The mental health treatment team as a work group: team dynamics and the role of the leader.

Psychiatry Interpersonal and Biological Processes

ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: http://www.tandfonline.com/loi/upsy20

The Mental Health Treatment Team as a Work Group: Team Dynamics and the Role of the Leader Glenn R. Yank, Jack W. Barber, David S. Hargrove & Patricia D. Whitt To cite this article: Glenn R. Yank, Jack W. Barber, David S. Hargrove & Patricia D. Whitt (1992) The Mental Health Treatment Team as a Work Group: Team Dynamics and the Role of the Leader, Psychiatry, 55:3, 250-264, DOI: 10.1080/00332747.1992.11024598 To link to this article: http://dx.doi.org/10.1080/00332747.1992.11024598

Published online: 03 Oct 2016.

Submit your article to this journal

View related articles

Citing articles: 14 View citing articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=upsy20 Download by: [Australian Catholic University]

Date: 07 August 2017, At: 23:15

Downloaded by [Australian Catholic University] at 23:15 07 August 2017

The Mental Health Treatment Team as a Work Group: Team Dynamics and the Role of the Leader Glenn R. Yank, Jack W. Barber, David S. Hargrove, and Patricia D. Whitt ALTHOUGH treatment teams have been examined often in the mental health literature, this literature seldom addresses the crucial property of "teamness" - the key set of intangible phenomena that allow a team to function synergistically as more than the sum of its parts, and with a sense of team identity. In this paper, the concept of the work group is used to develop a framework for understanding the factors contributing to effective team functioning and identity, and their implications for the tasks of team leadership and sociotherapy: "the art of maintaining a social system in which the treatment of an individual patient can best occur" (Edelson 1970). Leadership activities that promote team cohesiveness and boundary maintenance are discussed, and suggestions are provided for ways in which the subjective experiences and emotional reactions of the leader and team members can be used to promote improved task performance and clinical care. Although treatment teams and teamwork skills have been frequently discussed (Abramson 1989; Berg 1979; Berlin 1979; Brill 1976; Kane 1975b; Lewis 1969; Nash 1982; Paradis 1987) mental health professionals often report strain and frustration in their roles as team members (Banta and Fox 1976; Bloom and Parad 1976). Explanations for team dysfunction include role confusion among team members (Banta and Fox 1976); competition for authority and value (Be-

narroche and Astrachan 1983; Kane 1975a); conflict or uncertainty about team tasks, treatment philosophies, and models of care (Newton and Levinson 1973; Shaw et al. 1985; Toseland et al. 1986; and autocratic or otherwise "inadequate" team leadership (Fiorelli 1988; Mizrahi and Abramson 1985; Nash 1982). These approaches to team dysfunction can be synthesized by examining the relationship between leadership and work group effectiveness, and by considering

Glenn R. Yank, MD, is a professor at the University of Virginia Health Sciences Center, Department of Behavioral Medicine and Psychiatry, and Staff Psychiatrist at the Western State Hospital, Staunton, VA. Jack D. Barber, MD, is an assistant professor at the University of Virginia Health Sciences Center, Department of Behavioral Medicine and Psychiatry, and Director of Medical Services at the Western State Hospital, Staunton, VA. David S. Hargrove, PhD, is a professor at the University of Mississippi, Oxford, Department of Psychology, and chairperson of the department. Patricia D. Whitt, PhD, is a psychologist in practice in Fort Meyers, Florida.

250

PSYCHIATRY, Vol. 55, August 1992


THE TREATMENT TEAM AS A WORK GROUP

how issues and subjective experiences specific to the mental health workplace affect work groups and their leaders. Treatment teams are work groups, as described in the social psychology literature to denote groups established to carry out specific tasks (Dyer 1977; Likert 1961; Newton and Levinson 1973), rather than as Bion (1961) used the term "work group" to refer to the task-oriented aspect of a group's mental activity, not the group itself. However, the existence of non-task-oriented mental activity in groups is one of several factors that influence the ability of team members to work together to perform complex tasks and comprise an effective treatment team. The group dynamics literature provides concepts about work groups and leadership that are applicable to treatment teams (Cartwright and Zander 1968; Odhner 1970; Payne and Cooper 1981; Thibaut and Kelley 1959; Zander 1979). The concepts of group cohesiveness, transference and countertransference phenomena, basic assumptions, and group boundaries are applicable to treatment teams and relevant over the entire time and space of the team's life beyond designated "team" activities, because "people do not have to come together into the same room to form a group" (Rioch 1970). The following discussion extends and adapts these concepts for use by clinicians in the role of "social system clinician" (Greenblatt 1957). GROUP COHESIVENESS AND ORGANIZATIONAL STRUCTURE

The concepts of cohesiveness and synergy apply to a team's sense of "teamness" and being more than the sum of its parts (Cartwright 1968; Festinger et al. 1950; Gross and Martin 1952; Hackman 1982; Libo 1953; Schachter et al. 1951; Seashore 1984). Group cohesiveness describes an attribute or dimension of groups that reflects group members' ability to work together and is generally


linked to group productivity. Festinger and co-workers (1950) defined cohesiveness as "the resultant of all forces acting on members to remain in the group." Schachter et al. (1951) emphasized the relationship of cohesiveness to group morale and members' feelings of belonging to the group. Cartwright and Zander (1960) stressed group members' motivation to participate in group tasks and the coordination of effort and work toward a common goal. Other investigators have stressed group members' psychological investment in the group (Kaplan and Razin 1981), as well as the psychological states that enable unity of feeling and working in harmony (Hartman 1981). Some definitions focus more directly on group productivity than Festinger's definition and more strongly link productivity to the emotional states of the group and its members. Although Goodman et aI. (1987) showed that empirical data about work groups in industry do not always link cohesiveness and productivity, they (Goodmanet al. 1988) subsequently showed a positive correlation between productivity and group synergy in self-managing teams. Group synergy is explicitly defined in terms focusing on productivityinteraction that reduces process losses and creates process gains (Seashore 1954), closely resembling psychodynamic definitions of group cohesiveness, which emphasize the degree to which teams are consciously and unconsciously held together to perform tasks in a united manner, with all members filling their roles and with team bonds developed and maintained (Hartman 1981; Kaplan and Razin 1981; Kellerman 1981; Rioch 1970; Wong 1981). Group cohesiveness results from factors that attract members to a group and promote developing identification as group members. Similarities among members, incentives and rewards for belonging, expectations of benefit from belonging, congruence of group and individual goals, and participation in decision mak-

