Observing Organisations: Anxiety, Defence and Culture in Health Care. Hinshelwood, R. D. and Skogstad, Wilhelm, Eds. Philadelphia: Routledge, 2000. xiv + 175 pp. Paperback $29.95.
The collected papers in this volume describe training exercises undertaken by Dr. Hinshelwood’s student-professionals in a psychiatry seminar. Each observed the work environment or “culture” of a health care setting similar to his or her own work place. Five of the 11 chapters have been previously published as journal articles. The central eight chapters, which report the qualitative findings of the observations, share a set of assumptions and a research method.
After a foreword by Oberholzer and a dialogic preface in which the editors recount the history of their collaboration, the shared assumptions are set forth in chapter 1 and the method described in chapter 2. The next eight chapters report on observational studies of psychiatric care in a ward for chronic patients, a mental hospital dining hall, an acute admission ward, a long-stay psychiatric ward emptied of those appropriate for community placement, and a community hostel with minimal staffing. Three additional observational studies are included from a general medical ward, an ambulatory care day surgery, and a palliative care unit. The editors’ concluding summary comprises chapter 11.
Hinshelwood is a Kleinian psychoanalyst, and this orientation is apparent in the shared object relations frame of reference that informs the method of these studies and shapes analyses of the data. The assumptions of this orientation are clearly laid out in chapter 1. Hinshelwood and Skogstad see organizational cultures in health care settings as amalgams of defenses against the anxieties inherent in care giving tasks and those personal anxieties and defense strategies brought to the work by people drawn to it. Defense mechanisms motivate attitudes and beliefs in health care workers that energize rationalizations about the way work is to be carried out. Such attitudes and beliefs are modeled or actively taught to new workers and the anxiety-culture-defense complex becomes fixed in the system of care. Work practices formed in this way may manage anxiety in an adaptive and productive manner or may more rigidly defend against it in ways that demoralize workers and interfere with humane task performance. The sensitive observer’s own subjective response to the atmosphere that has evolved to incorporate these unconscious defensive strategies is assumed to be the best instrument to detect and interpret the anxieties and defenses extant in the organizational culture.
Menzies, on whose work this is built, interviewed nursing personnel as well as observing them. In this volume, however, evidence of anxieties and defensive maneuvers is derived solely from observation. To many psychiatric professionals (particularly those with a cognitive-behavioral orientation) and to medical anthropologists and sociologists, the method used to study organizational cultures will appear peculiar. Laid out clearly in chapter 2, it is recapped in each of the research reports. What is described in the abstract and in the initial paragraphs of chapter 2 as the chosen method of participant observation is more accurately described by contributors as observation without participation. In fact, the stated ideal is for the observer to interact with others as little as possible. This required lack of interaction seems both an integral part of this psychoanalytic method and its weakness in terms of producing results that nonanalysts will find credible. In pursuit of what is perhaps the psychoanalytic ideal of the blank screen onto which the other might project unconscious mental contents, the observers strive for an impossible invisibility and neutrality, in part by making observations on the same day and hour each week and sitting static in the same place. The total hours of observation number about 12 in each study.
