primary nurse'); and secondly in all elected roles (where patients manage an activity and responsibility) they are partnered by a nurse i.e every responsibility has a nurse manager working with a patient manager.
iii. The whole of this elaborate system of activities is permanently scrutinised for its failings and successes. A system of meetings, overseen by a Community Management Team (mostly staff) two community meetings and various activities meetings (mostly patients) report and receive observations on the running of the Community and discuss problems and ideas for improvement.
iv. Parallel with this is a psychotherapeutic system in which each primary nurse is paired with a psycho-analytic psychotherapist who will provide twice weekly psychotherapy for their patient.
The Hospital therapeutic programme is an interconnected structure of meetings, between staff and patients, doctors and nurses, seniors and juniors. Integration of these different aspects of treatment provides a structured predictable programme (James 1987). In effect it has a containing function for patients' projected aspects, as would an analytic session.
The intention is that the practice is informed at all possible times by psycho-analysis which is applied in two ways in the treatment programme, and this is known as a dual approach (Janssen 19**). These two forms of treatment are called within the Hospital, -the community- and the -psychotherapy-.
The community: The patients live within the community of the hospital which is serviced largely by nurses. Patients graduate to elected positions of real responsibility for managing the many groups that perform the various activities. All patients are supported not only by their primary nurse, but also, in the elected roles they are partnered by a nurse i.e every responsibility has a nurse manager working alongside a patient manager (Barnes 1968, Griffiths and Leach 19**). The nursing role is not, directly to care for patients, but to support patients in their own capacities to care for each other and for the community
Thus the nursing service has developed a specific practice, known as 'Cassel nursing', which depends on a psycho-analytically informed understanding of the patient's development through activity and carrying responsibility as well as the guilt that goes with it. It is the application of psycho-analysis to non-verbal (or less verbal) setting.
The therapy: Each patient, including children who are old enough to use language, are provided with twice weekly psycho-analytic psychotherapy (or child psychotherapy). This is a form of psycho-analytic psychotherapy adapted to in-patient work (Bell 1995). It is also short-term therapy. The therapist will employ in his own mind the concepts of transference and counter-transference, but has to be alert to the various forms of divided transference and multiple transferences that will be operating within the wider therapeutic setting. This becomes extremely complicated but, because the patient lives within the setting, the intensity of the transference can be greatly amplified with a potential corresponding effectiveness.
Because of the intensity of the transferences that operate, the counter-transference that both individuals and groups experience is equally intense and the staff require very considerable support and supervision to sustain a consistent sense of themselves and their work.
The culture of enquiry: However, it is the capacity to sustain enquiry that needs support (Hinshelwood 1994). One of the most important ways of sustaining enquiry is to be clear about the central focus of the work. Extremely clear models of the inpatient psychotherapy and the psychosocial nursing have been achieved over the years (Barnes 1968, Kennedy et al 1987, Bell 1995). So it is against a backdrop of a clear model that enquiry about any piece of current practice can be made.
Although a formal blueprint is an important function in the formal supervision of both the primary nurse and the therapist, there is a need for other structural components.
The two aspects of therapy need to be brought together carefully, and the subtle (and indeed blatant) ways in which patients will arouse different responses in different members of staff is both a familiar aspect of the work, and also an important indicator of the way a patient is processing his own experiences. The primary nurse and the psychotherapy are key figures in this process and there is both a formal and informal structure for the nurse-therapist system to be examined by themselves and/or in a supervision period set aside for nurse-therapist supervision. This is an important space for reflection that can contain and integrate the overall counter-transference experiences of this crucial couple.
In addition, weekly, the whole hospital meets to discuss these counter-transferences aroused within the staff, as a whole. These -strains- emerge in terms of individual patients and incidents as well as in terms of the organisational dynamics of the staff, its sub-groups, its authority and its relations with the external world.
Another notable feature is the division into three Units providing for families, single adults and adolescents. One advantage of three partly separated teams is the possibility of cross-Unit dialogue. One hard-pressed Unit gains help from comment and enquiry from members of another Unit team.
The role that one of us (PG) has, is to undertake 'Action Learning Sets' (Pedler 1991) with groups of nurses within the hospital. These were set up originally to help these nurses define their roles and to relate them to the system they are working in. This has involved role, social structural and work culture analysis to varying degrees and is a collaborative task. However, through the task and a consequent mirroring and sharing of each others' fragments of emotional experience, we have begun to identify a latent realm of institutional experience with both the power to disturb and to liberate the nurses in redefining their role relatedness between each other and with others.
These are specific structural components - nurse-therapist supervision, the staff 'strains' meeting, the interacting system of Units, the role of a specific member of staff devoted to action research - which are a means instituting a self-reflective culture of enquiry. In some ways they represent early attempts to practice what is now formally required in the NHS as clinical audit. However, as Main addressed early on, it is not just the structural components that are important - it is the way they are worked, the culture. To provide a space in the timetable for reflection does not necessarily mean it will be matched by the individuals' willingness to enquire of themselves and each other about their practice. A complex interaction exists between the use of a reflective space for enquiry, and its use for other things that are remote from enquiry.
