The Dynamics of Change

Tavistock Approaches to Improving Social Systems

Mannie Sher

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781780490601
• eBook ISBN: 9780429920509
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book focuses on the hallmark or approaches of the Tavistock Institute—combining research in the social sciences with professional practice in organisational and social change. It shows how consultant and client system are partners in the process of organisational analysis and design.

PART I

PSYCHOTHERAPY IN THE PUBLIC SECTOR

CHAPTER ONE

Psychiatric social work and general practice*

Introduction

In the field of psychiatric social work (PSW) and general practice (GP) collaboration, conflict of roles, different functions, lines of accountability, and distributing scarce resources are key issues. If the two professions are to work comfortably together, then both also need to share the despair, hopelessness, anxiety, and anger that are the occupational hazards of each. We suggest new ways for GPs and PSWs to look at the pain their patients are suffering for the benefit of the patient and the professionals’ own working relationships. We present our view of a psychodynamically orientated PSW attachment to a large London group medical practice. The attachment forms part of a larger research project initiated by the Community Unit of the Adult Department of the Tavistock Clinic in 1972.

The project

Brook and Temperley (1976) describe the aim of the project “to study the contribution that can be made to group medical practices by the presence in the surgery of a professional worker with specialised training in a psychotherapeutic approach” (p. 86). By close co-operation and mutual education, they hope to increase the psychotherapeutic resources of the practice. As part of the project, several Tavistock Clinic workers, drawn from the disciplines of psychiatry, psychology, and psychiatric social work, but all having training in psychotherapy, are attached for one session a week to group practices in the vicinity for a period of two years.

Brook and Temperley describe the type of referrals made to the attached workers in the project. Because of the workers’ psychotherapeutic bias, many referrals focus on psychological and relationship difficulties, especially in younger patients, who are more likely to be at stages of life when relationships are in states of change: for example, marriage, parenthood, divorce, or death. As the attachment developed, more referrals involving physical illness and disability are being referred to the PSW. We note that there is a tendency to select those cases for referral where the GPs “know” they need support; where the task is of such a dimension that one person working alone cannot be expected to listen, understand, treat, and manage the patients’ clinical problems. Such referrals, for example, marital problems particularly, make use of the PSW resource to diminish the confusion and wastage through a meagre understanding of the meaning of the presenting problem: for example depression, anxiety, or psychosomatic symptoms. Working together makes it easier for the GP and PSW to recognise the locus of the problem and to avoid potentially being misled by the patient’s perception of the problem.

The practice

The practice described in this chapter (one of four in the project) has 17,500 patients, six partners, two assistant general practitioners, one trainee general practitioner, twelve reception and administration staff (many part-time), and two health visitors (liaised). It is a large practice and is administered like a health centre. This provides opportunities to explore and understand the complexities of liaison, referral, and shared care of patients. It is common, for instance, for case conferences to take place in the practice, attended by local authority social workers, educational psychologists, psychiatrists, and teachers, thus adding weight to the philosophy of whole-person medicine with the local general practice serving as a central base for patient care and decision making.

The attachment

The PSW attends the surgery for half a day a week, when one new referral and one or two old cases are seen for about an hour each. The remaining time is spent in consultation with the referring general practitioner, who retains medical responsibility for the patient. The attachment confirms the view “of the crucial importance of giving time and thought to advance planning” (Brook & Temperley, 1976). The PSW and referring GPs have agreed to discuss all cases before taking any action. These discussions help us to determine how to proceed: either for the PSW to see the patient, the patient to be seen jointly by GP and PSW, to include other members of the patient’s family, or, where the GP feels, after discussion, that he understands something additional about the patient, to continue independently, secure in the knowledge that support is available. In addition to these discussions, an alternative way of communicating is through regular practice meetings, partly to discuss cases and partly to monitor the experience of the attachment.

With heavy pressures on both PSWs’ and GPs’ time and emotional resources, the need for careful exploration of the patient’s presenting problem and environment, before acting, is even more important. Precipitate action, before the problem is fully understood, we know, often leads to the rejection by the patient of the help offered. GPs and PSWs can easily feel themselves to be acting out of role because they have unrealistic expectations of each other, and the patient often has unrealistic expectations of both. This can confuse them and the patient, resulting in everyone feeling frustrated and angry and unable to collaborate profitably.

Sharing work

In this section, we illustrate a variety of planned interventions and how we work together with patients in different ways.

Patient 1

Miss K, a young single librarian, tells her GP about her depression due to a lack of feminine sexual characteristics, viz. flat chest and a masculine-type physique. She cannot maintain stable relationships with men. The GP feels unable to like this angry young woman, but she reveals intriguing insights into her relationships with men, and, in particular, with her father. The GP believes that further exploration of the relationship with her father is appropriate, but he is unable to take up these issues directly with her, because he fears that to do so would interfere with a well-entrenched neurotic relationship with her father and would probably invite an angry response towards himself.

