States of Abjection

Introduction

In a recent meeting, a group of colleagues and I were discussing a young woman who had been referred to our National Health Service (NHS) primary care mental health service. This young woman was experiencing an episode of quite severe depression and had gone to her doctor seeking psychotherapeutic help. In the letter from the doctor, we learned that she had experienced a number of problems since early childhood: she had initially been raised in foster care; abused by a neighbour, she had left home at only 17, and subsequently engaged in a series of emotionally and sexually abusive relationships with men. The father of her baby had recently been jailed for drug-related crime, and now, at 24, she was raising her 2-year-old by herself. She was currently unemployed, struggling to manage on government benefits, and appeared to have no family and few support networks available. The GP was clearly very concerned about her, and was putting the service under considerable pressure to treat her as a matter of priority.

During the discussion, a disagreement between various members of the group turned into a full-scale debate about the nature of the service, what it should be offering the community and the criteria for accepting patients into the service. Whilst one or two clinicians, including myself, felt that it was possible to offer this young woman some focused, brief work to address the current problem, the majority, including the clinical lead, felt that this patient’s history meant that this was unlikely to be helpful. A number of anxieties were raised about the value of the brief psychotherapeutic work that would be available: suppose the patient regressed? How could the service manage and contain the probable risk issues? If ongoing support was needed pending any necessary referral to the community mental health team, how would this be reflected in targets and staff activity data, already under scrutiny by senior management? In the course of this lengthy debate, one of my colleagues, by now no doubt tired and exasperated, asked whether we thought the service was simply there to deal with ‘shit life syndrome’. This rather vivid rhetorical question resulted, unsurprisingly, in some further heated discussion which was eventually cut short by the clinical lead who agreed that, despite pressure from the doctor to accept this patient, the service could indeed not afford to take on everyone who suffered from ‘shit life syndrome’, and took the decision to reject the referral.

I have since become very curious about this expression ‘shit life syndrome’, not the least because of the implicit consensus by everyone in the meeting, including myself, as to what it meant. The phrase seemed to denote a level of long-standing poverty, family breakdown, lack of stability, unemployment and potential risk factors common to many of the predominantly young, working-class patients referred to the service. There was no doubt that, quite apart from important debates about the inclusion and exclusion criteria for the service, these issues aroused a number of unspoken anxieties in all of us present at the meeting. But the particular choice of words used by my colleague I think tells us something about the unconscious nature of these anxieties. For shit, of course, is something that we generally prefer not to think about – something we continually reject, get rid of or hide. At the same time, it is something that we cannot completely repudiate; it is part of us, something we need, something that is ineluctably part of our status as human beings, as subjects. Those suffering from ‘shit-life syndrome’, then, would seem to be those individuals whose problems are deemed to be so terrible, so untouchable, that they quite literally cannot be thought about, cannot be handled by the service. At the same time, the organization is obliged to do so; it is confronted by continual pressure from the public and from referrers to provide psychological care and treatment for these same individuals who arouse such intense anxiety and from whom its staff wish to distance themselves.

Whilst much psychoanalytic thinking about organizational dynamics traditionally draws on the object relations theories of Klein (1946) and Bion (1962), in this paper I want to consider Kristeva’s (1982) notion of the abject as a possible alternative lens through which to think about anxiety within mental health services. Kristeva suggests that anxiety indexes the perpetual attempt by the subject to expel something of the self that is deemed to be repulsive or untouchable, a dynamic that I will suggest has remained significant throughout society’s long history of care for the mentally ill. The arguments in this paper are located in the context of contemporary UK public mental health services which have been identified by Thomas and Davies (2005), along with all public sector organizations, as ‘sites of transformative change’ (2005: 684) since the 1980s, as a result of New Public Management (NPM) restructuring of health, education and social services. This restructuring has been introduced and maintained by successive governments with a view to making public services more efficient, accountable and responsive to ‘customer’ need. Ferlie et al. (1996) have argued that NPM has also aimed to make professional practice more transparent and controllable. Private sector notions of market forces, assessment and management have underpinned the rise of managerialism (Loewenthal, 2002), audit culture (Power, 1997) and ‘neo-bureaucracy’ (Harrison & Smith, 2003) in public sector services, where economic rationalism and technicism, efficiency, accountability and performativity are privileged over basic trust in public sector professionals (O’Neill, 2002).

A particular emphasis in NPM is the introduction of new disciplinary technologies (Townley, 1994) and discourses, aimed at instilling new organizational attitudes sponsoring workers’ compliance with government target systems. These targets, and the technologies designed to generate them, actively construct the organizations in which they operate, shaping the behaviour and subjectivities of staff as well as the public perception of problems for which they are considered to be the solution (Power, 1997). The contribution of this paper lies in its attempt to link the unconscious dynamics of abjection with the organizational policies, structures and practices of contemporary UK mental health services subject to these technologies and in its exploration of how the interpenetration of such organizational dynamics and praxes shape and define the behaviour and subjectivities of mental health professionals who work within them.

Using the above example as a starting point then, I offer a brief outline of Lacanian and Kristevan views of anxiety before situating the study of abjection within the current organizational literature. I briefly explore the social defence model in psychoanalytic theory, subsequently drawing on work by Foucault (2003) and Shildrick (2002) to consider how individuals deemed to be psychologically distressed are cast as monstrous or ‘other’ by society. Exploring the way in which NPM preoccupations with regulation, surveillance and governance within mental health institutions may be characterized as a symbolic attempt to gain mastery over feelings unconsciously deemed to be abject reminders of the body, I then offer a short illustrative case study drawing on my work as psychotherapist and clinical supervisor within a mental health service. I conclude by suggesting that the dynamics of abjection may shed new light on difficulties experienced in public sector health services and propose that theorizing abjection offers rich prospects for future debate and research within the field of organization studies.

Psychoanalytic Theories of Anxiety: Lacan and Kristeva

Whilst Fotaki et al. (2012) point out the recent emergence of Lacanian psychoanalytic perspectives within organizational studies (Arnaud, 1998; Fotaki, 2011, 2012; Hoedemakaekers, 2009, 2010; McSwite, 1997; Vanheule and Verhaeghe, 2004, 2005), Kristeva’s theories, drawing on psychoanalysis, linguistics, literary theory and philosophy, remain dauntingly abstruse to many scholars and researchers in the field. Her work has been associated with approaches to intertextuality (Keenoy and Oswick, 2004; Riad, Vaara, & Zhang, 2012) but is more usually elaborated by feminist writers concerned with culture, gender and sexuality (e.g. Butler, 2004; Fotaki, 2011; Hopfl, 2008; Tietze, 2003). It is probably fair to say that her contribution to the field of organizational studies has yet to be more widely appreciated.

