An Organizational-Distress Syndrome: Diagnosis and Treatment LOUIS
N. GRUBER,
M.D.
Assistant Professor Department ofPsychiatry Louisiana State University New Orleans, Louisiana
and Behavioral Sciences Medical Center
Organizational disturbances often begin with seemingly plausible complaints, which the author calls mass symptoms, that are presented repeatedly from many sources and that cannot be clarified or resolved. They are essentially pseudo-problems by which responsibility f or organizational failing is transferred elsewhere. Treatment consists primarily of restoring functional job-related communication, often by means of small, explicit changes in communication pathways rather than by attitudinal changes in communication or by open’ or emotionally candid communication. The author describes the occurrence and treatment of mass symptoms in a military hospital unit, a mental health center, and a university teaching unit. ‘ ‘
‘
UCollective disturbances in organizations frequently begin insidiously, with epidemics of diversionary complaints that may actually obscure the real problems. Such complaints are frequently described in relation to therapeutic communities1’2 but are by no means limited to psychiatric organizations. They can occur in churches, schools, clubs, military units, and even nations. These complaints, which I have termed “mass symptoms,” often follow characteristic patterns that can be recognized clinically. After observing them in therapy groups of psychotic inpatients, I subsequently identified them in a spectrum of organizational staff disturbances. In a therapy group or ward meeting, one may hear repeated assertions that all problems would be solved if
Dr.
Gruber’s
New ting: Vol. 2
address
Orleans, D.
E.
at
Louisiana ‘ Staff
Raskin,
Symptoms
and
the
medical
70112. Work
Units,”
An
Examination
Hospital
of
& Community
is
1542
Tulane
‘
& Community The
Antitherapeutic
Psychiatry,
Avenue,
Health
in a Mental
Hospital
Solutions,”
26, July 1975, pp. 455-456. M. H. Sacks and W. T. Carpenter,
munity:
center
Dysfunction
Pseudotherapeutic Forces Vol.
25,
Set-
Psychiatry, Com-
on
Psychiatric
May
1974,
315-318.
HOSPITAL
& COMMUNITY
PSYCHIATRY
pp.
only the patients could all go home, or if showers were given at a different time, or if the coffee pot were available earlier in the morning, and so on. Such cornplaints are clearly defensive and do not respond to realistic problem-solving. Of greater importance, however, are complaints of that type that occur among staff. The mass symptom is a seemingly plausible pseudoproblem by which responsibility for an organizational failing is transferred elsewhere. The complaint crops up in the most remarkable way from many different mdividuals or in different parts of the organization. It can change overnight to another complaint or can alternate rapidly with a variety of apparently unrelated cornplaints. Yet although the problem seems plausible, understandable, and solvable, it apparently cannot be resolved by discussion, ventilation, or open communication. Indeed, the more it is discussed, the more confusing and obscure it may become. If a seemingly acceptable solution is proposed, either it doesn’t work or a new complaint immediately replaces the old one. Efforts to elucidate the real problem’ meet with surprising resistance. Even the basic facts seem unobtainable. Three case studies from different organizations will illustrate these collective disorders. ‘ ‘
‘ ‘
‘ ‘
‘
The military hospital unit. Patients in a military hospital unit in Japan greeted their doctors each morning with bitter complaints about this place” and demands to be sent elsewhere. Although the average stay was less than three weeks, patients showed the remarkable conviction that all their problems were due to this place.” Nurses and corpsmen complained bitterly that changes in patients’ status were made without regard to their ward behavior, yet somehow patients’ misbehavior on the unit was seldom made known to the physicians until after a behavioral explosion of some kind. Repeated attempts to clarify the problems invariably raised more issues than they resolved, ending in bitter arguments about race relations, military discipline and the competence of the doctors and vague allegations of improper sexual advances (by unnamed persons) toward the female nurses. The mental health center. Following the resignation of its long-time administrator, this mental health center “
“
VOLUME
28
NUMBER
7
JULY
1977
517
By correctly diagnosing complaints as mass#{149} symptomatic, the administrator can avoid wasting time and energy in trying to solve a pseudo. problem or succumbing to the contagious group anxiety himself.