The GP and PSW discuss the matter and decide that the PSW will see the patient in order to better understand the relationship with her father. She is seen alone by the PSW for five sessions, during which it emerges that she is drawn to men who are inferior to her and have serious emotional problems themselves, and even though she is aware of this tendency, she cannot desist. She feels she has to “make the going” in all her relationships, because if men show any interest in her she is convinced there is something unstable about them. Unwittingly, she chooses men she knows will not gain the approval of her parents, who would be hurt by her choice. Miss K feels that she is just getting over her irrational need to hurt her parents, but she fears that, at thirty, she might have left it too late to sort out her conflicts. She sees herself heading for a long and bitter spin-sterhood. Miss K describes her mother as weak, ailing, and demanding, holding on to her husband through illness. Their marriage, she claims, is empty and they stay together for the children. She expresses warm and protective feelings towards her father, whom she feels she needs to save from a sterile marriage. The close relationship with her father and the disparagement of her mother might, in fact, be a denial of the anger she feels because her parents are more important to each other than she is to either of them, and, in addition, a denial that the original longing may have been for her mother. The first indication of these angry feelings is the subjective experience of “unlikeability” felt by the GP that leads to the referral.

She returns later to her GP with more physical complaints and she tells him she is angry with the PSW for unreasonably concentrating on her relationship with her father. Nevertheless, when more openly challenged, this time by her GP, she acknowledges that she is less depressed and has been able to limit the extent to which her alcoholic boyfriend sponges on her, without feeling guilty. She is able to question the belief in her parents’ lack of sexual relationship, which makes her feel unrealistically responsible for her father. She sees that maintaining this position during adolescence had prevented her from seeking and receiving adequate help from her parents when, because of her masculine sexual characteristics, she felt so desperate and lonely. She would call attention to her psychological needs by being aggressive and demanding, which alienated her family. Over the five sessions with the PSW, Miss K is gradually able to disengage herself from her parents as well as her current boyfriend, and, after some months, she returns to her GP asking for referral for psychotherapeutic help.

Discussion

The GP refers this case to the PSW because of troubled feelings about his patient’s anger towards him. This stirs his own anger, which threatens to interfere with his capacity to continue working with her. Discussion of these feelings with the PSW frees the doctor–patient relationship of some of its hostility, which, in turn, allows the patient to express her anger and to ask for help.

Patient 2

Mrs N, a mother with three children, presents herself as a physically diseased, depressed alcoholic with murderous feelings towards her children, husband, parents, and parents-in-law. The GP is concerned for the safety of the children, but he has been cautioned by a psychiatrist, who previously had seen Mrs N, not to accede to her request for psychotherapy since she is thought to have minimal defences to cope with the horrors and her huge childhood deprivation that included rape by her alcoholic father. For these reasons, it is suggested that Mrs N and her husband should attend a joint consultation with a view to providing support through her family. The contrast in their appearance is startling—Mr N is well-dressed in jacket and tie and has a neatly trimmed beard; Mrs N arrives late with many apologies, dressed in dirty jeans, broken sandals, and with uncombed hair. The workers are struck by Mrs N’s need to cling to the depressive aspects of her past and present life and by her fascination with destructive aspects of society, for example, racial tensions and nuclear annihilation, probably standing for the state of her inner feelings, whereas Mr N, with ample reason to be depressed, as he, too, comes from a disturbed family background, with early separation from his parents, maintains a detached, almost carefree attitude. It seems to us that Mr N’s feelings of anger and depression are off-loaded on to his wife, who is left unsupported in her misery and chaos. This process of getting rid of painful feelings leaves Mr N free to indulge in his pleasurable pastimes away from home without feeling too guilty.

Behind Mrs N’s near-madness lies a desperately sane plea for a need to be separate from her husband and in-laws and not exploited in her vulnerable state. To this end, the workers support Mrs N’s desire for greater separateness coupled with practical support from the health visitor, PSW, and GP, and strongly discourage further invasions of her feelings through psychotherapy, which Mrs N is requesting and Mr N pushing her towards. Mr N appears unable to face his own depressed feelings and does not attend further meetings. Mrs N is supported in her role as a woman and mother. A year later, with the help of occasional fairly calm contacts with her GP, Mrs N is still working as an art teacher and caring adequately for her family, but without her husband, who has left.

Discussion

This case illustrates the difficult dilemma often facing GPs and PSWs, which is to resist pressures from the families of patients, and even from patients themselves, to regard them as mentally ill, requiring immediate treatment or hospital care. Resisting the pressure and adopting a different treatment plan for the patient can infuriate other members and even lead to the break-up of the family, as happened in the case of Mr and Mrs N. Should the GP collude with the diagnosis of “mental illness” in Mrs N, admit her to hospital, separating mother from children? Or should he act independently on his judgement and provide enough environmental support for a vulnerable and deprived woman so that she can cope a little better and risk the husband leaving? Either way, the decision is difficult, since other people, often vulnerable children, are affected. This kind of situation impinges upon GPs philosophies about mental illness, families staying together, and mothers remaining with children. These issues are discussed and the GP is helped to face the guilt and anxiety arising from whichever decision he takes.