Freedom from Thought
Main was well aware that such critical faculties, embodied in an organisational culture of enquiry, could frequently be corrupted or lost. Like all human endeavour it runs into trouble. And this is frequent as the continual internal demand on staff, as well as patients, to sustain an enquiry into the hardly known, and unconscious, dynamics is emotionally taxing. In a successful therapeutic community, an ongoing culture of action research, role, social structural and work culture analysis, informed by psychodynamic and social systems thinking needs continually to be set going again.
We will argue that the capacity for the organisation to become more or less enquiring compares with the dynamics within a psycho-analysis which lead the patient to move towards or away from insight into himself. It is to those moments when the organisation laps from its continual enquiry in these many settings that Main directed his attention in his paper on learning and freedom from thought.
In Knowledge, learning and freedom from thought, Main (1967) describes how ideas and theories become internal mental objects and are subject to all the vicissitudes of object relations. Ideas can be passed from one person to another and change their mental residence, moving from the thinking areas of the ego, into the fixed morality of the ego ideal and super-ego. He suggests that this hierarchical promotion of ideas, from the ego into the super-ego, operates at both the individual and group level and at inter-generational levels. Teaching, knowledge and learning can be used by the next generation to avoid thought, feeling and the anxieties that accompany it.
This process has various effects. It saves the individual and the group from the emotional pain, uncertainty and anxiety, in re-thinking their techniques and their problems. They avoid having to find solutions of their own. Staff use or look for earlier precedents or existing knowledge. Rationales for action become the parroted solutions of earlier learning, or an earlier generation. Interesting mental tools become mere beliefs, sets of never-to-be-questioned, always-to-be-believed rules, which now handicap thought, and the culture of enquiry is lost.
Attempts to question these rationales are at first met with benign disinterest (or dishonest interest) and later, feelings of persecution and outrage that such cherished fundamentals should be questioned. Fixed procedures emerge out of flexible techniques and ideas become moralities. Individuals and organisations move from possessing an idea, to being possessed by it.
Above all the quality of the thinking in the institution subsides into a stale repetition of what is already known and done. And this occurs despite individual talents of the individual people. Tradition attains priority over travail. It is well known that therapeutic communities have continually to regenerate themselves, and to re-affirm their allegiance to enquiry and awareness. Norton suggests: -the burden of awareness falls to staff by virtue of their particular role and function in the community. This demands allegiance to the basic principles and ideologies of the therapeutic community, albeit in a thinking way - [our underlining] (Norton 1992, p. 22-23).
Routinisation: Manning (1979) has suggested that therapeutic communities share, with scientific innovations and social movements, similar characteristics: an early phase of dynamic innovation, often attributable to a few or perhaps one person's enthusiasm; followed by a wider acceptance of the idea, at which point the idea becomes routinised and institutionalised. As the well-spring of the therapeutic community is the spontaneous interaction between people, the growth of the therapeutic community movement hit a paradox: -Inevitably [expansion] has brought about issues of standardization and conformity - the antithesis of innovation- (Hinshelwood and Manning 1979, p. xiii)
This paradox of the 'anti-institution' (Punch 1974) may defeat the endeavour of the therapeutic community movement. Manning (1979) suggests that therapeutic communities came under increasing external pressure, to change from an experiment, to a conventional treatment, from 'innovation' to delivering the goods in terms of patient treatment and improvement. Thus one inroad into the innovatory culture of enquiry, was due to external pressures to concentrate on providing a service and another the internal self satisfaction that the ideas had been sufficiently developed. These phenomena are of course not merely the preserve of therapeutic communities but affect all organisations.
In this case study we will describe the to-and-fro dynamics around the culture of enquiry; first with a brief historical account, and secondly some detailed description of processes which threaten such a culture.
Whilst the Hospital's work remained based in the model we have described, after Main left in 1976 a period of some disturbance supervened. Main's centralised organising power and authority, was replaced by a committee of medical consultants who could find no common purpose. Rayner (1989) speaks movingly of this period: -the altered social structures of the hospital sundered in many places. Many rumours seemed to point to imminent collapse- (Rayner 1989 p xxvi).
The staff's reflexivity on and of their own practice declined in vigour. One mark of this, was the much lower production of papers published about the work of the hospital, than there had been in the three decades previously. Notable exceptions were two outcome studies (Denford et al 1983, Rosser et al 1987) demonstrating the effectiveness of the hospital's methods; yet it is interesting to note that until recently, neither of these papers were kept in the hospital library!
The decline of an enquiring culture, was probably furthered by a number of other factors; an inward looking individualistic, psychodynamic culture; the expectation both from within and outside the hospital (ex-Cassel staff) that ideas would be maintained and carried forward (perhaps preserved for posterity). Staff employed at the hospital, tend to stay for many years. This produces a strong residual culture but one that is difficult to challenge and that resists new ideas. Ex-staff who have left, often perceive their time at 'The Cassel', as a seminal period in their professional development. There is in some of these ex-staff, a wish for the Cassel to remain as they left it and this wish finds itself into the Cassel in a number of overt and sometimes more invisible ways. The 'international reputation' outsiders tell us we have, perhaps enhances the inward (rather than outward) looking culture.