In order to contextualize Kristeva’s concept of abjection, I will offer a very brief summary of the Lacanian thinking from which her theoretical framework derives, starting with the notion of subjectivity. Whilst both Lacan and Kristeva view anxiety as central to subjectivity, Lacan sees subjectivity as constituted by the interweaving of the three psychic realms of the Imaginary, the Symbolic and the Real. Subjectivity is what arises in the face of primordial anxiety sponsored by contact with the unrepresentable Real which it will never fully be able to master. ¹ In Lacan’s (1953) ‘mirror stage’, his template for the Imaginary order, the child’s primordial anxiety is a response to its lack of physical coherence and motor co-ordination. This anxiety is only ameliorated by identification with his or her mirror image, which confers a subjective feeling of wholeness, completeness and self-mastery. The child’s response, ‘in a flutter of jubilant activity’ (p. 2), is triumphantly to assume a narcissistic ideal, an anticipated sense of self-unity and control that it does not yet have. This identification with the mirror image, the basis of an imaginary ego, is thus fundamentally a ‘meconnaissance’, a misrecognition on which our imaginary identity and thus our psychological dependence on the other is created and sustained. The specular re-constitution of the fragmented body at this stage covers over the ego’s basic lack or insufficiency which is experienced as profound anxiety in the face of the Real.

It is this fundamental loss of the (Imaginary) self that the individual attempts throughout life to recover via holding on to the ‘objet petit a’, and which, through entry into the Symbolic order, it tries to make good via language and recognition by the (Symbolic) other. Whilst Lacan claims that it is the symbolic order or the Law that instates the subject, i.e. that there is no subject prior to the oedipal stage, Kristeva instead suggests that the child’s pre-linguistic experience is maternally-oriented and is not lost with the acquisition of language. In a break with Lacan, she argues that the pre-symbolic, pre-linguistic order precedes, underpins and guarantees the subject of the symbolic order. For Kristeva, there is a retroactive process whereby ‘the symbolic becomes instituted “apres coup”’ ² (Sjholm, 2005: 18), identifying the body with the process of signification. Kristeva’s elaboration of Lacanian thinking here importantly distinguishes between the semiotic drives and ‘semiotics’ as a field of study in structural linguistics (de Saussure, 1986 [1983]). For Kristeva, the semiotic is considered to be an aspect of subjectivity not fully captured by the structure of language as defined by internal relations of difference. As such, it is defined by the marginalized or unrepresentable aspect of language, manifest within the rhythm, prosody and tone of text or speech. The semiotic is considered by Kristeva to underpin and threaten the hegemony and stability of the paternally-oriented symbolic order governing language, grammar and syntax.

Drawing on Plato’s Timaeus, she introduces the notion of the chora, an ancient term denoting that which takes in or receives matter, engendering transformation. Kristeva (1982) similarly sees the mother’s body as a receptacle, a ‘site of investments’ (Sjholm, 2005: 20), a place of semiotic drives and boundaryless plenitude. In this symbiotic state, akin to Lacan’s Imaginary register, the infant experiences himself as one with and fulfilled by a mother guaranteeing wholeness and unity. In order to enter the Lacanian order of the Symbolic, to become a differentiated subject constituted by lack, the subject has to discard the unclean, improper or impure aspects of the maternal body while it is still within this symbiotic tie. The rejected parts of the self ‘may be such things as faeces and sour milk, but they may also include symbolic representations of the child’s relationship with its mother’ (Holmes et al., 2006: 307). Kristeva (1982) suggests that feelings of anxiety, disgust, repulsion and fear are ways in which each individual subsequently experiences and attempts to distance him or herself from what is felt to be improper or unclean in order to establish and strengthen his or her own subjectivity and retain a self that is ‘propre’ or clean:

The abject confronts us, on the other hand, and this time within our personal archaeology, with our earliest attempt to release the hold of maternal entity even before existing outside of her, thanks to the autonomy of language. It is a violent, clumsy breaking away, with the constant risk of falling back under the sway of a power as securing as it is stifling. … In such close combat, the symbolic light that a third party, eventually the father, can contribute helps the future subject, the more so if it happens to be endowed with a robust supply of drive energy, in pursuing a reluctant struggle against what, having been the mother, will turn into an abject. (p. 13)

In this struggle, then, the maternal body is abjected and the semiotic chora becomes the site of primal repression, which nonetheless remains the seat of maternally-oriented psychic energy beneath the symbolic order. In this sense, pace Lacan, the symbolic is inextricably linked with the semiotic and cannot be defined merely in opposition. Abjection is thus clearly linked to the construction of the speaking subject and his or her relationship to culture and language. It is a process whereby the individual’s sense of self and corporeal boundaries is established and positioned; where subject and object are distinguished; where toxicity and waste are rejected and order installed. In this struggle, whatever is not clearly demarcated in this way is connoted as abject: ‘It is not lack of cleanliness or health that causes abjection’, writes Kristeva (1982), ‘but what disturbs identity, system, order. What does not respect borders, positions, rules. The in-between, the ambiguous, the composite’ (p. 4). Building on Bataille’s statement in his Essaie de sociologie that ‘Abjection … is merely the inability to assume with sufficient strength the imperative act of excluding abject things’, Kristeva (1982) further points out that there are:

… lives not sustained by desire, as desire is always for objects. Such lives are based on exclusion. … The unconscious contents remain here excluded but in a strange fashion: not radically enough to allow for a secure differentiation between subject and object, and yet clearly enough for a defensive position to be established. (pp. 6–7)

The abject thus constitutes the very measure by which the subject defines what is ‘I’ and what is ‘not I’. However, Kristeva (1977) offers the term ‘sujet en proces’ to index the way in which the subject is never completely established but is rather, like the maternal body, constituted by a continual process of negotiating the ‘other’ within: we exist in a continual state of instability, at once driven towards yet simultaneously repulsed by the abject which is always already present within the subject. This oscillation marks both a desire to return to the undifferentiated state of the chora and an anxiety about the loss of subjectivity entailed.

Abjection in Organizational Studies

To date, the sparse organizational literature on abjection has attempted to illuminate the various ways in which institutions come to silence, exclude or disavow feelings, practices, groups or discourses within the workplace (e.g. Linstead, 1997; Tyler, 2011). More specifically, feminist perspectives have recently focused on the way in which emotions, the feminine and the maternal, reproductive body become sites of both fascination and disgust within organizations (Hopfl and Matilal, 2007; Tietze, 2003). Philips and Rippin (2010), for example, in their New Historicist re-reading of the autobiography of Starbuck’s CEO, Howard Schultz, point to the progressive de-feminization of the two-tailed mermaid, Starbuck’s logo, as a symbol of abjected femininity and sexuality within the organisation and, indeed, within Howard himself: ‘… emotion leaks and gushes from Howard’s narrative’, claim the authors. ‘This is not a discourse expected of heroic, macho CEOs. … Abjection lurks in the borders of Howard’s text’ (pp. 490–1). Fotaki (2011), too, drawing on work by Irigaray, Cixous and Kristeva, argues that the abjection of women’s bodies in academic institutions renders their position ‘untenable in the knowledge creation process’ (p. 45). Arguing that the ‘speaking, female subject exists uneasily in the symbolic order’ (p. 47), she explores the various forms of ‘violence by proxy’ (p. 48) that are deployed by universities to prevent disruption of the phallogocentric ³ order.