Patient 3

This case describes the experiences of a GP who feels crushed by the tragedy of a very promising ballerina of twenty-three, Miss D, who became permanently tetraplegic, as a result of breaking her neck in a dancing accident on stage.

The GP is much involved in the management of the physical aspects of the patient’s care: for example, electronic aids, chairs, lifts, retraining. He realises, after a light-hearted reference to suicide by Miss D, that he is ignoring the full extent of her despair and hopelessness, which is overtaking him, too. He asks for consultation with the PSW, who like himself, feels the horror of the tragedy and also experiences a wish to “do” things, whether or not they are realistic. Both realise that it is necessary to discuss the implications of a bleak and depressing future openly and honestly with Miss D. This decision is given added weight because the GP has responsibility for her general medical care and the patient turns to him in despair when she realises how vain her hopes are of ever walking again. It is agreed that the PSW should act as a consultant to the GP, so that he can understand his sense of inadequacy stirred by her tragic situation. The PSW would be available for certain crucial joint interviews, in order to monitor and regulate the pace with which Miss D is confronted with her feelings of depression and despair. One particular joint interview is arranged to coincide with the first anniversary of the accident, a time especially painful for the patient, since there has been no apparent improvement in her condition.

Both GP and PSW soon discover, when they nearly drop Miss D trying to carry her upstairs, how easy it is to be blind to the limitations which her disability imposes. Miss D values these interviews, which extend over three months, in which her feelings of rage, resentment, and despair are understood and accepted, rather than denied, as they tend to be by others around her. Later, having acknowledged the unlikelihood of walking again, Miss D successfully applies to study art. She still retains an interest in the world of ballet in the different, but more appropriate, area of set design and promoting safety standards for ballet dancers.

Discussion

This case illustrates how a tragedy can overwhelm a GP and lead to denying the truth of a dreadful disablement. Sharing these feelings through discussion with a coIleague enables the GP to spot and check his impulse to take flight. The case also underlines the GP’s continuity of care and responsibility for the patient, which extends beyond the merely physical aspects of the condition, important though these are. Care professionals are in their roles to give comfort and put things right. Tragically, some conditions cannot be put right, and when this is discovered there is a danger of the patient being abandoned. The PSW’s presence in a number of crucial interviews helps bring into the open some of the harrowing feelings overlooked by both the patient and GP; it also strengthens the practitioner’s ability to grasp and talk honestly about the very disturbing emotions aroused by the permanently crippled life of a young person.

Summary

These three brief examples give some idea not only of the variety of problems presented in general practice, but also different styles of coIlaboration between the professionals concerned. The common factor in all the cases is in the GP identifying feelings that are bewildering and threatening to his normal decision-making abilities and capacity to offer help. The consultations release the GP from a frustrated position and help him regain a clearer perspective of the doctor–patient relationship. The nature of this relationship is different in each case. In the first case, the GP feels uneasy on account of his anger towards a difficult young woman. He hands the case to the PSW, who deals directly with her angry feelings and this removes some of the hostility from the doctor–patient relationship. In the second case, involving joint marital interviews, the GP is shocked by the violence of the material. Through joint interviews, a more practical appraisal of the GP’s contribution becomes possible. Care is exercised not to be over-enthusiastic, or to dwell upon morbid and destructive thoughts and ideas.

In the third case, both GP and PSW share the horror and despair of a young person whose hopes and ideals are suddenly dashed. The GP is nearly submerged by the patient’s enormous despair when the realities of her future dawn upon both. Working together helps contain the threat to the GP’s integrity, and provides the patient with opportunities to face her dreadful situation honestly with people who understand and accept her position, in ways that others do not.

The help given in all the examples consists of increasing the GPs capacity to listen and be responsive to the patient’s mode of communicating, thereby helping patients take stock of themselves and think seriously about their lives, problems, and attitudes.

Experiences of working together

We have indicated how the attachment of a PSW provides the practice staff and the patients with an additional resource for dealing with psychological problems. It is common for general practitioners to offer help to patients with emotional and relationship difficulties. Through this attachment, they are themselves helped to recognise the danger of persisting on their own for too long and possibly getting out of their depth with the patient. Equally, the GPs are, in many instances, encouraged to support patients further, rather than refer them to specialist agencies in the belief that specialists could offer something more masterful.

In considering the nature of the attachment and what it offers to the professional workers, we need to look at what we started with: a doctor, primarily trained in the physical aspects of medical care, and a PSW with psychotherapeutic skills and an understanding of relationships. The workers had different philosophies about human behaviour, different methods of care, attitude...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I: PSYCHOTHERAPY IN THE PUBLIC SECTOR
• PART II: GROUP RELATIONS
• PART III: ORGANISATIONAL DEVELOPMENT AND CHANGE CONSULTANCY
• PART IV: BOARDROOM EVALUATION
• REFERENCES
• BIBLIOGRAPHY
• INDEX