251


GLENNR. YANK ET AL.

ing all increase a group's cohesiveness, with the latter two factors having the greatest effect (Cartwright 1968). Role differentiation and the status consensus about key group leaders also affect cohesiveness (Bales and Slater 1955; Heslin and Dunphy 1964). A common, internalized value system is a defining property of work groups and guides members in their roles (Edelson 1970; Parsons 1951; Parsons and Shils 1951; Parsons et al. 1953). Organizations and professions have distinct cultures that include their enduring values, beliefs, assumptions, and expectations, which therefore effect work group cohesiveness because a team is "embedded" in the organizational culture of its parent organization and the professional cultures of its members (Newton and Levinson 1973; Schein 1985, 1990). Team values, beliefs, and assumptions must be sufficiently congruent with those of the parent organization and professional groups to avoid loyalty conflicts between team members that could undermine cohesiveness. If team members are united in their disagreement with a belief or policy of the parent organization, team cohesiveness can increase, although stress between the team and the parent organization may increase. Organizational structure influences team cohesiveness and task performance because these factors are based, in part, on work group members' differentiated and internalized role expectations (Bales and Slater 1955). The organization affects role differentiation at the team level through supervisory and policy regulation of team structure and members' functioning. The treatment team may exist in an organizational matrix of numerous "lines" of authority from each discipline, and it represents an attempt to meld a work group from staff who have supervisors external to the team. Conflicts about authority and role expectation may arise if team leadership and discipline "line" supervisors disagree about team members' roles. Because development of internalized role expectations requires that work

252

group members "internalize the social system as a superordinate object" (Parsons and Shils 1951), work group cohesiveness requires congruence between the role expectations of the team leaders and the discipline supervisors external to the team, who may not share the emotional commitment to the team necessary to foster cohesiveness, and who may have other agendas for their supervisees intended to promote the identity of their disciplines. Such agreement is especially important with regard to expectations about fulfilling team tasks that are not discipline specific but can be considered milieu or "programmatic" functions, such as conducting community meetings, leading therapy groups, managing token economies, and providing psychoeducational services. Thus, organizational structure and the ability of supervisors to work collaboratively within that structure can profoundly influence a team's "atmosphere." A collection of people assigned by their supervisors to work together do not necessarily comprise a team; leadership from within the work group is required in order to "gel" into a team. THE LEADER AND COHESIVENESS

Team leaders must integrate responsibilities to patients with responsibilities to the team. Leaders can promote cohesiveness by emphasizing, in team meetings, the congruence of individual and team goals for both patient care and the team. For example, showing how a particular member's role in carrying out a patient's treatment plan fits into the overall team goal for the patient reinforces that individual and group goals are complementary. Differences in team members' opinions about patient goals must be sufficiently resolved for the team to agree on a common course of action that allows treatment to progress and prevents these differences from impairing the team's sense of cohesiveness. Leaders may profitably




distinguish differences in opinion about a treatment plan from differences in intent to put the plan into effect. The team may have a shared value that differences in opinions and attitudes need to be tolerated: Such a value is often needed in working with patients whose behavior can be viewed as "deviant" from societal norms. Emphasizing that while members can disagree, they will still act as a team - both to implement the particular plan and also to provide role modeling of rational means of resolving differences for patients - shifts the focus from the initial area of disagreement to areas of consensus: The team "agrees to disagree" in a way that emphasizes the shared values of toleration, teamwork, effectiveness, and role modeling. Conflict may occur between patientspecific goals, such as discharge from an inpatient unit, and the team's needs for stability, which may include stability of its patient population. New professional staff on a team who seek to increase the rate of patient movement, either by discharge or transfer, stress the team by increasing its workload of new patients to evaluate and by facilitating a shift in the patient mix to higher levels of acuity. There may also be differences between team members about whether discharge or transfer really is in a patient's best interest, or is primarily driven by administrative and financial pressures. External forces including managed care, more stringent utilization review requirements, changes in insurance coverage, and public sector belt tightening have all driven care in the direction of shorter stays, more rapid turnover, and higher levels of acuity. Leaders must attempt to minimize the effects of these stresses on team cohesiveness by clarifying which pressures are external, and therefore need not divide the team, and which are internal and require processing and resolution. Goal conflict may also occur when a team member shares with the team a personal goal of career advancement that requires leaving the team for training or a position elsewhere. This individual goal


conflicts with the team's necessary goal of preserving its membership to maintain its ability to function. However, the team may also value individuals' (at least patients') "rights" to pursue their preferred career choices and "self-actualization" (Maslow 1954). The team leader can thus frame the issue of a team member's career advancement in terms of the individual's goal being congruent with these team values, thus decreasing the team's sense of goal conflict and potential feelings of devaluation from the loss of a team member. Related structural issues about members leaving teams are discussed in the section on team boundaries. Team cohesiveness requires consensus about the team's "primary task," defined as the task that must be achieved if the team is to survive in the organization (Miller and Rice 1967), and the priorities required by that task. In addition to clinical tasks, mental health teams may participate in research and training activities or have significant financial responsibilities to a parent organization. Conflicts between team members or between the team and its parent organization about the relative priorities of these different tasks can adversely affect team morale (Newton and Levinson 1973). Team leaders must be alert to such potential conflicts and make sure that they can be discussed by all team members in an atmosphere of openness and that they are resolved sufficiently to enable the team to work productively. Resolving competing priorities may require the use of subteams, assistant leaders, or other structurally assigned "spokespersons" for each competing task to facilitate open discussion of the issues that have been raised, and leaders may have to actively initiate discussions and outline the various "sides" of the issues in order to give other team members the "permission" to speak to organization management. Team participation in decision making promotes cohesiveness. However, not every decision can be a "team" decision: Some decisions are the responsibilities of particular team members with specific ex-