Fotaki’s (2011) work points out how certain forms of gendered sexuality become tacitly embedded within the norms of what constitutes organizational success for men and women. This draws attention to the wider issue of how normative frameworks organize and permit recognition of the subject within the workplace. Indeed, Kenny (2010) argues that we adopt roles, identities and discourses in order to avoid the catastrophic consequences of abjection. Drawing on Butler (2004), she suggests that ‘if we cannot be recognised as legitimate human beings in the terms offered to us by a wider sociality, if we fall outside the norm then “we are not possible beings; we have been foreclosed from possibility” (Butler, 2004: 31)’ (Kenny, 2010: 3). Examining an ethical living discourse within a developmental sector organization, she found various exclusionary practices that created a ‘zone of uninhabitability’ (Butler, 2004: 235) for staff perceived to be in opposition to the norm. ‘The production of a domain of unintelligibility’, she writes, ‘simultaneously involved the production of a domain of the unthinkable: those abject beings that feel outside its discourse’ (Kenny, 2010: 13).

One of the central dynamics involved in abjection is the importance of monitoring the boundary between the symbolic order and the semiotic drives that continually threaten to unsettle and disrupt it. Grint’s (2010) discussion of organizational leadership, whilst not directly referencing Kristeva, is concerned with the ‘separation between the profane and the sacred’ (p. 93), arguing that this distinction is necessary and indeed constitutive of leadership. The language that Grint (2010) deploys here interestingly mirrors Kristeva, who argues that the abject requires a mode of control in order to keep it at a safe distance from the symbolic order. This is seen by Kristeva as the social function of religious rituals and practices that are adopted in order to protect the subject from the abjection inherent in materiality and death. Grint’s focus on the notion of the ‘sacred’ in leadership thus abuts notions of abjection by focusing on the various ways in which this boundary is policed and maintained. These include the sacrifice and scapegoating of staff as well as the silencing of opposition, resistance and anxiety within the workplace which not only perpetuates the hegemony of leadership but ensures loyalty and an existential ‘security blanket’ for staff who might otherwise have to take responsibility for leadership themselves.

Controlling the boundary region between organizational workers and their customers is considered central to the healthy functioning of an organization. Rigid or inflexible boundary regions limit contact between staff and customers, resulting in excessive differentiation or ‘othering’. However, Stein (2007) argues that where organizational boundaries are insufficiently demarcated, staff may fall prey to a powerful unconscious fantasy that they have inhaled something poisonous. Examining the problem of boundaries between staff and customers in the workplace, he suggests this leads to an unconscious infiltration of ‘toxicity’ into the organization resulting in acts of revenge by staff who come to feel polluted and unclean. Similarly, Gabriel’s (2012) notion of ‘organizational miasma’ compellingly articulates the state of depression and ‘rottenness’ that may pervade organizations undergoing radical change and transformation. He proposes a process akin to abjection where feelings of loss and grief for the staff and practices of the ‘old order’ are disavowed or repressed, and where the ‘dead wood’ of old leaders is cleared away and purified.

Abjection and the Social Defence Model

In psychosocial studies, it is the social defence model that has been most commonly used to examine the various ways in which boundaries are demarcated and sustained in healthcare organizations. Dominated by the so-called ‘Tavistock model’, such work draws mainly on Kleinian psychoanalytic thinking to articulate how organizations structure themselves and the subjectivities of staff in order to defend against primitive anxieties. Isabel Menzies-Lyth (1959), in her seminal study investigating the reasons for increasing numbers of student nurses leaving the profession, found nurses experienced enormous emotional difficulties in handling, working with and caring for the sick, injured and dying patients in their care and argued that such work resurrected primitive anxieties. Her study identified a number of working practices such as strict routines and division of labour, the identification of patients by number rather than by name and the idealization of the professional ‘detached’ nurse, untouched by the death of a patient, that were understood by Menzies-Lyth as institutionally-embedded defences against death anxiety. Paradoxically, these same social defences reduced nurses’ emotional investment in their work and satisfaction in their relationships with patients. Inhibition of nurses’ creative energies led to high levels of doubt and job dissatisfaction which ultimately led to a destabilizing level of staff turnover at the hospital.

The Kleinian perspective offered by Menzies-Lyth (1959) and more recent theorists such as Obholzer (2003) tends to emphasize the way in which medical services are unconsciously experienced as a defence against the overwhelming realities of illness and death. Much contemporary psychoanalytic theorizing on organizational dynamics also draws on Bion (1962) as a basis for assuming the significance of the institution as a container for the projected feelings and anxieties of society (e.g. Hinshelwood, 1994). However, the defensive position of exclusion that Kristeva describes I think helps us consider the notion of social defences from a perspective that problematizes precisely this notion that anxiety can be contained. For example, it is clear from Menzies-Lyth’s description below that nurses were not simply struggling with ‘strong and conflicting feelings’; they were profoundly engaged in an attempt to cope with the reality and subjective impact of physical damage, deterioration, death and decay of the human body:

Nurses face the reality of suffering and death as few lay people do. Their work involves carrying out tasks which, by ordinary standards, are distasteful, disgusting and frightening. Intimate physical contact with patients arouses libidinal and erotic wishes that may be difficult to control. The work arouses strong and conflicting feelings: pity, compassion and love; guilt and anxiety; hatred and resentment of the patients who arouse these feelings; envy of the care they receive. (1959: 98)

Kristeva’s (1982) notion of the abject instead draws our attention to the ‘distasteful, disgusting and frightening’ aspects of these nurses’ work: the repulsion and disgust of those who, charged by society with health promotion and illness prevention, are forced to encounter – yet protect themselves from contact with – individuals who threaten their integrity and subjectivity. This in turn permits a rather different conceptualization of some of the defensive practices identified by Menzies-Lyth: not simply as institutional defences against a yet-to-be contained anxiety, but rather as part of the institution’s enduring efforts to impose symbolic order on an anxiety that can never be completely managed, that is perpetually present and must continually be opposed. At an organizational level, then, the hospital’s identification of patients by number rather than by name, the emphasis on ritual, protocol and guidelines and the denial of nurses’ feelings and so forth may be seen as an ongoing unconscious attempt by the symbolic to overwrite the semiotic, to control and define the body’s boundaries and to regulate the marginalized and unrepresentable aspects of experience in order to safeguard institutional system and order.

