Disorganised responses to refusal and spoiling in traumatised organisations

A substantial literature attests that practitioners who are charged with the delivery of health and social care to the homeless, the dangerous, the disordered and others who find themselves at the margins of society, frequently become traumatised and interpersonally 'dis-ordered', while the teams, agencies and organisations in which they work become 'dis-organised'. This systemic 'dis-order' and dis-organisation frequently mirrors, or reciprocates, the difficulties and distress of the client population; and sometimes even generates or exacerbates their clients difficulties. A root cause of this dis-order and dis-organisation, we contend, is that many 'evidence-based' policies and interventions aimed at people with severe mental health and social problems depend upon, and indeed at times problematically assume, levels of motivation, pro-social aspiration and reality-oriented engagement from those towards whom the help is targeted. However, it is the fate of many socially organised responses to founder upon the rock of the refusal of this chronically excluded population. Not only do they refuse to 'come in from the cold', but in their refusal they are also experienced as making a mess of societys best (and perhaps sometimes worst) intentions and interventions. In this chapter we take as a paradigm for these psycho-social dynamics, severe disturbances of eating and the spoiling and refusal of food in severe anorexia nervosa. We explore what happens when traumatised dis-organisations, who identity themselves as would-be helpers, become bound up with identifications in which they experience themselves as inhabiting the providing role. We examine what happens to them when their food and provisions are refused, messed around, with and thrown back at them by clients who nonetheless remain famished, emaciated and in desperate need of nourishment. To express this in different language, we explore the nature and impact of problematic processes of projective and introjective identification between 'the would-be helpers' and the 'refuse-to-be helped' clients when the relationship between them comes to be characterised by interpersonal dis-order and collective dis-organisation. We will also examine the ways in which the mutual hatred and reciprocal violence which inevitably emerges is projected into the would-be-helping organisation, both from inside (the reasonable and unreasonable expectations of the staff), and from outside (the reasonable and unreasonable expectations of the general public, the clients, the funders and other stakeholders); and how collective identifications with these projections result in traumatised dis-organisation.