Who are the real insane?

Our perceptions of disordered thinking and behaviour as defences against imagination

Mannie Sher, PhD Tavistock Institute of Human Relations (*)

Paper presented at the Public Winter Series Seminar Organised by

The International Futures Forum and the Glasgow Centre for Population Health

4th December 2013

In this paper, I will explore the social dimension of mental illness and the role it plays for and on behalf of the individual, the staff who are responsible for them and for society and what role mental illness plays in defending against imagination. I currently work with several public service organisations which have large concerns about mental health issues in the population groups they serve. I will illustrate my talk with examples of institutionally-induced madness that should make policy-makers and organisational leaders rethink the kinds of structures they create for others to work in, and where the work itself is difficult or traumatic. Such work, I argue, requires containing supports to protect both staff and service users against inhumane living conditions. I will talk from the proposition that all work generates anxiety and that the people involved in the work - strategists, leaders, managers and front-line staff, generate personal and institutional defenses to cope with that anxiety. The nature of those defenses and their construction and management, will ultimately influence how the staff manage their own and their teams anxieties. In many cases, the need to manage this anxiety is ignored, it where that happens, the team and institution generally are dysfunctional, serving neither the patient/client/customer, nor the staff, who may experience high levels of stress, burnout, illness or leave the job altogether. A second proposition from which I shall speak is that in most public service organisations, the primary task which is meant to guide the strategies, policies and practices of the staff, is usually unclear and may even be confounded by having a second primary task, often unconscious, for example, in the health service, the primary task of

treatment and cure; of care and compassion, may be overtaken by a value-for-money cost-effectiveness primary task, i.e. the introduction of a target culture, that may reduce the quality of care and compassion and demoralizes staff making them do things that conflict with their professionalism, their values and their desire to serve.

A third proposition is that mental health problems are usually linked to the complexities inherent in a system whose working task is based on a double task1. The double task may comprise, say, the primary task of diagnosis, treatment, detention, imprisonment or military service; which often conflicts with the second task of a duty of care towards the population group detained and respecting their dignity and human rights. This contradiction and conflict in the double task is demonstrated by the following statements from one of the organisations: From the point of view of senior management: We have a duty of care, but mental health issues are secondary to our primary task. In many instances, we are able to identify mental health issues early and clearly. Our job is detention, but there is a group of people in the middle that are not so ill as to be sectioned, and it is with this group that we have often lost our cases in court. From the caseworkers point of view: Reasons for detention are not well defined. We pay special attention where there is high risk of harm to the public. The
See Trist, E.L. and H. Murray (1990) The Social Engagement of the Social Sciences: A Tavistock Anthology Vol. 1: The sociopsychological perspective London: Free Association Books 1

spectrum of risk makes it difficult to arrive at satisfactory decisions. Sometimes, there are conflicting positions that complicate matters for us. We have to be risk-averse when it comes to public safety. From the interviews with detainees the following is an example of a theme that emerged very strongly: Staff need to recognise what people tell them regardless of whether it is true or false. We are locked up and this is difficult for vulnerable people. It is like a prison here. Either we have served our sentences or we should be sent to a real prison. Why are ill people here? Everyone here has their stories, but what brings us together are our experiences that this feels like a prison. We are treated as prisoners, but we are not prisoners. Staff back each other up instead of providing care. As prisoners, we are helpless and vulnerable. The relationships between policy makers, managers and front-line staff, healthcare staff and caseworkers can be characterised by intense processes of mutual blame and defensiveness. For example, health care is blamed by detention staff for not responding to referrals quickly enough. Detention staff are blamed by health care staff for not using their common sense in referrals leading to health care facilities being overwhelmed with numerous unnecessary referrals. Thus the two groups use each other to export and import wrong-doing and failure into the other. By this we mean that each group carries the one element of the contradictory double task. Consequently, detention worker staff members work at preventing escape, whereas healthcare staff members

