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Mira Erlich-Ginor and Shmuel Erlich Mira Erlich-Ginor, M.A., is Chairwoman of OFEK, the Israel Association for the Study of Group and Organizational Processes; Faculty, The Program in Organizational Consultation and Development, Israel; Training Analyst, Israel Psychoanalytic Society and Institute. H. Shmuel Erlich, Ph.D., is Sigmund Freud Professor of Psychoanalysis, and Director, Sigmund Freud Center for Psychoanalytic Study and Research, The Hebrew University of Jerusalem; Member, Executive board, OFEK; Faculty, The Program in Organizational Consultation and Development, Israel; Training Analyst, Israel Psychoanalytic Society and Institute. E-Mail: mserlich@mscc.huji.ac.il |
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This is the story of a crisis intervention in a mental health service that sustained a most distressing and unusually cruel blow -- the murder of four of its staff by a patient-client. We think it is important to tell this story for a number of reasons:
1. CHRONICLE OF THE MURDER What follows is the account of the events as reconstructed by the Center’s staff: The patient, a 21-year-old man, applied to the Mental Health Center serving West Jerusalem several weeks prior to the events. Although in this sense he was a new admission, he had intermittently been in treatment at the Center as an adolescent until he was drafted into the army. There he continued to be treated by the army’s mental health service, was prone to making suicidal threats, and menaced his superiors and therapists when he experienced them as unhelpful and thwarting. His frustration was often vented in crying spells and raging outbreaks, following which he would calm down. In the thick file that accumulated on him, he was never diagnosed as suffering from mental illness. Nevertheless, he was prematurely released from army service. Following his discharge, and after a full year without treatment, he contacted the Center and was seen once. The woman-therapist summed up the interview with the feeling that this time he was truly motivated and interested in being helped. Another appointment was set up, but he did not keep it. Around noon on the day of the murder he telephoned and asked to speak with the director of the Center or with the therapist who had seen him. He spoke with her on the phone for about fifteen minutes. He sounded angry and upset for having been denied a license for driving a truck. The therapist did her best to calm him down and to encourage and support him in this moment of crisis. She then invited him to resume his therapeutic sessions. By the end of this telephone conversation, he appeared to have calmed down. At 14:00 o’clock he arrived at the Center, stood at the entrance to the main office, which was as usual full with staff and without a word indiscriminately opened fire from a pistol, which was licensed to him in his position as a security guard. Four members of the Center staff, all of them women, were killed. Two other staff members, a woman and a man, were wounded. Three more staff members who were present in the room escaped uninjured. The murderer then escaped to the roof of a nearby building. The police were summoned, but their efforts to engage him in conversation were unsuccessful. When it appeared that he was about to threaten the life of bystanders he was shot, and died on route to hospital. The entire sequence of violence and horror lasted only a few minutes. Nevertheless, it sent ripples of shock waves throughout the community. In the wake of the public outrage, commissions were set up to investigate what happened; criteria for licensing firearms were reviewed; and channels of communication and lines of responsibility between different authorities, such as the Army and the Ministries of Health, Interior and Transportation, were double checked. One outcome was to place an armed guard and electronic surveillance at the entrance of every mental health facility in the country, a living testimony to the murder that took place, and a reminder of its possible recurrence. The national mental health system was deeply shocked and upset. The age of innocence was gone, probably forever. In the waves that swept the entire country after the murder there was a tendency to neglect the Center and its personnel. There was no shortage of new events and tragedies to occupy the public attention of Israel in the 90’s. The Center’s staff was soon left to fend for itself, which is when we were asked to intervene. The nature of our relatedness and relationship (Miller, 1989) to the Center and its staff had been anything but neutral, distant, or anonymous. We had worked for many years in the psychiatric hospital that created the Center as its community outpost. In our role as senior staff, we played a significant part in establishing and setting up its professional and organizational modes of functioning, through teaching and supervision, actual work relationships, and organizational and administrative decisions. The nature of our intervention was thus certainly not one in which the consultant’s role is well established vis-a-vis the organization and buttressed by a measure of professional distance and anonymity. 