253


GLENN R. YANK ET AL.

pertise, clinical privileges, or administrative or legal accountability. Other team members can still provide information that the responsible team member(s) consider(s) in the decision process. For example, because physicians' legal responsibilities about prescribing medication cannot be delegated or fully shared, medication usage (whether drugs should be used at all, type of drug, specific agent, dosage, laboratory monitoring, etc.) is not technically a "team" decision. Physicians can, however, solicit input from other team members about patients' clinical progress, social functioning, compliance history, supervision needs, and the supervision available at patients' residences; and can ask other team members for their observations about what they have seen be effective in similar situations. Such participation allows other team members to be involved by providing physicians access to a wider range of observations and information about patients on which to base decisions, and thus communicates a message of value, yet still clarifies physicians' authority for medication decisions. At other times, however, a leader must make, or at least catalyze, decisions that the team finds difficult. One example is deciding that a particular treatment plan has not been and is not likely to be effective, and needs to be changed, which is difficult for the team because it is an admission of the team's limitations. To minimize such decisions resulting in feelings of devaluation, leaders must join with the team by asserting that all treatment plans are "our" plans, and that "we," as a team, do well together or falter together. Decisions about allocating valued resources to particular patients, such as one-to-one staff time for supervision, can be difficult because they increase workloads, hinder efforts to decrease costs, or cause intense emotions in team members required to spend one-to-one time with patients who make them feel helpless, devalued, and/or angry. Supervisors may be reluctant to order this level of staff attention for such patients, fearing to upset staff and engender resentment

254

against the patients or themselves, fearing to upset administrators trying to minimize costs, or because of their own ambivalence toward these patients. In such circumstances, the leader must assume responsibility for the decision but do so in a manner that protects cohesiveness by framing the decision as one required by responsibility to the team and its goals. Emphasizing the shared team value and fact of responsibility - rather than authority to make the decision, which is not shared - protects cohesiveness. The leader can assert that the decision is being made on behalf of the team, which underscores that the leader is part of the team and downplays the leader's authority to make the decision, which accentuates the difference between the leader and other team members. Team leadership must address social and emotional aspects of cohesiveness in addition to task-related aspects. Separate and distinguishable task leader and emotionalleader roles develop in groups, and task performance correlates positively with both roles being filled and consensus about who fills them (Bales and Slater 1955). Although filling of both roles by one person may be optimal (Heslin and Dunphy 1964), not all leaders are adept at both sets of tasks. Awareness of these phenomena allows leaders to assure that both roles are filled by appropriate team members with the leaders' support (Munich 1986). These observations support the use of mUltiple leadership and "coordinating" roles in treatment teams. However, such functional roles can impair cohesiveness if not clearly defined or empowered, or if they are not consistent with members' positions and authority in the organization's structure, because lack of consistency between position and role decreases cohesiveness and morale (Newton and Levinson 1973). Leaders can promote cohesiveness in the emotional dimension by providing value messages, which is particularly important when team members are assigned to the team, rather than actively choosing it, and when many team members are


~--~~~-----~-----~~----------~-----~-----~-~

-~~

----~---~------~~-~--~

~ -----~----------

-~~----~



nonprofessionals. Because the team's day-to-day work may yield few clear signs of accomplishment, team members do not consistently receive a sense of validation and value from the work itself. Many patients have serious mental illnesses and can change only slowly, even with optimal treatment. Further, some patients' psychopathology results in their overtly devaluing staff and/or using the psychological defense mechanism of projective identification (Jaffee 1968; Jureidini 1990; Kemberg 1975a; Malin and Grotstein 1966; Meissner 1980; Ogden 1979) so that staff identify with the patients' feelings of worthlessness (Burke and Tansey 1985; Meissner 1982). Leaders must appreciate the magnitude of staff members' feelings of being devalued by the patient(s) and the corresponding feelings evoked in staff members of anger, guilt, and inadequacy. These factors can negatively affect team members' self-esteem. Therefore the leader's acknowledgement and validation of a team member's efforts, and meaningful communication that the team member is valued, can help maintain team members' self-esteem and can be very powerful reinforcers for the sense of belonging to the team. Leaders need to be aware of the effects of team and organizational culture and valued traditions on cohesiveness when they act as change agents. Relevant examples include changing team orientations from custodial to active treatment (Greenblatt 1957), from psychodynamic to biological paradigms (Newton and Levinson 1973), and from clinically focused to research-focused (Newton and Levinson 1973). All of these examples involve team cultural factors that need to be understood and valued by leaders if change is to result in successful programs - ignoring them can lead to team members feeling devalued. For example, hospital environments called "custodial" may have strong cultural values of caring for and protecting patients. Leaders must acknowledge these values and provide means for them to be utilized and ex-


panded upon as active treatment programs are developed. Long-term treatment wards in both the public and the private sector may have cultural values of a stable and predictable environment, which require change agents to proceed with patience and to address resource and milieu constancy issues raised by more rapid patient turnover. Psychodynamic and milieu-oriented programs have cultural values of teamwork, personal growth, and adaptive change through talking about and understanding problems, which must be respected and preserved in some form as biologic treatments become more central to these programs. Leaders must demonstrate their team membership overtly by participating in team functions such as physical interventions for patients, team outings, and "after hours" events such as picnics and parties. Frequent references to "we" and "the team" indicate that leaders perceive themselves as team members. The less psychologically sophisticated the team, the more the joining by and with the leader is a result of nonverbal behaviors such as participation in the team's work (whether physical interventions with patients, outreach visits, meetings, etc.) and paying attention to team members' opinions and problems. These behaviors promote cohesiveness by expressing the leader's valuing of the team. The leader is asserting that the team is "good enough" for the leader to join. Further, team members' tendency to identify with the leader (see subsequent discussion) will lead to identification with the leader's valuing of the team and team membership. THE USE OF TRANSFERENCE AND BASIC ASSUMPTIONS