You’re always apologizing.” “That’s just the way I am.” “I wonder if you’re decathecting from the unit.” He tries to do everything.” Discussions of the problems often took on an adversarial tone-for example, We seem to be making all the concessions’ or They’ve won’ or If it comes to a showdown As in the other cases, repeated discussions, ventilation, and catharsis among the many principals did not lead to a solution. ‘ ‘
“
“
‘
TYPICAL
went through a period of severe turmoil. Staff seemed to divide into two groups: those who were loyal to the former administrator versus those who supported her successor. A weekly meeting of department heads became the focus of contention among staff, who felt that secret decisions were being made there and that changes were planned in the center’s comfortable way of operating. Weekly staff meetings became boisterous encounter sessions in which many issues were raised, but none were brought to a conclusion. Staff members frequently took sick leave after the sessions, yet it was not uncommon to hear such statements as It’s good to get these things out in the open’ or We’re really starting to communicate.” As this pattern continued for several weeks, the working relationships in the center continued to deteriorate, amid endless complaints and threats of resignation. The teaching unit. In a university psychiatric inpatient unit, an academic year that had begun with a great deal of promise was soon marred by conflicts between the psychiatric residents and the nursing staff. Conflicts became increasingly frequent, ranging over such issues as the use of restraints, the quality of medical care, the supplying of the emergency cart, and the attitudes of the residents toward the nursing staff. Discussions with the personnel involved invariably produced solutions that sounded reasonable but either were not carried out or did not work. The residents’ complaints became increasingly stereotyped, with statements such as “We won’t accept second-class medical care” or “I won’t let the system wear me down.” The unit director found himself responding with slogans about “the team approach” and “working together.” Much as Raskin has described,3 a preoccupation with staff-to-staff relationships began to drain valuable time from patient care and supervision. Residents, administrators, and nurses devoted much attention to each other’s personality traits. Among the typical comments: “He shouldn’t be in psychiatry.” “She’s strange.” “He’s decompensating.” “You never make decisions.” ‘ ‘
‘
“
Raskin, op. cit.
518
& COMMUNITY
PSYCHIATRY
‘
‘ ‘
SYMPTOMS
Anything that can be complained of can be a mass symptom. Yet certain patterns tend to recur. The most common is the stereotyped transfer of blame to others, inside or outside the organization-for example, the administration, the state, the lack of funds, the press, the other hospital, the night shift, the day shift, and so forth. Sometimes it is the large patient load,” at other times the kind of patients we are getting.” Sacks and Carpenter have referred to this process as assignment of irresponsibility.4 If some outside group or agency can be blamed, the members may feel more comfortable. Preoccupation with the external frustration leads to endless discussions, complaints, and expressions of hopelessness. It also prevents the organization from dealing with its own shortcomings. Responsibility may be shifted grandiloquently to the System or to Society, a maneuver that may be difficult to counter. A dangerous variant is the scapegoating of one person, patient or staff member, within the organization. The irrational anger directed toward him may be intense enough to expel him from the organization or permanently impair his functioning. While some of the anger often is based on realistic grievances, it appears erratically and can change to warm acceptance almost overnight. In some organizations various members take turns being the scapegoat. Not infrequently the leader or administrator becomes the target, especially at times of organizational stress. In a closely related syndrome, the organization divides into hostile factions, each of which blames the problems on the other. Variations of this process are infinite: doctors versus nurses, nurses versus aides, blacks versus whites, administration versus staff, and so on. Again, the alignments can change suddenly and unpredictably, enemies becoming allies and vice versa. Another form of mass symptom is manifested by escapism and denial. The members can blandly insist that there are no problems at all, preferring to gloss over or avoid obvious difficulties. A period of such denial may be the calm before an organizational storm. Breaking of rules and testing of limits can also take on mass-symptom characteristics. Epidemics of absenteeism, lateness, and threats to resign are common among psychiatric staffs; assaultive behavior, theft, and “
“
#{176}Sacks and
HOSPITAL
MASS
“
Carpenter,
op.
cit.
elopements may similarly occur among psychiatric inpatients. The striking feature of all mass symptoms is that they facilitate the evasion of responsibility. Large amounts of energy are tied up in pseudo-problematic issues, which tends to obscure the real problems that could be solved.
DIFFERENTIAL
DIAGNOSIS
Diagnosis is the critical first step in treatment. By correctly diagnosing the complaints as mass-symptomatic, an administrator can avoid two serious errors. The first is to waste valuable time and energy in attempting to solve’ a diversionary pseudo-problem. The second is to succumb to contagious group anxiety and thus become part of the problem himself. The diagnosis of mass symptoms is made by differentiating the complaints from healthy consensus and from individual symptoms. The former can be closely mimicked by prevalent mass symptoms. The latter can be contagious or can appear in more than one person simultaneously. The mass symptom is characterized by its erratic and ever-shifting presentation from multiple sources. One day the complaint is nonexistent; the next day it has ‘ ‘ always been a problem’ and no one ever does anything” about it. By that evening it has been overshadowed by a more urgent problem, only to reappear two days later as an.acute emergency. Discussions of mass symptoms tend to be rambling, confusing, and inconclusive, with frequent changes of topic and raising of unrelated issues. Usually no conclusion is reached, but at times some fragile agreement may allow the staff members to save face or close an unproductive meeting. The critical feature is the group’s use of the problem to avoid working together. The apparent unanimity is quickly revealed as a deceptive collusion when the group is asked to develop a solution from its own resources. The complaints are invariably accompanied by two other phenomena: intense, pervasive anxiety and the breakdown of job-related communication. The latter is exemplified by the supervisory bypass described by deVito,5 the disappearance of important information about patients, and the “problem person” who is never told there is a problem. By contrast, if a problem is presented consistently over time, if investigation makes the problem clearer, if efforts to work on the problem are sustained and effeclive and seem to draw the group together, then the problem is real, and the group’s unanimity represents a true consensus. When such a problem is undet discussion, it stays in the foreground until some closure has been achieved. The discussion is easy to guide and is not interrupted by diversionary issues or unrelated ‘ ‘
ETIOLOGY
‘
‘
‘R. tional ber
problems. Even if the problem turns out to be uncorrectable, a feeling of closure will result from successfully facing it. When the discussion is concluded, the problem can be dropped, and the organization can turn to new issues. As for differentiating mass symptoms from individual symptoms, a problem that seems to arise in one member or subsystem of the organization and that draws the group together as an issue of mutual concern may be an individual’s symptom. Such a problem can be localized and can even become a focal point for constructive group support.
