Competition and Coherence: Creating a new Balance between Economic Change and Social Identity in Health Care Organizations

The rapid changes in the basic economic conditions of the health care system have over the years led to a generally apprehensive climate in the health care organizations: the endeavour to offer high quality therapy conflicts with economic constraints to save costs and ensure a good rate of return. The general consolidation of work threatens familiar free spaces and leads to increased stress, the work relations between management and staff become more and more tense. The demand for quick changes collides with the distinct need for stability in health care organizations this corresponds to a structural dilemma: because of the nature of work in helping professions, which may be defined as 'stabilization of destabilized systems', and because of many helpers personal history and psychological structure, we can frequently find that the prevailing values in health care teams are continuity, stability and orientation within their organization. This relates to the fact that people working in organizations have a basic need for coherence: to identify sufficiently with ones own role, task and organization. They might try to fill this need primarily by maintaining stability of familiar structures and processes. On the other hand, they often underestimate the need for orientation by the demands of the environment that is by context and change. While work teams in commercial profit-organizations are used to the fact that their survival is linked directly to the economic success of their product or of the service they offer on the market, health care teams tend to define themselves rather by their therapeutic success with the clients they care for, and by their colleagues appreciation. The institutions economic context, the mechanisms of the market and the increasing influence of competition on the other hand appear to be an annoying and irritating factor in the face of the 'real' helping activity. In view of the economizing aspects within the health care system, as well as the increasing pressure through competition and cost saving, and the resulting need to actively integrate economic thinking, such attitude becomes increasingly dysfunctional a one-sided economic orientation, which does not take into account the specific way of working in 'helping professions', has an equally destructive effect by breaking up meaningful work coherence! Helpers appear to be strangely afraid to apply such aspects of organizational dynamics to balance influences of different dimensions instead, especially the members of mental health care teams tend to rely on what they know and usually do well in relating to their clients. They show empathy, they take a long time deliberating and are suspicious of any quick action. This leads to an over-stretching of the standard psycho-social repertory dealing with organizational problems and challenges from the environment: The helpers act as if there was no difference between direct client contact and the cooperation and management in an organization and between organizations. This frequently results in avoiding defined responsibilities, clear assignment of authority and power as well as in the fear of taking decisions. Group phenomena like competition and envy get projected into the 'bad world of business and finances' or into the management. Yet when an organization succeeds in balancing the need for developments forced by competition with the need for coherence and social identity, and bringing both together in the shared vision to develop an evaluation of the financial needs, but also of what is their own tradition (that is keeping an eye on the client and support their own staff), then there is a chance of finding a new balance for the dilemma described above. The paper outlines the conditions for such an integrating organizational basic attitude which tries to balance the different influential entities. Psychoanalytic and social-analytical concepts are used to explicate the development of self-management at the different organizational levels. The change of values within the society and its influence on the culture of organizations is discussed in a historical perspective. Examples from the authors consultation work with mental health care organizations illustrate the working hypotheses of the paper.