One response to the fragmentation of the late 1970s was to invite an external consultancy to advise on the way forward. They worked for several years with the staff, and there were no shortage of ideas and proposals for the work. However, the more radical intention of a complete re-definition of the role of therapy in relation to the role of the nurse (James and Wilson 1981), has never been accepted or agreed and continues to raise controversy, whenever it is discussed.
A decision to create a body that concerned the therapeutic community per se, the Community Management Team, was instituted but, until recently, it was never given the authority to undertake its role adequately. Indeed it would seem that the communal culture of enquiry that Main envisaged, was ghettoised into this authority-less team, allowing other hospital teams to go their own way and not have to consider the needs (and conflicts associated with these) of the other teams and community as a whole.
Radical proposals were stifled by internal opposition and stimulated conflict between senior hospital staff and between disciplines. This led eventually to the early retirement of the consultant who had initiated this consultancy. Two of the papers produced at that time were later published (in Kennedy et al 1987). However, the radical quality of their implications and questions were played down and they were never fully taken up in practice. Many of the papers were, until recently, left to gather dust in a number of filing cabinets. It was difficult to trace their whereabouts. The knowledge of their existence had been, as it were, suppressed and removed from the Hospital's collective memory.
In the nineteen eighties there were many minor threats of closure but in January 1990 came the most serious.
The general manager of the health authority planned closure by the autumn of 1990. The history and effects of this threat of closure, and how it was overcome, have been written about elsewhere (Hartnup 1994, Robinson 1994).
The period of struggle
Many attempts to regenerate the culture have occurred over the last 20 years. One of the consultants, elected as chairperson to the Medical Executive Committee in the early nineteen eighties, attempted to involve an outside consultancy in re-evaluating the social structures and therapeutic rationales of the hospital. This led to a number of changes within the practice and structures of the hospital (James 1984); the development of regular nurse/therapist supervision and the establishment of a Community Management Team, to oversee and monitor the overall working of the whole community.
Faced with that external threat, in 1990, the Hospital was still sufficiently spirited to produce a leader for a successful fight. It also led to a re-evaluation of the work of Tom Main in a major international conference in 1993 entitled Tom Main and After - His Legacy, and this was held with great success. An ex-Cassel nurse at the end of the conference said: - Perhaps now, Tom Main can be finally laid to rest and the hospital can get on with the work he started, in the present day context.
That leader, the Medical Chairperson, retired shortly after this conference and a 'Clinical Director' was appointed. The change of title for the leader of the Cassel implies a significant change in the power/authority ratio of his position (Obholzer 1994). A new Lead Nurse was appointed a little later. An external agency was brought in to help define and re-define our relatedness to our outside environment; the necessity for this being further stimulated by the enormous structural and managerial changes taking place within the National Health Service.
This initiative highlighted our limited relatedness to the outside environment, to the external threats that lay ahead, as well as to our strengths and the possible opportunities that existed.
Major re-generative efforts have been taking place since then. The development of a new Adolescent Unit, a major change within the social/structural fabric of the hospital, was born from this venture. There has also begun, a gradual, ongoing, re-evaluation of the internal work of the hospital; a re-evaluation of authority structures; re-definition of the relationships between the different teams; re-appraisal of the concept of community, of the social structures, and of the therapeutic practices; and examination of the relationships with the outside world. The Psycho-Social Nursing Course has been university validated and completely overhauled. Nurses have also begun re-clarifying and re-defining their roles, through focused Action Learning Sets (Pedler 1991), looking at both the psychosocial nursing model they operate and the roles they take up in relation to this.
If there is, perhaps, a current re-awakening of an innovative culture within the hospital, it has in part been propelled by the closure threat, its survival, and the head-start in thinking about the commercial that the survival threat endowed the Cassel with. Despite these optimistic trends, enquiry at the Cassel survives within a tension between creative questioning and obstructive phenomena.
In the second part of this paper we will focus on some ways in which a culture of enquiry can be hampered.
Factors mitigating against a culture of psycho-analytic enquiry
Main's descriptions a rigid system of dogmas that squeeze out active thought and initiative from true enquiry is a vivid account. It reigns true in many ways as Bell (1990) commented, both in relation to the Casell Hospital and generally to social organisations.
Contradictions: Posed by Main as a conflict, it may be a largely unresolvable one. It is a close relation of the contradiction that we discovered in Manning (see above) between innovation and routinisation. A further close relation are the observations of Bott (1976) that caring organisations are peculiarly characterised by internal contradictions in their work. Her version identified, in a traditional mental hospital, the contradiction between care and custody.
