Fall 2001, Vol. 9, No. 1

Organizational Consultation

What does organizational consultation offer the psychiatrist?

Robert P. Gordon, MD
Chicago, IL

Today's psychiatrists find themselves in a narrowing field, often confined to very disturbed patients and psychopharmacology. The result of multiple factors including managed care, new discoveries in neurobiology and the medicalization of the field, this limited scope is disappointing for those who were attracted to the field because of a holistic view of human experience. Most powerfully associated with the great American psychiatrist Adolph Meyer, the concept of psychobiology saw man in a complex field that included biology, individual dynamics, and large social systems. Organizational consultation allows the modern psychiatrist to reconnect with Meyer's wide-ranging point of view.

From a Meyerian perspective, one can see psychopharmacology as the biological part, psychodynamics as the psychological part, and the organization and its systems as the social part. For the practitioner who seeks involvement with this comprehensive kind of approach, organizational consultation is a golden opportunity. I will present a case that is the amalgam of several actual consultations and show how the organizational psychiatrist must use multiple vantage points to adequately address complicated situations. To do this properly, one must be able to make an accurate diagnosis, understand psychodynamic issues, and then see how these fit into a complicated social structure.

In my experience a psychiatrist is chosen rather than another kind of consultant because one person in an organization is labeled as the "problem." Once the system designates someone as "sick," a psychiatrist is a logical choice. While sometimes this designated patient is really the cause of the problem and individual treatment solves the problem (drug or alcohol issues, depression, anxiety disorder, and serious personality issues), this initial framing of the problem is more often an entrée to a complicated organizational story.

Three years ago I received an anxious call from Adam, owner of a large automobile parts manufacturer, Alpha Auto, who said that his vice president for manufacturing (Ken) had a serious drinking problem that was wreaking havoc with the company and needed immediate attention. He said that Ken had agreed to be evaluated and wanted to set up an appointment for him as quickly as possible. He went on to say that recently this person had become extremely argumentative, defensive, and unwilling to listen to anyone who disagreed with him. While I said that I would be happy to meet with Ken, I also told Adam that I would need to meet with him and key staff. The questions that I had for myself at this point were: Was this a more complicated systems problem? What were the business issues? Why had Ken been chosen as the designated patient? Was Ken actually an alcoholic? What other personality problems might he have? What was the relationship between Ken and the owner?

I interviewed Ken three days later. He acknowledged that on occasion he drank heavily, but felt that it in no way had interfered with his work. He said that the main problem was a major cost cutting program in the business that he had vehemently opposed. This involved a major shift from domestic to foreign subcontractors. He felt that the higher quality and lower return rate of the domestic parts more than offset their higher price and that the shift to foreign suppliers would really end up increasing costs. At the same time a new position, senior vice president for manufacturing, had been established to oversee both the domestic and international suppliers but had not yet been put into effect. As vice president for manufacturing Ken would now just oversee the domestic suppliers and report to the new senior vice president, while in the past he had reported directly to the president. He denied that there had been any compromise in his functioning and said that he served the company best by not being a yes man. He acknowledged that he was "intense" and that in retrospect he might have gotten too angry when making his points. He also talked about the close relationship that he and the owner of the company had enjoyed over the years as they had watched the company grow. While he seemed to be tense during the interview, he showed no overt signs of alcoholism but did seem to be mildly depressed. My impression was that he might have a drinking problem and probably did have an affective disorder but that this was secondary to a less obvious organizational issue.

The next day I met with the owner, the chief operating officer, and the new senior vice president for manufacturing. All three felt that the situation had become more acute over the past months as the cost cutting program was being implemented. While Ken had always isolated his department to some degree, lately it was felt that he had become anti-management and was unwilling to follow through on decisions agreed upon by the executive team. He had begun to see all questions as attacks, though it was noted that he had sometimes acted this way in the past. It was also reported that he had used bullying tactics and threats to get his way and this had been a longstanding pattern. The senior managers also noted his significant strengths: bright, talented, great with numbers, quick thinker, and very competitive. They felt that he had been unable to adjust to new ways of doing business and had begun to see himself as a dinosaur.

Management had addressed the problem by proposing a new structure where Ken would manage only national suppliers, and the new senior vice president for manufacturing would have authority over both domestic and international manufacturing. Ken had been told about the reorganization. Everyone seemed to be extremely apprehensive about how he might react and delayed putting the structure into place. The anxiety level in the senior managers and how they seemed to be unable to implement the change impressed me. As the meeting went on I tentatively proposed that the problem was senior management's difficulty in implementing the change and instead of dealing directly with that, they had projected their own feelings of impotence and rage onto Ken (he's seen as the enraged alcoholic unable to do his work). Being unable to deal with Ken directly, they were using his "alcoholism" as an excuse to get me to deal with him or get rid of him.

