SYSTEMIC CONSIDERATIONS OF PSYCHIATRIC REFORMATION

Kyriakos Katzourakis paint This work was presented by the author at the 10^th EFTA Conference in Napoli, September 11^th –14^th 2019.

Abstract

This article focuses on the one hand on the labeling of systemic epistemological concepts that differentiate the understanding of the mental disorder from the classical medical model and on the other hand on presenting some considerations on the management of change within consolidated and rigid organisms. Taking these into consideration, we will discuss some systemic concepts and concepts from complexity theory.

Key-Words :scientific paradigm, emergence, edge of chaos, bottom-up change, extraordinary management

Contribution of Family Therapy Unit in P.H.A. to the Public Psychiatric System

The FAMILY THERAPY UNIT (FTU) is a cross-sector department of the Psychiatric Hospital of Attica. This psychiatric hospital has been for many years the largest mental institution in the Balkans and has been established in popular imaginary as a symbolic place of displacement for the mentally ill.  It is also the same hospital that has played a historical role in the pioneering of the ongoing psychiatric reform at work over the last 30 years in Greece. Today this institution includes a network of community mental health services and specialized psychotherapy units that serve most of the needs of the region around the capital of Greece.

The Family Therapy Unit has been offering free psychotherapy to families and individuals for 25 years.  Public psychotherapy at the level of public institutions has a “raison d'être” when it responds to serious or urgent problems with a registered social dimension: psychoses, addictions, etc. and in particular groups in society, such as children. Family therapy became widely accepted in the established psychotherapy areas –such as with children and the poor- and this is why it has maintained a privileged relationship with the public sector, for many years and in many countries (Charalabaki K. 2017).

Also the psychotherapeutic work plays an important role in the promotion of mental health and in the prevention of problems such as anxiety, depression and addictions.

Many professionals have been trained in the Family Therapy Unit and with their knowledge they are grafting and raising awareness of systemic ideas in their services. The introduction of systemic conceptual frameworks and practices into community mental health services mediates a change of the approach, from restrictive bio-medical paradigms and interventions to holistic.

Such an approach to psychiatric care introduces changes in the relationships and hierarchies of services, as it attributes specific meaning to the function of the therapeutic team.

Thus the systemic approach introduces another scientific discourse and a dialogue with the other disciplines.  This sort of diversity is welcome as it allows for the possible emergence of innovation.

The theoretical concepts of circular causality and the 2nd order cybernetics, lead to a revision of classical concepts in psychiatry such as diagnosis, prognosis, and classifications. Overcoming separations and classifications and dichotomies, such as normal/pathological or neurosis/psychosis, takes us to a unified theory of the psyche.

Attempting a Psychiatric Reform

In Greece, a reform is being attempted in the public psychiatric care system, which means a transition from a hospital-centered system to a community based system.  Several professionals with a systemic theoretical background and several who were trained in the Family Therapy Unit participated in working groups with the aim of designing and implementing a national plan for psychiatric care.

As far as the planning of the psychiatric system is concerned, I will refer to the notions of the scientific paradigm, of the edge of chaos, of the emergence, of bottom-up change, and of extraordinary management.

Scientific Paradigm

A system changes with interventions in:

1. Infrastructure (quantitative figures, structures)

2. Information (flow of information, positive and negative feedback)

3. The rules and objectives.

4. The scientific paradigm, from which the objectives, rules, and structure arise.   In terms of the value of interventions, the most important actions are those relating to beliefs or the scientific paradigm.

Managers are making efforts to improve "numbers", and most such interventions go in the wrong direction.

The belief in diversity and pluralism is a prerequisite for changing existing systems.  As nature's diversity allows new forms to emerge, so diversity in humans will make new forms of organization emerge.

In the new paradigm, the inter-subjective relationship replaces the subject-object relationship and there is a coupling between the humanistic and scientific culture and everything, each being, is part of a co-organizational relationship with its environment. Inclusion within the community is also the recognition of identity and the right to speak, because the deprivation (through the psychiatric institution) of the right to participate in the interactive community is tantamount to identity loss and this is one of the greatest human pains, creating a void of existence as it is violent and brings about anxiety.

A different psychiatric system is not exclusively and primarily a question of expenditure or a question of buildings, but rather a matter of another scientific discourse.  The presence of educated, aware personnel forms the foundation of such a system. The training of the staff is not oriented towards over-qualification, but rather acquires an experiential character through processes of empathy and co-operation within the group.

The quality of the relationship that the practitioner forms with the patient and with the members of the therapeutic group receives our attention. Emphasis is given on group and community processes. Group therapy was invented at a time of economic crisis.  Similarly, the current crisis may be an opportunity for a new and more effective system of psychiatric care to emerge.

The Edge of Chaos

The truly creative changes and the big shifts occur right at the edge of chaos,”

Robert Bilder

‘Edge of Chaos, is defined as the marginal transition zone between order and complete randomness or chaos that is hypothesized to exist within a wide variety of systems of non-linear feedback. This transition zone is a region of bounded instability that engenders a constant dynamic interplay between order and disorder (Lawler, E., et al 2015). The idea of the ‘edge of chaos’ applies in many fields of social science such as psychology, political science, and ecology.

Mathematical models and theoretical assumptions have shown that many complex adaptive systems evolve intuitively when they are in a state close to the boundary between chaos and order (Kauffman, S.A. 1993).  All living organisms and systems are constantly changing their inner properties to better adapt to the current environment. The potential for self-regulation -including the ability to avoid chaos- is inherent in many natural systems (Lawler, E., et al 2015).

However, the operating modes on the edge of chaos in both nature and human systems are fleeting. Then the systems are driven either to  decomposition or to a return to homeostasis.

