“[O]nly 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..........The helpful and the helpless meet and put pressures on each other to act not only in realistic but also fantastic collusion....  Staff and patients are thus inevitably to some extent creatures of each other” (Main, 1975)

This paper evokes events at a psychiatric day clinic as illustrative of a theory that whilst on the conscious level the aim of community psychiatry is the care and rehabilitatation of people with mental illness its unconscious function is to fashion a barrier of mystification and separation between public and patient. 

This clinic was the subject of a doctorate and a book (“From Asylum to Anarchy”) by Claire Baron.   Though the only observable  “anarchy” was organisational, arising from the staff group of the Day Clinic enacting an omnipotent group phantasy, Baron evokes the vulnerability, fragmentation and need for structure of the patients in her argument for increased administrative hegemony and the curtailing of professional autonomy. That the patients’ behaviour throughout the affair was constructive, appropriate and ‘normal’, and judging by the high attendance of this traditionally “hard-to-engage” group “the new venture” was offering something attractive and useful, was lost on participants and subsequent commentators.      

From this curious myopia, characteristic of mental health services rhetoric, indicates an unconscious relationship between the experiential framework of patients diagnosed with “serious enduring mental illness”  and specific aspects of community psychiatry.  I suggest an unconscious phantasy of the broader social milieu – enacted through the service – maintains a status quo  through creation of a technologically-validated “otherness” of the mentally ill.  The  “new venture” at Paddington Day Clinic, in its refusal of this and its attempt to engage with the “other” – both within patients and within the institution - threatened this reassuring cultural phantasy and was terminated by the NHS establishment on the rationale that it was not adequately monitored and controlled.  Distancing of the patient was reasserted through intensified organisational technologies of audit, systems governance, hierarchical dominance and justified by definition of the patient as biologically dysfunctional. 

These instrumentalising pseudo-scientific technologies in the mental health services, far from moving human relations away from irrationality, reify praxis into process, constructing a new organisational defence against unconscious primitive group anxiety.  The contemporary, supposedly rational, scientistic paradigm, based in pharmacological control, systems governance, audit and evidence-based practice is more irrational, more defensive, more ritualistic than were former notions of demonic possession or "illness" involving more – not less – mystification than historically-constructed  “otherness” (Ingleby).

Paddington Day Clinic: “Case Study” 

One day in 1974 the Medical Director [1] of Paddington Day Clinic announced  a ‘new venture’ in the clinic.  He would assume the often-disturbing behaviour and ideas of the Clinic’s patients [2] originated in unconscious phantasy.  He would provide psychoanalytic interpretation as the route out of psychic distress and social rejection.  Psychotherapy would shift the patient from psychosis to neurosis, exchange isolation and dependency for the ordinary miseries of normality.

The Psychotherapy Institute of which the clinic was a part established in 1962, and comprised the day clinic (initially a “half-way-house” rehabilitating patients discharged from one of London’s large psychiatric hospitals, closed with the rolling-on of the Government’s “care in the community” initiative); the child guidance department (formerly the psychiatric department of a hospital for nervous diseases); and the adult outpatients (which  joined the Institute in 1965 and was staffed by Freudian-oriented psychoanalysts offering individual psychothrapy).

Aside from shared premises, administration and secretarial services, there was little interaction between departments.  The commitment of most members of the day clinic team was part-time since they worked in the adult department also.  In addition some further staff – a psychologist, a social worker, two art therapists and an occupational therapist -  worked to the Institute as a whole, dividing their time between departments according to demand.

The day clinic was a pioneer endeavour in the field,  the first non-residential therapeutic community in the UK, but the staff still felt the constraints of National Health Service structure inhibited its development.  They considered the large-group psychotherapy experiment (Goodburn’s “new venture”) represented both a  radical departure from drug-orientated, regimented, traditional psychiatry and by providing psychoanalysis for outpatient groups, from conventional psycho-analysis.   There was a messianic belief that the day clinic had found the secret of ‘curing’ mental illness.  The ideological argument was that formerly the treatment of patients had erred in regarding them as social deviants. [3]