Group cohesiveness is an important theoretical bridge between the social psychology literature about work group effectiveness and the psychodynamic literature about the psychological forces that influence work groups. Team identity and cohesiveness are affected by the attitudes

255



and feelings that leaders evoke in team members (Tourquet 1974). Such attitudes and feelings can be "positive" or ''negative": Groups can be united in their "anger" at a leader (at least for a time), yet function well if the leader still commands respect. The leader's ability to direct these "binding" forces has a major effect on the team's development (Hartman and Gibbard 1974; Slater 1966) and cohesiveness as a work group (Wong 1981). The attitudes and feelings about the leader that affect teams include both conscious and unconscious components, including transference to the leader. Freud (1921) was the first psychodynamic theorist to emphasize the importance of shared unconscious reactions to the leader, particularly identification, in fostering group identity. Although a full discussion of transference phenomena in groups is beyond the scope of this paper, this discussion derives from the fact that interpersonal learning in emotionally significant relationships at any age has a significant effect on subsequent relationships. Those aspects of previous relationships that have been "internalized" contribute to a person's "information" regarding relationships with significant others. This information may be evoked by current relationships, but this process and its effects may not always be accessible to consciousness. The specific information evoked (transference paradigm) is determined by both the "personal" attributes of the individuals and by role aspects of the current group relationship context (Rice 1965; Rioch 1971). Team leaders need to be aware of and able to reflect upon the types of transference paradigms that they might evoke in other team members, due to both personal and role factors, and the potential effects of these phenomena on the team's functioning. Among Bion's (1961) contributions to group theory are his concepts of the "work group," defined as the mental activity of the group directed toward accomplishing the group's tasks, and the ''basic assumptions," which refer to aspects of

256

group functioning that are based upon tacit assumptions and have the attributes of powerful emotional drives. Basic assumptions affect group behavior while usually operating outside of awareness. Bion identified three primary types of basic assumptions, termed "dependency," "fight-flight," and "pairing," which seldom, if ever, exist in pure form, but rather in admixtures. Group regression can be described as increased energy and time invested in the basic assumptions aspect of the group, rather than its primary task (Kernberg 1978,1979). The manner in which a team leader can best utilize knowledge of group psychodynamic theory and transference phenomena highlights several important ways in which treatment teams as work groups differ from therapy groups. First, the primary task in a treatment team is not defined as change in the team members. There is no assumption that team members need to change or have problems which participation in the team will "help." The "social contract" between the team and its leader usually is not understood to include interpretive or other "therapeutic" interventions (Spiro 1983). Thus, team members do not anticipate these interventions, and comments about transference phenomena and other aspects of group process cannot be presumed to be of value in helping team members understand the interpersonal behavior/experience patterns that emerge in the team's process in a manner that will facilitate team functioning. Although self-knowledge may be a shared team value in some treatment settings, the team leader's primary goal is to maximize the team's effectiveness, not its selfknowledge. Second, treatment team members derive self-esteem from seeing themselves as role models for the patients they treat. Although they therefore may be willing to accept that a certain amount of selfreflectiveness is a necessary personality attribute, they are not likely, in their roles as team members, to accept the idea that their behavior "is a problem" or that it




needs to be "analyzed." Team members need to feel respected by the team leader in order to preserve their self-esteem. Staff do not always have the training to utilize comments about the possible psychodynamic factors involved in their interactions with patients, or with other team members, to increase their feelings of competence, and thus their self-esteem. Instead, overly interpretive comments, or remarks that imply that the leader is "analyzing" team members' behavior and motives, may make team members feel devalued because they perceive that they are being dealt with in the same way that patients are treated. Such comments may be perceived as an assertion of the leader's unequal power and knowledge, and may therefore decrease the extent to which the leader is "joined" to the team. A group leader who simultaneously acts and comments on the group's behavior stimulates regression (Spiro 1971). Group regression, which is an increase in non-task-related mental activity at the expense of task-related activity, decreases team efficiency in the primary task of treating patients. The nature of mental health work in organizations inherently fosters regression through intense contact with patients in primitive ego states (Kernberg 1978). Accordingly, treatment team leaders should generally avoid interpretive comments in order to minimize this additional contribution to regressive behavior (Spiro 1983). Other differences between treatment teams as work groups and therapy groups, and how leaders can best utilize transference phenomena in the service of group goals, derive from examining these groups from the perspective of social action systems (Edelson 1970; Parsons 1951; Parsons and Shils 1951; Parsons et al. 1953). Edelson(1970) posits that there are four basic types of functions that operate in a group, only one of which can predominate during a particular period: adaptation to the environment and acquiring the means to perform the group's primary task; consummation of the task through goal-directed action; integration


of group goals, priorities, and accomplishments and choosing between alternatives for action; and renewal of group members' motivational commitments to the group and its values. Compared to therapy groups, work groups require a far greater proportional expenditure of time and energy in members' outer-directed adaptive and consummative actions, utilize more formal processes for choosing between alternatives for action, and do not require motivational· commitments to members' self-knowledge and change. Further, treatment teams must address all of these group functions to some degree at any time, because different patients are at different stages in the treatment process, whereas therapy groups can be much freer to predominantly focus on one of the specific functions. Because the leader's tasks of directing and balancing efforts in these four areas of function differ between work groups and therapy groups, the best use of transference phenomena in the service of attaining the group's goals will also differ. For example, one of us (J.W.B.) was the leader of a long-term treatment ward that entered a period of being overwhelmed due to more rapid patient turnover and inadequate staffing and structure for the resultant patient mix and aggregate pathology. The ward staff as a team regressed, with verbal sniping between individuals and cliques under the guise of "open communication" that was rapidly becoming more personal and divisive. These phenomena illustrate the basic assumptions of pairing and fight-flight. From Edelson's (1970) perspective, the team's difficulties in adapting to changes in its environment led to questioning of team members' motivational commitments and values, and to an arrest in the normal cyclic process of team functioning. The leader's intervention was to comment to the team that "it appears that our program is now inadequate to meet the challenges of our patients, who have become more difficult-let's take a good look at the treatment program and see if it needs to be amended in any way." This