Social Defences and Abjection in Psychological Care

What, then, is the relevance of abjection in psychological care? Hoggett (2006) points out that the social defence model has yet to fully articulate the ways in which feelings and anxieties can be culturally organized and how these collective feelings may be experienced and managed by corporations, governments and those who work within them. This quest is clearly in line with Fotakiet al.’s (2012) recent lament in this journal that ‘The social and political dimensions of emotion tend to be missing from many conceptualizations dominating management and organizations’ (p. 1114). I now want to suggest that the dynamics of abjection have a role to play in understanding not only how anxiety becomes the work of the mental health team and the organization, but also how it is enacted at the level of mental health policy.

In order to address this issue, it is important to remember that the care of the mentally ill has a long and dismaying history, in which their abjection within society has been a constant if tacit dynamic. Foucault (1964) points out that in the Middle Ages it was the leper who occupied a place on the margins of communities, a space that seemed to open up after leprosy as an illness largely disappeared from the western world. It is in within these ‘wastelands’ that Foucault sees certain people being defined and excluded from society. Indeed, over the next three centuries the poor, the criminals and the insane would come to take the place of the leper within society, occupying a liminal position where they were permitted to live in cities yet were confined within institutions that were intended to control public spaces, clean the streets of ‘problem people’ and act as correctional establishments to address the various economic and social problems emerging from within Europe.

From the 15th century on, the mentally ill individual was constructed as a monster requiring segregation from human society. The notion of madness in the guise of a beast meant that madness could only be controlled by incarceration and training; the dehumanization of the mentally ill was justified on these grounds and legitimated their exclusion from society as well as a number of abusive practices committed by the authorities. Foucault’s (2003) notion of the ‘bestial man … the monster who is both man and beast’ is offered as a construction of madness as beyond the Law, as inherently transgressive:

The frame of reference of the human monster is, of course, law. The notion of the monster is essentially a legal notion in a broad sense, of course, since what defines a monster is that fact that its existence and form is not only a violation of the laws of society, but also a violation of the laws of nature. Its very existence is a breach of the law at both levels. …The monster is the limit both at the point at which law is overturned and the exception that is found only in extreme cases. The monster combines the impossible and the forbidden. (2003: 55–6)

The mentally ill individual, then, is defined by Foucault as somehow ‘monstrous’, incarnating something that violates the boundaries between what is deemed normal and abnormal, sane and insane, human and non-human. Shildrick’s (2002) notion of monstrosity draws on the Lacanian account of the ‘mirror stage’ in infant development and suggests that a sense of our own fragmentation and lack is what we encounter when we see any kind of deformity, disability, damage or vulnerability in others. The cherished modernist ideal of the independent autonomous body and mind are threatened by this encounter, but the ontological unease we experience is not simply anxiety in the face of difference: it is an acknowledgement of the interrelatedness of the familiar and the unfamiliar and recognition that a fundamental lack of unity, an ineluctable vulnerability, is the basis of our shared humanity. She goes on to argue that the predictable, ‘normal’ body is preserved and protected only by a process of normalization that ensures the monstrous other is abjected, marginalized and excluded. MacCallum (2002) has similarly referred to a process of ‘othering’ by which means we establish clear boundaries between those who are ‘normal’ and those who are deemed to be different. In this way certain groups, such as the mentally ill, can be objectified, depersonalized and defined as Other. However, Shildrick (2002), in line with Freud’s (1919) notion of the ‘uncanny’, seems to be pointing to the way in which such a process is implicitly suffused with an anxiety sponsored by the threat of return, the reappearance of the abject:

Monsters haunt us, not because they represent an external threat – and indeed some are benign – but because they stir recognition within, a sense of our openness and vulnerability that western discourse insists on covering over. (p. 81)

Abjection and Contemporary Mental Health Services

The above discussion suggests that the mentally ill or psychologically distressed individual threatens us with the return of the abject, helping us to define our own normality and subjectivity by comparison with a radical or ‘monstrous’ other. This threat is, of course, particularly salient within mental health services where the professional role of staff in caring for the mentally ill may be at odds with personal feelings of unease and vulnerability when faced with those who, as Shildrick (2002) suggests, unconsciously remind them of their own fragmentation and lack.

It is precisely here that I want to draw attention to the complex interplay between unconscious dynamics, organizational structure and government health policy. Recent UK government-backed initiatives have resulted in the development of mental health services whose organizational structures are increasingly characterized by the manageralism, surveillance and bureaucracy typical of NPM. The central values of NPM, underpinned by a philosophy of economic rationalism privileging efficiency, performance and transparency over professional accountability and collegiality, have led in the UK to a government health policy agenda that aims to reform clinical practice and professional identity via systems of clinical governance that include a raft of performance indicators, audit, evaluation and league tables. McGivern and Ferlie (2007) point out that the current political focus on audit and accounting ‘colonizes and socially constructs environments so that people believe they can and should be measured and audited, undermining the legitimacy of practices less amenable to measurement’ (2007: 1363). I want to suggest that these ‘rituals of verification’, typical of the ‘audit society’ described by Power (1997) and its logic of coercive accountability, are constitutive of a mental health service’s symbolic attempt to regulate and define the limits and borders of its own culture, defending the organization and its staff against the return of the abject.

In line with this view, Höpfl (2003) has argued that organizations have traditionally been constructed as patriarchal and masculine, and that such representations reduce the notion of organizations to abstract relationships, rational action and purposive behaviour. She contrasts this with a view of the maternally-oriented organization that questions and problematizes the ambivalence that is concealed and regulated by the patriarchal, symbolic order. In line with Höpfl, Tietze (2003) points out that notions of loving, caring, protecting and suffering are intimately linked to notions of motherhood. ‘This very essence of motherhood’, she writes, ‘is problematic in modern organisations, where the emotive is the abject, the pain of labour denied, the jouissance and horrors of intimacy rejected’ (p. 65).

Tiezte’s claim is particularly challenging in the context of mental health services which are part of the broader welfare system that Cooper and Lousada (2005) argue constitutes ‘a socially-sanctioned system of concern’ (p. 21). They question the way in which ‘Little reference is made to intensity of feeling as lying at the heart of the work of welfare’ (p. 26) and point to the paradox that ‘Day by day the welfare project continues to be about people, as it always has been and must be. Yet a parallel state of mind has been created and maintained through its adoption of a position that denies, ignores, and repudiates this experience’ (p. 27).