A.
deVito,
Anxiety,” 1974,
pp.
“The
Hospital 724-725.
Supervisory
“
Bypass:
& Community
A Symptom
Psychiatry,
of OrganizaVol.
25,
Novem-
Mass-symptom eruptions often seem to be related to changes of command, changes of program, or shifts of power within an organization. At such times longstanding stress and conflict within the system may suddenly become symptomatic. The process seems to involve a progressive decompensation of communication within the organization. Systems of communication that have become dependent on personal rapport and comfortable habit may prove inadequate to the stress of new demands and changing relationships. Important messages are not received or, if received, are not acknowledged, which leads to misunderstandings and difficultjes in getting the work done. The next step is for these failures in transmission to be misinterpreted as deliberate, hostile acts. When that happens, resentment and anxiety build within the organization. Communication takes on an increasingly regressive quality. People begin to act as though their thoughts and feelings should be knowj without their speaking them; if their wishes are not known, they feel it must be due to incompetence, malice, or both. There may be a general awareness that the problems are somehow related to communication, yet attempts to remedy the situation by delving into personal feelings and motivations seem to make the problem worse. Informal communication channels cannot operate in a climate of hostility and suspicion. Time and energy devoted to personality and role issues are not available for work; as a result the job becomes more difficult, and the level of anxiety inevitably rises. By the time mass symptoms have become clinically troublesome, the original causes’ of the disturbance may have become obscure, and the symptoms may have become selfperpetuating. Treatment must be addressed to the perpetuating factors-anxiety, administrative confusion, and dysfunctional communication-rather than to the original causes. “
‘
TREATMENT
OF
MASS
SYMPTOMS
Attempts to deal with mass symptoms on the level are invariably both futile and harmful. solving approaches are useful only when a sensus has developed. Effective treatment is the restoration and maintenance of effective
VOLUME
28
NUMBER
7
JULY
1977
symptom Problemtrue conbased on working
519
.
communications. Supportive measures may be required at first, followed by definitive treatment. In supportiye intervention, mass-symptom cornplaints should be listened to politely and attentively and should not be disparaged. At first they should be accepted as problems. But discussions of the complaints should not be allowed to go on indefinitely. Dramatic pseudo-solutions may be proposed, but they should not be allowed to raise false expectations or divert the energies of the group. Thus the group’s attention must be directed gently but firmly to more productive concerns. During supportive interventions, the destructive potential of the group must be contained. Personal attacks must be blunted. Personality traits of individuals should not be discussed. Emotional discussions of interpersonal staff issues may need to be discouraged. The administrator may need to intervene actively to prevent scapegoating. At times he himself may become the scapegoat. While that situation can be tolerated for short periods, it is ultimately unacceptable. Destruction of the leader will not solve the problems of the group. Thus certain communications must be reduced in intensity. Measures that help staff members develop emotional distance froni the problem, such as an outside consultant, a neutral meeting place, or a change in routine, may be helpful. For the organization in acute distress, an encounter group is contraindicated. Definitive treatment is based on intervention in the communication pathways of the system. The goal is to achieve more functional transmission of information in support of the job-for example, more effective transmission of data about patients. By modifying the logistics of information transfer, a new state of the system is produced. However, the communication changes do not imply that communication will be more open,’ expressive, or emotionally candid. The emphasis is on technical changes-’ technical’ in the sense used by Hall to mean explicit, conscious, and easily described procedures6-as opposed to attitudinal changes in communication. Such small, technical interventions in the communication process can ultimately produce farreaching changes in the organization. Hallmarks of effective intervention are the easy, effortless, and routine transmission of job-related information from those who have it to those who need it, in support of the organization’s avowed goals. ‘ ‘
‘
APPLYING
‘
‘
THE
TECHNIQUES
Such technical communication changes were used to treat the mass symptoms described in the three case studies. In the first case, in the military hospital unit, the ward physicians instituted formal walking rounds at which all changes in patient status were to be made. All concerned were advised that no requests, and no inforE. T. 1959,
520
pp.
Hall,
The
Silent
Language,
Doubleday,
New
York
City,
68-77.