257



intervention did not comment on the transference forces active in the team, but rather used the team's identification with the leader to redirect energy back to the level of the work group and away from the personal level on which pairing and fight-flight were being expressed. Further, the leader emphasized that it was "our" program, thus indirectly suggesting emotional commitment to the program by asserting his own. This intervention stabilized the regression, allowed team members' energy to be reinvested in the work group, and emphasized the need for the team to adapt and act. One common pattern of team behavior toward the leader is a dependent attitude in which team members experience the leader as the only group member able to carry out the team's tasks, based upon transference paradigms of team members collectively projecting strivings for autonomy and competence onto the leader. Team members avoid feelings of responsibility that may feel overwhelming until the leader has valued and empowered them sufficiently to allow reinternalization of their feelings of competence. This pattern is also an aspect of the basic assumption of dependence. Recognizing this active basic assumption, the leader has two available types of interventions to increase team effectiveness. The choice depends upon the level of development (defined as the collective ability to resist regressive influences and remain task oriented), psychological "mindedness," and "ego strength" of the team. Although team leaders should not encourage regressive phenomena (as they might in some therapy groups) or interpret them, some teams possess the psychological self-awareness and maturity to benefit from the leader addressing the operating basic assumptions in a matter-offact way, based on observable phenomena. Other teams benefit more from the leader's directly asserting confidence that team members can successfully accomplish their assigned tasks. This "intervention" returns to the team directly the as-

258

pects of autonomy and competence that they have attributed to the leader without suggesting that team members have utilized psychological mechanisms that can be labeled as "transference," "pathological," "unconscious," etc., or even attempting to bring the process into conscious awareness. Utilizing transference in this way employs a dynamic similar to that used in supportive and suggestive therapies or the "placebo" effect, but differs in that the leader does not deliberately try to increase transference phenomena in order to be able to make use of them at a later time. Circumstances in which the team leader can usefully encourage and guide the team in team self-reflection generally do not focus on team members' feelings about the leader. In such endeavors, the team leader must take an active, participatory role to minimize further amplification of transference phenomena that can interact with other intense team feelings. For example, intense feelings in the team or particular team members that are induced by patients who devalue staff and/ or use the psychological defense mechanism of projective identification may be utilized to help team members better understand and therapeutically join with these difficult-to-treat patients. The leader can productively utilize these feelings by first acknowledging his or her own experiencing of these feelings, either in the present circumstance or in previous, similar circumstances. Such an acknowledgment supports other team members' self-esteem and facilitates their need to feel differentiated from these patients by allowing team members to identify with the leader. The leader could then ask how the team is being made to feel the intense feelings of anger, hopelessness, and/or worthlessness. Linking these feelings in the team to the behaviors of patients who are acting out their own intense feelings (of anger, hopelessness, and/or worthlessness) will both decrease the intensity of the team's feelings and help team members appreciate the pa-




tients' emotional predicament. Key to this process are the leader's acknowledgment of intense feelings and joining with other team members in this experience, which make the subsequent reflection upon the team's emotional experience a discussion between colleagues who are participating together, rather than a quasi-therapeutic interpretation or clarification. THE LEADER'S SUBJECTIVE EXPERIENCE: COUNTERTRANSFERENCE

Team leaders can benefit from attention to their subjective "countertransference" experiences evoked by other team members as individuals and by the team as a whole. "Countertransference" is used here in a manner analogous to the "totalist" perspective described in the psychotherapy literature (Gorkin 1987; Sandler 1976; Tansey and Burke 1989)-that is, the total response of the leader to the situation, including all thoughts and feelings experienced. The leader's subjective experience is a source of crucial information about the team's functioning (Kernberg 1975b). Leaders therefore need to develop the ability to reflect on their subjective experience and develop the information potential inherent in their experience. Because leaders, like all team members, bring their personality styles and the residues of previous experience to the current team situation, awareness of these factors helps to distinguish those components of subjective experience directly related to the team in the here-andnow. Common subjective experiences of leaders include feeling that one must do everything oneself, feeling completely overwhelmed, feeling unappreciated, feelings of isolation, and feeling that all of one's efforts are futile. Leaving aside the possible bases in reality for these feelings, utilizing these experiences as "leadership countertransference" begins with recognizing them as such. Keys to such recog-


nition include that feelings are unusually intense, seem "out of proportion," or seem atypical compared to the leader's typical subjective experience. Anger, emptiness, and apathy are common affective components of such experiences, derived from the team's tendencies to "project" uncomfortable and ego-dystonic affective states and to seek nurturance from the leader. Recognizing a subjective experience and its accompanying affect as (at least in part) countertransference decreases the intensity of the dysphoric affect and shifts the leader's mind-set to a more cognitive one. Useful hypotheses/approximations for understanding these subjective experiences include that the leader is feeling an intensified variant of what other team members feel, that the leader is experiencing feelings unconsciously "warded off' by other team members by the mechanism of projective identification, and/or that the team is somehow inducing the leader to act in a particular way related to the "basic assumptions" active in the group (Bion 1961). Parallel processes between patient-staff interaction and staff-leader interaction are often important components of the leader's subjective experience. Feelings derivative of the team inform the leader of the team's affective state and allow fostering of cohesiveness through validation of the team's affective state by overtly (and consciously) identifying with it to "join" with the team. A leader's overt acknowledgment of the frustration felt working with difficult patients, or the anger caused by "bureaucratic red tape," or inadequate resources may "permit" other team members to talk about these feelings. The leader does not need to state the assumption that other team members feel these feelings. Indirect and permissive approaches least provoke staff anxieties about discussing issues, because staff are not directly asked to share their feelings or express their opinions. If indirect and permissive approaches fail, but the leader senses that the team's affective state needs to be con-

259

GLENNR. YANKET AL.

sidered, a useful technique may be to ask the team aloud "Does anybody else feel ... ," which embeds the comment that the leader is experiencing a particular feeling in a direct question.