It is interesting to note that the standard word ‘feeling’ is so commonly used that we seldom stop to remember that it relates to a physical, tactile and, above all, a corporeal experience. Höpfl (2003) argues:

Since the physicality of the real body is too threatening, the lack of the body is compensated for in organisational terms by the construction of a representational body. Over the past ten to fifteen years, there has been increasing interest in the emotion in organisations, in diversity, ethics, care and of course the ubiquitous pursuit of quality. However, these concerns have invariably been reduced to issues of management and regulation, to capture, via regulatory matrices, taxonomies and proliferating classifications systems. (p. 6)

My thesis is that the rise of NPM strategies of accountability and control within welfare services in general, and in public mental health services in particular, are part and parcel of the way in which mental illness and feelings of psychological distress, along with the vulnerability to which they give rise, are abjected within society and within these organizations. Insofar as the abject is violently expelled from the body, so too I suggest that notions of psychological vulnerability may be violently expelled from the social body that is the organization, that expulsion effectively establishing such feelings as alien, as ‘Other’. The ordered, regulated rationality of the Symbolic order expressed by the institution’s attempt at regulation, surveillance and governance can be characterized as an attempt to gain ‘mastery’ over these abject reminders of the body or what Höpfl (2003) calls the ‘pre-linguistic flux’ of the unorganized semiotic drives. In doing so, a defensive position is established within the organization in which the resurgence of abjected elements constantly threatens the prevailing order. I suggest this provides us with a provocative framework for understanding the government’s current obsession with ‘counting, control and calculation’ (Power, 2004) within healthcare organizations where the symbolic requirements of the ‘audit culture’, or the Law, are given precedence over feelings or the unarticulated drives of the body.

Thomas and Davies (2005) remind us that the literature on NPM lacks articulation of ‘its daily enactment in specific organisational settings’ (p. 683). I now attempt to address this by offering a short retrospective case study, drawing on my work as a psychotherapist and clinical supervisor within a recently expanded NHS mental health service. The material is autoethnographical in nature, and is reflective of my position as a female senior clinician within the service. In this sense, I am a ‘participant-observer’, with both ‘one foot in and one foot out’ (Duncan & Diamond, 2011) of the organization, a position that is not without risk in terms of individual disclosure and organizational protection. Nonetheless, it is precisely this position that potentially enables me, as Parry and Boyle (2009) suggest, to ‘uncover and illuminate the tacit and subaltern aspects of organisation, such as how actions which lead to negative or positive organisational outcomes actually play out’ (p. 694).

Parry and Boyle (2009) also argue that a further advantage of organizational autoethnography is that it allows us to construct a richer, more informative understanding of organizational life, by ‘connecting the micro and everyday and mundane aspects of organisational life with the broader political and strategic organisational agendas and practices’ (p. 694). Indeed, my decision to focus on a single illustrative vignette demonstrating the way abjective dynamics are refracted in one particular organization is influenced not only by my familiarity with the case study genre within psychoanalytic clinical work (Freud, 1905; Fonagy & Moran, 1987; Szeczody, 2008) but is also guided by the wish to consider, in some depth and detail, the complex interplay between unconscious dynamics, staff behaviour and the particular regulatory procedures to which both I and my colleagues were subject. In this respect, I hope a focus on the ‘particular’ offers the potential for understanding something of the ‘universal’ (Warnock, 1987), shedding light on the wider significance, function and mechanisms of abjection in public sector organizations.

In bringing a psychoanalytic sensibility to my role as ‘participant-observer’, I have been mindful of the need to use the self as an instrument of research (Hunt, 1989) and to be as conscious of my own emotional reactions to the work environment as my colleagues’. Humphreys (2005), too, has noted the importance of self-awareness and reflexivity within autoethnographic research which he suggests ‘would benefit from the explicit and overt presence of the first-person “I” of the researcher’ (2005: 853). However, Arnaud (2012), in this journal, points out that organizational researchers need to

set up a system – similar to what takes place in training analyses …– by which researchers are supervised by someone or a group of people external to the situation, such as colleagues, consultants, psychologists and so on. … As well as allowing countertransference to be dealt with, such a system allows a certain distance to be established, especially with respect to the myth of pure and affectively-neutral research, which psychoanalysis reveals to be an illusion. (2012: 1126)

To this end, I was able to discuss the following episode with two clinical supervisors, one who worked within the service and one who was external to the organization. I have therefore drawn on supervision records of the time where the following issues were debated and my own countertransference reactions considered. The illustrative verbatim extracts I include, which are drawn from clinical notes also taken at the time, may perhaps be seen as akin to the ‘evocative fieldnotes’ advocated by Emerson, Fretz and Shaw (2001) in their discussion of participant-observation in the field.

Case Example: Improving Access to Psychological Therapies

The UK government’s recent Improving Access to Psychological Therapies (IAPT) programme has sponsored an ambitious agenda of reform within primary care psychological services. The programme was introduced by the Labour government in response to the influential Layard (2004) report, Mental Health: Britain’s Biggest Social Problem, where a forceful economic case for treating those with anxiety and depression resulted in an initial investment by the government of £173 million to fund the implementation of evidence-based psychological therapy services. Drawing on the stepped-care model recommended by the National Institute for Health and Clinical Excellence’s (NICE) Guidelines, the IAPT model introduced large numbers of newly-trained NHS mental health workers or ‘Psychological Wellbeing Advisors’ (PWPs) offering ‘low-intensity’ psychoeducation and guided self-help based on cognitive-behavioural principles as well as more experienced ‘high-intensity’ staff offering face-to-face therapy. The present Coalition Government has committed to increasing its provision of psychological therapies, investing a further £70 million in services for children and young people, older people, and those with long-term physical or mental health conditions. It has also expanded the range of ‘NICE-compliant’ psychological therapies ⁴ available within IAPT services to include brief dynamic psychotherapy (dynamic interpersonal therapy), counselling, interpersonal therapy and couples therapy.

The IAPT model can be contextualized within the overall NPM framework privileging increasingly standardized and regulated forms of practice within public sector services. Hoggett (2010) has drawn attention to the emphasis on performance management within such services, where practitioners are increasingly subject to intensified surveillance of their work. This is particularly evident within IAPT services where both the inexperienced ‘Psychological Wellbeing Practitioners’ (PWPs) and trained cognitive-behavioural therapists are required to undertake a battery of standardized diagnostic, assessment and treatment protocols, including multiple clinical measures at every contact with a client. They receive frequent case management in order to review their caseload and clinical outcomes and are required to evidence increasingly high activity and clinical outcome targets. Nor are managers and service leads exempt from such demands. They too are required to participate in similar regulatory mechanisms and to defend service activity and clinical outcomes to a centralized IAPT administration.

In this particular expanded IAPT service, a large number of PWPs and cognitive-behavioural therapists were complemented by a small number of part-time psychotherapists in offering short-term interventions and counselling for individuals referred for anxiety and depression. In line with their IAPT colleagues, I and my psychotherapist colleagues had recently been required to use the full IAPT dataset and software systems for recording clinical activity and outcome measures for each patient session. In addition, a decision was taken by senior management to expand psychotherapy provision to include several trainees who needed to gain clinical experience and practice hours for their professional accreditation. As their clinical supervisor, I was asked to ensure that these trainees complied with the IAPT data collection requirements, inputting their activity and clinical measures onto the same software system used by all practitioners in the service. The software system involved filling in each patient’s demographic details, selecting a preliminary psychiatric diagnosis from a drop-down list, and completing several sets of online clinical measures to be undertaken each time the client was seen.

