Does anyone realise…the lunatics actually are in charge of the asylum?

In 1959 Isabel Menzies-Lyth – psychoanalyst and organisational consultant, published a study of a teaching hospital in London. The study, initiated by senior staff at the hospital, was expected to underpin institutional change given concerns that the system was under significant strain. Essentially, senior nurses were worried about their capacity to provide adequate practical support for trainee nurses whilst at the same time maintaining patient care. Something was wrong: Sickness rates amongst staff were worryingly high as was the drop out rate from training.

Menzies -Lyth spent time in the hospital, talking to people and carefully noticing the issues, diagnosing the problems. What she describes in her seminal paper is an odd, brittle culture where nurses were more automatic than compassionate, efficient rather than kind; a culture within which the nurses were given a diverse range of tasks which meant that they had little contact with any one patient. A culture which allowed them to refer to patients not by their names but by their symptoms (“the liver in bed 10”).

Despite the fact that the nurses presumably had different skills and interests, it was not supposed to matter in this place who you nursed or what their symptoms were. Brisk professionalism was prized as was a way of working characterised by detachment and routine. Complex, challenging issues and decisions were avoided by ritual and rendered silly through grim tradition. There was nothing special about anyone.

One assumes, from reading the paper that there was little humanity in the way that the nurses approached their tasks. They do not appear to work with humility or in a way that allows them to be known by their patients as individuals. One imagines that gentleness and humour were killed by this strangely dispassionate culture, that clever minds had to be put away. The paper describes a place full of people but with obstacles to all the lively, kind and happy stuff that should happen between them.

Why did they work like this? Were they monsters? Psychopaths? Power crazed harridans? We already know they weren’t as just asking the question illuminates how ridiculous those angry assumptions are: These nurses would have been normal, nice people; people driven by vocation and by wanting to look after others, by wanting to do something that matters. By reminding us that this dour, uninspiring, vaguely embattled culture would have emerged for very good reasons, Menzies Lyth introduces us to an important discourse: She directs our gaze away from condemning the practices themselves and towards the urgent task that the nurses were faced with and for which these practices presented a solution.

All human beings act badly when we’re anxious or afraid and we act even worse when we have no reason or space to reflect on the fact that we are anxious or afraid. Instead we pretend we know things, we avoid people or cling to people, drink too much or take drugs or drive too fast or shout too loud.  Menzies-Lyth reminds us about the nature of the task for these nurses; the anxiety inherent in caring jobs – the anxiety (or, to be more specific, the fear, shame, incompetence, envy….) that every one of us feels in all our interpersonal encounters. She spells out the things that make nursing particularly difficult: the bloody, messy, disgusting bodies, the frustrated, suffering patients who act badly themselves. Then she goes further and helps us to see how awful this would be – to hate the people you are supposed to care for, to face illness that can’t be cured, to be uncertain that you can make a difference, to be an expert who sometimes doesn’t know and can’t really help. She helps us to understand the envy an exhausted nurse would feel towards the patient lying prone, being served and the dreadful dilemma faced by all of us paid to care for people who irritate us, harass us, bore us, overwhelm us, love us…how to manage the relentless tumult of emotions that we are faced with when we look after humans? How to manage our guilt and our shame at feeling all the “unprofessional” things we’re not supposed to feel and can’t possible voice?

Menzies-Lyth concluded that the curious culture at the hospital emerged as a way of helping to manage the tension and distress associated with the job. The nurses had unconsciously ‘requested’ that the hospital sanction various practices which worked to help them manage their own anxiety. Intimacy and individuality were avoided meaning that loss (when people died or worsened) could also be avoided. Relationships, humour, gentleness and kindness would have been eradicated through the singular efforts that this organisation made to avoid disgust and fear and the pain associated with not always knowing or being able to make people well. Strange ‘cliques’ within the nursing team would have allowed the nurses to discharge their anger and blame their colleagues rather than confront their own limitations.

The practices, or “social defences” would have emerged subtly and insidiously, masquerading as ‘good practice’, or ‘professional conduct’. They were practices which would have felt normal, clear and dutiful when in fact they worked to ‘rescue’ the nurses while undermining the very purpose of the organisation. The workers themselves collectively, subconsciously agreed to sacrifice their capacity to care humanely for humans who were suffering in order to manage the intrusive, disturbing stuff in their own minds.

Menzies-Lyth and her colleagues introduced a discourse that situates organisations as part of a dynamic process. She shows us that, far from being benign practitioners, all of us who work in caring professions are thrown fully into a daily, complex interpersonal reality. She helps to position our bad practice as threat responses and reminds us that none are immune. The impact of the work (of caring for humans) is inevitable….how could it be otherwise for social beings designed to be sensitive in relation to others?

This is a discourse which helps us to understand that the work that we do caring for others makes us mad. It renders good, diligent, caring people capable of creating stupid services that work badly and fail the people who use them. This is a discourse which makes sense of rigid, meaningless targets and dehumanising language, of bureaucracy and neglect and our sheer inability to remember that our ‘patients’ are, quite literally, people we can know.