TEAM BOUNDARIES

The psychological boundaries of a group "define who belongs to the group and who does not" (Redlich and Astrachan 1969) and are affected by members' subjective experiences regarding whether they feel and perceive themselves as "within" the group's psychological space. The integrity of a team's psychological boundaries is therefore related to both the team's cohesiveness and each member's identity as a team member, through the linking concept of "belonging." Boundaries are structural aspects of the team and parent organization, and include assignments, positions, roles, and the "rules" for joining, belonging to, and leaving the team. Team boundaries also encompass task priorities, value systems, theoretical models, and treatment ideologies, all of which affect the sense of belonging. Many of these factors have also been seen to effect team cohesiveness. Team boundaries and cohesiveness can therefore be understood as complementary concepts that address the factors that hold teams together. The concept of boundaries represents a structural approach to these factors, and the concept of cohesiveness addresses them from a process point of view. Treatment team members' shared subjective experiences, including those that can be described as transference experiences in relation to the team leader and as countertransference experience in relation to the team's patients, influence members' sense of belonging to the team and thus affect team boundaries. Team leaders have key roles regarding team boundaries, and many leaders' actions can be understood as boundary interventions (Kernberg 1975b). Leaders can utilize group members' common subjective expe-

260

riences, including transference and countertransference feelings, to strengthen team boundaries. Leaders must be aware of situations in which patients evoke disparate countertransference feelings in different team members through the defense mechanism of "splitting" in which they experience different ego states with accompanying transference/countertransference paradigms in the presence of different staff members (Kernberg 1975a). Such situations can polarize teams and decrease cohesiveness and the sense of a common team boundary, and require active interventions to foster staff communication and understand team members' experiences as derivative of the patients' psychopathology. Shifting emphasis from the specific different experiences of team members to the common experience of having intense feelings evoked by patients rebuilds the team's cohesiveness and sense of boundary. A team's boundaries and sense of cohesiveness are stressed by members joining and leaving. Team members "officially" join a team by being assigned to its roster and through their job descriptions. Real joining requires the recognition of common goals, values, and the ability to work together based on professional and personal factors. Other subjective factors include accepting an identity as a member of the team and being a "team player," that is, being willing to subordinate personal needs and goals to those of the team. Joining is complicated because a new member joins not only the work group but also the basic assumption group of the team. The term "work group" here refers to "that aspect of group functioning which has to do with the real task of the group" (Bion 1961). The particular basic assumptions operating in the group influence the joining process. For example, if dependency is operating, group members may be concerned about what the new member can give to the group, or whether he or she will compete for the leader's favor. If pairing is operating, concern may focus on who will bond to the new mem-




ber, with attendant fantasies about what that allows the future (and hopefully the pair will "produce" and how the group more permanent) new team member to rewill be affected. Fight-flight may lead to place a person who has only partially fantasies that the new member could ei- joined the team, because temporary stather save the group or destroy it, power- tus does not allow full joining. fully distorting group perceptions about A more subtle boundary issue is posed and expectations of the new member. by different models of psychopathology These examples show how the basic as- and treatment that members bring to the sumption group aspect of the team's func- team (Shaw et al. 1985). These models tioning can affect team process and thus must be integrated into a common "conneeds to be considered by the team's ceptual boundary" related to the team's leaders. sense of identity, reflecting the team's unDepartures of team members threaten derstanding of how it accomplishes its the sense that the team boundary can ad- primary task. The various mental health equately perform its function of preserv- disciplines place different emphases on ing team identity. Group psychodynamic the roles of biological factors, psychologitheories have tended to explain this phe- cal adaptation, learned behavior patterns, nomenon in terms of the issues of loss and environmental influences, in the deevoked by the departure, and by the velopment and treatment of mental disorgroup's experience of the leader as unable ders. The team's valuing of each of these to protect the group. The leader is often factors extends, by association, to the perceived as responsible for boundary team members most closely identified (Tourquet 1974) and other "protection" is- with each theoretical model, requiring the sues, especially if the basic assumptions team leader to assert a holistic model of of dependency or fight-flight are operat- psychopathology, treatment, and rehabiling. This perspective provides useful in- itation in order to make all team members sights about certain types of problems feel that they "belong." In addition, intethat teams face in replacing highly valued grating different clinical and theoretical members. approaches results in improved clinical Feelings about the team's loss, which services based on the synergistic effects are not necessarily accessible to con- of complementary interventions (Frank et sciousness, can become displaced onto al. 1990; Klerman 1990; Schooler and Hothe "new replacement." The team may de- garty 1987). value the new member to preserve the "good" image of the former member (a CONCLUSIONS form of "splitting"), displace anger toward the former member for leaving onto the We appear to have traveled, in our arnew member, and/or attempt to preserve guments, in a somewhat circular manner: a fantasy that the previous member will from "intangible" phenomena to "holistic" return by not letting the new member models, from synergy through cohesivetake his or her role. Particularly difficult ness to boundaries and back, and from situations of team loss include sudden, subjective experiences as team members unexpected departures; departures due to to subjective experiences as leaders. In a death, injury, or illness; and departures of similar manner, the rhythm of the group key members from relatively less mature life of a treatment team seems circular teams. One potentially useful interven- but is ideally more like a spiral, evolving tion in such situations is allowing the role over time in the direction of increased effito remain unfilled for a time, which allows cacy and member satisfaction. The leaderteam members time to process their feel- ship that guides such evolution is as ings and acknowledge the need for the much an art as a science and, like jazz team to have someone in the role. Using a music, requires the ability to improvise in temporary replacement is an intervention addition to knowledge and technical skill.


261


Yet a leader's improvisations must be guided by knowledge, and technique must be taught in supervision and polished through experience. We have examined how the extensive knowledge base in group dynamics can be used to develop clinically useful approaches to the func-

tioning of treatment teams and the roles of leaders. Further, clinical skills based upon the informed awareness of the subjective experiences can be adapted to help clinicians develop the capacity to provide empathic leadership to their treatment teams.