HOSPITAL
& COMMUNITY
PSYCHIATRY
mation, would be acted on unless presented during the rounds. This po’icy was then carried out scrupulously by the physicians. Nurses and corpsmen accompanied the physicians on the rounds, and whenever changes in status were under discussion, the nurses and corpsmen were asked for a report of the patient’s behavior, in the patient’s presence. Anxiety levels on the unit dropped rapidly, and most staff began to fol1ow the new rules. Problems continued to occur, but could now be localized to particular patients or staff members and dealt with accordingly. In the second case, in the mental health center, the administrator met individually with each staff member to advise that free-form ventilation of discontent would no longer be acceptable. Problems could be discussed with him individually, but ultimately each staff member would have to decide personally whether he or she could be happy at the center. The weekly staff meetings were given a structured format. Each member of the staff reported on his current activities, programs, or needs so that everyone could be informed about the work of the whole center. Freewheeling discussions of personal feelings came to an end. Two staff members who had been strongly identified with the old regime later resigned, one of them to accept a job under the former administrator. The rest of the staff quickly settled back to work. In the third case, in the teaching unit, the disturbances continued for almost four months, and the treatment course was stormy. The mass-symptomatic nature of the complaints was not recognized until considerable time had elapsed. The diagnosis was missed for many reasons: the complaints were valid, the residents were bright and earnest, and the anxiety of all concerned was not recognized until it reached crisis proportions. Indeed, early on, the faulty members commented to each other on the maturity and cohesiveness of the residents, and the constructive manner in which they seemed to present grievances and complaints as a group. Yet the faculty overlooked the fact that the residents’ cohesive presentations were invariably requests for changes to be made by others. Even after the true situation became clearer, progress was difficult, as several administrators were attempting therapy for the problem and their efforts were not coordinated. The result was a blurring of administrative boundaries and a more confusing system of work-related communication. Much of the communication between residents and faculty members took place through the department chairman rather than directly, adding to the atmosphere of mystification, confusion, and defensiveness that had begun to develop. A number of apparent turning points and partial successes in each of the attempts at therapy took place before the administrators themselves began to communicate effectively. The major technical intervention in this case was the administrative restructuring of the inpatient unit, resulting in shorter and more efficient lines of communication about more manageable areas of concern. Pre-
5’
viously the two physicians in charge had attempted to supervise the entire 30-bed unit, and to “know everything” about the unit, but they now divided the unit staff into two smaller teams, including psychiatric residents, students, patients, and nursing personnel. This approach allowed each physician to concentrate his efforts more effectively. Team meetings were more informative, as there was time for detailed discussion of patients’ behavior and treatment planning. With more effective supervision of patients, treatment became easier and more effective. Finally, the department chairman brought together all the administrators involved and insisted that they begin to communicate with each other. Although the disturbances did not clear up rapidly, there was a gradual resumption of working, teaching, and patient care, and the number of meetings devoted to solving the problem began to decrease. After successful interventions, mass symptoms tend
to subside undramatically. Problems recede from the foreground of attention without ever being clearly “solved.” Energies freed from pseudo-problems gradually become available for work. After some time there may be a surge of new enthusiasm in the organization. It is not uncommon for new projects and innovative approaches to emerge at these times. Problems that remain tend to be realistic problems that are susceptible to further clarification or solution. As old realistic problems are solved, new ones continue to emerge. Although the wounds of such disturbances do heal, deep scars may remain. Trust that is destroyed may be long in returning. Ultimately the same lesson always seems to be learned. Communication is hard work and has nothing to do with good will or enthusiasm. Communication pathways must be structured so that they support the work of the organization, and they must be continually brought up to date as the organization changes.U
Egalitarianism in a Mental Health Center: An Experiment That Failed MARINA
CHAPMAN
DOYLE,
Senior Outpatient Therapist South Pinellas Mental Health St. Petersburg, Florida
R,N. Center
A core group of staff hired to open a new community mental health center attempted to employ the concepts of egalitarianism and role-blurring to avoid the rigidity and the strictly hierarchical approach to decision-making that existed in the state hospital where they formerly worked. The new structure permitted no authority figures, and decisions were made by the staff as a group. All staff, including the unit chief-a physicianand the psychologist, social workers, nurses, and attendants, were expected to rotate shifts and interchange jobs. The author discusses the inefficiencies and the lack of direction that resulted, and describes the evolution of a more traditional authoritative structure that enabled staff to proceed toward the goal of quality patient care.
Ms.
Doyle
paper.
Her
burg,
Florida
was
psychiatric
mailing 33704.
address
supervisor is 2031
at Locust
the
center
discussed
Street,
N.E.,
in St.
this
Peters-
Sin some areas of medicine, specialization of staff functions is the rule. It offers a streamlined method of communication and an assurance that someone is directly responsible for meeting a patient’s needs. However, such a system may become codified, rigid, and inflexible. Patients whose needs do not fit the specialist functions are often forced to adapt to the system or simply to go with their needs unmet. It is in reaction to such rigidity that the concept of blurred roles, equality of functioning, and the principle of the generalist worker was conceived. Generalization and a kind of egalitarianism seem especially attractive possibilities in the mental health field. It seems, on first viewing, that the medical model of the general hospital need not be followed in a psychiatric setting since most jobs can be performed by most workers if they are properly trained. However, while a blurred-role concept may be valid and useful when superimposed over an already existing structural framework, total equality without the underpinnings of a delineation of authority can have a deleterious effect on the very excellence of patient care that is sought. A total commitment to egalitarianism can impede actualization of a new facil-
VOLUME
28
NUMBER
7 JULY
1977
521
N. GRUBER,
M.D.
