Organizational schism: Looking after a psychiatric service

Abstract

What is opposed to psychoanalysis is not psychiatry but psychiatrists. (Freud, 1916–1917, p. 254)

The defence that schism affords against the development-threatening idea can be seen in the operation of schismatic groups, ostensibly opposed but in fact promoting the same end. (Bion, 1961, p. 159)

This paper deals with group dynamics, not about therapeutic groups, but about professional groups. Mental health workers labour in a setting of high stress. One of the forces that affect groups under stress is that they can divide into two, which often exist in mutual opposition: Psychodynamic psychotherapy itself has never been free of oppositional relations with other groups. We need a framework for thinking about the schisms that we are a part of, on the one hand with orthodox psychiatry and psychiatrists, and on the other, with psychologists and CBT. This paper will attempt to look at the stress of uncertainty and the stress of risk management, stresses which arise from the work, and emerge as interdisciplinary feuds.

Keywords:

• professional psychodynamics
• schisms
• externalization of conflict
• community care
• multidisciplinary teams
• stressors in mental healthcare

Notes

1. The process of externalization relies on rather more primitive psychological mechanisms, and is different from the process of repression, where one-half of the conflict is rendered unconscious and the conflict remains within the mind. So, there are various alternatives when the mind is in conflict. Normally we make a choice between alternatives, all the time in our lives. We will try to compromise but often we simply accept one side, and give up the other – with the need for little piece of mourning. Second, and more problematic, is the non-resolution when one element is repressed becoming walled-off from the other by the boundary that separates consciousness from the unconscious – conflict remains but becomes a conscious versus unconscious conflict. It remains within the mind. Then, third, and finally, is the process described here by which the internal conflict becomes to all intents and purposes an external one – a conflict with someone else. Little Katy's conflict with Grampa has taken over, once she has mother's arm around her, from her internal conflict in wanting either cuddles or mother’ arm around her.

2. Many years ago I worked part-time as a therapist in a prison (Hinshelwood, 1993). I wrote up this difficult experience sometime later. The upshot was a description of a complex cultural division within the prison, and amongst separate groups and sub-groups of people who lived or worked there. In this harsh, male environment, there tended to be a stress on hardness, strength, and unfeeling dominance, and this captured both staff and inmates. However I noticed there were sub-groups of both staff and prisoners who were identified as not strong, but weak and denigrated for it. In the prison therefore there was a dynamic which tended to separate out the groups into those who were strong, and those who were weak – often with considerable violence. One group as it were spat out their weakness into the other.

3. There were other factors that included the new enthusiasm for what could be achieved in the recently created NHS; and also the invention in the 1950s of the psychiatric wonder drugs believed to cure schizophrenia.

4. The report is most easily available on line: http://www.healthcarecommission.org.uk/_db/_documents/Communicty_mental_health_full_report.pdf; and similarly the Commission's summary: http://www.healthcarecommission.org.uk/_db/_documents/Community_mental_health_summary_report.pdf