are focussed on the overall physical and psychological needs of the detainees. This splitting of the task is detrimental to the overall efficiency of services where mental health is an issue. It results in mutual blaming processes and collusive relationships in which the different parts of the total system engage adversely with each other. The reason for this split is to protect staff from the potentially overwhelming psychologically and emotionally distressing traumas of their charges. As a result of this, groups under pressure use these defensive mechanisms to protect themselves from feelings of helplessness and hopelessness by placing responsibilities onto other groups. An alternative would be to think imaginatively together in joint meetings on how inter-disciplinary relationships can best be used for the benefit of their charges. These dynamic processes of blame and recrimination get replicated throughout the system. There are similar systemic dynamics operating in the relationship of the relevant higher level department and the NGO sector: with mutual projections of hostility and mistrust between voluntary organisations, special interest groups, and charities on one hand, and the civil service on the other. Responsibility for resolving these complex inter-organisational difficulties is often left to the private sector the unspoken wish/hope is that sub-contractors and private sector agencies would more easily resolve these dynamic tensions. That is a vain hope because privatisation is meant to stimulate competition, not collaboration.

Theories-in-use The four domains covered by this paper are the military, prisons, the NHS psychiatric services and services for victims of sexual violence. In our work, we rely on what we call theories-in-use and I will spell out a few of these and the questions they raise. Theories-in-use helps throw light on the reasons for the high levels of mental health problems in the services and the difficulties of taking imaginative and effective measures to reduce them. Organisational Theory2 Organizational Theory describes the structures, tasks, attitudes, experiences, practices, beliefs and values - personal and cultural - of an organization. It is the specific collection of values and norms that are shared by people and groups in an organization that control the way they interact with each other and with stakeholders outside the organization. Organizational values are the beliefs and ideas about the kinds of goals members of an organization pursue and ideas about the appropriate standards of behaviour that organizational members use to achieve their goals. From organizational values develop organizational norms, guidelines or expectations that prescribe appropriate kinds of behaviour by employees in particular situations and control the behaviour of organizational members towards one another. A strong culture exists where staff respond to work because of their alignment to organizational values. Strong cultures help organisations
Trist, E.L. and H. Murray (1990) The Social Engagement of the Social Sciences: A Tavistock Anthology Vol. 1: The sociopsychological perspective London: Free Association Books Trist, E.L. and H. Murray (1993) The Social Engagement of the Social Sciences: A Tavistock Anthology Vol. 2: The sociotechnical perspective London and: Philadelphia: University of Pennsylvania Press Trist, B. and H. Murray (199?) The Social Engagement of the Social Sciences: A Tavistock Anthology London Vol. 3: The socioecological perspective Philadelphia: University of Pennsylvania Press 2

operate with outstanding execution. A weak culture results from poor alignment with organizational values and control must be exercised through extensive procedures and bureaucracy. Where culture is strong, people do things because they believe it is the right thing to do. Strong cultures also produce quick and easy ways to refer to a mode of thinking that people engage when they are deeply involved in a cohesive ingroup. In authoritarian cultures, people, even if they have different ideas, do not challenge organizational thinking, and therefore there is a reduced capacity for innovative and imaginative ideas. This occurs where there is heavy reliance on a central authority in the organization. People who challenge standard practices are seen as negative influences by the rest of the group, because their ideas bring conflict. Organizations need individuals to challenge the status quo, whether it is groupthink or bureaucracy; otherwise, imagination is repressed and new ideas are difficult to implement effectively. In the context of statutory organisations, the questions that stem from organisational theory might be: how well do the values and practices of outsourced companies align with the Government Departments values? To what extent do prison officers and Health Care staff share similar objectives, attitudes and norms towards the management of prisoners cases? How are the tensions that are generated by the primary task of detention, imprisonment, psychiatric in-patient or military service and secondary task of duty of care managed by that organisations different staff groups? An over-riding question would be whether the sometimes competing cultures in detention centres, prisons and hospitals and central administration cause detainees to become psychiatrically ill, contribute to existing mental health conditions, or make no difference.