The therapeutic community is no exception, no stranger to these contradictions. Our therapeutic endeavour, on the one hand, derives from Freud's methods of non-judgemental listening, yet, on the other, it is also a piece of real life in the sense that social limits and boundaries of behaviour have to be set and sustained. However much the symptoms and uncontained nature of the individuals is listened to in our community, they must also be contained and even controlled within generally agreed limits. Enquiry has to live alongside control.
At the Cassel Hospital this contradiction has come to be represented in a very specific way, largely under the influence of the psycho-analytic frame of reference, and somewhat differently from most therapeutic communities. A sharp divide is cultivated between the privacy of the individual, held within the confidentiality of the individual psycho-analytic psychotherapy, and the public side of the individuals expressed in their behaviour within the community. It is easy for enquiry and control to follow this divide - to the detriment of both.
Contradictions of these kinds - enquiry versus rigid morality, innovation versus routinisation, care versus custody, listening versus control, or privacy versus public behaviour - are endemic within society and give an authenticity to the therapeutic community. They are also ever-present and represent tensions which have to be lived with. They can be resolved only by tolerating them without polarising one way or another - too much listening or too much control, for instance. They can be lived with only by judging in each particular case the correct balance of one with the other. There has therefore to be constant recognition of contradictions, not eradication of them.
The version of this ubiquitous social contradiction which is most evident is, as we have just remarked, that between the privacy of the internal world, and the public face of behaviour within the community. And we need to comment for a moment on this as a site of particular risk for our community to lurch into difficulties.
The individual and the pair: The central ideas in the socio-technical system of the Cassel Hospital derive from psycho-analysis, and thus inevitably the couple forms a unique reference point for thinking, and often for action.
For many patients, working within a pair is experienced as intensely intimate and private, and this highlights especially the psychotherapy within the patient-therapist couple. This is implicit in the whole of psycho-analysis and the forms of practice derived from it. In a psychoanalytically informed hospital/community, it is perhaps thus not surprising that the focus of understanding concerning emotional experience, is to be found in the space between the pair. Eisold (1994) draws attention to the importance of this configuration in discussing the intolerance of diversity within psychoanalytic institutions. He suggests: -the primacy of the involvement of the pair, generates greater ambivalence at best and resentment at worst about the constraints of organisational life; the organisation is seen more easily as intrusive and becomes more readily the object of attack- (Eisold 1994, p. 793). The hospital institution tends to become, in the minds of its members, understood as a set of relationships and affiliations based upon the pair. It is not so much an enterprise in itself. Enquiry is drawn to the emotional space between the pair. Staffs knowledge and thought-through experience, concerning their shared emotional space within the institution, is much less comprehended.
Patients are intent on an individualistic outcome. This is realistic but skews their attention to the work of the organisation. However their emphasis may also be greatly enhanced by narcissistic pathology with which they are encumbered. What happens therefore between the pair, nurse/patient, therapist/patient or nurse/therapist is given the greatest status by patients and by the institution employing psycho-analytic psychotherapy.
Nurses come to the Cassel, often motivated by a wish to undertake one-to-one work with patients. In the nurse training, they are taught that their role lies in their therapeutic use of their sense of self, in their working space with patients. Nurses have regular supervision but this is invariably on a one-to-one basis. Many of the nurses commence their own personal therapy whilst working at the hospital, the need often stimulated by the resonance of the nature of their work with patients. Yet this is almost invariably individual psychoanalytic psychotherapy, and the pairing is again repeated.
The therapists who come to work at the hospital, are either trained or come to train at the hospital. Those who come trained, are all trained in individual psychoanalytic psychotherapy. Those who come to train, are all doctors and they come to train to qualify as Consultant Psychotherapists. They are invariably encouraged to undertake at the same time, a training in individual psycho-analysis or psycho-analytic psychotherapy. The work and thinking of these therapists concentrates on attention to and understanding of, the emotional experience of the space between the pair.
Needy patients in searching for the ideal pair (Denford; Griffiths 1993, Mason 1994), come to the hospital and find both nurses and therapists, in search of patients; all arrive with conscious and unconscious motives that are frequently based on the notion of the therapeutic pairs. In historical terms, pairings have proliferated throughout the hospital. This began with Tom Main and Doreen Weddell and continues through lineage to today's present Clinical Director and Lead Nurse. This pairing continues on the Units. There is the Consultant and Senior Nurse, the Therapist and Nurse for each patient, a pair of Patient Chairpeople for each firm unit and a pair of Patient Chairpeople for the Community. Every job within the hospital requires a pair, a nurse and patient to undertake it, and to take joint responsibility and accountability for it.
Aspects of the pair, commensurate with a psycho-analytic setting come to be used to explore, name and make sense of what is happening in the community and organisation. This understanding is informed by the concepts of transference/countertransference, re-enactment, repetition and projective identification. The evidence for this is present in unit staff meetings, nurse meetings, individual supervision, joint supervision and within the whole hospital staff meeting. It would seem that in an institution drenched in psycho-analytic ideas an inevitable tension must exist, a tension between the powerful focus psycho-analysis applies to the pair, and the psycho- analytic enquiry into the social system. These two directions of psycho-analytic enquiry are, in one sense, obviously complementary, but, in another, they work against each other. We do not wish to suggest that this elaboration of the socio-technical system as a slide into an inappropriate individualism, occurs on its own.