2. STAGES IN THE INTERVENTION Our work with the Center can be described in terms of several stages, which may be pictured as concentric circles, starting from the traumatic event itself and moving away from it gradually. At every stage, there is a recurrence or resurgence of the traumatic wound, each time from a different angle, but also at a more advanced level of coping with the trauma. In this sense, the work described may be seen as lasting three months, or a year and three months, or four years. Our involvement began immediately upon hearing the horrible news on the radio - we instantaneously felt it was "our" Mental Health Center that was reported on, in spite of the fact that we had both left it and the hospital with which it is associated ten years earlier. We found ourselves going again and again to the funeral house, taking part emotionally and personally in a blood curdling and shocking series of four funerals, of tears, of a deep sense of pain and crisis, of questions, perplexities and preoccupations which remained without answers and consolation. The request for intervening came on a Thursday, on the day that marked the end of the mourning. The Director of the Center, in a telephone conversation with both of us, recounted the story of a week of inability to return to routine work coupled with efforts at self-healing. The staff sat for endless hours in small groups, ventilating feelings, focusing on details, collecting and accounting for minutes and seconds in an effort to reconstruct the traumatic chain of events. They tried hard to understand and to analyze: How did it happen? Could it have been predicted? Was it possible to prevent the events? Eventually, however, the feeling was that they could not cope on their own and needed external help. The request was for "a focused and short term intervention." Several names had come up as possibilities, and following an unclear process of elimination and choice, he approached both of us, leaving it to us to decide who would do what. We obligated ourselves to provide an answer by the end of the weekend. In retrospect, we appreciated the fact that we had no real question about our positive response. The only issue was around the choice of a course of action. In the three days that elapsed until we gave our answer, we tried to understand the meaning of the request for help to us. Our feelings and thoughts pointed in several directions. Mainly, however, it appeared that we were experienced as being "on the boundary." We were perceived at one and the same time as belonging and not belonging to them, near and distant, next of kin and friendly standbys. Another aspect of the choice had, perhaps, to do with our being a couple: it seemed to arouse wishes for a beneficent and constructive pairing, and for parents who might provide the wished for mending and reparation of the traumatic wound. In our countertransference, we responded to the wish for pairing and good parenting, which would bring with it healing and the relief of pain. We shared their wish that we would be knowledgeable and capable of helping the wounded system. At the same time, we felt overwhelmed by the enormity and uniqueness of the traumatic break. We wondered if we had any knowledge at all that might be relevant to dealing with something of such awful nature and proportions. We organized ourselves efficiently and speedily, formulating hypotheses and a primary task for our entry into the system. In retrospect, it is quite clear that our need to assume the position and posture of "experts" reflects a sense of being heavily flooded and threatened by our own anxiety and wish to be of real help; and a response to the enormous anxieties and other feelings rampant in the system. From our discussion with the Center’s Director, several notions emerged: The staff found itself in an extremely passive position, of a helpless and deserted victim, during the traumatic event. Secondly, the description of the events focused around a preoccupation with the question, ‘Where exactly was everyone at the precise moment of the murder?’ From the chronicle that emerged, we gleaned two maps of the staff: one was a picture of the staff arranged by the usual criteria of seniority, position, profession, formal and informal standing, etc. The other map - superimposed, as it were, on the first one - was of the day of the murder and of each person’s whereabouts and location at the precise moment: in the office, on the floor, in the building, on the way to or from the Center, etc. The "picture of the world" that emerged was one of concentric circles, centered on the office as the focal point of the shock wave. In view of the passivity that colored the experience, we decided to engage the staff in a manner that will allow them to become active partners in the proceedings; and that our contact with the staff would be direct, and not channeled through the Director. We therefore offered to meet with the entire staff, so that they could all be part of forming the work contract. The understanding, which at this stage was largely intuitive, that there needed to be a shift from passivity to activity, and hence for eliciting the active participation of the staff, became the theme and guideline for much of the intervention, and contributed greatly to such success that it had. Some evidence for the correctness of this understanding was also provided by the fact that where we failed to abide by these principles and to obtain full cooperation, we encountered crisis and setback. 2. 1. FIRST MEETING WITH ENTIRE STAFF - DIAGNOSIS AND CONTRACT Three weeks after the murder, we attended a staff meeting at the Center. It was the first formal work session of the staff following the event. Because of the considerations we raised above, we felt it was important that our meeting with the staff be within structured work time, and not after or in addition to it. During the meeting, anyone who wished could speak freely. We participated from our position at the time, of having been invited by the group to do some yet undefined work with it. We were careful not to take the position of leaders or facilitators. The following are brief excerpts from what came up in the course of the conversation:
The first meeting furthered our understanding and enabled us to draw inferences from which it was possible to diagnose more precisely the nature of the injury they sustained, and in turn to formulate the primary task and aim of the intervention. It became clear that what was very deeply hurt and injured, beyond the personal losses, was inextricably tied up with the staff’s capacity to go on working as professionals. The feeling was that members of staff had lost their faith in themselves, in their ability to assess and appraise, understand and cope with what they encountered. In addition, it seemed they have lost faith in the larger society on whose behalf they worked and from whom they derived authority and validation for the roles they filled. In brief, they were ridden with disillusionment and doubts as to how much this society was willing and able to provide them with adequate understanding and support, as well as the security, protection, and means necessary for carrying out their difficult task. 2. 2. DIAGNOSING THE INJURY In the first place, it was that members of staff sustained a serious traumatization -- the abrupt and devastating loss of significant and meaningful persons and relationships. Moreover, however, the trauma occurred at the place and in the context of their daily work and in close conjunction with it; hence, in each and every one of them a part of their professional ‘work-self’ was injured or "killed." Secondly, we saw the client of our work to be the Center as an organization, and not the individuals who comprised its staff. We elected to regard the primary injury as the "wounding" of the entire system. The individuals within this system were, overall, healthy and capable persons who had undergone and were responding to a terrible calamity, and coped with it individually as any one would in their stead. Out of this diagnostic formulation the primary task of the intervention was constructed as follows:
The aim of the intervention was defined as assisting the staff in restoring its capacity for work, each in his or her specific professional role, without undue avoidance, denial, and splitting, but also without regression into the patient’s position and posture. The focus of the intervention was thus on work and professional role, and not on the ventilation of feelings. This formulation made use of concepts like resilience, referring to the recovery and rehabilitation of adaptive capacities and resources inherent to the organization. 3. THE STRUCTURING OF THE INTERVENTION:
The need for two Work Groups stemmed from the size of the staff, which numbered about 40, in order to allow more space for self-expression and active work, and to reduce potential regression to passive participation at the margins of the group. The injury was experienced and referred to in very personal, almost intimate terms. It therefore seemed appropriate to enable the expression, discussion, and experiencing of such feelings in a relatively smaller, more intimate setting. Assigning people to the two work groups was in accordance with the two maps referred to above, taking into account the map of role, seniority, and position at the Center, together with the map of the day of the trauma. Consequently, each of the two groups had some members who were in the direct "line of fire" (i.e., in the Office), and others in growing concentric circles of distance from the event, all the way to those entirely at the periphery of the Center. We also saw the need for plenary meetings, in which the totality of the staff group could find expression, and so as not to allow the staff to split, and that we as a couple could work together and be experienced as such. We proposed a series of eight consecutive weekly meetings: Six (I, II, III, V, VI, VII) Work Group sessions, and two sessions (IV and VIII) in Plenary. The compact and relatively brief structure reflected our feeling that long, protracted, and open-ended work was uncalled for, and probably counter-indicated as likely to contribute to regression and passivity. We were also responding to the staff’s original request for a relatively brief and well-circumscribed intervention. On reflection, perhaps this also reflected our collusion with the wish expressed by the staff that the wound be healed quickly. The following provides an illustration of the quality, contents, and experience of the process in the Work Groups:
The following Work Group sessions were moved to a nearby Community Center, where conditions were more appropriate. What came up in these sessions had to do with therapeutic burnout and despair, loss of faith in the profession, and thoughts about how they might protect themselves against threats of harm and violence. The feelings of closeness and togetherness, which were so prominent right after the event, all but disappeared, and they felt themselves isolated and estranged. They wondered: Do instances of violence disproportionately move them, or have the rose-tinted glasses through which they saw the world been shattered, and now things appeared as they really are? Has this murder removed the cork from the bottle and let out the demons? There was a strong wish to turn inwardly and withdraw. The depression was less on the surface, yet only more deeply internalized. A woman who was in the eye of the storm, in the Office, was saddled with the role of the "living-dead" - to be the carrier of the traumatic memory, without any possibility of movement, and this fixation made it more difficult to get at the present. Various queries and musings were voiced: "Can one say ‘no’ to a patient, or set boundaries? Does such rejection mean we are throwing those that we would not treat into others’ garbage cans? Are we the garbage bin of society? How can we be a treatment center and not a garbage bin? How can one say ‘no,’ or find someone not fit for treatment, without feeling guilty and impotent?" 