Because observers decline to move about or interact, they are sometimes left with only fragmented bits of conversation taking place within earshot and partially obscured views of what happens in other rooms. From these, they must first surmise some surface meaning and then construct the deeper often unconscious meanings of the words they have barely heard and truncated action sequences they have partially observed. Thus, the data from which interpretations are drawn are primarily the observers’ own emotional reactions to the process of observation, perhaps congruent with the introspective psychoanalytic method outlined, but also serendipitous as there is little else to go on. Most observers comment on the discomfort that their own rolelessness and passivity created in them. Not a few spend ink describing their emotional reactions to finding their usual chairs occupied or moved. The observers’ reactions are accepted as the main grist for the mill of analysis because these emotions are assumed to reflect those extant in the atmosphere of the space they are observing; emotions that emanate, unrecognized, from patients or staff. Thus, if the observer feels isolated by belonging to neither the group of patients nor the group of staff, she may conclude that patients feel isolated. If staff do not approach or verbally recognize the observing visitor—after a period in which brushed off interaction may have accustomed them to ignoring him—he may record a frustrated wish for human interaction and propose this to be a regular feature of the ward environment. Skogstad’s chapter on observation of an acute medical ward, includes, for example:
What I experienced in myself—the longing for contact and recognition, the sense of loss and abandonment, the wish to hold onto my physical place and the feelings of displacement if this was lost—reflected feelings that patients and nurses probably shared but often dared not think about or express. At times, nurses seemed able to be in touch with some of those feelings, but more often they turned to a defensive way of functioning. (p. 111)
The editors liken their espoused method to the participant observation of the psychoanalyst in four of five described aspects of clinical practice: observation with distributed and nonjudgmental attention, examination of one’s subjective experience, reflection on the gestalt of that experience, and recognition of its unconscious dimensions. The fifth aspect of clinical practice not held to be part of this method is the formulation of interpretations and explorations of same in dialogue with the observed. Indeed, many of the researchers were asked to provide results to the teams observed. This consultation step is not part of any of the research reports and apparently did not take place although the method used is compared to the kind of management consultancy undertaken by systems theorists of the Tavistock Institute.
Observers participated in a 9-month-long seminar, doing background reading during the first trimester, doing and discussing the observations during the second, and organizing and writing up material and interpretations for the third, all under Hinshelwood’s supervision. One might say that observers were thoroughly inducted into a point of view that produced the tautological conclusions of their manuscripts. The introductory chapters explain that general medical work excites unconscious fantasies of harming, sexual arousal from intimate contact with bodies, and fears of contagion and contamination. Psychiatric work brings with it attendant fears of loss of self-control. Working from these premises about the kinds of anxieties particular to different kinds of medical work, observers discover evidence of defenses against these same anxieties.
Despite the epistemological limitations of the described method, there is the ring of veracity to many of the descriptions and interpretations advanced. Those who have attended a ward “community meeting” will recognize Donati’s description in chapter 3 of a seesawing between urging patients to express themselves and shutting down their unwanted contributions. Skogstad’s insightful unpacking of observations on a medical ward helps one to understand the often noted and seemingly incongruous playful eroticism seen in that setting. Contributors are appropriately tentative in asserting results, as is apparent in the quote from Skogstad above. In the final chapter, Hinshelwood and Skogstad distill each of the research projects down to an axiomatic statement or two of cultural attitudes that prevailed in the settings observed. For example, the ethos of the medical ward is summed up as: “If enough friendliness is generated, then fear, anxiety, and pity won’t have to be felt. Busy activity is the antidote to, or mastery of, death (p. 162).”
From Chisea’s description of an acute admission ward, the axiom derived is: “The job is simply to clear up whatever others do and drop here.” Stripped down to this bare essence, Chisea’s conclusion resonates with some of Rhodes’ (1991) findings in a longer work based on a much longer period of interactive, involved participant observation in a similar setting, and informed by a Foucauldian social control frame of interpretation.
One of Freud’s stated intentions with publication of Totem and Taboo in 1913 was to bridge the gap between students of anthropology and those of psychoanalysis. Disagreement about the nature of culture persists; the gap still exists, and this volume may just slip into the chasm. Those inclined to accept the assumptions inherent in the method and analyses of this volume will likely accept the results and conclusions drawn, whereas those who do not, will not.
Juli McGruder, Ph.D.
Sociocultural Anthropology, Professor, Occupational Therapy, University of Puget Sound
1. Freud S (1950 ) Totem and taboo: Some points of agreement between the mental lives of savages and neurotics, J Strachey trans. New York: W.W. Norton
2. Rhodes LA (1991) Emptying beds: The work of an emergency psychiatric unit. Berkeley, CA: University of California Press