Although the day clinic staff felt that their work in the Institute was and should be exclusively that of psychotherapists they were still managed as members of their own disciplinary hierarchy outside the Institute, in the broader NHS structure.  The Institute strongly resisted any form of hierarchical organization arguing that all its therapists were colleagues working on an equal basis. [4] However as in every area of the NHS involving multi-disciplinary team working the medical profession carried ultimate clinical responsibility for the patient.  Since the Institute existed for the practice of psychotherapy it was as psychotherapists that the psychiatrists viewed themselves, participating in a flattened hierarchy. The day clinic staff comprised the Medical Director, who was a Consultant Psychiatrist (trained in addition in group psychoanalytic methods by Henry Ezriel at The Tavistock [5]), two more doctors with both medical and psychotherapy training, two Occupational Therapists, one medically-trained Registrar and 2 psychiatric nurses, all defining themselves as “psychotherapists” though employed as members of their respective disciplines and accountable to their superiors in their particular hierarchy.  Four out of  the eight staff lacked formal training and qualification for the “new venture” of analytic groupwork. 

When the non-medically-trained staff of the Institute as a whole demanded the creation of a multi-disciplinary committee the Chairman of the Medical Executive Committee – the main conduit of contact between the Institute and Area management -  refused to consider it.  The professional staff therefore set up “the Professional Staff Committee” (“the PSC”) of which everyone holding a professional position automatically became a member.   For some time after this, both committees reported to the Managment Committee of the Local Hospital Group of which the Medical Executive Committee was the on-site formal embodiment; the administration endeavoured to take account of the views expressed by the PSC despite its lack of formal status.

In 1971 the Management Committee  proposed closing the day clinic down.  A new psychiatric unit with day places was  being created at the mother hospital.  The Medical Director was told to wind down his psychotherapy programme.  There followed a year of uncertainty and of solidarity in the day clinic in response to the threat.  The patients  did not want to return to the conventional treatment methods many had experienced for decades in traditional hospitals.  The staff wished to protect an organization that allowed them to learn and practice psychotherapy in an NHS setting – a rare, if not unique, situation.   Staff and patients formed an action committee, contested the closure, and the day clinic was reprieved by a decision of the Secretary of State.

During the next three years most of Goodburn’s team attended Ezriel’s seminars.  All were involved in interpretation in the large psychotherapy group.  Many  lost interest in other aspects of the day clinic , all such involvement  now deemed as interfering with the  large-group transference relationship.

By the end of 1975 every matter occurring in the day clinic was “brought to the large group”, theoretically in operation whenever people were present.  Attendance  varied from 5 to 30 patients (usually around 25) and staff, frequently only 1 or 2.    Formal selection procedures fell into abeyance; all patients became self-selected.  Those who could tolerate the lack of structure, the dirt (the cleaner left, and was not replaced!) and the mode of treatment, continued to attend.  By 1976 this had resulted in an almost-exclusively male patient group.

The unconscious level of reality was the prime and single focus of attention.  Any other level of discussion was deemed illegitimate and irrelevant.

Then the staff decided there should be no more meals or fares restitution, these transactions constituting “avoided relationships”. [6] This provoked a complaint from the patients who in January 1976 sent a letter about conditions and treatment in the day clinic to the Area Administrator, with a copy to the Minister of Health and another to the Chair of the PSC.  It criticised the unavilability of staff and the lack of choice of therapy offered.  There had been no cleaner for 6 months at this stage.  The patients complained that though they could clean for themselves the Medical Director’s perspective was that if a patient could clean up after everyone he no longer required treatment.  The doubt was expressed whether the large group comprised treatment.  The letter claimed that  many patients had “left, withdrawn or overdosed”.  They requested re-instatement of  rules, the day to be structured, for staff to do their jobs, and the clinic to be run conventionally.

Senior administrators who hitherto felt they could not challenge the professional judgement of the Medical Director now acted to re-establish managerial control over autonomous doctors and other professions.

Though he had had no knowledge of his staff’s intention to withdraw meals and fares Goodburn defended their decision on the basis that the day clinic’s “primary task” was treatment of psychic distress through psychotherapy, and all activities within its boundaries should be seen as part of this process.  He considered the matter could be discussed by outsiders but not fully understood by those not involved in day-to-day transference/counter-transference dynamics.  He expressed willingness to discuss the complaint in the large group if this would further the aims of therapy.  The PSC Chair refused.   