Socio-Technical Systems Theory (STS)3 Much of contemporary scientific management subordinates the human element to technological imperatives. The concept of the socio-technical system jointly optimises all the variables in the organisation and thus the possibility of increasing choice. Socio-technical systems theory shifts attention from the individual to work groups and the wider organisation as a whole. STS theory emphasises the inter-relatedness of technical and socio-psychological factors in work alongside political and economic factors. The STS concept questions the salience of technology as determining social, political and other relationships within organisations. As a result, organisational choice increases since it is possible to design forms of work organisation that optimise the best fit for these factors. One consequence of the socio-technical approach to organisational design has been the emergence of the concept of semi-autonomous work groups. The corollary to this idea is that every individual who takes up a role in a work group, and by extension in an organisation, is called upon to manage themselves in role. This is done in two ways: by managing oneself in relation to one's work tasks and activities and by managing relationships with other role holders.

Emery, F.E., and Trist, E.L. (1960) Socio-technical systems. In C.W. Churchman and M. Verkulat (eds.) Management Science 214-232 London: Pergamon Press

ENVIRONMENT

GOALS AND STRATEGIES

CULTURE

INPUTS (RESOURCES)

BEHAVIOUR AND PROCESSES

OUTPUTS

TECHNOLOGY

STRUCTURE

Open System Diagram

In relation to mental health issues in the statutory provision of services, questions that Socio-technical Systems theory address are: i) Structural: how integrated in practice are the different departments, units and sections of the over-arching authority, and how coordinated are these units with its partner organisations like, health and the justice systems and outsourced commercial companies that provide services on behalf of the higher level departments?

ii)

Professional: how collaborative are the different professions that provide psychiatric and physical health services for detainees/prisoners/military personnel on behalf of the higher level departments?

iii)

Psychological: how well are the causes and effects of mental illhealth understood and practiced by the staff within these organisations, and their associated organisations, like Health, Police and the courts? Is mental illness located in individuals only, or can mental health problems be caused and spread by the social situations people are in?

Linked to socio-technical systems theory is the concept of social systems as a defence against anxiety4. The Social Systems as a Defence against Anxiety construct postulates that in order to avoid the anxieties aroused by the work of the organisation, people develop defences to avoid psychological involvement with patients, prisoners, clients, charges, etc. These defences include: The idea that professionals are interchangeable all should look the same (wearing uniforms to avoid individualised appearance) and should be willing to move to different workplaces at short notice. Breaking down tasks into a series of mundane routines that can be repeated with many people (e.g. one professional performing the
4

See a seminal paper of this nowadays well established concept in Menzies Lyth, I. (1960) Social systems as a defense against anxiety: an empirical study of the nursing service of a general hospital, Human Relations 13: 95-121

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same task on different people, another professional performing a different task with the same people) rather than each professional extending in-depth care with one person. Avoiding expression of individual initiative or decision-making by making all professional and/or administrative tasks prescribed from above Discouraging expressions of emotion or interest in individual patients, prisoners, charges, etc. These defences are aimed at reducing the anxiety aroused by intimate physical and emotional involvement with ill patients, clients, children, charges. These social defences are not the result of the individual personalities of the professional, but embedded in the culture and routines of the organisation and woven into the professional identity and practices of the staff in their training programmes. Ultimately, these defences are ineffective because staff are still subject to the difficult emotional demands of the work and they become disengaged from their patients or charges. This means that they are not able to effectively engage with the causes of their anxiety. By not being able to think and acknowledge the impact of their work, they are not able to learn from their experiences or to work through feelings of loss, helplessness or guilt. This results in many talented potential professionals and workers not engaging emotionally with their charges and thus unconsciously allowing the growing mental health issues to prevail.

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Questions that the theory of Social Systems as a Defence Against Anxiety raise are: Does the type of professional training for detention centre staff, health care staff, military personnel and caseworkers encourage initiative or unthinkingly lead them to perform routine tasks and keep relationships with detainees at a superficial level? What are the unspoken anxieties in organisations where these people are held/located? What might be the consequences of these anxieties for how people work together? What social defences does the higher level department have that stop people thinking clearly about the difficult feelings people experience at work? Do these defences work?