The upshot is that enquiry tends to be skewed in terms of a gaze narrowed to the couple. This is an effect not only because of the central psycho-analytic focus on the oedipus complex, but also because of the chosen practice of psychotherapy within a pair.
Much of the tension involved in preserving enquiry is therefore concerned with separating as far as possible the control from the enquiry, whilst accepting that such a sealed boundary cannot occur in a community setting.
Specific methods of closing enquiry.
Experience within the Cassel demonstrates a number of ways in which the reflective space for enquiry can be closed off. In Menzies (1960) descriptions of a nursing service in a general hospital, she pinpointed a series of 'defensive techniques'. These techniques are forms of actual practice which protect the individuals from experiences of a traumatic kind that they might otherwise have to confront in the work. In that instance, young nurses are in daily and prolonged contact with people who are in pain, mutilated and dying. If nurses relate too closely and emotional with suffering patients they could suffer greatly themselves. Work practices therefore have grown up which keep nurses at a safe emotional distance from patients.
Similarly in our view, practices in a therapeutic community can grow up which create a distance for staff (and patients) from too much enquiry, and impel a freedom from thought. These phenomena of a 'culture of anti- enquiry' are used and needed as defences against individuals' experiences within the Hospital. Often, they are not so much an unwillingness to face the unknown, as a means of avoiding the unknown known.
The packed timetable: Much of the daily timetable is a plethora of meetings, each beginning as another ends. Whilst they are seen as part of the daily work and regarded as 'containing for patients', they are often embedded in unquestioned assumptions. The meetings themselves often mirror the timetable with an impossibly packed agenda. This kind of rush obviates thought and enquiry, and avoids painful anxiety about our adequacy to the task. Much guilt, failure and depression arises from the idealised wishful expectations of our patients, and our own idealised reparative motives (Meinrath and Roberts 1982).
The projection of despair: A similar avoidance is accomplished by the emphasis on how difficult the patients are - hopeless cases at the end of the road. In reflecting the patients' perceptions that treatment is often their last chance, their last hope (Denford and Griffiths 1993), staff can feel relieved that anything they do is better than nothing however inadequate it feels. Such cultivated despair can numb curiosity about the real possibilities for some patients.
Paranoid explanations/interpretations: One regularly hears staff using phrases such as 'I felt attacked', 'You were obviously attacked' or 'That's an attack on the institution', about patients. At these times the emphasis concentrates on how unpleasant, or monstrous the patients are. Their inherent malevolence is assumed. An enquiry into the real possibilities is obliterated. Seemingly critical and devaluing of patients, in truth it often reflects the staff's vulnerability. Patients feel aggrieved, deprived, frustrated or disappointed (especially disappointed with staff), and staff are vulnerable to feeling disappointed in themselves. Paranoid attitudes evade the tension that patients are both attacking and at the same time appreciatively grateful, and also the tension that staff may feel (or at times be) sadistic, whilst also in need of co-operative patients.
Last minutism: An often crisis-led, fire-fighting atmosphere often prevails. Short term service needs predominate, often exacerbated recently by 'business' considerations. A just-in-time, last minutism pervades. It cramps space for reviewing current experience, or for developing a vision for the future. Planning, even in terms of days or weeks, gets overtaken by crisis-management. The Hospital business plan tends to state what we do, less of what we might become. In a hospital recently marked down for closure, anxiety about survival might understandably be avoided by obliterating the future itself. However, at least as important is the avoidance in this of the problematic future of the often hopeless patients.
'Tribalism': Structurally separated into three Units, the Hospital can tend towards a pernicious defect, institutional fission, as the separateness can drift into opposition between the clinical Units. Each Consultant jealously preserves the autonomous action of his Unit. Each team, functions as a 'tribe' addressing only its own interests. Though censured as anti-communal, it is at the same time sustained, as if no-one can change it. This tribalism impoverishes enquiry about difficult work, because it comfortingly locates anxiety about such work in another Unit.
One instance concerns a meeting (of senior clinicians from each Unit) held at the end of each week, with a ritualised agenda in which each Unit gave a rote description of their clinical issues/concerns and to which others paid respectful dis-interest. It was recently agreed to re-define the purpose of this meeting, as a more open discussion, to favour more creative thought on issues that affect each or all the Units. It was striking how uncomfortable and vulnerable the members of the meeting felt with this format and attempts to re-define the meeting, or end it early, were a regular feature at the time its re-definition.