4. A CHANGED FORMAT -- TOWARDS ENDING Two meetings took place in the format described above, of the two parallel Work Groups, followed by a Plenary. Three more Work Groups were to take place after this Plenary. After the fourth Work Group, however (following the first Plenary), we felt that the group processes were becoming overly fixated, stuck, and regressive, and that we were moving away from the primary task we had set. We therefore proposed a change in the structure: each of the Work Groups would divide itself into three "Very Small Groups" working in open space. The task in the VSG’s would be to share an actual recent event in which hurt or injury was experienced in either the personal and/or professional sphere. The structural change aimed to introduce movement into the fast rigidifying existing structure, by means of a reshuffle that would allow options to remain open; to encourage more autonomous and independent work as we approached the ending of the set work period; and to reframe and refocus the primary task. The proposal was initially met with considerable resistance and unwillingness to part from the familiar groups. Although the proposal was accepted following some discussion, we were brought up against the tremendous vulnerability of the group and the individuals, expressed as the need to preserve the existing structure. We were also offered an array of counter-interpretations: "You are anxious, because pretty soon you will leave us, and we are not well yet." "Don’t worry, we’ll work things out at our own pace, even if these meetings are over." "Nothing really happened, so you decided to change; actually a lot happened, let things go on this way." In retrospect, these interpretations hit accurately on where we were in our countertransference close to the end of the intervention. There were also other responses, such as: "We are pretty fed up with your telling us what to do." And: "How good it is that there is somebody who decides and says what to do. You decide what it is you want, and we will do it." Two meetings took place using the more complex Very Small Group format. Actually, once the debate was over and the work in the more intimate format began, it soon felt easier to talk. The new structure enabled a different kind of exchange, which brought about a further change of atmosphere. Following the two VSG sessions, there was a final Plenary and ending. Parting and separation was difficult and dramatic. The central feeling expressed was: "You found us covered with blood, and in the sessions we cleaned up the blood." There was also, however, a sense of disappointment and some complaint about what was perceived to be our distance: "Perhaps we worked together, but we did not cry together." Sadness and reconciliation, appreciation and unfulfilled hunger were all mixed together. There was a powerful, overarching sense that the trauma that had united them was moving further away, and with it the sense of unity and closeness which had so characterized the first days after the murder. The sense of loneliness grew stronger, and depression and impotence gradually made room for personal mourning and sorrow, as if everyone was returning to his and her isolated position. With this, we had completed our intervention. While the ending was as planned, it was nonetheless experienced as abrupt. On one hand, we felt that we lived up to the task, as it had been defined for and by us. But at the same time, and along with this feeling, we had a number of unanswered questions: Did we succeed in healing what needed to be healed? Did the intervention fulfill the expectations of comforting the pain, mending the breach, and restoring the organizational and systemic capacity for work? Such questions continued to plague us. After a while we understood these doubts and preoccupations to reflect our own reaction to the enormous emotional burden placed on us. We had absorbed very powerful projections, which continued, of course, to work within us despite the ending. These projections were largely of parents who had ‘promised’ security and hope, but whose promises were crashed by the rocks of a harsh and difficult reality, leaving behind a bitter burden of disappointment, rage, and despair. Over the next few weeks, our feelings of unrest and dissatisfaction grew stronger. It is not entirely clear whether these were feelings of worry for the welfare of the ‘patient,’ a reaction to the silence and disruption that suddenly dominated our relationship and communications with the Center, or our concern for the continuation and development of the work project. In any event, after some six weeks went by, we sent a letter to the management of the Center in which we reviewed and summed up the work that had been done up to that point, with the following addition:
We suggested work with the management of the Center, in order to rehabilitate it from residual effects of the traumatization, and through it the rest of the staff. As part and parcel of such a rehabilitative process, it was important to foster the management’s sense of its responsibility and leadership role. The hierarchy of the Center included the Director and a Leading Team (LT) consisting of senior representatives of the various professions. The LT approved our proposal, and for the next eight months the work continued along two parallel lines: 1. A series of meetings with the Director. 2. Work with the LT. This work, involving in both instances a more familiar consultative stance, was carried out by one of us (MEG), with periodic consultations taking place between the two of us. Our observations gave rise to several hypotheses. The trauma had both legitimized and concretized a number of previously existing problems, such as feelings of being dissatisfied and disadvantaged; problems with delegating and taking up authority; the prohibition of internal differentiation according to knowledge, experience, or profession. These problems, in and of themselves, were not unique to the Center, and are frequently met with in the general culture and in the mental health field. In this particular case, however, they were aided and abetted, fortified and justified by the trauma. Work with the LT focused on the level of existing organizational difficulties and problems deriving from or fixated by the traumatization, and proceeded along familiar lines of consultation. The focus of the consultation with the LT as well as with the Director was closely related to the trauma and its ramifications. A task force had been created to investigate the chronology of the murder, to attempt to understand the murderer, and evaluate the impressive therapeutic efforts and contacts with him over a long period. The findings were presented and discussed at a number of internal staff meetings, as well as invited external presentations. The first anniversary of the murder arrived, and its meaning, design, and character required an inordinate amount of time and thoughtfulness on the part of the staff and the LT. Each such occasion required tremendous emotional investment and involvement, and played an important part in the continued working through of the trauma, the mourning process, and the guilt feelings that accompanied it. The possibility for senior staff to leave the system and the Center proved to be another sensitive issue. The person who harbored such intentions experienced guilt and inhibition, while those "left behind" felt resentment and rejection. Although other events and matters now occupied center stage, such feelings and emotional positions indicated that the trauma of the murder was still present in the background. Certain events could all at once bring the murder and the traumatic fixation to the surface. The following event, for instance, took place one year after the murder:
The sad truth, however, is that "here" such play was no longer possible, because the illusion created by the treatment room had been shattered, and with it the elusive boundary between fantasy and reality, wish and action. Working at the boundary between internal psychic actuality and external reality is, of course, what makes psychotherapy possible, and serves its potency and efficacy. This boundary and space, however, had been drastically constricted by the impact of the trauma. The staff’s relationship and relatedness with the various systems and organizations in which it was embedded - psychiatric hospital, national mental health services, Ministry of Health - repeatedly came up. This subject was always accompanied with considerable emotional involvement and poignancy. Toward the completion of the work with the LT, this was focused on participation in the annual Israeli International Group Relations Conference on "Authority and Leadership." Several members of the Center’s staff wanted to take part in the conference and expected support and reimbursement from the Ministry of Health as their employer. When the Ministry did not accede, a wave of frustration, disappointment, anger, resentment, and accusation was set in motion. What emerged were expectations and wishes that the system should act as a parental figure. Against the backdrop of such childlike hopes and desires, there surfaced widespread and powerful feelings, of abuse, exploitation, and being deserted and orphaned by this "parental" system, which bubbled and sizzled under a thin veneer of compliance. The hurt and vulnerability centered on the question: Are they entitled to the support of the Ministry? Do they deserve support as victims of an unwarranted attack, comparable to a terrorist action or as professionals who would like to further their own development? Associated with these dilemmas were anger and resentment at the system and bureaucratic apparatus that discriminated between the murdered victims, and offered to pay compensations to the families according to the positions they had held: "Blood is blood, but blood-money goes by the book." The LT could not bear this discrimination, and, feeling outraged and repetitively traumatized, sent representatives to wage a prolonged and stubborn struggle with the bureaucracy, which were eventually successful in reverting what was perceived to be an inhumane stance. In the course of clarifying this issue, a new formulation was achieved: The system is neither persecutory nor evil mongering, but it is also not a concerned and nurturing parent. Living with and within the "beast-system" peaceably requires expending effort to know its ways and habits. Giving up their dependency wishes toward the system was experienced as a real concession, yet it also felt like an emancipation: They were free to think for themselves and of their own interests, and even to separate and leave the system. Terminating the work with the LT was dominated by the sense that "the stone around [their] neck grew smaller, but had not disappeared." There was more room for emerging out of the undifferentiated mass and individuating. There was also a notable feeling of coming out of depression, with greater readiness to act on their own behalf. The consultant’s feeling was also a good one: even if not all expectations were met, there was evidence that new tools and ways of thinking had evolved, and that they would be able to proceed with these on their own. There was the future prospect of a joint writing venture, and a good measure of mutual respect and affection. Half a year after the