Systems psychodynamic theory5 Systems psychodynamics is an interdisciplinary field comprising three fields of study (i) psychoanalysis, (ii) group relations, and (iii) the concepts of task and boundary within open systems perspectives. Systems psychodynamics has its intellectual foundations in the Tavistock method of working experientially with groups and the study of organizations. Systems psychodynamics is the term used to refer to the collective psychological behaviour within and between groups and organizations. Systems psychodynamics theory and practice provides a way of thinking about energizing or motivating forces resulting from the interconnection between various groups and sub-units of a social system. The theory focuses on the challenges of crossing boundaries

Gould, J, Stapley, L. and Stein, M. (2001) (eds) The Systems Psychodynamics of Organisations Karnac: London

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and how unconscious factors affect leadership efforts, learning, productivity, communication and social change. Questions covered by this theory: how well do the various groups, centres, sub-divisions and categories within the higher level department, the various stakeholders outside it, within the UK and internationally, understand the meaning of mental illness for the people who are designated ill and for the public? How well do they integrate their efforts to address the problems of psychiatric patients, immigrants, prisoners, returning military personnel? How well is the construct of crossing psychological boundaries understood in relationship between mental illness and mental health? In crossing organisational boundaries in inter-departmental relationships; in crossing sector boundaries between a Government Department and its out-sourced providers? In crossing international boundaries in the inter-national context of immigrants wishing to land in the UK?

Theory of Mental Illness/Mental Health The term mental illness refers to significant changes in peoples thinking, feelings or behaviour. The changes need to be bad enough to affect how the person functions or to cause distress to them or to other people. If a person has always had a problem in their thinking, feeling or behaviour, then this is not usually called mental illness; rather a developmental problem or a difficulty with their personality (sometimes called a personality disorder). Mental health is the opposite it means mental wellbeing, good mental functioning or having no particular problems in thinking, feelings or behaviour unlikely in situations of incarceration.
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Boundary Theory Organisational theories emphasize the significance of the boundary that separates the organisation from its environment, one division from another and people from the roles they play. A system imports resources and information across its boundary, transforms them into useful products or services, and then exports them across the boundary to customers and clients. The boundary separates the outer world of opportunities and challenges from the inner world of work and transformation. Without a well-managed boundary, each unit in an organisation will respond in its own way to the environment, so that relationships within the organisation will be as unpredictable as the environment it is in. The boundary across which commodities like materials, people, information, ideas, or values flow in and out, both separates any given system from, and links it to, its environment. It marks a discontinuity between the task of that particular system and the tasks of the related systems with which it interacts. Because these relations are never stable and static, and because the behaviour and identity of the system are subject to continual re-negotiation and re-definition, the system boundary is best conceived, not as a line, but as a region. That region is the location of those roles and activities that are concerned with mediating relations between inside and outside. In organisations this is the function of leadership. The leadership exercised in this region can protect the internal sub-systems from the disruption of fluctuating and inconsistent demands from outside; but it also has to promote those internal changes that will enable the system to be adaptive, and indeed proactive, in relation to its environment. The health and ultimately the survival of a

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system therefore depend on an appropriate mix of insulation and permeability in the boundary region. By "standing at the boundary", leadership creates a more controllable world in which activities within the boundary are relatively predictable and organised. The boundary region separates certainty from a broader region of uncertainty. This is the task of the management. When boundaries are poorly designed and managed, they cause considerable stress and anxiety. This happens when leaders cannot influence management and management cannot influence front-line staff. In turn, front-line staff, unable to influence the people on whom they depend, cannot reduce the uncertainty they face when doing their work, resulting in feelings of alienation and unhappiness. Authority Theory Authority is imposed by superiors upon subordinates either by force (structural authority) or by argument authority. Usually authority has components of both compulsion and persuasion. For this reason, authority is differentiated between legal power and persuasive political rank or standing. Legitimate Authority Power" is defined as "the ability to influence somebody to do something that he/she would not have done"; "authority" refers to a claim of legitimacy, the justification and right to exercise that power. Questions: How is authority dispersed among the various groups in the statutory services? How coherent are the levels of authority derived from legislation and the policies and procedures that interpret the legislation?

