Containment – Finding The Right Psychological Space For Change

A key lesson from psychology is that productive work is healthy and containing for people – it produces a virtuous circle where the satisfaction of being stretched and of doing a job well inspires people to show even more initiative in their roles. Many leaders I have worked with know this instinctively from the passion and energy that they bring to their jobs, but they sometimes struggle to generate that same passion in their staff. At a time of austerity when staff are overwhelmed but organisations most need them to innovate and absorb rapid changes, how can leaders create the right psychological environment, so staff can rise to the challenge?

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The Liver In Bed Number 10

Imagine a large NHS hospital ward late at night. A uniformed nurse works her way down the row of beds, shaking each patient awake one after the other to administer sleeping pills or painkillers. The patients take their medication and go back to sleep while she makes meticulous notes of the dosage. Later, at the crack of dawn, staff wake each patient to flannel their faces vigorously and to sit them up well ahead of the medical consultants’ ward rounds later that morning.  During the course of a busy day colleagues issue brisk instructions, referring to patients by their conditions: “The liver in bed 10” needs attention! “The pneumonia in bed 15” wants water.[1]

Why are these systems so impersonal and dehumanising? Why do these nurses follow instructions with so little regard for the patients? How could leaders inject vitality into such a soulless workplace?

These are the sorts of bleak scenarios that Isabel Menzies Lyth described in her groundbreaking analysis of nursing practice in a London teaching hospital 50 years ago. She had been commissioned to investigate the worrying 30% drop-out rate amongst student nurses, and during the course of her research she uncovered an extraordinary array of alienating processes – which failed the personal needs of patients, the psychological needs of individual nurses, the educational requirements of the nursing workforce, and the efficiency of the wider hospital system.

Her historical text is considered to be the foundation stone of contemporary organizational consulting, and is still relevant to today’s leaders, because she demonstrated how the failure of the hospital to care for its staff was deeply inter-connected with its failure to develop an effective working culture.

Understanding The Hospital System

Nursing culture in the hospital was deeply impersonal.  A ‘stiff-upper-lip’ and bullish culture prevailed – so nurses were discouraged from expressing their feelings, were frequently reprimanded for mistakes, and were seldom praised for hard work. Little consideration was given to nurse development because nursing was seen to be a vocation (“nurses are born, not made”[2]).  Individual nurses were considered to be interchangeable, and were switched between different specialist wards at short notice, which prevented them from preparing well for their placements.   It also prevented them from forming attachments to individual patients – which deprived patients of the opportunity to express gratitude to individual nurses for their care, and deprived nurses of the satisfaction of experiencing the positive benefits of their hard work.

Nurse managers believed these impersonal procedures were necessary because the hospital had to be run with ruthless efficiency. There wasn’t time to attend to the emotional sensitivities of individual nurses; they just had to toughen up.  Yet far from being a super-efficient machine, the hospital was actually highly disorganised. Students made up the bulk of the 700 strong nursing workforce, yet there had been no planning to consider the optimum number of undergraduate or qualified nurses required to run each ward. Nor had there been any planning to ensure that nurses travelled a clear learning pathway through each of the range of specialist services before graduation. The leaders were so anxious to give the appearance of efficiency that they were oblivious to how dysfunctional the systems really were.

The control and command model of leadership diminished the workforce, and reduced efficiency. The hospital recruited highly capable people onto the programme, but then subjected them to overbearing procedures designed to instruct the least competent of the staff: there was only ever one acceptable way to carry out each task (eg making the beds).  The best nurses became resentful and stressed, and jumped ship[3], leaving behind less capable colleagues, who had to be micro-managed yet further. Because nurses were shifted around rapidly, they never got to bond into effective work teams and couldn’t rely on each other for support. Lines of responsibility were vague and diffused, so decisions were endlessly delegated upwards.