Assistant Professor Department ofPsychiatry Louisiana State University New Orleans, Louisiana
and Behavioral Sciences Medical Center
Organizational disturbances often begin with seemingly plausible complaints, which the author calls mass symptoms, that are presented repeatedly from many sources and that cannot be clarified or resolved. They are essentially pseudo-problems by which responsibility f or organizational failing is transferred elsewhere. Treatment consists primarily of restoring functional job-related communication, often by means of small, explicit changes in communication pathways rather than by attitudinal changes in communication or by open’ or emotionally candid communication. The author describes the occurrence and treatment of mass symptoms in a military hospital unit, a mental health center, and a university teaching unit. ‘ ‘
‘
UCollective disturbances in organizations frequently begin insidiously, with epidemics of diversionary complaints that may actually obscure the real problems. Such complaints are frequently described in relation to therapeutic communities1’2 but are by no means limited to psychiatric organizations. They can occur in churches, schools, clubs, military units, and even nations. These complaints, which I have termed “mass symptoms,” often follow characteristic patterns that can be recognized clinically. After observing them in therapy groups of psychotic inpatients, I subsequently identified them in a spectrum of organizational staff disturbances. In a therapy group or ward meeting, one may hear repeated assertions that all problems would be solved if
Dr.
Gruber’s
New ting: Vol. 2
address
Orleans, D.
E.
at
Louisiana ‘ Staff
Raskin,
Symptoms
and
the
medical
70112. Work
Units,”
An
Examination
Hospital
of
& Community
is
1542
Tulane
‘
& Community The
Antitherapeutic
Psychiatry,
Avenue,
Health
in a Mental
Hospital
Solutions,”
26, July 1975, pp. 455-456. M. H. Sacks and W. T. Carpenter,
munity:
center
Dysfunction
Pseudotherapeutic Forces Vol.
25,
Set-
Psychiatry, Com-
on
Psychiatric
May
1974,
315-318.
HOSPITAL
& COMMUNITY
PSYCHIATRY
pp.
only the patients could all go home, or if showers were given at a different time, or if the coffee pot were available earlier in the morning, and so on. Such cornplaints are clearly defensive and do not respond to realistic problem-solving. Of greater importance, however, are complaints of that type that occur among staff. The mass symptom is a seemingly plausible pseudoproblem by which responsibility for an organizational failing is transferred elsewhere. The complaint crops up in the most remarkable way from many different mdividuals or in different parts of the organization. It can change overnight to another complaint or can alternate rapidly with a variety of apparently unrelated cornplaints. Yet although the problem seems plausible, understandable, and solvable, it apparently cannot be resolved by discussion, ventilation, or open communication. Indeed, the more it is discussed, the more confusing and obscure it may become. If a seemingly acceptable solution is proposed, either it doesn’t work or a new complaint immediately replaces the old one. Efforts to elucidate the real problem’ meet with surprising resistance. Even the basic facts seem unobtainable. Three case studies from different organizations will illustrate these collective disorders. ‘ ‘
‘ ‘
‘ ‘
‘
The military hospital unit. Patients in a military hospital unit in Japan greeted their doctors each morning with bitter complaints about this place” and demands to be sent elsewhere. Although the average stay was less than three weeks, patients showed the remarkable conviction that all their problems were due to this place.” Nurses and corpsmen complained bitterly that changes in patients’ status were made without regard to their ward behavior, yet somehow patients’ misbehavior on the unit was seldom made known to the physicians until after a behavioral explosion of some kind. Repeated attempts to clarify the problems invariably raised more issues than they resolved, ending in bitter arguments about race relations, military discipline and the competence of the doctors and vague allegations of improper sexual advances (by unnamed persons) toward the female nurses. The mental health center. Following the resignation of its long-time administrator, this mental health center “
“
VOLUME
28
NUMBER
7
JULY
1977
517
By correctly diagnosing complaints as mass#{149} symptomatic, the administrator can avoid wasting time and energy in trying to solve a pseudo. problem or succumbing to the contagious group anxiety himself.