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Do the large numbers of differing groups working with detainees, prisoners, soldiers, etc. have different interpretations of the policies and procedures? Does this lead to arbitrary decision-making in relation to these people and their mental health? Usually, people know what the facts are and what solutions have already been recommended. That being so, the main question is: Why is implementation so problematic? The problematics of implementation From our reading of past reviews of the services we have worked with, we saw that many sensible ideas about the care of mentally ill people under their control were suggested. However, implementing them was difficult if not impossible because of dominating cultural influences and the organisation of the work. Implementing recommendations requires serious internal work within the management system. To summarise so far: 1. Impacts that affect the work Outside influences often impact negatively on the work of the organisations, such as competition to achieve targets and deadlines. 2. Resources Almost all statutory organisations concerned with mental health do not have enough psychiatric resources - nurses and doctors. More training is needed - more input to sensitise staff at all levels to mental health issues.

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3. Culture Current cultures6 in statutory organisations where mental health is an issue will continue and will override resources inputs, such as training, more staff, different providers. New and more staff do not necessarily change things. There is a definite detainee/prisoner/patient culture that promotes all kinds of expectation. Detainee cultures mutually reinforce one another, supported by their legal representatives and other external bodies. The cultural dynamic becomes entrenched. Most staff will agree that the descriptions of detainee/prisoner/patient cultures ring true, but there is a sense of hopelessness about the situation, with few questions on how to change cultures. There are ways of introducing culture change which are not as difficult as they sound. The place to start is to clearly state the task of the organisation. This would mean a realignment of the staff culture and the working relationships within the organisations. There is the challenge of achieving targets. Focus groups and events should, from the beginning, focus on preparing people to return to their work, roles, and lives they had before detention. 4. Double Task The concept of the double task can be useful here, viz. (i) the main task of detention/imprisonment/diagnosis and treatment/fighting and (ii) a secondary task of health and care of detainees of the same standard that is expected outside. This process and dynamics around

The concept of organisational climate is well described by Schein, E.H. (1992). Organisational Culture and Leadership. (2nd

ed) San Francisco, California: Jossey-Bass

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the double task can negatively impact on the mental health of detainees. The task of detention should not be privileged over the task of care and welfare they need to run in tandem. If they do not, the effect on individuals is to exacerbate their mental health problems. The longer they stay in limbo the increased chances of their mental health deteriorating. Understanding the Process of Grief Our observations based on working with organisations were liberty is restricted is that not enough recognition is made of the psychological impact of detention. In these situations people, whether they are deemed mentally ill or not, suffer from feelings of loss. A vast body of psychological literature informs us that loss is experienced as bereavement within ensuing grief. 7. Unresolved mourning and grief plays a significant role in the aetiology of mental ill-health. People whose liberty has been curtailed experience some of the following symptoms: shock, sadness, crying; changes in life roles and responsibilities; fears about the future, feelings of helplessness and hopelessness, anxiety, loneliness, confusion, yearning. The normal stages that people go through who have suffered a major loss are: shock, protest, disorganization, re-organisation. After a significant loss many people have the sense they are going crazy, particularly if they have not sustained a major loss before. (Murray Parkes) Though people experience phases of grief, they are not helpless victims. There are

A useful explanation of the process is available in Marris, P. 1974 Loss and Change Routledge and Kegan Paul, London

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emotional tasks which a person can actually work through following the death of someone close, a divorce, or been victimized through abuse. The following 4 phases of grieving must be worked through and it will take a period of time to do it: Shock vs. reality; the task of this stage is to accept the reality of the loss. The life you had maybe is over and will not return vs. denial/unbelief of the loss.