During a clinical supervision session which I was facilitating, it was clear to me that one member of my group of three trainees appeared upset and agitated and needed to be heard as a matter of priority. She told the group that she had seen a patient the previous week and had been very worried that this young woman she had been working with had walked out of the session after only twenty minutes. This patient had been referred for help with what the referring doctor had termed ‘severe depression’ following a recent termination and was finding it difficult to talk about her feelings of guilt, self-loathing and shame. At the start of the session, my trainee said she had persuaded her to complete the various clinical measures required by the service as she had been concerned at the patient’s obviously depressed mood. After sullenly filling in the forms, her patient thereafter spent the session mainly in silence, remaining hunched in her coat with her chin tucked into the collar, tears continuously pouring down her face and her nose running. My trainee said that she had found this frank and uninhibited display of continual misery very difficult to bear: ‘She had snot all over her face’, she exclaimed, ‘her collar was sodden; it was just …revolting!’ The patient had largely ignored my trainee’s efforts to engage her and seemed to be utterly sunk in a mood of rage alternating with apathy. Eventually, she had stood up and said that she couldn’t put up with it anymore, and strode out of the room. My trainee said that she had felt ‘completely paralysed’, unable to think, and was left feeling very worried indeed about her client. It transpired that during the week, she had found herself becoming increasingly uncomfortable, guilty and concerned at this young woman’s psychological plight, and it had become apparent to her that she was spending quite a lot of time thinking about this young woman, something, she said, she was not used to doing.

She then said that a few days after the session she had been discussing the case with a senior cognitive-behavioural therapist in the service. It seemed to me, hearing my trainee’s story at this point, that this very experienced (male) colleague of mine clearly felt that my trainee’s anxiety was not justified by her patient’s presentation, and had tried to help her think more calmly about the case. He had asked to see the clinical measures that the trainee had taken from this young woman and, on finding that these were relatively low, said to her that there wasn’t really any need to be too anxious, the patient was clearly showing sub-clinical scores, so my trainee could not be held accountable were any risk issues to arise before the next session. In the group, my trainee said that she had felt partially reassured by this and then spoke at length, and with some tears of her own, about her unaccustomed feelings of disgust and repulsion at her patient’s uncontrollable distress.

In fact, this colleague had spoken to me during the week about the incident and it had been clear to me that he had become somewhat irritated with my trainee’s request for help. Indeed, after a while he admitted that although he had initially been pleased to talk to her, he couldn’t really manage what he called ‘all this anxiety’. He had work of his own to do, and said that he had been feeling under considerable pressure to complete all his own data collection requirements in order to achieve his weekly targets. He spoke about the ‘real requirements’ of the service, and suggested to me, politely but impatiently, that postgraduate psychotherapy trainees ought to be able to contain themselves better. ‘They don’t just want spoon-feeding’, he finally remarked, rather brusquely, ‘they really want breast-feeding. It’s not up to us to do that!’ Somewhat taken aback at this rather vivid statement, I lamely tried to defend my trainee whilst struggling with a sudden mixture of anger, helplessness and what I later realized was a strong feeling of shame in myself; but it was to no avail. During the following week the clinical lead of the service asked me to ensure that my trainees did not request any further meetings with cognitive-behavioural therapists as this would reduce the time they needed to meet their increased activity targets.

Discussion

The conversation with my colleague had left me feeling confused, humiliated and angry, not just by the apparent relegation of my trainee to the status of demanding infant, but also, by extension, by my demotion to what I felt was some kind of nursemaid. Indeed, following Hunt (1989), it is possible to understand my feelings of shame as a possible phenomenological index of the abjective dynamics at work here, arising in the face of a phallogocentric symbolic order dismissing the maternal, caring role as unnecessary to the ‘real requirements’ of the service. I certainly felt an underlying unease – and subsequently, as I admitted in supervision, outright anger – about the overt privileging of targets and data-collection, which I felt were the only aspects of clinical work recognized and acknowledged within the service. In part, my anger rested on an awareness of an already-present, deeply-entrenched tension in the service between those whose training and theoretical orientation (cognitive-behavioural) favoured the IAPT culture and its emphasis on ‘evidence-based clinical outcomes’ (on which future funding depended), and those, like myself and my psychotherapist colleagues, whose theoretical interests (psychoanalytic) were more critical of such positivist epistemologies and praxes. In this sense, it can be seen that I had already positioned myself on one side of a fissure within the organization constituted along theoretical, clinical and, indeed, as the discussion with my colleague suggests, gendered lines – a split that my trainee and I were now struggling to manage.

Splitting, of course, is a familiar Kleinian term, pointing to the difficulty of integrating or reconciling ambivalent feelings. A traditional Kleinian reading of the above episode might also draw on Bion’s (1962) notion of the ‘container-contained’, emphasizing my trainee’s difficulty in containing and managing her patient’s feelings of anger and grief. Such an analysis might explore the way in which these feelings are subsequently split off and projected on to my colleague who then admits he cannot contain ‘all this anxiety’. But I think a Kristevan reading helps us to focus on something occurring within the organization that cannot and will not be contained. The notion of breastfeeding is not only maternal, feminine: it is abject, a messy, leaky business involving the exchange of body fluids. My colleague’s reaction suggests that he feels it is not up to him, either as a man, or a clinician, to provide such intimate care for my trainee: rather, the more ordered, symbolic activity of clinical and diagnostic measures is invoked as a means of understanding and managing both the client’s and the trainee’s distress. More, the intimacy and blurring of boundaries implied in the notion of breastfeeding as metaphor for maternal, emotional care is contrasted with the need for more legitimate, ‘real requirements’ of ‘data collection’, something that is privileged within the organizational structure. ‘A representative of the paternal function takes the place of the good maternal object that is wanting’, writes Kristeva. ‘There is language instead of the good breast. Discourse is being substituted for maternal care’ (1982: 45). I suggest this opposition creates a continual movement or dynamic in the organization between the revulsion entailed by engaging in messy emotional contact (‘breastfeeding’) and the desire to undertake the more ordered, symbolic activities required of the organization. Indeed, the former could be said to mock the latter, threatening to subvert or sabotage the Law (‘it’s not up to us to do that!).