The PSC debates about the day clinic’s “primary task” and psychotherapy were very heated with finally the PSC  dissociating itself from the day clinic.  Despite its lack of constitution and formal authority the PSC had gained considerable power.  The District Administrator stood in a managerial relationship to the day clinic (excluding the consultants who as doctors had professional autonomy) but before he started inquiry proceedings needed the specialist knowledge of the PSC members as he had no psychotherapeutic training and was geographically remote from the Institute.

The Medical Director continued to maintain that the patients’ complaint and demand for the old, infantilising system was a defence against psychic reintegration; their understandible rejection of the form of help offered at the day clinic was a retaliation against life-long dis-enfranchisement through incarceration in mental hospitals and prisons.  The day clinic worked with people with gross material and emotional deprivation, usually “screened out” of the system as being “too sick” or “not intelligent enough” for psychotherapy.  He explained the treatment aim to be understanding by examination of  psychic functioning. “The hospital is the drawing board on which patients are invited to portray themselves”, necessitating a simultaneous understanding of both the patient and the clinic. He maintained that whilst the approach was unlikely to please either patients (since it explored their anxieties rather than placating and repressing them) or the NHS (since the behaviour involved in the testing out of new manifestations of self was challenging)  it fulfilled the aim of a flourishing community psychiatric service treating appropriately and effectively.  He maintained that anything concerning the patients would continue to be brought up for discussion within the treatment context – i.e. the large psychotherapy group.

Though the PSC had no official authority to make decisions the Area Health Authority took its opinion seriously and acted, pressing for an inquiry by an independent body. [7] The Medical Director was within his rights to reject the involvement of the PSC as it did not have a legitimate managerial role vis a vis his work. 

The Inquiry committee consisted of the Area Health Authority Chair and Vice-Chair, four AHA officers, the Area Medical Officer, the Area Nursing Officer, the Area General Administrator and a secretary, a Consultant Psychotherapist, a Professor of Psychiatry, and a Chief Nursing Officer.  The Inquiry was not public so as to “allow the witnesses to feel completely free in giving their evidence”.  All members of staff were invited to  testify.

Goodburn, present in the first days, ceased attending when the Committee refused to transcribe the inquiry proceedings for the patients’ benefit.  He continued to maintain that all matters relating to patients’ treatment in the day clinic be brought to the large group as material for analytic interpretation.

The Committee deliberated for six weeks, confirmed the legitimacy of the patients’ complaint and reinstated bureaucratic procedures and regulations including intake procedures,  data-collection, patient history, diagnosis, treatment plan, reports to G.P’s, a  register of patients, discharge procedures and follow-ups, staff supervision of patients at all times,  on-call roster for doctors,  casenotes,  resumption of meal-provision and reimbursement of fares.

The Committee criticised Goodburn’s reduction of the variety of  therapeutic interventions to one but had to conclude that he “is free as a clinician to use this technique.....It cannot be said to....constitute bad practice”  they considered it cause for grave concern that the therapeutic approach had not been documented carefully as an experiment to be evaluated at regular stages.  The Inquiry Committee confirmed the PSC as an appropriate place for discussing matters relating to the day clinic.  If the Medical Director was to continue his experiment it must be discussed with the PSC, planned carefully, and systematically evaluated.

All staff except two (who were subsequently “eased out” of post in September 1977) implemented the Inquiry recommendations.   The Medical Director refused, denying the legitimacy of the PSC. This was reported  to the Area Health Authority, which insisted he commit to its recommendations.  Goodburn was now operating two types of treatment in the day clinic – “mixed treatment methods” following the Committee recommendations, and “psychoanalytic therapy” where he was directly responsible.  All patients and staff were free to choose whichever method they preferred, but could not have both.

The Area Health Authority objected to Goodburn running two treatment programmes and demanded that he confirm his compliance with the Inquiry recommendations.  In October 1976 the Medical Director “withdrew his labour”.  The PSC requested the Area Health Authority demand his resignation as his presence at the Institute was “harmful to patients”.  Since he refused to “unequivocally accept” the principal recommendations of the Inquiry report he was suspended in November 1976.

The AHA set up another inquiry into the running of the day clinic and Goodburn’s failure to comply with the recommendations.  In January 1978 they announced their findings; the Medical Director did not meet the required standards of care expected of a consultant in the NHS.  He was not struck off the Professional Register of doctors and malpractice was not established.  However he  was demoted to the grade of Registrar or Clinical Assistant and summarily dismissed from post.