In today's unstable social and political environment which has a lot of uncertainty, the social structures and institutions that were formed at the time of the flourishing of the social state become increasingly obsolete. In short, we are in a transforming society that produces chaotic experiences that bring about aspects of "decay".

The Emergence

Successful strategies, especially the long-term ones, do not result from defining an organizational intention and mobilizing around it; they emerge from the complex and continuing interaction between people . Jonathan Rosenhead The country's economic crisis and the dramatic decline in welfare resources have led to a disintegration of the psychiatric care system. However, it is also this destabilization of the existing psychiatric system which renders change more likely. We therefore welcome the disorder as a partner, as it is at this time in which organizations operate in a state of instability when their chances of bringing about the new increase.

The aim is to harness instability positively. In this way, new possible futures for the organization will emerge, arising out of a fermentation of ideas which it should try to provoke. The released creativity leads to an organization which continuously re-invents itself. If organizations are to be transformed, what is needed is the encouragement of “informal structures”, for example, workshops around specific topics or procedures, involving members from different hierarchical levels, roles, and theoretical approaches (Rosenhead J., 1998).  Those who will support the change will be professionals from the lower ranks of the hierarchy, as well as the recipients of the services. The change will come from the base.

Bottom- Up Change

In the introduction of a change initiated by the leadership, the staff is forced to align with the "plan" of the administrative or scientific authority. In this case, the staff does not embrace the organizational goals or does not perceive any immediate personal benefit.  In this way, incentives tend to obtain a rather instrumental form, e.g. payment, promises of "promotion", etc. In the Greek public sector, given its bureaucratic tradition and its current situation that further deteriorated during the years of crisis, employees tend to safeguard their own private interests. There is a gap between the objectives of the Agency and the individual objectives of the employees. The employee seeks to gain as many benefits as possible (money, days off, etc.) and offers as little as possible.  An example, derived from a hospital, concerns a nurse that wants to make his shift as effortless as possible: For these purposes, he/she will require the psychiatrist to chemically and mechanically suppress the restless patient. The psychiatrist, on the other hand, who wants to project his image as a reformer (something that will give him prestige and possibly promotion), often actsat the expense of the nurse who will suffer the consequences of poor management of the patient.

The bottom-up approach assumes that the new organizational structure will emerge dynamically and will be self-organized to reflect the prospects and capabilities of the staff.  In the organizations that emerge from the base, called Multi-Agent Systems (MAS), the "rules" are aligned with the innovations of the staff. Here the motives are primarily the expression of the employee's creativity and initiative; the instrumental ones are secondary.

The implementation of management tools, the introduction of which is currently being attempted into the National Healthcare System, will promote totalitarian thinking, which is incompatible with the values of psychiatric reform. The experience of the implementation of such management tools, oriented towards the optimization of profit and the diminution of costs, in the British National Healthcare System, has shown that the original “ Spirit of the Hospital”  is lost: (Lawrence 1995). Hospitals no longer differ from other productive or service-oriented enterprises, where the anxiety of the employees over the possibility of losing their jobs is predominant.

The anxiety of annihilation, both that of losing one’s job and one’s professional identity, re-activates the employees most primordial anxieties. They are therefore in danger of losing the capacity to contain the (annihilation) anxieties of patients, which they experience in relation to their illness (MenziesI, 1960).

To the extent that the psychodynamics of the hospital (or one or more of its subsystems) is tainted by anxieties and defenses of a paranoid-schizoid kind, it is most unlikely that role holders can deal with patients from a depressive position, according to Melanie Klein's theory (1959), which would provide sufficient care, ‘love’ and the acknowledgement of ambivalences. (Sievers B. 2006)

Ordinary and Extraordinary Management

Ordinary management deploys a logical analytic process that includes data analysis, goal setting, evaluation of options against goals, rational acts of choosing, implementation through hierarchy and primarily control. Adequate ordinary management is necessary if the organization is to perform the daily problem solving necessary for achieving established goals. (Stacey 1996)

Extraordinary management activates the implicit knowledge and creativity available within the organization. This requires the encouragement of informal structures, for example, workshops around specific topics or procedures, involving members from different hierarchical levels, roles, and theoretical approaches. These groups should be self-organizing so that group learning may occur.

The theorist of organizations, Ralph Stacey (1996), proposes that both ordinary and extraordinary management is needed in sustainable organizations, and these courses of action must be able to coexist. This coexistence, however, requires reasonable flexibility within the structure, as well as balance between rationality and creativity. The strategic role of senior management lies, on one hand, in the management of these boundaries and, on the other, in the facilitation of the procedures of dialogue that hold innovative potentials.

Conclusion

Systemic theory introduces a different scientific discourse. The new epistemology revises the structures through which psychiatric care is practiced.

Nevertheless, experience has shown that administrative decisions at the level of authority are not sufficient to change the systems; rather processes that will allow the new to emerge are needed. These are informal processes such as workshops, social movements, social dreaming^[1] (Lawrence, 2005) etc. and the utilization of the destabilization of the system.  What will emerge can neither be predicted nor controlled.  The system will take the form that is consistent with its ontogeny and its auto-poetic organization (Maturana H., 1981).

References

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Χαραλαμπάκη Κάτια (2017)  Οικογένειες σε δίσεκτα χρόνια , Εκδόσεις Καστανιώτη Αθήνα

[1] Social dreaming is a kind of experiential workshop devised by W. Gordon Lawrence in 1982 that focuses on discovering the social meaning and significance of dreams through sharing them with each other’s.Not only do dreamers dream from their ecological niche, but also they dream about themes that are systemically related. Social Dreaming can be used in organizational systems, professional communities and other groups”