completion of this phase of the work, we (MEG & SE) met again with the LT. The meeting was designed to discuss the upcoming presentation of this work at an OFEK forum to which they had been invited, not merely in the role of passive listeners, but as counterpart to the intervention - the client, who was to participate in the presentation. In spite of the fact that they took up our invitation and attended the forum, they were unable to make a presentation, and were content to be present and participate in the general discussion. Two and a half years after ending the intervention, and four years after the event, we were invited once again to meet with the LT with the aim of thinking together about a symposium which they proposed, in which they wished us to take part. Once again, this meeting, as each of its forerunners, became an opportunity to reflect together upon the relationship and relatedness between them and us, and the long way they had come and were still on, and to add yet another layer to the work on the injury. The proposed symposium eventually took place and was actively prepared and led by them. 6. DISCUSSION The intervention presented is characterized by the attempt to blend a psychoanalytic approach with an organizational-systemic one. The discussion accordingly integrates these two approaches and focuses on: (1) A psychoanalytic level that deals with trauma and psychic pain; loss and reparation; and transference and countertransference. (2) A systemic level that treats the organization: as a structural unit with boundaries and functions; and an open system related to other organizations and the society within which it exists. The discussion specifically focuses on three aspects of this unique blend: The meaning and implications of group trauma; the holding environment and its breakdown; and transference-countertransference (CT) relationships as a resource and a facilitation in the work. 6. 1. THE MEANING AND IMPLICATIONS OF GROUP TRAUMA The essence and definition of trauma is the rupture of the protective barrier or envelope, flooding the system beyond its capability to process, contain and absorb. This conception makes sense at the individual physical and even psychic level. When we speak of a wounded social system, however, or of group trauma, as we understood and conceptualized the injury and reaction of the Center, what are we referring to? As in the case of every social institution, the Center is defined and delineated by boundaries. These boundaries consist of various elements -- physical, bureaucratic and others that derive from and exist in the social realm, such as behavioral norms and expectations. The murder violated these boundaries. Indeed, an immediate response to the murder was the investment in consolidating the physical boundaries: In every ambulatory mental health service in the country guards and electronic-surveillance gates were introduced as a means of control and supervision. Yet, in this specific case, the murderer entered the system not as a terrorist, a foreign body, or a hostile intruder, but as someone known to the system as a patient and recognized by it as its legitimate client. In fact, he did not invade but was invited by it. The traumatic break did not consist in breaking the physical, administrative, or procedural boundaries of the organization. The break in this case is the violation of a social taboo. The taboo in question is the internalized prohibition of hurting or damaging the integrity of the parental figure. The murderous wishes which every infant experiences toward the mother are projected into her and reintrojected by the infant after they have been "metabolized" through the maternal reverie (Bion, 1961). In order to be able to have her reverie, the mother must be certain indeed that the infant will not kill her. Otherwise, her anxiety will be of such proportions that she will not be able to tolerate the infant’s projections, to digest and dilute it for him. Analogously to the infant-mother metaphor, the mental health system assumes the role of containing the violent, aggressive, and destructive projections, feelings, and fantasies aimed at it, and through it at society as a whole. The mental health system can act as such a container, and thus fulfill its unique social role, as long as the taboo against actual damage and injury is maintained. The taboo against raising a hand against it serves it as a protective envelope, and allows the containment and processing of the rejected and threatening parts directed at it. The break of this taboo was the traumatic wound sustained by the Center, as a mental health unit and a component-part of this social system. Beyond the Center, however, this traumatic break affects society itself. The mental health system serves a critical social function: it is charged by society with containing its rejected madness and insanity, and the measure of violence and aggression associated with them (as distinct from violence stemming from other sources). The mental health system serves to contain the murderous, violent, and mad fantasies and impulses that exist in everybody’s unconscious, regardless of external circumstances, such as status and conditions of poverty or affluence. Society protects the mental health system through the taboo imposed against hurting and injuring it, and, in turn, is preserved and protected by it from the irrational elements it cannot contain or cope with. Breaking the taboo, therefore, injures and wounds not only the mental health system, but also society itself, which runs the risk of being flooded by violent wishes and insane and irrational fantasies once the dyke that was to contain them has collapsed. 6. 