For  eighteen months after the second Inquiry the day clinic attempted to run to its revived bureaucratic regime. 9 out of the 28 patients who had been accepted after screening 117 referrals did not attend, and 9 others of the total admitted had been discharged.  Attendance was down to an average 9 per day whereas at the height of the “self-selection” experiment in 1974-75, daily attendance averaged between 25 – 30 patients.

The AHA statement in June 1979 claimed its decline was due to its geographical remoteness from other mental illness facilities and its lack of clearly defined selection criteria.  The Authority felt it inappropriate “to allocate scarce resources to a facility of such limited scope and application in terms of services for the mentally ill generally”.  Not only would closure of the day clinic not affect services adversely, but would also save £60,000 in revenue per year.  It was closed in August 1979, the few remaining part-time day clinic staff being redeployed in the Adult Department.

What’s going on, besides chaos?

This vignette contains all the elements of current conflict in community psychiatry in “the New NHS” which began restructuring in 1974.  Constituent groups appear neither to know nor understand “what is going on”; there is a steeply-hierarchical, heterogenous organisation in denial of its organisational purpose and reality;  there are the clearly-delineated, conflicting “models of mental illness” - the biomedical versus psycho-social; there are the seeds of current NHS “audit culture”, systems governance and commercial enterprise; there is the sense that the organisation’s rhetoric bears no relationship to it’s delivery;  the impression that groups purportedly working to the same ends are involved in “turf wars” within a context of fear and lack of communication;  there is the basic-assumption “pairing phantasy” of organisational salvation through new technology; there is avoidance of engaging in dialogue with, rather than about, “the patient”.

Could the declared primary task be at odds with some underlying unconscious phantasy, organisational chaos arising as defense against feared psychic contagion (Jodelet [8]) as the institution re-contextualises its work “in the community” and the historic spatial and definitional barriers between public and patient dissolve?

In a recent essay Hinshelwood writes:-

“not only have long-standing patients in large numbers been set free to be cared for in hostels, community centres and day care and often to roam the streets, but institutionally trained staff, too, have been pushed out of the traditional tightly knit, or even rigid, teams in the old hospital wards.  They are required to roam the streets too in search of their liberated patients.  Too often both patients and staff become lost.  Staff now have to confront seriously disturbed clients – and their anxious, often pathogenic, families -  on the doorsteps in the alien environment of a domiciliary visit or the hostile neighbourhood.  Staff are no longer on their home territory.  They lack the immediate colleagueship of the old mental hospital teams, the regular procedures and comfort of hallowed traditions........it was hoped that mentally ill people could be inserted back into networks of ordinary (or genuine) human relationships which constitute the community.  Instead, without training in the latter, ex-patients are inserted back into a network of professional care with, moreover, a highly anxious network of professionals”

and furthermore:-

“....various processes operating within the organization [blame-culture, fragmentation of service] reduce the quality of the work.  Changes of staff, high levels of absence, scapegoating of patients, splits within and between teams, have a very negative effect.....morale must fall.............In addition, the processes in the organisation bring out primitive processes in the individuals – splitting, denial and projection.........the disastrous and “meaningless” distress suffered by clients infiltrates the staff and ends up “in” the organization, which becomes in reality a disturbed service..............................It might not be going too far to claim that attending to the mental health of the workers is as important as attending to the mental health of the patients – if not more so!"

One problem with this model of the organisation’s dynamics as contained (the patients) contaminating the container (the service) is that it uncritically echoes the cultural stereotype of the mentally ill as powerful, destructive and intrusive – a caricature as absolutist in its way as the completely vulnerable patient of Main’s quotation at the start of this paper.  Whenever such dichotomised views of a particular social group are current, primitive unconscious group phantasy is in operation, the phantasy apparently permeating the anxiety-defence heuristic itself! 