Protest vs. experience; the task is to experience the pain of grief rather than suppress or avoid it. One needs to face the pain of loss, feel the pain and express his/her grief rather than run away from it.

Disorganization vs. adjustment: Adjusting to the environment without the life you had planned. Coming to terms with the reality of the situation.

Attachment vs. reorganization: Detaching from the life plan, memories and hopes and reinvesting in other relationships or in the case of abuse: forgiving and letting go of the past trauma.8

1. All people who are detained or are aggressed are emotionally troubled. The more fragile ones are more likely to tip over into florid
Parkes, C. Bereavement: Studies of Grief in Adult Life; publ. Pelican, London and Routledge, London & New York (3rd Ed 1996) Parkes, C. Love and Loss: the roots of Grief and its Complications. Routledge, London & New York (2006) 8

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mental illness. A consequence of this is that staff need training in the assessment of the likelihood of detainees breaking down. 2. Assessment: with all the organisations I have worked, the assessment process when being detained needs to be improved. More psychiatric oversight at the start of the detention process would help. Better information on detainees histories could inform the assessment process. In many instances, it was said that if detainees histories were known at the time of detention, they would not have been detained.

3. All seem to agree that detention is definitely harmful to mental health. It would seem that mental health care is inadequate from reception onwards and staff seem inadequately trained in assessing risk of self-harm. To improve this would require in-depth screening, staff training, more Registered Mental nurses, more use of interpreters and doctors trained to make a proper mental health assessment. 4. Better assessments will help staff identify vulnerable individuals who can then be looked after adequately. However, this individual approach will not address the institutional cultures where people are detained. Many organisational cultures cause people to break down with mental health problems in spite of better assessment at reception. The two cultures that we are aware of are:

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 the detainee culture which could be characterised as resisting detention through many appeals and ensuing behavioural problems, such as a variety of self-harm activities; the staff culture characterised as one of disbelief and psychological distancing, that results in failure to be proactive and deal with problems quickly and effectively. These two cultures when they interact with each other create confusion as opposed to a system that is purposeful and in tune with Central Office policies. 5. The centres need to adopt a way of thinking that emphasises the two aspects of the task detention combined with care and welfare. Institutional difficulties in integrating these two elements of the task, need to be recognised, but it is possible with the right sort of governance and cultural change to achieve both. 6. Working with the wider system of stakeholder groups is important. All organisations attempt to engage in dialogue with their stakeholders, but these are usually problematic. One way of reinstituting regular dialogue and exchange of views is to have standing conferences in which all parties are invited to engage in dialogue. This is best achieved by having the standing conferences designed and facilitated by a neutral party. 7. Creation of a Futures Group. From our organisational development experience, we know that change occurs only as a result of the work of a dedicated group of sufficiently senior and authorised staff that

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have the powers to make the necessary changes. Often we have worked with a group of operational managers who have told us that they agree with the changes that need to take place, but dont have the power to make them happen. Therefore this Futures Group would need to be a vertical slice of the whole system so that all voices can be heard. From these ideas flow a clear requirement for any organisation to pay attention to the following aspects of their functioning. Firstly, whilst a major strength of any organisation is its business-like image, which conveys a sense of paternalistic protectiveness, this can be rather recessive. We believe that whilst it is essential not to downgrade an organisations masculine characteristics, it is important in shaping the future to add a more feminine emphasis like listening, understanding, nurturing, promoting, integrating, sustaining, etc. Secondly, organisations need to adopt holistic approaches to the individual, their group and "change" and "communications" and to consider the individual and technology in a linked way, i.e. to aim towards integrated socio-technical systems. This is highly motivating to people and presents an opportunity for organisations to emphasise what are the contemporary and relevant benefits. Thirdly, the defence mechanisms against integrating change policies and communications systems within work-related activities, means that the people perceive themselves as isolates. It is easy to metaphorically "keep your head down" and pretend that the issues do not affect one. There is