You’re always apologizing.” “That’s just the way I am.” “I wonder if you’re decathecting from the unit.” He tries to do everything.” Discussions of the problems often took on an adversarial tone-for example, We seem to be making all the concessions’ or They’ve won’ or If it comes to a showdown As in the other cases, repeated discussions, ventilation, and catharsis among the many principals did not lead to a solution. ‘ ‘
“
“
‘
TYPICAL
went through a period of severe turmoil. Staff seemed to divide into two groups: those who were loyal to the former administrator versus those who supported her successor. A weekly meeting of department heads became the focus of contention among staff, who felt that secret decisions were being made there and that changes were planned in the center’s comfortable way of operating. Weekly staff meetings became boisterous encounter sessions in which many issues were raised, but none were brought to a conclusion. Staff members frequently took sick leave after the sessions, yet it was not uncommon to hear such statements as It’s good to get these things out in the open’ or We’re really starting to communicate.” As this pattern continued for several weeks, the working relationships in the center continued to deteriorate, amid endless complaints and threats of resignation. The teaching unit. In a university psychiatric inpatient unit, an academic year that had begun with a great deal of promise was soon marred by conflicts between the psychiatric residents and the nursing staff. Conflicts became increasingly frequent, ranging over such issues as the use of restraints, the quality of medical care, the supplying of the emergency cart, and the attitudes of the residents toward the nursing staff. Discussions with the personnel involved invariably produced solutions that sounded reasonable but either were not carried out or did not work. The residents’ complaints became increasingly stereotyped, with statements such as “We won’t accept second-class medical care” or “I won’t let the system wear me down.” The unit director found himself responding with slogans about “the team approach” and “working together.” Much as Raskin has described,3 a preoccupation with staff-to-staff relationships began to drain valuable time from patient care and supervision. Residents, administrators, and nurses devoted much attention to each other’s personality traits. Among the typical comments: “He shouldn’t be in psychiatry.” “She’s strange.” “He’s decompensating.” “You never make decisions.” ‘ ‘
‘
“
Raskin, op. cit.
518
& COMMUNITY
PSYCHIATRY
‘
‘ ‘
SYMPTOMS
Anything that can be complained of can be a mass symptom. Yet certain patterns tend to recur. The most common is the stereotyped transfer of blame to others, inside or outside the organization-for example, the administration, the state, the lack of funds, the press, the other hospital, the night shift, the day shift, and so forth. Sometimes it is the large patient load,” at other times the kind of patients we are getting.” Sacks and Carpenter have referred to this process as assignment of irresponsibility.4 If some outside group or agency can be blamed, the members may feel more comfortable. Preoccupation with the external frustration leads to endless discussions, complaints, and expressions of hopelessness. It also prevents the organization from dealing with its own shortcomings. Responsibility may be shifted grandiloquently to the System or to Society, a maneuver that may be difficult to counter. A dangerous variant is the scapegoating of one person, patient or staff member, within the organization. The irrational anger directed toward him may be intense enough to expel him from the organization or permanently impair his functioning. While some of the anger often is based on realistic grievances, it appears erratically and can change to warm acceptance almost overnight. In some organizations various members take turns being the scapegoat. Not infrequently the leader or administrator becomes the target, especially at times of organizational stress. In a closely related syndrome, the organization divides into hostile factions, each of which blames the problems on the other. Variations of this process are infinite: doctors versus nurses, nurses versus aides, blacks versus whites, administration versus staff, and so on. Again, the alignments can change suddenly and unpredictably, enemies becoming allies and vice versa. Another form of mass symptom is manifested by escapism and denial. The members can blandly insist that there are no problems at all, preferring to gloss over or avoid obvious difficulties. A period of such denial may be the calm before an organizational storm. Breaking of rules and testing of limits can also take on mass-symptom characteristics. Epidemics of absenteeism, lateness, and threats to resign are common among psychiatric staffs; assaultive behavior, theft, and “
“
#{176}Sacks and
HOSPITAL
MASS
“
Carpenter,
op.
cit.
elopements may similarly occur among psychiatric inpatients. The striking feature of all mass symptoms is that they facilitate the evasion of responsibility. Large amounts of energy are tied up in pseudo-problematic issues, which tends to obscure the real problems that could be solved.
DIFFERENTIAL
DIAGNOSIS
Diagnosis is the critical first step in treatment. By correctly diagnosing the complaints as mass-symptomatic, an administrator can avoid two serious errors. The first is to waste valuable time and energy in attempting to solve’ a diversionary pseudo-problem. The second is to succumb to contagious group anxiety and thus become part of the problem himself. The diagnosis of mass symptoms is made by differentiating the complaints from healthy consensus and from individual symptoms. The former can be closely mimicked by prevalent mass symptoms. The latter can be contagious or can appear in more than one person simultaneously. The mass symptom is characterized by its erratic and ever-shifting presentation from multiple sources. One day the complaint is nonexistent; the next day it has ‘ ‘ always been a problem’ and no one ever does anything” about it. By that evening it has been overshadowed by a more urgent problem, only to reappear two days later as an.acute emergency. Discussions of mass symptoms tend to be rambling, confusing, and inconclusive, with frequent changes of topic and raising of unrelated issues. Usually no conclusion is reached, but at times some fragile agreement may allow the staff members to save face or close an unproductive meeting. The critical feature is the group’s use of the problem to avoid working together. The apparent unanimity is quickly revealed as a deceptive collusion when the group is asked to develop a solution from its own resources. The complaints are invariably accompanied by two other phenomena: intense, pervasive anxiety and the breakdown of job-related communication. The latter is exemplified by the supervisory bypass described by deVito,5 the disappearance of important information about patients, and the “problem person” who is never told there is a problem. By contrast, if a problem is presented consistently over time, if investigation makes the problem clearer, if efforts to work on the problem are sustained and effeclive and seem to draw the group together, then the problem is real, and the group’s unanimity represents a true consensus. When such a problem is undet discussion, it stays in the foreground until some closure has been achieved. The discussion is easy to guide and is not interrupted by diversionary issues or unrelated ‘ ‘
ETIOLOGY
‘
‘
‘R. tional ber
problems. Even if the problem turns out to be uncorrectable, a feeling of closure will result from successfully facing it. When the discussion is concluded, the problem can be dropped, and the organization can turn to new issues. As for differentiating mass symptoms from individual symptoms, a problem that seems to arise in one member or subsystem of the organization and that draws the group together as an issue of mutual concern may be an individual’s symptom. Such a problem can be localized and can even become a focal point for constructive group support.