Defending Against Anxiety

 Although people go into nursing wanting the emotional reward of being able to heal patients and restore them to full health, in reality nursing practice exposes staff to distressing psychological undercurrents. They get to experience patients’ suffering, pain and death, or incomplete recovery. Nurses deal with bodily functions and injuries that they may find distasteful, disgusting or frightening. Their work can bring them into intimate physical and emotional contact with patients, which can stir up feelings of pity, compassion, love, lust and guilt. They might identify closely with some patients, or patients may remind them of their own family members. When patients recover or die, the bond with them is broken and nurses have little space in which to grieve. Nurses may feel resentment and envy at the good care that their patients receive, when the nurses got so little support from their own managers. Equally, nurses are exposed to hostile feelings from patients and their families who feel helpless and dependent on the hospital system.

Menzies Lyth argued that the hospital systems had evolved to be impersonal out of an unconscious desire to block out these distressing feelings and ward off anxiety. But instead the systems had made the anxiety worse: Nurses felt deeply fearful of being reprimanded, insulted about having to follow instructions to the letter (eg. waking up a patient to administer sleeping pills), and also guilty knowing that this bad nursing was failing their patients.

With all this in mind, she argued that managers must help nursing staff to confront anxiety-evoking experiences and develop the capacity to deal with them more effectively, rather than sweep them under the carpet. She proposed that the “success and vitality of a social institution are immediately connected with the techniques it uses to contain anxiety.” [4]

Image

Her explanation can be summarized in this diagram adapted from Hirschhorn and The Center for Applied Research.[5] At the heart of the diagram is the idea that people approach their work with passion and energy, which can either be channelled into productive work or wasted in dysfunctional activity. In psychological terms, each piece of work entails an idealised primary task (“We restore patients to full health.”) and a nightmarish primary risk (“If I get this dosage wrong, I could kill the patient!”). If this anxiety is left unchecked staff go about their work defensively, trying to block out their distress and trying to remain disconnected from the tasks they are doing. They get caught up in devising dysfunctional processes and inhibiting structures – which lead to distorted perceptions, poor decisions, and destructive team dynamics.

Effective work happens when staff are able to connect at a more human level with their colleagues and service users. This is possible when:

  • Staff are invested with an appropriate level of authority – the freedom to act within an agreed set of boundaries. And they choose to take up their authority.
  • Staff have a facilitating structure which enables them to be mindful of anxiety without being overwhelmed by it, so they can use it wisely to guide their decisions.

Voluntary Sector Leadership Pressures

These dynamics are particularly relevant to the voluntary sector because: staff and volunteers are often more emotionally enmeshed in their organisations; they often work with particularly vulnerable clients; there is such a complex web of stakeholders to engage; the trustee-staff structure is complex to manage; staff question the authority of their leaders more; and some people assume that voluntary sector staff should sacrifice themselves for the survival of the charity (much like the nurses being expected to sacrifice themselves for the hospital efficiency).

I think there are also specific issues here for social care charities at present. Under the procurement agenda charities are being forced to cut costs radically, and there is a growing reliance on low-paid and isolated bank staff to care for highly vulnerable clients. Some charities are taking over the employment of former NHS or local government staff from services that have been under-resourced, anxious and depressed for many years. There are tremendous opportunities here for charities, but there is also the potential for frontline staff to feel extremely exposed and anxious, and prone to the destructive dynamics that Menzies Lyth described in the hospital.

The Psychology Of Change

People derive a sense of purpose from satisfying work, and as Menzies Lyth explains, all workplace systems are partly designed to protect people from anxiety. So any organisation change that disrupts these systems will threaten people’s psychological security – which is why people react so emotionally to having change forced upon them. For change to be effective, it has to be approached both as a rational task in deciding what strategy to adopt, and as a psychological task in deciding how to engage staff in those changes. Staff need to feel ‘held’ by their organisations so they can safely acknowledge and manage their difficult feelings, can free up their minds to think, and can engage with the primary risk of change.

Having a clear thinking structure goes some way towards supporting staff psychologically, but it isn’t enough. Without that sense of feeling contained people can’t engage rationally in analytic tasks like horizon scanning or strategic planning – their views will be distorted by their defensive reactions to anxiety and they will unconsciously sabotage the planning process (such as: denial of looming financial crises; grandiose ideas about winning huge contracts or running miracle fundraising campaigns; helpless resignation to closure; furious battles with commissioners, or blaming the CEO for organisational problems).