2. THE HOLDING ENVIRONMENT AND ITS BREAKDOWN The violation of the taboo and barrier against madness and violence constituted a rupture and wounding of the Center as a unit and of the wider society that needs the Center to contain these elements. A large part, however, of what surfaced in the course of our intervention, occasioned by the trauma and in its wake, had to do with the expectations and fantasies of the staff of the Center toward the social institutions representing society. What are the nature and the source of these fantasies and largely unconscious wishes? Let us proceed once more from the view that social institutions and organizations are living and vital systems, and as such, they possess strata of unconscious life. Thus viewed, the work place acts as a social defense against the unconscious fantasies of the workers (and as pointed out above, of society), generally related to the nature and character of the work itself (Jacques, 1955; Menzies Lyth, 1960). In an organization like the Mental Health Center, the unconscious fantasies and expectations are related to the fears of the negative and threatening aspects of psychic life with which the workers are daily in contact, and with which they struggle in their work with patients. These psychic threats include anxieties about alienation and isolation, dread of regression and fragmentation, and loss of mental and emotional capacities, fear of depression and of being flooded by the unconscious, and so on. For all of these, the well functioning mental health organization serves as a sort of oxidation basin -- a place where toxic waste matter can be contained, detoxified, and turned into useful materials. This process may, of course, serve to neutralize similar dangerous and unwanted products in the workers, but that is not the entire story. The analogy of the infant who projects the difficult feelings he is unable to cope with into the mother, who in turn digests and neutralizes them on his behalf, comes up again in the present connection. Now, however, the infant is the staff, and the Center-organization is the mother. The expectation directed toward the organization-mother is that it would contain and neutralize what the individual worker, or group of workers, project into it, and that, in this sense, it be viable, stable, and capable of performing this transformation. The expectation and wish are thus for the Center-as-social-institution to provide stability, durability, and capacities of containment, just like a good mother. Beyond this, that it also should look out for the welfare of its employee-child, and be concerned and helpful regarding his or her development and psychological and professional growth. It is our intention to point out the less conscious aspect of these processes. This finds expression in a sense of entitlement, but even more so in the creation of growing dependency on the organization. At the unconscious level, the organization is expected to act as a merciful and concerned parent, and when it does not live up to such expectations, anger, disappointment, and rage are directed against it. Undoubtedly, the organization can show commitment toward those who work in it. It must be remembered, however, that the system is not an "other," totally cut off and alienated from those working within it. The meeting and satisfaction of needs is an aim, the achievement of which is also contingent upon the capacities of those who make up the system and are part of it. In this particular wounded system, feelings of unmet and unsatisfied dependency came up forcefully in the form of frustrated expectations and disappointments aimed at the larger system -- hospital, mental health services, the Ministry of Health. Indeed, the larger system did respond to such demands from a certain point onward with distance and qualification. The feeling of the staff was clearly that they were "a ship of lepers," deserted and shunned by everyone. These feelings were better understood in the course of our work as rage over unfulfilled dependency needs, and this understanding opened the door to the exploration of the actual capabilities of the staff, to their activation and better utilization. Parallel with these developments in the staff, certain changes were under way in the larger system in preparation for a new National Health Bill and its numerous implications and ramifications. The prospective changes demanded a more autonomous, independent, and self-supportive professional and organizational stance. The impact of these demands and new conditions was actually in the direction we have described, i.e., emerging from a position of dependence and moving towards greater autonomy. But the coincidence in time of the organizational change in the health delivery system and the residual impact of the trauma was experienced by the staff as yet another cruel, deserting, and alienated demand. It only hurt more where the wound was still open and throbbing, and increased the staff’s feeling of being deserted, and standing alone and in isolation against a hostile and threatening world. Working with these feelings of disappointed dependency enabled the organization to regain the energies and capacities dormant in it, to start activating and actualizing them, and eventually to turn the dependent expectations and demands into ideas, the germs of wishes and goals, and the fulcrum of active planning and achievement. 6. 