A.
deVito,
Anxiety,” 1974,
pp.
“The
Hospital 724-725.
Supervisory
“
Bypass:
& Community
A Symptom
Psychiatry,
of OrganizaVol.
25,
Novem-
Mass-symptom eruptions often seem to be related to changes of command, changes of program, or shifts of power within an organization. At such times longstanding stress and conflict within the system may suddenly become symptomatic. The process seems to involve a progressive decompensation of communication within the organization. Systems of communication that have become dependent on personal rapport and comfortable habit may prove inadequate to the stress of new demands and changing relationships. Important messages are not received or, if received, are not acknowledged, which leads to misunderstandings and difficultjes in getting the work done. The next step is for these failures in transmission to be misinterpreted as deliberate, hostile acts. When that happens, resentment and anxiety build within the organization. Communication takes on an increasingly regressive quality. People begin to act as though their thoughts and feelings should be knowj without their speaking them; if their wishes are not known, they feel it must be due to incompetence, malice, or both. There may be a general awareness that the problems are somehow related to communication, yet attempts to remedy the situation by delving into personal feelings and motivations seem to make the problem worse. Informal communication channels cannot operate in a climate of hostility and suspicion. Time and energy devoted to personality and role issues are not available for work; as a result the job becomes more difficult, and the level of anxiety inevitably rises. By the time mass symptoms have become clinically troublesome, the original causes’ of the disturbance may have become obscure, and the symptoms may have become selfperpetuating. Treatment must be addressed to the perpetuating factors-anxiety, administrative confusion, and dysfunctional communication-rather than to the original causes. “
‘
TREATMENT
OF
MASS
SYMPTOMS
Attempts to deal with mass symptoms on the level are invariably both futile and harmful. solving approaches are useful only when a sensus has developed. Effective treatment is the restoration and maintenance of effective
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communications. Supportive measures may be required at first, followed by definitive treatment. In supportiye intervention, mass-symptom cornplaints should be listened to politely and attentively and should not be disparaged. At first they should be accepted as problems. But discussions of the complaints should not be allowed to go on indefinitely. Dramatic pseudo-solutions may be proposed, but they should not be allowed to raise false expectations or divert the energies of the group. Thus the group’s attention must be directed gently but firmly to more productive concerns. During supportive interventions, the destructive potential of the group must be contained. Personal attacks must be blunted. Personality traits of individuals should not be discussed. Emotional discussions of interpersonal staff issues may need to be discouraged. The administrator may need to intervene actively to prevent scapegoating. At times he himself may become the scapegoat. While that situation can be tolerated for short periods, it is ultimately unacceptable. Destruction of the leader will not solve the problems of the group. Thus certain communications must be reduced in intensity. Measures that help staff members develop emotional distance froni the problem, such as an outside consultant, a neutral meeting place, or a change in routine, may be helpful. For the organization in acute distress, an encounter group is contraindicated. Definitive treatment is based on intervention in the communication pathways of the system. The goal is to achieve more functional transmission of information in support of the job-for example, more effective transmission of data about patients. By modifying the logistics of information transfer, a new state of the system is produced. However, the communication changes do not imply that communication will be more open,’ expressive, or emotionally candid. The emphasis is on technical changes-’ technical’ in the sense used by Hall to mean explicit, conscious, and easily described procedures6-as opposed to attitudinal changes in communication. Such small, technical interventions in the communication process can ultimately produce farreaching changes in the organization. Hallmarks of effective intervention are the easy, effortless, and routine transmission of job-related information from those who have it to those who need it, in support of the organization’s avowed goals. ‘ ‘
‘
APPLYING
‘
‘
THE
TECHNIQUES
Such technical communication changes were used to treat the mass symptoms described in the three case studies. In the first case, in the military hospital unit, the ward physicians instituted formal walking rounds at which all changes in patient status were to be made. All concerned were advised that no requests, and no inforE. T. 1959,
520
pp.
Hall,
The
Silent
Language,
Doubleday,
New
York
City,
68-77.