I next met with the three senior executives individually. Adam, the owner of the business, was a forceful and aggressive man who liked to see himself as a kind, benign father figure. He had difficulty acknowledging how angry he was with Ken and appeared to find it more ego-syntonic to express deep concern about the "alcoholism" rather than deal directly with the demotion. In addition, Ken had often played the role of the bad cop to Adam's good cop when problems had arisen in the company. This close relationship and Ken's role in facilitating Adam's denial of his own hostility was a further complication. So he felt both guilty about demoting him and also was fearful that without Ken, he might lose the good guy image.

Bill, the new vice president for manufacturing, was returning to Alpha Auto after having spent five years at another company. Before leaving Alpha he had worked under Ken and saw him as a mentor. He had idealized him for his business savvy even though he felt that he was a little rough around the edges. While on business trips he had seen him drink heavily but noted that the next morning Ken was always up and on top of things. He not only felt guilty about being in charge of his former mentor but the change in their position undermined the idealization that was an important part of his self structure. It was easier for him to see Ken as an alcoholic who had the possibility of cure rather than accept him as an underling, not able to deal with changed conditions in the auto parts business.

Charlie, the chief operating officer, had an interesting family history. His father had run a business started by his mother's family. When he reached late adolescence, new technology in the field made the company's product non-competitive. The business diminished in value and had to be sold, and Charlie's mother blamed the father and attacked him for ruining the family's life. He felt caught between the two and especially protective of his father. Eventually the parents divorced and the father ended up in small apartment with a limited income. Charlie felt angry with him and responsible for him simultaneously. He had become so uncomfortable with the situation that he had sought therapy three years previously. As we discussed Ken's situation, he quickly recognized that he identified Ken with his father and this had made it difficult to deal with the situation within a business framework. He was unable to move forward with the reorganization because he was afraid that it would undo Ken. Consciously he felt protective of Ken but unconsciously felt angry with him in a way that mirrored his attitudes towards his father. So, he too was unable to deal with the issue directly and instead found it easier to delay the changes and frame the issue as drinking problem.

In each of the three executives, conscious and preconscious factors prevented them from dealing with Ken in rational way. Ken meant something different to all of them and in order to deal with their own intrapsychic resistance to demoting him, they decided to bring in a doctor who could absolve them from responsibility and deal with Ken in a supposedly humane medical context rather than business one. With this diagnosis in hand, I decided upon my strategy. I referred Ken to a colleague to further evaluate his drinking and affective disorder. He also needed the opportunity to deal with blow to his self-esteem as he anticipated the demotion.

I next formulated an approach to deal with the main problem-helping the management to implement their decision to restructure the company and demote Ken. I started out by looking at how each of them had dealt with me. This would give me an indication of the kind of persuasive power that I might have with each of them. Adam, the owner, clearly needed to feel in charge and maintain his good guy image. Also, he was not about to take any advice from someone 15 years his junior. I decided to use what I thought would be an ego-syntonic approach, one that would emphasize his basic humanity and concern for Ken and how difficult it was for him to demote this loyal employee. That instead of confronting him directly about the real issues, he seemed to be trying to "revive" him by getting medical help. He was able to hear this and began to recognize his hesitation and ambivalence.

In my meetings with Bill and Charlie, I felt that they both had looked to me as a wise authority figure and had probably established an idealizing father transference with me. Therefore, I felt that I could confront each of them with the powerful motivations that were out of awareness. In separate meetings I told them my impressions (as noted above) and both seemed to be relieved. They were then better able to focus on their anxieties about changing Ken's position.

I had one more meeting with all three and they then seemed ready to get on with the reorganization. At this point Adam was ready to reassert his commander-in-chief status. He thanked me for the help and the consultation ended. As is often the case, I had started a process but didn't have a chance to see how it completely played out.

While modified for heuristic purposes and confidentiality, this case provides a good example of the domain covered by the organizational psychiatrist. One had to understand issues that ranged from the diagnosis of Ken, to the unconscious dynamics of each of the key players, to how all of these fit into a large social system. As I thought about this case and other consultations that I have done, it brought to mind American psychiatry's debt to Adolph Meyer and how a "fully" trained psychiatrist is an ideal consultant in a case like Alpha Auto.

 
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