If we evoke other models for exploring the psychosocial transactions within the service we find Miller and Rice (1967) focus on a concept of transactions across a “sentient boundary” suggesting an  ego-function equivalent mediating between the primary task of the enterprise and its environment, optimally balanced sentient and organisational boundaries enabling creative interaction between container and contained.  Bott Spillius (1976; 1990) theorises that incompatibility of the aims of the mental health institution (to control, to care, to cure) constitute unconscious impediment to the functioning of services.  Jaques (1976) considers that the absence of  “requisite organisation” leads to lack of containment of group anxiety. All these heuristics seem eminently applicable to the Paddington Day Clinic;  dramatic shifts in sentient individual and organisational boundaries, historically built-in ambivalence of the nature of the container, and inherent structural contradictions at manifest organisational level, are all apparent.  However I suggest the issue is even deeper!

The devolution of services from the large (usually rural) institutions to small urban purpose-built sites is based on two connected and erroneous assumptions; that the former were expensive ineffective methods of rehabilitation, and the latter were effective and cheap.  An increasingly-large lobby argues the reasons were pecuniary; the old asylums were prime real estate, the selling-off of which generated huge income sustaining other political projects.  Figlio, in a paper on unconscious aspects of health and the public sphere, suggests the decline of public medicine and the institution of an alternative “private sector” degrades “public” into a depository for the phantasised healthy private sector’s destructive mad aspects.  Public sector expenditure then evokes phantasies of greed of psychotic proportions projected onto such aspects of the service as “demand”.

The cost of treatment of biomedical conditions in “public health” begins to represent a parasitic phantasy threatening the healthy group and anxiety and aggression are set loose. Though the large therepy-group approach at Paddington appears to have been bearing fruit the clinic was shut and the Area Health Authority  “saved”  £60,000 per annum.

Simultaneously with being “set loose” into the “community” with its attendant demystification, those deemed mentally ill  are stigmatised in a novel manner. Madness, formerly out of sight and out of (public) mind must be re-defined and reified into malignant process in keeping with the combined objectives of consumer capitalism and modern medical psychiatry. Lived praxis becomes inanimate process.  The “other-than-human” is created to cope with this unaccustomed dangerous proximity, evoking as it does the phantasy of psychic contagion (Jodelet).

Figlio writes that in such transactions nature is an “other” with whom we have a complex dependant relationship which is denied.  A scientific relationship to nature which denies dependency requires continual defendedness. Identification with the non-human world implies a projection of a non-human part of ourselves into it.  This identification - about which Searles writes extensively - includes a terror of absorption, of comforting merger, of sharing in its immense power (Searles 1960).  There is a narcissistic satisfaction of identification with the absolute quality of relentless processes signalling a primitive level of the psychic transaction.

Projection of destructiveness into parts of both the body and society localize it and allow it to be separated from the centre of selfhood, whether individual or cultural.  This “telic decentralization” is linked with the mythical theme of sacrifice which can be understood as an attempt to omnipotently control primitive annihilatory anxiety.

Identification with nature’s power achieves, in phantasy, a cementing of group solidarity without which the group would be aware of internal difference and of the nature of praxis with its components - ageing, illness, death.  Aggression turned outwards acts to externalize dread reality and lodge it elsewhere.  Minor differences mark out a group to absorb a massive projective transfer of “bad” internal objects.  That the anxiety of extinction associated with “illness” can be replaced by a group phantasy in which another group is attacked for minor differences reflecting back narcissistic injury serves equally well.

Searles writes that the repressed love of the infant for the mother – not alone destructive envy or anxiety – constitutes the ambivalence at the root of paranoid-schizoid dissociation.  This repressed feeling-complex, being largely split off from the conscious ego, fails to mature and become fully differentiated into qualitatively distinct feelings.  When love of the mother does at times succeed in breaking through and emerging into awareness, it has a primitive form, often oral-incorporative, associated with frustration-rage and other destructive emotions with which the love-feelings are mixed.  This originates in maternal phantasy that her primitive love-impulses are potentially dehumanizing for her babies.

Unconscious dynamics of shifting anxiety, variously, between public and patient are dyadic. However they represent in mental health rhetoric as post-oedipal (triangulated), as a configuration of  patient-psychiatry-public transaction.  This obscures their primitive pre-oedipal nature.  The intensity of the repressed ambivalent love of the healthy (public) group for its sacrificed pre-oedipal undifferentiation (now contained in the social representation of the patient as biologically defective!) evokes anxiety which demands even greater splitting, since projective identification cannot assuage psychic conflict simply relocates it. Replacement of praxis by process in the scientific worldview precludes identification.