REFERENCES ABRAMSON, J. S. Making teams work. Social Work With Groups (1989) 12:45-63. BALES, R. F., and SLATER, P. E. Role differentiation in small decision-making groups. In T. Parson and R. F. Bales, eds., Family, Socialization and Interaction Process. Free Press, 1955. BANTA, H. D., and Fox, R. C. Role strains of a health care team in a poverty community. Social Science and Medicine (1976) 6:697-722. BENARROCHE, C. L., and ASTRACHAN, B. M. Interprofessional role relationships. In J. A. Talbott and S. R. Kaplan, eds., Psychiatric Administration: A Comprehensive Text for the ClinicianExecutive. Grune & Stratton, 1983. BERG, L. K. Coordination of service: The interdisciplinary team and social work practice in community mental health. In A. Katz, ed., Community Mental Health. Council on Social Work Education, 1979. BERLIN, R. The team approach in hospital practice as defense of the psychiatrist. Comprehensive Psychiatry (1979) 11:147-57. BION, W. Experiences in Groups. Basic Books, 1961. BLOOM, B. L., and PARAD, H. J. Interdisciplinary functioning: A survey of attitudes and practices in community mental health. American Journal of Orthopsychiatry (1976) 46(4):669-77. BRILL, N. I. Team Work: Working Together in the Human Services. Lippincott, 1976. BURKE, W. F., and TANSEY, M. J. Projective identification and countertransference turmoil: Disruptions in the empathic process. Contemporary Psychoanalysis (1985) 21:372-402. CARTWRIGHT, D. The nature of group cohesiveness. In D. Cartwright and A. Zander, eds., Group Dynamics: Research and Theory. Harper and Row, 1968. CARTWRIGHT, D., and ZANDER, A. Group Dynamics. Row, Peterson, 1960. CARTWRIGHT, D., and ZANDER, A. Group Dynamics: Research and Theory. Harper and Row, 1968. DYER, W. G. Team Building: Issues and Alternatives. Addison-Wesley, 1977. EDELSON, M. Sociotherapy and Psychotherapy. University of Chicago Press, 1970. FEST INGER, L., SCHACHTER, S., and BACK, K. Social Pressures in Informal Groups. Harper, 1950.

262

FIORELLI, J. S. Power in work groups: Team members' perspectives. Human Relations (1988) 41:112. FRANK, E., KUPFER, D. J., PEREL, J. M., et al. Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry (1990) 47:1093-99. FREUD, S. Group Psychology and the Analysis of the Ego. Hogarth, 1921. GOODMAN, P. S., RAVLIN, E. C., and SCHMINKE, M. Understanding groups in organizations. In B. M. Staw and L. L. Cummings, eds., Research in Organizational Behavior, Vol. 9. JAI Press, 1987. GOODMAN, P. S., DEVADAS, R., and HUGHSON, T. L. Groups and productivity: Analyzing the effectiveness of self-managing teams. In J. P. Campbell, R. J. Campbell, and associates, eds., Productivity in Organizations. Jossey-Bass, 1988. GORKIN, M. The Uses of Countertransference. Aronson, 1987. GREENBLATT, M. The psychiatrist as social system clinician. In M. Greenblatt, D. J. Levinson, and R. H. Williams eds., The Patient and the Mental Hospital. Free Press, 1957. GREENBLATT, M., LEVINSON, D. J., and WILLIAMS, R. H. The Patient and the Mental Hospital. Free Press, 1957. GROSS, N., and MARTIN, W. On group cohesiveness. American Journal of Sociology (1952) 57:533-46. HACKMAN, J. R. The design of work teams. In J. W. Lorsch, ed., The Handbook of Organizational Behavior. Prentice-Hall, 1982. HARTMAN, J. J. Group cohesion and the regulation of self-esteem. In H. H. Kellerman, eds., Group Cohesion. Grune & Stratton, 1981. HARTMAN, J. J., and GIBBARD, G. S. Anxiety, boundary evolution, and social change. In G. S. Gibbard, J. J. Hartman, and R. D. Mann, eds., Analysis of Groups. Jossey-Bass, 1974. HESLIN, R., and DUNPHY, D. Three dimensions of member satisfaction in small groups. Human Relations (1964) 17:99-112. JAFFEE, D. S. The mechanism of projection: Its dual role in object relations. International Journal of Psycho-Analysis (1968) 49:662-76. JUREIDINI, J. Projective identification in general psychiatry. British Journal of Psychiatry (1990) 157:656-60.



THE TREATMENT TEAM AS A WORK GROUP KANE, R. A. Interprofessional Teamwork. Syracuse University School of Social Work, 1975a. KANE, R. A. The interprofessional team as a small group. Social Work in Health Care (1975b) 1:1932. KAPLAN, S. R., and RAZIN, A. M. Psychosocial dynamics of group cohesion. In H. H. Kellerman, ed., Group Cohesion. Grune & Stratton, 1981. KELLERMAN, H. (Ed.) Group Cohesion. Grune & Stratton, 1981. KERNBERG, O. Borderline Conditions and Pathological Narcissism. Aronson, 1975a. KERNBERG, O. A systems approach to priority setting of interventions in groups. International Journal of Group Psychotherapy (1975b) 25:25174. KERNBERG, O. Leadership and organizational functioning: Organizational regression. International Journal of Group Psychotherapy (1978) 28: 3-25. KERNBERG, O. Regression in organizational leadership. Psychiatry (1979) 42:24-39. KLERMAN, G. L. Treatment of recurrent unipolar major depressive disorder: Commentary on the Pittsburgh study. Archives of General Psychiatry (1990) 47:1158-62. LEWIS, J. M. The organizational structure of the therapeutic team. Hospital and Community Psychiatry (1969) 20:36-38. LIBO, L. Measuring Group Cohesiveness. Institute for Social Research, 1953. LIKERT, R. New Patterns of Management. McGrawHill,1961. MALIN, A., and GROTSTEIN, J. S. Projective identification in the therapeutic process. International Journal of Psycho-Analysis (1966) 42:26-31. MASLOW, A. Motivation and Personality. Harper & Row, 1954. MEISSNER, W. W. A note on projective identification. Journal of the American Psychoanalytic Association (1980) 28:43-67. MEISSNER, W. W. Notes on countertransference in borderline conditions. International Journal of Psychoanalytic Psychotherapy (1982) 10:89123. MILLER, E. J., and RICE, A. K. Systems of Organization. Tavistock Publications, 1967. MIZRAHI, T., and ABRAMSON, J. Sources of strain between physicians and social workers: Implications for social workers in health care settings. Social Work in Health Care (1985) 10:33-51. MUNICH, R. L. The role of the unit chief: An integrated perspective. Psychiatry (1986) 49: 325-36. NASH, K. B. Managing Interdisciplinary Teams. In M. Austin and W. E. Hershey, eds., Handbook of Mental Health Administration. Jossey Bass, 1982. NEWTON, P. M., and LEVINSON, D. J. The work group within the organization: A sociopsychological approach. Psychiatry (1973) 36:115-42. ODHNER, F. Group dynamics of the interdisciplin-