It was this dynamic that seemed to be exemplified by my trainee’s inability to manage the distress and vulnerability of her patient who, silent and tearful, faced her with an experience of vulnerability and utter abjection for which the symbolic discourse of the service – its clinical measures – appeared radically insufficient. Indeed, the patient’s presenting problem – the termination of an unwanted baby – could be seen as paradigmatic of abjection itself: the violent expulsion of unwanted parts of the self, which are now threatening to return in her unspoken feelings of depression, rage and guilt. In my own supervision at the time I was able to examine my countertransference feelings that arose during this whole episode. Whilst I was able to be open about the mixture of fascination, horror and pity I experienced at hearing about my trainee’s patient, it took me far longer to acknowledge my unaccustomed feelings of real exasperation at my trainee’s difficulties, my irritated impatience and a concealed desire at the time to move rapidly on to another trainee in the group, one with whom I could, perhaps, demonstrate some kind of supervisory competence. It was these feelings, my own repudiation, perhaps, of an unwelcome ‘nursemaid’ role and the concomitant wish to adopt the more ‘phallic’ position of competent supervisor, that can in a deeper sense be seen to shed further light on the abjective dynamics, offering a potential route for understanding how abjection can percolate through an organization, in this case shaping my trainee’s, her patient’s and ultimately my own subjectivity and behaviour. Indeed, my trainee’s feelings of disgust and revulsion at her patient’s tearful face and snotty nose seemed in turn to be mirrored not only in my countertransference reactions but also in my colleague’s distaste at the prospect of ‘breastfeeding’ or managing her – and his own – abjected vulnerability; the use of clinical measures was then co-opted in the service of managing and ultimately dismissing as illegitimate a sense of anxiety and alarm about this patient’s evidently fragile psychological state. Finally, the entire process appeared to be transferred to the clinical lead of the service who instated the Law by insisting that cognitive-behavioural therapists were to be protected from psychotherapy trainees’ feelings of guilt and anxiety in the interests of conserving valuable time needed for the more symbolic activities required by the service – data collection and meeting organizational targets. Perhaps it was not altogether surprising that my trainee’s patient subsequently failed to return to the service and that it was I, positioned within the organization as woman/nursemaid, who was left to manage my trainee’s feelings of guilt, distress (and tears) and to help her think about her patient’s, and indeed her own, psychological distress.

What seems to be at stake here is something that has to be kept at bay within the organization: an experience that is ‘ejected beyond the scope of the possible, the tolerable, the thinkable. It lies there, quite close, but it cannot be assimilated’ (Kristeva, 1982, p. 1). If it is difficult to articulate, perhaps this is because, as Butler (1998) argues, abjection is something that is conferred, not a given; it is discursively performed and linguistically constructed:

It is not as if the unthinkable, the unliveable, the unintelligible has no discursive life: it does have one. It just lives within discourse as the radically uninterrogated and as the shadowy contentless figure for something that is not yet made real. (p. 281)

In the above case example, I suggest we can distinguish some of the ways in which a mental health service may confer abjection on staff and those they care for: firstly, by a process of psychiatric classification (‘depression’) that interpellates ⁵ the individual into a medical discourse which thereafter defines his or her problem and determines what is deemed to be the appropriate kind of treatment for the diagnostic categories it generates; secondly, by subjecting managers and clinicians to increasing surveillance via clinical governance systems that regulate, evaluate and legitimate clinical activity and outcomes (the ‘real requirements’ of the service); and thirdly, by the continual articulation, demarcation and extension of boundaries, rules and protocols within the service which define and proscribe ‘the Law’ – i.e. what is or is not permitted to occur within the organization, between staff and within psychological treatment (‘it’s not up to us to do that!’). All these processes are clearly located within the Symbolic order, where the materiality and the corporeality of mental illness and psychological distress is specified, tabulated, diagnosed and otherwise situated within a phallogocentric discourse that exiles the emotional, messy aspects of caregiving. This in turn defends the organization against the ‘monstrous’ psychological fragility of individuals referred to the service as well as the feelings of staff who provide care for them. Recall Fotaki’s (2011) suggestion, in the context of academia, that ‘the abjection of the (maternal and feminine) body makes [women’s] position untenable in the knowledge creation process’ (p. 45). Whilst recognizing the inadmissibility of generalizing from a single case example, the above vignette similarly argues that the abjection of the messy, emotional feminine body in the organization of the caregiving process may render a woman’s position in mental health services equally precarious. But mental health services are not at all the same as academic institutions! Society has constructed caregiving as necessarily maternally-oriented and it is precisely this construction that I suggest creates a peculiar paradox between the explicit aims of a service aiming to provide care for the mentally ill and the government-sponsored policies and protocols generating organizational dynamics, instrumental behaviour and clinical practice that serve to regulate, disavow and abject the very care such services are mandated by the public to provide. This in turn highlights a fundamental conflict between the explicit, rational aims of state-funded mental health provision and the unconscious, ambiguous and contradictory psychic mechanisms underpinning its implementation.

States of Abjection

Kristeva argues that the rejected maternal body or semiotic drives are a continual source of subversion and disruption within the paternal Symbolic order, sponsoring a continual fear of return and resulting in redoubled efforts to assert the hegemony of the Law. It is possible that this conflict underpins some of the commonly noted difficulties within mental health organizations (Hoggett, 2006; Long, 2009, Rizq, 2011, 2012a, 2012b), including the perverse forms of ‘turbulence’ that Fischer (2012) has recently noted in discussing the collapse of a mental health care organization. More generally, however, the above scenario offers new insights into Fotaki’s (2010) illuminating thoughts about ‘why government policies fail so often’. Fotaki’s (2010) paper articulates the imaginary and fantasmatic basis of many UK government health policies, including the pursuit of ‘Choice For All’, suggesting that such policies offer ‘a stark testimony of the impossibility of realizing the policy objectives it proclaims, despite or perhaps because of its universalistic (and omnipotent) aspirations. … The attempt to attain the fantasy of the impossible can also explain policy recycling and repetition of the same ideas, despite many documented failures (p. 9). A central tenet of the IAPT programme has been to ‘improve not only the health and well-being of the population, but also to promote social inclusion and improve economic productivity’ (DoH, 2007, p. 4). Certainly, the politically ambitious scale of the IAPT mental health programme currently being marketed to the public with its promise of equal access to therapy for all and the notion that this will sponsor social inclusion and improved economic prosperity in a time of global austerity may be regarded as aspirational at best rather than attainable, since such an agenda appears to be founded on the omnipotent and imaginary illusion of total unity, satisfaction and social harmony. Indeed, Fotaki (2010) argues on this basis that some government policies are prone to ‘capture’ by certain political groups for their own ideological purposes. This is certainly a persuasive reading of the IAPT agenda which unequivocally recasts contemporary social and economic problems – the ‘shit-life syndrome’ I identify at the start of this paper – within the template of middle-class individualism.