The healthy group defends against the patient-other by redefining her as non-human process crystallised and abstracted in pseudo-scientific organisational technologies such as audit, service governance and researched object, including, increasingly, through instrumentalising psychoanalytic ideas.  The arena for this conflict is community psychiatry.  Not surprisingly anxiety is high.  As Bott-Spillius suggested, psychiatry is  the site where the mores of the culture are articulated, defining “what does not” constitute membership of the social group.  The contingent porous nature of the boundary between “healthy culture” and “sick individual” illuminated in transference/countertransference work, especially when this work addresses paranoid-schizoid levels of phantasy,  threatens the absolutist group assumption of health and rationality and the reified barrier between what is (symbolised) socio-logic and the (unsymbolisable, primitive-affective) bio-logic, culturally  represented as mutually exclusive in the social group’s defence against re-minding. 

Figlio writes that “Public” and “health” are reservoirs of phantasy of a commonweal easily degraded into defensively structured systems in which projective loops dissolve and encase the primitive phantasies that such systems evoke in the endeavour to be “objective”. “Health” is a public word; “disease” a private one challenging to it, relying on mastering anxiety by externalization.  “Public” and “health” allied provide reservoirs of benign group phantasy in that they are removed from the projective loop.  However reservoirs of communal participation not colonised by primitive group phantasies become scarcer with the advance of the consumerist ethic.

Bion in 1957 speculated whether the deficits of schizophrenic thought could throw light on the essential function of 'having a mind', the paranoid-schizoid resembling  “a mind that fails to operate as a mind”.  ‘Alpha function' enables individuals to deal with the affective storms created by interaction with others, transforming the storm into material that can be used for thinking.

The conversion process takes raw experience and creates thoughts possessing the quality of 'meaning something', an inherent quality of the thoughts. Mind  deals in meaning,  a 'substance' or  category which is not  facts or information “about” something but a specific experience of meaningfulness. What is registered in mind acquires a collateral felt quality. Recognition with meaning produces  'representation'. ‘Mental representations' have sentient existence,  feel tangible, are not simply passive process.......their roots are in both the bio-logic and the socio-logic spheres.

Alpha-function, in addition to registering and meaningfulness, gives a sense of “mental space”, a location where representations connect and transform each other creating new meanings. This additional aspect of alpha-function is the experience of 'having a mind'.  Bion’s view was that the creation of objects of thought (alpha particles) is co-terminous with the creation and development of the mind to think them.  Alpha-function transformations creating representations also create the sense of a mind in which the products of the encounter exist. Thoughts require a thinker. They are mutually constituted.

Space/time co-ordinates where thinking occurs is then identified with a specific material place – is embodied. Alpha-function thus initiates recognition, meaning, representations, a thinking mind, a sense of personal identity and a self  irrevocably linked to that space (mental) and location (physical).

Paranoid-schizoid functioning dismantles the symbolic, consensual categorisations of experience, relationship and status underlying the socio-logic; affect, not thought, is communicated.  Fundamental to the Klein-Bion model is recognition that paranoid-schizoid roots (the bio-logic) feed even the most cultivated aspects of our sociability, are the eclipsed component of sublime and public feelings.

On the basis of his clinical work (1955) Bion hypothesised that group mentality is psychotic mentality.  In  basic assumption mode the feelings and actions of the group are not representative of the alpha-function of its constituent individuals.  Moral sense and mature judgement, recognition of cause-and-effect and sense of time are absent.  There is reversal of alpha-function as a group – not of individual members of the group.   'Bizarre objects' (paranoid phantasies) replace integrated perception on the group level.  Work-group function reverses. There is homogeneity, but it is an agreement to incoherence and disconnectness, co-operation based in paranoia.  This implies a complex phenomenology of the person as both individual and group member:-

Thus we have a situation in which the individuals behave as if they were conscious, as individuals, of the basic assumption, but unconscious of it as members of the group (Bion 1961, p. 94).

Sentient boundaries,  by nature cognitive/affective, structure relations in the organisation (Miller) delineating the projected, symbolised, reified  “mind” of the social group functioning in time and space with consciously articulated purpose. Cause-and-effect, legitimate authority, hierarchy of competence, sense of agency and individuality established through rhythms of identification and differentiation are “minded” as potentially benign reification – the “requisite organisation” itself – its efficaciousness residing in meaning something both inter- and intra-psychically (Kaës).