Interprofessional relations: As with the 'tribal' rivalries between the firms, so are there rivalries between the disciplines. Differences concerning status, pay, working rationales, practices and the knowledge and assumptions that underpin them, are obviously natural. Stokes (1994) has recently written on the difficulties of multidisciplinary team working and the often confusing and conflicted picture that presents when different staff groups mobilise different basic assumption mentalities for sophisticated use, in the pursuit of their work. The pairing role of therapist and patient, may often be at odds with the dependent or fight/flight, reality-orientated role of the nurse in the community work. The question for any institution is how to mediate and live with inequalities, jealousy and rivalry. Unlike the Units, tribal division is not usually an option; the multidisciplinary team working, is a badge of the Cassel Hospital. However it can become a fetish and therefore itself difficult to question. So, interdisciplinary conflict becomes cloaked in the super-egoish rationale, of the 'containing' the need for a united front if patient splitting is not to occur. In addition, the relations between the Unit teams, too, can become cloak for very unhappy relations between the disciplines.
Stoking the interdisciplinary rivalries is patients emphasis on the differences between them. Therapists are often perceived as providing for the hopeful thinking/feeling space; and are regularly and consistently present for patients, in a one to one manner. Nurses on the other hand are present in an inconsistent/consistent manner, through working shifts and taking days off in lieu of emergency hours; patients have to compete for the nurses time, with other patients. So, nurses are perceived by the patients (and therapists) as responsible for the patients and all their needs, during all the community life when the patient is not seeing the therapist. Patients are often hostilely dependent on the nurse for this nursing; nursing is often quite confrontative, in terms of making patients aware of both their daily responsibilities and the effects of their actions on others. Are dangerous split can occur between a sympathetic and understanding therapist on one hand and a confrontative, socially controlling nurse on the other. And often a split in which therapists are agrandized as the guardians of the reflective function whilsy nurses, react and bustle.
Interdisciplinary differences in work practices could be enriching were it not a cleavage that allows a distance in place of the contradictions that we described above, and an evasion of that tension.
Pseudomutualism: Another response to the painful inequalities between staff is a pseudomutual world in which true differentiation is avoided in a sentimental egalitarianism Gustafson (1976). In such a culture, enquiry and development is seen as an irrelevance, at times a nuisance and moreover a threat. Gustafson (1976) suggested that in such a culture anyone questioning the rationales of the culture will either be marginalised and or promoted into a position of impotence.
The abuse of psycho-analysis
Four more phenomena involve the plentiful sophistication in psycho-analytic ideas which exist at the Cassel Hospital. They are, in this sense, a perversion of knowledge rather than a simple denial of it. And they comprise phenomena comparable to those recently described in psycho-analytic work by Joseph (1989) and Steiner (1993).
Ritual interpretations: Being two-person interpretations, psycho-analytic insights can, as we suggested earlier, close off the opportunity to enquire of the organisational dynamics and the richness of the multilayered system.
But this is more than just the natural slippage of an organisational practice based on the ideas of a dyadic pair. There is a more deliberate avoidance. Reiterated psycho-analytic insights can be preferred to what is unknown about the patient. Staff holidays in the summer, Christmas festivities, leavings from the Hospital, and so on, can ritualistically be invoked as causality for a multitude of largely unexplored individual and organisational symptoms. The absence f anger in the community is invariably suspect as evidence of repressed anger; overt anger is a denial of sadness, overt sadness is false because it excludes ambivalence, and so forth. Subtly people can claim the wisdom of a supervisor through such incantations, often sympathetically intoned, so that what looks like thinking is in fact a rather superior distance from a distress which is thereby rendered silent.
The corporate individual: At other times, the state of the Hospital can be addressed in terms of individual mechanisms as described by psycho-analysis. Transposed to the organisational level, unconscious phantasies discovered in individuals are re-found as corporate entities. They can often then be felt as imposed upon the individual members, and certainly strikes out the possibility to struggle to recognise the real attributes and problems of individuals homogenized at the organisational level.
Competitive interpretation: In many meetings the temptation to make interpretations of a group or individual kind overtakes a number of people at any one time. A competition is risked. Serial interpretations, in which each interpretation tends to interpret the one before leads to, or creates, a kind of league table of interpreters striving for the 'Nobel Prize winning interpretation' (Main 1975). There appears to be little true insight gained from these attempts to understand. One effect is that real work and decision-making grinds to a halt in what one of us (PG) has called analysis-paralysis. At that point, with frustration mounting at the inauthenticity of the discussions, a clinching intervention will describe all the interpretations as if it were 'play'. The implication is it should be stopped in favour of the real business of clinical work. Again, the agony of not knowing, and of being at sea, is submerged in the competition.
Competition may be useful to stimulate striving, but in this instance it appears more in the service of achieving a pre-eminence. Psycho-analytic understanding is perverted in this instance into a commodity for asserting superior knowledge, rather than as the 'beam of darkness' that Bion advocated.
Discipline: The even balance between social control and understanding is easily disturbed in a therapeutic institution. Often an authority is given to the function of the psychotherapists, quite beyond their actual range - or effectiveness. They are required to use interpretation to assert a form of social control over patients behaving deviantly. Psycho-analysis is removed, by excess anxiety, from a role of enquiring and understanding the individual and his organisational context, to become a super-ego for the individual.