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scope to find ways of fostering integration at a perceptual level and in reality within organisations so that "change" and "communications" becomes more integrated into work. Fourthly, in all organisations there is a clear need for education, training and development, and being aware that in order to work, slow, step-bystep organic approaches are required in order to change attitudes and behaviour with relevance to work-related thought and activity. Research highlights the importance of individual, departmental and organizational activity, which can be used in different ways to generate interest, provide information and to shape the nature of communications as a resource which promotes the organisations general purpose. communication. Fifthly, there is a need to develop people's knowledge of other parts of their organisations and their roles in relation to those parts in a tangible way. Inductions, joint seminars, study days, conferences, local and international, more social occasions, spontaneous and formal, can be fostered. Finally, in terms of the approach to education and training, there is a requirement to provide activities which are integrated with day-to-day work, rather than removed from it. These should be carried out in an environment committed to learning, the acquisition of knowledge and skills, so that people believe they have a choice and may be motivated towards participating in the choice process imaginatively. They can be helped to see that they can use their organisations constructively, and that they will Personnel everywhere need continuing education in order to enrich work-related

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not be absorbed or trapped by them or denied their creativity, so that their organisations would become bad employers.

Target-driven services mean that the focus of the service is on the target rather than the person the service is designed to help. And targeting people by their deficits as unemployed; as an offender; as a teenage parent, as an illegal immigrant, etc., is itself part of the problem. It defines people within their deficits instead of enabling them to develop thriving, sustainable independent lives. The study of social systems from a systems psychodynamics standpoint offers the view that the perception of certain groups of people is influenced by deep-seated social fears that tend to demonise these groups, turning them into the other, pigeon-holing them and controlling them in order that they should no longer pose a threat. There is a trend of defining these groups of people as moral panics. (Cohen, S. (1973). Folk Devils and Moral Panics. St Albans: Paladin). Moral panics result in treating people as either mad, bad or sad with consequent overregulation, criminalisation and medicalisation of people detained, treating them as objects of surveillance and control, rather than as capable and creative contributors to society. These aspects of the beneath-thesurface dynamics probably permeate all layers of our detention systems and tend to remove power, growth and independence from people.

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Conclusion Our main point of theoretical importance, and of relevance for the social systems as a defence against anxiety construct, is our understanding of the types of organisations I have been talking about, as a projection of the anxieties evoked by the primary task of the organisation (coping with the effects of sexual violence, illegal immigration, warfare), and the failure to contain or process these primary issues and anxieties within the social system itself. By accepting these types or organisations within its jurisdiction, the higher level department must be aware of an inherent risk to the organisation of this task, and in particular of the potential for management failures. I have set out to demonstrate the relevance of the anxiety thesis and to show how powerfully it explains evolving catastrophic developments in our institutions. We urge a greater focus on the role of unconscious defences and their enactment, and I have demonstrated that these ideas about social systems as a defence against anxiety capture the meaning of it in beneficial ways. I have focused on the particularity of the anxieties that arouse the specific defences which are relied on to cope with them, such as suppression, denial and projection, when working with the consequences of incarceration and denial of civil liberties upon weak and unprotected members of society. In the case of the service for victims of sexual violence, sexual scapegoating of female patients had got translated unconsciously into sexual scapegoating of the services all-female leadership and all-female staff. It seemed that women had to be made into victims socially, institutionally and individually.

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This paper has a more obviously central theoretical purpose and tries to set out its understanding in a way that might help all the parties better understand what happens in their institutions. In the events that unfold it should be important to downplay the implications of blame, even if blame might sometimes seem to be justified. We need to acknowledge that inevitably partisan feelings do get stimulated in an environment of acts of violence, restraint and injustice, as a consequence of the emotions which this work involves, but we need to try to get beyond these and to try to understand the situation and its passions as a whole, explaining what is happening to everyone involved. An element of critique can hardly be avoided, but our emphasis should be upon understanding the unconscious effects of working in situations of violence, detention and retribution.

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