ary team. American Journal of Orthopsychiatry (1970) 24:484-87. OGDEN, T. G. On projective identification. International Journal of Psycho-Analysis (1979) 60:35773. PARADIS, B. A. An integrated team approach in community mental health. Social Work (1987) 32: 101-04. PARSONS, T. The Social System. Free Press of Glencoe,1951. PARSONS, T., and SHILS, E. A. Values, motives and systems of action. In T. Parsons and E. A. Shils, eds., Toward a General Theory of Action. Harvard University Press, 1951. PARSONS, T., BALES, R. F., and SHILS, E. A. Working Papers in the Theory of Action. Free Press, 1953. PAYNE, R., and COOPER, C. L. Groups at Work. Wiley & Sons, 1981. REDLICH, F. C., and ASTRACHAN, B. M. Group dynamics training. American Journal of Psychiatry (1969) 125:1501-07. RICE, A. K. Learning for Leadership. Tavistock, 1965. RIOCH, M. J. The work of Wilfred Bion on groups. Psychiatry (1970) 33:56-66. RIOCH, M. J. "All we like sheep-" (Isaiah 53:6): Followers and leaders. Psychiatry (1971) 34:25873. SANDLER, J. Countertransference and role-responsiveness. International Review of Psychoanalysis (1976) 3:43-47. SCHACHTER, S., ELLERSTON, N., McBRIDE, D., et al. An experimental study of cohesiveness and productivity. Human Relations (1951) 4:229-38. SCHEIN, E. H. Organizational Culture and Leade,... ship. Jossey-Bass, 1985. SCHEIN, E. H. Organizational culture. American Psychologist (1990) 45:109-19. SCHOOLER, N. R., and HOGARTY, G. E. Medication and psychosocial strategies in the treatment of schizophrenia. In H. Y. Meltzer, ed., Psychopha,... macology: The Third Generation of Progress. Raven Press, 1987. SEASHORE, S. Group Cohesiveness in the Industrial Work Group. Institute for Social Research, 1954. SHAW, S. J., HERRON, W. G., and POLAND, H. V. Team approach in mental health services: Generalists or specialists? Perceptual and Motor Skills (1985) 61:423-32. SLATER, P. E. Microcosm: Structura~ Psychological and Religious Evolution in Groups. Wiley, 1966. SPIRO, H. R. The "old:new land" of group psychotherapy. In J. Masserman, ed., Science and Psychoanalysis, Vol. 18. Grune & Stratton, 1971. SPIRO, H. L. Psychodynamic theories. In J. A. Talbott and S. R. Kaplan, eds., Psychiatric Administration. Grune & Stratton, 1983. TANSEY, M. J., and BURKE, W. F. Understanding Countertransference. Analytic Press, 1989. THIBAUT, J. W., and KELLEY, H. H. The SocialPsychology of Groups. Wiley, 1959.

263

GLENN R. YANK ET AL. WONG, N. The application of object-relations theory to an understanding of group cohesion. In H. H. Kellerman, ed., Group Cohesion. Grune & Stratton, 1981. ZANDER, A. Groups at Work. Jossey-Bass, 1979.


TOSELAND, R. W., PALMER-GANELES, J., and CHAPMAN, D. Teamwork in psychiatric settings. Social Work (1986) 31:46-52. TOURQUET, P. M. Leadership: The individual and the group. In G. S. Gibbard, J. J. Hartman, and R. D. Mann, eds., Analysis of Groups. Jossey-Bass, 1974.

264


The interprofessional team as a small group.

The Modern Neurosurgical Leader as a Cure for Team Burnout.

Mental health team of the year.

Exploring core competencies for mental health and addictions work within a Family Health Team setting.

The role of team goal monitoring in the curvilinear relationship between team efficacy and team performance.

Cohesion, team mental models, and collective efficacy: towards an integrated framework of team dynamics in sport.

The mental health team as a differential decision-maker for child patients: a national survey.

The role of the dental team in promoting health equity.

Mental health integration: normalizing team care.

The mental health rehabilitation worker: A new member of the psychiatric team.

The work of the South Manchester Accident Rescue Team (SMART).

Making Teamwork Work: Team Knowledge for Team Effectiveness.

Exploring the concept of a team approach to wound care: MANAGING WOUNDS AS A TEAM.

Women's health team of the year.

Community mental health care: primary team and specialist services.

Improving the rate of Patient Feedback for a Later Life Mental Health Liaison Team.

The effect of a nurse team leader on communication and leadership in major trauma resuscitations.

Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach.

Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review.

Development and validation of the primary care team dynamics survey.

The role of podiatric medicine in the health-care team. A paradigm shift.

Prerequisites for sustainable care improvement using the reflective team as a work model.

The ex-addict as a member of the therapeutic team.

The myth of the team captain as principal leader: extending the athlete leadership classification within sport teams.