These last four processes represent the way psycho-analytic interpretations themselves can be specifically recruited to shut down thought and enquiry of a psycho-analytic kind. These obviously obstructive ways of using psycho-analysis are reminiscent of the perversion of truth, which so characterises the personality disorders of the patients we typically treat in in-patient psychotherapy and these features in the Hospital, may well be causally linked, to the task we undertake.
If we consider these various manoeuvres from a psycho-analytic vantage point we have to understand that they are, in the main, unconscious; and that such unconscious function protects the individual persons within the culture from certain painful experiences.
The anxieties: In the relatively safe environment of a seminar, nurses have been able to describe some of the anxieties that they feel are inherent in the nature of their work: -Bizarre thoughts/dreams, fear of failure, empathising with pain, recognising one's own madness, exposure and vulnerability, fears of destructiveness and being destroyed, nameless dread, fear of persecution and fear of the recognition in the large group, of ones' own madness-. This was in a safe place. In the heat of experience, a defensive protection is secured through the various methods that close off the space for reflection. Anxiety may then be expressed for the organisation by certain others to represent anxiety for everyone. It is noticeable how individual nurses or therapists are often set up by others, to discuss their concerns and anxieties, about a particular patient they are working with. Others are invariably ready to offer help, support and advice but retreat from sharing the common experience. For example, a nurse recently was pressed by another nurse to speak about her feelings concerning a patient of 'hers', who had committed suicide a year earlier (this was the anniversary). She clearly, and perhaps not surprisingly felt uncomfortable with this. Not only in relation to the memory of the event but also because she was being asked to talk on behalf of the group. The fear of a patient committing suicide is ever present at the Cassel, for most of our patients are chronically suicidal and treatment invariably raises the possibility of the enactment of previous events. So this nurse's forced memory served as a container for everyone's denied fears.
Many of these anxieties are versions of the problem that has been described elsewhere in the helping professions (Menzies 1959, Hinshelwood 1994).
Social defences: Social structures working ways are not necessarily therapeutic. They are often held onto absolutely even though at an individual level this can be acknowledged. At a group level they cannot be changed.
All too often individuals have an intense, frustrating and fearful experience of these social defences. They cannot initiate change even though certain benefits may be completely clear, because they feel in the presence of a stifling hospital super-ego, that thwarts any attempt at change to the practice. Of course this super-ego does and does not exist. It exists in the minds of employees and is projected into this anonymous, amorphous thing called the Cassel culture, and then, out of fear of its global and persecuting nature, communal space is denied for dialogue to enquire into a reality which could be tested and experienced.
Part of the problem is that to give up these defensive techniques and rationalisations, means question and embarking on a journey into the unknown, which may feel quite intolerable. To get in touch with these basic assumptive processes within the institution (defences against knowing and wanting to know), would require giving up an important assumption: that emotional experience is strictly limited within one's own skin, or that of another, the pair. Because of the defensive need this assumption has been unconsciously determined, and has form the core of a social system of defence, against persecutory and depressive anxiety. They defend staff against the specific pain and horror of our work: sexual and physical abuse, infanticide, murder and murderous feelings, violence to self, amongst many others.
Menzies (1959) postulated is commonly accepted: that resistance to social change is likely to be greatest in institutions whose social defence systems are dominated by primitive psychic defence mechanisms. She highlighted the fact that fundamental change can only take place with great difficulty within such institutions: -it is unfortunately true of the paranoid defence systems that they prevent true insight into the nature of problems and realistic appreciation of their seriousness. Thus, all too often, no action can be taken until a crisis is very near or has actually occurred- (Menzies 1959 p. 42) Despite the need of the social defence system Menzies insisted it impaired both the nurses' ability to function and indeed created more anxiety. Armstrong (1991) suggested: -Paradoxically, of course, this denial, far from liberating the individual from the matrix of collective emotional experience, imprisons him or her firmly within it. The more this experience is disowned the less modifiable it becomes: the less modifiable it becomes the more it has to go on being disowned- (Armstrong 1991 p. 6).
We claim that a culture of enquiry is feared for the same reasons as social change. Both threaten to disturb social defences. Indeed the culture of enquiry, in Menzies terms, is intended to enquire into socially defensive practices - and thus to destabilise them.
The place of psycho-analysis: A psycho-analytically sophisticated organisation clearly has the possibility of understanding this interplay between anxieties, social defences and intractable organisational impasse. However as we have asserted that sophistication can be turned into a sophisticated method of undermining enquiry and sticking closely to the already known. The predictability of many 'interpretations' to become a worn-out and cliched currency is the equivalent of the routinisation observed in therapeutic communities in general. Yet the routinised interpretations do, mercifully, create distance from the awful experiences they are supposed to address, and some respite from the experience of the work.
Like the therapeutic community, psycho-analysis has the potential for both innovative change in persons and for a routinisation in a lost culture of enquiry.
This fate of psycho-analytic helpfulness within the hospital, is not trivial. Indeed it is the stuff of an analysis itself. The continual use of the psycho-analytic relationship for non-enquiring activity is known as the transference. And interestingly it is analysis of the transference, par excellence, which reveals the unknown which is being fought off. It is likely to be little different in organisations. Those impasses in organisational change, which we might so bemoan, are of the highest interest just because they conceal (and thus reveal) the points of maximum anxiety and pain within the work. We could take heart that we have such indicators of the place where anxiety is most concentrated, and thus most needs containing.