HOSPITAL
& COMMUNITY
PSYCHIATRY
mation, would be acted on unless presented during the rounds. This po’icy was then carried out scrupulously by the physicians. Nurses and corpsmen accompanied the physicians on the rounds, and whenever changes in status were under discussion, the nurses and corpsmen were asked for a report of the patient’s behavior, in the patient’s presence. Anxiety levels on the unit dropped rapidly, and most staff began to fol1ow the new rules. Problems continued to occur, but could now be localized to particular patients or staff members and dealt with accordingly. In the second case, in the mental health center, the administrator met individually with each staff member to advise that free-form ventilation of discontent would no longer be acceptable. Problems could be discussed with him individually, but ultimately each staff member would have to decide personally whether he or she could be happy at the center. The weekly staff meetings were given a structured format. Each member of the staff reported on his current activities, programs, or needs so that everyone could be informed about the work of the whole center. Freewheeling discussions of personal feelings came to an end. Two staff members who had been strongly identified with the old regime later resigned, one of them to accept a job under the former administrator. The rest of the staff quickly settled back to work. In the third case, in the teaching unit, the disturbances continued for almost four months, and the treatment course was stormy. The mass-symptomatic nature of the complaints was not recognized until considerable time had elapsed. The diagnosis was missed for many reasons: the complaints were valid, the residents were bright and earnest, and the anxiety of all concerned was not recognized until it reached crisis proportions. Indeed, early on, the faulty members commented to each other on the maturity and cohesiveness of the residents, and the constructive manner in which they seemed to present grievances and complaints as a group. Yet the faculty overlooked the fact that the residents’ cohesive presentations were invariably requests for changes to be made by others. Even after the true situation became clearer, progress was difficult, as several administrators were attempting therapy for the problem and their efforts were not coordinated. The result was a blurring of administrative boundaries and a more confusing system of work-related communication. Much of the communication between residents and faculty members took place through the department chairman rather than directly, adding to the atmosphere of mystification, confusion, and defensiveness that had begun to develop. A number of apparent turning points and partial successes in each of the attempts at therapy took place before the administrators themselves began to communicate effectively. The major technical intervention in this case was the administrative restructuring of the inpatient unit, resulting in shorter and more efficient lines of communication about more manageable areas of concern. Pre-
5’
viously the two physicians in charge had attempted to supervise the entire 30-bed unit, and to “know everything” about the unit, but they now divided the unit staff into two smaller teams, including psychiatric residents, students, patients, and nursing personnel. This approach allowed each physician to concentrate his efforts more effectively. Team meetings were more informative, as there was time for detailed discussion of patients’ behavior and treatment planning. With more effective supervision of patients, treatment became easier and more effective. Finally, the department chairman brought together all the administrators involved and insisted that they begin to communicate with each other. Although the disturbances did not clear up rapidly, there was a gradual resumption of working, teaching, and patient care, and the number of meetings devoted to solving the problem began to decrease. After successful interventions, mass symptoms tend
to subside undramatically. Problems recede from the foreground of attention without ever being clearly “solved.” Energies freed from pseudo-problems gradually become available for work. After some time there may be a surge of new enthusiasm in the organization. It is not uncommon for new projects and innovative approaches to emerge at these times. Problems that remain tend to be realistic problems that are susceptible to further clarification or solution. As old realistic problems are solved, new ones continue to emerge. Although the wounds of such disturbances do heal, deep scars may remain. Trust that is destroyed may be long in returning. Ultimately the same lesson always seems to be learned. Communication is hard work and has nothing to do with good will or enthusiasm. Communication pathways must be structured so that they support the work of the organization, and they must be continually brought up to date as the organization changes.U
Egalitarianism in a Mental Health Center: An Experiment That Failed MARINA
CHAPMAN
DOYLE,
Senior Outpatient Therapist South Pinellas Mental Health St. Petersburg, Florida
R,N. Center
A core group of staff hired to open a new community mental health center attempted to employ the concepts of egalitarianism and role-blurring to avoid the rigidity and the strictly hierarchical approach to decision-making that existed in the state hospital where they formerly worked. The new structure permitted no authority figures, and decisions were made by the staff as a group. All staff, including the unit chief-a physicianand the psychologist, social workers, nurses, and attendants, were expected to rotate shifts and interchange jobs. The author discusses the inefficiencies and the lack of direction that resulted, and describes the evolution of a more traditional authoritative structure that enabled staff to proceed toward the goal of quality patient care.
Ms.
Doyle
paper.
Her
burg,
Florida
was
psychiatric
mailing 33704.
address
supervisor is 2031
at Locust
the
center
discussed
Street,
N.E.,
in St.
this
Peters-
Sin some areas of medicine, specialization of staff functions is the rule. It offers a streamlined method of communication and an assurance that someone is directly responsible for meeting a patient’s needs. However, such a system may become codified, rigid, and inflexible. Patients whose needs do not fit the specialist functions are often forced to adapt to the system or simply to go with their needs unmet. It is in reaction to such rigidity that the concept of blurred roles, equality of functioning, and the principle of the generalist worker was conceived. Generalization and a kind of egalitarianism seem especially attractive possibilities in the mental health field. It seems, on first viewing, that the medical model of the general hospital need not be followed in a psychiatric setting since most jobs can be performed by most workers if they are properly trained. However, while a blurred-role concept may be valid and useful when superimposed over an already existing structural framework, total equality without the underpinnings of a delineation of authority can have a deleterious effect on the very excellence of patient care that is sought. A total commitment to egalitarianism can impede actualization of a new facil-
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1977
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