I suggest that as these state-governed aspirational policies are implemented across mental health services in the UK, social and organizational defences, including the dynamics of abjection, reinforce the impossibility of success, thus condemning such policies and the praxis they dictate to failure. Indeed, the problematic effects of recent government targets on healthcare, education and other public services have generated an entire literature (e.g. Bevan & Hood, 2006; Clapham, 2010; Hoggett, 2006, 2010; Shore, 2010; Shore & Wright, 1999). Notions of ‘playing tick-box games’ (McGivern & Ferlie, 2007) or ‘gaming behaviour’ (Bevan & Hood, 2006) confirm that performance measurement systems similar to those currently being deployed within IAPT services may actually be ‘fatal remedies’ (Sieber, 1981) whose unintended consequences undermine the very activity they seek to assess and quantify. Perhaps it is not too much to suggest that these policies act to formalize a process of abjection within mental health services, giving rise to the unconscious dynamics illustrated above. If so, this offers a new way to understand the self-sabotaging nature of NPM reforms designed to improve transparency in public sector services (McGivern & Fischer, 2011; Strathern, 2000; Tsoukas, 1997) and brings a fresh perspective to how this is played out between staff and patients in a service. Perhaps what the above case study most vividly demonstrates is how mental health policy, unconscious organizational dynamics and clinical practice intersect to confer, sustain and enact abjection in ways that undermine and destabilize an organization’s primary caring role.

In bringing a Kristevan lens to organizational theory, it is important to note that some have regarded her understanding of the semiotic as being outside of culture whilst simultaneously holding the potential for subversion of the patriarchal Law both paradoxical and problematic (e.g. Fraser, 1992). Indeed, the question of whether the semiotic lies ‘outside’ or ‘above’ the symbolic order, rather than being intertwined with it, is central to questions about how an understanding of abjective dynamics might bring about social or political change. This issue is further problematized by Butler (1990), who suggests from a Foucauldian perspective that the mechanism of repression is not only prohibitive but generative. In other words, ‘the female body … is itself a construct produced by the very law it seeks to undermine’ (1990, p. 118). Butler goes on to argue that the repudiated female body may ‘prove to be yet another incarnation of that law, posing as subversive but operating in the service of that law’s self-amplification and proliferation’ (p. 119). How, then, is it possible for the feminine to challenge the legitimacy and hegemony of the patriarchal Symbolic order, without subscribing to the very discourses and ‘rhetoric’ (Höpfl, 1995) that perpetuate its unstable position on the margins of the organization? This question is particularly relevant given Butler’s (1990) claim that the desire for recognition forces us to adopt normative frameworks in order to avoid the pain of abjection. Whilst critics such as McNay (2003) argue that Butler’s theorizing precludes any concrete suggestions for agency and resistance, we can look to Thomas and Davies’s (2005) examination of NPM discourses to see how public service professionals are in fact extremely active in their engagement with NPM discourses. ‘When facing the subjectivizing effects of NPM’, they argue, ‘individuals may choose to draw on some aspects as a “discursive resource” … in asserting an identity, while attempting to subvert and “wriggle out” of the other ways that NPM attempts to classify, determine and categorize them’ (p. 700). They point to the way in which resistance may emerge in ‘low levels of disturbance’ that loosen, disrupt and unsettle hegemonic NPM discourses, clearing small spaces where alternative subjectivities and identities can emerge. In mental health settings, where I have suggested that abjective dynamics are formalized by NPM discourses and the policies to which they give rise, the protection of ‘formative spaces’ (McGivern et al., 2009) such as clinical supervision, reflective practice groups or psychoanalytic case study discussion may be particularly crucial in this regard. From a Kristevan perspective, then, these practices may be seen to foster the potential for change via intervention from within the Symbolic order. However, as illustrated in the case study, abjection may percolate down through the organization and become unconsciously embedded within the behaviour, language and practice of staff. It may therefore be helpful to enlist external facilitators and supervisors who can offer support for developing such alternative identities, discourses and ways of thinking.

Conclusion

This paper proposes Kristeva’s concept of abjection as a useful alternative lens through which to examine unconscious dynamics and processes within public mental health services. I have argued that the presence of the abject serves as a perpetual if unconscious reminder of the existence of the ‘monstrous’ other within the self, and offers a view of the divided individual as perpetually engaged in the struggle to demarcate his or her subjectivity. Clinical work within mental health services thus entails a continual effort by the organization and its staff to work with and empathically respond to patients who evoke unrecognized feelings of disgust and fear, and from whom they simultaneously seek to distance themselves. This unconscious conflict may lead to feelings of guilt and despair in staff as they struggle with uncontrollable feelings of anxiety and seek to maintain a sense of integrity. The theme of abjection thus deepens our understanding of problematic interactions between staff and patients in mental health services, and extends our theoretical understanding of such organizational dynamics beyond the more traditional Kleinian notions of projection, enactment and projective identification. In this way, an understanding of abjection enables us to revise and refine the theoretical literature on the deployment by staff of unconscious social defences within organizations (Menzies-Lyth, 1959; Jaques, 1955; Hinshelwood, 1994; Obholzer, 1994).

Further, the dynamics of abjection suggest that the abjection of the female body and semiotic drives within mental health services paradoxically undermines and subverts the very care these services set out to provide. This supports the view that the rationalist agenda of many public health policies ignores the unconscious, irrational motivations that underlie clinicians’ behaviour and fails to recognize how these may both be influenced by and contribute to the defensive practices of the organization. This links to the wider perspective discussed by Fotaki (2010), who points out that the rationalist and realist epistemology of contemporary socio-economics fails to take account of the unrecognized, imaginary or fantasmatic basis of much public health policy-making and is one reason why such policies fail so often.

Importantly, this paper has attempted to shed new light on the nature of the ‘rituals of verification’ (Power, 1997) characteristic of NPM’s growing demand for transparency, accountability and governance within public sector services. In the context of an IAPT mental health service, I have argued that an understanding of abjection contributes to our theoretical understanding of contemporary social practices of quality assurance, audit and evaluation, which can now be recast as the organizational attempt to defend and uphold the Symbolic order, and the struggle to define and maintain an institutional frontier against the semiotic drives of the body. This in turn potentially illuminates and deepens our understanding of the ‘tyranny of transparency’ (Strathern, 2000) common in public sector services as well as the related problems associated with clinical practitioners’ ‘reactivity’ to regulatory mechanisms, for example in medicine and psychotherapy (McGivern & Fischer, 2011).

Just as we cannot get rid of shit, so I suggest we cannot free ourselves from psychological distress and mental ill-health. As Shildrick (2002) suggests, these issues arouse huge anxiety in us at both individual and organizational levels because they bring us into unwilling contact with our own abjected vulnerability, our own ‘monstrous’ need, our own ineluctable lack or fragmentation within. Developing theoretical accounts of the way in which institutions and services continually attempt to control, overwrite or subdue the abject is a relatively underdeveloped area within organization studies, and in this paper I have attempted to outline some of the ways in which an investigation of these processes may offer a fertile, if provocative, area for future debate and research.