The nature of enquiry: Following Bion (1959) we could say that thinking is the creative process of making links between thoughts. And therapeutic thinking entails, especially, the creation of containing links - emotionally containing ones; and thus, as we said earlier, the thinking in one's feelings and the feeling in one's thinking.
At the level of the institution, what does this kind of emotionally linking enquiry entail?
In a recent paper, one of us (RDH) investigated this kind of linking in small group therapy (Hinshelwood 1994).
It was possible to observe various kinds of linking processes going on between people in the group. The links that were made from moment to moment as each person spoke, differed in the degree to which they indicated an emotional closeness or distance from what the preceding spokesperson had said. It was possible to build up an impression of the characteristic kind of linking - either deadening each other's contributions, or enlivening them with apt and sensitive responses to each other. It was also possible to follow the effects of the therapist's descriptions of these processes, sometimes enabling a closer dialogue to be tolerated, and sometimes his comments were forced down the same deadening route. These observations were made in a small group psychotherapy. At the level of the organisation is there anything comparable to the internal linking of thought and feeling within a person, or the delicate inter-personal linking (or otherwise) in a group?
Armstrong (1991) suggests that if a psychoanalytic approach to organisational life is to be sustained, its practitioners must be able to remain alert to the institution inside themselves and their relatedness to it. That this is not just about surviving in an institution, it is about -learning the possibilities inherent in a certain emotional configuration; the configuration that is between individuals in a bounded space, a configuration that is replicated within- (Armstrong 1991, p. 7)
Emotional experience is located within institutions in the interactions between the person, the group and the system. Attention to, and formulation and interpretation of, the emotional experience of the whole group or organisation, has the potential for new thoughts and transformations. One way of fostering this is to address the relationships at the inter-group level as the primary focus for institutional work. The aim would then be to assess the culture of enquiry in terms of the degree to which one sub-group within the institution can relate sensitively to the emotional expressions from another group with an overall co-operative thinking about 'other' groups' experiences.
Menzies drew attention to the real differences between psychoanalytic practice and psychoanalytically oriented consultancy. The 'institution in the mind' of institutional members, and their emotional experience, can often only be elicited through its representations in the reality of the living-together community. My (PG) action research therefore looks both ways: at the 'real' world of work and community, as well as the latent and unconscious experience of the institution and the role relatedness between staff. With the provision and sanctioning of time, in a safe place, to undertake the role-redefinition task, we can discover and reflect upon the latent institutional emotional space.
This paper has been both born out of and contributed too an ongoing enquiry of the hospitals structure and culture; in some ways it is already dated. But it is in itself a record of some reflection that we have managed to open up. This is the stuff of therapeutic community practice, to develop and use activities that lead to the opening of a space for enquiry.
Internal consultancy: Much of the work and thinking in this country about the distinctive relevance of psychoanalytic understanding to organisations derives from external consultants invited in to an organisation, and maintaining the advantages of a perch that is neither quite 'in' nor 'out' of the organisation.
Even in the work of external consultancy there is however an implicit assumption that an organisation might develop an awareness of its own psychodynamics. Some companies and organisations have their own departments devoted to a psychodynamic awareness. Often psychotherapists within a psychiatric department adopt the role of being the thinking space for understanding the unconscious processes of the psychiatric Unit. In all these cases the awareness that develops is the function of and, in the first instance the property of, a defined segment of the organisation. The function that develops a psychodynamic awareness, whether it is an external consultant or an internal segment (we could call it an internal consultancy), has the opportunity to remain in this ambiguously productive half-in and half-out position.
Different organisations will sanction the use of that understanding in a variety of ways. One problem is that the sanction is often not clear, or is seriously subverted. The function is sequestered into its own domain and not listened to. The boundary around that function becomes the site for distorted or perverse inter-group relations. And this can occur even when the function is an external consultancy. The rest of the organisation remains a naive one.
We have tried to describe an institution that is organised differently with respect to self-reflective insight. In this case there is an attempt to make reflection part of the primary task, and to recognise that reflection upon the vicissitudes of the primary task is itself the primary therapeutic thrust. To this end we struggle to open a reflective space for enquiry, in which new experiences can be found, felt and thought about. At least this is the stuff of our therapeutic community, that we continually struggle, to prevent, from being closed off.
This paper has not shirked the difficulties of therapeutic community work, and of the central function of 'internal consultancy' to create such a reflective space for enquiry. Though we have risked a sense of pessimism in the way we have described our work, we believe it is only realistic not to recommend an ideal institution, only to recommend the investigation of an institution that realistically acknowledges its shortcomings, and reflects creatively upon them. To err is human, and we can expect no better from our organisations. To reflect on the errors of our ways is psycho-analytically divine, and we might expect our organisations to struggle haltingly towards that.
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