Re-contextualisation of mental health services “in the community”  releases primitive unconscious phantasies of greed and talion of the broader society’s rejected other – the “mentally dysfunctional patient”. Devolution of the service into the community precludes the continuance of a cultural phantasy of projected affective irrationality and/or demonic possession “contained elsewhere”, and appears unable to produce a contemporary containing phantasy.

However the threat to an unconscious cultural phantasy of unalloyed rationality constituted by the re-contexualisation of mental health services, re-minded “in the community” and the illumination of the nature of this cultural defence through engagements with the “other as self” (such as Goodburn’s “venture”) produce a new anxiety and new defences against it.  In the absence of an articulating symbol there is something more deadly, annihilatory.  The organisation pours increasing resources and energy into construction of  objectifying technologies which re-present human praxis as process through re-definition of the patient as biological dysfunction, monitored and adjusted through the mutating forms of the organisation itself  - systems governance, audit, pharmacological regulation and a-temporal, uni-directional paradigms of objectifying research - organisationally reconstituting the patient as non-human “other”.

Notes

[1]Julian Goodburn, M.D., MRCPsych. (1936 – 2001).  During the 1970’s Medical Director of Paddington Day Hospital,  the first non-residential therapeutic community in the UK and a founder member of the Association of Therapeutic Communities.

[2] Baron writes that though the Day Clinic eschewed diagnostic labels, the “borderline” label (“between neurosis and psychosis” Rycroft C. “A Critical Dictionary of Psychoanalysis” Nelson 1968)  was formally used in describing PDC’s patients in case conferences and by the administration.

[3] Durkheim considered deviant groups to be essential to social stability, their labelling, ostracizing, punishing and rehabilitating being part of the continuous process of self-definition of the whole culture.  He sought social “facts” in lawlike relation to replace moral evaluation of social life, priviliging the scientific over the ideological.  Talcott Parsons (1958) in his turn conceptualised illness as deviance.  Deviance as illness in a Durkheimian formulation could be observed and treated as a natural fact – a lawful, though pathological, variation of the organismic properties of a society.

[4] Howard Schwartz (Revolt of the Primitive  Praeger 2000) theorises that the malaise of contemporary institutional life is the feminisation of the workplace.  He evokes Chasseguet-Smirgel’s idea (1986) of the overthrow of the oedipal achievement:- “The father, his penis and reality itself must be destroyed in order for the paradise world of the pleasure principle to be regained”. 

[5] Ezriel’s theoretical formulation is similar to that of S.H.Foulkes and equal applicability to group analysis.  Ezriel theorised that unconscious phantasies structure mentation in the here-and-now, setting up tension and concomitant need for relief through patterns of rigid transferential relationship with the therapist(s) determining content and sequence of remarks and behaviours. Large-group dynamics exhibit unconscious common group tension built up through accumulation of apparently unrelated remarks and behaviours. Unconscious selection, rejection and distortion of remarks fashion a common denominator of the dominant unconscius phantasies of participants.  The group “structures” itself so that object-relationships (i.e. transference relationships) accord with unconscious defenses of individual members.  The whole group in a given session as well as the roles various members take within the group display individuals’ characteristic defence mechanisms, and are analysed.  For Ezriel the “correct interpretation” was the crux, the description of the forces operating in the patient’s mind at that particular moment.

[6] In Ezriel’s formulation, “avoided relationship” emerges as the required relationship is interpreted, the patient then testing out his fears and finally comparing the situation where the calamity has not happened with the unconscious phantasy of calamity.

[7] The decision to proceed with an inquiry accorded with the Code of Practice for dealing with hospital complaints (Davies Committee 1973).

[8] Denise Jodelet spent 10 years in the 1980’s researching the oldest residential therapeutic community in Europe - Ainee-le-Chateau in France, through combined quantitative/qualitative methodology.  The mentally ill live in the townland as boarders of the local people.  Though their demeanour and daily activities (they work on farms, serve in shops etc) is indistinguishible from their hosts and they live as members of the family the stereotype persists in representations of “madness” their hosts retain, and there is a custom of keeping the eating utensils and washing area of the boarders separate from that of the family.

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