And I think we need it more than ever as you just have to listen to the news to know how lost we are….In August last year SkyNews reported that investigations into abuse in mental health services have  nearly doubled in three years. Reports peppered the news towards the end of 2017 about a crisis in mental health service provision: not enough staff (The Independent, 30th Sept 2017); long waits for treatment (The Guardian, 7th July 2017); leading charities urging the Government to address a crisis given that so many people in need are ‘locked out of services’ (The Independent, 4th November 2017); services for people who self harm or are wanting to kill themselves are under “unprecedented pressure” (BBC news, 27th July 2017).

People continue to be excluded from, made worse, stigmatised, blamed and hurt by services. The service user movement on social media is vociferous and raging – justifiably angry at our crass, dumb attempts to create services which alleviate distress and mental anguish. Outraged at the fact that we sometimes – often – make things worse through an inability to create services which are, at their core, simply humane.

The point of the discourse introduced by Menzies-Lyth and her colleagues is that this is all of us…not just the ‘bad’ ones. There are no ‘bad’ ones…there are just ones who haven’t noticed what has happened to them. The ‘bad’ ones are simply services which have made no provision for helping the staff, leaders who are too caught up in their own anxiety to create space for noticing or to model a helpful approach. More worryingly (and less hopefully) they are services which are ill served by political agendas that ramp up the anxiety and make it harder, or even impossible, to notice. The ‘bad’ ones are simply those who lack the space to think, or refuse the space to think because they are too afraid, too threatened to be inexpert.

Last year a friend and colleague undertook training in dealing with complaints in her NHS Trust. They worked through a real life, anonymised example which centred around rude, dismissive conduct from a staff member over the phone. My friend had the complainant in her mind – a relative with a recently admitted, highly distressed son. This was a woman who, presumably, in the midst of being terrified and desperate, asked the responsible NHS Trust to notice that they had acted badly. Notice, perhaps, a social defence which had emerged…a way of working which allowed the worker to put the phone down a little quicker, discharge a little irritation.

The group worked through the example, worked through the process and discussed the outcome which would be – and had been in real life – disciplinary proceedings. My friend expressed surprise…wasn’t this behaviour the result of someone stressed, someone managing anger or annoyance? Someone who was maybe overworked or under pressure? Maybe, just before the call, this staff member had been yelled at or attacked or had cut someone down, been the first on the scene, witnessed something terrible that they would never really forget.

The tutors, according to my friend, had no answer. There was no narrative about why this staff member had behaved the way they had. Only that they shouldn’t. My friend was confused – how would disciplinary proceedings (in the absence of anything more exploratory about why this behaviour occurred) help? If there were good reasons for this poor behaviour, then how would sanctions help? Would this not add to the stress, blame, shame?

Menzies Lyth would no doubt argue that this complaints process emerged as another social defence: An organisationally sanctioned process which works (crudely) to manage the institutional anxiety at the expense of a more restorative process which ultimately would serve the people who use the services much better but which would require more of the organisation.

Talking about the stress that we experience as workers who strive to make lives better for some of the most distressed/distressing, frightened and frightening people in our society is, I think, considered bad form. We are supposed to be unrelentingly compassionate, unproblematically kind and giving. But caring for people who are scared and damaged is scary and damaging. It can’t (and shouldn’t) be any other way. It is what we signed up for. But we need institutions that help us manage this properly so that we can stay thoughtful and kind in the midst of the struggle and the feelings of overwhelming incompetence.

We need this discourse because a lot of the (subtle, normal) stuff we do is very bad indeed. We need this discourse to help us examine the governance and accountability structures around organisations that are tasked with alleviating human suffering. We need a discourse which asks: ‘what are we doing”? and “why”?….a discourse which makes it okay for us to notice that we, as workers, are struggling.


Menzies Lyth, I (1959) The Functioning of Social Systems as a Defence Against Anxiety Human Relations (13) pp 95-121

One thought on “Does anyone realise…the lunatics actually are in charge of the asylum?

  1. It’s not easy to join human rights discourse. This is a brave & powerful start, with some unfortunate blunders (eg. refers to patients harassing, which is stigmatising, rather than nurses feeling harrassed, which is both natural and understandable).

    I’d urge the author to reflect on the role of the law as a leading, but imperfect, force in human rights, rather than a threat. Disciplinary proceedings are a horrifically blunt instrument, but redress and enfranchisement of patients are profoundly important. The fiduciary role of a lawyer cannot be replicated by any alternative. Don’t throw the baby out with the bathwater; domestic and European Court of Human Rights judgments agonise over the paternalistic nature of patient-staff relationships. People with power over others must learn that they cannot be their own adjudicators, as uncomfortable as this seems. What we want is a more restorative process, as the author alludes to.

    Well done for telling this story, and providing such an important analysis.

    Liked by 1 person

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