Containment

Before you can engage staff and generate passion for your change programme, they have to feel sufficiently contained. The concept of “containment” which I’ve referred to throughout this paper, is widely used in human relations consulting to describe a psychological state where people feel robust, secure and resourceful. They have the presence of mind to think clearly, can tolerate their difficult thoughts and feelings, and know that these anxieties will pass. They can modulate the way they express their feelings, and know when and where it is safe to discharge them. If they know that they can take care of themselves, or if they understand how the organisation will take care of their needs, they are freed up to tend to the needs of the organisation.

Talk of organisational psychology can be daunting for leaders who are accustomed to approaching the world from a rational perspective, but many of the things that effective leaders already do come under the umbrella of containment. Here are some examples:

Modelling steady stewardship of your organisation – by being thoughtful, taking urgent issues in your stride, describing your feelings when appropriate but not “emoting” or relying on staff for your own emotional support. Bringing the temperature down when others emote. Finding your own appropriate sources of support (eg. coaching) – so that you feel robust and contained yourself.

Fostering a supportive culture which is mindful of difficult feelings, and which encourages peer support. Developing emotional literacy in the organisation by carefully naming the feelings that staff might be experiencing. Providing agreed spaces and opportunities where staff can let off team and express their frustrations, especially during times of organisational change.

Arranging ongoing structured psychological support for staff whose work is routinely stressful, so they can manage their workloads, can deal with the anxieties, projections and frustrations thrown up by the work, and can model tranquil containment for their service users. (eg. counselling, clinical supervision, case conferences, staff support groups, debriefing sessions, or line management supervision etc.)

Ensuring role clarity and appropriate role authority for each job, and supporting staff teams and divisions to manage relationships across the boundaries of their roles.

Providing as much structure and consistency as possible during periods of change. Having clear consultation processes, clear timescales for when crucial decisions will be taken. Being clear about the bottom line for what has to change and what will not change.

Facilitating and enabling powerful team discussions. Being clear about the task, helping the team to structure their thinking processes, and synthesising different perspectives into a coherent decision. Having agreed ground rules, and if necessary surfacing difficult issues, supporting the team to say what is unspeakable in a managed way, and to reach a resolution.

Ensuring organisational clarity through rigorous analysis of your vision, values, mission, and strategic direction, with regular reviews to ensure these are fit for purpose. Involving staff in developing these so they feel a sense of ownership and appreciate the need for change. Clear communications to reinforce the core messages.

Managing upwards. Holding your role authority and managing the boundaries with your chair and board so that trustees govern, and you and your staff have the full authority to carry out the executive work. If necessary challenging boundary breaches and ‘speaking truth to power’.

While many of those are “soft” skills, containment is also about doing the necessary tough things to keep your organisation safe and ensure its survival, but doing these in a mindful way. Facing up to the need for cuts, and implementing redundancies if these are essential; sticking with unpopular decisions when you know they are right; challenging poor performance and holding people to account. These are containing if they are carried out in a way that reinforces the charity’s values and principles, and in a way that is sensitive to the emotional impact that they may have. Paradoxically, staff may kick against these painful changes, but internally they will also have a sense of security from knowing that the organisation is in a safe pair of hands. They just might not thank you out loud for it!

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This Thought Piece was written for The Centre for Charity Effectiveness at City University Cass Business School, where I am a Principal Consultant. My grateful thanks to Denise Fellows for her comments, though all errors and opinions are entirely my own. 

References & Reading

Hirschhorn, L (1997) Reworking Authority, leading and following in the postmodern organisation, MIT, Massachusetts, USA

Jarrett, M. Kellner, K (1996) Coping With Uncertainty: a psychodynamic perspective on the work of top teams, in Journal of Management Development, vol 15 no 2 MCB University Press, UK

Menzies Lyth, I (1988) Containing Anxiety In Institutions Vol 1, Free Association Books, London


[1] Menzies Lyth 1988, 52

[2] ibid, 61

[3] ibid, 76

[4] ibid, 78

[5] reproduced in Jarrett et al, 1996

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