Medicine And Books

The Unconscious at Work: Individual and Organizational Stress in the Human Services

BMJ 1995; 310 doi: (Published 04 March 1995) Cite this as: BMJ 1995;310:608
  1. Tom Sensky

    Ed Anton Obholzer, Vega Zagier Roberts Routledge, £14.99, pp 224 ISBN 0 415 10206 5

    Working with people who are ill has always been stressful. Organisations concerned with health care, because of the complexity of their aims and their structure, are stressful places in which to work. Uncertainty and change, prominent features of today's health service, are also acknowledged as important stressors. There are many publications on stress among health care workers, some of them focusing on fashionable concepts such as burnout, others attempting to identify people in the professions particularly vulnerable to the effects of stress. Yet it is undoubtedly feasible not only to sustain a career in medicine or one of its sister professions but also to gain much satisfaction from it. How is this possible?

    The contributors to the The Unconscious at Work have all been associated with the “Consulting to Institutions” workshop at the Tavistock Institute of Human Relations. The book begins with a review of basic psychodynamic and other principles relevant to organisations and then offers descriptions, with commentaries, of dysfunctional groups to which the book's contributors have acted as consultants.

    Implicit in many of the contributions is the important principle that when problems arise in a group or institution it is essential to seek both the origins of the difficulties and potential solutions within the institution. The importance of this principle cannot be overstated.

    The assumption throughout the book is that institutions cannot be adequately understood without a psychoanalytical perspective because, as the introduction states, social science lacks the methods to take account of the unconscious aims and needs of the people within the institution. To understand such unconscious processes the (psychoanalytically trained) organisational consultants use their own experiences of and feelings about the institution. They are able to make sense of their own responses through experience gained from personal analysis.

    What is difficult to find in the text is any insight into institutions that function adequately. The book is intended to “enable readers to increase their understanding of the processes which undermine effectiveness and morale in their organisations,” but an outside consultant with specific training (or possibly personal analysis) seems necessary to solve such problems. Perhaps personal analysis is also required to appreciate some of the book's more radical assertions, such as that an important element of community care is “an unconscious attempt to solve the problem of currently incurable forms of mental illness through denial by allowing sufferers to die from exposure in a hostile environment.”


    The ability of single photon emission computed tomography to localise functional changes in tissues has led to its rapid transfer from the laboratory to clinical practice. A good example of its value is this three dimensional picture of the brain, in which the pink areas represent seizure foci, from Clinical SPECT Imaging (Raven, $164, ISBN 0 7817 0190 2).

    Nevertheless, it could be argued that the success of the approach described in the book is supported by its accounts of successful interventions. There are some striking examples of a seminal event after which the presence of the consultant is viewed differently and the group makes progress. Creating such seminal events and taking advantage of them doubtless takes skill and experience. One example, however, stands out for a different reason. In this consultation it took three years to set up regular staff meetings that could provide a suitable forum for exploration of group processes and a further year to get the group to accept and begin to work with the consultant's model of institutional processes. Sadly, no acknowledgement is given of the need to evaluate the benefits of such work in today's climate, in which cost effectiveness is a manifestly conscious preoccupation.—TOM SENSKY, senior lecturer in psychiatry, West Middlesex University Hospital

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