3. TRANSFERENCE AND COUNTERTRANSFERENCE RELATIONSHIPS AS A RESOURCE Transference-CT processes are inimical to relationships and relatedness; in fact, they are another mode of discoursing about and conceptualizing them. In any systemic-organizational intervention, numerous transference-CT processes are clearly present and active. When the intervention is carried out from a psychoanalytic perspective, however, these implicit, typically inferred, processes attain such position, presence, and meaningfulness as to render them a central tool in the intervention. Thus, for instance, the above described understanding of unconscious dependency wishes in the context of the impact of the trauma, relied entirely on what we experienced in the transference onto us and in our own CT. While such understanding is very useful, however, it is not sufficient, in and of itself, to bring about change. Change demands that whatever it is we wish to work with must be experienced with a certain degree of actuality within the context of the transference-CT relationship, as in the psychotherapeutic situation. A central dimension in the relatedness to us was the pronounced readiness to develop dependency on us. We have already alluded to the significance and meaning of the choice made in contacting us: we were well known to the staff, as persons and figures, in a way that enabled them to relate to us as sources of hope. In Bion’s (1961) terms, a mixture of two basic assumptions -- dependency and pairing – occurred in the group relatedness to us. We, on the other hand, made it possible for the group to continue along these lines by entering into and accepting the role of "knowers," of people who know what they do, who can diagnose and make decisions. Thus, for example, they wanted us to determine the structure of the meetings and allocations to Work Groups. At several points, the group evidenced opinions and positions different from ours. Each time, however, after turning it back to them for discussion and determination, it was decided to do as we had suggested. Our declared position and actual wish were to support the active parts of the staff, and to prevent as much as possible sinking into passivity. In fact, it seems that we have accepted the dependency on us as a real need, especially at the initial stage, and met them where they actually were. In the immediate post-traumatic phase, a powerful link can be observed between dependency and hope. As we have already reflected, the trauma set off a deep shock wave, which upset and undermined the staff’s capacity to believe in themselves, in their professional capabilities, and in the skills they had acquired and had at their disposal. In this specific area, a severe blow was dealt to the staff’s professional ego and ideal self. It was in this context that the transference to us was as parents who had given them professional life or teachers and mentors through whom a significant portion of their primary professional identification was achieved. Out of this transference relatedness they turned specifically to us with the wish to restore the faith and hope damaged by the trauma. In our CT, we responded to this part of the dependency and obliged it, out of our own need to restore and rehabilitate these personal and professional aspects of the wounded staff. In the transference, we chose not to interpret or reflect these projections, but to accept and enable this relatedness. By responding in this manner, we made "sophisticated" use of basic assumption dependency (baD), and to some extent also of basic assumption pairing (baP), in the service of the restoration of hope (Bion, 1961). This, we believe, is what made it possible to enact within the transference-CT relationship the "play" around restoring hope. In the post-traumatic situation, there is usually an enormously powerful tendency toward concretization and the fixation of experience. In the context of such increasing rigidification, the free play accorded to transference-CT processes -- both relationships and relatedness -- made possible a potential play space, within which symbolization processes could once more take place and be reactivated. 7. TOWARD ENDING We were invited to "do something" in order to help an injured staff group. We accepted the invitation out of a wish to be of use as members of society and as professional colleagues. We marshaled such tools as were at our disposal, and what we did was described in this paper. Have we been of help? We believe so. Was it possible to do otherwise? Most likely, yes. We cannot end this presentation without paying tribute to and expressing our genuine esteem for the members of this staff, who were hurled into a calamity, wounded, coped with it, and overcame it. Their competence finds expression in their personal and professional stance – in their ability to seek help, recognize the limits of their own professional capacities, their commitment to work on themselves seriously and continuously, without making allowances for themselves, without becoming unfocused, and without sinking too far into the victim’s position. Organizational work, as any psychotherapeutic endeavor, is also political action, in that it always aims to alter and change the existing balance of forces. In terms of the specific local politics, this staff came out the winner. As far as the politics of society, however, the question is still open: whether, in what ways, and to what extent has the social balance of forces really been changed as a result of this tragedy. REFERENCES Bion, W. R. (1961) Experiences in Groups. New York: Basic Books. Jacques, E. (1955) Social systems as a defense against persecutory and depressive anxiety. In M. Klein, P. Hermann, and R. E. Money-Kyrle, Eds. New Directions in Psycho-Analysis. Tavistock, pp. 478-498. Menzies, I.E.P. (1960) A case study in the functioning of social systems as a defense against anxiety. Human Relations, 13:95-121. Miller, E. J. (1989) The ‘Leicester’ Model:
Experiential Study of Group and Organizational Processes. Occasional
Paper Number 10, Tavistock Institute of Human Relations
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